Randomised controlled trial of effect of feedback on general practitioners' prescribing in Australia

Effect of Antibiotic Prescription Audit and Feedback on Antibiotic Prescribing in Primary Care: A Randomized Clinical Trial

Importance

Antibiotics are commonly prescribed in primary care, increasing the risk of antimicrobial resistance in the population.

Objective

To investigate the effect of quarterly audit and feedback on antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates.

Design, Setting, and Participants

This pragmatic randomized clinical trial was conducted from January 1, 2018, to December 31, 2019, among 3426 registered primary care physicians and pediatricians in single or small practices in Switzerland who were among the top 75% prescribers of antibiotics. Intention-to-treat analysis was performed using analysis of covariance models and conducted from September 1, 2021, to January 31, 2022.

Interventions

Primary care physicians were randomized in a 1:1 fashion to undergo quarterly antibiotic prescribing audit and feedback with peer benchmarking vs no intervention for 2 years, with 2017 used as the baseline year. Anonymized patient-level claims data from 3 health insurers serving roughly 50% of insurees in Switzerland were used for audit and feedback. The intervention group also received evidence-based guidelines for respiratory tract and urinary tract infection management and community antibiotic resistance information. Physicians in the intervention group were blinded regarding the nature of the trial, and physicians in the control group were not informed of the trial.

Main Outcomes and Measures

The claims data used for audit and feedback were analyzed to assess outcomes. Primary outcome was the antibiotic prescribing rate per 100 consultations during the second year of the intervention. Secondary end points included overall antibiotic use in the first year and over 2 years, use of quinolones and oral cephalosporins, all-cause hospitalizations, and antibiotic use in 3 age groups.

Results

A total of 3426 physicians were randomized to the intervention (n = 1713) and control groups (n = 1713) serving 629 825 and 622 344 patients, respectively, with a total of 4 790 525 consultations in the baseline year of 2017. In the entire cohort, a 4.2% (95% CI, 3.9%-4.6%) relative increase in the antibiotic prescribing rate was noted during the second year of the intervention compared with 2017. In the intervention group, the median annual antibiotic prescribing rate per 100 consultations was 8.2 (IQR, 6.1-11.4) in the second year of the intervention and was 8.4 (IQR, 6.0-11.8) in the control group. Relative to the overall increase, a -0.1% (95% CI, -1.2% to 1.0%) lower antibiotic prescribing rate per 100 consultations was found in the intervention group compared with the control group. No relevant reductions in specific antibiotic prescribing rates were noted between groups except for quinolones in the second year of the intervention (-0.9% [95% CI, -1.5% to -0.4%]).

Conclusions and Relevance

This randomized clinical trial found that quarterly personalized antibiotic prescribing audit and feedback with peer benchmarking did not reduce antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates.

Trial Registration

ClinicalTrials.gov Identifier: NCT03379194.

Nudge interventions to reduce unnecessary antibiotic prescribing in primary care: a systematic review

OBJECTIVES

Antibiotic prescribing in primary care contributes significantly to antibiotic overuse. Nudge interventions alter the decision-making environment to achieve behaviour change without restricting options. Our objectives were to conduct a systematic review to describe the types of nudge interventions used to reduce unnecessary antibiotic prescribing in primary care, their key features, and their effects on antibiotic prescribing overall.

METHODS

Medline, Embase and grey literature were searched for randomised trials or regression discontinuity studies in April 2021. Risk of bias was assessed independently by two researchers using the Cochrane Effective Practice and Organisation of Care group's tool. Results were synthesised to report the percentage of studies demonstrating a reduction in overall antibiotic prescribing for different types of nudges. Effects of social norm nudges were examined for features that may enhance effectiveness.

RESULTS

Nineteen studies were included, testing 23 nudge interventions. Four studies were rated as having a high risk of bias, nine as moderate risk of bias and six as at low risk. Overall, 78.3% (n=18, 95% CI 58.1 to 90.3) of the nudges evaluated resulted in a reduction in overall antibiotic prescribing. Social norm feedback was the most frequently applied nudge (n=17), with 76.5% (n=13; 95% CI 52.7 to 90.4) of these studies reporting a reduction. Other nudges applied were changing option consequences (n=3; with 2 reporting a reduction), providing reminders (n=2; 2 reporting a reduction) and facilitating commitment (n=1; reporting a reduction). Successful social norm nudges typically either included an injunctive norm, compared prescribing to physicians with the lowest prescribers or targeted high prescribers.

CONCLUSIONS

Nudge interventions are effective for improving antibiotic prescribing in primary care. Expanding the use of nudge interventions beyond social norm nudges could reap further improvements in antibiotic prescribing practices. Policy-makers and managers need to be mindful of how social norm nudges are implemented to enhance intervention effects.

Feedback of Antibiotic Prescribing in Primary Care (FAPPC) trial: results of a real-world cluster randomized controlled trial in Scotland, UK

OBJECTIVES

To evaluate the effect of general practice-level prescribing feedback on antibiotic prescribing in a real-world pragmatic cluster randomized controlled trial.

METHODS

Three hundred and forty general practices in four territorial Health Boards in NHS Scotland were randomized in Quarter 1, 2016 to receive four quarterly antibiotic-prescribing feedback reports or not, from Quarter 2, 2016 to Quarter 1, 2017. Reports included different clinical topics, benchmarking against national and health board rates, and behavioural messaging with improvement actions. The primary outcome was total antibiotic prescribing rate. There were 16 secondary prescribing outcomes and 5 hospital admission outcomes (potential adverse effects of reduced prescribing). The main evaluation timepoint was 1 year after the final report (Quarter 1, 2018), with an additional evaluation in the quarter after the final report (Quarter 2, 2017). Routine administrative NHS data were used to generate the feedback reports and analyse the effects.

RESULTS

Total antibiotic prescribing rates were lower at the main evaluation timepoint in both intervention (1.83 versus baseline 1.93 prescriptions/1000 patients/day) and control (1.90 versus baseline 1.98) practices, with no evidence of intervention effect [adjusted rate ratio (ARR) 0.98 (95% CI 0.94-1.02; P = 0.35)]. At the additional timepoint, adjusted total antibiotic prescribing rates were 1.67 and 1.73 prescriptions/1000 patients/day, with evidence of a small intervention effect, ARR 0.99 (0.98-1.00; P = 0.03).

CONCLUSIONS

This well-designed, practice-level antibiotic-prescribing feedback had limited evidence of additional effects in the context of decreasing antibiotic prescribing and an established national stewardship programme.

Antibiotic prescription monitoring and feedback in primary care in Switzerland: Design and rationale of a nationwide pragmatic randomized controlled trial

INTRODUCTION

Antibiotic consumption is highest in primary care, and antibiotic overuse furthers antimicrobial resistance. In our recently published pilot-RCT, we used monthly aggregated claims data to provide personalized antibiotic prescription feedback to general practitioners (GPs). The pilot-RCT has shown that personalized prescription feedback is a feasible and promising low-cost intervention to reduce antibiotic prescribing. Here, we describe the rationale and design of the follow-up RCT with 3426 GPs in Switzerland. We now have access to pseudonymized patient-level data from routinely collected health insurance data of the three largest health insurers in Switzerland.

METHODS AND ANALYSIS

1713 GPs randomized to the intervention group received once evidence-based treatment guidelines at the beginning, including region-specific antibiotic resistance information from the community and personalized feedback of their antibiotic prescribing, followed by quarterly personalized prescription feedback for two years. The first and the last mailings were sent out in December 2017 and September 2019, respectively. The 1713 GPs randomized to the control group were not notified about the study and they received no guidelines and no prescription feedback. The personalized prescription feedbacks and the analyses of the primary and secondary outcomes are entirely based on pseudonymized patient-level data from routinely collected health insurance data. The primary outcome is prescribed antibiotics per 100 patient consultations during the second year of intervention. The secondary outcomes include antibiotic use during the entire two-year trial period, use of broad-spectrum antibiotics, hospitalization rates (all-cause and infection-related), and antibiotic use in different age groups. If the feedback intervention proves to be efficacious, the intervention could be continued systemwide.

ETHICS AND DISSEMINATION

The trial is publicly funded by the Swiss National Science Foundation (SNSF, grant number 407240_167066). The trial was approved by the ethics committee "Ethikkommission Nordwest-und Zentralschweiz" (EKNZ Project-ID 2017-00888). Results will be disseminated in peer-reviewed journals and international conferences.

