Characteristics of GPs responding to an educational intervention to minimise inappropriate prescriptions: subgroup analyses of the Rx-PAD study.

BACKGROUND: Interventions aimed at improving GPs' prescribing practice usually apply a 'one size fits all' when analysing intervention effects. Few studies explore intervention effects by variables related to the GPs' age, sex, specialist status, practice type (single-handed versus group), practice setting (urban versus rural), and baseline performance regarding the target of an intervention. AIM: To explore the characteristics of the GPs responding to a comprehensive educational intervention. DESIGN & SETTING: A secondary analysis of a cluster, randomised educational intervention in Norwegian general practice. Pre-intervention data were captured from January 2005 to December 2005, and post-intervention data from June 2006 to June 2007. The intervention was carried out from January to June 2006. METHOD: Eighty continuing medical education (CME) groups, including 449 GPs aged 27-68 years, were randomly allocated to either an education intervention arm (41 groups, 250 GPs) or a control arm (39 groups, 199 GPs). The primary outcome was GPs' change in potentially inappropriate prescriptions (PIPs) per 100 prescriptions issued to patients aged ≥70 years. The interaction between intervention outcome and variables related to the GPs and their practices were tested. RESULTS: Improvements in prescribing were highest among GPs aged 57-68 years (incidence rate ratio [IRR] = 0.77 [95% confidence interval {CI} = 0.73 to 0.81]), those who were specialists (IRR = 0.80 [95% CI = 0.78 to 0.82]), and those who worked in single-handed practices (IRR = 0.75 [95% CI = 0.68 to 0.83]), among GPs with 2.4 to 2.9 PIPs per 100 prescriptions at baseline (IRR = 0.74 [95% CI = 0.70 to 0.78]), and GPs with ≥15 prescriptions per patient per year at baseline (IRR = 0.77 [95% CI = 0.73 to 0.80]). CONCLUSION: The GPs with the lowest adherence to recommended practice at baseline improved their practice most.

Potentially Inappropriate Prescribing to Older Patients: Criteria, Prevalence and an Intervention to Reduce It: The Prescription Peer Academic Detailing (Rx-PAD) Study - A Cluster-Randomized, Educational Intervention in Norwegian General Practice.

Potentially inappropriate prescriptions (PIP) is drug treatment, which in general, at the group level for a median/mean patient, can be considered unfavourable meaning that the risks commonly may outweigh the benefits. This MiniReview reports and discusses the main findings in a large cluster-randomized educational intervention in Norwegian general practice, aimed at reducing the prevalence of PIPs to patients ≥70 years (The Rx-PAD study). Targets for the intervention were general practitioners (GPs) in continuing medical education (CME) groups receiving educational outreach visits (i.e. peer academic detailing). A Delphi consensus process, with a panel of medical experts, was undertaken to elaborate a list of explicit criteria defining PIPs for patients ≥70 years in general practice. Agreement was achieved for 36 explicit PIP criteria, the so-called Norwegian General Practice (NorGeP) criteria. Using a selection (n = 24) of these criteria during a 1-year baseline period on the prescribing practice of 454 GPs (i.e. those enrolled to participate in the intervention trial), we found a prevalence rate of 24.7 PIPs per 100 patients ≥70 years per year. In the Rx-PAD study, 449 GPs completed an educational intervention (96.6% of the included GPs), 250 in the intervention group and 199 in the control arm. Following the intervention, PIPs were reduced by 13% (95% CI 8.6-17.3), and the number of patients who were no longer exposed to one or more PIPs was reduced by 1173 (8.1%). The GPs who responded most strongly to the educational intervention were the oldest GPs (57-68 years), and these were the GPs with the highest prevalence of PIPs at baseline before the intervention.

Prescription peer academic detailing to reduce inappropriate prescribing for older patients: a cluster randomised controlled trial.

