One-to-one versus group sessions to improve prescription in primary care: a pragmatic randomized controlled trial

Bridging the gap in knowledge and use of antibiotics among pediatric caregivers: comparing two educational interventions

BACKGROUND

The inappropriate use of antibiotics in pediatrics contributes to antimicrobial resistance. Behavior change intervention involving education to improve the use of antibiotics is a strategy included in antimicrobial stewardship. This study aims to evaluate and compare the impact of two educational interventions on knowledge of antibiotic and its use among pediatric home caregivers.

METHODS

This was a cross-sectional study conducted in the pediatric out-patient department of a healthcare facility. A structured questionnaire was administered to sixty pediatric caregivers. Pediatric caregivers were grouped in two of 30. Caregivers in a group filled the questionnaire, and refilled the same questionnaire after a one-on-one education. The second arm refilled the questionnaire after a group education. Ethical clearance was obtained and participants gave consent. Data analysis was done using SPSS version 22 and Graph pad Instat, p values < 0.05 were considered significant.

RESULTS

Fouty-nine (81.7%) participants believe that antibiotics can treat malaria infection [8(13.3%) after education)], 43(71.7%) of respondents agreed that antibiotics can be used to treat all kinds of diarrhea, while 45(65%) of them thought that antibiotics in powder form can be reconstituted with hot or warm water before use [7(11.7%) after education]. Mean score among the sixty participants before and after education on knowledge and use of antibiotics were 36.1 ± 6.467 versus 46.7 ± 4.027 (p≤0.0001) and 29.82 ± 4.949 versus 36.92 ± 3.997 (p≤ 0.0001), respectively. Mean score on knowledge and use of antibiotics for one-on-one versus group education were 46.7 ± 4.027 versus 43.3 ± 6.249 (p = 0.022) and 37.9 ± 3.044 versus 35.93 ± 4.608 (p = 0.039), respectively.

CONCLUSIONS

Many pediatric caregivers had poor knowledge on antibiotics and use which improved significantly after education. One-on-one education has more impact than group education. Pharmacists and other healthcare professionals can use counseling opportunity to inform caregivers on appropriate knowledge and use of antibiotics consistently to change behavior.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

Academic Detailing From Medical Students: Part of a Plan to Emphasize Feedback in One Clerkship

Introduction

Medical schools have an enduring need to provide ongoing faculty development and to foster educational alliances between teachers and learners, so that feedback provided to learners is both frequent and of high quality. We hypothesized that medical students trained as academic detailers with a mission to increase the emphasis on feedback could serve in this role during our clerkship, while still being evaluated as students in our clerkship rotation.

Methods

The family medicine clerkship at Mayo Clinic School of Medicine launched a revised curriculum in 2016 in which students were taught how they might build an educational alliance with preceptors, were taught characteristics of high-quality feedback, and practiced requesting more useful feedback when initial quality was poor. After utilizing a clerkship-specific curriculum with small group sessions on receiving feedback, and training students and preceptors on the SNAPPs model, students were then directed to request feedback from their preceptors and model successful feedback conversations for preceptors. The study evaluated the medical students' summative evaluations to compare the rate from the preintervention year (2015-2016) and the intervention year (2016-2017) at which preceptors added comments on students' use of feedback.

Results

Preceptors' written comments about students seeking feedback increased at about a four-fold rate (74.4% vs 18.8%, P<.001) after implementing a suite of changes to our clerkship curriculum.

Conclusions

Using medical students to change preceptor behaviors was an important part of our suite of interventions. This intervention directed preceptor attention toward our instructional goal of increased medical student feedback.

Pharmaceutical companies information and antibiotic prescription patterns: A follow-up study in Spanish primary care

Objectives

To assess the impact of sources of drug information on antibiotic prescribing patterns (quantity and quality) among primary care physicians.

Methods

We conducted a cohort study on primary care physicians who were actively engaged in medical practice in 2010 in a region in north-west Spain (Galicia), fulfilling inclusion criteria (n = 2100). As the independent variable, we took the perceived utility of 6 sources of information on antibiotics, as measured by the validated KAAR-11 questionnaire. As dependent variables, we used: (1) a quality indicator (appropriate quality, defined as any case where 6 of the 12 indicators proposed by the European Surveillance of Antimicrobial Consumption Network [ESAC-Net] were better than the mean values for Spain); and, (2) a quantity indicator (high prescribing), defined as any case where defined daily doses (DDD) per 1 000 inhabitants per day of antibacterials for systemic use were higher than the mean values for Spain. The adjusted odds ratio for a change in the interquartile range (IqOR) for each sources of information on antibiotics was calculated using Generalized Linear Mixed Models.

Results

The questionnaire response rate was 68%. Greater perceived utility of pharmaceutical sales representatives increases the risk of having high prescribing (1/IqOR = 2.50 [95%CI: 1.63–3.66]) and reduces the probability of having appropriate quality (1/IqOR = 2.28 [95%CI: 1.77–3.01]). Greater perceived utility of clinical guidelines increases the probability of having appropriate quality (1/IqOR = 1.25 [95%CI: 1.02–1.54]) and reduces the probability of high prescribing (1/IqOR = 1.25 [95%CI: 1.02–1.54]).

Conclusions

Sources of information on antibiotics are an important determinant of the quantity and quality of antibiotic prescribing in primary care. Commercial sources of information influence prescribing negatively, and clinical guidelines are associated with better indicators.

Academic Detailing to Improve Opioid Safety: Implementation Lessons from a Qualitative Evaluation

Objective

Academic detailing (AD) is a promising intervention to address the growing morbidity and mortality associated with opioids. While AD has been shown to be effective in improving provider prescribing practices across a range of conditions, it is unclear how best to implement AD. The present study was designed to identify key lessons for implementation based on a model AD program in the Veterans Health Administration (VA).

Design

Qualitative process evaluation using semistructured interviews.

Setting

Seven VA health care systems in the Sierra Pacific region.

Subjects

Current and former academic detailers (N = 10) and VA providers with varying exposure to AD (high, low, or no; N = 20).

Methods

Semistructured interviews were audio-recorded and transcribed. We used a team-based, mixed inductive and deductive approach guided by the Consolidated Framework for Implementation Research.

Results

Key lessons identified by academic detailers and providers coalesced around key themes: 1) one-on-one sessions customized to the provider's patient population are most useful; 2) leadership plays a critical role in supporting providers' participation in AD programs; 3) tracking academic detailer and provider performance is important for improving performance for both groups; 4) academic detailers play a key role in motivating provider behavior change and thus training in Motivational Interviewing is highly valuable; and 5) academic detailers noted that networking is important for sharing implementation strategies and resources.

Conclusions

Identifying and incorporating these key lessons into the implementation of complex interventions like AD are critical to facilitating uptake of evidence-based interventions addressing the opioid epidemic.

A comparison of the efficacy of three intervention trial types: postal, group, and one-to-one facilitation, prior management and the impact of message framing and repeat messages on the flock prevalence of lameness in sheep

The aim of this study was to evaluate the effectiveness of three knowledge-transfer intervention trial types (postal, group, one-to-one) to promote best practice to treat sheep with footrot. Further aims were to investigate whether farmer behaviour (i.e. management of lameness) before the trial was associated with uptake of best practice and whether the benefits of best practice framed positively or negatively influenced change in behaviour. The intervention was a message developed from evidence and expert opinion. It was entitled "Six steps to sound sheep" and promoted (1) catch sheep within three days of becoming lame, (2) inspect feet without foot trimming, (3) correctly diagnose the cause, (4) treat sheep lame with footrot or interdigital dermatitis with antibiotic injection and spray without foot trimming, (5) record the identity of treated sheep, (6) cull repeatedly lame sheep. In 2013, 4000 randomly-selected English sheep farmers were sent a questionnaire, those who responded were recruited to the postal (1081 farmers) or one-to-one intervention (32 farmers) trials. A random sample of 400 farmers were invited to join the group trial; 78 farmers participated. A follow-up questionnaire was sent to all participants in summer 2014. There were 72%, 65% and 91% useable responses for the postal, group and one-to-one trials respectively. In both 2013 and 2014, the prevalence of lameness was lower in flocks managed by LC1 farmers than LC2 and LC3 farmers. Between 2013 and 2014, the reduction in geometric mean (95% CI) period prevalence of lameness, proportional between flock reduction in lameness and within flock reduction in lameness was greatest in the one-to-one (7.6% (7.1-8.2%) to 4.3% (3.6-5.0%), 35%, 72%) followed by the group (4.5% (3.9-5.0%) to 3.1% (2.4-3.7%), 27%, 55%) and then the postal trial (from 3.5% (3.3-3.7%) to 3.2% (3.1-3.4%), 21%, 43%). There was a marginally greater reduction in lameness in farmers using most of Six steps but slow to treat lame sheep pre-trial than those not using Six steps at all. There was no significant effect of message framing. The greatest behavioural change was a reduction in therapeutic and routine foot trimming and the greatest attitude change was an increase in negative attitudes towards foot trimming. We conclude that all three intervention trial approaches were effective to promote best practice to treat sheep with footrot with one-to-one facilitation more effective than group and postal intervention trials. Results suggest that farmers' behaviour change was greater among those practising aspects of the intervention message before the trial began than those not practising any aspect.