Social norms interventions to change clinical behaviour in health workers: a systematic review and meta-analysis

Background

A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. These low-cost interventions can be used to encourage health workers to follow recommended professional practice.

Objective

To summarise evidence on whether or not social norms interventions are effective in encouraging health worker behaviour change, and to identify the most effective social norms interventions.

Design

A systematic review and meta-analysis of randomised controlled trials.

Data sources

The following databases were searched on 24 July 2018: Ovid MEDLINE (1946 to week 2 July 2018), EMBASE (1974 to 3 July 2018), Cumulative Index to Nursing and Allied Health Literature (1937 to July 2018), British Nursing Index (2008 to July 2018), ISI Web of Science (1900 to present), PsycINFO (1806 to week 3 July 2018) and Cochrane trials (up to July 2018).

Participants

Health workers took part in the study.

Interventions

Behaviour change interventions based on social norms.

Outcome measures

Health worker clinical behaviour, for example prescribing (primary outcome), and patient health outcomes, for example blood test results (secondary), converted into a standardised mean difference.

Methods

Titles and abstracts were reviewed against the inclusion criteria to exclude any that were clearly ineligible. Two reviewers independently screened the remaining full texts to identify relevant papers. Two reviewers extracted data independently, coded for behaviour change techniques and assessed quality using the Cochrane risk-of-bias tool. We performed a meta-analysis and presented forest plots, stratified by behaviour change technique. Sources of variation were explored using metaregression and network meta-analysis.

Results

A total of 4428 abstracts were screened, 477 full texts were screened and findings were based on 106 studies. Most studies were in primary care or hospitals, targeting prescribing, ordering of tests and communication with patients. The interventions included social comparison (in which information is given on how peers behave) and credible source (which refers to communication from a well-respected person in support of the behaviour). Combined data suggested that interventions that included social norms components were associated with an improvement in health worker behaviour of 0.08 standardised mean differences (95% confidence interval 0.07 to 0.10 standardised mean differences) (n = 100 comparisons), and an improvement in patient outcomes of 0.17 standardised mean differences (95% confidence interval 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I 2 of 85.4% (primary) and 91.5% (secondary). Network meta-analysis suggested that three types of social norms intervention were most effective, on average, compared with control: credible source (0.30 standardised mean differences, 95% confidence interval 0.13 to 0.47); social comparison combined with social reward (0.39 standardised mean differences, 95% confidence interval 0.15 to 0.64); and social comparison combined with prompts and cues (0.33 standardised mean differences, 95% confidence interval 0.22 to 0.44).

Limitations

The large number of studies prevented us from requesting additional information from authors. The trials varied in design, context and setting, and we combined different types of outcome to provide an overall summary of evidence, resulting in a very heterogeneous review.

Conclusions

Social norms interventions are an effective method of changing clinical behaviour in a variety of health service contexts. Although the overall result was modest and very variable, there is the potential for social norms interventions to be scaled up to target the behaviour of a large population of health workers and resulting patient outcomes.

Future work

Development of optimised credible source and social comparison behaviour change interventions, including qualitative research on acceptability and feasibility.

Study registration

This study is registered as PROSPERO CRD42016045718.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 41. See the NIHR Journals Library website for further project information.

The effect of a mystery shopper scheme on prescribing behavior in primary care: Results from a field experiment

BACKGROUND

Health care systems in many countries are characterized by limited availability of provider performance data that can be used to design and implement welfare improving reforms in the health sector. We question whether a simple mystery shopper scheme can be an effective measure to improve primary care quality in such settings.

METHODS

Using a randomized treatment-control design, we conducted a field experiment in primary care clinics in a Chinese city. We investigate whether informing physicians of a forthcoming mystery shopper audit influences their prescribing behavior. The intervention effects are estimated using conditional fixed-effects logistic regression. The estimated coefficients are interpreted as marginal utilities in a choice model.

RESULTS

Our findings suggest that the mystery shopper intervention reduced the probability of prescribing overall. Moreover, the intervention had heterogeneous effects on different types of drugs.

CONCLUSIONS

This study provides new evidence suggesting that announced performance auditing of primary care providers could directly affect physician behavior even when it is not combined with pay-for-performance, or measures such as reminders, feedback or educational interventions.

Improved Antibiotic Prescribing within a Veterans Affairs Primary Care System through a Multifaceted Intervention Centered on Peer Comparison of Overall Antibiotic Prescribing Rates

Reducing inappropriate outpatient antibiotic use is an important national goal. Limited data exist on targeted education and peer comparison of overall antibiotic prescribing rates as an antimicrobial stewardship strategy. Primary care professionals (PCPs) from all seven clinics within our health care system were offered an education session, followed by monthly e-mails with their antibiotic prescribing rate, peer prescribing rates, and a system target. A pre-post analysis was conducted to compare prescribing rates during the intervention period (January to June 2017) to a seasonal baseline (January to June 2016) using a regression model. A random sample of prescriptions was reviewed for adherence to consensus guidelines. Educational sessions were attended by 68.5% (50/73) of PCPs. From the baseline to the intervention period, the mean rate of monthly antibiotic prescriptions declined from 76.9 to 49.5 per 1,000 office visits (35.6% reduction [P < 0.001]). Among reviewed cases, unnecessary antibiotic prescribing declined (58.8% [80/136] versus 38.9% [70/180]; 33.9% reduction [P = 0.0006]), and the rate of optimally prescribed antibiotics increased (19.9% [27/136] versus 30% [54/180]; 50.8% increase [P = 0.05]). If an antibiotic was indicated, there were no significant differences in prescribing of guideline-discordant agents (21.4% [12/56] versus 19.1% [21/110] [P = 0.8]) or guideline-concordant agents for a guideline-discordant duration (38.6% [17/44] versus 39.3% [35/89] [P = 1]). There were significant reductions in azithromycin and fluoroquinolone prescriptions (50.9% and 59.4% [P values of <0.001], respectively), but most prescriptions for these agents in the intervention period remained inappropriate. Initial education followed by monthly peer comparison of overall antibiotic prescribing rates reduced total and unnecessary antibiotic prescribing in primary care clinics.

What motivates general practitioners to change practice behaviour? A qualitative study of audit and feedback group sessions in Dutch general practice

OBJECTIVES

Adopting an attributional perspective, the current article investigates how audit and feedback group sessions contribute to general practitioners' (GPs) motivation to change their practice behaviour to improve care. We focus on the contributions of the audit and feedback itself (content) and the group discussion (process).

METHODS

Four focus groups, comprising a total of 39 participating Dutch GPs, discussed and compared audit and feedback of their practices. The focus groups were analysed thematically.

RESULTS

Audit and feedback contributed to GPs' motivation to change in two ways: by raising awareness about aspects of their current care practice and by providing indications of the possible impact of change. For these contributions to play out, the audit and feedback should be reliable and valid, specific, recent and recurrent and concern GPs' own practices or practices within their own influence sphere. Care behaviour attributed to external, uncontrollable or unstable causes would not induce change. The added value of the group is twofold as well: group discussion contributed to GPs' motivation to change by providing a frame of reference and by affording insights that participants would not have been able to achieve on their own.

CONCLUSIONS

In audit and feedback group sessions, both audit and feedback information and group discussion can valuably contribute to GPs' motivation to change care practice behaviour. Peer interaction can positively contribute to explore alternative practices and avenues for improvement. Local or regional peer meetings would be beneficial in facilitating reflection and discussion. An important avenue for future studies is to explore the contribution of audit and feedback and small-group discussion to actual practice change.

An educational intervention to promote appropriate antibiotic use for acute respiratory infections in a district in Egypt- pilot study

Background

Antibiotic overuse is the most important modifiable factor contributing to antibiotic resistance. We conducted an educational campaign in Minya, Egypt targeting prescribers and the public through communications focused on appropriate antibiotic use for acute respiratory infections (ARIs).

Methods

The entire population of Minya was targeted by the campaign. Physicians and pharmacists were invited to participate in the pre-intervention assessments. Acute care hospitals and a sample of primary healthcare centers in Minya were randomly selected for a pre-intervention survey and all patients exiting outpatient clinics on the day of the survey were invited to participate. The same survey methodology was conducted for the post-intervention assessments. Descriptive comparisons were made through three assessments conducted pre- and post-intervention. We quantitated antibiotic prescribing through a survey administered to patients with an ARI exiting outpatient clinics. Additionally, physicians, pharmacists, and patients were interviewed regarding their attitudes and beliefs towards antibiotic prescribing. Finally, physicians were tested on three clinical scenarios (cold, bronchitis, and sinusitis) to measure their knowledge on antibiotic use.

