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Patel M, Patel J. An evaluation of the effectiveness of induction programmes on foundation doctor preparedness: a rapid review of the literature. Ir J Med Sci 2021; 191:1399-1406. [PMID: 34191242 PMCID: PMC9135807 DOI: 10.1007/s11845-021-02683-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/09/2021] [Indexed: 12/01/2022]
Abstract
There is an increase in mortality when medical graduates replace the previous cohort of foundation doctors. As of 2012, it is now mandatory for new doctors in the UK to participate in induction training in order to ease this transition and reduce the negative impact on patient outcomes. However, there is no guidance on how best to deliver these induction programmes. This review aims to evaluate the effectiveness of several induction programmes to provide insight on this. Medline and Scopus were searched for relevant literature using keywords. Duplicates were removed and inclusion criteria were created to screen the remaining literature. Five studies were included in this review and they were all quality appraised using the Medical Education Research Study Quality Instrument. Different hospital trusts utilised varying induction programmes. The most common method of assessing their effectiveness involved exploring preparedness in junior doctors post-induction through surveys. Patient outcome, anxiety levels and knowledge were also measured. Induction programmes play a vital role in preparing new foundation doctors for practice and thus improving patient outcomes. Although there may be trust-specific variation, some elements of the programme should be standardised to ensure basic requirements are met universally. New doctors should be assessed on aspects of the programme after completion to increase confidence and knowledge. Organisational considerations such as costs and staff availability need to be taken into account. The quality of future research papers could be improved through inclusion of baseline data, control groups, multi-centred studies and outcomes higher on Kirkpatrick’s hierarchy.
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Affiliation(s)
- Monika Patel
- University of Exeter Medical School, Exeter, UK.
| | - Jasmine Patel
- Ashford and St. Peter's Hospitals NHS Foundation Trust, Surrey, UK
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2
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Goulao B, Scott C, Black I, Clarkson J, McArthur L, Ramsay C, Young L, Duncan E. Audit and feedback with or without training in-practice targeting antibiotic prescribing (TiPTAP): a study protocol of a cluster randomised trial in dental primary care. Implement Sci 2021; 16:32. [PMID: 33781284 PMCID: PMC8007384 DOI: 10.1186/s13012-021-01098-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antimicrobial resistance is an increasingly serious threat to global public health and patient safety. Overuse of antibiotics has aggravated this issue. Around 7% of all antibiotics in Scotland are prescribed by dentists. Audit and feedback has been shown to decrease these prescriptions, but there is evidence that dentists still prescribe unnecessarily. Our aim is to compare the effectiveness of a theory-informed in-practice training session (TiPTAP) in addition to individualised audit and feedback, with audit and feedback alone for reducing antibiotic prescribing by NHS dentists working in NHS primary care dental practices. METHODS We will conduct a 2-arm parallel cluster randomised trial: out of 228 practices, 114 will be randomised to the theory-informed in-practice training session targeting antibiotic prescribing and individualised audit and feedback; 114 practices will be randomised to audit and feedback alone. The theory-informed session will include (a) an introductory session including several behaviour change techniques; (b) problem solving discussion, setting and recording action plans; (c) practice-level prescribing feedback discussion. The primary outcome is the number of antibiotic items per 100 NHS treatment claims over a 1-year period post-randomisation for each dentist. Secondary outcomes are the number of amoxicillin 3 g and broad spectrum antibiotics prescribed per 100 NHS treatment claims over a 1-year period; amoxicillin 3 g and broad spectrum antibiotics defined daily doses of antibiotics per 100 claims. Process measures include fidelity, knowledge, and confidence. Primary and secondary outcomes will be obtained using routine data. DISCUSSION This study provides the opportunity to robustly assess the effect of adding an in-practice training co-intervention to audit and feedback. Its behaviour change theory-informed content will allow replication of the different components and can inform future training interventions. TRIAL REGISTRATION ISRCTN, ISRCTN12345678 . Registered 18 June 2020.
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Affiliation(s)
- Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland.
| | | | | | - Jan Clarkson
- NHS Education for Scotland, Edinburgh, UK.,Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, Dundee, UK
| | | | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Linda Young
- NHS Education for Scotland, Edinburgh, UK.,Dental Health Services Research Unit, Dundee Dental School, The University of Dundee, Dundee, UK
| | - Eilidh Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
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3
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Rohrbasser A, Harris J, Mickan S, Tal K, Wong G. Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae- A scoping review. PLoS One 2018; 13:e0202616. [PMID: 30557329 PMCID: PMC6296539 DOI: 10.1371/journal.pone.0202616] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/04/2018] [Indexed: 01/02/2023] Open
Abstract
Quality circles or peer review groups, and similar structured small groups of 6–12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners’ behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.
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Affiliation(s)
- Adrian Rohrbasser
- Department of Continuing Education University of Oxford, Oxford, United Kingdom
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- * E-mail:
| | - Janet Harris
- University of Sheffield School of Health & Related Research, Sheffield, United Kingdom
| | - Sharon Mickan
- The Gold Coast Health, Griffith University, Southport, Australia
| | - Kali Tal
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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McDowell R, Bennett K, Moriarty F, Clarke S, Barry M, Fahey T. An evaluation of prescribing trends and patterns of claims within the Preferred Drugs Initiative in Ireland (2011 -2016): an interrupted time-series study. BMJ Open 2018; 8:e019315. [PMID: 29678966 PMCID: PMC5914712 DOI: 10.1136/bmjopen-2017-019315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To examine the impact of the Preferred Drugs Initiative (PDI), an Irish health policy aimed at enhancing evidence-based cost-effective prescribing, on prescribing trends and the cost of prescription medicines across seven medication classes. DESIGN Retrospective repeated cross-sectional study spanning the years 2011-2016. SETTING Health Service Executive Primary Care Reimbursement Service pharmacy claims data for General Medical Services (GMS) patients, approximately 40% of the Irish population. PARTICIPANTS Adults aged ≥18 years between 2011 and 2016 are eligible for the GMS scheme. PRIMARY AND SECONDARY OUTCOMES The percentage of PDI medications within each drug class per calendar quarter. Linear regression was used to model prescribing of the preferred drug within each medication group and to assess the impact of PDI guidelines and other relevant changes in prescribing practice. Savings in drug expenditure were estimated. RESULTS Between 2011 and 2016, around a quarter (23.59%) of all medications were for single-agent drugs licensed in the seven drug classes. There was a small increase in the percentage of PDI drugs, increasing from 4.64% of all medications in 2011 to 4.76% in 2016 (P<0.001). The percentage of preferred drugs within each drug class was significantly higher immediately following publication of the guidelines for all classes except urology, with the largest increases noted for lansoprazole (1.21%, 95% CI: 0.84% to 1.57%, P<0.001) and venlafaxine (0.71%, 95% CI: 0.15% to 1.27%, P=0.02). Trends in prescribing of the preferred drugs between PDI guidelines and the end of 2016 varied between drug classes. Total cost savings between 2013 and 2016 were estimated to be €2.7 million. CONCLUSION There has been a small increase in prescribing of PDI drugs in response to prescribing guidelines, with inconsistent changes observed across therapeutic classes. These findings are relevant where health services are seeking to develop more active prescribing interventions aimed at changing prescribing practice.
