Dataset Information

A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: study protocol.

ABSTRACT:

Background

The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?; and what are the costs of implementing the strategy?

Methods

In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year.

Discussion

We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines.

SUBMITTER: Trietsch J

PROVIDER: S-EPMC2656449 | biostudies-literature | 2009 Feb

REPOSITORIES: biostudies-literature

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Publications

A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: study protocol.

Trietsch Jasper J van der Weijden Trudy T Verstappen Wim W Janknegt Rob R Muijrers Paul P Winkens Ron R van Steenkiste Ben B Grol Richard R Metsemakers Job J

Implementation science : IS 20090217

<h4>Background</h4>The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy ...[more]

PMID: 19222840

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Project description:BackgroundMuch 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.MethodsWe 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.ResultsTwenty-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.ConclusionsOur 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 registrationThis trial was registered at the Dutch trial register under number ISRCTN40008171 on August 7th 2007.

Project description:BackgroundRedundant use of diagnostic tests in primary care has shown to be a contributor to rising Dutch healthcare costs. A price display in the test ordering system of the electronic health records (EHRs) could potentially be a low-cost and easy to implement intervention to a decrease in test ordering rate in the primary care setting by creating more cost-awareness among general practitioners (GPs). The aim of this study was to assess the effect of a price display for diagnostic laboratory tests in the EHR on laboratory test ordering behavior of GPs in the Westelijke Mijnstreek region in the Netherlands.MethodsA pre-post intervention study among 154 GPs working in 57 general practices was conducted from September 2019, until March 2020, in the Netherlands. The intervention consisted of displaying the costs of 22 laboratory tests at the time of ordering. The primary outcome was the mean test ordering rate per 1.000 patients per month, per general practice.ResultsTest ordering rates were on average rising prior to the intervention. The total mean monthly test order volume showed a non-statistically significant interruption in this rising trend after the intervention, with the mean monthly test ordering rate levelling out from 322.4 to 322.2 (P = 0.86). A subgroup analysis for solely individually priced tests showed a statistically significant decrease in mean monthly test ordering rate after implementation of the price display for the sum of all tests from 67.2 to 63.3 (P = 0.01), as well as for some of these tests individually (i.e. thrombocytes, ALAT, TSH, folic acid). Leucocytes, ESR, vitamin B12, anti-CCP and NT-proBNP also showed a decrease, albeit not statistically significant (P > 0.05).ConclusionsOur study suggests that a price display intervention is a simple tool that can alter physicians order behavior and constrain the expanding use of laboratory tests. Future research might consider alternative study designs and a longer follow-up period. Furthermore, in future studies, the combination with a multitude of interventions, like educational programs and feedback strategies, should be studied, while potentially adverse events caused by reduced testing should also be taken into consideration.

Project description:BackgroundPotentially inappropriate prescribing (PIP) has been linked with adverse health outcomes and increased healthcare costs. Feedback interventions targeting PIP have shown promising results. However, translation from research to everyday practice remains a challenge. With the Normalisation Process Theory (NPT) as overarching framework, we aimed to explore the implementation processes performed by general practices in a real-life, quality improvement intervention using feedback on practice-level prescribing.MethodsAll 376 general practices in the Central Denmark Region received a prescribing feedback intervention targeting selected types of PIP. Six months later, they received an evaluation questionnaire, to which 45% responded. Among 102 practices reporting to have made changes in response to the intervention, we conducted individual, semi-structured interviews with ten GPs. Maximum variation was sought in terms of baseline prescribing status, implementation activities, practice type and geographical location. The interviews were analysed thematically using NPT.ResultsThe implementation processes in general practice reflected the four NPT constructs. Key motivators for implementation included the GPs' professional values and interests, but pragmatic considerations were also of importance (coherence). A collective versus an individual approach to the engagement and planning of the implementation process (cognitive participation) was observed. Similarly, a distinction was evident between practice-level actions involving the entire practice team as opposed to individual-level actions performed by the individual GP (collective action). Several challenges to the implementation processes were identified, including patient influences and competing priorities at multiple levels (reflexive monitoring). Additionally, internal evaluation and normalisation of new practices occurred in varying degrees.ConclusionNPT provided a useful framework for understanding implementation processes in general practice. Our results emphasise that clear professional aims and feasible content of interventions are key for GP motivation. This may be ensured through cooperation with GPs' professional organisation, which may strengthen intervention legitimacy and uptake. Two main implementation strategies were identified: practice-level and GP-level strategies. Intervention developers need to recognise both strategies to deliver intervention content and implementation support that promote sustainable improvements in prescribing practice. Competing demands and patient influences remain important challenges that need to be addressed in future studies to further facilitate the reduction of PIPs.

