Evaluating the impact of educational interventions on use of antithrombotics in Australia.

PURPOSE: The National Prescribing Service (NPS) aims to improve prescribing and use of medicines consistent with evidence-based best practice. In particular, specific educational programmes were commenced in 2003 to improve general practitioner (GP) prescribing of antithrombotics. This report assesses the impact of these multiple educational interventions in terms of changes in prescribing rates. METHODS: Monthly prescribing data (July 1996-December 2005) were obtained from a national claims database, and yearly data (2001-2006) from a GP-patient encounter database. The target group was all GPs in Australia and interventions were active (voluntary) and passive (mail-outs). Responses to the interventions were measured by changes in the mean number of antithrombotic prescriptions (for ticlopidine, clopidogrel, warfarin and dipyridamole) per 1000 consultations for each GP each month. These data were analysed using seasonally adjusted piecewise linear dynamic regression. The data from the GP-patient encounter database were reported as mean prescribing rates per 100 GP encounters. RESULTS: NPS interventions either had an effect in the expected direction or had no discernable impact. Prescribing appeared to have decreased for dipyridamole, clopidogrel and ticlopidine, although the decline was only statistically significant for dipyridamole. Prescribing of warfarin continued to rise steadily despite NPS efforts. CONCLUSIONS: The NPS antithrombotics programme appears to have had modest success, but such evaluations raise questions about whether a focus on outcomes at a national level is appropriate, given likely concealment of effects at local levels. Lessons learned should be applied in the evaluation of other programmes aimed at influencing prescribing.

Evaluation of a national programme to reduce inappropriate use of antibiotics for upper respiratory tract infections: effects on consumer awareness, beliefs, attitudes and behaviour in Australia.

The over-use of antibiotics, in particular, inappropriate use to treat upper respiratory tract infections (URTIs), is a global public health concern. In an attempt to reduce inappropriate use of antibiotics for URTIs, and, in particular, to modify patient misconceptions about the effectiveness of antibiotics for URTIs, Australia's National Prescribing Service Ltd (NPS) has undertaken a comprehensive, multistrategic programme for health professionals and the community. Targeted strategies for the community, via the NPS common colds community campaign, commenced in 2000 and have been repeated annually during the winter months. Community strategies were closely integrated, using the same tagline, key messages and visual images, and were delivered in numerous settings including general practice, community pharmacy, child-care centres and community groups. Strategies included written information via newsletters and brochures, mass media activity using billboards, television, radio and magazines and small grants to promote local community education. The evaluation used multiple methods and data sources to measure process, impact and outcomes. Consistent with intervention messages, the integrated nationwide prescriber and consumer programme is associated with modest but consistent positive changes in consumer awareness, beliefs, attitudes and behaviour to the appropriate use of antibiotics for URTIs. These positive changes among the community are corroborated by a national decline in total antibiotic prescriptions dispensed in the community (from 23.08 million prescriptions in 1998-99 to 21.44 million in 2001-02) and, specifically, by a decline among the nine antibiotics commonly used for URTI such that by 2003 nationally 216,000 fewer prescriptions for URTI are written each year by general practitioners.

Measurement of changes in antihypertensive drug utilisation following primary care educational interventions.

PURPOSE: To measure changes in drug utilisation following a national general practice education program aimed at improving prescribing for hypertension. METHODS: A series of nationally implemented, multifaceted educational interventions using social marketing principles focusing on prescribing for hypertension, was commenced in October 1999, and repeated in September 2001 and August 2003. The target group was all primary care prescribers in Australia and interventions were both active (voluntary) and passive. Newsletter and prescribing feedback was mailed in October 1999, September 2001 (newsletter only) and August 2003. Approximately a third of general practitioners (GPs) in Australia undertook at least one active educational activity (clinical audit, educational visit or case study) during the period October 1999-April 2004. National dispensing data from 1996 to 2004 were analysed using time series methodology with a decay term for intervention effect, to assess trends in prescribing of various classes of antihypertensives. In particular, the program aimed to increase the prescribing of thiazide diuretics and beta blockers. RESULTS: Consistent with key intervention messages, the program achieved an increase in low-dose thiazide and beta blocker prescribing. The rate of prescribing of low-dose thiazides doubled from 1.1 per 1000 consultations in October 1999 to 2.4 per 1000 in October 2003. Beta-blocker utilisation showed a more modest but significant increase over the time of the study, with the change in observed versus expected rate of prescribing increasing by 8% by April 2004. Therapeutic options for treating hypertension changed markedly in the time of the study with the advent of ACE inhibitor/Angiotensin II receptor antagonists and thiazide combination products. It is important, therefore, to interpret the results in light of these changes. CONCLUSION: A national education program aimed at GPs was successful in improving prescribing for hypertension. Lessons learned will be applied in evaluation of future NPS programs and are also applicable to analysis of other interventions aimed at influencing prescribing behaviour.

