Use of social network analysis methods to study professional advice and performance among healthcare providers: a systematic review - Systematic Reviews

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Definitions

For any systematic review, it is critical to clarify our meaning when using terms that define a search strategy. For this review, we have operationally defined “healthcare providers,” “professional communication,” and “performance” as follows.

In this context, we defined “healthcare providers” as physicians, clinical officers, nurses, midwives, counselors, physician’s assistants, and others who provide health-related services to patients in formal medical environments. Additionally, community-based cadres such as community health workers, village health workers, traditional birth assistants, and others were also considered healthcare providers.

For our purposes, we defined “professional communication” as formal or informal professional advice-seeking or giving or discussion about hypothetical or actual work situations or patients. For example, studies exploring friendship networks of healthcare providers were not considered eligible, unless they also captured communication related to work situations or patient care and documented patient health outcomes.

We defined “performance” as a study including a patient health outcome. Studies that only considered “patient satisfaction” or healthcare provider “perceptions of performance” were not eligible for inclusion.

Search strategy

The search strategy focuses on the intersection of SNA and diffusion of innovations, the term used in the SNA community most relevant for professional communication related to knowledge sharing and transfer. Since health policy and health systems research often use “knowledge translation or transfer” language, the search strategy also includes the intersection between those terms and SNA. As a methodologically focused review, this review will highlight the range of SNA methods applied.

To address the research questions, the systematic review focused on three concepts that are integral to the primary research question: (1) SNA, (2) diffusion of innovations, and (3) knowledge translation and transfer. The key terms for these concepts are shown in Additional file 1 and truncation search terms will be used to make the search inclusive.

Concept 1: social network analysis

The search strategy for the SNA concept was adapted from the Chambers et al.’s scoping systematic review of Social Network Analysis and healthcare settings [5]. This was particularly helpful guidance as a more recent SNA review; Cunningham et al. noted the challenge of “social network” yielding irrelevant social media or social support articles [13]. One of the changes from the Chambers et al. review was an expansion of the list of SNA software listed (from four: UCINET, NetDraw, Pajek, and KrackPlot to 56), which was guided by a chapter in the SAGE Handbook of Social Network Analysis [14]. Depending on the database, specific software packages (Blanche, InFlow, Jung, ORA, ORS, Pnet, Puck UNISoN, SNAP, and STRUCTURE) were excluded as they yielded thousands of off-topic articles. See Additional file 2 for a list of exclusions by database. None of these exclusions were the SNA packages included in the previous review and for the most part are not the most commonly used software packages for SNA. The one exception is ORA, a SNA software package that, for 6 of 10 databases, returned thousands of articles that used odd ratios in their analysis. However, as this review still yielded two studies that used ORA, we do not feel that this negatively impacted the search.

Concept 2: diffusion of innovations

The search strategy for the diffusion of innovations concept was influenced by the original search strategy used as a starting point for a meta-narrative on Diffusion of Innovations in Health Service Organizations [15]. However, the focus on health service organizations was seen as potentially too limiting. Therefore, terms related to health service organizations were not included to let the review capture a broader range of studies. “Diffusion of innovations” is a phrase that is relatively new to health systems research. Consequently, the review used a third concept to ensure all relevant studies were captured, which corresponds to diffusion of information: knowledge translation and transfer.

Concept 3: knowledge translation and transfer

Knowledge translation and transfer (KT) are terms describing a relatively new discipline, which does not have an agreed upon lexicon. A systematic study of KT terms used in 12 journals found inconsistent use of KT terms such that less than half of what the authors classified as “KT articles” used the presumed “KT terms” leading the authors to refer to the situation as a “tower of babel” [16]. The search strategy for this concept was developed by determining the common terms across six sources including four systematic reviews [17,18,19,20] and two articles on knowledge translation “KT” or “K*” terms [16, 21]. A comprehensive listing of all 253 K* terms can be found in Additional file 3. An initial search conducted using all the terms yielded over 6000 articles in MEDLINE, which led to a revision of the approach for this concept. Priority terms for inclusion in the search strategy were those that appeared in more than one source.

The search strategies were then developed looking at the intersection of concept 1 with concept 2 and the intersection of concept 1 with concept 3. They were then adapted to each of the databases included in the review, including mapping the above terms to MeSH terms. Detailed search strategies for each of the 10 databases are available upon request—an example is included in Additional file 4.

