Controlled trial evaluation of a General Practitioner education package on incontinence: use of a mailed questionnaire

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

Background

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

Methods

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

Results

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

Conclusions

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

What is the effectiveness of printed educational materials on primary care physician knowledge, behaviour, and patient outcomes: a systematic review and meta-analyses

BACKGROUND

Printed educational materials (PEMs) are commonly used simple interventions that can be used alone or with other interventions to disseminate clinical evidence. They have been shown to have a small effect on health professional behaviour. However, we do not know whether they are effective in primary care. We investigated whether PEMs improve primary care physician (PCP) knowledge, behaviour, and patient outcomes.

METHODS

We conducted a systematic review of PEMs developed for PCPs. Electronic databases were searched for randomized controlled trials, quasi randomized controlled trials, controlled before and after studies, and interrupted time series. We combined studies using meta-analyses when possible. Statistical heterogeneity was examined, and meta-analysis was performed using a random effects model when significant statistical heterogeneity was present and a fixed effects model otherwise. The template for intervention description and replication (TIDieR) checklist was used to assess the quality of intervention description.

RESULTS

Our search identified 12,439 studies and 40 studies met our inclusion criteria. We combined outcomes from 26 studies in eight meta-analyses. No significant effect was found on clinically important patient outcomes, physician behaviour, or physician cognition when PEMs were compared to usual care. In the 14 studies that could not be included in the meta-analyses, 14 of 71 outcomes were significantly improved following receipt of PEMs compared to usual care. Most studies lacked details needed to replicate the intervention.

CONCLUSIONS

PEMs were not effective at improving patient outcomes, knowledge, or behaviour of PCPs. Further trials should explore ways to optimize the intervention and provide detailed information on the design of the materials.

PROTOCOL REGISTRATION

PROSPERO, CRD42013004356.

Effectiveness of educational interventions to raise men's awareness of bladder and bowel health

BACKGROUND

Urinary incontinence is a common health problem with significant medical, psychological and economic burdens. Health education is capable of improving perceptions about and attitudes towards incontinence in turn encouraging them to seek help.

AIM

The aim of the present study was to determine the effectiveness of educational interventions at raising men's awareness of bladder and bowel health.

INCLUSION CRITERIA

Types of participants. Adult and adolescent men (age 12 years and over) and it was anticipated that some interventions/promotions may be directed at family members or carers of, and health professionals caring for, adult men and therefore these would also be considered for inclusion. Types of intervention. Any intervention, program or action that provided information, or attempted to raise awareness of men's bladder and bowel health. Type of outcome. Any measure defined by included studies such as: bladder and bowel management and treatment, increased knowledge of bladder and bowel health and number of attendees at promotion. Type of studies. Concurrent controls, such as: systematic reviews of concurrently controlled trials, meta-analysis, randomised controlled trials, controlled clinical trials, interrupted time series and controlled before after designs and observational design (cohort, case-control). Search strategy. A search for published and unpublished studies in the English language was undertaken restricted by a publication date of 10 years prior, with the exception of a review of seminal papers before this time.

METHODOLOGICAL QUALITY

Each study was appraised independently by two reviewers using the standard Joanna Briggs Institute instruments.

DATA COLLECTION AND ANALYSIS

Information was extracted from studies meeting quality criteria using the standard Joanna Briggs Institute tools. For two studies with similar population types, interventions and outcomes quantitative results were combined into a meta-analysis using Revman 5.0 software. However, the majority of studies were heterogenous and results are presented in a narrative form.

RESULTS

With the exception of instruction for pelvic floor muscle exercises for men after prostatectomy, little quantitative research has been performed that establishes the effectiveness of interventions on men's awareness of bladder and bowel health. While numerous interventions have been trialled on mixed gender populations, and these trials suggest that the interventions would be effective, their effectiveness on the male component cannot be definitively established.

CONCLUSION

There is little quantitative evidence for the effectiveness of interventions to improve men's awareness of bladder and bowel health therefore few recommendations can be made. Well-designed controlled trials using male sample populations only are needed.

