The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA). Cluster randomised controlled trial of an educational outreach visit to improve influenza and pneumococcal immunisation rates in primary care. A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. A randomized controlled trial of an intervention designed to improve the care given in general practice to Type II diabetic patients: patient outcomes and professional ability to change behaviour. Cost effectiveness of two interventions for reducing outpatient prescribing costs. Reducing antibiotic use in children: a randomized trial in 12 practices. Primary care nurses using guidelines in Thailand: a randomized controlled trial. A controlled trial of educational visiting to improve benzodiazepine prescribing in general practice. Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme. An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475]. Physician behavior modification using claims data: tetracycline for upper respiratory infection. The influence of an academic representative on prescribing by general practitioners. Rational prescribing in primary care (RaPP): economic evaluation of an intervention to improve professional practice. Evaluating the effectiveness of 2 educational interventions in family practice. An educational intervention to improve physician reporting of adverse drug reactions: a cluster-randomized controlled trial. Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial. Effectiveness of a two-part educational intervention to improve hypertension control: a cluster-randomized trial. Outreach education to improve quality of rural ICU care. Results of a randomized trial. Randomised trial of three approaches for marketing smoking cessation programmes to Australian general practitioners. Sleeping with the enemy? A randomized controlled trial of a collaborative health authority/industry intervention to influence prescribing practice. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). Effects of "group detailing" on the prescribing of lipid-lowering drugs: a randomized controlled trial in Swedish primary care. Impact of a physician-oriented intervention on follow-up in colorectal cancer screening. Practice visits as a tool in quality improvement: mutual visits and feedback by peers compared with visits and feedback by non-physician observers. A clinic-based mammography intervention targeting inner-city women. A RCT of three training and support strategies to encourage implementation of screening and brief alcohol intervention by general practitioners. Improving office-based physician's prevention practices for sexually transmitted diseases. A randomized trial of an acid-peptic disease management program in a managed care environment. Impact of patient care appraisal on physician behaviour in the office setting. Improving antiulcer agent prescribing in a health maintenance organization. Influencing prescribing in primary care: a comparison of two different prescribing feedback methods. Evidence to action: a tailored multifaceted approach to changing family physician practice patterns and improving preventive care. Small group intervention vs formal seminar for improving appropriate drug use. [Improving drug prescription in primary care: a controlled and randomized study of an educational method]. Feasibility of a national cholesterol guideline in daily practice. A randomized controlled trial in 20 general practices. Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: a cluster-randomized controlled trial. Academic detailing has no effect on prescribing of asthma medication in Danish general practice: a 3-year randomized controlled trial with 12-monthly follow-ups. A controlled trial of educational outreach to improve blood transfusion practice. Is untargeted outreach visiting in primary care effective? A pragmatic randomized controlled trial. One-to-one versus group sessions to improve prescription in primary care: a pragmatic randomized controlled trial. A multimethod quality improvement intervention to improve preventive cardiovascular care: a cluster randomized trial. Educational outreach in diabetes to encourage practice nurses to use primary care hypertension and hyperlipidaemia guidelines (EDEN): a randomized controlled trial. Cluster randomized controlled trial of the effectiveness of audit and feedback and educational outreach on improving nursing practice and patient outcomes. Evaluation of a continuing education intervention "Periodontics in General Practice". Improving prevention systems in primary care practices: the Health Education and Research Trial (HEART) The effect of industry-independent drug information on the prescribing of benzodiazepines in general practice. Intensive support to improve clinical decision making in cardiovascular care: a randomised controlled trial in general practice. Management of obesity in primary care. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. Benzodiazepine prescribing by GP registrars. A trial of educational outreach. The impact of face-to-face educational outreach on diarrhoea treatment in pharmacies. Randomised controlled trial of educational package on management of menorrhagia in primary care: the Anglia menorrhagia education study. Clustered randomised trial of an intervention to improve the management of asthma: Greenwich asthma study. Academic detailing to improve use of broad-spectrum antibiotics at an academic medical center. A randomised controlled trial of the effect of educational outreach by community pharmacists on prescribing in UK general practice. Promoting better use of the PSA test in general practice: randomized controlled trial of educational strategies based on outreach visits and mailout. Physician education and report cards: do they make the grade? results from a randomized controlled trial. Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London. A multidisciplinary approach for improving services in primary care: randomised controlled trial of screening for haemoglobin disorders. Guidelines and educational outreach visits from community pharmacists to improve prescribing in general practice: a randomised controlled trial. Educational strategies to promote evidence-based community pharmacy practice: a cluster randomized controlled trial (RCT). Improving family physicians' use of evidence-based smoking cessation strategies: a cluster randomization trial. Modification of general practitioner prescribing of antibiotics by use of a therapeutics adviser (academic detailer). Randomised trial of educational visits to enhance use of systematic reviews in 25 obstetric units. Optimizing antibiotic prescribing for acute cough in general practice: a cluster-randomized controlled trial.
To evaluate the impact of regular multidisciplinary team interventions on the quantity and quality of psychotropic drug prescribing in Swedish nursing homes.
                A randomized controlled trial.
                A sample of 33 nursing homes: 15 experimental homes and 18 control homes representing 5% of all Swedish nursing homes.
                The sample consisted of 1854 long-term care residents with an average age of 83 years. Seventy percent of the residents were women, and 42% had a documented diagnosis of dementia. An additional 5% had a psychotic disorder, and 7% had a diagnosis of depression.
                Experimental homes participated in an outreach program that was designed to influence drug use through improved teamwork among physicians, pharmacists, nurses, and nurses' assistants. Multidisciplinary team meetings were held on a regular basis throughout the 12-month study period.
                Lists of each resident's prescriptions were collected 1 month before and 1 month after the 12-month intervention. Measures included the proportion of residents with any psychotropic drug, polymedicine, and therapeutic duplication and proportion of residents with nonrecommended and acceptable drugs in each psychotropic drug class, as defined by current Swedish guidelines.
                Baseline results show extensive psychotropic drug prescribing, with the most commonly prescribed drugs being hypnotics (40%), anxiolytics (40%), and antipsychotics (38%). After 12 months of team meetings in the experimental homes, there was a significant decrease in the prescribing of psychotics (-19%), benzodiazepine hypnotics (-37%), and antidepressants (-59%). Orders for more acceptable antidepressants also increased in the experimental homes. In the control homes there was increased use of acceptable antidepressants, but there were no significant reductions in other drug classes.
                There is excessive prescription of psychotropic drugs in Swedish nursing homes. Improved teamwork among caregivers can improve prescribing as defined by clinical guidelines. To determine whether asthma specialist nurses, using a liaison model of care, reduce unscheduled care in a deprived multiethnic area.
                Cluster randomised controlled trial.
                44 general practices in two boroughs in east London.
                324 people aged 4-60 years admitted to or attending hospital or the general practitioner out of hours service with acute asthma; 164 (50%) were South Asian patients, 108 (34%) were white patients, and 52 (16%) were from other, largely African and Afro-Caribbean, ethnicities.
                Patient review in a nurse led clinic and liaison with general practitioners and practice nurses comprising educational outreach, promotion of guidelines for high risk asthma, and ongoing clinical support. Control practices received a visit promoting standard asthma guidelines; control patients were checked for inhaler technique.
                Percentage of participants receiving unscheduled care for acute asthma over one year and time to first unscheduled attendance.
                Primary outcome data were available for 319 of 324 (98%) participants. Intervention delayed time to first attendance with acute asthma (hazard ratio 0.73, 95% confidence interval 0.54 to 1.00; median 194 days for intervention and 126 days for control) and reduced the percentage of participants attending with acute asthma (58% (101/174) v 68% (99/145); odds ratio 0.62, 0.38 to 1.01). In analyses of prespecified subgroups the difference in effect on ethnic groups was not significant, but results were consistent with greater benefit for white patients than for South Asian patients or those from other ethnic groups.
                Asthma specialist nurses using a liaison model of care reduced unscheduled care for asthma in a deprived multiethnic health district. Ethnic groups may not benefit equally from specialist nurse intervention. Improvement in the delivery of influenza and pneumococcal vaccinations to high-risk groups is an important aspect of preventive care for primary healthcare teams.
                To investigate the effect of an educational outreach visit to primary healthcare teams on influenza and pneumococcal vaccination uptake in high-risk patients.
                Cluster randomised controlled trial.
                Thirty general practices in the Trent region, UK.
                Fifteen practices were randomised to intervention and 15 to the control group after stratifying for baseline vaccination rate. All intervention practices were offered and received an educational outreach visit to primary healthcare teams, in addition to audit and feedback directed at improving influenza and pneumococcal vaccination rates in high-risk groups. Control practices received audit and feedback alone. All practices measured influenza and pneumococcal vaccination rates in high-risk groups. Primary outcomes were improvements in vaccination rates in patients aged 65 years and over, and patients with coronary heart disease (CHD), diabetes and a history of splenectomy.
                Improvements in pneumococcal vaccination rates in the intervention practices were significantly greater compared with controls in patients with CHD, 14.8% versus 6.5% (odds ratio [OR] = 1.23, 95% confidence interval [CI] = 1.13 to 1.34) and diabetes, 15.5% versus 6.8% (OR = 1.18, 95% CI = 1.08 to 1.29) but not splenectomy, 6.5% versus 4.7% (OR = 0.96, 95% CI = 0.65 to 1.42). Improvements for influenza vaccination were also usually greater in intervention practices but did not reach statistical significance. The increases for influenza vaccination in intervention versus control practices were for CHD, 18.1% versus 13.1% (OR = 1.06, 95% CI = 0.99 to 1.12); diabetes, 15.5% versus 12.0% (OR = 1.07, 95% CI = 0.99 to 1.16), splenectomy 16.1% versus 2.9% (OR = 1.22, 95% CI = 0.78 to 1.93); and those over 65 years 20.7% versus 25.4% (OR = 0.99, 95% CI = 0.96 to 1.02).
                Practices where primary care teams received an educational outreach visit demonstrated a significantly greater improvement in uptake in high-risk groups for pneumococcal but not influenza vaccine. Although psychoactive medications have substantial side effects in the elderly, these drugs are used frequently in nursing homes. Few interventions have succeeded in changing this situation, and little is known about the clinical effects of such interventions.
                We studied six matched pairs of nursing homes; at one randomly selected nursing home in each pair, physicians, nurses, and aides participated in an educational program in geriatric psychopharmacology. At base line we determined the type and quantity of drugs received by all residents (n = 823), and a blinded observer performed standardized clinical assessments of the residents who were taking psychoactive medications. After the five-month program, drug use and patient status were reassessed.
                Scores on an index of psychoactive-drug use, measuring both the magnitude and the probable inappropriateness of medication use, declined significantly more in the nursing homes in which the program was carried out (experimental nursing homes) than in the control nursing homes (decrease, 27 percent vs. 8 percent; P = 0.02). The use of antipsychotic drugs was discontinued in more residents in the experimental nursing homes than in the control nursing homes (32 percent vs. 14 percent); the comparable figures for the discontinuation of long-acting benzodiazepines were 20 percent vs. 9 percent, and for antihistamine hypnotics, 45 percent vs. 21 percent. In the experimental nursing homes residents who were initially taking antipsychotic drugs showed less deterioration on several measures of cognitive function than similar residents in the control facilities, but they were more likely to report depression. Those who were initially taking benzodiazepines or antihistamine hypnotic agents reported less anxiety than controls but had more loss of memory. Most other measures of clinical status remained unchanged in both groups.
                An educational program targeted to physicians, nurses, and aides can reduce the use of psychoactive drugs in nursing homes without adversely affecting the overall behavior and level of functioning of the residents. Our objective was to evaluate the effect of training in a patient-centred intervention for GPs and practice nurses on outcomes for patients with Type II diabetes.
