Clark 2000.

Methods	Randomization procedure: Unclear. A convenience sample of 74 physicians were randomly assigned to intervention or control status  Informed consent obtained: Yes Protection against contamination: Adequate. Only one doctor per physician group could participate to control for group culture Outcomes assessors blinded: Data collected from parents as well as doctors. Parents and children blinded. Physicians rated their own behaviour and were not blinded Intention to treat analysis: Not done. There were no differences in experimental and control group drop out on demographic variables. However, there were differences in dropout rate related to healthcare utilization and children with more hospital stays and ED visits were more likely to be in the intervention group than the control. This is likely to have led to a conservative estimate of the treatment effect Potential for unit of analysis error: Yes. Acknowledged and adjusted for using generalised estimating equations Comments on study quality: Both physician and patient outcomes were measured but for patients, baseline values were corrected. The problem was acknowledged and to guard against bias, data were collected for parents of patients about physician behaviour as a means of corroborating physician reports. There was a close correlation reported between physician and parent descriptions of behaviour
Participants	Profession: Medicine Specialty: Pediatrics primary care Years experience: No data  Clinical setting: Private practice Level of care: Primary Country: United States Health problem/Type of patient: Asthma in children. 70% male; 7% < 2yrs, 59% 2‐7yrs, 34% 8‐12yrs; Parents 60% 30‐39yrs; 75% married; ˜90% > high school; 20% 20,000 annual income, 16% < poverty ($15,000/yr); 17% on government assistance for healthcare at baseline; 30% nonwhite (15% Latino/Hispanic, 15% African American)
Interventions	Aim of study (Hypothesis): To evaluate the long term impact of an interactive seminar for physicians based on principles of self‐regulation on provider behaviour, children's use of health services for asthma, and parents' views of physician performance. Content of intervention: Physicians were trained to observe, evaluate and react to their own efforts to treat and educate patients. The training used interactive methods focused on helping physicians create conversation with patients to promote the following: Deriving information for making therapeutic decisions. Creating a supportive atmosphere so patients would be candid. Reinforcing positive efforts for families to self‐manage. Providing a supportive climate for problem‐solving. Strengthening patients' skills in using medicines. Providing the patient with a long‐term therapeutic plan. Building patients' confidence at controlling symptoms. The seminar components included optimal clinical practice based on National Asthma Education and Prevention Program guidelines, patient teaching, and communication. Activities and materials included lectures, videotapes, and case study presentations. They were given printed materials for professionals, didactic presentations about asthma and treatment of asthma, video examples, and patient handouts. Providers were taught data gathering, relationship building, informing, motivating, shared decision making, skills taught could be replicated from the description and references listed.      Conceptual focus: The intervention encouraged sharing control of the consultation. Providers were taught to share management of health problems with the patient. Focus in the consultation on the patient as a whole person within social contexts. Interactional skills, and doctor patient relationships/interviewing skills. Duration and timing: 2‐3 sessions, 2‐3 hours each for 2‐3 weeks Number of providers receiving intervention: (start) 12/23(end) 12/23 (low income sample) (full group start = 38/74 end = 34/67) Number of patients receiving intervention (start) 17/36 (end) 17/36 (low income sample) (full group start = 336/637 end = 202/369) Fidelity/integrity of intervention: A random sample of patients was selected to assess the effectiveness of the training program
Outcomes	Primary outcomes: Patient ED visits & hospitalizations. Physician behavior changes in teaching and communication skills. Parent’s view of paediatrician’s performance. Patient’s use of health care for asthma. (Clark 2000) Consultation process: anti‐inflammatory medication prescribed, treatment/action plan given (patient/parent report, provider survey Satisfaction: Patient report using Likert‐type scale items to assess doctor performance of consultation skills. Health behaviours: Emergency department visits, hospitalizations, school days missed (Parent/patient report) Health status: NA
Notes	References included in review of this article: Clark, Gong, Schork, et al. Impact of education for physicians on patient outcomes. Pediatrics. 1998; 101: 831‐6; Brown 2004 included in above review Meta‐analysis: Dichotomous variable=Consultation Process; Patient and provider level data: No ICC
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	A convenience sample of 74 physicians were randomly assigned to intervention or control status
Allocation concealment (selection bias)	High risk	Did not state. Unlikely given description
Blinding (performance bias and detection bias) All outcomes	High risk	Data collected from parents as well as doctors. Parents and children blinded. Physicians rated their own behaviour and were not blinded
Incomplete outcome data (attrition bias) All outcomes	High risk	103/369 patients were lost to follow‐up (i.e. 27.9%) and intention to treat analysis was not done
Selective reporting (reporting bias)	High risk	outcomes were split into different papers. Clark assessed physician behaviour changes in teaching communication skills (10 variables), behaviour when prescribing new medicine (5 variables), therapeutic steps (6 variables), and time spent with patient (1 variable); parent's view of the paediatrician's performance (20 variables); and patient's use of healthcare for asthma (four variables). Authors did not report results for all these variables and they did not indicate that they adjusted for multiple comparisons. Reported only final logistic regression models Brown assessed changes in parent's view of physician performance; change in child's health status, and healthcare utilisation and also only presented final logistic regression model for the last 2 categories
Other bias	Low risk	Tried to protect against contamination; potential for unit of analysis error was acknowledged and adjusted for. Baseline data was conducted and accounted for, although they were not reported