BACKGROUND: Older patients are at particular risk for adverse drug reactions. In older people, interventions targeting potentially inappropriate prescriptions (PIPs) are considered important measures to minimise drug-related harm, especially in the general practice setting where most prescriptions for older patients are issued. AIM: To study the effects of a multifaceted educational intervention on GPs' PIPs for older patients. DESIGN AND SETTING: This was a cluster randomised, educational intervention study in Norwegian general practice. Pre-study data were captured from January 2005 to December 2005 and post-study data from June 2006 to June 2007. The educational intervention was carried out from January 2006 to June 2006. METHOD: Eighty continuing medical education (CME) groups (465 GPs) were randomised to receive the educational intervention on GPs' PIPs for older patients (41 CME groups; 256 GPs) or another educational intervention (39 CME groups; 209 GPs); these two groups acted as controls for each other. GPs' prescription data from before and after the intervention were assessed against a list of 13 explicit PIP criteria for patients aged ≥70 years. In the CME groups, trained GPs carried out an educational programme, including an audit, focusing on the 13 criteria and their rationale. RESULTS: A total of 449 GPs (96.6%) completed the study; 250 in the intervention group and 199 in the control group. After adjusting for baseline differences and clustering effects, a reduction relative to baseline of 10.3% (95% confidence interval = 5.9 to 15.0) PIPs per 100 patients aged ≥70 years was obtained. CONCLUSION: Educational outreach visits with feedback and audit, using GPs as academic detailers in GPs' CME groups, reduced PIPs for older patients aged ≥70 years in general practice.

Changed terms for drug payment influenced GPs' diagnoses and prescribing practice for inhaled corticosteroids.

BACKGROUND: Inhaled glucocorticosteroids (ICS) are first-line anti-inflammatory treatment in asthma, but not in chronic obstructive pulmonary disease (COPD). To restrict ICS use in COPD to cases of severe disease, new terms for reimbursement of drug costs were introduced in Norway in 2006, requiring a diagnosis of COPD to be verified by spirometry. OBJECTIVES: To describe how GPs' diagnoses and treatment of patients who used ICS before 2006 changed after a reassessment of the patients that included spirometry. METHODS: From the shared electronic patient record system in one group practice, patients ≥ 50 years prescribed ICS (including in combination with long-acting beta2-agonists) during the previous year were identified and invited to a tailored consultation including spirometry to assure the quality of diagnosis and treatment. GPs' diagnoses and ICS prescribing patterns after this reassessment were recorded, retrospectively. RESULTS: Of 164 patients identified, 112 were included. Post-bronchodilator spirometry showed airflow limitation indicating COPD in 55 patients. Of the 57 remaining patients, five had a positive reversibility test. The number of patients diagnosed with asthma increased (from 25 to 62) after the reassessment. A diagnosis of COPD was also more frequently used, whereas fewer patients had other pulmonary diagnoses. ICS was discontinued in 31 patients; 20 with mild to moderate COPD and 11 with normal spirometry. CONCLUSION: Altered reimbursement terms for ICS changed GPs' diagnostic practice in a way that made the diagnoses better fit with the treatment given, but over-diagnosis of asthma could not be excluded. Spirometry was useful for identifying ICS overuse.

The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients. A modified Delphi study.

OBJECTIVE: To establish a clinically relevant list with explicit criteria for pharmacologically inappropriate prescriptions in general practice for elderly people > or =70 years. DESIGN: A three-round Delphi process for validating the clinical relevance of suggested criteria (n = 37) for inappropriate prescriptions to elderly patients. SETTING: A postal consensus process undertaken by a panel of specialists in general practice, clinical pharmacology, and geriatrics. Main outcome measures. The Norwegian General Practice (NORGEP) criteria, a relevance-validated list of drugs, drug dosages, and drug combinations to be avoided in the elderly (< or =70 years) patients. RESULTS: Of the 140 invited panellists, 57 accepted to participate and 47 completed all three rounds of the Delphi process. The panellists reached consensus that 36 of the 37 suggested criteria were clinically relevant for general practice. Relevance of three of the criteria was rated significantly higher in Round 3 than in Round 1. At the end of the Delphi process, a significant difference between the different specialist groups' scores was seen for only one of the 36 criteria. CONCLUSION: The NORGEP criteria may serve as rules of thumb for general practitioners (GPs) related to their prescribing practice for elderly patients, and as a tool for evaluating the quality of GPs' prescribing in settings where access to clinical information for individual patients is limited, e.g. in prescription databases and quality improvement interventions.