Results

Post-intervention patient exit surveys revealed a 23.1% decrease in antibiotic prescribing for ARIs in this population (83.7 to 64.4%) and physicians and pharmacists self-reported less frequently prescribing antibiotics for ARIs on their follow-up surveys. We also found an increase in correct responses to the clinical scenarios and in attitude and belief scores for physicians, pharmacists, and patients regarding antibiotic use in the post-intervention sample.

Conclusions

Overall, the samples surveyed after the community-based educational campaign reported a lower frequency of antibiotic prescribing and improved knowledge and attitudes regarding antibiotic misuse compared to the samples surveyed before the campaign. Ongoing interventions educating providers and patients are needed to decrease antibiotic misuse and reduce the spread of antibiotic resistance in Egypt.

Effectiveness of audit and feedback in addressing over prescribing of antibiotics and injectable medicines in a middle-income country: an RCT

Overprescribing of antibiotics and injectable medicines is common in ambulatory care in many low- and middleincome countries. We evaluated the effects of three different interventions in improving physician prescribing. We conducted a four-armed randomized controlled trial with one-month and three- months follow-up. General physicians, pediatricians, and infectious disease specialists were included in this study if they had an outpatient office in Tehran, Iran. The study involved two behaviorally guided interventions: "new-design audit and feedback (NA&F)"; "printed educational material (PEM)" and an existing intervention of "routinely conducted audit and feedback (RA&F)". The theoretical framework underpinning the intervention was the theory of planned behavior. Main outcome measures were the percentage change in the proportion of prescriptions containing injectable dexamethasone; oral amoxicillin and cefixime. NA&F reduced the proportion of prescriptions particularly those containing dexamethasone injectable and cefixime (1.64, 0.99 absolute percentage change, p = 0.006, p = 0.01 respectively). PEM reduced the proportion of prescriptions containing cefixime (0.93 absolute percentage change p = 0.04). Other primary outcomes had no significant differences. A secondary outcome measure showed overall prescribing of injectables also reduced (absolute risk reduction: 3%). Overally, the study provides strong evidence that using theoretical insights in the development of the intervention improved prescribing behavior that lasted at least three months after the intervention. The design, format, and presentation of messages in feedback forms significantly influence the impact of audit and feedback on physician prescribing. While the interventions were effective, the impacts on inappropriate prescribing were modest and limited. In settings with rampant problems of overprescribing, intensive interventions are required to substantially improve prescribing patterns. Graphical abstract Graphical abstract.

Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections

OBJECTIVES

Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes.

METHODS

This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic.

RESULTS

Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt.

CONCLUSIONS

Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.

[Effectiveness of an intervention strategy in the biosimilar glargine prescription pattern in primary care]

Objetivos

Evaluar el impacto de una estrategia de intervención en el patrón de prescripción de la insulina glargina biosimilar (IGBio) respecto al compuesto de referencia y analizar la influencia del perfil del prescriptor y su repercusión económica.

Diseño

Estudio cuasiexperimental de tipo antes/después, con un grupo control.

Emplazamiento

Dos áreas de gestión sanitaria (AGS) de Sevilla: AGS Sur (área intervención) y AGS Osuna (área control).

Participantes

La totalidad de los médicos de atención primaria de cada área: 220 y 100, respectivamente.

Intervención

Se realizaron sesiones formativas, se envió un boletín farmacoterapéutico e informes de retroalimentación mensual durante los 6 meses tras la intervención formativa. El estudio fue llevado a cabo desde la comercialización del biosimilar, en octubre de 2015, hasta febrero de 2016 (pre-intervención) y desde febrero hasta agosto de 2016 (intervención).

Mediciones principales

Los indicadores analizados han sido porcentaje de pacientes y porcentaje de dosis diaria definida (DDD) con IGBio respecto al total y el coste. Los médicos han sido analizados por subgrupos de edad, sexo, formación, tipo de contrato, años de experiencia y cupo.

Resultados principales

Ambos indicadores aumentan al mismo nivel en ambas áreas antes de la intervención. Sin embargo, después de la intervención fueron significativamente diferentes entre las áreas (p < 0,0005), intervalo de confianza al 95% (2,5-4,7). La razón del porcentaje de incremento relativo acumulado de ambas variables entre áreas fue 3,73 veces mayor tras la intervención. En el área intervención no se encontraron diferencias para los subgrupos de médicos evaluados.

Conclusiones

Estrategias encaminadas a la formación/información, así como el seguimiento a los profesionales sanitarios, inciden en el patrón de prescripción y pueden tener una repercusión económica. Nuestros resultados no se han visto influenciados por el perfil del prescriptor.

Effect of audit and feedback with peer review on general practitioners' prescribing and test ordering performance: a cluster-randomized controlled trial

BACKGROUND

Much research worldwide is focussed on cost containment and better adherence to guidelines in healthcare. The research focussing on professional behaviour is often performed in a well-controlled research setting. In this study a large-scale implementation of a peer review strategy was tested on both test ordering and prescribing behaviour in primary care in the normal quality improvement setting.

METHODS

We planned a cluster-RCT in existing local quality improvement collaboratives (LQICs) in primary care. The study ran from January 2008 to January 2011. LQICs were randomly assigned to one of two trial arms, with each arm receiving the same intervention of audit and feedback combined with peer review. Both arms were offered five different clinical topics and acted as blind controls for the other arm. The differences in test ordering rates and prescribing rates between both arms were analysed in an intention-to-treat pre-post analysis and a per-protocol analysis.

RESULTS

Twenty-one LQIC groups, including 197 GPs working in 88 practices, entered the trial. The intention-to-treat analysis did not show a difference in the changes in test ordering or prescribing performance between intervention and control groups. The per-protocol analysis showed positive results for half of the clinical topics. The increase in total tests ordered was 3% in the intervention arm and 15% in the control arm. For prescribing the increase in prescriptions was 20% in the intervention arm and 66% in the control group. It was observed that the groups with the highest baseline test ordering and prescription volumes showed the largest improvements.

CONCLUSIONS

Our study shows that the results from earlier work could not be confirmed by our attempt to implement the strategy in the field. We did not see a decrease in the volumes of tests ordered or of the drugs prescribed but were able to show a lesser increase instead. Implementing the peer review with audit and feedback proved to be not feasible in primary care in the Netherlands.

TRIAL REGISTRATION

This trial was registered at the Dutch trial register under number ISRCTN40008171 on August 7^th 2007.

Improving Antimicrobial Use in the Hospital Setting by Providing Usage Feedback to Prescribing Physicians

Objective.

To determine whether feedback on antimicrobial use improves physician compliance with local hospital guidelines on antimicrobial prescribing.

Design.

In this time series analysis, in which a historical control period was compared with an intervention period, all orders for antimicrobials (except those for surgical prophylaxis) placed from November 1, 2002, through April 30, 2004, were prospectively evaluated by an antimicrobial management team (AMT) for compliance with local hospital guidelines. During the control period, orders were evaluated to determine compliance with hospital guidelines before and after recommendations by the AMT were provided to physicians. Feedback was given for the second 9-month period in the form of a weekly report to prescribing physicians, a monthly hospital newsletter, and a quarterly report to various hospital committees. During the intervention period, orders were evaluated to determine compliance with hospital guidelines before and after recommendations by the AMT were provided to physicians.

Setting.

The Veterans Affairs Medical Center, a 110-bed facility, in Louisville, Kentucky.

Participants.

Internal medicine physicians and general surgeons.

Results.

A total of 2,807 antimicrobial courses were evaluated. Compliance with hospital guidelines before AMT recommendations was 70% during the control period and 74% during the intervention period (P= .02). Compliance after AMT recommendations was 90% during the control period and 93% during the intervention period (P≤ .01).

Conclusion.

The use of feedback had a significantly favorable impact on physician compliance with the hospital's guidelines on antimicrobial prescribing. Use of feedback should be added to the list of interventions that promote appropriate antimicrobial use in the hospital setting.

Faculty Communication Knowledge, Attitudes, and Skills Around Chronic Non-Malignant Pain Improve with Online Training

OBJECTIVE

Many physicians struggle to communicate with patients with chronic, non-malignant pain (CNMP). Through the use of a Web module, the authors aimed to improve faculty participants' communication skills knowledge and confidence, use of skills in clinical practice, and actual communication skills.

SUBJECTS

The module was implemented for faculty development among clinician-educators with university faculty appointments, outpatient clinical practices, and teaching roles.

