Measurement of changes in antihypertensive drug utilisation following primary care educational interventions

A Curriculum on Advanced Topics in Hypertension for Internal Medicine Residents

OBJECTIVES

Hypertension (HTN) affects nearly half of US adults. Our multi-institutional survey revealed that Internal Medicine residents lack proficiency in advanced HTN topics. We developed a curriculum to address knowledge gaps in these topics and aimed to assess the effects of the curriculum on residents' confidence, desire for future training, and knowledge in advanced HTN topics.

METHODS

HTN experts taught four advanced topics in HTN: conducting a workup for secondary HTN, managing HTN in chronic kidney disease, managing HTN in patients who are or may become pregnant, and managing hypertensive urgency (severe asymptomatic HTN) in the outpatient setting. The setting of the curriculum was an ambulatory educational half-day, during which residents rotated through small-group sessions dedicated to each HTN topic. We developed pre-, immediate post-, and 8 weeks postcurriculum surveys assessing residents' confidence and desire for future training in the four topics (4-point Likert scales), and multiple-choice quizzes to assess changes in knowledge. We used repeated-measures analysis of variance to compare means between time points for surveys and quizzes.

RESULTS

A total of 112 Internal Medicine residents participated in the curriculum. The mean confidence scores for all four topics increased from 1.79 to 2.61 precurriculum to 2.90 to 3.45 immediately postcurriculum (all P < 0.001) and remained higher (2.53-3.18) than precurriculum at 8 weeks postcurriculum (all P < 0.02). The mean desire for future training scores decreased from 2.74 to 2.96 precurriculum to 2.06 to 2.36 immediately postcurriculum (all P < 0.001 except for managing HTN in patients who are or may become pregnant, which was P = 0.17) and remained lower (2.08-2.36) than precurriculum at 8 weeks postcurriculum (all P ≤ 0.003). The mean knowledge score increased from 48% precurriculum to 62% immediate postcurriculum (P < 0.001) and remained higher (55%) than precurriculum at 8 weeks postcurriculum (P = 0.015).

CONCLUSIONS

A curriculum on advanced HTN topics produced durable gains in confidence and knowledge and partially satisfied the desire for future learning among Internal Medicine residents.

Training general practitioners to improve evidence-based drug treatment of patients with heart failure: a cluster randomised controlled trial

Aims

To assess whether a single training session for general practitioners (GPs) improves the evidence-based drug treatment of heart failure (HF) patients, especially of those with HF with reduced ejection fraction (HFrEF).

Methods and results

A cluster randomised controlled trial was performed for which patients with established HF were eligible. Primary care practices (PCPs) were randomised to care-as-usual or to the intervention group in which GPs received a half-day training session on HF management. Changes in HF medication, health status, hospitalisation and survival were compared between the two groups. Fifteen PCPs with 200 HF patients were randomised to the intervention group and 15 PCPs with 198 HF patients to the control group. Mean age was 76.9 (SD 10.8) years; 52.5% were female. On average, the patients had been diagnosed with HF 3.0 (SD 3.0) years previously. In total, 204 had HFrEF and 194 HF with preserved ejection fraction (HFpEF). In participants with HFrEF, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers decreased in 6 months in both groups [5.2%; (95% confidence interval (CI) 2.0–10.0)] and 5.6% (95% CI 2.8–13.4)], respectively [baseline-corrected odds ratio (OR) 1.07 (95% CI 0.55–2.08)], while beta-blocker use increased in both groups by 5.2% (95% CI 2.0–10.0) and 1.1% (95% CI 0.2–6.3), respectively [baseline-corrected OR 0.82 (95% CI 0.42–1.61)]. For health status, hospitalisations or survival after 12–28 months there were no significant differences between the two groups, also not when separately analysed for HFrEF and HFpEF.

Conclusion

A half-day training session for GPs does not improve drug treatment of HF in patients with established HF.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01487-x) contains supplementary material, which is available to authorized users.

Impact of NPS MedicineWise general practitioner education programs and Choosing Wisely Australia recommendations on prescribing of proton pump inhibitors in Australia

Background

This study evaluated the impact of multifaceted NPS MedicineWise programs that targeted all general practitioners (GPs) in Australia in 2009 and 2015 with the aim of reducing unnecessary prescribing of proton pump inhibitors (PPIs) and encouraged stepping down to a lower strength PPI or to discontinue treatment. The 2015 intervention coincided with the release of Choosing Wisely Australia recommendations from the Royal Australian College of General Practitioners (RACGP).