Pharmacologically inappropriate prescriptions for elderly patients in general practice: How common? Baseline data from The Prescription Peer Academic Detailing (Rx-PAD) study.

OBJECTIVE: To assess Norwegian general practitioners' (GPs') level of potentially harmful drug prescribing for elderly patients. DESIGN: Prescription data for 12 months were retrospectively retrieved from the Norwegian Prescription Database (NorPD). Data were assessed in relation to 13 prescription quality indicators. SETTING: General practice. SUBJECTS: A total of 454 GPs attending continuous medical education (CME) groups in Southern Norway, 85,836 patients >or=70 years who received any prescription from the GPs during the study period. MAIN OUTCOME MEASURES: Number of prescriptions assessed in relation to pharmacological inappropriateness based on a list of 13 explicit prescription quality indicators. RESULTS: Some 18.4% of the patients (66% females with mean age 79.8 years, 34% males with mean age 78.7 years) received one or more inappropriate prescriptions from their GP. An NSAID in a potentially harmful combination with another drug (7%) and a long-acting benzodiazepine (4.6%) were the most frequent inappropriate prescriptions made. Doctor characteristics associated with more inappropriate prescribing practice were old age and working single-handed with many elderly patients. CONCLUSION: The study reveals areas where GPs' prescribing practice for elderly patients can be improved and which can be targeted in educational interventions.

[Healthcare providers' experience with multi-dose packaged medicines]. / Helsepersonells oppfatninger om multidosepakkede legemidler.

BACKGROUND: To prevent medication errors, community homecare services (CHS) increasingly use multi-dose packaged medicines (MDPM) for their clients. More knowledge is needed on how MDPM affects routines and quality of medication handling in the CHS. MATERIAL AND METHODS: Four CHS districts in a Norwegian community (27 GPs, 121 nurses) participated in the study. Structured questionnaires with some open-ended questions were used during interviews. The questionnaire focused on experience and satisfaction with MDPM as compared to the old system, and on how the MDPM had influenced collaboration between different categories of health personnel. RESULTS: With the MDP-system most nurses and GPs felt that medication control had become easier (CHS 76%, GPs 56%; p = 0.03) and that routines had improved (CHS 84%, GPs 52%; p < 0.001) with the MDP-system. Three of four GPs felt more confident than before about patients receiving the medication they had prescribed (CHS 73%, GPs 78%; p = 0.7). 44% of the GPs felt that they spent more time on prescribing medication with MDPM. INTERPRETATION: MDPM was generally found to improve routines, the quality of medication handling and medication safety. GPs were less content with the arrangement than nurses, probably because they had to collaborate with more CHS districts with different routines for exchanging information. When introducing MDPM in the CHS, explicit and definite orders of responsibility should be established as well as uniform collaboration routines between the GPs, the CHS and the MDPM-providers.

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

BACKGROUND: Age-related alterations in metabolism and excretion of medications increase the risk of adverse drug events in the elderly. Inappropriate polypharmacy and prescription practice entails increased burdens of impaired quality of life and drug related morbidity and mortality. The main objective of this trial is to evaluate effects of a tailored educational intervention towards general practitioners (GPs) aimed at supporting the implementation of a safer drug prescribing practice for elderly patients > or = 70 years. METHODS/DESIGN: Approximately 80 peer continuing medical education (CME) groups (about 600 GPs) in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. The control group will not receive any intervention towards prescription patterns in elderly, but will be the target of an educational intervention for prescription of antibiotics for respiratory tract infections. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, a set of quality indicators (QIs), i.e. explicit recommendations for safer prescribing for elderly patients, will be presented and discussed. Software will be handed out for installation in participants' practice computers to enable extraction of pre-defined prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Feedback reports will include QI-scores on individual- and group levels, before and after the intervention. The main outcome of this trial is the change in proportions of inappropriate prescriptions (QIs) for elderly patients > or = 70 years following intervention, compared to baseline levels. DISCUSSION: Improvement of prescription patterns in medical practice is a challenging task. Evidence suggests that a thorough evaluation of diagnostic indications for drug treatment in the elderly and/or a reduction of potentially inappropriate drugs may impose significant clinical benefits. Our hypothesis is that an educational intervention program will be effective in improving prescribing patterns for elderly patients in GP settings.