METHODS

Participants completed the Collaborative Opioid Prescribing Education Risk Evaluation and Mitigation Strategy (COPE-REMS®) module, a free Web module designed to improve provider communication around opioid prescribing. Main study outcomes were improvements in CNMP communication knowledge, attitudes, and skills. Skills were assessed by comparing a subset of participants' Observed Structured Clinical Exam (OSCE) performance before and after the curriculum.

RESULTS

Sixty-two percent of eligible participants completed the curriculum in 2013. Knowledge-based test scores improved with curriculum completion (75% vs. 90%; P < 0.001). Using a 5-point Likert-type scale, participants reported improved comfort in managing patients with CNMP both immediately post-curriculum and at 6 months (3.6 pre vs. 4.0 post vs. 4.1 at 6 months; P = 0.02), as well as improvements in prescribing opioids (3.3 vs. 3.8 vs. 3.9, P = 0.01) and conducting conversations about discontinuing opioids (2.8 vs. 3.5 vs. 3.9, P < 0.001). Additionally, CNMP-specific communication skills on the OSCE improved after the curriculum (mean 67% vs. 79%, P = 0.03).

CONCLUSIONS

Experienced clinician-educators improved their communication knowledge, attitudes, and skills in managing patients with CNMP after implementation of this curriculum. The improvements in attitudes were sustained at six months. A Web-based curriculum such as COPE-REMS® may be useful for other programs seeking improvement in faculty communication with patients who have CNMP.

The effect of registry-based performance feedback via short text messages and traditional postal letters on prescribing parenteral steroids by general practitioners--A randomized controlled trial

BACKGROUND

It is conjectured that providing feedback on physicians' prescribing behavior improves quality of drug prescriptions. However, the effectiveness of feedback provision and mode of feedback delivery is not well understood. The objective of this study was to assess and compare the effect of traditional paper letters (TPL) and short text message (STM) feedback on general practitioners' prescribing behavior of parenteral steroids (PSs).

METHODS

In a single-blind randomized controlled trial, 906 general practitioners (GPs) having at least 10 monthly prescriptions were randomly recruited into two interventions and one control study arms with 1:1 allocation, stratified by percentage of prescriptions. The intervention was the provision of 3 feedback messages containing prescribing indices in TPL and STM (in the first two arms) versus the control arm (CG) with an interval of 3 months between these messages. We calculated the PS Defined Daily Dose (DDD) for every GP, every month, and compared between the 3 arms, before and after the interventions. The expected primary outcome was to reduce prescription of parenteral steroids by participants. The study was performed in the Kerman Social Security Organization in Iran.

RESULTS

A total of 906 GPs were selected for the trial, but only 721 of them (TPL=191, STM=228, CG=302) were recruited for the 1st feedback. The mean age of GPs was 44 and 59% of them were male. The prescribed parenteral steroid DDDs at baseline were similar (TPL=121.62, STM=127.49, CG=115.68, P>0.5). At the end of the study, DDDs in the TPL and STM arms were similar (TPL=104.38, STM=101.90, P>0.9) but DDDs in each intervention arm was statistically significantly lower than in CG (CG=156.17, P<0.0001). Being in TPL and STM arms resulted in 36.1 and 41.7 units of decrease in DDD respectively, compared to the control arm (P<0.02 and P<0.005) after the one-year duration of the study.

CONCLUSION

Feedback by TPLs and STMs on prescribing performance effectively reduced prescribing PSs by GPs. STM, being a cheap and fast tool, is potentially powerful and efficient for drug prescription rationalization.

Irrational prescribing of over-the-counter (OTC) medicines in general practice: testing the feasibility of an educational intervention among physicians in five European countries

BACKGROUND

Irrational prescribing of over-the-counter (OTC) medicines in general practice is common in Southern Europe. Recent findings from a research project funded by the European Commission (FP7), the "OTC SOCIOMED", conducted in seven European countries, indicate that physicians in countries in the Mediterranean Europe region prescribe medicines to a higher degree in comparison to physicians in other participating European countries. In light of these findings, a feasibility study has been designed to explore the acceptance of a pilot educational intervention targeting physicians in general practice in various settings in the Mediterranean Europe region.

METHODS

This feasibility study utilized an educational intervention was designed using the Theory of Planned Behaviour (TPB). It took place in geographically-defined primary care areas in Cyprus, France, Greece, Malta, and Turkey. General Practitioners (GPs) were recruited in each country and randomly assigned into two study groups in each of the participating countries. The intervention included a one-day intensive training programme, a poster presentation, and regular visits of trained professionals to the workplaces of participants. Reminder messages and email messages were, also, sent to participants over a 4-week period. A pre- and post-test evaluation study design with quantitative and qualitative data was employed. The primary outcome of this feasibility pilot intervention was to reduce GPs' intention to provide medicines following the educational intervention, and its secondary outcomes included a reduction of prescribed medicines following the intervention, as well as an assessment of its practicality and acceptance by the participating GPs.

RESULTS

Median intention scores in the intervention groups were reduced, following the educational intervention, in comparison to the control group. Descriptive analysis of related questions indicated a high overall acceptance and perceived practicality of the intervention programme by GPs, with median scores above 5 on a 7-point Likert scale.

CONCLUSIONS

Evidence from this intervention will estimate the parameters required to design a larger study aimed at assessing the effectiveness of such educational interventions. In addition, it could also help inform health policy makers and decision makers regarding the management of behavioural changes in the prescribing patterns of physicians in Mediterranean Europe, particularly in Southern European countries.

A Conceptual Framework for Understanding and Reducing Overuse by Primary Care Providers

Primary care providers frequently recommend, administer, or prescribe health care services that are unlikely to benefit their patients. Yet little is known about how to reduce provider overuse behavior. In the absence of a theoretically grounded causal framework, it is difficult to predict the contexts under which different types of interventions to reduce provider overuse will succeed and under which they will fail. In this article, we present a framework based on the theory of planned behavior that is designed to guide overuse research and intervention development. We describe categories of primary care provider beliefs that lead to the formation of intentions to assess the appropriateness of services, and propose factors that may affect whether the presence of assessment intentions results in an appropriate recommendation. Interventions that have been commonly used to address provider overuse behavior are reviewed within the context of the framework.

Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01]--study protocol and baseline practice and provider characteristics

BACKGROUND

Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians.

METHODS/DESIGN

The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider's rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease.

DISCUSSION

The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics.

TRIALS REGISTRATION

ClinicalTrials.gov: NCT01454947.

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).

Prescribing Data in General Practice Demonstration (PDGPD) project--a cluster randomised controlled trial of a quality improvement intervention to achieve better prescribing for chronic heart failure and hypertension

BACKGROUND

Research literature consistently documents that scientifically based therapeutic recommendations are not always followed in the hospital or in the primary care setting. Currently, there is evidence that some general practitioners in Australia are not prescribing appropriately for patients diagnosed with 1) hypertension (HT) and 2) chronic heart failure (CHF). The objectives of this study were to improve general practitioner's drug treatment management of these patients through feedback on their own prescribing and small group discussions with peers and a trained group facilitator. The impact evaluation includes quantitative assessment of prescribing changes at 6, 9, 12 and 18 months after the intervention.

METHODS

A pragmatic multi site cluster RCT began recruiting practices in October 2009 to evaluate the effects of a multi-faceted quality improvement (QI) intervention on prescribing practice among Australian general practitioners (GP) in relation to patients with CHF and HT. General practices were recruited nationally through General Practice Networks across Australia. Participating practices were randomly allocated to one of three groups: two groups received the QI intervention (the prescribing indicator feedback reports and small group discussion) with each group undertaking the clinical topics (CHF and HT) in reverse order to the other. The third group was waitlisted to receive the intervention 6 months later and acted as a "control" for the other two groups.De-identified data on practice, doctor and patient characteristics and their treatment for CHF and HT are extracted at six-monthly intervals before and after the intervention. Post-test comparisons will be conducted between the intervention and control arms using intention to treat analysis and models that account for clustering of practices in a Network and clustering of patients within practices and GPs.

DISCUSSION

This paper describes the study protocol for a project that will contribute to the development of acceptable and sustainable methods to promote QI activities within routine general practice, enhance prescribing practices and improve patient outcomes in the context of CHF and HT.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), Trial # 320870.