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Affiliation(s)
- Ronald McDowell
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland Medical School, Dublin, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland Medical School, Dublin, Ireland
| | - Sarah Clarke
- Health Service Executive Medicines Management Programme, Trinity Centre for Health Sciences, St James’s Hospital, Dublin, Ireland
| | - Michael Barry
- National Centre for Pharmacoeconomics, Trinity Centre for Health Sciences, St. James’s Hospital, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland Medical School, Dublin, Ireland
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5
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06100] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundInterventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.ObjectivesThis study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.DesignThe review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.SettingPrimary and secondary care.ParticipantsNot applicable.InterventionsStudies related to antimicrobial prescribing for doctors in training.Main outcome measuresNot applicable.Data sourcesEMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.Review methodsClearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.ResultsA total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.LimitationsMost articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.ConclusionsThis review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.Future workMore work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.Study registrationThis study is registered as PROSPERO CRD42015017802.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Mark Pearson
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - Simon Briscoe
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Sá L, Teixeira ASC, Tavares F, Costa-Santos C, Couto L, Costa-Pereira A, Hespanhol AP, Santos P, Martins C. Diagnostic and laboratory test ordering in Northern Portuguese Primary Health Care: a cross-sectional study. BMJ Open 2017; 7:e018509. [PMID: 29146654 PMCID: PMC5695440 DOI: 10.1136/bmjopen-2017-018509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/11/2017] [Accepted: 10/03/2017] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To characterise the test ordering pattern in Northern Portugal and to investigate the influence of context-related factors, analysing the test ordered at the level of geographical groups of family physicians and at the level of different healthcare organisations. DESIGN Cross-sectional study. SETTING Northern Primary Health Care, Portugal. PARTICIPANTS Records about diagnostic and laboratory tests ordered from 2035 family physicians working at the Northern Regional Health Administration, who served approximately 3.5 million Portuguese patients, in 2014. OUTCOMES To determine the 20 most ordered diagnostic and laboratory tests in the Northern Regional Health Administration; to identify the presence and extent of variations in the 20 most ordered diagnostic and laboratory tests between the Groups of Primary Care Centres and between health units; and to study factors that may explain these variations. RESULTS The 20 most ordered diagnostic and laboratory tests almost entirely comprise laboratory tests and account for 70.9% of the total tests requested. We can trace a major pattern of test ordering for haemogram, glucose, lipid profile, creatinine and urinalysis. There was a significant difference (P<0.001) in test orders for all tests between Groups of Primary Care Centres and for all tests, except glycated haemoglobin (P=0.06), between health units. Generally, the Personalised Healthcare Units ordered more than Family Health Units. CONCLUSIONS The results from this study show that the most commonly ordered tests in Portugal are laboratory tests, that there is a tendency for overtesting and that there is a large variability in diagnostic and laboratory test ordering in different geographical and organisational Portuguese primary care practices, suggesting that there may be considerable potential for the rationalisation of test ordering. The existence of Family Health Units seems to be a strong determinant in decreasing test ordering by Portuguese family physicians. Approaches to ensuring more rational testing are needed.
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Affiliation(s)
- Luísa Sá
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Family Health Unit Nova Via, Porto, Portugal
| | - Andreia Sofia Costa Teixeira
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Fernando Tavares
- Department of Studies and Planning, Northern Regional Health Administration, Porto, Portugal
| | - Cristina Costa-Santos
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Luciana Couto
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Altamiro Costa-Pereira
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Alberto Pinto Hespanhol
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Paulo Santos
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Carlos Martins
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
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Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, Everitt H, Kennedy A, Qureshi N, Rogers A, Peacock R, Murray E. Achieving change in primary care--effectiveness of strategies for improving implementation of complex interventions: systematic review of reviews. BMJ Open 2015; 5:e009993. [PMID: 26700290 PMCID: PMC4691771 DOI: 10.1136/bmjopen-2015-009993] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To identify, summarise and synthesise available literature on the effectiveness of implementation strategies for optimising implementation of complex interventions in primary care. DESIGN Systematic review of reviews. DATA SOURCES MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from first publication until December 2013; the bibliographies of relevant articles were screened for additional reports. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Eligible reviews had to (1) examine effectiveness of single or multifaceted implementation strategies, (2) measure health professional practice or process outcomes and (3) include studies from predominantly primary care in developed countries. Two reviewers independently screened titles/abstracts and full-text articles of potentially eligible reviews for inclusion. DATA SYNTHESIS Extracted data were synthesised using a narrative approach. RESULTS 91 reviews were included. The most commonly evaluated strategies were those targeted at the level of individual professionals, rather than those targeting organisations or context. These strategies (eg, audit and feedback, educational meetings, educational outreach, reminders) on their own demonstrated a small to modest improvement (2-9%) in professional practice or behaviour with considerable variability in the observed effects. The effects of multifaceted strategies targeted at professionals were mixed and not necessarily more effective than single strategies alone. There was relatively little review evidence on implementation strategies at the levels of organisation and wider context. Evidence on cost-effectiveness was limited and data on costs of different strategies were scarce and/or of low quality. CONCLUSIONS There is a substantial literature on implementation strategies aimed at changing professional practices or behaviour. It remains unclear which implementation strategies are more likely to be effective than others and under what conditions. Future research should focus on identifying and assessing the effectiveness of strategies targeted at the wider context and organisational levels and examining the costs and cost-effectiveness of implementation strategies. PROSPERO REGISTRATION NUMBER CRD42014009410.
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Affiliation(s)
- Rosa Lau
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
| | - Fiona Stevenson
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
| | - Bie Nio Ong
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, UK
| | - Krysia Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Scotland, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Hazel Everitt
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton,UK
| | - Anne Kennedy
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Nadeem Qureshi
- Division of Primary Care, University of Nottingham, Derby, UK
| | - Anne Rogers
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | | | - Elizabeth Murray
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
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Wong G, Brennan N, Mattick K, Pearson M, Briscoe S, Papoutsi C. Interventions to improve antimicrobial prescribing of doctors in training: the IMPACT (IMProving Antimicrobial presCribing of doctors in Training) realist review. BMJ Open 2015; 5:e009059. [PMID: 26493460 PMCID: PMC4620181 DOI: 10.1136/bmjopen-2015-009059] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Antimicrobial resistance has been described as a global crisis-more prudent prescribing is part of the solution. Behaviour change interventions are needed to improve prescribing practice. Presently, the literature documents that context impacts on prescribing decisions, yet insufficient evidence exists to enable researchers and policymakers to determine how local tailoring should take place. Doctors in training are an important group to study, being numerically the largest group of prescribers in UK hospitals. Unfortunately very few interventions specifically targeted this group. METHODS AND ANALYSIS Our project aims to understand how interventions to change antimicrobial prescribing behaviours of doctors in training produce their effects. We will recruit a project stakeholder group to advise us throughout. We will synthesise the literature using the realist review approach-a form of theory-driven interpretive systematic review approach often used to make sense of complex interventions. Interventions to improve antimicrobial prescribing behaviours are complex-they are context dependent, have long implementation chains, multiple non-linear interactions, emergence and depend on human agency. Our review will iteratively progress through 5 steps: step 1--Locate existing theories; step 2--Search for evidence; step 3--Article selection; step 4--Extracting and organising data; and step 5--Synthesising the evidence and drawing conclusions. Data analysis will use a realist logic of analysis to describe and explain what works, for whom, in what circumstances, in what respects, how and why to improve antimicrobial prescribing behaviour of doctors in training. ETHICS AND DISSEMINATION Ethical approval was not required for our review. Our dissemination strategy will be participatory and involve input from our stakeholder group. Tailored project outputs will be targeted at 3 audiences: (1) doctors in training; (2) clinical supervisors/trainers and medical educators; and (3) policy, decision makers, regulators and royal societies.