Polish Physicians’ Attitudes Towards Antibiotic Prescription and Antimicrobial Resistance

Antimicrobial resistance has been one of the biggest global current issues in medicine and public health. Overuse and imprudent use of antimicrobial agents are recognized as one of the leading causes of antibiotic resistance. The aim of this study was to analyze the attitudes of Polish physicians practicing at the community level towards antibiotics and antimicrobial resistance. The majority of physicians taking part in the survey believed that Polish people overuse antibiotics (98%). Most physicians (91%) considered that antimicrobial resistance is a major problem at present. The majority of physicians indicated the reasons for prescribing the antibiotic are related to health factors, such as optimal recovery (best effectiveness, least side effects) (80%), latest therapeutic guidelines (70%) and microbiological/epidemiological factors (63%). Knowledge of the National Recommendations for the management of Community-Acquired Respiratory Tract Infections 2010 (NR-CA-RTI) developed within National Programme for Protection of Antibiotics was declared by 84% of respondents. Among those who are aware of the NR-CA-RTI, the majority follow them in their daily practice (91%). Among physicians, 62% are not familiar with the Centor/McIsaac scores used to differentiate bacterial and viral infections in patients presenting with a sore throat. Among physicians familiar with the scores, 90% use them in their daily practice. Rapid microbiological detection methods for Group A beta-hemolytic streptococcal pharyngitis are used only by 20% of respondents. Almost all of physicians declared readiness to use these tests. Main sources of information on antibiotics prescribing originate from Polish medical journals, scientific conferences organized by medical societies, pharmaceutical companies.

Education-only versus a multifaceted intervention for improving assessment of rehabilitation needs after stroke; a cluster randomised trial

Background

In 2011, more than half of the patients with stroke in Australian hospitals were not assessed for the need for rehabilitation. Further, there were no recommended criteria to guide rehabilitation assessment decisions. Subsequently, a decision-making tool called the Assessment for Rehabilitation Tool (ART) was developed. The ART was designed to assist Australian hospital clinicians to identify the rehabilitation needs of patients with stroke using evidence-based criteria. The ART was released and made freely available for use in 2012. This study evaluated the effectiveness of an education-only intervention (1 onsite education session and distribution of the ART) and a multifaceted intervention (2 or more onsite education sessions, distribution of the ART, audit and feedback, barrier identification, site-specific strategy development, promotion of interdisciplinary teamwork, opinion leaders and reminders) for improving assessments of rehabilitation needs after stroke.

Methods

Ten hospitals in 2 states of Australia were randomly assigned to an education-only or a multifaceted intervention. Medical records were audited by assessors blinded to group allocation before and after the implementation period. Difference in the proportion of patients assessed for rehabilitation before and after the intervention was analysed using mixed-effects logistic regression analysis, with time period as the dependent variable, an interaction between intervention type and time included to test for differences between the interventions, and hospital included as the random effect to account for patient clustering.

Results

Data from 586 patients (284 pre-intervention; 302 post-intervention; age 76 years, 59 % male) showed that the multifaceted intervention was not more effective than education-only in improving the proportion of patients whose rehabilitation needs were assessed (reference category education-only; odds ratio 1.29, 95 % confidence interval 0.63–2.67, p = 0.483). Post-intervention, the odds of a patient’s rehabilitation needs being assessed was 3.69 times greater than pre-intervention (95 % confidence interval 2.57–5.30, p < 0.001). Evidence-based criteria were not consistently used when patients were deemed to have no rehabilitation needs.

Conclusions

A multifaceted intervention was not more effective than education-only in improving the assessment of rehabilitation needs of patients with stroke. Further interventions are required to ensure that all patients are assessed for the need for rehabilitation using evidence-based criteria.

Trial registration

ANZCTR (Australian New Zealand Clinical Trials Registry), ACTRN12616000340437

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0487-2) contains supplementary material, which is available to authorized users.

Insights Into Successful Change Management: Empirically Supported Techniques for Improving Medical Practice Patterns

This article identifies empirically supported techniques for improving medical practice patterns by relying on both The Delta Group's professional change management experience and a thorough review of the literature relating to the essential characteristics of successful change management programs in health care. The purpose of this article is to provide health care professionals with an overview of the various change management techniques that have been widely regarded as having the greatest impact on the clinical and financial success of improvement programs before health care professionals initiate change management activities within their own organization.

Tailored interventions to address determinants of practice

BACKGROUND

Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants.

OBJECTIVES

To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants.

SEARCH METHODS

We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals.

SELECTION CRITERIA

Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified.

MAIN RESULTS

We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression.

AUTHORS' CONCLUSIONS

Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.

Educational interventions to improve prescription and dispensing of antibiotics: a systematic review

Background

Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings.

Methods

We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011.

Results

We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively.

Conclusion

The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.

A systematic review of the effectiveness of knowledge translation interventions for chronic noncancer pain management

BACKGROUND

Reliable evidence detailing effective treatments and management practices for chronic noncancer pain exists. However, little is known about which knowledge translation (KT) interventions lead to the uptake of this evidence in practice.

OBJECTIVES

To conduct a systematic review of the effectiveness of KT interventions for chronic noncancer pain management.

METHODS

Comprehensive searches of electronic databases, the gray literature and manual searches of journals were undertaken. Randomized controlled trials, controlled clinical trials and controlled before-and-after studies of KT interventions were included. Data regarding interventions and primary outcomes were categorized using a standard taxonomy; a risk-of-bias approach was adopted for study quality. A narrative synthesis of study results was conducted.

RESULTS

More than 8500 titles and abstracts were screened, with 230 full-text articles reviewed for eligibility. Nineteen studies were included, of which only a small proportion were judged to be at low risk of bias. Interactive KT education for health care providers has a positive effect on patients' function, but its benefits for other health provider- and patient-related outcomes are inconsistent. Interactive education for patients leads to improvements in knowledge and function. Little research evidence supports the effectiveness of structural changes in health systems and quality improvement processes or coordination of care.

CONCLUSIONS

KT interventions incorporating interactive education in chronic noncancer pain led to positive effects on patients' function and knowledge about pain. Future studies should provide implementation details and use consistent theoretical frameworks to better estimate the effectiveness of such interventions.

Developing an active implementation model for a chronic disease management program

Background

Introduction and diffusion of new disease management programs in healthcare is usually slow, but active theory-driven implementation seems to outperform other implementation strategies. However, we have only scarce evidence on the feasibility and real effect of such strategies in complex primary care settings where municipalities, general practitioners and hospitals should work together. The Central Denmark Region recently implemented a disease management program for chronic obstructive pulmonary disease (COPD) which presented an opportunity to test an active implementation model against the usual implementation model. The aim of the present paper is to describe the development of an active implementation model using the Medical Research Council’s model for complex interventions and the Chronic Care Model.

Methods

We used the Medical Research Council’s five-stage model for developing complex interventions to design an implementation model for a disease management program for COPD. First, literature on implementing change in general practice was scrutinised and empirical knowledge was assessed for suitability. In phase I, the intervention was developed; and in phases II and III, it was tested in a block- and cluster-randomised study. In phase IV, we evaluated the feasibility for others to use our active implementation model.

Results

The Chronic Care Model was identified as a model for designing efficient implementation elements. These elements were combined into a multifaceted intervention, and a timeline for the trial in a randomised study was decided upon in accordance with the five stages in the Medical Research Council’s model; this was captured in a PaTPlot, which allowed us to focus on the structure and the timing of the intervention. The implementation strategies identified as efficient were use of the Breakthrough Series, academic detailing, provision of patient material and meetings between providers. The active implementation model was tested in a randomised trial (results reported elsewhere).