The cost-effectiveness of tailored, postal feedback on general practitioners' prescribing of pharmacotherapies for alcohol dependence

AIMS

The aims of this study were to conduct a randomised controlled trial to evaluate the cost-effectiveness of tailored, postal feedback on general practitioners' (GPs) prescribing of acamprosate and naltrexone for alcohol dependence relative to current practice and its impact on alcohol dependence morbidity.

METHODS

Rural communities in New South Wales, Australia, were randomised into experimental (N=10) and control (N=10) communities. Tailored feedback on their prescribing of alcohol pharmacotherapies was mailed to GPs from the experimental communities (N=115). Segmented regression analysis was used to examine within and between group changes in prescribing and alcohol dependence hospitalisation rates compared to the control communities. Incremental cost-effectiveness ratios (ICERs) were estimated per additional prescription of pharmacotherapies and per alcohol dependence hospitalisation(s) averted.

RESULTS

Post-intervention changes, relative to the control communities, in GPs' prescribing rate trends in the experimental communities significantly increased for acamprosate (β=0.24, 95% CI: 0.13-0.35, p<0.001), and significantly decreased for naltrexone (β = -0.12, 95% CI: -0.17 to -0.06) per quarter. Quarterly hospitalisation trend rates for alcohol dependence, as principal diagnosis, significantly decreased (β=-0.07, 95% CI: -0.13 to -0.01, p<0.05), compared to control communities. The median ICER per quarterly hospitalisation(s) averted due to intervention was dominant (dominant--$12,750).

CONCLUSION

Postal, tailored feedback to GPs on their prescribing of acamprosate and naltrexone for alcohol dependence was a cost-effective intervention, in rural communities of NSW, to increase the overall prescribing of pharmacotherapies with a plausible effect on incidence reduction of hospitalisations for alcohol dependence as principal diagnosis.

Audit and feedback: effects on professional practice and healthcare outcomes

BACKGROUND

Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011).

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included.

DATA COLLECTION AND ANALYSIS

All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors.

MAIN RESULTS

We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention.

AUTHORS' CONCLUSIONS

Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.

The effect of a physician-targeted intervention on metoclopramide prescribing practice

Background

Metoclopramide use is associated with serious and potentially irreversible neurologic side effects. However, it is often used for questionable or unclear indications in clinical practice.

Objectives

To (1) determine whether an intervention targeted at the prescribing physician would increase the rate of metoclopramide discontinuation among patients prescribed the medication for questionable or unclear indications; and (2) assess the durability of the discontinuation.

Study design

A randomized controlled trial.

Setting

Ambulatory practices of a quaternary care medical center.

Participants

Ambulatory, electronic medical record-utilizing clinicians of the quaternary medical center.

Intervention

A letter regarding participating clinicians’ prescription(s) of metoclopramide for patients with questionable or unclear indications.

Main outcome measures

The rate and the durability of metoclopramide discontinuation.

Results

Fourteen of 31 (45%) patients of intervention group clinicians and 10 of 30 (33%) patients of nonintervention group clinicians had metoclopramide discontinued within 12 weeks, yielding a risk ratio for metoclopramide discontinuation of 1.4 (95% confidence interval [CI] 0.6–3.0) in the intervention versus nonintervention group. Of the 29 patients who had their metoclopramide discontinued during the study, 26 (90%, 95% CI 73%–98%) still had no active metoclopramide prescription in the subsequent 6 months. No adverse events were detected during the follow-up period.

Conclusion

A physician-targeted intervention letter did not lead to a statistically significantly increased rate of metoclopramide discontinuation among patients who had questionable or unclear indications for the medication. Discontinuation of metoclopramide therapy for questionable or unclear indications was durable in most patients.

Effect of mailed feedback on drug prescribing profiles in general practice: a seven-year longitudinal study in Storstrøm County, Denmark

BACKGROUND

Whether written feedback on drug prescribing in general practice affects prescribing habits is controversial. Most short-term studies showed no effect. However, the issue has not been tested in long-term studies involving the local general practitioner community.

AIMS OF THE STUDY

To assess whether prescribing levels in general practice are affected by long-term, unsolicited, systematically repeated, mailed feedback.

METHODS

Each of the 94 general practices in Storstrøm County, Denmark, received semi-annual, mailed feedback about their prescribing volumes and costs within 13 major drug groups, in relation to the levels for all the other 93 practices over a 7-year period in a project initiated by the local general practitioner association. Data on the number of defined daily doses (DDDs) prescribed per 1000 listed patients in each practice per 6-months, and practice characteristics, were obtained from the Pharmaceutical Database at the County Health Department.

RESULTS

There was a large variation in drug prescribing volume between practices, but little within-practice variation over time. After adjustments for the influence of practice size and other potential outcome-affecting variables, there was no evidence of a general change of prescribing volume over time, no change among practices with a high or a low prescribing level, and no significant change within the various drug groups.

CONCLUSIONS

We found no significant effects on prescribing levels of mailed feedback, even when repeated semi-annually during 7 years and initiated by the local general practitioner community.

Changing utilization of pro re nata ('as needed') sedation in a child and adolescent psychiatric inpatient unit

OBJECTIVE

The primary purpose of the present study was to examine changes in utilization of pro re nata (PRN; 'as required') sedation over time within a child and adolescent psychiatric inpatient unit. The secondary purpose was to assess whether changes in PRN sedation were related to changing patient characteristics.

METHODS

A retrospective chart review examined 257 medical charts from a child and youth mental health inpatient service over two time periods (wave I, n = 122; wave II, n = 135) and collected data on PRN sedation, patient characteristics and routine medications.

RESULTS

Over time a significant reduction was observed in the proportion of patients prescribed PRN sedation from 70% to 54% (p < 0.01), and a reduction in the proportion of patients given PRN sedation from 46% to 26% (p < 0.01). The most commonly administered drug was chlorpromazine in wave I, and diazepam in wave II. Multivariate analysis indicated that reductions in PRN sedation occurred independently of changes in patient characteristics.

CONCLUSIONS

High utilization rates of PRN sedation are not inevitable in a child and adolescent psychiatric inpatient unit and may be reduced over time. Changing utilization of PRN sedation occurred independently from changing patient characteristics. More treatment outcome studies are required to optimize use of PRN sedation in young people.

Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis

BACKGROUND

Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often inappropriately prescribed.

RESEARCH DESIGN AND METHODS

We searched the Cochrane Collaboration's Effective Practice and Organisation of Care database, supplemented by MEDLINE and manual review of article bibliographies. We included randomized trials, controlled before-after studies, and interrupted time series. Two independent reviewers abstracted all data, and disagreements were resolved by consensus and discussion with a third reviewer. The primary outcome was the absolute reduction in the proportion of patients receiving antibiotics.

RESULTS

Forty-three studies reporting 55 separate trials met inclusion criteria. Most studies (N = 38) addressed prescribing for acute respiratory infections (ARIs). Among the 30 trials eligible for quantitative analysis, the median reduction in the proportion of subjects receiving antibiotics was 9.7% [interquartile range (IQR), 6.6-13.7%] over 6 months median follow-up. No single QI strategy or combination of strategies was clearly superior. However, active clinician education strategies trended toward greater effectiveness than passive strategies (P = 0.096). Compared with studies targeting specific conditions or patient populations, broad-based interventions extrapolated to larger community-level impacts on total antibiotic use, with savings of 17-117 prescriptions per 1000 person-years. Study methodologic quality was fair.

CONCLUSIONS

QI efforts are effective at reducing antibiotic use in ambulatory settings, although much room for improvement remains. Strategies using active clinician education and targeting management of all ARIs (rather than single conditions in single age groups) may yield larger reductions in community-level antibiotic use.

Polypharmacy management among Australian veterans: improving prescribing through the Australian Department of Veterans' Affairs' prescriber feedback programme

BACKGROUND

Older patients are potentially at risk from the effects of polypharmacy (PP) and/or drug-drug interactions.

AIMS

To examine the effects of a targeted patient-specific prescriber feedback programme on patients prescribed more than 19 individual medications over the 3-month study period.

METHODS

The Commonwealth Department of Veterans' Affairs commissioned a review of Repatriation Pharmaceutical Benefit Scheme claims data to identify patients potentially at risk of drug injury through either PP (> or =20 unique medications during 3 months) or clinically significant drug interactions (DI). Dispensing information for the patient at risk, relevant clinical guidelines and a personalized covering letter were mailed to the main prescribing general practitioner of the identified veteran patient. The claims data were then re-analysed after the programme.

