Rational Prescribing in Primary Care (RaPP-trial). A randomised trial of a tailored intervention to improve prescribing of antihypertensive and cholesterol-lowering drugs in general practice [ISRCTN48751230]

A realist synthesis of educational outreach visiting and integrated academic detailing to influence prescribing in ambulatory care: why relationships and dialogue matter

BACKGROUND

Many quality improvement initiatives in healthcare employ educational outreach visits, integrating academic detailing to bridge evidence-practice gaps and accelerate knowledge translation. Replicability of their outcomes in different contexts varies, and what makes some visiting programmes more successful than others is unclear.

OBJECTIVE

We conducted a realist synthesis to develop theories of what makes educational outreach visiting integrating academic detailing work, for whom, under which circumstances and why, focusing on the clinician-visitor interaction when influencing prescribing of medicines in ambulatory care settings.

METHODS

The realist review was performed in accordance with RAMESES standards. An initial programme theory was generated, academic databases and grey literature were screened for documents with detail on contexts, intervention and outcomes. Using realist logic of analysis, data from 43 documents were synthesised in the generation of a refined programme theory, supported by additional theoretical frameworks of learning and communication.

RESULTS

Twenty-seven interdependent context-mechanism-outcome configurations explain how clinicians engage with educational outreach visits integrating academic detailing through programme design, what matters in programme design and the educational visitor-clinician interaction and how influence extends beyond the visit. They suggest that in addition to relevance, credibility and trustworthiness of a visit's contents, communication and clinical skills of educational visitors, the relationship between the educational visitor and clinician, built on a dialogue of learning from and sense-making with each other, creates conditions of critical thinking which are conducive to facilitating prescribing practice change when necessary.

CONCLUSION

This realist synthesis elucidates that the quality of clinician-educational visitor interactions is pivotal to educational outreach visiting programmes. Building and sustaining relationships, and establishing an open dialogue are important; neglecting these undermines the impact of visits. Educational visitors can facilitate clinicians' reflection on practice and influence their prescribing. Clinicians value the discussion of individualised, tailored information and advice they can translate into their practice.

PROSPERO REGISTRATION NUMBER

CRD42021258199.

The antibiotic prescribing behaviors of physicians are changed via rapid antigen test practice in the context of rational drug use

Background/aim

Rapid antigen test (RAT) is a practical test to detect the presence of Group A beta hemolytic streptococcus antigens in throat swab samples. The aim of this study is to investigate the changes in the empiric antibiotic prescribing behavior of 10 family physicians in Kırıkkale Province after using RAT in 2017.

Materials and methods

RAT test practice started in Family Medicine in February 2017. Family Medicine Information System (FMIS) includes clinical and prescription records of 10 family physicians, providing health service to approximately 35,000 residents in Kırıkkale. The numbers of antibiotics prescribed by the physicians according to the ICD-10 codes (including upper respiratory tract infections) in February, March, and April of 2015, 2016, 2017 were determined. The number and group of antibiotics prescribed by the family physicians with the determined diagnosis and time periods were specified in the FMIS and recorded.

Results

Antibiotic prescription behaviors of family physicians do not show a significant difference between 2015 and 2016. There was a dramatic and significant decrease in the number of prescribed antibiotics in 2017 compared to 2015 and 2016 (P < 0.05).

Conclusion

This study shows that there has been a significant decrease in antibiotic prescription in 10 Family Medicine departments in 2017 in comparison to February, March, and April 2015 and 2016. The use of RAT resulted in a decrease in antibiotic prescription rates in 2017.

Risk scoring for the primary prevention of cardiovascular disease

BACKGROUND

The current paradigm for cardiovascular disease (CVD) emphasises absolute risk assessment to guide treatment decisions in primary prevention. Although the derivation and validation of multivariable risk assessment tools, or CVD risk scores, have attracted considerable attention, their effect on clinical outcomes is uncertain.