Methods

Outcome measures included monthly dispensing rates of different strength PPIs prescribed by GPs to concessional patients in Australia. All PPIs were categorized according to the May 2019 revised classifications for standard and low strength PPIs except for esomeprazole 40 mg which was classified as a standard strength and esomeprazole 20 mg as low strength for this analysis. Time series analyses was conducted of the dispensing rates of PPI prescriptions for concessional patients between January 2006 and June 2016 using the Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) databases in Australia. Participants were GPs with dispensed PPI prescriptions to concessional patients between January 2006 and June 2016.

Results

Following the 2009 NPS MedicineWise program we observed a 6.7% reduction in the expected dispensing rate of standard strength PPIs for concessional patients between April 2006 and March 2015, and an 8.6% reduction between April 2009 and June 2016 following the 2015 program launch. We observed a significant increase of 5.6% in the dispensing rate of low strength PPIs for concessional patients between April 2009 and March 2015, and no significant change in trend following the 2015 program.

Conclusions

The NPS MedicineWise programs were associated with reductions in the dispensing rate of standard strength PPIs by June 2016 and an increase in the dispensing rate of low-strength PPIs by March 2015 although this trend did not continue following the 2015 program. This suggests that GPs are stepping down patients to lower strength PPIs following the educational programs. However, lower strength PPIs are still not the majority of PPIs dispensed in Australian and regular interventions to sustain and improve PPI management by GPs may be warranted.

Effect of an educational intervention on the number potential drug-drug interactions

Background

The objective of this study was to evaluate effect of an Educational intervention on the number Potential Drug-Drug Interactions in the Emergency Hospital.

Methods

The prevalence and structure of Major Drug-Drug Interactions at Emergency care Hospitals of Aktobe, Uralsk, Atyrau cities (Kazakhstan) were studied (pharmacoepidemiological, cross-sectional study). Educational interventions were developed and implemented to improve pharmacotherapy in the Cardiology Department of the Aktobe Emergency Hospital, followed by an assessment of their effect.

Results

The effect of educational interventions was revealed, which led to a significant decrease in the indicators of drug interactions of the Major Drug-Drug Interactions by 18.2% (OR: 0.45; 95% CI, 0.25-to-0.82) in the cardiological patients of the Emergency Care Hospital of Aktobe city compared to the Regional Cardiology Center of Uralsk.

Conclusion

The implementation of educational pharmacotherapy programs decreased the number of clinically significant drug interactions in the Cardiology Department of Emergency Hospitals.

Relationship between antimicrobial-resistance programs and antibiotic dispensing for upper respiratory tract infection: An analysis of Australian data between 2004 and 2015

Objective NPS MedicineWise aims to ensure that medicines are prescribed and used in a manner consistent with current evidence-based best practice. A series of nationwide educational and advertising interventions for general practitioners and consumers were implemented in Australia between 2009 and 2015 with the aim of reducing antibiotic prescriptions for upper respiratory tract infections (URTIs). The work described in this paper quantifies the change in antibiotic dispensing following these interventions. Methods Antibiotic dispensing data between 2004 and 2015 were obtained from a national claims database. A Bayesian structural time series model was used to forecast a series of antibiotic dispensing volumes expected to have occurred if the interventions had not taken place. These were compared with the volumes that were actually observed to estimate the intervention effect. Results On average, 126,536 fewer antibiotics were dispensed each month since the intervention programs began in 2009 (95% Bayesian credible interval = 71,580-181,490). This change represents a 14% total reduction in dispensed scripts after the series of intervention programs began in 2009. Conclusions Continual educational intervention programs that emphasise the judicious use of antibiotics may effectively reduce inappropriate prescribing of antibiotics for the treatment of URTIs at a national level.

Prescribing Data in General Practice Demonstration (PDGPD) project--a cluster randomised controlled trial of a quality improvement intervention to achieve better prescribing for chronic heart failure and hypertension

BACKGROUND

Research literature consistently documents that scientifically based therapeutic recommendations are not always followed in the hospital or in the primary care setting. Currently, there is evidence that some general practitioners in Australia are not prescribing appropriately for patients diagnosed with 1) hypertension (HT) and 2) chronic heart failure (CHF). The objectives of this study were to improve general practitioner's drug treatment management of these patients through feedback on their own prescribing and small group discussions with peers and a trained group facilitator. The impact evaluation includes quantitative assessment of prescribing changes at 6, 9, 12 and 18 months after the intervention.