RESULTS

There was a significant reduction in the mean number of unique medications prescribed over a 3-month period 1 year after the prescriber feedback (mean change = -2.22; 95% confidence interval -3.54 to -0.90; P = 0.0013) for patients identified with ongoing PP. There was also a significant reduction in the number of DI pairs (mean change = -0.73; 95% confidence interval -0.77 to -0.69; P < 0.0001) for the patients identified with an ongoing DI. The number of patients dispensed one or more DI pairs decreased from 836 to 318 after the feedback.

CONCLUSION

A targeted prescriber feedback programme can influence general practitioner prescribing at an individual patient level and, therefore, contribute to the quality use of medicines.

Improving medication safety: influence of a patient-specific prescriber feedback program on rate of medication reviews performed by Australian general medical practitioners

PURPOSE

To determine if patient-specific prescriber feedback for general medical practitioners (GPs), supported by educational material mailed to their patients, would increase home medicines review (HMR) rates.

METHODS

An observational study was conducted using the Repatriation Pharmaceutical Benefits Scheme (RPBS) Pharmacy Claims Database. The intervention group (n = 40 270) included all veterans aged >/=65 years, dispensed >/=5 unique medicines each month over a 4 month period. Comparison group veterans (n = 49,227) were those who did not have >/=5 or more unique medicines dispensed each month, but did have at least one prescription each month and >/=20 prescriptions over 4 months, of which five were unique medicines, Intervention GPs (n = 11,384) were subdivided into 2 groups: GPs with intervention veterans (n = 2097) and GPs with both intervention and comparison group veterans (n = 9287). The comparison group of GPs (n = 3630) were primary prescribers to the comparison veterans only. Rates of HMRs pre and post-intervention and the number of new GPs participating in HMR services were examined.

RESULTS

There was a significant increase in HMR rates in intervention group, from 2.2 per 1000 in the pre-period to 4.6 per 1000 per month in the post-intervention period (Rate Ratio (RR) 2.06, 95% Confidence Interval (CI) (1.90, 2.22), p < 0.0001). HMR rates increased in the intervention group compared with the comparison group (p < 0.0001). HMR rates increased in the intervention group GPs compared with the comparison group (RR 1.79, 95% CI (1.58, 2.02), p < 0.0001).

CONCLUSION

Patient-specific feedback provided to GPs, supported by educational material mailed directly to their patients increased HMR rates for targeted veterans and increased GP participation in the delivery of HMRs.

Antibiotic prescribing in Australian general practice: How has it changed from 1990–91 to 2002–03?

There is increasing evidence that antibiotics have limited value for many respiratory illnesses. This study investigates changes in overall antibiotic prescribing rates, and rates for specific conditions, by Australian general practitioners (GPs) between 1990-91 and 2002-03. This is a comparative study of two cross-sectional surveys of general practice activity, the Australian Morbidity and Treatment Survey (AMTS) 1990-91 and Bettering Evaluation and Care of Health (BEACH) 2002-03. Both studies used random samples of GPs, each providing data about a cluster of patient encounters. Outcome measures are the antibiotic prescribing rate per 100 encounters or per 100 selected problems managed. Between 1990-91 and 2002-03, the overall antibiotic prescribing rate decreased 24.3% from 18.9 prescriptions per 100 encounters to 14.3 (P<0.001). For children, the decrease for acute upper respiratory tract infection (URTI) was from 39.0 per 100 URTI problems to 24.4 (P<0.001), while the antibiotic prescribing rate increased for acute otitis media, decreased for bronchitis/bronchiolitis, and remained unchanged for other respiratory problems analysed. For adults the antibiotic prescribing rate for URTI decreased from 58.2 per 100 URTI problems to 40.0 (P<0.001), increased significantly for sinusitis and remained unchanged for all other respiratory problems. Antibiotic prescribing decreased significantly between 1990-91 and 2002-03 but the decrease was selective. The decline has been more pronounced among children than adults, and particularly for URTI. While the message of educators may be achieving its goal for URTI, other approaches targeting specific respiratory problems may be required to reduce antibiotic prescribing in these areas.

[Do we primary care doctors improve our prescription of generic medicines after the intervention of the area pharmacist?]

OBJECTIVE

To evaluate the prescription of generic medicines by the primary care doctors in a health district after an intervention programme conducted by the area pharmacist.

DESIGN

Intervention study. Two indicators were selected as indicators of pharmaceutical prescription of generics.

SETTING

Primary care. District 8 of Area 3, Valencian Community, Spain.

PARTICIPANTS

Eleven family doctors and 2 paediatricians.

INTERVENTIONS

a) Information session in the health centre given by the area pharmacist; b) delivery of the catalogue of generic medicines; c) delivery of the control panel to every physician; and d) possibility of connection to the GAIA system.

MAIN MEASUREMENTS

A before-and-after evaluation was made (at 6 months and 12 months from the intervention) of every doctor. Values were compared with the 2 indicators of pharmaceutical prescription.

RESULTS

Before the intervention, no doctor was fulfilling the Indicators of pharmaceutical prescription 1 and 2. At 6 months, all the doctors had increased their prescription of generics. Seven doctors met the objective of Indicator 1; and 8, that of indicator 2. At 12 months the increase remained and even grew.

CONCLUSIONS

The prescription of generics measured with indicators of pharmaceutical prescription 1 and 2 improved.

Informed patient consent to participation in cluster randomized trials: an empirical exploration of trials in primary care

Cluster randomized trials are increasingly common. Obtaining informed patient consent to participation in these trials raises practical challenges and ethical issues. The aims of this paper were to 1) develop a typology of interventions employed in cluster randomized trials in primary care; 2) assess whether the likelihood of seeking individual consent to participation varies by intervension type; 3) assess whether this likelihood has increased over time; 4) assess evidence for under reporting of consent procedures; 5) articulate reasons for not obtaining consent; and 6) make recommendations for future trial investigators. We collected data on trial interventions and consent procedures from reports of 152 recently published trials, and 47 unpublished trials. We develop a typology of interventions based on reasons for adopting a clustered design. We examine proportions seeking individual consent to participation among trials involving different types of intervention, in different periods, and among published and unpublished trials. Two-thirds of the trials had multifaceted interventions. Trials involving different types of intervention had different propensities to seek consent, largely because of practical obstacles to obtaining consent. Obtaining consent can compromise internal validity. More recent trials are no more likely to obtain consent than past trials. There was no evidence of under-reporting of consent procedures in publications. In conclusion, future trial investigators should consider both practical reasons and scientific arguments for not obtaining individual patient consent for all interventions in their trials. Where feasible, they should allow patients to opt out of the trial. Lay individuals should represent trial participants as part of the process of cluster consent to participation, and lay individuals could also be involved in considering ethical issues during trial planning. A more public debate may clarify the general acceptability of not obtaining consent in certain situations.

Audit and feedback: effects on professional practice and health care outcomes

BACKGROUND

Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004.

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality.

MAIN RESULTS

Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies.

AUTHORS' CONCLUSIONS

Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.

Evaluation of a national quality use of medicines service in Australia: an evolving model

RATIONALE

To describe the first phase of a global evaluation framework for the National Prescribing Service (NPS), with a focus on services for health professionals, and in particular highlight the lessons learnt from evaluation around the establishment and implementation of this national program.

METHODS

The agreed evaluation framework used mixed methods focused around a series of evaluation questions, aimed at measuring the overall effect of this new organization as well as the individual programs within it. The evaluation questions were determined a priori and were based on the objectives established by the organization in its first year of operation. A detailed analyses has been completed of: the process, scope and reach of program delivery using both quantitative and qualitative measures; changes in attitudes and knowledge measured through key informant interviews and surveys of professional groups and consumers; and changes in prescribing behaviour and savings to the Pharmaceutical Benefits Scheme (PBS) through analysis of prescription data. The evaluation period for this report was mid-1998 to mid-2004.

RESULTS

The NPS has successfully implemented a complex, multi-faceted program across Australia. From 1998 to 2004, in addition to print material provided to all general practitioners (GPs) and pharmacists, 90% of all GPs have been actively involved in one or more educational activity; 116 of 120 divisions of general practice have coordinated local NPS programs; and 9% of pharmacists have actively participated in at least one educational activity. Sixty per cent of GPs and pharmacists rated the printed educational materials as good or very good. In the last three years, the NPS activities have generated savings in the range of $121-163 million to the PBS, owing to changes in prescribing practices.

CONCLUSION

The national evaluation framework has informed program delivery and ongoing design and development. Continued refinement of existing evaluation methods and further exploration of new techniques will remain a priority for the organization.

