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]

Jørund Straand, Arne Fetveit, Sture Rognstad, Svein Gjelstad, Mette Brekke, Ingvild Dalen, Jørund Straand, Arne Fetveit, Sture Rognstad, Svein Gjelstad, Mette Brekke, Ingvild Dalen

Abstract

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.

Trial registration: ClinicalTrials.gov NCT00281450.

Figures

Figure 1
Figure 1
Flow of practices through The Rx-PAD Study. *Electronic Patient Record, **Norwegian Prescription Database, ***Prescription Peer Academic Detailer
Figure 2
Figure 2
Logistics of data collection. Flow-chart of merging process of prescription data provided by the Norwegian Prescription Database (NorPD) and data from the electronic patient record (EPR) systems. Patients' Civil Personal Registration (CPR) numbers are unique Norwegian residents' identification keys. Health Personnel Registration (HPR) numbers are unique Norwegian health personnel registration keys. Identifiable data will be deleted from the research database when the merge is completed, as the de-identified personal IDs will be sufficient for the subsequent data analysis. Statistics Norway, which is the public institution in Norway responsible for collecting, analyzing and disseminating official statistics, will provide CPR and HPR pseudonyms making it possible to merge the two data sources.

References

    1. Fried L, Walston J. Frailty and failure to thrive. In: Hazzard WH, Blass JP, Ettinger WH, Halter JB and Ouslander JG, editor. Principles of Geriatric Medicine and Gerontology. 4th. New York, McGraw-Hill; 1999. pp. 1387–1402.
    1. Turnheim K. Drug dosage in the elderly. Is it rational? Drugs Aging. 1998;13:357–379. doi: 10.2165/00002512-199813050-00003.
    1. WHO . The role of the hospital. , Tec Rep Ser; 1969. pp. 425:5–24.
    1. Atkin PA, Veitch PC, Veitch EM, Ogle SJ. The epidemiology of serious adverse drug reactions among the elderly. Drugs Aging. 1999;14:141–152. doi: 10.2165/00002512-199914020-00005.
    1. Beard K. Adverse reactions as a cause of hospital admission in the aged. Drugs Aging. 1992;2:356–367.
    1. Sarlov C, Andersen-Karlsson E, von Bahr C. [Adverse effects of drugs in patients with heart disease lead to hospital care] Lakartidningen. 2001;98:5349–5353.
    1. Beijer HJ, de Blaey CJ. Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies. Pharm World Sci. 2002;24:46–54. doi: 10.1023/A:1015570104121.
    1. Mjorndal T, Boman MD, Hagg S, Backstrom M, Wiholm BE, Wahlin A, Dahlqvist R. Adverse drug reactions as a cause for admissions to a department of internal medicine. Pharmacoepidemiol Drug Saf. 2002;11:65–72. doi: 10.1002/pds.667.
    1. Ebbesen J, Buajordet I, Erikssen J, Brors O, Hilberg T, Svaar H, Sandvik L. Drug-related deaths in a department of internal medicine. Arch Intern Med. 2001;161:2317–2323. doi: 10.1001/archinte.161.19.2317.
    1. WHO The problems of drug therapy in the elderly, . 2004.
    1. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. Jama. 1998;279:1200–1205. doi: 10.1001/jama.279.15.1200.
    1. Hanlon JT, Schmader KE, Ruby CM, Weinberger M. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc. 2001;49:200–209. doi: 10.1046/j.1532-5415.2001.49042.x.
    1. Lacoste-Roussillon C, Pouyanne P, Haramburu F, Miremont G, Begaud B. Incidence of serious adverse drug reactions in general practice: a prospective study. Clin Pharmacol Ther. 2001;69:458–462. doi: 10.1067/mcp.2001.116145.
    1. Ruths S, Straand J, Nygaard HA. Psychotropic drug use in nursing homes--diagnostic indications and variations between institutions. Eur J Clin Pharmacol. 2001;57:523–528. doi: 10.1007/s002280100348.
    1. Straand J, Rokstad KS. Elderly patients in general practice: diagnoses, drugs and inappropriate prescriptions. A report from the More & Romsdal Prescription Study. Fam Pract. 1999;16:380–388. doi: 10.1093/fampra/16.4.380.
    1. Rognstad S, Straand J. [Do general practitioners know what medication community nurses give their shared patients?] Tidsskr Nor Laegeforen. 2004;124:810–812.