                We carried out a randomized controlled trial within general practices as the basis for randomization and a before-and-after design for measures of patient outcome. A parallel process study examined the use of the method by professionals. The study was carried out in 29 general practices in South Glamorgan who had participated for at least 2 years in a local scheme of audit and CME in relation to Type II diabetes care. The subjects were 252 Type II diabetic patients recruited by 15 experimental and 14 control practices. The main outcome measures were changes in glycosylated haemoglobin, patient satisfaction with care and treatment, functional health status and professional ability to apply the intervention.
                Professionals adopted the innovative method with enthusiasm, but after 2 years only 19% continued to apply the method systematically. The trial was, therefore, unable to demonstrate significant biochemical or functional improvements. This highlights the need to understand the factors associated with professional uptake and subsequent ability to sustain changes in behaviour.
                The efficacy of this behavioural intervention remains unproved, despite its acceptability to professional staff. Detailed and prolonged development and testing of behavioural interventions is an essential first step before embarking on randomized controlled trials which involve complex behavioural changes in professionals or patients. This prospective, randomized, controlled trial, based in a Veterans Administration Hospital general medicine clinic, compared the cost effectiveness of two behaviorally oriented interventions designed to reduce physicians' drug prescribing costs. Clinical pharmacists visited one group of 11 physicians during weekly clinic sessions to counterdetail the prescribing of certain targeted drugs. A second group of 10 physicians were given data each week comparing their individual prescribing costs to those of their colleagues (peer-comparison feedback). A control group of 10 physicians received neither intervention. Written patient-specific suggestions for cost-effective prescribing were employed in both intervention groups. Baseline prescribing costs were monitored through the hospital's computer during a three-month, preintervention period and a seven-month intervention period. The 2026 written suggestions made by the doctors of pharmacy resulted in 613 (30.3 percent) prescribing changes, including deletion, substitution, or change in dosage of targeted drugs. There were no intergroup differences in the response to written suggestions. However, the group receiving face-to-face visits from the clinical pharmacists achieved lower average prescription costs than the control group during seven of eight months. Intergroup differences were statistically significant (p less than 0.05) during three of the last five months of the study. The face-to-face meeting intervention was cost-effective, saving +478 per physician over seven months after accounting for Pharm.D. salary costs. There was no significant decrease in the number of prescriptions written by the face-to-face group compared with the control group, suggesting that drug substitution rather than deletion was the method used by physicians to lower drug costs. No savings resulted from the use of peer-comparison feedback. We conclude that personal visits by a Pharm.D. are a cost-effective technique for reducing physicians' prescribing costs, and are superior to peer-comparison feedback. To test whether an educational outreach intervention for families and physicians, based on the Centers for Disease Control and Prevention (CDC) principles of judicious antibiotic use, decreases antimicrobial drug prescribing for children younger than 6 years old. Setting. Twelve practices affiliated with 2 managed care organizations (MCOs) in eastern Massachusetts and northwest Washington State. Patients. All enrolled children younger than 6 years old.
                Practices stratified by MCO and size were randomized to intervention or control groups. The intervention included 2 meetings of the practice with a physician peer leader, using CDC-endorsed summaries of judicious prescribing recommendations; feedback on previous prescribing rates were also provided. Parents were mailed a CDC brochure on antibiotic use, and supporting materials were displayed in waiting rooms. Automated enrollment, ambulatory visit, and pharmacy claims were used to determine rates of antibiotic courses dispensed (antibiotics/person-year) during baseline (1996-1997) and intervention (1997-1998) years. The primary analysis (for children 3 to <36 months and 36 to <72 months) assessed the impact of the intervention among children during the intervention year, controlling for covariates including patient age and baseline prescription rate. Confirmatory analyses at the practice level were also performed.
                The practices cared for 14 468 and 13 460 children in the 2 study years, respectively; 8815 children contributed data in both years. Sixty-two percent of antibiotic courses were dispensed for otitis media, 6.5% for pharyngitis, 6.3% for sinusitis, and 9.2% for colds and bronchitis. Antibiotic dispensing for children 3 to <36 months old decreased 0.41 antibiotics per person-year (18.6%) in intervention compared with 0.33 (11.5%) in control practices. Among children 36 to <72 months old, the rate decreased by 0.21 antibiotics per person-year (15%) in intervention and 0.17 (9.8%) in control practices. Multivariate analysis showed an adjusted intervention effect of 16% in the younger and 12% in the older age groups. The direction and approximate magnitude of effect were confirmed in practice-level analyses.
                A limited simultaneous educational outreach intervention for parents and providers reduced antibiotic use among children in primary care practices, even in the setting of substantial secular trends toward decreased prescribing. Future efforts to promote judicious prescribing should continue to build on growing public awareness of antibiotic overuse. Nurses run primary health centres in Thailand. We examined whether clinical guidelines improved the quality of the care they provide.
                Eighteen nurse-led health centres randomized to (a) guidelines, receiving a training workshop plus educational outreach visit, with guidelines for children (acute respiratory tract infection and diarrhoea) and adults (diazepam prescribing and diabetes management) or (b) usual care. Outcomes were changes at 6 months in antibiotic use, diazepam prescribing, drug costs per patient, and a composite process index for diabetes care.
                Baseline prescribing was high for antibiotics (37% of all attendees), and no difference between intervention and control sites was detected at follow-up for this variable. In children (0-5 years old), antibiotics were widely used for acute respiratory tract infection (34%), and fell with guidelines (intervention: 42% at baseline to 27% at follow-up; control: 27-30%, P=0.022), with an associated fall in drug costs per patient. Antibiotics were widely prescribed for diarrhoea in children (91%), but no change was detected with guidelines. In adults, diazepam prescribing at baseline was high (17%), and fell in the guidelines group (intervention: 17-10%; control 21-18%; P=0.029). Diabetes care was generally good, and changed little with guidelines.
                Staff at primary health centres over-prescribe antibiotics in children and tranquilizer in adults. Clinical guidelines implemented with workshops and educational outreach visits improved some but not all aspects of prescribing in the short-term. A randomised controlled trial studied the effect of an educational visit on benzodiazepine prescribing. An approximately representative sample of 286 general practitioners was allocated to an intervention or a control group. Rates of benzodiazepine prescriptions were derived from two comprehensive self-report surveys seven months apart. Two months after the first survey the intervention group received an educational visit and supporting material from a doctor or pharmacist, ostensibly unconnected with the surveys. The overall benzodiazepine prescribing rate fell by 23.7 per cent from the first to the second surveys, from 4.93 to 3.76 prescriptions per 100 encounters (P < 0.001). Anxiety and insomnia diagnosis rates also declined from 4.68 to 3.76 per 100 encounters (19.7 per cent). After adjusting for confounders, there was a differential downward trend in prescriptions per diagnosis of insomnia but not to a statistical level. The same was true of initial prescriptions per insomnia diagnosis. In a subsidiary analysis selecting only new insomnia diagnoses, the intervention had a strong effect in reducing initial prescriptions (odds ratio 0.18, 95 per cent confidence interval 0.04 to 0.73). No effect was seen on prescribing for anxiety diagnoses. Educational practice visiting for benzodiazepine prescribing in anxiety, as we conducted it, is not justified in an unselected population of general practitioners. Specific education on prescribing for insomnia is probably useful. Our interpretation of the reduction in benzodiazepine prescribing is that probably there was an effect from self-monitoring alone which overwhelmed a main-analysis intervention effect. Retrospective diagnosis may also have obscured a real intervention effect. To establish the effect of an educational intervention for general practitioners on the health behaviours and wellbeing of elderly patients.
                Randomised controlled trial with 1 year follow up.
                Metropolitan general practices in Melbourne, Australia.
                42 general practitioners and 267 of their patients aged over 65 years.
                Educational and clinical practice audit programme for general practitioners on health promotion for elderly people.
                Patients' physical activity, functional status, self rated health, immunisation status, social contacts, psychological wellbeing, drug usage, and rate of influenza vaccination. Primary efficacy variables were changes in outcome measures over 1 year period.
                Patients in the intervention group had increased (a) walking by an average of 88 minutes per fortnight, (b) frequency of pleasurable activities, and (c) self rated health compared with the control group. No change was seen in drug usage, rate of influenza vaccination, functional status, or psychological wellbeing as a result of the intervention. Extrapolations of the known effect of these changes in behaviour suggest mortality could be reduced by 22% if activity was sustained for 5 years.
                Education of the general practitioners had a positive effect on health outcomes of their elderly patients. General practitioners may have considerable public health impact in promotion of health for elderly patients. The aim of this project was to assess whether outreach visits would improve the implementation of evidence based clinical practice in the area of falls reduction and stroke prevention in a residential care setting.
                Twenty facilities took part in a randomized controlled trial with a seven month follow-up period. Two outreach visits were delivered by a pharmacist. At the first a summary of the relevant evidence was provided and at the second detailed audit information was provided about fall rates, psychotropic drug prescribing and stroke risk reduction practices (BP monitoring, aspirin and warfarin use) for the facility relevant to the physician. The effect of the interventions was determined via pre- and post-intervention case note audit. Outcomes included change in percentage patients at risk of falling who fell in a three month period prior to follow-up and changes in use of psychotropic medications. Chi-square tests, independent samples t-test, and logistic regression were used in the analysis.
                Data were available from case notes at baseline (n = 897) and seven months follow-up (n = 902), 452 residential care staff were surveyed and 121 physicians were involved with 61 receiving outreach visits. Pre-and post-intervention data were available for 715 participants. There were no differences between the intervention and control groups for the three month fall rate. We were unable to detect statistically significant differences between groups for the psychotropic drug use of the patients before or after the intervention. The exception was significantly greater use of "as required" antipsychotics in the intervention group compared with the control group after the pharmacy intervention (RR = 4.95; 95%CI 1.69-14.50). There was no statistically significant difference between groups for the numbers of patients "at risk of stroke" on aspirin at follow-up.
                While the strategy was well received by the physicians involved, there was no change in prescribing patterns. Patient care in residential settings is complex and involves contributions from the patient's physician, family and residential care staff. The project highlights challenges of delivering evidence based care in a setting in which there is a paucity of well controlled trial evidence but where significant health outcomes can be attained. Professional Standards Review Organization claims data were used in defining, planning, implementing and evaluating an approach to an ambulatory medical care problem utilizing educational intervention. Modification of physicians' tetracycline prescribing behavior was achieved in an actual practice setting by personal visits from peer physicians. 1. The effect of providing information about medicines by a short 'sales' interview between individual general practitioners and an 'academic representative' on prescribing was investigated. 2. The promotional campaign was designed to encourage a rational approach to prescribing of non-steroidal anti-inflammatory agents in an intervention group of 101 general practitioners selected at random from the Leeds Family Practitioner Committee (FPC). The remaining general practitioners in the Leeds FPC acted as a reference group. 3. The prescribing data for each group for 5 months immediately prior to and 5 months following intervention were compared. 4. Intervention produced a significant increase (P less than 0.005) in the prescribing cost of ibuprofen, the non-steroidal promoted as first choice agent, which was sustained for at least 5 months. 5. Prescribing of the second choice agent, piroxicam, decreased in the reference group but not in the intervention group. 6. There was a decrease in the average prescribing cost of pounds 6.60 per doctor per month in the intervention group compared with the reference group. Interventions designed to narrow the gap between research findings and clinical practice may be effective, but also costly. Economic evaluations are necessary to judge whether such interventions are worth the effort. We have evaluated the economic effects of a tailored intervention to support the implementation of guidelines for the use of antihypertensive and cholesterol-lowering drugs. The tailored intervention was evaluated in a randomized trial, and was shown to significantly increase the use of thiazides for patients started on antihypertensive medication, but had little or no impact on other outcomes. The increased use of thiazides was not expected to have an impact on health outcomes.