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Affiliation(s)
- Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research Assessment, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Karen Mattick
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Mark Pearson
- Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula, University of Exeter Medical School, Exeter, UK
| | - Simon Briscoe
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Skoog J, Midlöv P, Beckman A, Sundquist J, Halling A. Indication for pharmacological treatment is often lacking: a cross-sectional study on the quality of drug therapy among the elderly. BMC Geriatr 2015; 15:117. [PMID: 26449212 PMCID: PMC4599792 DOI: 10.1186/s12877-015-0117-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 10/05/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Although the elderly have a substantially higher drug use than younger patients, even after adjustment for multimorbidity, there is limited knowledge about the elderly's indication for treatment. It is essential for elderly patients to have a well-planned drug therapy. The first step towards a correct and safe drug therapy is to ensure that the patient's drugs have an indication, i.e. correct diagnoses are linked to all of the prescription drugs. The aim of this study was to examine to what extent elderly patients have indication for a number of their prescribed drugs and, furthermore, if there are any differences in indication for treatment depending on gender, age, level of multimorbidity and income. METHOD Data were collected on individuals aged 65 years or older in Östergötland County in Sweden. To estimate the individual level of multimorbidity the Johns Hopkins ACG Case-Mix System was used. A report from the Swedish National Board of Health and Welfare was used to identify prescription drugs, for which it is important to have a correct diagnosis. The proportions of patients having indication for these prescription drugs were calculated. Odds ratios of having indication for treatment depending on gender, age, multimorbidity level and income were calculated. RESULTS On average 45.1 % (range 12.9 % - 75.8 %) of the patients' prescribed drugs had indication. Proton pump inhibitors were associated with the lowest level of indication (12.9 %) and digoxin was associated with the highest level of indication for treatment (75.8 %). Patients aged 80 years or older had the lowest odds ratios of having indication for treatment. CONCLUSION On average, there was indication for treatment in less than half of the prescription drugs studied. The quality was highest in relation to multimorbidity and lowest in relation to age. The result may to some extent be explained by substandard registration of diagnoses. Since lack of quality of prescription drug use is highly associated with inconvenience among the elderly, as well as high costs to society, it is important that future research and allocation of resources focus on the quality of elderly patients' drug therapy.
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Affiliation(s)
- Jessica Skoog
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, SE-205 02, Malmö, Sweden.
| | - Patrik Midlöv
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, SE-205 02, Malmö, Sweden.
| | - Anders Beckman
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, SE-205 02, Malmö, Sweden.
| | - Jan Sundquist
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, SE-205 02, Malmö, Sweden. .,Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA.
| | - Anders Halling
- Department of Clinical Sciences in Malmö, Center for Primary Health Care Research, Lund University, SE-205 02, Malmö, Sweden. .,Research Unit of General Practice, Department of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, DK-5000, Odense C, Denmark.
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10
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Ryan R, Santesso N, Lowe D, Hill S, Grimshaw J, Prictor M, Kaufman C, Cowie G, Taylor M. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014; 2022:CD007768. [PMID: 24777444 PMCID: PMC6491214 DOI: 10.1002/14651858.cd007768.pub3] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use. OBJECTIVES To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence. METHODS SEARCH METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012. SELECTION CRITERIA We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. DATA COLLECTION AND ANALYSIS We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses. MAIN RESULTS We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity. AUTHORS' CONCLUSIONS This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, School of Public Health and Human Biosciences, La Trobe University, Bundoora, VIC, Australia, 3086
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Brennan N, Mattick K. A systematic review of educational interventions to change behaviour of prescribers in hospital settings, with a particular emphasis on new prescribers. Br J Clin Pharmacol 2013; 75:359-72. [PMID: 22831632 PMCID: PMC3579251 DOI: 10.1111/j.1365-2125.2012.04397.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 07/18/2012] [Indexed: 12/26/2022] Open
Abstract
AIMS Prescribing is a complex task and a high risk area of clinical practice. Poor prescribing occurs across staff grades and settings but new prescribers are attributed much of the blame. New prescribers may not be confident or even competent to prescribe and probably have different support and development needs than their more experienced colleagues. Unfortunately, little is known about what interventions are effective in this group. Previous systematic reviews have not distinguished between different grades of staff, have been narrow in scope and are now out of date. Therefore, to inform the design of educational interventions to change prescribing behaviour, particularly that of new prescibers, we conducted a systematic review of existing hospital-based interventions. METHODS Embase, Medline, SIGLE, Cinahl and PsychINFO were searched for relevant studies published 1994-2010. Studies describing interventions to change the behaviour of prescribers in hospital settings were included, with an emphasis on new prescibers. The bibliographies of included papers were also searched for relevant studies. Interventions and effectiveness were classified using existing frameworks and the quality of studies was assessed using a validated instrument. RESULTS Sixty-four studies were included in the review. Only 13% of interventions specifically targeted new prescribers. Most interventions (72%) were deemed effective in changing behaviour but no particular type stood out as most effective. CONCLUSION Very few studies have tailored educational interventions to meet needs of new prescribers, or distinguished between new and experienced prescribers. Educational development and research will be required to improve this important aspect of early clinical practice.
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Affiliation(s)
- Nicola Brennan
- Institute of Clinical Education, Peninsula Medical School, University of Plymouth, Plymouth PL4 8AA, UK.