    1. Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. Jama. 1994;272:292–296. doi: 10.1001/jama.272.4.292.
    1. Straand J, Rokstad K. General practitioners' prescribing patterns of benzodiazepine hypnotics: are elderly patients at particular risk for overprescribing? A report from the More & Romsdal Prescription Study. Scand J Prim Health Care. 1997;15:16–21.
    1. Eraker SA, Kirscht JP, Becker MH. Understanding and improving patient compliance. Ann Intern Med. 1984;100:258–268.
    1. Stuck AE, Beers MH, Steiner A, Aronow HU, Rubenstein LZ, Beck JC. Inappropriate medication use in community-residing older persons. Arch Intern Med. 1994;154:2195–2200. doi: 10.1001/archinte.154.19.2195.
    1. Aparasu RR, Mort JR. Inappropriate prescribing for the elderly: beers criteria-based review. Ann Pharmacother. 2000;34:338–346. doi: 10.1345/aph.19006.
    1. Prescribing Support Unit PSU. Prescribing measures and application. An explanation. Leeds, ; 1998.
    1. Roland M, Holden J, Campbell S. Quality assessment for general practice: supporting clinical governance in primary care groups. Manchester, National Primary Care Research and Development Centre; 1998.
    1. Campbell SM, Roland MO, Quayle JA, Buetow SA, Shekelle PG. Quality indicators for general practice: which ones can general practitioners and health authority managers agree are important and how useful are they? J Public Health Med. 1998;20:414–421.
    1. Buetow SA, Sibbald B, Cantrill JA, Halliwell S. Appropriateness in health care: application to prescribing. Soc Sci Med. 1997;45:261–271. doi: 10.1016/S0277-9536(96)00342-5.
    1. Cantrill JA, Sibbald B, Buetow S. Indicators of the appropriateness of long-term prescribing in general practice in the United Kingdom: consensus development, face and content validity, feasibility, and reliability. Qual Health Care. 1998;7:130–135.
    1. Avery AJ, Heron T, Lloyd D, Harris CM, Roberts D. Investigating relationships between a range of potential indicators of general practice prescribing: an observational study. J Clin Pharm Ther. 1998;23:441–450. doi: 10.1046/j.1365-2710.1998.00187.x.
    1. Bateman DN, Eccles M, Campbell M, Soutter J, Roberts SJ, Smith JM. Setting standards of prescribing performance in primary care: use of a consensus group of general practitioners and application of standards to practices in the north of England. Br J Gen Pract. 1996;46:20–25.
    1. Campbell SM, Cantrill JA, Roberts D. Prescribing indicators for UK general practice: Delphi consultation study. Bmj. 2000;321:425–428. doi: 10.1136/bmj.321.7258.425.
    1. Campbell SM, Braspenning J, Hutchinson A, Marshall M. Research methods used in developing and applying quality indicators in primary care. Qual Saf Health Care. 2002;11:358–364. doi: 10.1136/qhc.11.4.358.
    1. McGlynn EA, Asch SM. Developing a clinical performance measure. Am J Prev Med. 1998;14:14–21. doi: 10.1016/S0749-3797(97)00032-9.
    1. Seddon ME, Marshall MN, Campbell SM, Roland MO. Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand. Qual Health Care. 2001;10:152–158. doi: 10.1136/qhc.0100152...
    1. Marshall M, Campbell SM. Introduction to quality assessment in general practice. In: Marshall M, Campbell SM, Hacker J and Roland MO, editor. Quality indicators for general practice: a practical guide for health professionals and managers. London, Royal Society of Medicine; 2002. pp. 1–6.
    1. Arana A, Rivero E, Egberts TCG. What do we show and who does so? An analysis of the abstracts presented at the 19th ICPE. Pharmacoepidemiol Drug Saf. 2004. pp. S330–331.
    1. Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman A, O'Brien MA. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39:II2–45. doi: 10.1097/00005650-200108002-00002.
    1. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Cmaj. 1995;153:1423–1431.
