Improving Private Practitioners' Adherence to Clinical Practice Guidelines: A Quasi- Experimental Study in the Philippines Saniel MC, Acuin CS, Arciaga.

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