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Garjón FJ, Azparren A, Vergara I, Azaola B, Loayssa JR. Adoption of new drugs by physicians: a survival analysis. BMC Health Serv Res 2012; 12:56. [PMID: 22401169 PMCID: PMC3353238 DOI: 10.1186/1472-6963-12-56] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 03/08/2012] [Indexed: 11/10/2022] Open
Abstract
Background New drugs often substitute others cheaper and with a risk-benefit balance better established. Our aim was to analyse the diffusion of new drugs during the first months of use, examining the differences between family physicians and specialists. Methods Prescription data were obtained of cefditoren, duloxetine, etoricoxib, ezetimibe, levocetirizine, olmesartan, pregabalin and tiotropium 36 months after their launching. We obtained the monthly number of prescriptions per doctor and the number prescribers of each drug by specialty. After discarding those with less than 10 prescriptions during this period, physicians were defined as adopters if the number of prescriptions was over the 25th percentile for each drug and level (primary or secondary care). The diffusion of each drug was studied by determining the number of adopter family physicians throughout the study period. Among the group of adopters, we compared the month of the first prescription by family physicians to that of other specialists using the Kaplan-Meier method. Results The adoption of the drugs in primary care follows an exponential diffusion curve that reaches a plateau at month 6 to 23. Tiotropium was the most rapidly and widely adopted drug. Cefditoren spread at a slower rate and was the least adopted. The diffusion of etoricoxib was initially slowed down due to administrative requirements for its prescription. The median time of adoption in the case of family physicians was 4-6 months. For each of the drugs, physicians of a specialty other than family physicians adopted it first. Conclusions The number of adopters of a new drug increases quickly in the first months and reaches a plateau. The number of adopter family physicians varies considerably for different drugs. The adoption of new drugs is faster in specialists. The time of adoption should be considered to promote rational prescribing by providing timely information about new drugs and independent medical education.
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Affiliation(s)
- Francisco Javier Garjón
- Servicio Navarro de Salud, Servicio de Prestaciones Farmacéuticas, Plaza de la Paz s/n, E-31002 Pamplona, Spain.
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Fisher JE, Zhang Y, Sketris I, Johnston G, Burge F. The effect of an educational intervention on meperidine use in Nova Scotia, Canada: a time series analysis. Pharmacoepidemiol Drug Saf 2011; 21:177-83. [PMID: 22081471 DOI: 10.1002/pds.2259] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 09/13/2011] [Accepted: 09/13/2011] [Indexed: 11/12/2022]
Abstract
PURPOSE To evaluate the impact of a prescriber focused individual educational and audit-feedback intervention undertaken by the Nova Scotia Prescription Monitoring Program (NSPMP) in March/April 2007 to reduce meperidine use. METHOD The NSPMP records all prescriptions for controlled substances dispensed in community pharmacies in Nova Scotia, Canada. Oral meperidine use from 1 July 2005 to 31 December 2009 was examined using NSPMP data. Monthly totals for the following were obtained: number of individual patients who filled at least one meperidine prescription, number of prescriptions, and number of tablets dispensed. Data were analyzed graphically to observe overall trends. The intervention effect was estimated on the logarithmic scale with autocorrelations over time modeled by an integrated autoregressive moving average model for each outcome measure. RESULTS An overall trend toward decreasing use from July 2005 to December 2009 was apparent for all three outcome measures. The intervention was associated with a statistically significant reduction in meperidine use, after adjusting for the overall long-term trend. Compared with the pre-intervention period, the monthly number of patients declined by 12% (p < 0.001; 95% confidence interval [CI] = 5%-18%), prescriptions by 10% (p < 0.001; 95%CI = 3%-17%), and tablets by 13.5% (p < 0.001, 95%CI = 6%-29%) in the post-intervention period. CONCLUSION Given the risks associated with meperidine, determining that this intervention successfully reduced meperidine use is encouraging. This study highlights the potential for using population data such as the NSPMP to evaluate the effectiveness of population-level interventions to improve medication use, including professional, organizational, financial, and regulatory initiatives.
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Affiliation(s)
- Judith E Fisher
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.
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Ryan R, Santesso N, Hill S, Lowe D, Kaufman C, Grimshaw J. Consumer-oriented interventions for evidence-based prescribing and medicines use: an overview of systematic reviews. Cochrane Database Syst Rev 2011:CD007768. [PMID: 21563160 DOI: 10.1002/14651858.cd007768.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Numerous systematic reviews exist on interventions to improve consumers' medicines use, but this research is distributed across diseases, populations and settings. The scope and focus of reviews on consumers' medicines use also varies widely. Such differences create challenges for decision makers seeking review-level evidence to inform decisions about medicines use. OBJECTIVES To synthesise the evidence from systematic reviews on the effects of interventions which target healthcare consumers to promote evidence-based prescribing for, and medicines use, by consumers. We sought evidence on the effects on health and other outcomes for healthcare consumers, professionals and services. METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching both databases from start date to Issue 3 2008. We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. Standardised forms were used to extract data, and reviews were assessed for methodological quality using the AMSTAR instrument. We used standardised language to summarise results within and across reviews; and a further synthesis step was used to give bottom-line statements about intervention effectiveness. Two review authors selected reviews, extracted and analysed data. We used a taxonomy of interventions to categorise reviews. MAIN RESULTS We included 37 reviews (18 Cochrane, 19 non-Cochrane), of varied methodological quality.Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation, skills acquisition and information provision. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most commonly reported outcome, but others such as clinical (health and wellbeing), service use and knowledge outcomes were also reported. Reviews rarely reported adverse events or harms, and the evidence was sparse for several populations, including children and young people, carers, and people with multimorbidity.Promising interventions to improve adherence and other key medicines use outcomes (eg adverse events, knowledge) included self-monitoring and self-management, simplified dosing and interventions directly involving pharmacists. Other strategies showed promise in relation to adherence but their effects were less consistent. These included reminders; education combined with self-management skills training, counselling or support; financial incentives; and lay health worker interventions.No interventions were effective to improve all medicines use outcomes across all diseases, populations or settings. For some interventions, such as information or education provided alone, the evidence suggests ineffectiveness; for many others there is insufficient evidence to determine effects on medicines use outcomes. AUTHORS' CONCLUSIONS Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform these decisions and also to consider the range of interventions available; while researchers and funders can use this overview to determine where research is needed. However, the limitations of the literature relating to the lack of evidence for important outcomes and specific populations, such as people with multimorbidity, should also be considered.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, Australian Institute for Primary Care & Ageing, La Trobe University, Bundoora, VIC, Australia, 3086
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Haggard M. Poor adherence to antibiotic prescribing guidelines in acute otitis media--obstacles, implications, and possible solutions. Eur J Pediatr 2011; 170:323-32. [PMID: 20862492 PMCID: PMC3068524 DOI: 10.1007/s00431-010-1286-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 08/19/2010] [Indexed: 02/04/2023]
Abstract
Many countries now have guidelines on the clinical management of acute otitis media. In almost all, the public health goal of containing acquired resistance in bacteria through reduced antibiotic prescribing is the main aim and basis for recommendations. Despite some partial short-term successes, clinical activity databases and opinion surveys suggest that such restrictive guidelines are not followed closely, so this aim is not achieved. Radical new solutions are needed to tackle irrationalities in healthcare systems which set the short-term physician-patient relationship against long-term public health. Resolving this opposition will require comprehensive policy appraisal and co-ordinated actions at many levels, not just dissemination of evidence and promotion of guidelines. The inappropriate clinical rationales that underpin non-compliance with guidelines can be questioned by evidence, but also need specific developments promoting alternative solutions, within a framework of whole-system thinking. Promising developments would be (a) physician training modules on age-appropriate analgesia and on detection plus referral of rare complications like mastoiditis, and (b) vaccination against the most common and serious bacterial pathogens.