                We performed cost-minimization and cost-effectiveness analyses on data from a randomized trial involving 146 general practices from two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Only patients that were being started on antihypertensive medication were included in the analyses. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders. Pharmacists conducted the visits. A cost-minimization framework was adopted, where the costs of intervention were set against the reduced treatment costs (principally due to increased use of thiazides rather than more expensive medication). The cost-effectiveness of the intervention was estimated as the cost per additional patient being started on thiazides. The net annual cost (cost minimization) in our study population was 53,395 US dollars, corresponding to 763 US dollars per practice. The cost per additional patient started on thiazides (cost-effectiveness) was 454 US dollars. The net annual savings in a national program was modeled to be 761,998 US dollars, or 540 US dollars per practice after 2 y. In this scenario the savings exceeded the costs in all but two of the sensitivity analyses we conducted, and the cost-effectiveness was estimated to be 183 US dollars.
                We found a significant shift in prescribing of antihypertensive drugs towards the use of thiazides in our trial. A major reason to promote the use of thiazides is their lower price compared to other drugs. The cost of the intervention was more than twice the savings within the time frame of our study. However, we predict modest savings over a 2-y period. Structured feedback of information can produce change in physician behaviour. The objective of this study was to assess the effectiveness of 2 educational interventions for improving the quality of care provided by family physicians in Ontario: the Practice Assessment Report (PAR) and the Continuing Medical Education Plan (CMEP) with a follow-up visit by a mentor.
                The study was a randomized controlled trial. Physicians in the control group received only the PAR, whereas those in the experimental group received the PAR, CMEP and mentor interventions. The participants were 56 family physicians and general practitioners (27 in the PAR group and 29 in the CMEP group) in southern Ontario who agreed to participate in the interventions and provide data. A total of 2395 patients randomly sampled from the practices returned questionnaires and consented to have their medical records abstracted. The outcome measures were global scores in 4 areas--quality of care, charting, prevention and overall use of medications--and patient ratings of satisfaction with care and preventive practices. The measures were applied at the beginning (phase 1) and end (phase 2) of the study.
                The mean global scores at the end of the study for the PAR group were 70.1% for quality of care, 84.7% for prevention, 77.7% for charting and 82.2% for overall use of medications. The corresponding scores for the CMEP group were 68.3%, 82.1%, 76.4% and 83.2%. In the patient satisfaction component, the personal care scores at phase 2 were 93.6% for the PAR group and 94.6% for the CMEP group. Examples of the scores for prevention for the PAR group were 98.3% for children's current immunization, 96.6% for blood pressure measured within the previous 5 years, 79.4% for referral of women of the appropriate age for mammography within the previous 2 years, and 58.4% for discussion about alcohol use. The corresponding scores for the CMEP group were 95.8%, 97.6%, 77.6% and 64.6%. The changes in mean scores between phase 1 and phase 2 ranged from -1.9 to 2.3 points. There were no significant differences between the 2 groups in phase 1 or phase 2 scores or in change in scores. A total of 64.3% of the physicians rated the PAR as useful, 26.5% found the CMEP to be useful, and 41.0% considered the mentor strategy to be a useful form of continuing medical education. Although changes in practice related to the PAR, CMEP or mentor were reported by some physicians, they were not related to chart audit or patient scores.
                Educational interventions based on quality-of-care assessments and directed to global improvements in quality of care did not result in improvements in the outcome measures. Educational interventions may have to be targeted to specific areas of the practice, with physicians being monitored and receiving ongoing feedback on their performance. Data on the adverse effects of newly marketed drugs are limited. Voluntary reporting is an important part of postmarketing surveillance but is underused by physicians.
                To evaluate the effectiveness of educational outreach visits for improving adverse drug reaction (ADR) reporting by physicians.
                A cluster-randomized controlled trial covering all National Health System physicians in the north of Portugal, with intervention in March 2004 through July 2004, and 13 to 16 months of follow-up. A total of 1388 physicians were assigned in 4 spatial clusters to the intervention group, and 5063 were assigned in 11 clusters to the control group.
                One-hour educational outreach visits tailored to training needs identified in a previous study.
                Change in total number of reported ADRs and number of serious, high-causality, unexpected, and new-drug-related ADRs, using generalized linear mixed models adjusted for baseline ADR reporting, age, specialty, and work setting.
                At baseline, ADR reporting rates (per 1000 physician-years) did not differ significantly between the intervention groups and the control groups in reporting ADRs overall (7.6 vs 11.3), nor did they differ significantly by category: serious, 4.3 vs 6.0; high-causality, 5.4 vs 7.6; unexpected, 1.6 vs 3.5; and new-drug-related ADRs, 3.7 vs 3.8. (P>.05 for all comparisons). The control group had no significant increase in ADR reports during follow-up. The adjusted increase in ADR reporting rates attributable to intervention was 90.19 for total ADRs (95% confidence interval [CI], 54.51-125.87; relative risk [RR], 10.23; 95% CI, 3.81-27.51), 30.16 for serious ADRs (95% CI, 18.84-41.47; RR, 6.32; 95% CI, 2.09-19.16), 64.90 for high-causality ADRs (95% CI, 38.38-91.42; RR, 8.75; 95% CI, 3.05-25.07), 28.04 for unexpected ADRs (95% CI, 16.25-39.83; RR, 30.21; 95% CI, 4.54-200.84), and 42.17 for new-drug-related ADRs (95% CI, 21.58-62.76; RR, 8.05; 95% CI, 2.10 -30.83). The greatest difference occurred during the first 4 months after intervention, but differences remained statistically significant for 12 months.
                A targeted outreach program may improve high-quality reporting of ADRs among physicians. The Royal College of General Practitioners (RCGP) has produced guidelines for the management of acute low back pain in primary care.
                To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners (GPs).
                Group randomised controlled trial, using the health centre as the unit of randomisation.
                Primary care teams in north-west England.
                Twenty-four health centres were randomly allocated to an intervention or control arm. Practices in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain, as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms.
                Twenty-four centres were randomised. Two thousand, one hundred and eighty-seven eligible patients presented with acute low back pain during the study period: 1049 in the intervention group and 1138 in the control group. There were no significant differences between study groups in the proportion of patients who were referred for X-ray, issued with a sickness certificate, prescribed opioids or muscle relaxants, or who were referred to secondary care, but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit (difference in proportion = 12.2%, 95% confidence interval [CI] = 2.8% to 21.6%).
                The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs. An increase in referral to physiotherapy or educational programmes followed the provision of a triage service. To measure the effectiveness of a multifaceted educational intervention to improve ambulatory hypertension control.
                Cluster-randomized trial.
                Academic health system using an ambulatory electronic medical record.
                A total of 10,696 patients with a diagnosis of hypertension cared for by 93 primary care providers.
                Academic detailing, provision of provider-specific data about hypertension control, provision of educational materials to the provider, and provision of educational and motivational materials to patients.
                The primary outcome was blood pressure control, defined as a blood pressure measurement below 140/90 mm Hg, and was ascertained from electronic medical records over 6 months of follow-up. We determined the adjusted odds ratio for the association between the intervention and the achievement of controlled blood pressure. When we accounted for clustering by provider, this adjusted odds ratio was 1.13 (95% confidence interval 0.87-1.47). Adjusted odds ratios were 1.03 (95% confidence interval 0.78-1.36) in patients whose blood pressure was controlled at baseline and 1.25 (95% confidence interval 0.94-1.65) in those whose blood pressure was not. These odds ratios were not significantly different (p=0.11).
                These results were consistent with no effect or, at best, a relatively modest effect of the intervention among patients with hypertension. Had we not included a concurrent control group, the data would have provided an unduly optimistic view of the effectiveness of the program. The effectiveness of future interventions may be improved by focusing on patients whose blood pressure is uncontrolled at baseline. This study tests whether an outreach educational program tailored to institutional specific patient care practices would improve the quality of care delivered to mechanically ventilated intensive care unit (ICU) patients in rural hospitals. The study was conducted as a randomized control trial using 20 rural Iowa hospitals as the unit of analysis. Twelve randomly selected hospitals received an outreach educational program. After review of the medical records of eligible patients, a multidisciplinary team of intensive care unit specialists from an academic medical center delivered an educational program with content specific to the findings and capacity of the hospital. The outcome measures included patient care processes, patient morbidity and mortality outcomes, and resource use. Results indicated that the outreach program significantly improved many patient care processes (lab work, nursing, dietary management, ventilator management, ventilator weaning). The program marginally reduced hospital ventilator days. Both total length of stay and ICU length of stay fell markedly in the intervention group (by an average of 3.2 and 2.1 d, respectively), while the control group fell only 0.6 and 0.3 d, respectively. However, these effects did not reach statistical significance. Unfortunately, the program had no detectable effects on the clinical outcomes of mortality or nosocomial events. We conclude that an outreach program of this type can effectively improve processes of care in rural ICUs. However, improving processes of care may not always translate into improvement of specific outcomes. To compare three approaches for marketing a quit smoking intervention kit to general practitioners.
                Randomised trial of (a) personal delivery and presentation by an educational facilitator with a follow up visit six weeks later; (b) delivery to the receptionist by a friendly volunteer courier with a follow up phone call six weeks later, or (c) postal delivery with a follow up letter six weeks later.
                Melbourne, Australia.
                264 randomly selected general practitioners.
                A research assistant visited each doctor four months after delivery and measured use of components of the kit. A questionnaire measuring perceptions of aspects of the kit and its delivery was completed by doctors. Costs of each approach were calculated.
                Doctors receiving the educational facilitator approach were significantly more likely than those receiving the other two approaches to have seen the kit, to rate the method of delivery as engendering motivation to try the kit, to have used one of the "intensive intervention" components from the kit, to report that they found the kit less complicated, and to report greater knowledge of how to use the kit. There were no significant differences in use of "minimal intervention" components of the kit, ratings of overall acceptability of delivery, perceptions of cultural and structural barriers to using the kit, and ratings of the overall acceptability of the kit. The cost of the educational facilitator approach ($A142/doctor) was 24 times that of the mailed approach. The volunteer courier approach ($A14) was twice the cost of the mailed approach.
                Educational facilitators and volunteer couriers do not seem to be cost effective strategies for distributing smoking interventions. To evaluate the effectiveness of a health authority/pharmaceutical company collaborative intervention to influence the choice of proton pump inhibitors
                Randomized controlled trial, with general practices forming the unit of allocation and analysis.
                Constructive working relationships were achieved with five of six pharmaceutical companies involved. One hundred and two out of 140 practitioners in intervention group practices received at least one visit from an industry representative. There were no reports of representatives operating outside their agreed remit. Prescribing in both the intervention and control group moved towards that recommended by the guidelines but there was no difference between the groups in either the proportion of prescriptions in line with the guidelines or the overall cost.
                Health authorities can achieve professional working relationships with the pharmaceutical industry although no changes in practice attributable to the intervention are achieved. Further work is required to develop effective means to influence prescribing in line with independent guidelines especially in the context of the development of Primary Care Groups. The provision of nutritional support for patients in intensive care units (ICUs) varies widely both within and between institutions. We tested the hypothesis that evidence-based algorithms to improve nutritional support in the ICU would improve patient outcomes.
                A cluster-randomized controlled trial was performed in the ICUs of 11 community and 3 teaching hospitals between October 1997 and September 1998. Hospital ICUs were stratified by hospital type and randomized to the intervention or control arm. Patients at least 16 years of age with an expected ICU stay of at least 48 hours were enrolled in the study (n = 499). Evidence-based recommendations were introduced in the 7 intervention hospitals by means of in-service education sessions, reminders (local dietitian, posters) and academic detailing that stressed early institution of nutritional support, preferably enteral.
                Two hospitals crossed over and were excluded from the primary analysis. Compared with the patients in the control hospitals (n = 214), the patients in the intervention hospitals (n = 248) received significantly more days of enteral nutrition (6.7 v. 5.4 per 10 patient-days; p = 0.042), had a significantly shorter mean stay in hospital (25 v. 35 days; p = 0.003) and showed a trend toward reduced mortality (27% v. 37%; p = 0.058). The mean stay in the ICU did not differ between the control and intervention groups (10.9 v. 11.8 days; p = 0.7).