OBJECTIVES

To assess the effects of evaluating and providing CVD risk scores in adults without prevalent CVD on cardiovascular outcomes, risk factor levels, preventive medication prescribing, and health behaviours.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2016, Issue 2), MEDLINE Ovid (1946 to March week 1 2016), Embase (embase.com) (1974 to 15 March 2016), and Conference Proceedings Citation Index-Science (CPCI-S) (1990 to 15 March 2016). We imposed no language restrictions. We searched clinical trial registers in March 2016 and handsearched reference lists of primary studies to identify additional reports.

SELECTION CRITERIA

We included randomised and quasi-randomised trials comparing the systematic provision of CVD risk scores by a clinician, healthcare professional, or healthcare system compared with usual care (i.e. no systematic provision of CVD risk scores) in adults without CVD.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected studies, extracted data, and evaluated study quality. We used the Cochrane 'Risk of bias' tool to assess study limitations. The primary outcomes were: CVD events, change in CVD risk factor levels (total cholesterol, systolic blood pressure, and multivariable CVD risk), and adverse events. Secondary outcomes included: lipid-lowering and antihypertensive medication prescribing in higher-risk people. We calculated risk ratios (RR) for dichotomous data and mean differences (MD) or standardised mean differences (SMD) for continuous data using 95% confidence intervals. We used a fixed-effects model when heterogeneity (I²) was at least 50% and a random-effects model for substantial heterogeneity (I² > 50%). We evaluated the quality of evidence using the GRADE framework.

MAIN RESULTS

We identified 41 randomised controlled trials (RCTs) involving 194,035 participants from 6422 reports. We assessed studies as having high or unclear risk of bias across multiple domains. Low-quality evidence evidence suggests that providing CVD risk scores may have little or no effect on CVD events compared with usual care (5.4% versus 5.3%; RR 1.01, 95% confidence interval (CI) 0.95 to 1.08; I² = 25%; 3 trials, N = 99,070). Providing CVD risk scores may reduce CVD risk factor levels by a small amount compared with usual care. Providing CVD risk scores reduced total cholesterol (MD -0.10 mmol/L, 95% CI -0.20 to 0.00; I² = 94%; 12 trials, N = 20,437, low-quality evidence), systolic blood pressure (MD -2.77 mmHg, 95% CI -4.16 to -1.38; I² = 93%; 16 trials, N = 32,954, low-quality evidence), and multivariable CVD risk (SMD -0.21, 95% CI -0.39 to -0.02; I² = 94%; 9 trials, N = 9549, low-quality evidence). Providing CVD risk scores may reduce adverse events compared with usual care, but results were imprecise (1.9% versus 2.7%; RR 0.72, 95% CI 0.49 to 1.04; I² = 0%; 4 trials, N = 4630, low-quality evidence). Compared with usual care, providing CVD risk scores may increase new or intensified lipid-lowering medications (15.7% versus 10.7%; RR 1.47, 95% CI 1.15 to 1.87; I² = 40%; 11 trials, N = 14,175, low-quality evidence) and increase new or increased antihypertensive medications (17.2% versus 11.4%; RR 1.51, 95% CI 1.08 to 2.11; I² = 53%; 8 trials, N = 13,255, low-quality evidence).

AUTHORS' CONCLUSIONS

There is uncertainty whether current strategies for providing CVD risk scores affect CVD events. Providing CVD risk scores may slightly reduce CVD risk factor levels and may increase preventive medication prescribing in higher-risk people without evidence of harm. There were multiple study limitations in the identified studies and substantial heterogeneity in the interventions, outcomes, and analyses, so readers should interpret results with caution. New models for implementing and evaluating CVD risk scores in adequately powered studies are needed to define the role of applying CVD risk scores in primary CVD prevention.

Interventions to improve adherence to cardiovascular disease guidelines: a systematic review

BACKGROUND

Successful management of cardiovascular disease (CVD) is impaired by poor adherence to clinical practice guidelines. The objective of our review was to synthesize evidence about the effectiveness of interventions that target healthcare providers to improve adherence to CVD guidelines and patient outcomes.