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Affiliation(s)
- Mark Haggard
- Department of Experimental Psychology, MRC Multi-centre Otitis Media Study Group, University of Cambridge, Cambridge CB2 3EB, UK.
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Thompson A, Sullivan S, Barley M, Moore L, Rogers P, Sipos A, Harrison G. Effectiveness of a cognitive behavioural workbook for changing beliefs about antipsychotic polypharmacy: analysis from a cluster randomized controlled trial. J Eval Clin Pract 2010; 16:520-8. [PMID: 20210823 DOI: 10.1111/j.1365-2753.2009.01153.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Educational workbooks have been used in psychiatry to influence patient but not clinician behaviour. Targeted education interventions to change prescribing practice in other areas of medicine have only looked at changes in prescribing and not attitudes or beliefs related to the prescribing. We aimed to examine whether clinicians' beliefs about a common prescribing issue in psychiatry (antipsychotic polypharmacy prescription) changed alongside behaviour as a result of a complex intervention. METHOD Medical and nursing staff were recruited from 19 general adult psychiatry units in the south-west of the UK as part of a cluster randomized controlled trial. A questionnaire was used to assess beliefs on the prescribing of antipsychotic polypharmacy as a secondary outcome before and after completion of a cognitive behavioural 'self-help' style workbook (one part of a complex intervention). A factor analysis suggested three dimensions of the questionnaire that corresponded to predetermined themes. The data were analysed using a random-effects regression model (adjusting for clustering) controlling for possible confounders. RESULTS There was a significant change in beliefs on both of the factors: antipsychotic polypharmacy (coefficient = -0.89, P < 0.01) and rapid tranquilization (coefficient = -0.68, P = 0.01) specifically targeted by the workbook. There was a modest but statistically significant change in antipsychotic polypharmacy prescribing (odds ratio 0.43, 95% confidence intervals 0.21-0.90). CONCLUSIONS The workbook appeared to change staff beliefs about antipsychotic polypharmacy, but achieving substantial changes in clinician behaviour may require further exploration of other factors important in complex prescribing issues.
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Affiliation(s)
- Andrew Thompson
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK
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Rogers S, Wilson D, Wan S, Griffin M, Rai G, Farrell J. Medication-related admissions in older people: a cross-sectional, observational study. Drugs Aging 2010; 26:951-61. [PMID: 19848440 DOI: 10.2165/11316750-000000000-00000] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Medication-related admissions are an important cause of hospital admissions in older people. The scope for prevention is less clear. OBJECTIVES To characterize medication-related hospital admissions in older people and assess their preventability. METHODS This was a cross-sectional, observational study conducted over 3 months. A pharmacist based in the medical admissions ward of a north London hospital screened all patients aged > or =65 years. A specialist physician assembled additional information, which was presented to a multi-professional panel to confirm attribution and preventability. A total of 409 patients were screened, of whom 14% (95% CI 10.6, 17.4) had medication-related problems, 6.4% (95% CI 4.0, 8.8) were admitted because of medication-related problems and 3.9% (95% CI 2.0, 5.8) were considered to have preventable medication-related problems. Medicines to prevent or treat cardiovascular disease were implicated in 69% (18/26) of the medication-related admissions and 69% (11/16) of preventable medication-related admissions. Amongst hospitalized patients, admission attributed to adverse drug reaction was more likely as the number of medications being taken increased, and admission attributed to undertreatment was more likely as the number of pre-existing conditions increased. CONCLUSION Medication-related admissions are common in older people and over half are preventable. Morbidity associated with medicines used for cardiovascular disease is important. There is a difficult balance to be struck between avoiding iatrogenic illness in older people and ensuring they benefit from medications for pre-existing conditions. Opportunities exist for improving the delivery of care to reduce adverse outcomes.
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Affiliation(s)
- Stephen Rogers
- Department of Health Sciences, University of Leicester, Leicester, UK.
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Wensing M, Broge B, Riens B, Kaufmann-Kolle P, Akkermans R, Grol R, Szecsenyi J. Quality circles to improve prescribing of primary care physicians. Three comparative studies. Pharmacoepidemiol Drug Saf 2009; 18:763-9. [DOI: 10.1002/pds.1778] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bywood PT, Lunnay B, Roche AM. Strategies for facilitating change in alcohol and other drugs (AOD) professional practice: a systematic review of the effectiveness of reminders and feedback. Drug Alcohol Rev 2008; 27:548-58. [PMID: 18696301 DOI: 10.1080/09595230802245535] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In all areas of health research, including the alcohol and other drugs (AOD) field, funds are committed to developing and evaluating research and resources, yet little is invested into helping potential resource users understand, adopt and implement innovations. This study evaluated the effectiveness of two professional practice change interventions (reminders and feedback) that are designed to bridge the 'research-practice gap' by increasing knowledge and changing behaviour of health-care professionals and specialist AOD workers. We conducted a systematic review of general health, AOD and mental health literature (1966 to March 2005). Fourteen existing systematic reviews and 15 primary studies were assessed. Because few studies evaluated the effectiveness of reminders and feedback in the AOD context, evidence is drawn largely from the general health-care literature. Use of reminders and feedback is supported for a range of health behaviours. AOD-specific clinical behaviours that are most likely to be improved with the use of reminders or feedback include pharmacotherapy prescribing, AOD education, screening and counselling and monitoring/management of AOD treatment and/or related problems (e.g. depression). Reminders and feedback are effective strategies to facilitate professional practice change and have potential in the AOD field. However, further well-designed empirical studies are needed to assess fully the effectiveness of these professional practice change strategies in AOD-specific contexts.
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Affiliation(s)
- Petra T Bywood
- National Centre for Education and Training on Addiction, Flinders University, South Australia, Australia.
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Combined intervention programme reduces inappropriate prescribing in elderly patients exposed to polypharmacy in primary care. Eur J Clin Pharmacol 2008; 65:199-207. [DOI: 10.1007/s00228-008-0558-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Accepted: 08/22/2008] [Indexed: 11/26/2022]
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Thompson A, Sullivan SA, Barley M, Strange SO, Moore L, Rogers P, Sipos A, Harrison G. The DEBIT trial: an intervention to reduce antipsychotic polypharmacy prescribing in adult psychiatry wards - a cluster randomized controlled trial. Psychol Med 2008; 38:705-715. [PMID: 17825122 DOI: 10.1017/s003329170700147x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Clinical guidelines advise against prescribing more than one antipsychotic with limited exceptions. Despite this, surveys continue to report high antipsychotic polypharmacy rates. The aim of the study was to investigate the effectiveness of a multi-faceted intervention in reducing prescribing of antipsychotic polypharmacy on general adult psychiatry wards, compared with guidelines alone. METHOD A pragmatic cluster randomized controlled trial recruited 19 adult psychiatric units (clusters) from the South West of England. Participants were all ward doctors and nurses. The multi-faceted intervention comprised: an educational/CBT workbook; an educational visit to consultants; and a reminder system on medication charts. RESULTS The odds of being prescribed antipsychotic polypharmacy in those patients prescribed antipsychotic medication was significantly lower in the intervention than control group when adjusted for confounders (OR 0.43, 95% CI 0.21-0.90, p=0.028). There was considerable between-unit variation in polypharmacy rates and in the change in rates between baseline and follow-up (5 months after baseline). CONCLUSION The intervention reduced levels of polypharmacy prescribing compared to guidelines alone although the effect size was relatively modest. Further work is needed to elicit the factors that were active in changing prescribing behaviour.