Effectiveness of educational interventions to raise men's awareness of bladder and bowel health

EXECUTIVE SUMMARY

Urinary incontinence (UI) has been defined as a condition in which the involuntary loss of urine is a social or hygienic problem and is objectively demonstrable. Urinary incontinence is a common health problem that carries with it significant medical, psychosocial and economic burdens. Fecal incontinence has been defined as the involuntary or inappropriate passing of liquid or solid stool and can also include the incontinence of flatus. Studies suggest that twice as many men suffer from fecal incontinence compared to urinary incontinence whilst more than three times as many women suffer from urinary incontinence compared to fecal incontinence. The general consensus in the literature is that barriers exist for seeking help for those with incontinence. REVIEW QUESTION: 'How effective are educational interventions at raising men's awareness of bladder and bowel health?'

TYPES OF PARTICIPANTS

Adult and adolescent males (age 12 years and over).

TYPES OF INTERVENTIONS

Any intervention, program or action that provided information, or attempted to raise awareness of men's bladder and bowel health.

TYPES OF OUTCOME MEASURES

The primary outcomes of interest included any measure defined by included studies such as: TYPES OF STUDIES: As this review attempted to evaluate the effectiveness of an intervention or interventions, reviewers considered studies using concurrent controls.

SEARCH STRATEGY

The search strategy was designed to identify both published and unpublished material and was restricted to English language publications with a publication date of 10 years prior to the search with the exception of a review of seminal papers before this time.

ASSESSMENT OF METHODOLOGICAL QUALITY

The quality of included studies was assessed by two reviewers using the Joanna Briggs Institute Checklists for experimental and observational studies.

DATA EXTRACTION

For each included paper the type of information that was extracted and tabulated in a database followed the JBI Data Extraction Form for Experimental and Observational Studies.

DATA SYNTHESIS

Where possible relative risk (RR), odds ratios (OR), Mean differences and associated 95% confidence intervals (95% CI) were calculated from individual studies. For homogeneous studies quantitative results were combined into a meta-analysis for evaluation of the overall effect of an intervention. Where heterogeneity existed between studies the results were presented in a narrative summary.

REVIEW RESULTS

The review identified 12 RCT and 2 controlled trials. Ten studies evaluated the effectiveness of interventions on the incidence of urinary incontinence symptoms in men after prostatectomy Only two trials examined interventions to manage post-micturition dribble, one evaluated the effectiveness of lifestyle and behavioural modifications to manage lower urinary tract symptoms and one evaluated the use of a consensus guideline for the management of continence by primary health care teams in an urban general practice.No controlled trials evaluated interventions to improve men's knowledge or management of bowel health, or to improve men's attendance at promotional events.Few of the RCT described the method of randomisation and no trials reported using blinding either to assessment or to treatment.Two studies did not provide the measures of dispersion (no standard deviation), one study provided graphical data only and one presented no data whatsoever.Pelvic floor muscle exercises with or without additional interventions are effective at reducing the incidence of urinary incontinence in men >65 years who have had a prostatectomy.Education on lifestyle and behavioural modifications may be more effective in reducing lower urinary tract symptoms than doing nothing.Pelvic floor muscle exercisesmay be effective in treating post-micturition dribble in men with or without erectile dysfunction.Providing verbal feedback to participants to support pelvic floor muscle exercises technique appears to be as effective as biofeedback for improvement of urinary incontinence symptoms in this group.No evidence for the effectiveness of education interventions on faecal incontinence orNo evidence for the effectiveness of education interventions to improve men's attendance at promotional events.

DISCUSSION

The results of this review have highlighted that with the exception of pelvic floor muscle exercises (PME) after prostatectomy, few controlled trials have examined the effectiveness of any interventions at raising awareness of bladder and bowel health in males aged 12 years and over.The majority of trials that evaluated interventions to manage bladder and bowel health presented data for both male and female in a combined form making it impossible to estimate the effect of the intervention(s) on male participants only. In some cases, where the male data were presented separately, the population was too small to provide adequate power, and therefore most comparisons between treatment groups were found to have statistically insignificant differences in effectiveness.