Conclusion

The combination of the theoretical model for complex interventions and the Chronic Care Model and the chosen specific implementation strategies proved feasible for a practice-based active implementation model for a chronic-disease-management-program for COPD. Using the Medical Research Council’s model added transparency to the design phase which further facilitated the process of implementing the program.

Trial registration: http://www.clinicaltrials.gov/(NCT01228708).

Workshop- and telephone-based interventions to improve adverse drug reaction reporting: a cluster-randomized trial in Portugal

BACKGROUND

Spontaneous reporting of adverse drug reactions (ADRs) is the method most widely used by pharmacovigilance systems, with the principal limitation being the physician's underreporting.

OBJECTIVE

This study sought to evaluate the results of workshop and telephone-interview interventions designed to improve the quantity and relevance of ADR reporting by physicians.

METHODS

A cluster-randomized controlled trial was conducted on 6579 physicians in northern Portugal in 2008. Following randomization, we allocated 1034 physicians to a telephone-interview intervention, 438 to a workshop intervention and the remaining 5107 to the control group. At the workshop, a real clinical case was presented and participants were then asked to report on it by completing the relevant form. In the telephone intervention, participants were asked (i) whether they had ever had any suspicion of ADRs; (ii) whether they had experienced any difficulties in reporting; (iii) whether they remembered the different methods that could be used for reporting purposes; and (iv) whether they attached importance to the individual physician's role in reporting. We followed up physicians to assess ADR reporting rates to the Northern Pharmacovigilance Centre. In terms of relevance, adverse reactions were classified as serious or unexpected. Statistical analysis was performed on an intention-to-treat basis, and generalized linear mixed models were applied using the penalized quasi-likelihood method. The physicians studied were followed up over a period of 20 months.

RESULTS

Two hundred physicians underwent the educational intervention. Comparison with the control group showed that the workshop intervention increased the spontaneous ADR reporting rate by an average of 4-fold (relative risk [RR] 3.97; 95% CI 3.86, 4.08; p < 0.001) across the 20 months post-intervention. Telephone interviews, in contrast, proved less efficient since they led to no significant difference (p = 0.052) vis-à-vis the control group in ADR reporting (RR 1.02; 95% CI 1.00, 1.04). The effects of the interventions on the reporting rate of serious and high-causality ADRs indicated that the RRs associated with workshops were 6.84 (95% CI 6.69, 6.98; p < 0.001) for serious ADRs and 3.58 (95% CI 3.51, 3.66; p < 0.001) for high-causality ADRs.

CONCLUSIONS

Whereas telephone interventions only increased spontaneous reporting in the first 4 months of follow-up, workshops significantly increased both the quantity and relevance of spontaneous ADR reporting for more than 1 year.

Misprescription of antibiotics in primary care: a critical systematic review of its determinants

BACKGROUND

Antibiotic resistance is one of the principal public health problems worldwide. Currently, inappropriate use of antibiotics is regarded as the principal determinant of resistance, with most of these drugs being prescribed outside a hospital setting. This systematic review sought to identify the factors, attitudes and knowledge linked to misprescription of antibiotics.

METHODS

A systematic review was conducted using the MEDLINE-PubMed and EMBASE databases. The selection criteria required that papers: (1) be published in English or Spanish; (2) designate their objective as that of addressing attitudes/knowledge or other factors related with the prescribing of antibiotics; and (3) use quality and/or quantity indicators to define misprescription. The following were excluded: any paper that used qualitative methodology and any paper that included descriptive analysis only.

RESULTS

A total of 46 papers that met the inclusion criteria were included in the review. They were very heterogeneous and displayed major methodological limitations. Doctors' socio-demographic and personal factors did not appear to exert much influence. Complacency (fulfilling what professionals perceived as being patients'/parents' expectations) and, to a lesser extent, fear (fear of possible complications in the patient) were the attitudes associated with misprescription of antibiotics.

CONCLUSIONS

Before designing interventions aimed at improving the prescription and use of antibiotics, studies are needed to identify precisely which factors influence prescribing.

Effects of two educational programmes aimed at improving the utilization of non-opioid analgesics in family medicine clinics in Mexico

OBJECTIVES

To develop and test two educational programmes (interactive and passive) aimed at improving family doctors' (FD) prescribing practices and patient's knowledge and use of non-opioid analgesics (NOA).

METHODS

The educational programmes were conducted in two family medicine clinics by using a three-stage approach: baseline evaluation, design, and implementation of educational activities, and post-programme evaluation. An interactive educational programme (IEP) was compared with a passive educational programme (PEP); both were participated by FDs and patients. The IEP for FDs comprised of workshops, discussion groups, in-service training and guidelines, while for patients the IEP consisted of an interactive session with a video, leaflets and a discussion. The PEP consisted in delivering the guidelines to the FDs and the leaflets to patients. The effect of the programmes on the FDs was measured through the appropriateness of prescriptions and analysed using the differences-in-differences estimator (D-in-D), and on patients through changes in self-medication and in their knowledge about the proper use and adverse events by analysing the inter- and intra-group differences before and after the programmes.

RESULTS

The IEP obtained better results to improve appropriate FDs prescription of NOA than PEP (D-in-D = 15%). Regarding the patients, the PEP group reached higher reduction of self-medication than the IEP group (13.4% vs. 9.1%); the knowledge of proper NOA use increased by 8.5% in both groups, whereas knowledge of NOA-related adverse events was better in the IEP (39.6%) than in the PEP group (9.2%).

CONCLUSIONS

The IEP was better to improve the doctors' abilities to prescribe NOAs, and both programmes improved patients' knowledge.

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

BACKGROUND

In the previous version of this review, the effectiveness of interventions tailored to barriers to change was found to be uncertain.

OBJECTIVES

To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes.

SEARCH STRATEGY

For this update, in addition to the EPOC Register and pending files, we searched the following databases without language restrictions, from inception until August 2007: MEDLINE, EMBASE, CINAHL, BNI and HMIC. We searched the National Research Register to November 2007. We undertook further searches to October 2009 to identify potentially eligible published or ongoing trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions tailored to address prospectively identified barriers to change that reported objectively measured professional practice or healthcare outcomes in which at least one group received an intervention designed to address prospectively identified barriers to change.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed quality and extracted data. We undertook quantitative and qualitative analyses. The quantitative analyses had two elements.1. We carried out a meta-regression to compare interventions tailored to address identified barriers to change with either no interventions or an intervention(s) not tailored to the barriers.2. We carried out heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, concealment of allocation, rigour of barrier analysis, use of theory, complexity of interventions, and the reported presence of administrative constraints.

MAIN RESULTS

We included 26 studies comparing an intervention tailored to address identified barriers to change to no intervention or an intervention(s) not tailored to the barriers. The effect sizes of these studies varied both across and within studies.Twelve studies provided enough data to be included in the quantitative analysis. A meta-regression model was fitted adjusting for baseline odds by fitting it as a covariate, to obtain the pooled odds ratio of 1.54 (95% CI, 1.16 to 2.01) from Bayesian analysis and 1.52 (95% CI, 1.27 to 1.82, P < 0.001) from classical analysis. The heterogeneity analyses found that no study attributes investigated were significantly associated with effectiveness of the interventions.

AUTHORS' CONCLUSIONS

Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines. However, the methods used to identify barriers and tailor interventions to address them need further development. Research is required to determine the effectiveness of tailored interventions in comparison with other interventions.

Continuing education meetings and workshops: effects on professional practice and health care outcomes

BACKGROUND

Educational meetings are widely used for continuing medical education. Previous reviews found that interactive workshops resulted in moderately large improvements in professional practice, whereas didactic sessions did not.

OBJECTIVES

To assess the effects of educational meetings on professional practice and healthcare outcomes.

SEARCH STRATEGY

We updated previous searches by searching the Cochrane Effective Practice and Organisation of Care Group Trials Register and pending file, from 1999 to March 2006.

SELECTION CRITERIA

Randomised controlled trials of educational meetings that reported an objective measure of professional practice or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality. Studies with a low or moderate risk of bias and that reported baseline data were included in the primary analysis. They were weighted according to the number of health professionals participating. For each comparison, we calculated the risk difference (RD) for dichotomous outcomes, adjusted for baseline compliance; and for continuous outcomes the percentage change relative to the control group average after the intervention, adjusted for baseline performance. Professional and patient outcomes were analysed separately. We considered 10 factors to explain heterogeneity of effect estimates using weighted meta-regression supplemented by visual analysis of bubble and box plots.