METHODS

We searched PubMed, EMBASE, Cochrane Library, PsycINFO, Web of Science and CINAHL databases from inception to June 2014, using search terms related to adherence and clinical practice guidelines. Studies were limited to randomized controlled trials testing an intervention to improve adherence to guidelines that measured both a patient and adherence outcome. Descriptive summary tables were created from data extractions. Meta-analyses were conducted on clinically homogeneous comparisons, and sensitivity analyses and subgroup analyses were carried out where possible. GRADE summary of findings tables were created for each comparison and outcome.

RESULTS AND DISCUSSION

We included 38 RCTs in our review. Interventions included guideline dissemination, education, audit and feedback, and academic detailing. Meta-analyses were conducted for several outcomes by intervention type. Many comparisons favoured the intervention, though only the adherence outcome for the education intervention showed statistically significant improvement compared to usual care (standardized mean difference = 0.58 [95 % confidence interval 0.35 to 0.8]).

CONCLUSIONS

Many interventions show promise to improve practitioner adherence to CVD guidelines. The quality of evidence and number of trials limited our ability to draw conclusions.

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.

Effect of a workshop in rational pharmacotherapy for interns during family medicine clerkship in Samsun- Turkey

OBJECTIVE

We aimed to investigate the effect of rational pharmacotherapy workshop for interns on the rationality, cost and number of drugs prescribed.

METHODS

The participants were asked to prescribe a medication for acute noninflammatory osteoarthritis (ANOA), acute bacterial rhinosinusitis (ARS), acute otitis media (AOM), acute uncomplicated cystitis (AC), and acute bacterial tonsillopharyngitis (ABT) before and after workshop. Total 3000 prescriptions were scored regarding rationality of the drug choice (0-10), format (0-5), instructions (0-4), legibility (0-1) and total (0-20 points). The mean number of drug(s) and total costs per prescription were calculated. Paired samples t-test was used to compare the pre- and post score means.

RESULTS

Total pre- and post-prescribing scores (0-20) were significantly different (p=0.00 for each): ANOA (13.59±0.27, 18.33±0.18), ARS (13.26 ±0.18, 15.15 ±0.17), AOM (12.58 ± 0.26, 14.66±0.27), AC (13.53±0.17, 15.76±0.20), ABT (13.54±0.24, 15.49 ±0.28). Mean number of drugs per prescription for the indications in the pre-test and post-test were: ANOA (1.24 ±0.29, 1.02±0.01, p=0.00), ARS (2.08±0.04, 2.00±0.04, p=0.16), AOM (1.66±0.04 and 1.69±0.03, p=0.54), AC (1.55±0.04, 1.39±0.03, p=0.00) and ABT (2.10±0.05, 1.81±0.05, p=0.00). Mean costs per prescription in Turkish Liras: ANOA (6.31±0.29, 4.60±0.05, p=0.00), ARS (13.80±0.38, 4.63±0.04, p=0.00), AOM (10.18±0.28, 4.41±0.07, p=0.00), AC (11.33±0.21, 10.68±0.18, p=0.01) and ABT (12.03±0.34 and 10.41±0.35, p=0.00).

CONCLUSION

Training produced a significant improvement in rational prescribing.

Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (prescription peer academic detailing (Rx-PAD) study)

OBJECTIVE

To assess the effects of a multifaceted educational intervention in Norwegian general practice aiming to reduce antibiotic prescription rates for acute respiratory tract infections and to reduce the use of broad spectrum antibiotics.

DESIGN

Cluster randomised controlled study.

SETTING

Existing continuing medical education groups were recruited and randomised to intervention or control.

PARTICIPANTS

79 groups, comprising 382 general practitioners, completed the interventions and data extractions.

INTERVENTIONS

The intervention groups had two visits by peer academic detailers, the first presenting the national clinical guidelines for antibiotic use and recent research evidence on acute respiratory tract infections, the second based on feedback reports on each general practitioner's antibiotic prescribing profile from the preceding year. Regional one day seminars were arranged as a supplement. The control arm received a different intervention targeting prescribing practice for older patients.