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Affiliation(s)
- A Thompson
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK
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Abstract
RATIONALE, AIM AND OBJECTIVE Factors influencing doctors in prescribing of drugs have mostly been studied in primary care. Studies performed in hospital care have primarily focused on new drugs, not prescribing in general. An in-depth understanding of the prescribing process in the more specialized secondary care is not only important for secondary care itself, but because it also influences prescribing in primary care. The aim of this study is therefore to identify factors that secondary care doctors believe influence them in prescribing drugs, using a qualitative approach. METHOD Semi-structured interviews were conducted with 15 hospital doctors in different medical specialities and the interviews were analysed from an interpretivist perspective. The information gathered was on how prescribing decisions were made in general and how the doctors chose a specific drug therapy, including information sources used. RESULTS According to our interviews, the hospital doctors took patient-specific factors and cost into consideration when prescribing, informed by different written information sources and commercial verbal information. Personal practice, colleagues and therapeutic tradition at the hospital or clinic, were influential in the prescribing of drugs. The themes identified should not to be seen as individual influences; many of them probably act in combination. CONCLUSIONS If changes in prescribing behaviour are desired, factors warranting more attention include understanding how to influence therapeutic traditions and the doctor's personal habits for prescribing. The importance of clinical experience and information exchange with colleagues should not be underestimated in providing information about drugs to hospital doctors.
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Doran DM, Sidani S. Outcomes-focused knowledge translation: a framework for knowledge translation and patient outcomes improvement. Worldviews Evid Based Nurs 2007; 4:3-13. [PMID: 17355405 DOI: 10.1111/j.1741-6787.2007.00073.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Regularly accessing information that is current and reliable continues to be a challenge for front-line staff nurses. Reconceptualizing how nurses access information and designing appropriate decision support systems to facilitate timely access to information may be important for increasing research utilization. DESCRIPTION OF STRATEGY An outcomes-focused knowledge translation framework was developed to guide the continuous improvement of patient care through the uptake of research evidence and feedback data about patient outcomes. The framework operationalizes the three elements of the PARIHS framework at the point of care. Outcomes-focused knowledge translation involves four components: (a) patient outcomes measurement and real-time feedback about outcomes achievement; (b) best-practice guidelines, embedded in decision support tools that deliver key messages in response to patient assessment data; (c) clarification of patients' preferences for care; and (d) facilitation by advanced practice nurses and practice leaders. In this paper the framework is described and evidence is provided to support theorized relationships among the concepts in the framework. IMPLICATIONS The framework guided the design of a knowledge translation intervention aimed at continuous improvement of patient care and evidence-based practice, which are fostered through real-time feedback data about patient outcomes, electronic access to evidence-based resources at the point of care, and facilitation by advanced practice nurses. The propositions in the framework need to be empirically tested through future research.
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Affiliation(s)
- Diane M Doran
- Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
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Seager JM, Howell-Jones RS, Dunstan FD, Lewis MAO, Richmond S, Thomas DW. A randomised controlled trial of clinical outreach education to rationalise antibiotic prescribing for acute dental pain in the primary care setting. Br Dent J 2007; 201:217-22; discussion 216. [PMID: 16902573 DOI: 10.1038/sj.bdj.4813879] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2005] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the effect of educational outreach visits on antibiotic prescribing for acute dental pain in primary care. STUDY DESIGN RCT. SETTING General dental practices in four health authority areas in Wales. SUBJECTS AND METHODS General dental practitioners were recruited to the study and randomly allocated to one of the three study groups (control group, guideline group or intervention group). Following the intervention, practitioners completed a standardised questionnaire for each patient that presented with acute dental pain. INTERVENTIONS The control group received no intervention. The guideline group received educational material by post. The intervention group received educational material by post and an academic detailing visit by a trained pharmacist. The educational material included evidence-based guidelines on prescribing for acute dental pain and patient information leaflets. MAIN OUTCOME MEASURES The number of antibiotic prescriptions issued to patients presenting with dental pain and the number of 'inappropriate' antibiotic prescriptions. Antibiotics were considered to be inappropriate if the patient did not have symptoms indicative of spreading infection. RESULTS A total of 1,497 completed questionnaires were received from 23, 20 and 27 general dental practitioners in the control, guideline and intervention group respectively. Patients in the intervention group received significantly fewer antibiotic prescriptions than patients in the control group (OR (95% CI) 0.63 (0.41, 0.95)) and significantly fewer inappropriate antibiotic prescriptions (OR (95% CI) 0.33 (0.21, 0.54)). However, antibiotic and inappropriate antibiotic prescribing were not significantly different in the guideline group compared to the control group (OR (95% CI) 0.83 (0.55, 1.21) and OR (95% CI) 0.82 (0.53, 1.29) respectively). CONCLUSIONS Strategies based upon educational outreach visits may be successfully employed to rationalise antibiotic prescribing by dental practitioners.
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Affiliation(s)
- J M Seager
- Department of Oral Surgery, Medicine and Pathology, Wales College of Medicine, Cardiff University, Cardiff, CF14 4XY
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Influence of review system using computerized program for Acute Respiratory Infection upon practicing doctors' behaviour. HEALTH POLICY AND MANAGEMENT 2006. [DOI: 10.4332/kjhpa.2006.16.2.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Verstappen W, ter Riet G, van der Weijden T, Hermsen J, Grol R. Variation in requests for imaging investigations by general practitioners: a multilevel analysis. J Health Serv Res Policy 2005; 10:25-30. [PMID: 15667701 DOI: 10.1177/135581960501000107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To describe the variation in the numbers of imaging investigations requested by general practitioners (GPs) and to find likely explanations for this variation. METHODS Cross-sectional survey of the use of eight imaging investigations by 229 GPs collaborating in 40 local GP groups from five regions in the Netherlands during 1997. A multivariable, multilevel regression analysis was used to link these data with survey data on professional characteristics such as knowledge about and attitude towards test ordering, and with data on contextual factors such as practice type or experience with feedback on test-ordering data. RESULTS Data for 221 GPs (97%) were available. After adjustment for practice size and working time, the median number of imaging investigations ordered per GP was 148 (interquartile range 71 to 300), with large differences (up to twofold) between the regions (P<0.001). Overall, chest X-rays were the largest single category (median = 48 interquartile range 17 to 100). GPs working in a group practice requested, on average, 34% fewer investigations than their colleagues working in single-person practices (95% confidence interval 17 to 48%). CONCLUSIONS Only practice type was found to be associated with the number of imaging investigations requested, adjusted for practice size and working time factor. No further explanations were found for the inter-regional differences. Future studies on the ordering of imaging investigations by GPs should attempt to delineate contextual from regional factors.