MAIN RESULTS

In updating the review, 49 new studies were identified for inclusion. A total of 81 trials involving more than 11,000 health professionals are now included in the review. Based on 30 trials (36 comparisons), the median adjusted RD in compliance with desired practice was 6% (interquartile range 1.8 to 15.9) when any intervention in which educational meetings were a component was compared to no intervention. Educational meetings alone had similar effects (median adjusted RD 6%, interquartile range 2.9 to 15.3; based on 21 comparisons in 19 trials). For continuous outcomes the median adjusted percentage change relative to control was 10% (interquartile range 8 to 32%; 5 trials). For patient outcomes the median adjusted RD in achievement of treatment goals was 3.0 (interquartile range 0.1 to 4.0; 5 trials). Based on univariate meta-regression analyses of the 36 comparisons with dichotomous outcomes for professional practice, higher attendance at the educational meetings was associated with larger adjusted RDs (P < 0.01); mixed interactive and didactic education meetings (median adjusted RD 13.6) were more effective than either didactic meetings (RD 6.9) or interactive meetings (RD 3.0). Educational meetings did not appear to be effective for complex behaviours (adjusted RD -0.3) compared to less complex behaviours; they appeared to be less effective for less serious outcomes (RD 2.9) than for more serious outcomes.

AUTHORS' CONCLUSIONS

Educational meetings alone or combined with other interventions, can improve professional practice and healthcare outcomes for the patients. The effect is most likely to be small and similar to other types of continuing medical education, such as audit and feedback, and educational outreach visits. Strategies to increase attendance at educational meetings, using mixed interactive and didactic formats, and focusing on outcomes that are likely to be perceived as serious may increase the effectiveness of educational meetings. Educational meetings alone are not likely to be effective for changing complex behaviours.

A demonstration project of a multi-component educational intervention to improve integrated post-fracture osteoporosis care in five rural communities in Ontario, Canada

This study evaluated a multi-component intervention (educational materials and outreach visits) to increase knowledge and improve post-fracture care management in five rural communities in Canada. One hundred and twenty-five patients pre- intervention and 149 post-intervention were compared. No significant improvement in post-fracture care was documented suggesting that a more targeted intervention is needed.

INTRODUCTION

Currently, the majority of patients with a low trauma fracture are under-investigated and under-treated for osteoporosis. We set out to evaluate an educational intervention on increasing knowledge of post-fracture care among health care professionals (HCPs) and fracture patients and on improving post-fracture management.

METHODS

We studied five rural communities in Ontario, Canada, using a multi-component intervention ("Behind the Break"), including educational material for HCPs and patients and educational outreach visits to physicians. The study had a historical control, non-equivalent pre/post design. Telephone surveys were carried out with individuals > or =40 years of age who had a low trauma fracture in 2003 (n = 125) or in 2005 (n = 149). Family physicians and emergency department staff were also surveyed.

RESULTS

A total of 4,207 educational packages were distributed. Seventy-three percent of family physicians had an outreach visit. Two-thirds indicated that they received enough information about post-fracture follow-up to incorporate it into their practice. Despite this, no significant improvement in post-fracture care was documented (32% in the "pre" group had a bone mineral density test and 25% in the "post" group). Of those diagnosed with osteoporosis, the majority were prescribed a bone-sparing medication (63% "pre" and 80% "post").

CONCLUSION

A more targeted intervention linking fracture patients to their physician needs to be evaluated in rural communities.

Applying social marketing in health care: communicating evidence to change consumer behavior

Social marketing uses commercial marketing strategies to change individual and organizational behavior and policies. It has been effective on a population level across a wide range of public health and health care domains. There is limited evidence of the effectiveness of social marketing in changing health care consumer behavior through its impact on patient-provider interaction or provider behavior. Social marketers need to identify translatable strategies (e.g., competition analysis, branding, and tailored messages) that can be applied to health care provider and consumer behavior. Three case studies from social marketing illustrate potential strategies to change provider and consumer behavior. Countermarketing is a rapidly growing social marketing strategy that has been effective in tobacco control and may be effective in countering pharmaceutical marketing using specific message strategies. Informed decision making is a useful strategy when there is medical uncertainty, such as in prostate cancer screening and treatment. Pharmaceutical industry marketing practices offer valuable lessons for developing competing messages to reach providers and consumers. Social marketing is an effective population-based behavior change strategy that can be applied in individual clinical settings and as a complement to reinforce messages communicated on a population level. There is a need for more research on message strategies that work in health care and population-level effectiveness studies.

Educational outreach visits: effects on professional practice and health care outcomes

BACKGROUND

Educational outreach visits (EOVs) have been identified as an intervention that may improve the practice of healthcare professionals. This type of face-to-face visit has been referred to as university-based educational detailing, academic detailing, and educational visiting.

OBJECTIVES

To assess the effects of EOVs on health professional practice or patient outcomes.

SEARCH STRATEGY

For this update, we searched the Cochrane EPOC register to March 2007. In the original review, we searched multiple bibliographic databases including MEDLINE and CINAHL.

SELECTION CRITERIA

Randomised trials of EOVs that reported an objective measure of professional performance or healthcare outcomes. An EOV was defined as a personal visit by a trained person to healthcare professionals in their own settings.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. We used bubble plots and box plots to visually inspect the data. We conducted both quantitative and qualitative analyses. We used meta-regression to examine potential sources of heterogeneity determined a priori. We hypothesised eight factors to explain variation across effect estimates. In our primary visual and statistical analyses, we included only studies with dichotomous outcomes, with baseline data and with low or moderate risk of bias, in which the intervention included an EOV and was compared to no intervention.

MAIN RESULTS

We included 69 studies involving more than 15,000 health professionals. Twenty-eight studies (34 comparisons) contributed to the calculation of the median and interquartile range for the main comparison. The median adjusted risk difference (RD) in compliance with desired practice was 5.6% (interquartile range 3.0% to 9.0%). The adjusted RDs were highly consistent for prescribing (median 4.8%, interquartile range 3.0% to 6.5% for 17 comparisons), but varied for other types of professional performance (median 6.0%, interquartile range 3.6% to 16.0% for 17 comparisons). Meta-regression was limited by the large number of potential explanatory factors (eight) with only 31 comparisons, and did not provide any compelling explanations for the observed variation in adjusted RDs. There were 18 comparisons with continuous outcomes, with a median adjusted relative improvement of 21% (interquartile range 11% to 41%). There were eight trials (12 comparisons) in which the intervention included an EOV and was compared to another type of intervention, usually audit and feedback. Interventions that included EOVs appeared to be slightly superior to audit and feedback. Only six studies evaluated different types of visits in head-to-head comparisons. When individual visits were compared to group visits (three trials), the results were mixed.

AUTHORS' CONCLUSIONS

EOVs alone or when combined with other interventions have effects on prescribing that are relatively consistent and small, but potentially important. Their effects on other types of professional performance vary from small to modest improvements, and it is not possible from this review to explain that variation.

Academic Detailing to Improve Laboratory Testing Among Outpatient Medication Users

PURPOSE

To determine whether group academic detailing with performance feedback increases recommended laboratory monitoring among outpatients dispensed medications.

METHODS

Thirty-eight primary care practices in 3 states were randomized to group academic detailing with physician-level performance feedback (intervention) or a control group. Adjusted differences in creatinine and potassium testing between intervention and control group patients with a new or continuing dispensing for angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), diuretics, or digoxin were evaluated using generalized estimating equation approaches.

RESULTS

Monitoring among patients with an initial ACE/ARB and diuretic dispensing significantly improved with the intervention [odds ratio (OR) = 1.22, 95% confidence interval (CI): 1.08-1.38; and OR = 1.25, 95% CI: 1.08-1.44, respectively). The intervention also significantly improved monitoring among patients with a continuing dispensing for an ACE/ARB (OR = 1.39, 95% CI: 1.11-1.74) or a diuretic (OR = 1.28, 95% CI: 1.02-1.60). Adjusted differences in testing rates between study arms were modest (ranging from 2.5% to 4.9%). No significant differences in monitoring by study arm were detected among patients dispensed digoxin.