MAIN OUTCOME MEASURES

Prescription rates and proportion of non-penicillin V antibiotics prescribed at the group level before and after the intervention, compared with corresponding data from the controls.

RESULTS

In an adjusted, multilevel model, the effect of the intervention on the 39 intervention groups (183 general practitioners) was a reduction (odds ratio 0.72, 95% confidence interval 0.61 to 0.84) in prescribing of antibiotics for acute respiratory tract infections compared with the controls (40 continuing medical education groups with 199 general practitioners). A corresponding reduction was seen in the odds (0.64, 0.49 to 0.82) for prescribing a non-penicillin V antibiotic when an antibiotic was issued. Prescriptions per 1000 listed patients increased from 80.3 to 84.6 in the intervention arm and from 80.9 to 89.0 in the control arm, but this reflects a greater incidence of infections (particularly pneumonia) that needed treating in the intervention arm.

CONCLUSIONS

The intervention led to improved antibiotic prescribing for respiratory tract infections in a representative sample of Norwegian general practitioners, and the courses were feasible to the general practitioners.

TRIAL REGISTRATION

Clinical trials NCT00272155.

Change in antihypertensive drug prescribing after guideline implementation: a controlled before and after study

Background

Antihypertensive drug choices and treatment levels are not in accordance with the existing guidelines. We aimed to assess the impact of a guideline implementation intervention on antihypertensive drug prescribing.

Methods

In this controlled before and after study, the effects of a multifaceted (education, audit and feedback, local care pathway) quality programme was evaluated. The intervention was carried out in a health centre between 2002 and 2003. From each health care unit (n = 31), a doctor-nurse pair was trained to act as peer facilitators in the intervention.

All antihypertensive drugs prescribed by 25 facilitator general practitioners (intervention GPs) and 53 control GPs were retrieved from the nationwide Prescription Register for three-month periods in 2001 and 2003. The proportions of patients receiving specific antihypertensive drugs and multiple antihypertensive drugs were measured before and after the intervention for three subgroups of hypertension patients: hypertension only, with coronary heart disease, and with diabetes.

Results

In all subgroups, the use of multiple concurrent medications increased. For intervention patients with hypertension only, the odds ratio (OR) was 1.12 (95% CI 0.99, 1.25; p = 0.06) and for controls 1.13 (1.05, 1.21; p = 0.002). We observed no statistically significant differences in the change in the prescribing of specific antihypertensive agents between the intervention and control groups. The use of agents acting on the renin-angiotensin-aldosterone system increased in all subgroups (hypertension only intervention patients OR 1.19 (1.06, 1.34; p = 0.004) and controls OR 1.24 (1.15, 1.34; p < 0.0001).

Conclusions

A multifaceted guideline implementation intervention does not necessarily lead to significant changes in prescribing performance. Rigorous planning of the interventions and quality projects and their evaluation are essential.

Lipid-lowering drugs in ischaemic heart disease: a quasi-experimental uncontrolled before-and-after study of the effectiveness of clinical practice guidelines

Background

Cardiovascular diseases(CVD), specifically ischaemic heart disease(IHD), are the main causes of death in industrialized countries. Statins are not usually prescribed in the most appropriate way. To ensure the correct prescription of these drugs, it is necessary to develop, disseminate and implement clinical practice guidelines(CPGs), and subsequently evaluate them.

The main objective of this study is to evaluate the effectiveness of the implementation of consensual Lipid-lowering drugs (LLD) prescription guidelines in hospital and primary care settings, to improve the control of Low-Density Lipoprotein Cholesterol (LDL-C) levels in patients with IHD in the Terres de l'Ebre region covered by the Catalonian Health Institute. Secondary objectives are to assess the improvement of the prescription profile of these LLDs, to assess cardiovascular morbimortality and the professional profile and participant centre characteristics that govern the control of LDL-C.