                Implementation of evidence-based recommendations improved the provision of nutritional support and was associated with improved clinical outcomes. The objective was to study the effect of "academic group detailing" on the prescribing of lipid-lowering drugs in Swedish primary care. A randomized controlled trial was conducted, randomization being by group. Groups of doctors at 134 community health centres were randomly allocated to an intervention and a control group. The 67 intervention health centres were offered four sessions, conducted by a pharmacist, with group information on guidelines for the management of hyperlipidaemia. The number of prescriptions of lipid-lowering drugs per month increased in the intervention health centres and the increase was statistically different from the corresponding change in the control health centres among women in the age group 30-65 years (p = 0.03). The prescription of first-line lipid-lowering drugs increased by 20% in the intervention health centres (p = 0.03). "Academic group detailing" by pharmacists to primary care doctors can be an effective method for influencing prescribing practices. Complete diagnostic evaluation or CDE (i.e., colonoscopy or combined flexible sigmoidoscopy plus barium enema X-ray) is often not performed for persons with an abnormal screening fecal occult blood test (FOBT+) result.
                This study evaluated the impact of a reminder-feedback and educational outreach intervention on primary care practice CDE recommendation and performance rates. Four hundred seventy primary care physicians (PCPs) in 318 practices participated in the study. Patients were mailed an FOBT kit annually as part of a screening program. Practices were randomly assigned to a Control Group (N = 198) or an Intervention Group (N = 120). During an 18-month pre-randomization period and a 9-month post-randomization period, 2992 screening FOBT+ patients were identified. Intervention practices received the screening program and the intervention. Control practices received only the screening program. Study outcomes were baseline-adjusted CDE recommendation and performance rates.
                At baseline, about two-thirds of FOBT+ patients received a CDE recommendation, and about half had a CDE performed. At endpoint, CDE recommendation and performance rates were both significantly higher for the Intervention as compared to the Control practices (OR = 2.28; 95% CI: 1.37, 3.78, and OR = 1.63; 95% CI: 1.06, 2.50, respectively).
                The reminder-feedback plus educational outreach intervention significantly increased CDE recommendation and performance. To evaluate and compare the effects of two programmes of assessment of practice management in a practice visit: mutual visits and feedback by peers compared with visits and feedback by non-physician observers.
                Prospective, randomised intervention study, with follow up after one year.
                General practices in the Netherlands in 1993 and 1994.
                A total of 90 general practitioners (GPs) in 68 practices; follow up after one year comprised 81 GPs in 62 practices.
                Scores on indicators and dimensions of practice management in the visit instrument to assess practice management and organisation (a validated Dutch method to assess practice management in a practice visit). Change was defined as the difference in score between the first visit and the visit after one year on 208 indicators and on 33 dimensions of practice management.
                Data of 44 mutual visits by peers were compared with data of 46 visits by non-physician observers. After a year both programmes showed improvements on many aspects of practice management, but different aspects changed in each of the two programmes. After mutual practice visits, GPs scored significantly higher on content of the doctor's bag, on collaboration with colleagues, on collaboration with other care providers, and on accessibility of patient information than after a visit by a non-physician observer. The visits by non-physician observers resulted in a higher score on extent of use of records and on assessment on outcome and year report.
                Change after mutual practice visits and feedback by peers is more marked than after a visit and feedback by a non-physician observer. The objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women.
                A randomized controlled trial employing firm system methodology was conducted.
                The study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle.
                Women aged 50 to 74 years with at least one routine clinic appointment (when they were due for mammography) during the study period were enrolled in the trial (n = 314).
                The intervention program emphasized nursing involvement and included physician education, provider prompts, use of audiovisual and printed patient education materials, transportation assistance in the form of bus passes, preappointment telephone or postcard reminders, and rescheduling assistance. Control firm women received usual care.
                Mammography completion within 8 weeks of clinic visits was significantly higher among intervention (49%) than control (22%) firm women (p < .001). These effects persisted after adjustment for potential confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5; 95% confidence interval 1.9, 6.5). The intervention effect was modified by type of insurance coverage as well as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation.
                A clinic-based program incorporating physician education, provider prompts, patient education materials, and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women. Providing doctors with new research findings or clinical guidelines is rarely sufficient to promote changes in clinical practice. An implementation strategy is required to provide clinicians with the skills and encouragement needed to alter established routines.
                To evaluate the effectiveness and cost-effectiveness of different training and support strategies in promoting implementation of screening and brief alcohol intervention (SBI) by general practitioners (GPs).
                Subjects were 128 GPs, one per practice, from the former Northern and Yorkshire Regional Health Authority, who agreed to use the 'Drink-Less' SBI programme in an earlier dissemination trial. GPs were stratified by previous marketing conditions and randomly allocated to three intensities of training and support: controls (n = 43) received the programme with written guidelines only, trained GPs (n = 43) received the programme plus practice-based training in programme usage, trained and supported GPs (n = 42) received the programme plus practice-based training and a support telephone call every two weeks. GPs were requested to use the programme for three months. Outcome measures included proportions of GPs implementing the programme and numbers of patients screened and intervened with.
                Seventy-three (57%) GPs implemented the programme and screened 11,007 patients for risk drinking. Trained and supported GPs were significantly more likely to implement the programme (71%) than controls (44%) or trained GPs (56%); they also screened, and intervened with, significantly more patients. Costs per patient screened were: trained and supported GPs, 1.05 Pounds; trained GPs, 1.08 Pounds; and controls, 1.47 Pounds. Costs per patient intervened with were: trained and supported GPs, 5.43 Pounds; trained GPs, 6.02 Pounds; and controls, 8.19 Pounds.
                Practice-based training plus support telephone calls was the most effective and cost-effective strategy to encourage implementation of SBI by GPs. To determine whether office-based interventions increase primary care physicians' risk assessment of and counseling practices for patients regarding sexually transmitted diseases and the human immunodeficiency virus (HIV).
                Randomized controlled clinical trial.
                Washington, D.C., Metropolitan Statistical Area.
                Office-based primary care physicians (family or general practice, internal medicine, and obstetrics-gynecology).
                Mailed educational materials alone or coupled with a simulated patient instructor office visit.
                Self-reported and observed frequency of assessing and counseling patients regarding their risk factors for sexually transmitted diseases and HIV infection. Participants were interviewed by telephone before and after the intervention (n = 757). A subset of participants (n = 194) was also observed after the intervention by simulated patient evaluators in blinded office visits.
                89% of physicians who received both educational materials and a simulated patient instructor visit reported that they reviewed the educational materials compared with 53% of those who only received the educational materials (P < or = 0.001). Physicians in the combined intervention group had higher self-reported and observed rates for several risk assessment questions and counseling recommendations than did physicians in the control group or the group that only received educational materials. Seventy-three percent of physicians of the combined intervention group reported an increase in counseling patients about reducing risky sexual behavior compared with 53% of the group receiving only educational materials and 42% of the control group (P < or = 0.001).
                Mailed educational materials combined with an office visit by a simulated patient instructor for role-play and feedback on clinical performance increased the frequency of office-based physicians' risk assessment and risk reduction counseling of patients for sexually transmitted diseases and HIV infection. To study the effectiveness of a disease management program for patients with acid-related disorders.
                A cluster-randomized clinical trial of 406 patients comparing a disease management program with "usual practice."
                Enrolled patients included those presenting with new dyspepsia and chronic users of antisecretory drugs in 8 geographically separate physician offices associated with the Orlando Health Care Group. There were 35 providers in the intervention group and 48 in the control group. The disease management program included evidence-based practice guidelines implemented by using physician champions, academic detailing, and multidisciplinary teams. Processes of care, patient symptoms, quality of life, costs, and work days lost were measured 6 months after patient enrollment.
                Compared with usual practice, disease management was associated with improvements in Helicobacter pylori testing (61% vs 9%; P = .001), use of recommended H pylori treatment regimens (96% vs 10%; P = .001), and discontinuation rates of proton pump therapy after treatment (70% vs 36%; P = .04). There were few differences in patient quality of life or symptoms between the 2 study groups. Disease management resulted in fewer days of antisecretory therapy (71.7 vs 88.1 days; P = .02) but no difference in total costs.
                This disease management program for patients with acid-related disorders led to improved processes of care. The effectiveness of such a program in other settings requires further study. The effect of patient care appraisal on physicians' management of patients' problems was assessed. Sixteen family physicians were involved. The eight in the experimental group helped in the selection of two of the five disease conditions to be audited and in the generation of optimal criteria of care for two of the conditions. Participation in the generation of optimal criteria was followed by a significant improvement in the physicians' behaviour, but involvement in the selection of the conditions to be audited caused no change. The patient care appraisal did not lead to significant improvement of physicians' management of the conditions. In a second analysis, in which only essential criteria of care were considered, the physicians who participated in the patient care appraisal significantly improved their management of patients' problems. However, participation in the selection of the conditions and in the generation of the criteria of care had no effect on their performance. Patient care appraisal is an effective tool in continuing medical education and leads to improvement in the quality of care, provided the process focuses on essential criteria of care. A study was made of the effect of one-to-one educational meetings between prescribers and a pharmacist on the prescribing of antiulcer agents for outpatients in a health maintenance organization (HMO). Ten-minute presentations were developed that communicated the same basic facts through the use of case studies (vivid interventions) or statistical data (nonvivid interventions). After a control group (n = 8) was selected, prescribers (n = 16) were randomly assigned to receive vivid interventions or nonvivid interventions. Data on the prescribing of cimetidine, ranitidine, and sucralfate were collected for one month before the interventions and for two months afterward. Three clinical pharmacy professors independently evaluated prescriptions for appropriateness of indication, dosage, and duration. No differences in appropriateness were found between the two intervention groups, but in the first postintervention month the mean rate of inappropriate prescribing per control practitioner was 80%, versus less than 32% for the intervention groups (p less than 0.01). Each prescription in the first postintervention month entailed a mean cost of $31 per control practitioner for inappropriate prescribing, compared with less than $12 for the intervention groups (p less than 0.01). Mean costs of inappropriate prescriptions per practitioner per patient visit were $0.88 and less than or equal to $0.41 for the control and intervention groups, respectively (p less than 0.05). During postvisit month 2, inappropriate prescribing for both intervention groups increased slightly and was no longer significantly less than that in the control group. One-to-one educational meetings improved the prescribing of antiulcer agents for outpatients in an HMO. This study evaluated two different methods of providing practice-based, antibiotic prescribing feedback to general practitioners (GPs). The impact of face-to-face prescribing discussion visits led by a pharmaceutical prescribing adviser were compared to the provision of practice specific prescribing analysis workbooks. Sixty-six practices within one Family Health Services Authority were randomly stratified into one of two groups (Group 1: visits; Group 2: workbooks). The 23 practices who did not wish to participate were used as a self selected control group (Group 3). Twelve months after the start of the programme, visits were extended to Group 2 and Group 3. Prescribing patterns were evaluated using five prescribing indicators, before and at 12 and 24 months after the start of the programme. Analysis of practice prescribing patterns at 12-months demonstrated that the desired changes in the selected five indicators were greater in Group 1 than Group 2 or Group 3; changes were statistically significant for indicators 5, 4 and 2 in each group, respectively. After 24 months all groups demonstrated significant changes in five indicators. Face-to-face visits proved the most successful of the two methods to influence GP prescribing, although the workbook promoted more change than that seen in the control group. Although there is much room for improvement in the performance of recommended preventive manoeuvres, many inappropriate preventive interventions are being done. We evaluated a multifaceted intervention, delivered by nurses trained in prevention facilitation, to improve prevention in primary care.