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

BACKGROUND: More than half of all antibiotic prescriptions in general practice are issued for respiratory tract infections (RTIs), despite convincing evidence that many of these infections are caused by viruses. Frequent misuse of antimicrobial agents is of great global health concern, as we face an emerging worldwide threat of bacterial antibiotic resistance. There is an increasing need to identify determinants and patterns of antibiotic prescribing, in order to identify where clinical practice can be improved. METHODS/DESIGN: Approximately 80 peer continuing medical education (CME) groups in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, evidence-based recommendations of antibiotic prescriptions for RTIs will be presented and software will be handed out for installation in participants PCs, enabling collection of prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Main outcomes are baseline proportion of inappropriate antibiotic prescriptions for RTIs and change in prescription patterns compared to baseline one year after the initiation of the tailored pedagogic intervention. DISCUSSION: Improvement of prescription patterns in medical practice is a challenging task. A thorough evaluation of guidelines for antibiotic treatment in RTIs may impose important benefits, whereas inappropriate prescribing entails substantial costs, as well as undesirable consequences like development of antibiotic resistance. Our hypothesis is that an educational intervention program will be effective in improving prescription patterns by reducing the total number of antibiotic prescriptions, as well as reducing the amount of broad-spectrum antibiotics, with special emphasis on macrolides.

[The withdrawal of Vioxx: how did the patients react?]. / Hvordan opplevde pasientene tilbaketrekkingen av Vioxx?

BACKGROUND: The withdrawal of rofecoxib (Vioxx) from the global market because of adverse cardiovascular effects affected many patients and created a lot of publicity. MATERIAL AND METHODS: 287 patients from four general practices who had received prescriptions for rofecoxib in 2004 were identified from the medical records of their general practitioner (GP) and mailed a questionnaire addressing their reactions and their expectations of their GP in this respect. RESULTS: 140 out of 287 patients returned the questionnaire. More than half were scared by the media frenzy about the withdrawal. 15% had received information from their GP after the withdrawal, whereas 70% wanted this kind of information. 42% had received prescriptions for rofecoxib, even if the patients could not confirm the presence of the diagnostic criteria. INTERPRETATION: The media frenzy gave rise to concern among patients, who want their GP to be more active in informing them about their use of unsafe medication. Better routines and data tools are needed for GPs to better identify and inform patients when needed.

[Do general practitioners know what medication community nurses give their shared patients?]. / Vet fastlegen hvilke medisiner hjemmesykepleien gir pasientene?

BACKGROUND: Frail elderly outpatients often receive medicines from community nurses. There is little knowledge of how general practitioners (GPs) and nurses update and coordinate their medication lists for their shared patients. MATERIAL AND METHODS: Lists of regular medication for 90 randomly selected shared patients from GPs as well as community nurses were assessed with respect to agreement. An agreement score was calculated for number of medicines and for each drug: total daily dosage and dose regimen. Routines for updating medication lists were addressed in a questionnaire to GPs and community nurses. RESULTS: For three out of four patients, discrepancies were found between physicians' and nurses' lists of regular medication. 52% of the discrepancies were in relation to cardiovascular drugs and psychotropic drugs. Only 41% of the GPs reported explicit routines for updating their medication lists. INTERPRETATION: The GPs' lack of knowledge of what their patients actually receive may contribute to medication errors and adverse drug reactions.