METHODS

A pragmatic multi site cluster RCT began recruiting practices in October 2009 to evaluate the effects of a multi-faceted quality improvement (QI) intervention on prescribing practice among Australian general practitioners (GP) in relation to patients with CHF and HT. General practices were recruited nationally through General Practice Networks across Australia. Participating practices were randomly allocated to one of three groups: two groups received the QI intervention (the prescribing indicator feedback reports and small group discussion) with each group undertaking the clinical topics (CHF and HT) in reverse order to the other. The third group was waitlisted to receive the intervention 6 months later and acted as a "control" for the other two groups.De-identified data on practice, doctor and patient characteristics and their treatment for CHF and HT are extracted at six-monthly intervals before and after the intervention. Post-test comparisons will be conducted between the intervention and control arms using intention to treat analysis and models that account for clustering of practices in a Network and clustering of patients within practices and GPs.

DISCUSSION

This paper describes the study protocol for a project that will contribute to the development of acceptable and sustainable methods to promote QI activities within routine general practice, enhance prescribing practices and improve patient outcomes in the context of CHF and HT.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), Trial # 320870.

Antihypertensive drugs utilisation and educational activities

The mortality rate from cardiovascular diseases is high in Serbia. Analysis of antihypertensive drugs utilization is the basis for assessment of cardiovascular pharmacotherapy appropriateness. The aim of this study was to analyze the trend in antihypertensive drugs utilization among outpatients in Niš region, South Serbia compared to some Nordic countries (Norvay, Sweden) and Australia as well as to analyze trends in educational and drug promotion activities directed to primary healthcare workers within the same region. Using the ATC/DDD methodology, we analyzed the utilization of antihypertensive drugs dispensed on prescription in the Nis region over the 2003–2007 period. The study was retrospective, based on data obtained from Central City Pharmacy Nis. Educational and drug promotion activities were noted from the records of Medical Faculty, University of Nis, and from the records of local branches of pharmaceutical companies active in Serbia. Wilcoxon’s test was used in order to calculate the statistical significance of difference. A significant increase of 79.8% (153.8/ 276.6 DDD/inhabitants/day) in antihypertensive drug consumption was observed in the same period. This analysis showed there were substantial increases in the use of diuretics (134.7%), ACE inhibitors (79.5%) and calcium channel blockers (116.1%), especially amlodipin (241.2%). During the observed period, annual numbers of educational activities and of pharmaceutical sales representatives employed within the region increased for almost one fourth. This analysis pointed to a significant increase in the use of antihypertensive drugs in the Nis region, which was matched with increase in educational and drug promotion activities within the region, so that in 2006–2007 total consumption was approximate to some referential countries (Norvay, Sweden).

Comparison of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors use in Australia and Nova Scotia (Canada)

AIMS

Cyclooxygenase-2 (COX-2) inhibitors were marketed aggressively and their rapid uptake caused safety concerns and budgetary challenges in Canada and Australia. The objectives of this study were to compare and contrast COX-2 inhibitors and nonselective nonsteroidal anti-inflammatory drug (ns-NSAID) use in Nova Scotia (Canada) and Australia and to identify lessons learned from the two jurisdictions.

METHODS

Ns-NSAID and COX-2 inhibitor Australian prescription data (concession beneficiaries) were downloaded from the Medicare Australia website (2001-2006). Similar Pharmacare data were obtained for Nova Scotia (seniors and those receiving Community services). Defined daily doses per 1000 beneficiaries day(-1) were calculated. COX-2 inhibitors/all NSAIDs ratios were calculated for Australia and Nova Scotia. Ns-NSAIDs were divided into low, moderate and high risk for gastrointestinal side-effects and the proportions of use in each group were determined. Which drugs accounted for 90% of use was also calculated.

RESULTS

Overall NSAID use was different in Australia and Nova Scotia. However, ns-NSAID use was similar. COX-2 inhibitor dispensing was higher in Australia. The percentage of COX-2 inhibitor prescriptions over the total NSAID use was different in the two countries. High-risk NSAID use was much higher in Australia. Low-risk NSAID prescribing increased in Nova Scotia over time. The low-risk/high-risk ratio was constant throughout over the period in Australia and increased in Nova Scotia.

CONCLUSIONS

There are significant differences in Australia and Nova Scotia in use of NSAIDs, mainly due to COX-2 prescribing. Nova Scotia has a higher proportion of low-risk NSAID use. Interventions to provide physicians with information on relative benefits and risks of prescribing specific NSAIDs are needed, including determining their impact.

Systematic Review of Interventions to Improve Prescribing

Objective:

To update 2 comprehensive reviews of systematic reviews on prescribing interventions and identify the latest evidence about the effectiveness of the interventions.