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Affiliation(s)
- Wim Verstappen
- Department of General Practice, Maastricht University, 6500 MD Maastricht, The Netherlands
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Wensing M, Broge B, Kaufmann-Kolle P, Andres E, Szecsenyi J. Quality circles to improve prescribing patterns in primary medical care: what is their actual impact? J Eval Clin Pract 2004; 10:457-66. [PMID: 15304146 DOI: 10.1111/j.1365-2753.2004.00517.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Quality circles comprise small group sessions of doctors and written feedback on their individual practice patterns. Although 50% of German primary care doctors participate in quality circles, their effectiveness has hardly been evaluated in Germany. This study determined the impact of a large-scale programme of quality circles on quality and costs of prescribing. METHOD A controlled before-after study was performed, in which primary care doctors were allocated to a quality circles group or a control group. Subjects were 100,000 patients in 1996 and in 1998, who had visited one of 177 doctors in the 3 month registration periods in one region in Germany. The intervention comprised a quality circles programme, comprising 11 sessions and repeated feedback on prescribing. Main outcome measures were proportion of patients who received a prescription, mean prescription costs per patient and proportion of generic prescriptions. RESULTS The absolute numbers of prescriptions decreased in both groups, but the mean prescription costs per patient increased. The quality circles reduced the proportion of patients who received a prescription (OR = 0.86) and the mean prescription costs per patient (B = -3.99 euro), while it increased the proportion of generic drugs (OR = 1.10). The intervention had intended effects on four of the 15 secondary indicators. CONCLUSIONS Large-scale application of quality circles had intended effects on prescribing decisions in primary care in Germany. The effects found in this study may reflect better what improvements can be achieved than randomized trials of similar interventions.
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Affiliation(s)
- Michel Wensing
- Department of General Practice, University of Heidelberg, Germany.
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Coenen S, Van Royen P, Michiels B, Denekens J. Optimizing antibiotic prescribing for acute cough in general practice: a cluster-randomized controlled trial. J Antimicrob Chemother 2004; 54:661-72. [PMID: 15282232 DOI: 10.1093/jac/dkh374] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To assess the effect of a tailored professional intervention, including academic detailing, on antibiotic prescribing for acute cough. METHODS In a cluster-randomized controlled before and after study 85 Flemish GPs included adult patients with acute cough consulting in the periods February-April 2000 and 2001. The intervention consisted of a clinical practice guideline for acute cough, an educational outreach visit and a postal reminder to support its implementation in January 2001. Antibiotic prescribing rates and patients' symptom resolution were the main outcome measures. RESULTS Thirty-six of 42 GPs received the intervention and 35 of 43 GPs served as controls; 1503 patients were eligible for analysis. Only in the intervention group were patients less likely to receive antibiotics after the intervention [OR(adj) (95% CI)=0.56 (0.36-0.87)]. Prescribed antibiotics were also more in line with the guideline in the intervention group [1.90 (0.96-3.75)] and less expensive from the perspective of the National Sickness and Invalidity Insurance Institute [MD(adj) (95% CI)= Euro -6.89 [-11.77-(-2.02)]]. No significant differences were found between the groups for the time to symptom resolution. CONCLUSIONS An (inter)actively delivered tailored intervention implementing a guideline for acute cough is successful in optimizing antibiotic prescribing without affecting patients' symptom resolution. Further research efforts should be devoted to cost-effectiveness studies of such interventions.
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Affiliation(s)
- Samuel Coenen
- Centre for General Practice, University of Antwerp, BE 2610 Antwerp, Belgium.
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Krol N, Wensing M, Haaijer-Ruskamp F, Muris JWM, Numans ME, Schattenberg G, Balen J, Grol R. Patient-directed strategy to reduce prescribing for patients with dyspepsia in general practice: a randomized trial. Aliment Pharmacol Ther 2004; 19:917-22. [PMID: 15080853 DOI: 10.1111/j.1365-2036.2004.01928.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The percentage of patients receiving long-term treatment with acid suppressive drugs, mainly proton pump inhibitors, is higher than the prevalence of diseases that are commonly accepted as the proper indication for long-term proton pump inhibitor use. AIM To evaluate whether a patient-directed intervention (direct mail) reduced the prescription of antisecretory medication for dyspepsia in general practice. METHODS A cluster-randomized trial was performed. One hundred and thirteen chronic users of proton pump inhibitors were recruited by 20 general practitioners. An unsolicited information leaflet was sent to patients that suggested stopping or reducing the use of proton pump inhibitors. The number of patients who stopped or reduced proton pump inhibitor use was measured at 12 and 20 weeks after the intervention. Secondary outcome measures were dyspepsia symptom severity and perceived quality of life measured at 12 weeks after the intervention. RESULTS Fourteen of the 59 (24%) intervention group patients stopped or reduced their use of proton pump inhibitors, compared with three of the 45 (7%) control group patients (relative risk ratio 3.56; CI 95%: 1.088-11.642). Dyspepsia symptom severity and quality of life did not change. CONCLUSIONS A simple patient-directed intervention reduced the volume of long-term prescriptions of proton pump inhibitors in patients with dyspepsia.
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Affiliation(s)
- N Krol
- Centre for Quality of Care Research, University Medical Centre St Radboud, Nijmegen, The Netherlands.
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Atthobari J, Monster TBM, de Jong PE, de Jong-van den Berg LTW. The effect of hypertension and hypercholesterolemia screening with subsequent intervention letter on the use of blood pressure and lipid lowering drugs. Br J Clin Pharmacol 2004; 57:328-36. [PMID: 14998429 PMCID: PMC1884446 DOI: 10.1046/j.1365-2125.2003.02011.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2003] [Accepted: 09/08/2003] [Indexed: 12/17/2022] Open
Abstract
AIM To evaluate the effect of a letter intervention that was send to both the participants of a population screening and their general practitioners. We also tested what predicting variables influenced the GP to actually prescribe blood pressure lowering drugs (BPLD) or lipid lowering drugs (LLD). METHOD The study design was cross sectional, in the PREVEND outpatient clinic in Groningen University Hospital, the Netherlands. We used the clinical data of the 8592 subjects that participated in the first screening of the PREVEND study. Data on drug use was collected from community pharmacies. Drug use was measured the year before and after the screening with the subsequent intervention letter. As control population without intervention, we used the data from the InterAction DataBase (IADB) standardized for the population characteristics of the intervention group. The letter intervention was sent to participants who had shown after screening to have either an elevated blood pressure or plasma cholesterol, and the letter contained the advice to use a BPLD or LLD. Main outcome measures were proportion of patients prescribed BPLD and/or LLD in the year before and after the intervention, and variables that influence the GP to prescribe BPLD and LLD. RESULTS Data from the community pharmacy were available from 7567 (88%) subjects. 397 participants (5.2%) received a letter with advice to start a BPLD, and 326 participants (4.3%) received a letter with advice to start a LLD. The prevalence of patients who were using BPLD and LLD before the intervention was not significantly different between the intervention and control group, 16.6 (CI 95% 15.8 -17.5) vs 16.0 and 4.8 (4.4-5.3) vs 4.6, respectively. After the letter intervention, the prevalence of BPLD use was higher in the intervention group compared with the control group (19.4 [18, 5-20, 3]vs 17.0%), as was the prevalence of LLD use (7.1[6.5-7.7) vs 5.4%). The same held true for the incidence of BPLD (3.4[3.0-3.8]vs 2.5%) and LLD use (2.1 [1, 6-2, 4]vs 1.0%), respectively, in the year after the intervention. Univariate and multivariate analysis showed that a higher blood pressure and cholesterol level, but not the presence of other cardiovascular risk factors, were associated to with a greater percentage use of a BPLD and a LLD. CONCLUSION A population survey followed by a letter of intervention to both the patient and GP are effective to improve the use of blood pressure and lipid lowering drugs as a primary prevention in patients with hypertension and hyperlipidemia. Our therapeutic advice however, was followed only in about one of the three subjects with hypertension and one of the four subjects with hyperlipidemia. The levels of blood pressure and plasma total cholesterol are important variables influencing the GP to prescribe a BPLD and/or LLD.
