Primary care prescribing patterns in Ireland after the publication of large hypertension trials

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review.

OBJECTIVES

To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes.

SEARCH METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies.

MAIN RESULTS

We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend.

AUTHORS' CONCLUSIONS

The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Utilization Study of Antihypertensives in a South Indian Tertiary Care Teaching Hospital and Adherence to Standard Treatment Guidelines

AIM

Hypertension represents a major health problem primarily because of its role in contributing to the initiation and progression of major cardiovascular diseases. Concerns pertaining to hypertension and its sequelae can be substantially addressed and consequent burden of disease reduced by early detection and appropriate therapy of elevated blood pressure. This cross-sectional observational study aims at analyzing the utilization pattern of antihypertensives used for the treatment of hypertension at a tertiary care hospital in perspective of standard treatment guidelines.

MATERIALS AND METHODS

Prescriptions were screened for antihypertensives at the medicine outpatient department of a tertiary care teaching hospital. Medical records of the patients were scrutinized after which 286 prescriptions of patients suffering from hypertension were included. The collected data were sorted and analyzed on the basis of demographic characteristics and comorbidities.

RESULTS

The calcium channel blockers were the most frequently used antihypertensive class of drugs (72.3%). Amlodipine (55.6%) was the single most frequently prescribed antihypertensive agent. The utilization of thiazide diuretics was 9%. Adherence to the National List of Essential Medicines (NLEMs) was 65%. The combination therapy was used more frequently (51.5%) than monotherapy (48.8%). The use of angiotensin-converting enzyme inhibitors/angiotensin 2 receptor blockers (ACE-I/ARB) was 41.4% in diabetes.

CONCLUSIONS

The treatment pattern, in general, conformed to standard treatment guidelines. Few areas, however, need to be addressed such as the underutilization of thiazide diuretics, need for more awareness of drugs from the NLEMs and enhanced use of ACE-I/ARB in diabetic hypertensives.

Modelling Coronary Heart Disease Mortality declines in the Republic of Ireland, 1985-2006

BACKGROUND

Consistent declines in coronary heart disease (CHD) death rates have been previously observed in Ireland since 1985.

AIMS & METHODS

To use the previously validated Irish IMPACT CHD mortality model to further examine the subsequent CHD mortality falls from 1985 through to 2006, and to determine the contribution of risk factor changes and "evidence based" treatments to this decline by age and gender.

RESULTS

CHD mortality rates fell by 68% in men (63% in 65-84 years) and by 69% in women (66% in 65-84 years). This resulted in approximately 6450 fewer CHD deaths than if mortality rates had not changed. Overall, approximately 40% (38% in men; 45% in women) of the CHD mortality decline could be attributed to improvements in treatment uptake, particularly secondary prevention (12%), angina (9%), and heart failure therapies (8%). Approximately 48% of the CHD mortality decline was attributable to risk factor improvements (54% in men; 37% in women); the biggest contributions came from falls in population systolic pressure (28%), cholesterol (24%), and physical inactivity levels (10%). Negative trends in diabetes and obesity levels generated an estimated 17% additional CHD deaths. The largest benefits from improvements in risk factors were seen in men aged 25-64 years, while the greatest treatment benefits occurred in women aged 65-84 years. The model explained approximately 88% of the observed mortality declines.

CONCLUSION

Falls in CHD mortality have continued in both sexes in Ireland, but with notable gender and age differences. The continued increase in diabetes and obesity levels is particularly worrying.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines.

OBJECTIVES

To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes.

SEARCH METHODS

For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format.

MAIN RESULTS

The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness.

AUTHORS' CONCLUSIONS

The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Trends in co-prescribing of angiotensin converting enzyme inhibitors and angiotensin receptor blockers in Ireland

AIMS

(i) To examine the trends in co-prescribing of angiotensin converting enzyme inhibitor (ACEI) and angiotensin-II receptor blocker (ARB) therapy and (ii) to examine the influence of major clinical trials (CALM, COOPERATE, VALIANT and ONTARGET) on co-prescribing.

METHODS

The Irish HSE-Primary Care Reimbursement Services database was used to identify patients ≥16 years old co-prescribed ACEIs and ARBs between January 2000 and April 2009 (n= 266 554 prescriptions). The rate of prescribing per 1000 general medical services (GMS) scheme population was calculated for each month. Patients with diabetes, hypertension, heart failure and ischaemic heart disease were also identified by prescribing of certain medications. A linear trend test was used to examine prescribing trends. Logistic regression was used to examine prescribing according to patient characteristics. The effects of the major trials on prescribing were examined using segmented regression analysis for 12 months pre- and post-trials.

RESULTS

There was a significant linear trend in overall ACEI and ARB co-prescribing over the study period (P < 0.001). Rate of co-prescribing in January 2000 and April 2009 was 0.16 and 5.72, per 1000 eligible population, respectively. Those 45-64 years old (OR = 2.88, 95% confidence interval (CI) 2.71, 3.06) and ≥65 years (OR = 2.52, 95% CI 2.36, 2.68) were more likely to receive dual therapy compared with those <45 years old. Those with hypertension (OR = 8.85, 95% CI 8.45, 9.27), diabetes (OR = 4.10, 95% CI 3.97, 4.23) and heart failure (OR = 1.78, 95% CI 1.72, 1.84) were more likely to receive dual therapy compared with the general population. Significant increases in prescribing were observed only after the CALM (P= 0.03) and VALIANT (P= 0.007) trials.