CONCLUSIONS

The impact of a group academic detailing program with feedback on recommended laboratory monitoring among medication users was modest. Yet, given the numbers of outpatients dispensed medications for which laboratory monitoring is recommended, group academic detailing may offer 1 method by which outpatient medication safety can be significantly improved.

Characteristics and impact of drug detailing for gabapentin

BACKGROUND

Sales visits by pharmaceutical representatives ("drug detailing") are common, but little is known about the content of these visits or about the impact of visit characteristics on prescribing behavior. In this study, we evaluated the content and impact of detail visits for gabapentin by analyzing market research forms completed by physicians after receiving a detail visit for this drug.

METHODS AND FINDINGS

Market research forms that describe detail visits for gabapentin became available through litigation that alleged that gabapentin was promoted for "off-label" uses. Forms were available for 97 physicians reporting on 116 detail visits between 1995 and 1999. Three-quarters of recorded visits (91/116) occurred in 1996. Two-thirds of visits (72/107) were 5 minutes or less in duration, 65% (73/113) were rated of high informational value, and 39% (42/107) were accompanied by the delivery or promise of samples. During the period of this study, gabapentin was approved by the US Food and Drug Administration only for the adjunctive treatment of partial seizures, but in 38% of visits (44/115) the "main message" of the visit involved at least one off-label use. After receiving the detail visit, 46% (50/108) of physicians reported the intention to increase their prescribing or recommending of gabapentin in the future. In multivariable analysis, intent to increase future use or recommendation of gabapentin was associated with receiving the detail in a small group (versus one-on-one) setting and with low or absent baseline use of the drug, but not with other factors such as visit duration, discussion of "on-label" versus "off-label" content, and the perceived informational value of the presentation.

CONCLUSIONS

Detail visits for gabapentin were of high perceived informational value and often involved messages about unapproved uses. Despite their short duration, detail visits were frequently followed by physician intentions to increase their future recommending or prescribing of the drug.

Economic analysis of a randomized trial of academic detailing interventions to improve use of antihypertensive medications

The authors estimated the costs and cost savings of implementing a program of mailed practice guidelines and single-visit individual and group academic detailing interventions in a randomized controlled trial to improve the use of antihypertensive medications. Analyses took the perspective of the payer. The total costs of the mailed guideline, group detailing, and individual detailing interventions were estimated at 1000 dollars, 5500 dollars, and 7200 dollars, respectively, corresponding to changes in the average daily per person drug costs of -0.0558 dollars (95% confidence interval, -0.1365 dollars to 0.0250 dollars) in the individual detailing intervention and -0.0001 dollars (95% confidence interval, -0.0803 dollars to 0.0801 dollars) in the group detailing intervention, compared with the mailed intervention. For all patients with incident hypertension in the individual detailing arm, the annual total drug cost savings were estimated at 21,711 dollars (95% confidence interval, 53,131 dollars savings to 9709 dollars cost increase). Information on costs of academic detailing could assist with health plan decision making in developing interventions to improve prescribing.

The Effect of an Interactive Tutorial on the Prescribing Performance of Senior Medical Students

OBJECTIVES

To evaluate the effectiveness of small group tutorials in teaching senior medical students the requirements of prescription writing.

DESIGN

Random allocation to interactive tutorial or didactic lecture with blinded evaluation.

SUBJECTS

All 1999 6th year medical students, the University of Adelaide.

RESULTS

The Tutorial Attenders (mean 13.3, SD 2.6) performed significantly better than the Lecture Group (mean12.2, SD 3.0) p=0.041 and the Non-attenders (mean10.7, SD 3.1) p=0.041 and the Non-attenders (mean10.7, SD 3.1) p= 0.001. The 13 individual OSCE items formed four logical subgroups, and the Tutorial Attenders performed significantly better in Prescription Writing in all comparisons.

CONCLUSION

A single, one-hour interactive tutorial is likely to be the minimum amount of intervention that will be effective in improving prescribing skills.

[Chronic kidney disease: do generalists and nephrologists differ in their care?]

INTRODUCTION

Chronic kidney disease (CKD) is a major public health problem. We report an evaluation of the CKD perception from a French family physician's (FP) point of view.

METHODS

A questionnaire was sent to a representative and independently selected sample of 497 FP, i.e. 20% of the FP working in the administrative region Lorraine. There were 214 completed surveys, i.e. response rate: 43%.

RESULTS

Age of FP was: < 40 years of age: 13%, 40-50: 40%, > 50: 47%. The geographic working place was urban: 41%, rural: 22%, urban and rural: 37%. Ninety-nine per cent of FP has a nephrologist, devoted to CKD referral. Twenty-one per cent of FP has a comprehensive picture of CKD and 75% thinks that CKD diagnostic is difficult Thirty per cent of FP were aware of CKD guidelines. For FP, risk-factors for CKD were: hypertension: 93%, diabetes: 99%, age over 65: 64%, urinary infection: 34%, hematuria/proteinuria: 78%, anaemia: 43%, therapeutics associated with risk of renal injury: 79%, all of these circumstances: 20%. The referral decision to a nephrologist was done at a mean creatinine clearance of 41+/-12 ml/min. Age over 80, dementia, and cancer were considered to be a contra-indication of renal replacement therapy, for respectively 30%, 69%, and 63% of FP. CME was associated with better awareness of guidelines, and use of clearance rather than serum creatinin.

CONCLUSION

From FP point of view, overall awareness of CKD guidelines is low. In the context of the current nephrology services, greater sharing of CKD care with FP is needed.

Rational prescribing in primary care (RaPP): a cluster randomized trial of a tailored intervention

BACKGROUND

A gap exists between evidence and practice regarding the management of cardiovascular risk factors. This gap could be narrowed if systematically developed clinical practice guidelines were effectively implemented in clinical practice. We evaluated the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease.

METHODS AND FINDINGS

We conducted a cluster-randomized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practices in two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders linked to the medical record system. Pharmacists conducted the visits. Outcomes were measured for all eligible patients seen in the participating practices during 1 y before and after the intervention. The main outcomes were the proportions of (1) first-time prescriptions for hypertension where thiazides were prescribed, (2) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and (3) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals. The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug. Thiazides were prescribed to 17% of patients in the intervention group versus 11% in the control group (relative risk 1.94; 95% confidence interval 1.49-2.49, adjusted for baseline differences and clustering effect). Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals.

CONCLUSIONS

Our tailored intervention had a significant impact on prescribing of antihypertensive drugs, but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care.

¿Cómo aumentar la implicación del paciente de urgencias en su tratamiento?: eficacia de unos pósters informativos

OBJECTIVE

To determine whether posters/leaflets increase doctors' information on the allergies and on the medication their patients are taking and patients' understanding of their treatment.

DESIGN

First stage: multi-centre transversal descriptive study. Second stage: intervention with control and without randomisation.

SETTING

Primary care medical emergency services (MES).

PARTICIPANTS

MES patients under prescribed drug treatment.

INTERVENTIONS

Use of posters/leaflets.

MAIN MEASUREMENTS

1) Proportion of patients for whom the doctor was ignorant of allergies to drugs or of accompanying medication. 2) Proportion of prescriptions in which patients understood the dosage of the medication prescribed.

SOURCE

ad hoc questionnaire to patients.

ANALYSIS

chi2 test (category variables). In some cases, the Breslow-Day and Tarone tests were conducted.

RESULTS

Total patients included, 1233; 1766 prescriptions analysed; 53.4% women. Mean age: 29+/-18 years old. 1) Doctor's understanding of accompanying medication: at the second stage, drop of 25.5% (95% CI, 33.5-17.5) for intervention group versus drop of 12.5% (95% CI, 19.8-5.2) for control group, in the number of patients for whom the doctor did not know the medication (P=.024). 2) Patient's understanding of dosage: at the second stage, increase of 16.8% (95% CI, 9.8-23.8) for intervention group, versus a decrease of 1% in control group, in the medicines whose dosage the patient was aware of (P<.001).

CONCLUSIONS

The dissemination of posters/leaflets was effective in increasing patients' knowledge of their medication's dosage and doctors' understanding of questions affecting prescription.

Improving Pharmacotherapy After Myocardial Infarction by Group Academic Detailing Using Feedback Data on a Patient Level

STUDY OBJECTIVE

To develop and evaluate a peer review group (PRG) meeting using feedback data on a patient level to improve the quality of drug therapy for prevention of recurrent myocardial infarction.