Using aggregate data on dispensed drugs to evaluate the quality of prescribing in urban primary health care in Sweden

BACKGROUND

Valuable evaluations of the quality of drug prescribing in routine health care are difficult to perform. It is even more difficult to study prescribing in a non-gatekeeping healthcare system with a variety of caregivers involved in patient care. Consequently, there is a need to develop methods for evaluation using data available in routine health care.

OBJECTIVES

The aim of this study was to analyse possibilities and limitations for evaluation of the quality of drug prescribing using routinely collected aggregate data on dispensed drugs and health care provision. A secondary aim was to study the effects of allocating more resources to primary health care (PHC) on the quality of drug prescribing.

METHODS

The study was performed with routinely collected data from 10 PHC centres in Stockholm, Sweden that were participating in an intervention project that aimed to decrease the number of inhabitants per PHC doctor. Time periods for analysis were October-December 1999, 2000 and 2001. Data on dispensed prescriptions were analysed by age using Anatomical Therapeutic Chemical (ATC) classification/defined daily dose (DDD) methodology. The general quality of prescribing was determined using DU90% methodology (identifying the number of drugs constituting 90% of the volume expressed in DDDs and the adherence to evidence-based recommendations) and ratios between different treatment alternatives. The total volume and cost of drugs prescribed to the population was also analysed.

RESULTS

In 2001, PHC centres accounted for, on average, 27% (range 14-36%) of all doctor consultations and 32% (range 22-43%) of all prescriptions to populations in the corresponding primary care districts. There was great variation between the different PHC centres with regard to the prescribing doctors' compliance with guidelines from the regional drug and therapeutics committee, and the utilization of health care and drugs among the population in the corresponding primary care districts. No clear improvement was observed over time.

CONCLUSION

Analysis of aggregated prescription and healthcare data at population level was feasible. However, the effects of allocation of increasing resources to PHC on the quality of drug prescribing need to be analysed in a broader context.

Physician Response to Written Feedback on a Medication Discrepancy Found with Their Elderly Ambulatory Patients

OBJECTIVES

To assess physicians' responses to written feedback on medication discrepancies found with their elderly ambulatory patients.

DESIGN

Cross-sectional survey.

SETTING

Four clinics of a large university-affiliated, multispecialty group practice associated with a 186,000-member health maintenance organization.

PARTICIPANTS

Patients aged 65 and older (n=202) and their family physicians (n=32).

MEASUREMENTS

Medication discrepancies and physicians' responses to written feedback on letters and adhesive labels containing a list of patients' actual medications.

RESULTS

A medication discrepancy was identified with 171 of 202 patients (84.7%). They resulted from patients not taking charted medications (52.9%), patients taking medications that were not charted (34.3%), or difference in dosage and/or schedule (12.8%). The medications involved were mostly complementary/alternative (28.3%), respiratory/allergy (15.1%), and analgesics (14.1%). The majority of physicians reported that the letters (93.8%) and accompanying labels (90.6%) were helpful to them. Half of the physicians reported filing the letters in patients' charts, whereas the other half discarded them. The majority (93.8%) also perceived the labels as an additional benefit to their practice and placed them in patients' charts to be used to correct patients' medications. Receptivity to the feedback was unrelated to physician age group, sex, years in practice, or clinic of practice.

CONCLUSION

Although medication discrepancies are common in elderly ambulatory patients, their family physicians appreciate assistance in correcting these discrepancies, although potential problems, such as cultural or organizational resistance to the open disclosure of medication discrepancies in medical records due to associated legal ramifications, may need to be resolved.

A study of adherence to drug recommendations by providing feedback of outpatient prescribing patterns to hospital specialists

PURPOSE

To study the effect of feedback using prescribing profiles combined with interactive group discussions on hospital specialists' adherence to evidence-based guidelines for drug treatment of common diseases issued by a regional Drug and Therapeutics Committee.

METHODS

Intervention study performed at 17 clinics at a university hospital in a Swedish metropolitan health region with comparative clinics at a second university hospital as a control. Prescribing profiles based on aggregate pharmacy dispensing data were presented for the physicians in interactive group discussions. Deviations from the guidelines were discussed at each clinic and specific goals of improvement were formulated. The effect was assessed by pre- and post-intervention comparison of the adherence to guidelines for all drugs and within 11 selected therapeutic areas. The credibility and usefulness of the prescribing profiles were evaluated by a questionnaire.

RESULTS

The adherence to pharmaceutical products within the pharmacological groups stated in the guideline increased by 2.8%-units at the intervention hospital compared with 0.8%-units at the control hospital. The adherence to drug substance increased by 0.4%-units at the intervention hospital while it decreased by 1.8%-units at the control hospital. For 8 of 11 pre-defined specific goals of improvement, the change in adherence was more positive at the intervention hospital. Most doctors considered the feedback provided clear and relevant.

CONCLUSIONS

Interactive group discussions with prescribing profiles were found to be useful in improving hospital specialists' adherence to guidelines. However, the effect on the overall adherence was modest, indicating the importance of clear messages for improvement and relevant guidelines for the prescribing of specialist drugs but also more precise methods for evaluating the effect of real-life-interventions.

Interventions to improve antibiotic prescribing practices in ambulatory care

BACKGROUND

The development of resistance to antibiotics by many important human pathogens has been linked to exposure to antibiotics over time. The misuse of antibiotics for viral infections (for which they are of no value) and the excessive use of broad spectrum antibiotics in place of narrower spectrum antibiotics have been well-documented throughout the world. Many studies have helped to elucidate the reasons physicians use antibiotics inappropriately.

OBJECTIVES

To systematically review the literature to estimate the effectiveness of professional interventions, alone or in combination, in improving the selection, dose and treatment duration of antibiotics prescribed by healthcare providers in the outpatient setting; and to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialized register for studies relating to antibiotic prescribing and ambulatory care. Additional studies were obtained from the bibliographies of retrieved articles, the Scientific Citation Index and personal files.

SELECTION CRITERIA

We included all randomised and quasi-randomised controlled trials (RCT and QRCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of healthcare consumers or healthcare professionals who provide primary care in the outpatient setting. Interventions included any professional intervention, as defined by EPOC, or a patient-based intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality.

MAIN RESULTS

Thirty-nine studies examined the effect of printed educational materials for physicians, audit and feedback, educational meetings, educational outreach visits, financial and healthcare system changes, physician reminders, patient-based interventions and multi-faceted interventions. These interventions addressed the overuse of antibiotics for viral infections, the choice of antibiotic for bacterial infections such as streptococcal pharyngitis and urinary tract infection, and the duration of use of antibiotics for conditions such as acute otitis media. Use of printed educational materials or audit and feedback alone resulted in no or only small changes in prescribing. The exception was a study documenting a sustained reduction in macrolide use in Finland following the publication of a warning against their use for group A streptococcal infections. Interactive educational meetings appeared to be more effective than didactic lectures. Educational outreach visits and physician reminders produced mixed results. Patient-based interventions, particularly the use of delayed prescriptions for infections for which antibiotics were not immediately indicated effectively reduced antibiotic use by patients and did not result in excess morbidity. Multi-faceted interventions combining physician, patient and public education in a variety of venues and formats were the most successful in reducing antibiotic prescribing for inappropriate indications. Only one of four studies demonstrated a sustained reduction in the incidence of antibiotic-resistant bacteria associated with the intervention.

AUTHORS' CONCLUSIONS

The effectiveness of an intervention on antibiotic prescribing depends to a large degree on the particular prescribing behaviour and the barriers to change in the particular community. No single intervention can be recommended for all behaviours in any setting. Multi-faceted interventions where educational interventions occur on many levels may be successfully applied to communities after addressing local barriers to change. These were the only interventions with effect sizes of sufficient magnitude to potentially reduce the incidence of antibiotic-resistant bacteria. Future research should focus on which elements of these interventions are the most effective. In addition, patient-based interventions and physician reminders show promise and innovative methods such as these deserve further study.

Prescription audit adjunct to rational pharmacotherapy education improves prescribing skills of medical students

OBJECTIVE

To assess the impact of a rational pharmacotherapy (RP) teaching program during clinical pharmacology clerkship by analyzing the results of prescription audits (PAs) of the medical students. Collectively, we intended to observe the possible improvement of the students in their prescribing, problem solving and self-directed learning skills.

DESIGN

At the beginning and end of the clerkship, the students were presented with cases of uncomplicated osteoarthritis to assess their prescribing skills; format and rationality were scored.

SETTING

A medical school in Turkey that teaches RP to the fourth-year students in clinical pharmacology clerkship.