                Forty-six health service organizations (HSOs) were recruited from 100 sites in Ontario. After baseline data were collected, we randomly assigned the practices to either an 18-month (July 1997 to December 1998) multifaceted intervention delivered by 1 of 3 nurse facilitators (23 practices) or no intervention (23 practices). The unit of intervention and analysis was the medical practice. The outcome measure was an overall index of preventive performance, which was calculated as the proportion of eligible patients who received 8 recommended preventive manoeuvres less the proportion of eligible patients who received 5 inappropriate preventive manoeuvres.
                One HSO, in the intervention group, was lost to follow-up. Before the intervention, the index of preventive performance was similar for the intervention and control groups (31.9% [95% confidence interval (CI) 27.3%-36.5%] and 32.1% [95% CI 27.2%-37.0%] respectively). At follow-up the corresponding values were 43.2% (95% CI 38.4%-48.0%) and 31.9% (95% CI 26.8%-37.0%), for an absolute improvement in the intervention group of 11.5% (p < 0.001). The mean proportion of eligible patients who received the recommended manoeuvres was 62.3% (95% CI 58.2%-66.4%) in the intervention group, as compared with 57.4% (95% CI 54.1%-60.7%) in the control group, for an absolute improvement of 7.2% (p = 0.008). The corresponding values for the inappropriate manoeuvres were 19.1% (95% CI 15.6%-22.6%) and 25.5% (95% CI 20.0%-31.0%), for an absolute improvement of 4.4% (p = 0.019).
                The tailored multifaceted intervention delivered by nurse facilitators was effective in modifying physician practice patterns and significantly improved preventive care performance. In an attempt to evaluate the efficacy of different methods of interventions to improve the appropriate use of drugs for acute diarrhoea, a controlled study has been carried out in 6 districts in Yogyakarta and Central Java provinces, Indonesia. This study was designed to investigate the impacts of two different methods of educational intervention, i.e. a small group face-to-face intervention and a formal seminar for prescribers, on prescribing practice in acute diarrhoea. The districts were randomly assigned into 3 groups and 15 health centers were selected from each district. Prescribers in Group 1 underwent a small group face-to-face intervention conducted in the respective health center. Those in Group 2 attended a formal seminar conducted at the district level. Prescribers in Group 3 served as the control group. Both interventions were given on a single occasion without follow-up supervision or monitoring. Written information materials on the appropriate management of acute diarrhoea were developed and were provided to all prescribers in the intervention groups. Focus group discussions (FGDs) involving prescribers and consumers in the 6 districts were carried out to identify various underlying motivations of drug use in acute diarrhoea. The findings of the FGDs were used as part of the intervention materials. To evaluate the impacts of these interventions on prescribing practice, a prescribing survey for patients under five years old with acute diarrhoea was carried out in health centers covering 3-month periods before and after the intervention. The results showed that both interventions were equally effective in improving the levels of knowledge of prescribers about the appropriate management of acute diarrhoea. They were also partially effective in improving the appropriate use of drugs, reducing the use of non-rehydration medications. There was a highly significant reduction of antimicrobial usage either after small-group face-to-face intervention (77.4 +/- 2.7% to 60.4 +/- 2.9%; P < 0.001) or formal seminar (82.3 +/- 3.0% to 72.3 +/- 3.6%; P < 0.001), and the former caused significantly (P < 0.001) greater reduction than the latter. There was also a significant (P < 0.01) reduction in the usage of antidiarrhoeals after both interventions, i.e. from 20.3 +/- 3.7% to 12.5 +/- 3.3% (P < 0.01) after face-to-face intervention and from 48.5 +/- 4.1% to 27.0 +/- 4.3% (P < 0.01) after seminar. However, the formal seminar had a significantly (P < 0.01) greater impact than the small group face-to-face intervention. There was also a trend toward increased oral rehydration solution (ORS) usage after both interventions, but this did not achieve the level of statistical significance (P > 0.05). No changes were observed in the control group. Although the small group face-to-face intervention did not appear to offer greater impacts over large seminars in improving the appropriate use of drugs in acute diarrhoea, since the unit cost of training is far less costly than the seminar, it might be feasibly implemented in the existing supervisory structure of the health system. The aim of the present study was to assess whether educational intervention on the primary care physician may be an effective method to improve drug prescription.
                An experimental randomized controlled study was carried out in 244 physicians of the management area No. 5 of the Institut Català de la Salut. Intervention consisted in 3 individualized interviews with the 123 physicians of the study group (IG), during which written informative material was also presented. The issues were: cerebral and peripheral vasodilators (CPVD) and antibiotics. The changes in the prescription of CPVD, combination of anti-infective agents with expectorants, mucolytics and/or balsamics (R05C1) and cephalosporins were specially evaluated in both groups. Subsequently, a stratified analysis was carried out depending on the volume of prescription of the physicians.
                The IG showed a greater reduction in the prescription of CPVD (9.78 bottles per physicians and months versus 6.43, p less than 0.01). The relative reduction in R05C1 prescription was also higher in the IG (12.3% versus 6.7%, p less than 0.01). The expenditure showed similar results. The use of oral cephalosporins increased in the IG and was reduced in the CG (p less than 0.01).
                The results show a favorable impact of personalized information in the groups with high prescription volume, which is particularly remarkable in the highest prescribers. To evaluate the feasibility and implementation needs of a cholesterol guideline by assessing the effectiveness of simple dissemination as well as extensive implementation of this guideline on actual performance of general practitioners (GPs).
                Randomized controlled trial.
                Thirty-two Dutch GPs in 20 general practices, 3950 patient records.
                Guideline dissemination to all 32 GPs, and a 5-month programme for improvement in the intervention group. This programme was developed after barriers to working according to the guideline had been investigated, and consisted of group education, desktop supportive materials, feedback on performance, and face-to-face instruction on location.
                The outcome parameters were defined as quality of selective case finding and quality of diagnostic procedures, and were measured by chart audit.
                The quality of selective case finding, especially the targeting of cholesterol testing to those with positive cardiovascular risk profiles, did not improve following intervention. Performance of the procedure necessary to diagnose hypercholesterolaemia even deteriorated. The quantity of cholesterol testing increased in both groups, but this was probably explained by the increased availability of desktop cholesterol analysers.
                Neither simple dissemination nor an intensive programme for improvement had measurable impact on actual performance on working according to the cholesterol guideline. Both the validity and the opinion about feasibility of the guideline in daily practice deserve more attention during guideline development. To compare group versus individual academic detailing to increase diuretic or beta-blocker use in hypertension.
                We conducted a cluster-randomized controlled trial in a large health maintenance organization. Subjects (N=9820) were patients with newly treated hypertension in the year preceding the intervention (N=3692), the 9 months following the intervention (N=3556), and the second year following intervention (N=2572). We randomly allocated 3 practice sites to group detailing (N=227 prescribers), 3 to individual detailing (N=235 prescribers), and 3 to usual care (N=319 prescribers). Individual detailing entailed a physician-educator meeting individually with clinicians to address barriers to prescribing guideline-recommended medications. The group detailing intervention incorporated the same social marketing principles in small groups of clinicians.
                In the first year following the intervention, the rates of diuretic or beta-blocker use increased by 13.2% in the group detailing practices, 12.5% in the individual detailing practices, and 6.2% in the usual care practices. As compared with usual care practices, diuretic or beta-blocker use was more likely in group detailing practices (adjusted odds ratio (OR), 1.40; 95% confidence interval (CI), 1.11 - 1.76) and individual detailing practices (adjusted OR, 1.30; 95% CI, 0.95 - 1.79). Neither intervention affected blood pressure control. Two years following this single-visit intervention, there was still a trend suggesting a persistent effect of individual (OR, 1.22; 95% CI, 0.92 - 1.62), but not group, detailing (OR, 1.06; 95% CI, 0.80 - 1.39), as compared with usual care.
                Both group and individual academic detailing improved antihypertensive prescribing over and above usual care but may require reinforcement to sustain improvements. Educational outreach visits, particularly when combined with social marketing, appear to be a promising approach to modifying health professional behaviour, especially prescribing. Results from previous studies have shown a varying effect.
                The purpose of the study is to examine the effect of academic detailing as a method of implementing a clinical guideline in general practice.
                A cluster randomized, controlled, blinded study was carried out of the effect of an academic detail visit compared with postal distribution of a guideline for prescribing asthma medication. Half the practices in a Danish county with 100 practices were visited once. The outcome measure was routinely collected data from all Danish pharmacies on the sales of asthma medication. Data were collected monthly for 2 years before to 1 year after the intervention.
                There was no effect on the pattern of prescription of asthma medicines following the visit, neither immediately nor long term.
                We found no effect of academic detailing as a single intervention. To determine whether brief, face-to-face educational outreach visits can improve the appropriateness of blood product utilization.
                Randomized, controlled multicenter trial with 6-month follow-up.
                Surgical and medical services of two pairs of matched community and teaching hospitals in Massachusetts.
                One hundred one transfusing staff surgeons and attending medical physicians.
                A professionally based transfusion specialist presented one surgical- or medical-service-wide lecture emphasizing appropriate indications, risks, and benefits of red blood cell transfusions; brief, graphic, printed educational guidelines; and one 30-minute visit with each transfusing physician. No data feedback was provided. Educational messages emphasized the lack of utility of the traditional threshold for red blood cell transfusions (hematocrit, 30%) and transfusion risks (eg, viral hepatitis).
                Proportion of red blood cell transfusions classified as compliant or noncompliant with blood transfusion guidelines, or indeterminate 6 months before and 6 months after an experimental educational intervention.
                Based on analyses of 1449 medical record audits of red blood cell transfusions that occurred 6 months before and 6 months after the educational intervention, the average proportion of transfusions not in compliance with criteria declined from 0.40 to 0.24 among study surgeons (-40%) compared with an increase from 0.40 to 0.44 (+9%) among control surgeons (P = .006). These effects were consistent across procedure type and specialty. On average, study surgeons in the postintervention period performed transfusions when hematocrits were 2.0 percentage points lower than before the intervention (28.3% preintervention vs 26.3% postintervention), and lower than in the control group (28.3% preintervention and postintervention; P = .04). Likely savings in blood use for surgical services probably exceeded program costs, even without considering reduced risks of infection. No effects were observed among transfusions occurring in medical services, possibly because of substantially lower transfusion rates and lower pretransfusion hematocrits.
                Brief, focused educational outreach visits by transfusion specialists can substantially improve the appropriateness and cost-effectiveness of blood product use in surgery. More data are needed regarding the durability of changes in practice patterns and the health and economic benefits of such interventions. There is increasing evidence that clinical guidelines can lead to improvements in clinical care. However, they are not self-implementing. Outreach visits may improve prescribing behaviour.
                Within a before-and-after pragmatic randomized controlled trial, involving all general practices in one health district, routine methods were used to distribute guidelines for management of Helicobacter pylori eradication. Intervention practices were offered a visit and the conduct of an audit by a pharmacist trained in the techniques of outreach visiting. The intervention was evaluated using level three Prescribing Analysis and Cost (PACT) data for metronidazole and omeprazole for the two 12 month periods around the introduction of the guidelines.
                Of the 38 intervention practices 19 accepted an outreach visit and three accepted the offer of an audit. There was a significant increase in omeprazole use during the study of 0.24 [95 per cent confidence interval (CI) +0.19 to +0.29] dose units per year but no effect from the offer [-0.02 (95 per cent CI -0.12 to +0.08) dose units] or acceptance of a visit [-0.03 (95 per cent CI -0.15 to +0.08) dose units]. The results for metronidazole were similar, with an increase in use of 0.028 (95 per cent CI +0.018 to +0.038) dose units per year. The effect of the intervention was a non-significant change in prescribing of -0.005 (95 per cent CI -0.025 to +0.015) dose units. Accepting a visit had little effect on prescribing: a change of 0.003 (95 per cent CI -0.021 to +0.027) dose units.
                The routine use of untargeted outreach visiting is probably not a worthwhile strategy. The objective of the study was to evaluate the effectiveness of 2 educational strategies aimed at improving prescribing standards in primary care.