DESIGN

Prospective follow-up study.

DATA SOURCE

General practitioners' computerized patients records (intervention patients) and the PHARMO record linkage system (controls).

PATIENTS

Forty patients in the intervention group and 1030 control patients; both groups had documented myocardial infarction.

INTERVENTION

The intervention, which was based on the principles of group academic detailing, consisted of scoring current cardiovascular treatment on separate forms for each patient, presenting an overview of, and discussing, evidence-based treatment after myocardial infarction, defining the target population, formulating a binding consensus, and identifying patients who were eligible for improvement of pharmacotherapy.

MEASUREMENTS AND MAIN RESULTS

Drug therapy and adherence to the newly formulated PRG consensus were assessed at baseline and 1 year after the intervention. Of the patients who received the intervention and were not treated according to the PRG consensus at baseline, 40% received treatment according to the consensus 12 months after the PRG meeting. In the control group, the proportion of patients was 9.5% (prevalence ratio 4.2, 95% confidence interval 1.8-9.7).

CONCLUSION

Peer review group meetings can be a valuable tool for improving pharmacotherapy after myocardial infarction.

Impact of a general practitioner educational intervention on osteoarthritis treatment in an elderly population

PURPOSE

We examined whether a continuing medical education intervention increased general practitioners' ability to select the proper pharmacological treatment for patients with osteoarthritis.

SUBJECTS AND METHODS

Eight towns in Quebec, Canada were randomly allocated to one of four intervention options, workshop and decision tree, workshop, decision tree, or no intervention. All general practitioners practicing in each town were eligible to participate. We evaluated all dispensed prescriptions for either a cyclooxygenase (COX)-2 inhibitor, nonselective nonsteroidal anti-inflammatory drug or acetaminophen written by eligible general practitioners between May 2000 and June 2001 to elderly patients suffering from osteoarthritis. We used a multi-level Bayesian hierarchical model to assess the impact of the interventions on prescription adequacy.

RESULTS

We analyzed 5318 dispensed prescriptions written by 249 general practitioners in the five-month preintervention period and 4610 dispensed prescriptions written by the same physicians in the five-month postintervention period. A score of zero or one was given to every prescription, with one indicating prescription adequacy according to guidelines provided during the interventions. Bayesian hierarchical models showed some improvement in scores in the post- versus preintervention periods in all four groups. The probability of an improvement in the towns allocated the workshop and decision tree over the control was 94%, compared with 74% in the workshop group and 55% in the decision tree group.

CONCLUSION

An interactive approach offered by peers and complemented by easy to use guidelines may enhance the general practitioner's ability to manage osteoarthritis patients.

Promoting a biopsychosocial orientation in family practice: effect of two teaching programs on the knowledge and attitudes of practising primary care physicians

The bio-psychosocial (BPS) approach to patient care has gained acceptance in medical education. However, reported teaching programs rarely describe the efficacy of alternative approaches to continuing medical education aimed at promoting a BPS approach. The objective was to describe and evaluate the effect of two teaching programs on learners' BPS knowledge, management intentions, patient-centered attitudes, professional self-esteem, burnout, work related strain and mental workload. The learners were Israeli general practitioners. The first ("didactic") program consisted of problem-based reading assignments, lectures and discussions. The second ("interactive") program consisted of reading assignments, lectures and discussions, in addition to role-playing exercises, Balint groups and one-to-one counseling by a facilitator. One month before and six months after the teaching interventions, we used structured questionnaires to test for knowledge, management intentions (responses to questions, such as "what would you tell a patient with ...") and attitudes. Both programs led to measurable improvement in knowledge, intentions, patient-centered attitudes and self-esteem. The interactive teaching approach improved significantly more the learners' professional self-esteem and intentions than the didactic approach. Self-reported burnout significantly increased after the program. It is concluded that teaching intervention enhanced a BPS orientation and led to changes in knowledge, intentions, self-esteem and attitudes. An interactive method of instruction was more effective in achieving some of these objectives than a didactic one. The observed increase in burnout was unexpected and requires further study and confirmation.

Antibiotic prescription in primary health care: clinical and economic perspectives (Catalonia, Spain)

OBJECTIVE

To quantify clinical inappropriateness of antibiotic prescription and its costs in primary health care.

METHODS

2470 cases of infectious disease during 1998 were analysed.

RESULTS

Of all cases, 69.9% did not require antibiotic treatment. Global clinical inappropriateness amounted to 43.7%, rising to 56.7% with the introduction of economic criteria. Treatment unnecessary but antibiotic provided (27.9%) represented the most important category. Costs of inappropriateness reached 68.4% of the estimated total cost.

CONCLUSION

Appropriate antibiotic use should be focused on reducing antibiotic prescription when not indicated and restraining the use of penicillins maintaining restrictive and adequate health policies, and also achieving co-responsibility from the general population.

Utilización de coxibs: una estrategia de intervención en la atención primaria

OBJECTIVE

To evaluate an intervention designed to rationalize prescription of nonsteroidal anti-inflammatory drugs (NSAIDs), especially cyclooxygenase-2 inhibitors (COXIBs).

SUBJECTS AND METHODS

We performed a before-after intervention study. Face-to-face educational outreach visits were conducted in general practitioners who were heavy prescribers and group intervention for the remaining. Data on prescribing habits were obtained from the pharmacy database of the Catalan Health Institute. The pre-intervention period (period 1) was compared with the immediate postintervention period (period 2, which coincided with the publication of a safety alert on the adverse effects of COXIBs) and the late postintervention period (period 3). The data monitored were: a) expenditure due to COXIBs; b) consumption in daily defined doses (DDD) per 1,000 habitants/day (DHD); c) the percentage of COXIBs/total NSAIDs and the percentage of recommended NSAIDs/total NSAIDs, and d) the mean daily cost of DHD of NSAIDs.

RESULTS

The mean monthly reduction in expenditure on COXIBs was 19,480 euro/month in period 2 and was 18,555 euro/month in period 3. The percentage of reduction in DHD of COXIBs was 35.4% (p < 0.001), which remained stable throughout the study. The percentage of recommended NSAIDs/total NSAIDs increased 14% in the short term and 17% in the long term while the mean daily cost was reduced by 10.1% and 11.2%. The decrease in DHD of COXIBs in the face-to-face intervention group was 39.5% in period 2 and was 42.2% period 3 compared with 19.4% and 12.4% in the group intervention.

CONCLUSIONS

The educational intervention was associated with improvements in prescription of NSAIDs, although some of the improvement was probably due to the safety alert issued during the study period.

Analysis of case-crossover designs using longitudinal approaches: a simulation study

BACKGROUND

Application of case-crossover designs provides an alternative to time-series analysis for analyzing the health-related effects of air pollution. Although some case-crossover studies can control for trend and seasonality by design, to date they have been analyzed as matched case-control studies. Such analyses may exhibit biases and a lower statistical efficiency than traditional time series analyzed with Poisson.

METHODS

In this article, case-crossover studies are treated as cohort studies in which each subject is observed for a short period of time before and/or after the event, thus making possible analyzing with Andersen-Gill and generalized linear mixed models. We conducted a simulation study to compare the behavior of these models applied to case-crossover designs with time series analyzed with Poisson and with case-crossover analyzed by conditional logistic regression. To this end, we created a random variable that follows a Poisson distribution of low (2/day) and high mean events (22/day). This variable is a function of an unobserved confounding variable (that introduces trend and seasonality) and data on small particulate matter (PM10) from Barcelona. In addition, scenarios were created to assess the effect on exposure exerted by autocorrelation and the magnitude of the pollutant coefficient.

RESULTS

The full semisymmetric design analyzed with generalized linear mixed models yields good coverage and a high statistical power for air-pollution effect magnitudes close to the real values but shows bias for high effect magnitudes. This bias seems to be attributable to autocorrelation in the exposure variable.

CONCLUSIONS

Longitudinal approaches applied to case-crossover designs may prove useful for analyzing the acute effects of environmental exposures.

Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: a cluster-randomized controlled trial

PURPOSE

To compare group versus individual academic detailing to increase diuretic or beta-blocker use in hypertension.

METHODS

We conducted a cluster-randomized controlled trial in a large health maintenance organization. Subjects (N=9820) were patients with newly treated hypertension in the year preceding the intervention (N=3692), the 9 months following the intervention (N=3556), and the second year following intervention (N=2572). We randomly allocated 3 practice sites to group detailing (N=227 prescribers), 3 to individual detailing (N=235 prescribers), and 3 to usual care (N=319 prescribers). Individual detailing entailed a physician-educator meeting individually with clinicians to address barriers to prescribing guideline-recommended medications. The group detailing intervention incorporated the same social marketing principles in small groups of clinicians.

