Improving Private Practitioners' Adherence to Clinical Practice Guidelines: A QuasiExperimental Stud

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Improving Private Practitioners' Adherence to
Clinical Practice Guidelines A
Quasi-Experimental Study in the Philippines
Saniel MC, Acuin CS, Arciaga RS, Lansang MD,
NaidasOD, Sevilleja JE, Bustos MV, Balis AC,
Ross-Degnan D
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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

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Urinary Tract Infections Clinical Practice
Guideline
Task Force on UTI, Philippine Practice
Guidelines Group in Infectious Diseases. Urinary
Tract Infections Clinical Practice Guideline.
PPGG-ID Philippine Society for Microbiology and
Infectious Diseases Volume 1 No. 1 Quezon City,
Philippines.
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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

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Study Design
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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

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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

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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)

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Recommended Prescribing Practices for
Uncomplicated UTI (Acute Cystitis)
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Results
Adherence to recommended antibiotic regimen
at baseline and after the
dissemination strategies (Acute Cystitis,
Non-Pregnant)
OR140 (16,1205)
OR57 (16,206)
OR95 (11,817)
adherence
adherence
OR4 (1,18)
n384
n378
n307
n316
n309
n516
Group A
Group B
Numbers in parentheses are 95 CIs
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Results
Adherence to recommended antibiotic regimen
at baseline and after the
dissemination strategies (Acute Cystitis,
Pregnant)
OR2.2 (1.3,3.9)
OR0.7 (0.4,1.2)
OR0.7 (0.4,1.1)
OR0.5 (0.3,1.0)
adherence
adherence
n145
n129
n118
n130
n175
n162
Group A
Group B
Numbers in parentheses are 95 CIs
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Key Lessons

• 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

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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

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Implications and Recommendations

• 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

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Implications and Recommendations

• Feedback of physicians 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)

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Future Research

• 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