                A pragmatic controlled trial was designed; the study population included general and family practitioners in Galicia (northwestern Spain) divided into 3 study groups: a one-to-one education group (n = 98), a by-group education group (n = 92), and a control group (n = 405). The educational intervention included explicit recommendations for selecting nonsteroidal anti-inflammatory drugs (NSAIDs) for inflammation signs. Some of the subjects were given reminders. Mixed-effect linear models were applied to data analysis. Analyses were done by intention-to-treat. The dependent variable is a rate with a numerator that is the number of prescribed units of the NSAIDs recommended during intervention; the denominator is the total number of prescribed units of the NSAID total.
                One-to-one education obtained an average prescribing behavior improvement of 6.5% (P < 0.001) in the 9 months after intervention. In the education group, the average improvement was 2.4% (P < 0.05) for the same period. Statistically significant differences were observed between the group intervention and one-to-one groups. The reminder increased significantly the effectiveness of the one-to-one intervention.
                A single, short educational session to primary care doctors can improve their prescribing standards during long periods of > or = 9 months. Of the 2 strategies followed in the trial, one-to-one education has shown to be the most effective. Results also show that the effectiveness of these interventions increases when presented together with written material. Research is needed to validate effective and practical strategies for improving the provision of evidence-based medicine in primary care.
                To determine whether a multimethod quality improvement intervention was more effective than a less intensive intervention for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke.
                2-year randomized, controlled clinical trial with the practice as the unit of randomization.
                20 community-based family or general internal medicine practices in 14 states. All used the same electronic medical record.
                44 physicians, 17 midlevel providers, and approximately 200 staff members; data from the electronic medical records of 87,291 patients.
                All practices received copies of practice guidelines and quarterly performance reports. Intervention practices also hosted quarterly site visits to help them adopt quality improvement approaches and participated in 2 network meetings to share "best practice" approaches.
                The percentage of indicators at or above predefined targets and the percentage of patients who had achieved each clinical indicator.
                Intervention practices improved 22.4 percentage points (from 11.3% to 33.7%) in the percentage of indicators at or above the target; control practices improved 16.4 percentage points (from 6.3% to 22.7%). The 6.0-percentage point absolute difference between the intervention and control group was not statistically significant (P > 0.2). Patients in intervention practices had greater improvements than those in control practices for diagnoses of hypertension (improvement difference, 15.7 percentage points [95% CI, 5.2 to 26.3 percentage points]) and blood pressure control in patients with hypertension (improvement difference, 8.0 percentage points [CI, 0.0 to 16.0 percentage points]).
                The study involved a small number of practices and lacked a pure control group.
                Primary care practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines for cardiovascular disease and stroke prevention. To determine the effectiveness of specialist nurse delivered education in primary care to improve control of hypertension and hyperlipidaemia in patients with diabetes.
                Practice-level randomized controlled trial, Salford, England.
                From 44 practices, 10 303 subjects presenting in general practice with raised blood pressure (= 140/80 mmHg), raised total cholesterol (= 5.0 mmol/l) or both.
                Practices were randomized to receive either the intervention for hyperlipidaemia or for hypertension; practices acted as control for the intervention not received. Specialist nurses arranged a schedule of visits with general practitioners and general practice nurses, reminding them of diabetes protocols and clinical targets. They provided educational materials and protocols used in secondary care for nurse and doctor interventions including stepping up pharmacotherapy when necessary. Practices received a list of patients in their practice who were poorly controlled at their last annual review; new and recalled patients were targeted.
                At subsequent annual review, blood pressure and total cholesterol values were obtained from the Salford electronic diabetes register for patients from participating practices.
                Overall, specialist nurse-led educational outreach to primary care was associated with no improvement in patients achieving target after 1 year-odds ratio (OR): 1.03 (95% CI 0.95-1.11; P = 0.52). Similar results were achieved with hyperlipidaemia OR: 1.04 (95% CI 0.88-1.23; P = 0.62) and hypertension OR: 1.01 (95% CI 0.80-1.27; P = 0.93).
                This study provides evidence that the use of specialist nurses to perform educational outreach to improve target adherence to patients with diabetes in primary care is not effective. Current understanding of implementation methods is limited, and research has focused on changing doctors' behaviors.
                Our aim was to evaluate the impact of audit and feedback and educational outreach in improving nursing practice and patient outcomes.
                Using a factorial design, cluster randomized controlled trial, we evaluated 194 community nurses in 157 family practices and 1078 patients with diagnosis of urinary incontinence (UI) for nurses compliance with evidence-linked review criteria for the assessment and management of UI and impact on psychologic and social well-being and symptoms. In the outreach arms, nurses' self-reported barriers informed development of tailored strategies.
                In comparison with educational materials alone, the implementation methods tested did not improve care at 6 months follow-up. Moderate rates of improvement (10-17% of patients) in performance for the assessment of UI and greater rates of improvement (20-30% of patients) for the management of care were found but effects were similar across arms. Improvement in patient outcomes was more consistently positive for educational outreach than for audit and feedback but differences were not significant. Adjustment for caseload size, severity or duration of UI and patients' age did not alter results.
                Printed educational materials alone may be as effective as audit and feedback and educational outreach in improving nurses' performance and outcomes of care for people with UI. Greater understanding of the underlying processes in improving performance within multidisciplinary teams through further, theory-driven studies with "no intervention" control groups and longer follow-up are needed. Evidence exists that some dentists may be failing to perform adequate periodontal diagnostic and preventive care for their patients. Continuing education (CE) is an avenue that is frequently employed as a strategy to alter the style of practice. This paper presents an evaluation of a year-long continuing education intervention "Periodontics in General Practice", conducted among randomly selected private general dental practices in Adelaide, South Australia. The CE intervention featured a 1-day seminar, bi-monthly newsletters, individualised 3-monthly comparative feedback, and technical assistance. The study employed a longitudinal quasi-experimental design, which allowed for evaluation of the effectiveness of the intervention among practices employing hygienists (n = 12) and not employing dental hygienists (n = 12), taking into account the covariates of baseline level of provision of periodontal services, the practice's level of participation in the intervention and attendance at other CE courses in periodontics over the year. A comparison group of practice (n = 12) did not participate in the intervention over the year. Patient record audits, conducted at baseline and at 12 months, provided data for the evaluation of the effect of the intervention on the recording of periodontal diagnostic, preventive and treatment items. Practices participating in the intervention showed increases in the percentage of records containing at least one periodontal diagnostic notation, and those practices employing hygienists showed an increase in the percentage of records with at least one preventive notation and one treatment item.(ABSTRACT TRUNCATED AT 250 WORDS) The Health Education and Research Trial (HEART) was a multicenter clinical trial designed to test methods to improve primary care practice systems for heart disease prevention services. We present the trial methodology, the practices' use of medical record tools, and changes in documentation of cardiovascular risk factor screening and management.
                Primary care practices were recruited from 4 Midwestern states. The factorial design resulted in 4 study groups: conference only, conference and quality improvement consultations, conference and prevention coordinator, and all interventions combined. Medical record audits and physician, staff, and patient surveys assessed practice change in cardiovascular disease risk factor documentation.
                Practices participated fully in this project, set goals to improve preventive services, and implemented recommended medical record tools. The number of goals set and the increase in the use of medical record tools were greatest in the combined intervention group, with improvements noted in all groups. The use of patient history questionnaires, problem lists, and flow sheets was significantly higher in the combined intervention group when compared with the conference-only group. Documentation of risk factor screening in a recommended-medical record location improved in all intervention groups, with significant sustained improvements in the practices that received the combined intervention. Documented risk factor management significantly improved in all intervention groups compared with the conference-only control.
                Primary care practices are interested in improving prevention systems and can change these systems in response to supportive external interventions. Promoting organizational change to produce sustained improvement in preventive service clinical outcomes is a complex process that requires further research. In order to measure the effect of industry-independent information on the prescribing of benzodiazepines in general practice, 128 primary practitioners were randomly allocated to three intervention groups after stratification by year of graduation. One third of the participating physicians were forwarded written information about the indications and limitations of benzodiazepines, another third received both written and oral information, and the remaining third (the control group) obtained no information at all. A comparison of the number of benzodiazepines prescribed per 100 patient contacts with prescription before and after the intervention showed an average decrease of 3% in the control group, of 14% in physicians who received only written information, and of 24% in physicians who were given additional oral information. Post hoc pair-wise comparisons revealed a significant difference at the 1% level in the number of benzodiazepines prescribed between physicians who received both written and oral information and the control group. A follow-up survey conducted 4 weeks after the intervention showed that the oral information campaign positively affected physicians' attitudes about the value of oral drug information from an industry-independent source. To evaluate the effects of feedback reports combined with outreach visits from trained non-physicians on the clinical decision making of general practitioners (GPs) in cardiovascular care.
                Pragmatic cluster controlled trial with randomisation of practices to support (intervention group) or no special attention (control group); analysis after 2 years.
                124 general practices in The Netherlands.
                185 GPs.
                Compliance rates for 12 evidence-based indicators for the management of patients with hypertension, hypercholesterolaemia, angina pectoris, or heart failure. The evaluation relied on the prospective recording of patient encounters by the participating GPs.
                The GPs reported 30 101 clinical decisions at baseline and 22 454 decisions after the intervention. A significant improvement was seen for five of the 12 indicators: assessment of risk factors in patients with hypercholesterolaemia (odds ratio 2.04; 95% CI 1.44 to 2.88) or angina pectoris (3.07; 1.08 to 8.79), provision of information and advice to patients with hypercholesterolaemia (1.58, 1.17 to 2.13) or hypertension (1.55, 1.35 to 1.77), and checking for clinical signs of deterioration in patients with heart failure (4.11, 2.17 to 7.77). Single handed practices, non-training practices, and practices with older GPs gained particular benefit from the intervention.
                Intensive support from trained non-physicians can alter certain aspects of the clinical decision making of GPs in cardiovascular care. The effect is small and the strategy needs further development. Obesity is one of the most common presenting chronic medical conditions in primary care, yet it is not adequately treated. Physicians are often reluctant to counsel patients because of their limited training in treating chronic weight problems and negative attitudes toward obese patients. This study evaluated the feasibility of training physicians to provide weight control counseling to their patients. Eleven physicians were randomly assigned to either an obesity-counseling skills training group or to a control group. Physicians in the counseling skills group received training in behavioral and motivational weight control techniques using a five-step patient-centered model; they were also given patient materials for use in their practice. To evaluate pretraining to posttraining changes in physician counseling behavior, independent samples of patients with obesity were surveyed immediately after their visit to the physician's office. Physicians in both the counseling skills training and the control groups discussed weight with 42% to 47% of their patients at baseline. This increased to 89% in physicians who received training, whereas it remained at 42% in control physicians. Scores on a counseling measure also significantly increased from a mean of 2.7 to 9.9 in the counseling group, whereas scores in the control group remained low and stable (2.3 and 1.9, respectively). The training program was effective in improving the frequency and quality of counseling that physicians delivered to their patients with obesity. Future research is needed to evaluate the effect of physician counseling on the weight and physical activity level of their patients. To assess whether a multifaceted intervention can reduce the number of prescriptions for antimicrobials for suspected urinary tract infections in residents of nursing homes.
                Cluster randomised controlled trial.
                24 nursing homes in Ontario, Canada, and Idaho, United States.
                12 nursing homes allocated to a multifaceted intervention and 12 allocated to usual care. Outcomes were measured in 4217 residents.
                Diagnostic and treatment algorithm for urinary tract infections implemented at the nursing home level using a multifaceted approach--small group interactive sessions for nurses, videotapes, written material, outreach visits, and one on one interviews with physicians.
                Number of antimicrobials prescribed for suspected urinary tract infections, total use of antimicrobials, admissions to hospital, and deaths.