RESULTS

In the first year following the intervention, the rates of diuretic or beta-blocker use increased by 13.2% in the group detailing practices, 12.5% in the individual detailing practices, and 6.2% in the usual care practices. As compared with usual care practices, diuretic or beta-blocker use was more likely in group detailing practices (adjusted odds ratio (OR), 1.40; 95% confidence interval (CI), 1.11 - 1.76) and individual detailing practices (adjusted OR, 1.30; 95% CI, 0.95 - 1.79). Neither intervention affected blood pressure control. Two years following this single-visit intervention, there was still a trend suggesting a persistent effect of individual (OR, 1.22; 95% CI, 0.92 - 1.62), but not group, detailing (OR, 1.06; 95% CI, 0.80 - 1.39), as compared with usual care.

CONCLUSION

Both group and individual academic detailing improved antihypertensive prescribing over and above usual care but may require reinforcement to sustain improvements.

Influence of physicians' attitudes on under-notifying infectious diseases: a longitudinal study

OBJECTIVES

To identify practitioners' demographic and professional characteristics associated with reporting of mandatory-reporting diseases (MRDs), and to identify attitudes associated with MRD reporting.

DESIGN

Longitudinal study.

SETTING

Regional Health Service of Galicia (North-western Spain).

SUBJECTS

Random sample of 600 physicians.

MAIN OUTCOME MEASURES

A postal questionnaire was used to measure the physicians' beliefs, knowledge and attitudes regarding MRDs. Associations between the independent variables and outcomes (notification or non-notification of MRDs every week during 1998) were modelled using the Andersen-Gill proportional hazards model.

RESULTS

The response rate was 60.1%. The following beliefs, knowledge and attitudes were statistically associated with a smaller probability of reporting any given MRD: (1) I would only notify an MRD after confirming diagnosis; (2) the MRD reporting system interferes with my daily clinical practice; (3) besides the legal requirements, I would have to report MRDs as a medical professional; and (4) only the reporting of relevant or severe MRDs is necessary. Under-reporting was not associated with specialization (general or paediatric) or the type of contract (fixed or temporary), but was associated with gender.

CONCLUSIONS

Some physicians' beliefs, knowledge and attitudes regarding MRDs are associated with under-reporting. This suggests that modification of certain attitudes and knowledge in physicians could greatly reduce the under-reporting of MRDs.

Optimizing antibiotic prescribing for acute cough in general practice: a cluster-randomized controlled trial

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.

An evaluation of one-on-one advanced proficiency training in clinicians’ use of computer information systems

OBJECTIVE

We examined the effectiveness of a one-on-one training strategy for advanced proficiency in computer information systems (CIS) by clinicians in a large Health Maintenance Organization (HMO). Specifically, this study assessed the level of self-reported improvement in CIS efficiency following one-on-one training, and assessed the perceived value of one-on-one training compared to other teaching methods.

DESIGN

We performed a cross-sectional study using a paper-based survey of 129 clinicians practicing in the HMO.

MEASUREMENTS

We used a multi-item satisfaction index to measure clinician satisfaction with the one-on-one training. We measured whether clinicians thought they were more efficient using the system after training.

RESULTS

The one-on-one method was significantly preferred over other teaching methods. Compared to other CIS components, use of the electronic medical record (EMR) improved most following one-on-one training. Sixty-one percent of the clinicians reported major improvements (i.e., >3 on a 5-point Likert scale; five being the highest score) in using the EMR.

CONCLUSION

Perceived effectiveness of one-on-one training and overall satisfaction were ranked high by clinicians. The findings support the assumption that clinicians value one-on-one training and value this training method above other methods.

Pilot study on the feasibility and acceptability of academic detailing in general practice

OBJECTIVE

To investigate the feasibility and acceptability of academic detailing in general practice in the North-East-Flanders region of Belgium.

METHODS

All local quality groups in the study region were randomly allocated to either (1) two academic detailing visits to the individual members or (2) two academic detailing visits during the meetings of the local quality group. During these visits, the results of a systematic review of the literature on non-steroidal anti-inflammatory agents (NSAIDs) were presented.

RESULTS

Of 14 local quality groups, 12 allocated to the individual intervention agreed to participate. Of the 184 physicians invited to receive an academic detailer, 142 had two visits on NSAIDs. One hundred and five physicians gave their opinion on the visits by means of a questionnaire. The great majority of the responders (90%) wished to receive an academic detailer on other topics in the future, with a frequency of two visits per year. Of 13 local quality groups, 12 allocated to the group intervention, with a total number of 192 physicians who agreed to participate. Ten local quality groups with 166 members received the information on NSAIDs. The actual attendance rate per intervention session was approximately two out of three physicians. All 166 physicians of the participating local quality groups were offered an evaluation form, and 79 responded. Of the responders who received the full group intervention, 88% wished to have more academic detailing visits on other topics in their local quality group. A comparison between the evaluation forms of the individual and the group intervention revealed no major differences concerning the acceptability of the intervention.

CONCLUSION

The pilot study showed that academic detailing is feasible in the North-East-Flanders region of Belgium. Both the individual visits and the visits to the local quality groups were rated positively, and a majority of the general practitioners who returned the evaluation questionnaire wished to receive such visits in the future. The structure of the local quality groups implies limitations to the practical organisation of a visit, but requires less time investment than individual visits.

[Prescription of non-steroidal anti-inflammatories and gastric protectors in emergency service]

OBJECTIVES

To find the number of patients seen in casualty who received gastropathy prophylaxis with NSAIDs that complied with the pharmaco-therapeutic guidelines of the health district.

DESIGN

Descriptive study of technical-scientific quality.

SETTING

The Casualty Department of the Ramón y Cajal hospital.

PARTICIPANTS

Randomised sample of 400 emergencies attended in January 1999 and 2000, excluding paediatric cases, people previously treated with gastro-protectors, patients admitted and the deceased. Main measurements. On the basis of casualty records: suitability of indication and criteria used; if unsuitable, how; adequacy of selection of the principle, patient' age and sex, digestive pathology history, area and year of care.

RESULTS

NSAIDs were prescribed in 37.9% of cases (33.27-42.79), with prescription unsuitable in 21.19% (15.2-28.3). 15% (9.5-22) were unsuitable by default; and 54.2% (35.1-72.1), by excess. Unsuitability was greater among women, if there was history of digestive pathology, and among older people, with no differences found for area or year of care. The choice of gastric protector was not suitable in any case.

CONCLUSIONS

Given the amount of primary care prescription originating in hospital casualty departments, and its effect on the training of family medicine interns, strategies coordinated between health care levels must be introduced in order to improve gastric protection prescription in NSAID gastropathy prophylaxis. The effectiveness of these strategies must be evaluated.

Data collection methods for analyzing the quality of the dispensing in pharmacies

OBJECTIVE

To review and discuss the advantages and limitations of the different data collection methods for analyzing the dispensing quality in community pharmacies.

METHODS

A bibliographic search was carried out in MEDLINE (1980-2000). Articles with Medical Subject Heading (Mesh) "pharmacies" written in English and Spanish that evaluated the quality of dispensing (structure, process or outcome) were selected.

RESULTS

Various data collection methods were observed. To analyze the quality of the structure, questionnaires and pharmacist interviews were used. To analyze the quality of the process, self-completed records, external observers and simulated clients were used. For analyzing the quality of the outcome, questionnaires, client interviews, and biologic samples were collected.

CONCLUSIONS

The analysis of quality of structure can be useful as a first approach, however, this method may lack sensitivity. On the other hand, the analysis of outcome may be excessively complex and difficult to use, except for experimental or observational studies with large resources. Therefore, an analysis of the quality of the process is the best option. Methods utilizing external observers and simulated clients may best conjugate both internal and external validity.

