A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments.

OBJECTIVE: The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). DESIGN: and INTERVENTIONS: Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. SETTING AND PARTICIPANTS: Data were collected on 20 consecutive adult community-acquired pneumonia emergency department presentations by each hospital for each of three audits. MAIN OUTCOME MEASURES: Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. RESULTS: Thirty-seven hospitals, including public, private, rural and metropolitan institutions, participated. Twenty-six hospitals completed the full study (range: 462-518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%, 95% confidence interval [CI] 4-8) at baseline to 125/503 (25%, 95% CI 21-29; P < 0.0001) and 102/462 (22%, 95% CI 18-26; P < 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%, 95% CI 16-23) to 132/462 (30%, 95% CI 26-34; P < 0.0001) and 132/462 (29%, 95% CI 24-33; P < 0.001), respectively. CONCLUSIONS: Improved uptake of guideline recommendations for community-acquired pneumonia management in emergency departments was documented following a multi-faceted education intervention.

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.

Lessons from early large-scale adoption of celecoxib and rofecoxib by Australian general practitioners.

OBJECTIVE: To assess trends in the first two years of prescribing of COX-2-selective non-steroidal anti-inflammatory drugs (C2SNs) by Australian general practitioners. DESIGN: Retrospective analysis of deidentified electronic patient records from GPs enrolled in the General Practice Research Network (GPRN). SETTING AND PARTICIPANTS: Overall prescription rates for C2SNs and NSAIDs were assessed for all GPRN participants (437 GPs) between 1 September 1999 and 30 September 2002. Also, three cohorts of patients, with at least 12 months of prescription data, who received their first prescription for celecoxib between August and October 2000 (Cohort 1, 2366 patients), celecoxib between February and April 2001 (Cohort 2, 640 patients), and rofecoxib between February and April 2001 (Cohort 3, 608 patients) were selected for further analysis. MAIN OUTCOME MEASURES: Age and sex of patients; reason for prescription; previously prescribed pain medications and concomitant use of medications that could predispose to an adverse renal or bleeding event. RESULTS: Prescriptions for C2SNs increased dramatically after they were listed on the Pharmaceutical Benefits Scheme (PBS). C2SN prescriptions for patients aged less than 65 years accounted for 52.6%, 59.5% and 50.7% of those in Cohorts 1, 2 and 3, respectively; large numbers of patients in the study cohort had reasons recorded for prescription that did not comply with PBS restrictions, and between 36.7% and 61.3% of patients in the three cohorts had not received a prescription for any pain medication in the year before being prescribed a C2SN. Between 4.7% and 7.9% were coprescribed drugs that could cause renal complications. CONCLUSIONS: Rapid, early adoption of C2SNs by Australian GPs has resulted in prescribing and drug use patterns that were not in accord with quality use of medicine (QUM) principles.

The General Practice Research Network: the capabilities of an electronic patient management system for longitudinal patient data.

PURPOSE: To evaluate the potential of a general practice research database derived directly from de-identified electronic medical records to provide national prescribing data in Australia. To observe the utilisation of a computer-based patient management system over time. To evaluate the impact of the research network participation on data quality in participants' electronic records. METHOD: A random sample of 297 general practitioners (GPs) from 128 practices provided longitudinal patient data from electronic medical records (using Medical Director software) retrospectively from 1 January 1999 to April 2002. The General Practice Research Network (GPRN) database contains approximately 600,000 patients, representing over 4 million prescriptions from 4 million encounters. The quality and representativeness of data for prescribing, morbidity and software usage were evaluated by comparison with National data. RESULTS: Older GPs (> 55) were under-represented, perhaps due to lower computer usage rates, but patient visits were similar to the national distribution. Over time, there were increases in: the quality of prescribing data (with reason for visit/prescription being compulsorily recorded); recording of non-prescribing visits; and the use of other features of the electronic patient management software. CONCLUSIONS: Data derived from electronic general practice records is of sufficient quality to be used to provide national prescribing estimates and has potential value for pharmacoepidemiology and population health monitoring. Such longitudinal data has previously been unavailable in Australia. Monitoring of software usage demonstrates the evolution of the Australian GP user and will be increasingly useful in assessing and improving the quality of electronic medical records.