CONCLUSIONS

There is little quantitative evidence for the effectiveness of interventions to improve men's awareness of bladder and bowel health. Therefore few recommendations can be made. Pelvic floor muscle exercises with or without additional interventions such as biofeedback could be used to reduce the incidence of urinary incontinence in men who have had a prostatectomy.Education on lifestyle and behavioural modifications may be more effective in reducing lower urinary tract symptoms than doing nothing.Pelvic floor muscle exercises may be effective in treating post-micturition dribble in men with or without erectile dysfunction.With the exception of instruction of pelvic floor muscle exercises for men after prostatectomy, little quantitative research has been performed that establishes the effectiveness of interventions on men's awareness of bladder and bowel health. While numerous interventions have been trialed on mixed gender populations, and these trials suggest that the interventions would be effective, their effectiveness on the male component cannot be definitively established. Therefore, well designed controlled trials using male sample populations only are needed to confirm these suppositions.

Improving initial management of lower urinary tract symptoms in primary care: Costs and patient outcomes

OBJECTIVE

Guidelines for primary care management of lower urinary tract symptoms in older men recommend shared decision making regarding the choice of treatment. In this study we aimed to determine the costs and patient outcomes of an implementation strategy designed to enhance uptake of these guidelines.

MATERIAL AND METHODS

The intervention comprised a distance learning programme for general practitioners, comprising evidence-based information, assessment of learning needs, a knowledge test and patient education materials. The control group only received the written guidelines. A cluster randomized trial in 187 older male patients compared costs and outcomes in the two study groups. A healthcare perspective was taken in the economic evaluation, with a 3-month time horizon. The primary health outcome was patient-reported urinary symptoms at 3 months. Costs relating to the distance learning package and the healthcare provided were considered, using undiscounted standardized prices.

RESULTS

Patient-reported urinary symptoms at 3 months did not differ between the study groups: 66% and 61% with moderate symptoms and 7% and 11% with severe symptoms in the intervention and control groups, respectively. The mean total costs per patient were euro28.15 lower in the intervention group (euro93.11) compared to the control group (euro121.26), mainly because of a lower number of referrals to the urologist. A bootstrap analysis showed an incremental cost-effectiveness ratio of euro111.98 (95% CI -euro423 to +euro329).

CONCLUSIONS

The distance learning programme did not change health outcomes, but it reduced costs in the first 3 months after an initial consultation compared to written guidelines. Studies with a longer follow-up period are needed.

The value of continence training: does it change clinical practice?

It is estimated that one in six people over 40 are incontinent 'several times a month' and that most of them will not have sought help (Perry et al, 2000). Containment of the problem is no longer the first-line treatment and patients should be given access to an assessment, with a management plan addressing the cause of incontinence. It is thought that around 70% of the estimated population with continence problems in the UK would show a good response to treatment (Royal College of Physicians (RCP), 1995). However, it is recognized that healthcare professionals need knowledge and training to deliver care (Brittain et al, 2001). Previous studies have shown continence education, for both professionals and users, to be cost-effective because investment in techniques to promote continence can reduce dependence on incontinence containment products (Bradley and Morgan, 1998; Williams et al, 1999). This study was based on the belief that there is an educational gap between what is taught and what is practised (Macleod, 1998; Severinsson, 1998). The study drew on an opportunistic sample of students attending continence-training courses. They were asked to complete pre- and post-course questionnaires. Using a follow-up research design, three periods of data were collected. Data were analysed using Microsoft Excel and the Statistical Package for Social Science (SPSS). The results conclude that there was a statistically significant change in the quantitative measure - the test result - but qualified nurses were experiencing some difficulty relating the theory to clinical practice.

Disseminating research evidence. A controlled trial in continence care

The dissemination of research evidence from which clinical practice should be based poses many well-documented problems for nurses. This study set out to overcome some of the common barriers to dissemination by providing a research-based clinical handbook for continence care. The impact of the handbook on nurses' knowledge of both urinary and faecal incontinence was tested using an experimental and control group. The experimental group received the handbook while the control group did not. Both groups completed an assessment questionnaire at week 1, prior to the intervention in the experimental group, followed by a second assessment at week 7 after the intervention in the experimental group. Data were collected using semi-structured questionnaires. Statistically significant improvements in knowledge were found for those nurses who received a copy of the handbook, and nurses reported that they found the handbook useful and acceptable as a form of clinical updating. The dissemination of research findings is essential if evidence-based nursing is to become a reality, and this study clearly demonstrates one method by which this can be successfully achieved.