Measuring change in prescription drug utilization in Australia.

PURPOSE: The National Prescribing Service Ltd (NPS) aims to improve prescribing and use of medicines consistent with evidence-based best practice. This report compares two statistical methods used to determine whether multiple educational interventions influenced antibiotic prescription in Australia. METHODS: Monthly data (July 1996 to June 2003) were obtained from a national claims database. The outcome measures were the median number of antibiotic prescriptions per 1000 consultations for each general practitioner (GP) each month, and the mean proportion (across GPs) of each subgroup of antibiotics (e.g. roxithromycin) out of nine antibiotics having primary use for upper respiratory tract infection. Two approaches were used to investigate shifts in prescribing: augmented regression, which included seasonality, autocorrelation and one intervention; and seasonally adjusted piecewise linear dynamic regression, which removed seasonality prior to modelling, included several interventions, GP participation and autocorrelated errors. Both methods are variations of piecewise linear regression modelling. RESULTS: Both approaches described a similar decrease in rates, with a non-significant change after the first intervention. The inclusion of more interventions and GP participation made no difference. Using roxithromycin as an example of the analyses of proportions, both approaches implied that after the first intervention the proportion decreased significantly. The statistical significance of this intervention disappears when other interventions are included. CONCLUSIONS: The two analyses provide results which agree regarding the possible impact of the NPS interventions, but raise questions about what is the best way to model drug utilization, particularly regarding whether to include all intervention terms when they belong to an extended roll-out of related interventions.

Evaluation of a national quality use of medicines service in Australia: an evolving model.

RATIONALE: To describe the first phase of a global evaluation framework for the National Prescribing Service (NPS), with a focus on services for health professionals, and in particular highlight the lessons learnt from evaluation around the establishment and implementation of this national program. METHODS: The agreed evaluation framework used mixed methods focused around a series of evaluation questions, aimed at measuring the overall effect of this new organization as well as the individual programs within it. The evaluation questions were determined a priori and were based on the objectives established by the organization in its first year of operation. A detailed analyses has been completed of: the process, scope and reach of program delivery using both quantitative and qualitative measures; changes in attitudes and knowledge measured through key informant interviews and surveys of professional groups and consumers; and changes in prescribing behaviour and savings to the Pharmaceutical Benefits Scheme (PBS) through analysis of prescription data. The evaluation period for this report was mid-1998 to mid-2004. RESULTS: The NPS has successfully implemented a complex, multi-faceted program across Australia. From 1998 to 2004, in addition to print material provided to all general practitioners (GPs) and pharmacists, 90% of all GPs have been actively involved in one or more educational activity; 116 of 120 divisions of general practice have coordinated local NPS programs; and 9% of pharmacists have actively participated in at least one educational activity. Sixty per cent of GPs and pharmacists rated the printed educational materials as good or very good. In the last three years, the NPS activities have generated savings in the range of $121-163 million to the PBS, owing to changes in prescribing practices. CONCLUSION: The national evaluation framework has informed program delivery and ongoing design and development. Continued refinement of existing evaluation methods and further exploration of new techniques will remain a priority for the organization.

Antibiotic prescribing for upper respiratory-tract infections in primary care.

The use and overuse of antibiotics in humans is a major contributor to the selection of antibiotic resistance organisms. Recent evidence has shown that primary care prescribing selects for resistances of clinical importance. The National Prescribing Service runs both educational and audit activities. The latter provide some insight into general practice attitudes toward antibiotic prescribing.