Data Sources:

Systematic searches for English-language reports of experimental and quasi-experimental research were conducted in PubMed(1951–May 2007). EMBASE (1974–March 2008), International Pharmaceutical Abstracts (1970–March 2008), and 11 other bibliographic databases of medical, social science, and business research. Following an initial title screening process and after selecting 6 specific intervention categories (identified from the previous reviews) in community settings, 2 reviewers independently assessed abstracts and then full studies for relevance and quality and extracted relevant data using formal assessment and data extraction tools. Results were then methodically incorporated into the findings of the 2 earlier reviews of systematic reviews.

Data Selection And Synthesis:

Twenty-nine of 26,314 articles reviewed were assessed to be of relevant, high-quality research. Audit and feedback, together with educational outreach visits, were the focus of the majority of recent, high-quality research into prescribing interventions. These interventions were also the most effective in improving prescribing practice. A smaller number of studies included a patient-mediated intervention; this intervention was not consistently effective. There is insufficient recent research into manual reminders to confidently update earlier reviews and there remains insufficient evidence to draw conclusions regarding the effectiveness of local consensus processes or multidisciplinary teams.

Conclusions:

Educational outreach as well as audit and feedback continue to dominate research into prescribing interventions. These 2 prescribing interventions also most consistently show positive results. Much less research is conducted into other types of interventions and there is still very little effort to systematically test why interventions do or do not work.

Advertising of antihypertensive medicines and prescription sales in Australia

BACKGROUND

Drug promotion is one of the main factors that influence prescribing practices, but there are limited data available to quantify the relationship between drug advertising and prescription sales.

AIM

To investigate the relationship between advertising for antihypertensive medicines and prescription sales in Australia between 1993 and 2002.

METHODS

Retrospective observational study. Advertising trends were monitored by counting the number of advertisements published in three Australian medical journals. Monthly prescription dispensing data were obtained from Drug Utilisation Sub-Committee and expressed as numbers of defined daily doses/1000 inhabitants/day. Linear regression and cross-correlations of time series were used in the analysis.

RESULTS

The drug classes the most heavily advertised, angiotensin-converting enzyme inhibitors and calcium channel blockers, were also the most prescribed during the study period, while the drugs the least advertised, thiazide diuretics and beta-blockers, were the least used. In 5 of the 7 main antihypertensive classes, the product the most advertised was also the most prescribed. Other factors, such as the publication of large clinical trials, may have also influenced prescribing patterns.

CONCLUSION

Prescription sales of antihypertensives in Australia are correlated with promotional advertising. The newest and most expensive medicines may be chosen over older effective drugs by prescribers. New policies on drug promotion control need to be developed.

Do advertisements for antihypertensive drugs in Australia promote quality prescribing? A cross-sectional study

Background

Antihypertensive medications are widely prescribed by doctors and heavily promoted by the pharmaceutical industry. Despite strong evidence of the effectiveness and cost-effectiveness of thiazide diuretics, trends in both promotion and prescription of antihypertensive drugs favour newer, less cost-effective agents. Observational evidence shows correlations between exposure to pharmaceutical promotion and less ideal prescribing. Our study therefore aimed to determine whether print advertisements for antihypertensive medications promote quality prescribing in hypertension.

Methods

We performed a cross-sectional study of 113 advertisements for antihypertensive drugs from 4 general practice-oriented Australian medical publications in 2004. Advertisements were evaluated using a quality checklist based on a review of hypertension management guidelines. Main outcome measures included: frequency with which antihypertensive classes were advertised, promotion of thiazide class drugs as first line agents, use of statistical claims in advertisements, mention of harms and prices in the advertisements, promotion of assessment and treatment of cardiovascular risk, promotion of lifestyle modification, and targeting of particular patient subgroups.

Results

Thiazides were the most frequently advertised drug class (48.7% of advertisements), but were largely promoted in combination preparations. The only thiazide advertised as a single agent was the most expensive, indapamide. No advertisement specifically promoted any thiazide as a better first-line drug. Statistics in the advertisements tended to be expressed in relative rather than absolute terms. Drug costs were often reported, but without cost comparisons between drugs. Adverse effects were usually reported but largely confined to the advertisements' small print. Other than mentioning drug interactions with alcohol and salt, no advertisements promoted lifestyle modification. Few advertisements (2.7%) promoted the assessment of cardiovascular risk.

Conclusion

Print advertisements for antihypertensive medications in Australia provide some, but not all, of the key messages required for guideline-concordant care. These results have implications for the regulation of drug advertising and the continuing education of doctors.