Methods/Design

Design: Quasi-experimental uncontrolled before and after study. The intervention consists of the delivery of training strategies for guideline implementation (classroom clinical sessions and on-line courses) aimed at primary care and hospital physicians. The improvement in the control of LDL-C levels in the 3,402 patients with IHD in our territory is then assessed.

Scope: Primary care physicians from 11 basic health areas(BHAs) and two hospital services (internal medicine and cardiology).

Sample: 3,402 patients registered with IHD in the database of the Catalan Institute of Health(E-cap) before December 2008 and patients newly diagnosed during 2009-2010.

Variables: Percentage of patients achieving good control of LDL-C, measured in milligrams per decilitre. The aim of the intervention is to achieve levels of LDL-C < 100 mg/dl in patients with IHD. Secondary variables measure type and time of diagnosis of IHD, type and dose of prescribed cholesterol-lowering drugs, level of physician participation in training activities and their professional profile.

Discussion

The development of prescription guidelines previously agreed by various medical specialists involved in treating IHD patients have usually improved drug prescription. The guideline presented in this study aims to improve the control of LDL-C by training physicians through presential and on-line courses on the dissemination of this guideline, and by providing feedback on their personal results a year after this training intervention.

Potential value of electronic prescribing in health economic and outcomes research

Improving access and quality while reducing expenditures in the United States health system is expected to be a priority for many years. The use of health information technology (HIT), including electronic prescribing (eRx), is an important initiative in efforts aimed at improving safety and outcomes, increasing quality, and decreasing costs. Data from eRx has been used in studies that document reductions in medication errors, adverse drug events, and pharmacy order-processing time. Evaluating programs and initiatives intended to improve health care can be facilitated through the use of HIT and eRx. eRx data can be used to conduct research to answer questions about the outcomes of health care products, services, and new clinical initiatives with the goal of providing guidance for clinicians and policy makers. Given the recent explosive growth of eRx in the United States, the purpose of this manuscript is to assess the value and suggest enhanced uses and applications of eRx to facilitate the role of the practitioner in contributing to health economics and outcomes research.

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.

SUPPORT Tools for evidence-informed health Policymaking (STP) 12: Finding and using research evidence about resource use and costs

This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers.

In this article, we address considerations about resource use and costs. The consequences of a policy or programme option for resource use differ from other impacts (both in terms of benefits and harms) in several ways. However, considerations of the consequences of options for resource use are similar to considerations related to other impacts in that policymakers and their staff need to identify important impacts on resource use, acquire and appraise the best available evidence regarding those impacts, and ensure that appropriate monetary values have been applied. We suggest four questions that can be considered when assessing resource use and the cost consequences of an option. These are: 1. What are the most important impacts on resource use? 2. What evidence is there for important impacts on resource use? 3. How confident is it possible to be in the evidence for impacts on resource use? 4. Have the impacts on resource use been valued appropriately in terms of their true costs?

Identification of medication-related problems and health care provider acceptance of pharmacist recommendations in the DiabetesCARE program

OBJECTIVES

To evaluate the efficacy of pharmacist recommendations to health care providers, as part of PharmacistCARE, a single-center, pharmacist-run, diabetes medication therapy management (MTM) service. If the recommendation was accepted, a secondary objective was to measure the length of time for acceptance.

DESIGN

Prospective assessment.

SETTING

University of Kentucky (UK), from March 2003 through December 2006.

PATIENTS

172 adult patients with diabetes enrolled in the UK Health Plan who participated in the DiabetesCARE program.

INTERVENTION

Pharmacists provided medication therapy-related recommendations to health care providers.

MAIN OUTCOME MEASURES

Acceptance of pharmacist recommendations by health care providers, length of time to acceptance, and cost savings attained with formulary recommendations.