                Fewer courses of antimicrobials for suspected urinary tract infections per 1000 resident days were prescribed in the intervention nursing homes than in the usual care homes (1.17 v 1.59 courses; weighted mean difference -0.49, 95% confidence intervals -0.93 to -0.06). Antimicrobials for suspected urinary tract infection represented 28.4% of all courses of drugs prescribed in the intervention nursing homes compared with 38.6% prescribed in the usual care homes (weighted mean difference -9.6%, -16.9% to -2.4%). The difference in total antimicrobial use per 1000 resident days between intervention and usual care groups was not significantly different (3.52 v 3.93; weighted mean difference -0.37, -1.17 to 0.44). No significant difference was found in admissions to hospital or mortality between the study arms.
                A multifaceted intervention using algorithms can reduce the number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes. Despite ongoing concern about adverse effects and dependence on benzodiazepines, approximately 2% of Australians are still taking them on a regular basis. The aim of this study was to evaluate the effectiveness of an educational outreach or 'academic detailing' program about prescribing of benzodiazepines.
                In this randomised trial general practice registrars (n = 157) in New South Wales were allocated to an intervention group (n = 79), which received a 20 minute educational outreach visit; or a control group (n = 78) which received an intervention on an unrelated topic. Prescribing behaviour was monitored by a pre-intervention and two post-intervention practice activity surveys.
                These were the rate of benzodiazepine prescribing for all indications, for anxiety and for sleep disorders.
                Overall benzodiazepine prescribing by the intervention group declined from 2.3 to 1.7 per 100 encounters, while the control group also declined from 2.2 to 1.6 per 100 encounters. Analysis of variance showed this was a significant drop over time (P = 0.042) but there was no difference between groups (P = 0.99). The prescribing decrease observed was in continuing rather than initial prescriptions.
                A marked decrease in benzodiazepine prescribing was seen over the course of the study in both intervention and control groups but no differential effect due to the educational outreach visit was found. Private pharmacies are an important source of health care in developing countries. A number of studies have documented deficiencies in treatment, but little has been done to improve practices. We conducted two controlled trials to determine the efficacy of face-to-face educational outreach in improving communication and product sales for cases of diarrhoea in children in 194 private pharmacies in two developing countries. A training guide was developed to enable a national diarrhoea control programme to identify problems and their causes in pharmacies, using quantitative and qualitative research methods. The guide also facilitates the design, implementation, and evaluation of an educational intervention, which includes brief one-on-one meetings between diarrhoea programme educators and pharmacists/owners, followed by one small group training session with all counter attendants working in the pharmacies. We evaluated the short-term impact of this intervention using a before-and-after comparison group design in Kenya, and a randomized controlled design in Indonesia, with the pharmacy as unit of analysis in both countries (n = 107 pharmacies in Kenya; n = 87 in Indonesia). Using trained surrogate patients posing as mothers of a child under five with diarrhoea, we measured sales of oral rehydration salts (ORS); sales of antidiarrhoeal agents; and history-taking and advice to continue fluids and food. We also measured knowledge about dehydration and drugs to treat diarrhoea among Kenyan pharmacy employees after training. Major discrepancies were found at baseline between reported and observed behaviour. For example, 66% of pharmacy attendants in Kenya, and 53% in Indonesia, reported selling ORS for the previous case of child diarrhoea, but in only 33% and 5% of surrogate patient visits was ORS actually sold for such cases. After training, there was a significant increase in knowledge about diarrhoea and its treatment among counter attendants in Kenya, where these changes were measured. Sales of ORS in intervention pharmacies increased by an average of 30% in Kenya (almost a two-fold increase) and 21% in Indonesia compared to controls (p < 0.05); antidiarrhoeal sales declined by an average of 15% in Kenya and 20% in Indonesia compared to controls (p < 0.05). There was a trend toward increased communication in both countries, and in Kenya we observed significant increases in discussion of dehydration during pharmacy visits (p < 0.05). We conclude that face-to-face training of pharmacy attendants which targets deficits in knowledge and specific problem behaviours can result in significant short-term improvements in product sales and communication with customers. The positive effects and cost-effectiveness of such programmes need to be tested over a longer period for other health problems and in other countries. To determine whether an educational package could influence the management of menorrhagia, increase the appropriateness of choice of non-hormonal treatment, and reduce referral rates from primary to secondary care.
                Randomised controlled trial.
                General practices in East Anglia.
                100 practices (348 doctors) in primary care were recruited and randomised to intervention (54) and control (46). Interventions: An educational package based on principles of "academic detailing" with independent academics was given in small practice based interactive groups with a visual presentation, a printed evidence based summary, a graphic management flow chart, and a follow up meeting at 6 months.
                All practices recorded consultation details, treatments offered, and outcomes for women with regular heavy menstrual loss (menorrhagia) over 1 year.
                1001 consultation data sheets for menorrhagia were returned. There were significantly fewer referrals (20% v 29%; odds ratio 0. 64; 95% confidence interval 0.41 to 0.99) and a significantly higher use of tranexamic acid (odds ratio 2.38; 1.61 to 3.49) in the intervention group but no overall difference in norethisterone treatment compared with controls. There were more referrals when tranexamic acid was given with norethisterone than when it was given alone. Those practices reporting fewer than 10 cases showed the highest increase in prescribing of tranexamic acid.
                The educational package positively influenced referral for menorrhagia and treatment with appropriate non-hormonal drugs. To evaluate the effectiveness of an asthma resource centre in improving treatment and quality of life for asthmatic patients.
                Community based randomised controlled trial.
                41 general practices in Greenwich with a practice nurse.
                All registered patients aged 15-50 years.
                Nurse specialists in asthma who educated and supported practice nurses, who in turn educated patients in the management of asthma according to the British Thoracic Society's guidelines.
                Quality of life of asthmatic patients, attendance at accident and emergency departments, admissions to local hospitals, and steroid prescribing by general practitioners.
                Of 24 400 patients randomly selected and surveyed in 1993, 12 238 replied; 1621 were asthmatic of whom 1291 were sent a repeat questionnaire in 1996 and 780 replied. Of 24 400 patients newly surveyed in 1996, 10 783 (1616 asthmatic) replied. No evidence was found for an improvement in asthma related quality of life among newly surveyed patients in intervention practices compared with control practices. Neither was there evidence of an improvement in other measures of the quality of asthma care. Weak evidence was found for an improvement in quality of life in intervention practices among asthmatics registered with study practices in 1993 and followed up in 1996. Neither attendances at accident and emergency departments nor admissions for asthma showed any tendency to diverge in intervention and control practices over the study period. Steroid prescribing rates rose steadily during the study period. The average annual increase in steroid prescribing was 3% per year higher in intervention than control practices (95% confidence interval -1% to 6%, P=0.10).
                This model of service delivery is not effective in improving the outcome of asthma in the community. Further development is required if cost effective management of asthma is to be introduced. Antibiotic misuse is common and costly and may promote antibiotic resistance. We tested the efficacy of a targeted one-on-one educational program ("academic detailing") designed to improve the appropriateness of broad-spectrum antibiotic use.
                A randomized controlled trial was conducted in a large US teaching hospital. During an 18-week study period, 17 general medical, oncology, and cardiology services either received academic detailing or did not. The intervention was prompted by an order for either levofloxacin or ceftazidime that led to a computer-based review of data for that patient. Orders for the 2 target antibiotics deemed unnecessary by a priori criteria were included in the study. The primary outcome examined was the number of days that unnecessary levofloxacin or ceftazidime was administered in intervention and control groups.
                Before the trial, intervention and control services had similar prescribing patterns for the target antibiotics; the drugs were used for similar indications throughout the study period. During the intervention, there was a reduction of 37% in days of unnecessary levofloxacin or ceftazidime use per 2-week interval on services randomized to the educational intervention vs control services (P< .001). In multivariable analyses controlling for baseline prescribing and study interval, the rate of unnecessary use of the 2 target antibiotics was reduced by 41% on the intervention services compared with controls (95% confidence interval, 44%-78%; P< .001). Length of stay, intensive care unit transfers, readmission rates, and in-hospital death rates were similar in both groups (P> or =.10 for all).
                Targeted one-on-one education is a practical, effective, and safe method for reducing excessive broad-spectrum antibiotic use. Educational outreach visits are commonly used to promote changes in prescribing in family practice. However, the effectiveness of outreach visits has not been evaluated across a range of settings.
                To estimate the effectiveness of educational outreach visits on United Kingdom (UK) general practice prescribing and to examine the extent to which practice characteristics influenced outcome.
                Randomised controlled trial.
                General practices in 12 health authorities in England.
                Educational outreach visits were made to practices that received two of four guidelines. Each practice provided data on treatment of patients for all four guidelines for both pre and post-intervention periods. The primary outcome is average effect across all four guidelines. Secondary analyses examined the predictive effect of practice and guideline characteristics.
                Seventy per cent of practices approached agreed to take part in the intervention. Overall, educational outreach was associated with a significant improvement in prescribing practice (odds ratio [OR] = 1.24 [95% CI = 1.07 to 1.42]), a 5.2% (95% CI = 1.7% to 8.7%) increase in the number of patients treated within the guideline recommendations. Smaller practices (two or fewer full-time equivalent practitioners) responded much more favourably to educational outreach than larger practices. Smaller practices improved their performance in line with the guidelines by 13.5% (95% CI = 6% to 20.9%) attributable to outreach, while larger practices improved by only 1.4% (95% CI = -2.4% to 5.3%, P-value for interaction <0.001).
                In large practices, educational outreach alone is unlikely to achieve worthwhile change. There is good evidence to support the use of educational outreach visits in small practices. Prostate-specific antigen (PSA) testing for prostate cancer is controversial. Demand for PSA testing is likely to rise in the UK, Australia and other western countries. Primary care needs to develop appropriate strategies to respond to this demand.
                Our aim was to compare the effectiveness of educational outreach visits (EOVs) and mailout strategies targeting PSA testing in Australian primary care.
                A randomized controlled trial was conducted in general practices in southern Adelaide. The main outcome measures at baseline, 6 months and 12 months post-intervention were PSA testing rates and GP knowledge in key areas relating to prostate cancer and PSA testing.
                The interventions were able to demonstrate a change in clinical practice. In the 6 months post-intervention, median PSA testing rate in the EOV group was significantly lower than in the postal group, which in turn was significantly lower than the control group (P < 0.001). Statistically significant differences were not, however, maintained in the 6-12 month post-intervention period. The EOV group, at 6 months follow-up, had a significantly greater proportion of "correct" responses than the control group to questions about prostate cancer treatment effectiveness (P = 0.004) and endorsement of PSA screening by professional bodies (P = 0.041).
                Primary care has a central role in PSA testing for prostate cancer. Clinical practice in this area is receptive to evidence-based interventions. We sought to determine whether tailored educational interventions call improve the quality of care, as measured by the provision of preventive care services recommended by the US Preventive Services Task Force, as well as lead to better patient satisfaction.
                We performed a randomized controlled study among 41 primary care physicians who cared for 1,810 randomly selected patients aged 65 to 75 years old at Kaiser Permanente Woodland Hills, a group-model health maintenance organization in southern California. All physicians received ongoing education. Physicians randomly assigned to the comprehensive intervention group also received peer-comparison feedback and academic detailing. Baseline and postintervention (2 to 2.5 years later) surveys examining the provision of preventive care and patient satisfaction were performed and medical records were reviewed.
                Based on the results of patient surveys, there were significant improvements over time in the provision of preventive care in both the education and the comprehensive intervention groups for influenza immunization (79% versus 89%, P <0.01, and 80% versus 91%, P <0.01), pneumococcal immunization (42% versus 73%, P < 0.01 and 34% versus 73%, P < 0.01), and tetanus immunization (64% versus 72%, P <0.01, and 59% versus 79%, P <0.01). Mammography (90% versus 80%, P <0.01) and clinical breast examination (85% versus 79%, P <0.05) scores worsened in the education only group but not in the comprehensive intervention group. However, there were few differences in rates of preventive services between the groups at the end of the study, and the improvements in preventive care were not confirmed by medical record review. Patient satisfaction scores improved significantly in the comprehensive intervention group (by 0.06 points on a 1 to 5 scale, P = 0.02) but not in the education only group (by 0.02 points, P = 0.42); however, the improvement was not significantly greater in the comprehensive intervention group (P = 0.20).