Evaluating the Impact of an Educational Program on Practice Patterns of Canadian Family Physicians Interested in Depression Treatment

BACKGROUND: Depression is frequently unrecognized and undertreated. Therefore, there is a need to increase the knowledge and skills of primary care physicians regarding the diagnosis and treatment of depression. The aim of this study was to provide, and evaluate the impact of, a brief educational program with a number of practice tools and resources in order to improve family physicians' knowledge, diagnosis, and treatment of depression. METHODS: Two educational programs (general and enhanced) were delivered to family physicians interested in depression treatment. The enhanced program focused on more practical clinical issues such as use of diagnostic and symptom assessment tools, recommended dosing of citalopram, how to initiate and discontinue treatment, and relapse prevention. Physicians' knowledge of depression was assessed pretraining and posttraining. Chart audits were conducted for 6 months. Primary endpoints were recognition of depression and pharmacologic management (initial dose, maximum dose, length of treatment, adverse events, and concomitant psychotropic drugs). Secondary endpoints were patient satisfaction with treatment, compliance, withdrawal from the study, treatment outcome, use of adjunctive psychotherapy, and number of office visits. RESULTS: There was a global increase in physicians' knowledge of depression in the short term. Physicians in the enhanced group were more likely to use a symptom-based diagnostic checklist, record the diagnosis of depression, and prescribe the recommended initial dose of citalopram, and they referred less frequently for adjunctive psychotherapy. No difference between educational intervention groups was found in patient satisfaction, compliance, and treatment outcome. CONCLUSIONS: A well-designed brief, simple, and low-cost educational program can increase family physicians' knowledge of depression, improve their diagnostic skills, and optimize their treatment of depression.

Evidence based educational outreach visits: effects on prescriptions of non-steroidal anti-inflammatory drugs

AIMS

To evaluate the effectiveness of an evidence based group educational outreach visit on prescription patterns of non-steroidal anti-inflammatory drugs (NSAIDs) in primary care.

DESIGN

Randomised controlled simple blind trial, with randomisation into three groups: experimental (evidence based educational outreach visit), placebo (conventional education session), and control (without intervention).

SETTING

The 24 primary care centres of the National Institute of Healthcare Network in a rural province of Aragon, Spain.

PARTICIPANTS

The 24 primary health care teams of the network, with 158 general practitioners (GPs). The teams were randomised into the groups, experimental (8 teams, 48 GPs), placebo (8 teams, 54 GPs), and control (8 teams, 56 GPs).

INTERVENTION

Experimental group: one group educational outreach visit, conveying data based on a systematic review of the literature that was reinforced with printed material; placebo group: one non-structured educational session; control group: no intervention. Both educational sessions emphasised that there are no differences in the effectiveness of the NSAIDs reviewed (diclofenac, piroxicam, and tenoxicam); a recommendation was made to prescribe diclofenac over tenoxicam because of price differences.

MAIN OUTCOME MEASURES

Changes in the number of packages prescribed for each of the drugs and changes in the cost per package of NSAIDs prescribed during the six months before, and after the intervention.

RESULTS

There were no differences in the basal characteristics of the three groups, except for the number of prescriptions during the six months before the intervention. Prescriptions for NSAIDs decreased homogeneously in the three groups. For tenoxicam, the experimental group reduced prescriptions by 22.5% (95%CI: 34.42 to -10.76), compared with a reduction of 9.78% (95%CI: -17.70 to -1.86) in the placebo group and an increase of 14.44% (95%CI: 5.22 to 23.66) in the control group. The average cost per prescription decreased by 1.91% (95%CI: -0.33% to -3.49%) in the experimental group, 0.16% (95%CI: -0.27% to -2.93%) in the placebo group, and rose by 1.76% (95%CI: 0.35% to 3.17%) in the control group.

CONCLUSIONS

Evidence based educational outreach visits are more effective than no intervention at all. Results suggest that evidence based educational outreach visits are incrementally more effective than conventional educational sessions, which in turn are more effective than no intervention at all.

Does feedback improve the quality of computerized medical records in primary care?

OBJECTIVE

The MediPlus database collects anonymized information from generalpractice computer systems in the United Kingdom, for research purposes. Data quality markers are collated and fed back to the participating general practitioners. The authors examined whether this feedback had a significant effect on data quality.

METHODS

The data quality markers used since 1992 were examined. The authors determined whether the feedback of "useful" data quality markers led to a statistically significant improvement in these markers. Environmental influences on data quality from outside the scheme were controlled for by examination of the data quality scores of new entrants.

RESULTS

Three quality markers improved significantly over the period of the study. These were the use of highly specific "lower-level" Read Codes (p=0.004) and the linkage of repeat prescriptions (p=0.03) and acute prescriptions (p=0.04) to diagnosis. Clinicians who fall below the target level for linkage of repeat prescriptions to diagnosis receive more detailed feedback; the effect of this was also statistically significant (p<0.01.)

CONCLUSIONS

The feedback of four of the ten markers had a significant effect on data quality. The effect of more detailed feedback appears to have had a greater effect. The lessons learned from this approach may help improve the quality of electronic medical records in the United Kingdom and elsewhere.

Comparison between pediatricians and family practitioners in the use of the prokinetic cisapride for gastroesophageal reflux disease in children

OBJECTIVE

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the European Society of Pediatric Gastroenterology, Hepatology and Nutrition have recently issued treatment guidelines for the use of cisapride in children. Our hypothesis was that cisapride is misused in the community and is not prescribed according to suggested recommendations. Therefore, the aim of this study was to evaluate the knowledge of pediatricians and family practitioners regarding the prescribing practice and adverse effects of cisapride.

METHODS

A standardized questionnaire was sent to a randomly selected group of pediatricians and family practitioners in Northern Israel. The questionnaire was designed to evaluate the knowledge of the physician regarding the treatment of gastroesophageal reflux disease and the use of cisapride in children (indications, dosages, duration of treatment, limitations in certain age groups, the need for pretreatment laboratory tests, interactions with other drugs, and contraindications). Replies were scored from 0 to 100 according to the treatment guidelines of both the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. In addition, 2 questions dealt with the subjective efficacy of the drug and its adverse events.

RESULTS

The knowledge scores were 62% and 51% in the pediatricians and family practitioners, respectively. Other major findings were as follows: 1) 40% of pediatricians and 65% of family practitioners do not prescribe the recommended dose of cisapride, 2) 6% of pediatricians and 42% of family practitioners prescribe cisapride for infantile colic, 3) only 50% of pediatricians and 22% of family practitioners were aware of possible interactions with macrolides, and 4) only 31% of pediatricians and 54% of family practitioners were aware that cisapride might cause prolongation of the QT interval. Only minor adverse events were reported.

CONCLUSIONS

The knowledge of both pediatricians and family practitioners in the use of cisapride in children is suboptimal. It is essential to improve the education of community physicians to reduce the potential for adverse events arising from the misuse of this prokinetic agent.

Prescribing of psychotropics in the elderly: why is it so often inappropriate?

Psychotropic medications are an important treatment approach to mental health disorders; such disorders are common in the elderly population. Elderly patients are more likely to experience adverse effects from these agents than their younger counterparts due to age-related changes in pharmacodynamic and pharmacokinetic parameters. Because of these factors, inappropriate use of psychotropic medications in elderly patients has become a focus of concern. In general an agent is considered inappropriate if the risk associated with its use exceeds its benefit. Implicit and explicit criteria for inappropriate use of medications in the elderly have been created and include psychotropic agents. These criteria vary in their make-up but the explicit criteria tend to agree that amitriptyline, doxepin, and benzodiazepines that have long half-lives are not appropriate. Although explicit inappropriate medication criteria have been in existence since 1991, elderly patients continue to receive inappropriate psychotropic medications. A wide array of factors may be responsible for this practice. Provider-related causes include deficits in knowledge, confusion due to the lack of a consensus on the inappropriate psychotropic criteria, difficulties in addressing an inappropriate medication started by a previous provider, multiple prescribers and pharmacies involved in the care of a patient, negative perceptions regarding aging, and cost issues. Patients may contribute to the problem by demanding an inappropriate medication. Finally, the healthcare setting may inadvertently contribute to inappropriate prescribing by such policies as restrictive formularies or lack of reimbursement for pharmacists' clinical services. Successful approaches to optimising prescribing have been either educational or administrative. Educational approaches (e.g. one-on-one sessions, academic detailing) seek to influence decision making, while administrative approaches attempt to enforce policies to curtail the undesired practice. The US Omnibus Budget Reconciliation Act of 1987, which improved psychotropic medication use in long-term care, is an excellent example of administrative intervention. More research specifically focused on the causes of inappropriate psychotropic medication use and methods to avoid this practice is needed before targeted recommendations can be made.