RESULTS

A total of 692 recommendations were sent to health care providers; 425 (61.4%) were accepted. A total of 578 clinical recommendations were related to drug therapy problems; 348 (60.2%) were accepted by health care providers. Median time to acceptance for clinical recommendations was 13.5 days (0-229). Formulary recommendations accounted for 114 (16%) of the total recommendations, 77 (67.5%) were accepted, and median time to acceptance was 47.2 days (0-172). Average monthly cost savings per accepted formulary recommendation was $13.59 for the health plan and $13.85 for the patient.

CONCLUSION

A similar percentage of health care provider acceptance (61.4%) was seen compared with previous studies of pharmacists' interventions in different practice settings. To our knowledge, this is the first study to evaluate time to acceptance of pharmacist recommendations to health care providers, including the resolutions made through collaborative drug therapy management. Lastly, the current study reinforces the assertion that pharmacists can positively affect cost savings for both the patient and health plan, through formulary management.

A cluster randomized controlled trial of a clinical pathway for hospital treatment of heart failure: study design and population

BACKGROUND

The hospital treatment of heart failure frequently does not follow published guidelines, potentially contributing to the high morbidity, mortality and economic cost of this disorder. Consequently the development of clinical pathways has the potential to reduce the current variability in care, enhance guideline adherence, and improve outcomes for patients. Despite enthusiasm and diffusion, the widespread acceptance of clinical pathways remain questionable because very little prospective controlled data demonstrated their effectiveness. The Experimental Prospective Study on the Effectiveness and Efficiency of the Implementation of Clinical Pathways was designed in order to conduct a rigorous evaluation of clinical pathways in hospital treatment of acute heart failure. The primary objective of the trial was to evaluate the effectiveness of the implementation of clinical pathways for hospital treatment of heart failure in Italian hospitals.

METHODS/DESIGN

Two-arm, cluster-randomized trial. 14 community hospitals were randomized either to arm 1 (clinical pathway: appropriate use of practice guidelines and supplies of drugs and ancillary services, new organization and procedures, patient education, etc.) or to arm 2 (no intervention, usual care). 424 patients sample (212 in each group), 80% of power at the 5% significance level (two-sided). The primary outcome measure is in-hospital mortality. We will also analyze the impact of the clinical pathways comparing the length and the appropriateness of the stay, the rate of unscheduled readmissions, the customers' satisfaction and the costs treating the patients with the pathways and with the current practice along all the observation period. The quality of the care will be assessed by monitoring the use of diagnostic and therapeutic procedures during hospital stay and by measuring key quality indicators at discharge.

DISCUSSION

This paper examines the design of the evaluation of a complex intervention. Since clinical pathways are made up of various interconnecting parts we have chosen the cluster-randomized controlled trial because is widely accepted as the most reliable method of determining effectiveness when measuring cost-effectiveness in real practice.

TRIAL REGISTRATION

ClinicalTrials.gov ID [NCT00519038].

Can antibiotic prescriptions in respiratory tract infections be improved? A cluster-randomized educational intervention in general practice--the Prescription Peer Academic Detailing (Rx-PAD) Study [NCT00272155]

Background

More than half of all antibiotic prescriptions in general practice are issued for respiratory tract infections (RTIs), despite convincing evidence that many of these infections are caused by viruses. Frequent misuse of antimicrobial agents is of great global health concern, as we face an emerging worldwide threat of bacterial antibiotic resistance. There is an increasing need to identify determinants and patterns of antibiotic prescribing, in order to identify where clinical practice can be improved.

Methods/Design

Approximately 80 peer continuing medical education (CME) groups in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, evidence-based recommendations of antibiotic prescriptions for RTIs will be presented and software will be handed out for installation in participants PCs, enabling collection of prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Main outcomes are baseline proportion of inappropriate antibiotic prescriptions for RTIs and change in prescription patterns compared to baseline one year after the initiation of the tailored pedagogic intervention.