                A physician-targeted approach of education, peer-comparison feedback, and academic detailing has modest effects on patient satisfaction and possibly on the offering of selected preventive care services. The lack of agreement between patient reports and medical records review raises concerns about current methods of ascertaining compliance with guidelines for preventive care. To determine whether locally developed guidelines on asthma and diabetes disseminated through practice based education improve quality of care in non-training, inner city general practices.
                Randomised controlled trial with each practice receiving one set of guidelines but providing data on the management of both conditions.
                24 inner city, non-training general practices.
                East London.
                Recording of key variables in patient records (asthma: peak flow rate, review of inhaler technique, review of asthma symptoms, prophylaxis, occupation, and smoking habit; diabetes: blood glucose concentration, glycaemic control, funduscopy, feet examination, weight, and smoking habit); size of practice disease registers; prescribing in asthma; and use of structured consultation "prompts."
                In practices receiving diabetes guidelines, significant improvements in recording were seen for all seven diabetes variables. Both groups of practices showed improved recording of review of inhaler technique, smoking habit, and review of asthma symptoms. In practices receiving asthma guidelines, further improvement was seen only in recording of review of inhaler technique and quality of prescribing in asthma. Sizes of disease registers were unchanged. The use of structured prompts was associated with improved recording of four of seven variables on diabetes and all six variables on asthma.
                Local guidelines disseminated via practice based education improve the management of diabetes and possibly of asthma in inner city, non-training practices. The use of simple prompts may enhance this improvement. To investigate the feasibility of improving screening for carriers of haemoglobin disorders in general practice by using a nurse facilitator to work with primary care teams and the relevant haematology laboratories; to identify problems in communication between all those involved in delivering the service, and to implement solutions.
                Two year, practice based randomised controlled trial.
                North London area where 29% of residents and 43% of births are in ethnic groups at risk for haemoglobin disorders. Subjects: 26 of the 93 practices using the services of the area's haematology laboratory agreed to take part and were randomly divided into control and intervention practices.
                Change in number of requests for screening tests for haemoglobin disorders made by control and intervention practices in baseline and intervention years.
                The number of screening tests requested varied from 0-150 in the 93 practices in the baseline year. Study practices tended to have made a moderate number of requests (10-50) during this period. During the intervention year intervention practices made 292 more requests (99% increase) and control practices made 74 fewer requests (23% decrease; P=0.001 for difference in median change). Four practices, three of which were singlehanded, accounted for 75% of the increase. The number of requests from intervention practices, adjusted for baseline requests, was 3.2 times higher than control practices (P<0.0001).
                General practitioners and practice nurses are willing to undertake a new genetic screening service (or expand an existing one) if they are persuaded that it benefits the health of a significant proportion of their practice population. They need appropriate tools (for example, information materials for carriers and groups at risk), and the laboratory must be sensitive to their needs. Preconceptional carrier screening and counselling need to be coupled with antenatal screening. To evaluate the effectiveness of guidelines with or without one-to-one educational outreach visits by community pharmacists in improving general practice prescribing for non-steroidal anti-inflammatory drugs (NSAIDs).
                Cluster randomised trial of 20 general practices within Avon, England. Practices were randomised to three groups: control; mailed guidelines; mailed guidelines plus educational outreach visits. General practitioners (GPs) in the latter group received two one-to-one outreach visits from community pharmacists. Changes in prescribing were measured using outcomes derived from prescribing analysis and cost (PACT) data. The primary outcome measure was change in the volume of prescribing for ibuprofen, diclofenac and naproxen as a percentage of total NSAID prescribing. Six secondary outcomes included other measures of prescribing quality and volume. A cost-benefit analysis was performed.
                No significant differences were observed for the primary outcome measure: practices receiving outreach visits prescribed only 2.1% [95% confidence interval (CI): -0.8 to 5.0] more of the three recommended NSAIDs than the control practices did and 1.6% (95% CI: -1.4 to 4.7) more than practices that received guidelines only. Following adjustment for multiple comparisons, only one secondary outcome showed a statistically significant difference between the groups: the proportion of prescribing of the five most frequently used drugs was 2.2% (95% CI: 0.9 to 3.6) higher in the educational outreach group compared with the control group. A net increase in costs was shown with both interventions.
                Although good prescribing at baseline in the participating practices limited the capacity for improvement, this trial provides no evidence that guidelines with or without educational outreach visits from community pharmacists lead to substantial improvements in prescribing behaviour. Community pharmacists have increasing involvement in the self-management of minor illness as a result of the availability of a wider range of over-the-counter (OTC) medicines. We undertook a randomized controlled trial (RCT) to assess the effectiveness and efficiency of educational strategies to implement evidence-based guidelines for the sale of OTC anti-fungals in the community pharmacy setting.
                The aim of the study was to compare the effectiveness and efficiency of two guideline dissemination strategies in community pharmacy settings.
                A 2 x 2 factorial, cluster RCT was conducted with 60 community pharmacies in the Grampian region of Scotland. The interventions included dissemination of an evidence-based guideline for OTC management of vulvovaginal candidiasis (thrush) by postal dissemination (control), educational outreach visit or attendance at a continuing professional education session. Pre- and post-intervention simulated patient visits were made to participating pharmacies. The simulated patients completed assessment forms following each visit. The primary outcome was the appropriateness (based upon the guidelines) of sale or no sale of OTC anti-fungals.
                There were no significant differences in the proportion of appropriate outcomes following educational outreach [odds ratio (OR) = 1.1; 95% confidence interval (CI) 0.52 to 2.45] or continuing professional education (OR = 0.88; 95% CI 0.41 to 1.91).
                Neither strategy was effective in improving the appropriateness of OTC management of vulvovaginal candidiasis by community pharmacy staff. Further research is needed to identify barriers to guideline implementation and evidence-based practice in this setting. Family physicians (FPs) in Australia underutilize effective strategies to help patients stop smoking. We conducted a cluster randomization trial to evaluate a multifaceted, practice-based intervention involving audit, feedback, and academic detailing to improve FP smoking cessation advice.
                Sixty FPs in 39 practices participated. FPs' provision of smoking cessation advice was measured by patient recall, medical record audit, and FP self-report. Logistic regression analysis using generalized estimating equations was performed to assess improvements in practice, after adjustment for clustering by practice.
                Improvements between baseline and posttest in patient recall of FP advice about nicotine replacement patches and gum were significantly greater in the intervention than in the control group (P = 0.0056 and P = 0.0002, respectively). While there were substantial increases in patient recall of assessment of smoking status and FP use of "quit dates," behavioral advice, and written materials in the intervention group, these changes were not significantly greater than those in the control group. Notation of patients' smoking status and smoking cessation advice in medical records remained suboptimal in both groups.
                This multifaceted intervention was successful only in promoting FPs' use of nicotine replacement therapy. While the use of other effective cessation strategies appeared to increase, a larger trial is needed for further evaluation. This was a pilot study of the use of a clinical pharmacist as a therapeutics adviser (academic detailer) to modify antibiotic prescribing by general practitioners.
                Following a visit by the adviser (March-May), 112 general practitioners were recruited and randomised to control or active groups. A panel of experts prepared a best practice chart of recommended drugs for upper and lower respiratory tract infections, otitis media and urinary tract infections. The adviser made a 10-15 min visit to each prescriber in the active group (June-July), gave them the chart and discussed its recommendations briefly. Doctors in the control group were not visited nor given the chart. Prescription numbers for all prescribers were obtained from the Commonwealth Health Insurance Commission for the pre(March-May) and postdetailing (August-September) periods using a three month lag time for data collection. Data for total numbers of prescriptions and for selected individual antibiotics used in these two periods were analysed using nonparametric statistics.
                Prescribing patterns were similar for the control and active groups in the predetailing period. For both groups, there were significant (P<0.03) increases (45% for control and 40% for active) in total number of antibiotic prescriptions in the post compared with the predetailing period. This trend was anticipated on the basis of the winter seasonal increase in respiratory infections. In line with the chart recommendations for first-line treatment, doctors in the active group prescribed significantly more amoxycillin (P<0.02) and doxycycline (P<0.001) in the post vs predetailing periods. By contrast, doctors in the control group prescribed significantly more cefaclor (P<0.03) and roxithromycin (P<0.03), drugs that were not recommended. The total cost of antibiotics prescribed by doctors in the control group increased by 48% ($37 150) from the preto postdetailing periods. In the same time period, the costs for the active group increased by only 35% ($21 020).
                We conclude that the academic detailing process was successful in modifying prescribing patterns and that it also decreased prescription numbers and costs. Application of the scheme on a nationwide basis could not only improve prescriber choice of the most appropriate antibiotic but also result in a significant saving of health care dollars. To evaluate the effectiveness of an educational visit to help obstetricians and midwives select and use evidence from a Cochrane database containing 600 systematic reviews.
                Randomised single blind controlled trial with obstetric units allocated to an educational visit or control group.
                25 of the 26 district general obstetric units in two former NHS regions.
                The senior obstetrician and midwife from each intervention unit participated in educational visits. Clinical practices of all staff were assessed in 4508 pregnancies.
                Single informal educational visit by a respected obstetrician including discussion of evidence based obstetrics, guidance on implementation, and donation of Cochrane database and other materials.
                Rates of perineal suturing with polyglycolic acid, ventouse delivery, prophylactic antibiotics in caesarean section, and steroids in preterm delivery, before and 9 months after visits, and concordance of guidelines with review evidence for same marker practices before and after visits.
                Rates varied greatly, but the overall baseline mean of 43% (986/2312) increased to 54% (1189/2196) 9 months later. Rates of ventouse delivery increased significantly in intervention units but not in control units; there was no difference between the two types of units in uptake of other practices. Pooling rates from all 25 units, use of antibiotics in caesarean section and use of polyglycolic acid sutures increased significantly over the period, but use of steroids in preterm delivery was unchanged. Labour ward guidelines seldom agreed with evidence at baseline; this hardly improved after visits. Educational visits cost pound860 each (at 1995 prices).
                There was considerable uptake of evidence into practice in both control and intervention units between 1994 and 1995. Our educational visits added little to this, despite the informal setting, targeting of senior staff from two disciplines, and donation of educational materials. Further work is needed to define cost effective methods to enhance the uptake of evidence from systematic reviews and to clarify leadership and roles of senior obstetric staff in implementing the evidence. To assess the effect of a tailored professional intervention, including academic detailing, on antibiotic prescribing for acute cough.
                In a cluster-randomized controlled before and after study 85 Flemish GPs included adult patients with acute cough consulting in the periods February-April 2000 and 2001. The intervention consisted of a clinical practice guideline for acute cough, an educational outreach visit and a postal reminder to support its implementation in January 2001. Antibiotic prescribing rates and patients' symptom resolution were the main outcome measures.
                Thirty-six of 42 GPs received the intervention and 35 of 43 GPs served as controls; 1503 patients were eligible for analysis. Only in the intervention group were patients less likely to receive antibiotics after the intervention [OR(adj) (95% CI)=0.56 (0.36-0.87)]. Prescribed antibiotics were also more in line with the guideline in the intervention group [1.90 (0.96-3.75)] and less expensive from the perspective of the National Sickness and Invalidity Insurance Institute [MD(adj) (95% CI)= Euro -6.89 [-11.77-(-2.02)]]. No significant differences were found between the groups for the time to symptom resolution.
                An (inter)actively delivered tailored intervention implementing a guideline for acute cough is successful in optimizing antibiotic prescribing without affecting patients' symptom resolution. Further research efforts should be devoted to cost-effectiveness studies of such interventions.