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Affiliation(s)
- Jarir Atthobari
- Department of Social Pharmacy, Groningen University Institute for Drug Exploration (GUIDE), Groningen, the Netherlands
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Abstract
Major difficulties arise when introducing evidence and clinical guidelines into routine daily practice. Data show that many patients do not receive appropriate care, or receive unnecessary or harmful care. Many approaches claim to offer solutions to this problem; which ones are as yet the most effective and efficient is unclear. We aim to provide an overview of present knowledge about initiatives to changing medical practice. Substantial evidence suggests that to change behaviour is possible, but this change generally requires comprehensive approaches at different levels (doctor, team practice, hospital, wider environment), tailored to specific settings and target groups. Plans for change should be based on characteristics of the evidence or guideline itself and barriers and facilitators to change. In general, evidence shows that none of the approaches for transferring evidence to practice is superior to all changes in all situations.
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Affiliation(s)
- Richard Grol
- Centre for Quality of Care Research (WOK), Universities of Nijmegen and Maastricht, PO Box 9101, WOK 229 6500 HB, Nijmegen, Netherlands.
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Wolzt M, Ohrenberger G, Reichardt B. [Cost reduction with project based prescription of generic ACE inhibitors]. Wien Klin Wochenschr 2003; 115:23-8. [PMID: 12658907 DOI: 10.1007/bf03040268] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Increasing drug costs are an economic burden for the health insurance system. AIM The regional drug prescription pattern for ACE inhibitors in the Austrian county Burgenland was compared for patients discharged from hospital and those in primary care. Furthermore, the potential cost reduction by voluntary prescription of cheaper generic drugs was estimated in the project "Bessere Therapie zum besseren Preis". METHODS Following consensual analysis of the regional cross-sectional study, a cheaper generic of the most cost-intensive class of ACE-inhibitor drugs should be prescribed at internal medicine wards and in primary care. The number of prescriptions for patients from the largest health insurance company BGKK was studied and the costs were calculated. RESULTS Of the 1347 patients discharged during October 1999 from internal medicine departments of four different hospitals 879 patients received a total of 1440 cardiovascular drugs. The regional prescription pattern at hospitals matched that of physicians in primary care. Between the second quarter of 2000 and 2001, the prescription of ACE inhibitor drugs increased by project advertising from 23,627 packages by 13.1%, and drug costs in this group were reduced by [symbol: see text] 29,778 in this quarter (7.3% of costs). The number of Enalapril prescriptions increased by 33.4% with a percentual portion of generic Enalapril of 57.3%, and in the rest of Austria by 16.9% with 45.0% generics. CONCLUSION Consensus based projects are appropriate pharmacoeconomic interventions to change prescription patterns, increase the use of drugs and reduce the increasing cost requirements.
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Affiliation(s)
- Michael Wolzt
- Universitätsklinik für Klinische Pharmakologie, Allgemeines Krankenhaus Wien
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Affiliation(s)
- E John Gallagher
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467-2490, USA.
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Denig P, Wahlström R, de Saintonge MC, Haaijer-Ruskamp F. The value of clinical judgement analysis for improving the quality of doctors' prescribing decisions. MEDICAL EDUCATION 2002; 36:770-780. [PMID: 12191061 DOI: 10.1046/j.1365-2923.2002.01202.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Many initiatives are taken to improve prescribing decisions. Educational strategies for doctors have been effective in at least 50% of cases. Some reflection on one's own performance seems to be a common feature of the most effective strategies. So far, such reflections have mainly focused on the observed outcomes of the doctors' decisions, i.e. on what doctors do in practice. Studies in other fields have shown that another form of feedback based on the analysis of judgements may be useful as well. OBJECTIVES The objectives of the study were to discuss the principles underlying clinical judgement analysis, give examples of its use in the medical context, and discuss its potential for improving prescribing decisions. RESULTS Clinical judgement analysis can look behind the outcome of a decision to the underlying decision process. Carefully constructed or selected case material is required for this analysis. Combining feedback on outcomes with feedback based on clinical judgement analysis offers doctors insight both in what they do, and why or when they do it. It may reveal determinants of decision making which are not available through unaided introspection. Interventions using this combination of feedback for improving doctors' prescribing behaviour have been (partly) successful in 4 cases and unsuccessful in one case. CONCLUSIONS Clinical judgement analysis gives doctors a structured reflection on the decision-making policy, and can help them to improve their future decisions. It may be especially useful for groups of doctors who try to work towards a consensus policy. The approach is not very helpful when simple decision rules are appropriate.
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Affiliation(s)
- Petra Denig
- Department of Clinical Pharmacology, Medical Faculty, University of Groningen, The Netherlands.
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Hands D, Stephens M, Brown D. A systematic review of the clinical and economic impact of drug information services on patient outcome. PHARMACY WORLD & SCIENCE : PWS 2002; 24:132-8. [PMID: 12227245 DOI: 10.1023/a:1019573118419] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIM To establish what is known about the clinical and economic impact of drug information (DI) services on patient outcome. METHOD A systematic review and critical appraisal of world literature on work conducted by Drug Information Centres and UK Schools of Pharmacy. RESULTS Six relevant published articles were recovered--three from the UK; two from the US and one from Canada; just one was prospective in design. Four were single-centre and two were multi-centre studies. Four studies relied heavily on questionnaire surveys of the enquirer to establish an effect; only one monitored patient outcome independently and used peer review to assess impact. CONCLUSION The clinical and economic impact of drug information consultation and provision on patient care has not been investigated rigorously. A research methodology for such an investigation is suggested.
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Affiliation(s)
- David Hands
- South and West Drug Information Centre, Southampton, UK.
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