Discussion

Improvement of prescription patterns in medical practice is a challenging task. A thorough evaluation of guidelines for antibiotic treatment in RTIs may impose important benefits, whereas inappropriate prescribing entails substantial costs, as well as undesirable consequences like development of antibiotic resistance. Our hypothesis is that an educational intervention program will be effective in improving prescription patterns by reducing the total number of antibiotic prescriptions, as well as reducing the amount of broad-spectrum antibiotics, with special emphasis on macrolides.

A cluster-randomized educational intervention to reduce inappropriate prescription patterns for elderly patients in general practice--The Prescription Peer Academic Detailing (Rx-PAD) study [NCT00281450]

Background

Age-related alterations in metabolism and excretion of medications increase the risk of adverse drug events in the elderly. Inappropriate polypharmacy and prescription practice entails increased burdens of impaired quality of life and drug related morbidity and mortality. The main objective of this trial is to evaluate effects of a tailored educational intervention towards general practitioners (GPs) aimed at supporting the implementation of a safer drug prescribing practice for elderly patients ≥ 70 years.

Methods/design

Approximately 80 peer continuing medical education (CME) groups (about 600 GPs) in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. The control group will not receive any intervention towards prescription patterns in elderly, but will be the target of an educational intervention for prescription of antibiotics for respiratory tract infections. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, a set of quality indicators (QIs), i.e. explicit recommendations for safer prescribing for elderly patients, will be presented and discussed. Software will be handed out for installation in participants' practice computers to enable extraction of pre-defined prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Feedback reports will include QI-scores on individual- and group levels, before and after the intervention. The main outcome of this trial is the change in proportions of inappropriate prescriptions (QIs) for elderly patients ≥ 70 years following intervention, compared to baseline levels.

Discussion

Improvement of prescription patterns in medical practice is a challenging task. Evidence suggests that a thorough evaluation of diagnostic indications for drug treatment in the elderly and/or a reduction of potentially inappropriate drugs may impose significant clinical benefits. Our hypothesis is that an educational intervention program will be effective in improving prescribing patterns for elderly patients in GP settings.

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.

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

BACKGROUND

Strategies to implement change in health professional performance have variable impact. A potential explanation is that the barriers to implementation are different in different settings and at different times. Change may be more likely if the strategies were specifically chosen to address the identified barriers.

OBJECTIVES

To assess the effectiveness of strategies tailored to address specific, identified barriers to change in professional performance.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register and pending files until end of December 2002. English language articles only were included.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed quality. We also contacted study authors to obtain any missing information. Quantitative and qualitative analyses were undertaken.

MAIN RESULTS

We included 15 studies. For Comparison 1 (an intervention tailored to address identified barriers to change compared to no intervention or an intervention(s) not tailored to the barriers), there was no consistency in the results and the effect sizes varied both across and within studies.A meta-regression of a subset of the included studies, using a classical approach estimated a combined OR of 2.18 (95% CI: 1.09, 4.34), p = 0.026 in favour of tailored interventions. However, when a Bayesian approach was taken, meta-regression gave a combined OR of 2.27 (95% Credible Interval: 0.92, 4.75), which was not statistically significant.

AUTHORS' CONCLUSIONS

Interventions tailored to prospectively identify barriers may improve care and patient outcomes. However, from the studies included in this review, we were unable to determine whether the barriers were valid, which were the most important barriers, whether all barriers were identified and if they had been addressed by the intervention chosen. Based on the evidence presented in this review, the effectiveness of tailored interventions remains uncertain and more rigorous trials (including process evaluations) are needed. Further research needs to address explicitly the questions of identifying and addressing barriers.

Improving prescribing of antihypertensive and cholesterol-lowering drugs: a method for identifying and addressing barriers to change

BACKGROUND

We describe a simple approach we used to identify barriers and tailor an intervention to improve pharmacological management of hypertension and hypercholesterolaemia. We also report the results of a post hoc exercise and survey we carried out to evaluate our approach for identifying barriers and tailoring interventions.