MEDLINE, EMBASE, PsychINFO, CINAHL, Global Health, Social Policy and Practice, Health Management Information Consortium, and Web of Science were searched. Gray literature was searched via Popline. The Cochrane Library was searched to identify other systematic reviews and relevant studies. Several websites were searched including International Network for Social Network Analysis, American Evaluation Association Social Network Analysis Technical Interest Group, and in the International Sunbelt Social Networks Conference proceedings archives.

Articles were downloaded into Endnote X5.0.01, a bibliographic software package and duplicates within and across databases were removed. All 5970 articles were then assessed for meeting study inclusion criteria through a three-stage review process. Two independent reviewers (KS and DW) screened titles, abstracts, and full-text articles; after each step, discrepancies were discussed and reconciled.

The 10 systematic reviews identified through the search strategies that addressed SNA had the articles they included screened for inclusion in this review [5, 22,23,24,25,26,27,28,29].

The search strategies were executed originally from 1990 to January–March 2015 and then updated in April 2016, capturing articles published since the original search. All systematic reviews identified had the articles they included screened. The final set of articles had their reference lists screened and SCOPUS was used to conduct a prospective citation search. All articles were subjected to our two independent reviewer, 3-stage screening process. The PRISMA flow chart (Fig.1) reflects the combination of the searches and screenings conducted in 2015 and updated in 2016.

Fig. 1

PRISMA flow chart

Full size image

The study protocol was registered with PROSPERO DOI: 10.15124/CRD42015019328 URL: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015019328

Study inclusion and exclusion criteria

A checklist was developed to guide each reviewer. A single “no” response to any of the questions below was a cause of exclusion of the study from the systematic review:

Does the study use SNA methods?
Are the study subjects healthcare providers?
Is the communication/relationship of interest between healthcare providers?
Does the research focus on professional communication?
Is there some metric used for performance, defined as assessing patient outcomes?

Only English search terms were used, and studies included were limited to those published in English since 1990. This date was selected in part because in the previous review, Chambers et al. 2012 had 49 of 52 included articles published after 1990. Furthermore, modern SNA studies rely on software that has primarily existed after 1990.

This review excluded studies conducting SNA of patient-to-patient communication or patient-to-provider communication. Direct-to-consumer advertising and marketing studies, such as pharmaceutical companies marketing to potential patients, were also excluded. Publication or research networks, provider patient-sharing networks, provider friendship networks, and non-empiric research were excluded. Studies whose only measures of performance were “provider perceptions” or “patient satisfaction” were excluded as not being an objectively measurable health outcome.

These exclusions were made on that basis that they were not thought to lend insight into methods used to assess professional communications among healthcare workers and their association with patient outcomes.

Study quality assessment

Two tools were developed for critically appraising study quality—one for qualitative studies and the other one for quantitative study designs. These tools were informed by STROBE, EPOC, CASP, SIGN, ENTREQ, COREQ, RATS, QARI, and NICE Process and Methods guidelines and checklists and seminal articles on the subject [30,31,32,33,34,35,36,37,38,39,40]. Systematic reviews of SNAs identified through our search strategy were consulted as there is not a standard tool for assessing the quality of SNA, and some of the content of existing checklists for other study methods do not apply for network studies [5, 13, 22,23,24,25,26,27,28,29]. However the existing tools were useful starting points for assessing the quality of studies. See Additional files 5 and 6 for the tools developed to assess qualitative and quantitative studies and Table 2 for the summary of study quality. As per Cochrane and SIGN, guidance studies were assessed as being high, medium, and low quality with no summary score produced or a quality threshold for inclusion in the review [36, 41]. Mixed-methods studies had both tools applied and an overall study quality assessment provided drawing on both tools’ assessments.

Selected studies were independently critically appraised using these tools by two individuals (KS and DW). Discrepancies were discussed until reconciled.

Data extraction strategy

A data extraction matrix was developed after reviewing data extraction tools used in relevant systematic reviews and consulting with a SNA and health expert [5, 13, 22,23,24,25,26,27,28,29]. The tool was pilot-tested and revised for greater clarity and specificity with the final version covering 35 data points. Data were extracted independently by two individuals (KS and DW), results compared and discrepancies discussed and resolved by consensus. See Additional file 7 for the tool and Tables 2, 3, 4, 5, and 6 for a subset of the data extracted.