CONCLUSION

Increased co-prescribing of ACEIs and ARBs was observed in Ireland during 2000-09. Prescribing patterns did not appear to be affected by results from major trials.

Individuals at risk of beta-blocker discontinuation: a cohort study in 19,177 Chinese patients

PURPOSE

This cohort study evaluated the factors associated with discontinuation of antihypertensive pharmacotherapy among Chinese patients who were prescribed beta-blockers. We tested the hypothesis that patients' age, gender, socioeconomic status, clinical settings and the number of comorbidities were significantly associated with the discontinuation of beta-blockers.

METHODS

From a validated clinical database we included all adult patients 18 years or older who were prescribed a beta-blocker in any government primary care clinic in one large territory of Hong Kong during 01 January 2004-30 June 2007. We evaluated the cumulative incidence of drug discontinuation within 180 days of the prescriptions and the factors associated with discontinuation of beta-blockers by multivariable regression analysis.

RESULTS

From a total of 19,177 eligible patients (mean age = 59.1 years), 20.8% discontinued their medication. Younger patients [aged <50 years; adjusted odds ratios (aOR) 0.41-0.52 for patients aged >or=50 years; p < 0.001], female gender (aOR 0.87 for males, p = 0.001), fee-waivers (aOR 0.78 for fee-payers, p < 0.001), attendances in family medicine specialist clinics (FMSC) (aOR 1.49, p < 0.001) and staff clinics (aOR 2.32, p < 0.001), residence in more urbanized areas (aOR 0.80 for North District, p < 0.001), new visits (aOR 0.55 for follow-up visits, p < 0.001) and absence of concomitant comorbidities (aOR 0.60 for one comorbidity, p < 0.001; aOR 0.56 for two comorbidities, p = 0.002) were positively associated with drug discontinuation.

CONCLUSIONS

Patients who were prescribed beta-blockers with these associated factors should be monitored more closely for antihypertensive drug adherence.

Significant psychological morbidity occurs in irritable bowel syndrome: a case-control study using a pharmacy reimbursement database

BACKGROUND

Psychological problems are associated with IBS but the strength of this association is unclear.

AIM

To assess co-prescribing of antispasmodic and CNS-acting drugs through a nested case-control study.

METHODS

A national dispensing database identified patients who were first dispensed antispasmodic medicines for a continuous 3-month period or more during 2006, using 2005 as a run-in period. Each patient was matched with four control patients and excluded if they received drugs indicated for IBD.

RESULTS

Four hundred and seven patients commenced antispasmodic drugs during 2006. These patients were matched with 1628 controls. In 2005, patients subsequently prescribed antispasmodics were 2-3 times more likely to receive CNS-acting drugs than controls. In the year following commencement of IBS therapy, patients were 2-4 times more likely than controls to be prescribed CNS-acting drugs including antidepressants (35.4% vs. 9.3%), anxiolytics (27.8% vs. 8.8%), antipsychotics (9.8% vs. 3.3%) and hypno-sedatives (32.7% vs. 11.3%; P < 0.0001). The adjusted OR (95% CI) for antidepressant, anxiolytic, hypnosedative and antipsychotic prescribing in IBS patients were 3.81 (2.79-5.20), 2.84 (2.12-3.81), 2.62 (1.91-3.60) and 2.58 (1.80-3.66), respectively.

CONCLUSIONS

Patients prescribed ongoing therapy for presumed IBS are 2-4 times more likely to be prescribed CNS-acting drugs than controls, providing evidence of psychological comorbidity in IBS.

Patterns of antihypertensive prescribing, discontinuation and switching among a Hong Kong Chinese population from over one million prescriptions

To evaluate the prescription, discontinuation and switching profiles of antihypertensive agents, we studied computerized records for patients prescribed antihypertensive drugs in government primary care clinics of Hong Kong between January 2004 and June 2007, which include 1069836 antihypertensive drug visits (representing 67028 patients). The most commonly prescribed drugs were calcium channel blockers (CCBs, 49%), beta-blockers (BBs, 46%) and angiotensin-converting enzyme inhibitors (ACEIs, 19%). Although thiazide diuretic prescribing was low (13%) and on the decline (from 14% in 2004 to 12% in 2007), prescription of ACEIs was rising (from 16% in 2004 to 23% in 2007); drug discontinuation was highest for BBs (21%) and lowest for CCBs (12%) and the high rates of discontinuation in BBs remained apparent after controlling for confounders. CCBs may be particularly favourable antihypertensive drugs in Chinese and the low use of thiazide diuretics warrants further clinical and cost effectiveness studies among Chinese.

Choice of first antihypertensive--are existing guidelines ignored?

AIMS

To determine adherence to hypertension guidelines in relation to age and diabetes.

METHODS

The Irish HSE-PCRS prescribing database identified patients initiating antihypertensive monotherapy in 2005. Logistic regression predicted the likelihood of therapy according to guidelines.

RESULTS

The odds ratio (OR) of receiving therapies according to the guideline recommendations in those <55 years vs. > or =55 years was 1.31 (95% CI 1.26, 1.37). Diabetics were more likely than nondiabetics to receive antihypertensives other than beta-adrenoceptor blockers (OR 2.97, 95% CI 2.74, 3.21).

CONCLUSIONS

Our findings show some adherence to the guidelines in relation to age but selective prescribing of antihypertensives for diabetics.