Project description:BackgroundAustralian and international guidelines recommend benzodiazepines and related drugs (hereafter "benzodiazepines") as second-line, short-term medications only. Most benzodiazepines are prescribed by general practitioners (GPs; family physicians). Australian GP registrars ("trainees" or "residents" participating in a post-hospital training, apprenticeship-like, practice-based vocational training program), like senior GPs, prescribe benzodiazepines at high rates. Education within a training program, and experience in general practice, would be expected to reduce benzodiazepine prescribing.ObjectiveTo establish if registrars' prescribing of benzodiazepines decreases with time within a GP training program DESIGN: Longitudinal analysis from the Registrar Clinical Encounters in Training multi-site cohort study PARTICIPANTS: Registrars of five of Australia's 17 Regional Training Providers. Analyses were restricted to patients ??16 years.Main measuresThe main outcome factor was prescription of a benzodiazepine. Conditional logistic regression was used, with registrar included as a fixed effect, to assess within-registrar changes in benzodiazepine-prescribing rates. The "time" predictor variable was "training term" (6-month duration Terms 1-4). To contextualize these "within-registrar" changes, a mixed effects logistic regression model was used, including a random effect for registrar, to assess within-program changes in benzodiazepine-prescribing rates over time. The "time" predictor variable was "year" (2010-2015).Key resultsOver 12 terms of data collection, 2010-2015, 1161 registrars (response rate 96%) provided data on 136,809 face-to-face office-based consultations. Two thousand six hundred thirty-two benzodiazepines were prescribed (for 1.2% of all problems managed). In the multivariable model, there was a significant reduction in within-program benzodiazepine prescribing over time (year) (p?=?<?0.001, OR?=?0.94, CI?=?0.90, 0.97). However, there was no significant change in 'within-registrar' prescribing over time (registrar Term) (p?=?0.92, OR?=?1.00 [95% CI?=?0.94-1.06]).ConclusionsDespite a welcome temporal trend for reductions in overall benzodiazepine prescribing from 2010 to 2015, there is still room for improvement and our findings suggest a lack of effect of specific GP vocational training program education and, thus, an opportunity for targeted education.

Project description:BackgroundGeneral practitioners (GPs) make numerous care decisions throughout their workdays. Extended periods of decision making can result in decision fatigue, a gradual shift toward decisions that are less cognitively effortful. This study examines whether observed patterns in GPs' prescribing decisions are consistent with the decision fatigue phenomenon. We hypothesized that the likelihood of prescribing frequently overprescribed medications (antibiotics, benzodiazepines, opioids; less effortful to prescribe) will increase and the likelihood of prescribing frequently underprescribed medications (statins, osteoporosis medications; more effortful to prescribe) will decrease over the workday.MethodsThis study used nationally representative primary care data on GP-patient encounters from the Bettering the Evaluation and Care of Health program from Australia. The association between prescribing decisions and order of patient encounters over a GP's workday was assessed with generalized linear mixed models accounting for clustering and adjusting for patient, provider, and encounter characteristics.ResultsAmong 262,456 encounters recorded by 2,909 GPs, the odds of prescribing antibiotics significantly increased by 8.7% with 15 additional patient encounters (odds ratio [OR] = 1.087; confidence interval [CI] = 1.059-1.116). The odds of prescribing decreased significantly with 15 additional patient encounters by 6.3% for benzodiazepines (OR = 0.937; CI = 0.893-0.983), 21.9% for statins (OR = 0.791; CI = 0.753-0.831), and 25.0% for osteoporosis medications (OR = 0.750; CI = 0.690-0.814). No significant effects were observed for opioids. All findings were replicated in confirmatory analyses except the effect of benzodiazepines.ConclusionsGPs were increasingly likely to prescribe antibiotics and were less likely to prescribe statins and osteoporosis medications as the workday wore on, which was consistent with decision fatigue. There was no convincing evidence of decision fatigue effects in the prescribing of opioids or benzodiazepines. These findings establish decision fatigue as a promising target for optimizing prescribing behavior.HighlightsWe found that as general practitioners progress through their workday, they become more likely to prescribe antibiotics that are reportedly overprescribed and less likely to prescribe statins and osteoporosis medications that are reportedly underprescribed.This change in decision making over time is consistent with the decision fatigue phenomenon. Decision fatigue occurs when we make many decisions without taking a rest break. As we make those decisions, we become gradually more likely to make decisions that are less difficult.The findings of this study show that decision fatigue is a possible target for improving guideline-compliant prescribing of pharmacologic medications.

Project description:ObjectiveAt our emergency department (ED), opioid prescribing guidelines were implemented in September 2016. The opioid prescribing guidelines were adopted and revised from collective efforts and advocacy of the Michigan College of Emergency Physicians for ED-led opioid stewardship. We performed a retrospective before and after study to determine if opioid prescribing guidelines would change the use of intravenous opioids per patient and the morphine equivalent units (MEU) per patient in a suburban academic ED.MethodsA retrospective observational study was conducted at a tertiary care level 1 trauma center with an annual ED volume of ≈ 130,000 visits. All intravenous orders of fentanyl, morphine, and hydromorphone for adult patients from January 1, 2015, through December 31, 2017, were tabulated. A 3-month (August 2016-October 2016) washout period was used. Poisson and ordinary linear regression analyses were employed to evaluate any difference in number of intravenous opioids ordered before and after adoption of the guidelines. Within our opioid prescribing guidelines was also guidance for oral opioid orders within the ED and oral opioid prescriptions for discharge, although these elements were not included in this investigation.ResultsA total of 108,327 intravenous opioid orders were included in the final analysis. After adoption of the opioid prescribing guidelines, the expected number of intravenous opioids ordered dropped by 3.1% (eβ, 0.969; 95% confidence interval [CI], 0.779-1.209), and there was an additional decrease of 0.1% per month (eβ, 0.999; 95% CI, 0.990-1.010). After the adoption of opioid prescribing guidelines, the average MEU dropped by 0.3 mg (95% CI, -0.47 to -0.13), and there was decrease of 0.01 mg per month (95% CI, -0.02 to -0.004).ConclusionAfter the adoption of opioid prescribing guidelines, our analysis suggests that opioid prescribing guidelines are associated with clinically small but statistically significant changes in MEU ordered in ED. We cannot determine if this represented a continued trend of decreased opioid use or associated with the opioid prescribing guidelines.

Dataset Information

A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: study protocol.

Background

Methods

Discussion

Publications

A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: study protocol.

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