PARTICIPANTS

There were 94 students of the 2002-2003 academic year in three groups and a single group of students belonging to the previous academic year tested. Of those students from the previous academic year, 26 were also analyzed a year later to demonstrate the long-term impact of the training.

MAIN OUTCOME MEASURES

Prescribing skills of medical students and their opinions about PA.

RESULTS

Direct assessment via PA demonstrated that the scores for post-clerkship prescriptions were far better than those for pre-clerkship prescriptions in terms of format and rationality. Long-term assessment showed that the scores declined within a year following clerkship, but they were still higher than those of their pre-clerkship scripts. Analysis of the questionnaires revealed that the students were satisfied with PA. The majority of the students stated they had learned the general principles of RP and gained better prescribing skills, and they intended to apply most of the principles learned to their future professional lives. The script format scores of a retrospectively created PA-exempted group were significantly lower than those of the students to whom an established PA education was given.

CONCLUSION

PA sessions were shown to be an easy and a useful method of both evaluating and reinforcing prescribing skills gained though problem-based RP education.

National Prescribing Service: creating an implementation arm for national medicines policy

Medicines make an essential contribution to the health of the community, but rapidly rising drug budgets have caused governments to seek ways of ensuring this expenditure results in value for money. The National Prescribing Service was established against this background to implement a quality use of medicines service as part of the National Medicines Policy. A range of programmes that attempt to use evidence-based strategies to deliver evidence-based messages have been established. These use multifaceted interventions, such as newsletters, prescriber feedback, clinical audit and educational visiting, that are provided both centrally, through the national office, and locally, through Divisions of General Practice. The work is underpinned by an evaluation strategy that incorporates strong qualitative elements as well as an emphasis on time-series analyses for changes in drug utilization. Some 80% of Australian general practitioners have voluntarily participated in activities such as educational visiting and clinical audit within the National Prescribing Service programmes. New programmes for the community and consumers will be coordinated with the work that has become well established within general practice.

A Multifaceted Intervention to Improve Antimicrobial Prescribing for Upper Respiratory Tract Infections in a Small Rural Community

BACKGROUND

Antibiotic prescribing for upper respiratory tract infections (URTIs) is widespread, is often inappropriate, and may contribute to antibiotic resistance among community-acquired pathogens, such as Streptococcus pneumoniae.

METHODS

A multifaceted intervention involving health care professionals and patients was introduced to a small rural Utah community and included the repetitive use of printed diagnostic and treatment algorithms by professionals. Data on the quantity and class of antibiotic prescribing, which were collected from multiple sources, were measured for the intervention period (from January through June) in 2001 and compared with data for the baseline period during the same months in 2000.

RESULTS

Medicaid claims data revealed that the percentage of patients in the community who received antibiotics for URTIs during the intervention period was 15.6% less than that for the baseline period, whereas the percentage in the rest of rural Utah was relatively stable, with a 1.5% decrease (P=.006). The greatest impact of the intervention was on prescribing for acute bronchitis (decreases of 56.1% and 1.7% in the community and rural Utah, respectively; P=.024) and on prescribing of macrolides (decreases of 13.4% and 0.2% in the community and rural Utah, respectively; P<.001). Community pharmacy data likewise revealed a 17.5% decrease in the rate of antibiotic prescribing during the intervention period (P<.001), with the largest decrease observed for macrolide prescribing (50.9%; P<.001). Chart review data, in contrast, revealed no significant decrease in the percentage of patients with URTI who were prescribed an antibiotic (3.8%; P=.49), although there was a significant decrease of 11.2% in macrolide use (P=.045).

CONCLUSIONS

A multifaceted intervention involving the repetitive use of printed algorithms resulted in modest improvements in antibiotic prescribing for outpatient URTIs, although one data source did not corroborate this. However, macrolide prescribing decreased sharply, irrespective of the source of data.

The application of prescribing indicators to a primary care prescription database in Ireland

OBJECTIVE

To develop appropriate prescribing indicators and apply these to Irish prescription data.

METHODS

A postal survey of 145 randomly selected general practitioners working within the Eastern Health Board region of the State-supported General Medical Services scheme in Ireland regarding the applicability of selected prescribing indicators was carried out. Such indicators were then applied to aggregate prescription data.

RESULTS

Prescribing indicators based on agents of questionable efficacy/poor quality prescribing and those based on good prescribing practice were thought to make suitable indicators. Low rates of prescribing were noted for indicators based on drugs of limited efficacy, e.g. cerebral and peripheral vasodilators (rate 3.1 per 1,000 prescriptions), whilst indicators based on drugs associated with good prescribing practice were associated with higher prescribing rates, e.g. the prescription of aspirin in patients receiving nitrate therapy(rate 7.13 per 1,000 patients). However, a low rate of generic prescribing (4.6%) was found amongst general practitioners in the study. The largest variability in prescribing was seen with the prescribing of peripheral and cerebral vasodilators (75th/25th centile=5.6) and the prescription of long-acting sulphonylureas (75th/25th centile=66.6).

CONCLUSIONS

Quality indicators based on aggregate prescribing provide valuable information on prescribing standards and should be developed with the close involvement of prescribers.

Efectividad de una intervención en la mejora de la calidad de prescripción con receta médica en atención especializada

OBJECTIVE

The study was designed to research whether providing doctors with customized reports on prescription indicators,plus a presentation of the project to clinical departments and hospital boards, would improve prescription quality in specialized care.

MATERIAL AND METHODS

Quasi experimental intervention study. During three periods of time we observed whether any differences between physicians receiving said reports (intervention group) and physicians not receiving said reports (control group)occurred in three overall quality markers (94 physicians)--generic drugs, low therapeutic value drugs, and irrelevant novel drugs-and two specific indicators--angiotensin converting enzyme inhibitors (109 physicians) and omeprazole (169 physicians). Indicators were assessed using mean values (95% Cl) and differences between groups with the z test.

RESULTS

Prior to the intervention, indicators had no significant differences. At 4-6 months after delivering the report, generic drug prescription improved in the intervention group - 3.13%(1.79-4.47) versus 1.81% (1.08-2.54) in the control group,p = 0.041. After 10-12 months the intervention group had significantly improved versus the control group regarding: generic drugs, 4.01% (2.28-5.73) versus 2.22% (1.56-2.87), p = 0.025;ACE inhibitors, 58.89% (47.56-70.21) versus 45.91% (36.03-55.79), p = 0.042; and low therapeutic utility drugs, 8.57%(5.56-11.6) versus 12.35% (8.96-15.74), p = 0.047. Improvement regarding omeprazole did not reach statistical significance,and novel medications remained virtually unchanged.

CONCLUSION

The intervention proved effective for the improvement of qualitative prescription indicators in specialized care.

Improving test ordering in primary care: the added value of a small-group quality improvement strategy compared with classic feedback only

PURPOSE

We wanted to evaluate the added value of small peer-group quality improvement meetings compared with simple feedback as a strategy to improve test-ordering behavior. Numbers of tests ordered by primary care physicians are increasing, and many of these tests seem to be unnecessary according to established, evidence-based guidelines.

METHODS

We enrolled 194 primary care physicians from 27 local primary care practice groups in 5 health care regions (5 diagnostic centers). The study was a cluster randomized trial with randomization at the local physician group level. We evaluated an innovative, multifaceted strategy, combining written comparative feedback, group education on national guidelines, and social influence by peers in quality improvement sessions in small groups. The strategy was aimed at 3 specific clinical topics: cardiovascular issues, upper abdominal complaints, and lower abdominal complaints. The mean number of tests per physician per 6 months at baseline and the physicians' region were used as independent variables, and the mean number of tests per physician per 6 months was the dependent variable.

RESULTS

The new strategy was executed in 13 primary care groups, whereas 14 groups received feedback only. For all 3 clinical topics, the decrease in mean total number of tests ordered by physicians in the intervention arm was far more substantial (on average 51 fewer tests per physician per half-year) than the decrease in mean number of tests ordered by physicians in the feedback arm (P = .005). Five tests considered to be inappropriate for the clinical problem of upper abdominal complaints decreased in the intervention arm, with physicians in the feedback arm ordering 13 more tests per 6 months (P = .002). Interdoctor variation in test ordering decreased more in the intervention arm.

CONCLUSION

Compared with only disseminating comparative feedback reports to primary care physicians, the new strategy of involving peer interaction and social influence improved the physicians' test-ordering behavior. To be effective, feedback needs to be integrated in an interactive, educational environment.