Improving drug treatment in general practice

Abstract

In the international Drug Education Project, an educational program involving auditing and feedback in peer groups to improve the treatment of asthma and urinary tract infections (UTI) was developed and tested in primary care. Individualized feedback was provided and discussed in 24 Dutch peer groups showing doctors their prescribing practices and underlying reasons for treatment. A parallel, randomized controlled design was used to test the effect on competence and actual prescribing; in one study arm doctors received feedback on asthma treatment and in the other on UTI treatment. Especially the messages to treat asthma exacerbations with oral corticosteroids (17% increase) and to prescribe short courses for UTI (decrease duration of 1.8 days) brought about large improvements. Both messages concerned acute situations, and were clear and relatively easy for GPs to implement. GPs will experience more barriers when changing maintenance treatment of an asthma patient, which could explain the more limited success of this part of the educational program: the proportion of patients treated with inhaled corticosteroids increased 5%. A ceiling effect was experienced regarding drug choice for UTI.

Introduction

The implementation of clinical guidelines to improve quality of care is receiving increasing attention. Different educational strategies are being used to implement guidelines and to promote behavioral change. However, recent overviews of systematic reviews of educational interventions indicate once more the modest and mixed improvements in performance after interventions 1, 2. The effect of educational interventions is not consistent across practitioners, settings, and behaviors [3]. The impact of the education is influenced by modifying factors such as the source, timing, and format of the intervention, and the receptivity and involvement of the recipients 4, 5, 6.

Prerequisites for changing behavior are awareness, understanding, and acceptance of both the problem and its solution [7]. Each step in the change process may pose specific problems and barriers 7, 8. It is therefore not surprising that combined strategies that deal with different types of barriers to implementing evidence-based medicine are more effective than single strategies [4]. The first step is becoming aware that a problem may exist in one's practice behavior 7, 9. When looking at prescribing behavior, interviews and surveys among GPs indicated they often wrongly think they work according to the guidelines, and thus may think there is no need for change 10, 11. Providing feedback on actual prescribing behavior contributes to awareness and understanding of such a need [12]. Once the problem is acknowledged, one must learn and understand what caused the problem and how it can be solved. For this, elucidating and discussing the decision process underlying treatment decisions may be useful 13, 14. To accept new information or practice recommendations the credibility of the source is of importance 5, 7. In addition, discussing reservations with peers regarding new information is helpful to overcome certain barriers to its acceptance [15]. Social force may further stimulate the acceptance of guideline recommendations 7, 16. Once a doctor has accepted a new practice and has the intention to change, there still may be several barriers within the practice setting that prevent the actual implementation in practice [7]. Discussing problems encountered in everyday practice may help to overcome such barriers to implementation.

For improving prescribing behavior, both audit and feedback, which deal with awareness and understanding, as well as outreach visits and peer group review, which focus more on acceptance and implementation, seem to be effective 1, 3, 4, 7, 17, 18. A combination of these promising strategies, however, has hardly been studied in rigorous designs, and studies conducted in the European setting are scarce 3, 4, 12, 19.

The aim of this study was to evaluate the effect of a newly developed form of group education for improving the quality of prescribing in primary health care. The strategy combined the elements identified as being important for effectively changing prescribing behavior. Individual feedback on actual prescribing behavior was provided to raise awareness. In addition, individual feedback was given to each doctor on factors that may have triggered suboptimal prescribing 13, 14. Well-accepted national guidelines were used as reference 10, 20. The feedback was presented and discussed in small peer groups to facilitate acceptance.

The effect of this educational strategy was evaluated in a randomized controlled trial for two different indications: the prescribing for an acute illness [i.e., uncomplicated urinary tract infections (UTI)], and the prescribing for a chronic illness (i.e., asthma). As the educational program was developed to overcome different types of barriers, comparable effects were expected of both programs. In addition, the influence of modifying factors identified as relevant for the chosen educational approach was studied. Three factors were included that can modify the success of peer group discussions 12, 21: size of the group, quality of the group discussion, and climate in the group. In addition, the attendance rate at the peer group meetings was expected to modify the success of the intervention. Finally, one GP characteristic was included that has been identified as being important for receptivity to new information or guidelines: the number of years working in practice 6, 7.