    1. Rokstad K, Straand J, Fugelli P. Can drug treatment be improved by feedback on prescribing profiles combined with therapeutic recommendations? A prospective, controlled trial in general practice. J Clin Epidemiol. 1995;48:1061–1068. doi: 10.1016/0895-4356(94)00238-L.
    1. Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. Jama. 1992;268:1111–1117. doi: 10.1001/jama.268.9.1111.
    1. Freemantle N, Harvey EL, Wolf F, Grimshaw JM, Grilli R, Bero LA. Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2000:CD000172.
    1. Thomson O'Brien MA, Oxman AD, Davis DA, Haynes RB. Cochrane Library. Vol. 4. Oxford, Update Software; 2001. Educational outreach visits: effects on professional practice and health care.
    1. Jamtvedt G, Young JM, Kristoffersen DT, Thomson O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2003:CD000259.
    1. Oxman AD, Flottorp S. An overview of strategies to promote implementation of evidence based health care. In: Silagy C and Haines A, editor. Evidence Based Practice. 2nd. London, BMJ Books; 2001. pp. 101–109.
    1. Campbell MK, Steen N, Grimshaw JM, Eccles M, Mollison J, Lombard C. Design and statistical issues in implementation research. In: Thorsen T and Mäkelä M, editor. Changing Professional Practice. Chopenhagen, Danish Institute for Health Services Research and Development; 1999.
    1. Gjelstad S, Fetveit A, Straand J, Dalen I, Rognstad S, Lindbaek M. Study Protocol: 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] Submitted. 2006.
    1. NorPD . Oslo, Norway, Norwegian Prescription Database, Norwegian Institute of Public Health, ; 2005.
    1. Fretheim A, Oxman AD, Treweek S, Bjorndal A. Rational Prescribing in Primary Care (RaPP-trial). A randomised trial of a tailored intervention to improve prescribing of antihypertensive and cholesterol-lowering drugs in general practice [ISRCTN48751230] BMC Health Serv Res. 2003;3:5. doi: 10.1186/1472-6963-3-5.
    1. Rasmussen HM, Sondergaard J, Kampmann JP, Andersen M. General practitioners prefer prescribing indicators based on detailed information on individual patients: a Delphi study. Eur J Clin Pharmacol. 2005;61:237–241. doi: 10.1007/s00228-004-0870-9.
    1. Ruths S, Straand J, Nygaard HA. Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study. Qual Saf Health Care. 2003;12:176–180. doi: 10.1136/qhc.12.3.176.
    1. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med. 1997;157:1531–1536. doi: 10.1001/archinte.157.14.1531.
    1. McLeod PJ, Huang AR, Tamblyn RM, Gayton DC. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. Cmaj. 1997;156:385–391.
    1. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716–2724. doi: 10.1001/archinte.163.22.2716.
    1. Sosialstyrelsen . [Uppfõljning av ãldres lãkemedelsãnvendning] , Svenska Socialstyrelsen; 2004.
    1. Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32:1008–1015. doi: 10.1046/j.1365-2648.2000.01567.x.
    1. Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: characteristics and guidelines for use. Am J Public Health. 1984;74:979–983.
    1. Campbell SM, Cantrill JA. Consensus methods in prescribing research. J Clin Pharm Ther. 2001;26:5–14. doi: 10.1046/j.1365-2710.2001.00331.x.
    1. Normand SL, McNeil BJ, Peterson LE, Palmer RH. Eliciting expert opinion using the Delphi technique: identifying performance indicators for cardiovascular disease. Int J Qual Health Care. 1998;10:247–260. doi: 10.1093/intqhc/10.3.247.
    1. WHO . The ATC/DDD system. , WHO Collaborating Centre for Drug Statistics Methodology; 2005.
    1. Flottorp S, Oxman AD, Havelsrud K, Treweek S, Herrin J. Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat. Bmj. 2002;325:367. doi: 10.1136/bmj.325.7360.367.
    1. Donner A, Birkett N, Buck C. Randomization by cluster. Sample size requirements and analysis. Am J Epidemiol. 1981;114:906–914.
    1. Vickers AJ, Altman DG. Statistics notes: Analysing controlled trials with baseline and follow up measurements. Bmj. 2001;323:1123–1124. doi: 10.1136/bmj.323.7321.1123.

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