METHODS

We used structured reflection, searched for other relevant trials, surveyed general practitioners and talked with physicians during pilot testing of the intervention. The post hoc exercise was carried out as focus groups of international researchers in the field of quality improvement in health care. The post hoc survey was done by telephone interviews with physicians allocated to the experimental group of a randomised trial of our multifaceted intervention.

RESULTS

A wide range of barriers was identified and several interventions were suggested through structured reflection. The survey led to some adjustments. Studying other trials and pilot testing did not lead to changes in the design of the intervention. Neither the post hoc focus groups nor the post hoc survey revealed important barriers or interventions that we had not considered or included in our tailored intervention.

CONCLUSIONS

A simple approach to identifying barriers to change appears to have been adequate and efficient. However, we do not know for certain what we would have gained by using more comprehensive methods and we do not know whether the resulting intervention would have been more effective if we had used other methods. The effectiveness of our multifaceted intervention is under evaluation in a randomised controlled trial.

Assessment of cardiovascular risk and choice of antihypertensive therapy

Indications, choices of therapy, and goals of treatment for hypertension should be closely linked to the multivariate risk of cardiovascular events and ingredients of the vascular risk profile of patients with hypertension. Hypertension commonly occurs in combination with other cardiovascular disease risk factors, and the burden of the associated risk factors greatly affects the impact of elevated blood pressure and usually requires choices of specific antihypertensive agents shown to be particularly efficacious in the context of the associated risk factors or vascular conditions present. Guidelines assign highest priority to rigorous control of the blood pressure. Risk associated with hypertension has been shown to be incremental, with the level of blood pressure extending down to what was formerly considered the high-normal blood pressure range. In this "prehypertensive" state, drug treatment is justified only if the multivariate risk is substantial or there is target-organ damage. Most individuals with the metabolic syndrome, a condition commonly associated with hypertension, and singled out as an important consideration for treatment, are usually identified by the Framingham multivariate risk formulation. They require weight control and exercise, as well as specific choices of antihypertensive agents.

Back to thiazide-diuretics for hypertension: reflections after a decade of irrational prescribing

BACKGROUND

Whether newer antihypertensive drugs, such as calcium channel blockers, angiotensin converting enzyme inhibitors and alpha blockers are more effective than thiazides and beta blockers in preventing coronary disease, has been debated for years.

DISCUSSION

Recently several trials addressing this issue have been finalised, and they provide a convincing answer: the newer drugs are no better than the older ones. In the largest trial to date (ALLHAT), thiazide-type diuretic was found to offer advantages over newer drugs. The medical community should now be capable of reaching consensus, and recommend thiazides as the first line therapy for the treatment of hypertension. Prescribing physicians, cardiologists, drug companies and health authorities are all partly responsible for the years of irrational prescribing that we have witnessed.

SUMMARY

All stakeholders should now contribute in order to achieve what is clearly in the public's interest: implementing the use of thiazides in clinical practice.

The potential of electronic medical record systems to support quality improvement work and research in Norwegian general practice

BACKGROUND

Electronic medical record (EMR) systems are used for many purposes including patient care, administration, research, quality improvement and reimbursement. This study aimed to test a data extraction tool (QTools) and to provide information to support the interpretation of EMR data.

METHODS

Comparison of aggregated practice data for selected EMR fields and interviews with practice staff. Practices received summaries of their data and aggregated data for other practices. Summaries were discussed in interviews.

RESULTS

Fourteen general practices in the Oslo area using the Winmed EMR participated. QTools ran successfully at all 14 practices. Nine practices agreed to interviews. Apart from age and sex, general patient information was poorly recorded. Face-to-face consultations account for 59% of contacts but differences in coding led to variations between practices. Psychiatric problems accounted for 13% of diagnoses, other diagnosis groups rarely accounted for more than 5%. Over 90% of diabetics and 75% of patients with heart disease were identified by diagnosis code alone.

CONCLUSION

Some variation seen in EMR data is due to differences in the way staff use their EMR. These data can support quality improvement work but this requires an awareness of how the EMR is actually used by practice staff.