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Improving Private Practitioners' Adherence to Clinical Practice Guidelines: A Quasi-
Experimental Study in the PhilippinesSaniel MC, Acuin CS, Arciaga RS, Lansang MD, NaidasOD,
Sevilleja JE, Bustos MV, Balis AC, Ross-Degnan D
Problem Statement
The effectiveness of different strategies for disseminating clinical practice guidelines to private practitioners has been well studied in developed countries but rarely in developing countries
Urinary Tract InfectionsClinical Practice Guideline
Task Force on UTI, Philippine Practice GuidelinesGroup in Infectious Diseases. Urinary Tract Infections:Clinical Practice Guideline. PPGG-ID Philippine Society forMicrobiology and Infectious DiseasesVolume 1 No. 1 Quezon City, Philippines.
Task Force on UTI, Philippine Practice GuidelinesGroup in Infectious Diseases. Urinary Tract Infections:Clinical Practice Guideline. PPGG-ID Philippine Society forMicrobiology and Infectious DiseasesVolume 1 No. 1 Quezon City, Philippines.
Objective
To compare the effectiveness of problem based-lecture discussion (LD) versus interactive case-oriented session (ICS), each combined with feedback discussions (FD) of practice data, as strategies for improving diagnostic and antibiotic prescribing practices of private physicians for acute cystitis
Baseline Measurement of Prescribing Behavior
Problem-BasedLecture Discussion
Second Measurementof Prescribing Behavior
Group A Private Physicians
Urban A Semi-Urban A
Group B Private Physicians
Urban A Semi-Urban A
Feedback Session
Third Measurementof Prescribing Behavior
Baseline Measurement of Prescribing Behavior
Interactive Case-OrientedSession
Second Measurementof Prescribing Behavior
Feedback Session
Third Measurementof Prescribing Behavior
Study Design
MethodsDescription of Interventions
A. Problem based lecture discussion 45-minute problem based lecture on
guideline recommendations by an expert in the field followed by an open forum
B. Interactive case-oriented session Participants responded to questions
about diagnosis and management of 5 Acute UTI cases using electronic keypads
Aggregate responses were displayed and discussed with an expert panel
MethodsDescription of Interventions
C. Feedback session Individual prescription data over a 6
month period were aggregated and presented to participating MDs as part of a group discussion of issues on adherence to the CPGs
Methods Pre- and post- quasi experimental design Outcomes assessed: percentage of
prescriptions that adhered to CPG recommendations for acute cystitis in terms of antibiotic choice, dosage, and duration use of laboratory tests
Statistical analyses: descriptive statistics and bivariate analysis multivariate analysis using hierarchical cluster
models for logistic outcomes (Glimmix, SAS v.9)
Non-Pregnant Pregnant
Prescribe recommended antibiotic and dosage
Prescribe recommended antibiotic and dosage
Duration – 3 days Duration – 7 days
No lab work-up Order urinalysis, urine culture
Recommended Prescribing Practices for Uncomplicated UTI
(Acute Cystitis)
Results
0
5
10
15
20
25
30
Baseline Post-ICS Post-FD
0
5
10
15
20
25
30
Baseline Post-LD Post-FD
OR=95(11,817)*
OR=140(16,1205)
% a
dher
ence
% a
dher
ence
OR=4(1,18)
OR=57(16,206)
n=384 n=378 n=307 n=316 n=309 n=516
Adherence to recommended antibiotic regimen at baseline and after the dissemination
strategies (Acute Cystitis, Non-Pregnant)
Group A Group B
* Numbers in parentheses are 95% CIs
Results
0
10
20
30
40
50
60
Baseline Post-ICS Post-FD
0
10
20
30
40
50
60
Baseline Post-LD Post-FD
OR=0.5(0.3,1.0)*
OR=2.2(1.3,3.9)
% a
dher
ence
% a
dher
ence OR=0.7
(0.4,1.1)OR=0.7(0.4,1.2)
n=145 n=129 n=118 n=130 n=175 n=162
Group A Group B
* Numbers in parentheses are 95% CIs
Adherence to recommended antibiotic regimen at baseline and after the dissemination
strategies (Acute Cystitis, Pregnant)
Private practitioners in developing countries can be motivated to change prescribing behavior given evidence-based guidelines
Educational strategies that allow interactive discussion and feedback are more likely to change behavior than one-way communication strategies
Key Lessons
Combined multifaceted strategies are more effective than a single intervention in changing behavior
Other interventions that address specific obstacles to targeted behavior (ex. test ordering) may be necessary to complement CPGs
Key Lessons
Professional societies and other organizations in developing countries should incorporate effective multifaceted strategies for CPG dissemination, such as interactive educational sessions and performance feedback, in their CME programs
Health facilities and other institutions should likewise adopt these strategies in improving drug use
Implications and Recommendations
Feedback of physician’s performance necessitates measurements
Measurement: a challenge especially in private clinics where records are often inadequate
Develop innovative schemes for data collection that are acceptable to physicians
Evaluate surrogate quality indicators (e.g., admission rates for UTI)
Implications and Recommendations
Economic assessment of dissemination strategies
Impact on patient outcomes (cost-effectiveness)
Sustainability of strategies in eliciting behavior change
Effectiveness of alternative strategies to improve adherence to CPG recommendations on diagnostic tests
Future Research