Prescription peer academic detailing to reduce inappropriate prescribing for older patients: a cluster randomised controlled trial

Abstract

BackgroundOlder patients are at particular risk for adverse drug reactions. In older people, interventions targeting potentially inappropriate prescriptions (PIPs) are considered important measures to minimise drug-related harm, especially in the general practice setting where most prescriptions for older patients are issued. AimTo study the effects of a multifaceted educational intervention on GPs' PIPs for older patients. Design and settingThis was a cluster randomised, educational intervention study in Norwegian general practice. Pre-study data were captured from January 2005 MethodEighty continuing medical education (CME) groups (465 GPs) were randomised to receive the educational intervention on GPs' PIPs for older patients (41 CME groups; 256 GPs) or another educational intervention (39 CME groups; 209 GPs); these two groups acted as controls for each other. GPs' prescription data from before and after the intervention were assessed against a list of 13 explicit PIP criteria for patients aged ≥70 years. In the CME groups, trained GPs carried out an educational programme, including an audit, focusing on the 13 criteria and their rationale. ResultsA total of 449 GPs (96.6%) completed the study; 250 in the intervention group and 199 in the control group. After adjusting for baseline differences and clustering effects, a reduction relative to baseline of 10.3% (95% confidence interval = 5.9 to 15.0) PIPs per 100 patients aged ≥70 years was obtained. ConclusionEducational outreach visits with feedback and audit, using GPs as academic detailers in GPs' CME groups, reduced PIPs for older patients aged ≥70 years in general practice.

Effectiveness of a Multifaceted Intervention for Potentially Inappropriate Prescribing in Older Patients in Primary Care: A Cluster-Randomized Controlled Trial (OPTI-SCRIPT Study)

“…9,25,26 A limited number of Our results are consistent with 2 randomized controlled trials published since the start of the OPTI-SCRIPT study in finding a multifaceted intervention to be effective. 13,14 In the Rx-PAD study, Rognstad et al 14 and Straand et al 29 found peer academic detailing, delivered at continuing medical education meetings, with mailed prescriber feedback, produced a 10% (95% CI, 5.9%-15.0%) reduction in PIP. Bregnhøj et al 13 found interactive educational meetings and feedback resulted in a 5-point (95% CI, 7.3-to 2.6-point) improvement in the medication appropriateness index score.…”

“…11,12 To date, a limited number of multifaceted interventions have been evaluated in primary care to decrease PIP. 13,14 The purpose of the OPTI-SCRIPT study (Optimizing Prescribing for Older People in Primary Care, a cluster-randomized controlled trial) was to investigate the effectiveness of a multifaceted intervention in reducing PIP in older people in Irish primary care.…”

A qualitative study exploring the acceptability of the McNulty-Zelen design for randomised controlled trials evaluating educational interventions

“…The use of the Zelen design has been used to increase recruitment resulting in a 6-fold increase in recruitment in an arthroscopy study [16]. Our interviewees’ views agreed with a review of 44 studies using the Zelen design [17], in which half stated that they used the design to reduce bias, and is highlighted by the less than 50 % recruitment in several other GP educational cluster randomised trials [5, 18]. The McNulty-Zelen design has the advantage of demonstrating the real acceptance rate of an educational intervention [6].…”

Reducing Potentially Inappropriate Prescribing for Older People in Primary Care: Cost-Effectiveness of the Opti-Script Intervention

“…For example, if decision makers were willing to pay at least €2,500 to avoid a PIP, there is a probability of 0.845 or higher of the intervention being cost effective. That said, Rognstad et al (9) found that peer academic detailing, delivered at continuing medical education (CME) meetings, with mailed prescriber feedback, produced a 10% (95% CI 5.9 to 15.0) reduction in PIP. Similarly, Bregnhoj et al (8) found that interactive educational meetings and feedback resulted in a 5 point (95% CI: 2.6 to 7.3) improvement in the medication appropriateness index (MAI) score.…”

“…There is currently no single interventional strategy that has proved to be most effective, but there is an argument that a multifaceted approach, which combines a number of techniques within a single intervention, may be likely to be more effective (6,7). To date, a limited number of multifaceted interventions targeting inappropriate prescribing reductions have been evaluated in primary care and report positive findings (8)(9)(10). Nonetheless, further evidence on clinical and cost effectiveness is required before widespread adoption in primary care can be recommended.…”