KoKo - prosjektet. Kollegabasert TerapiVeiledning (KTV) The Prescription Peer Academic Detailing (Rx-PAD) study

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1 UNIVERSITY OF OSLO The Prescription Peer Academic Detailing (Rx-PAD) study Kollegabasert TerapiVeiledning (KTV) KoKo - prosjektet Forskningsrådet 24.nov 2015 Jørund Straand, Avdeling for allmennmedisin, Helsam, UiO Jørund Straand, General Practice Research Unit; Department of General Practice

2 Jørund Straand, 2015 General Practice Research Unit, University of Oslo

3 Jørund Straand, 2015 General Practice Research Unit, University of Oslo

4 UNIVERSITY OF OSLO Jørund Straand, 2015 General Practice Research Unit, University of Oslo

5 UNIVERSITY OF OSLO Overordnede policy-formål med KTV-prosjektet 1. Å fremme rasjonell farmakoterapi i allmennpraksis ved å styrke allmennlegenes klinisk faglige kompetanse. 2. Å utvikle redskap og rutiner som skal gjøre det praktisk mulig å ta i bruk reseptstatistikk fra Reseptregisteret (2004) til kvalitetssikring av farmakoterapi i allmennpraksis. 3. Å teste ut og evaluere en modell med kollegabasert terapiveiledning for etterutdanning i farmakoterapi i allmennpraksis, dvs. å evaluere både prosess og effekt på legers forskrivning. 4. Å legge grunnlag for en mulig fast framtidig, landsdekkende struktur for kvalitetssikrende etterutdanning i farmakoterapi i allmennpraksis. Jørund Straand, 2015 General Practice Research Unit, University of Oslo

6 The quality circle for improving practice in a CME group setting Need for further improvements? Teaching and learning in CME group setting After one year: What is new practice? (new report) Group setting One day course Change in practice? Reflection on todays practice based on individual reports, group setting

7 UNIVERSITY OF OSLO The PADs (Peer Academic Detailers) Norwegian: kollegakonsulent experienced GPs (n= 26); each responsible for visiting ~3-4 CME groups (i.e. elderly-peers and antibiotic peers ) 2 two days training sessions in group paedagogics, the content of the intervention, methods etc Fee for service according to standards established by the Norwegian Medical Association. Plus CME-credit for being a Rx-PAD Jørund Straand, 2015 General Practice Research Unit, University of Oslo

8 Rx-PAD Study I Protocols: BMC Health Services Research 2006; 6: 72 & 75 Randomization of GP Baseline-data Intervention Feedback Analysis CME groups (n=80) Antibiotics/ RTI Control for Drugs/ elderly Drugs/ elderly Control for antibiotics/ RTI Retrospective data extraction from all GPs (both groups) and from the NorPD Two CME peer group sessions led by trained PADs. Reflection on own performance (individual report - baseline) 1 day CMEcourse Retrospective data extraction from all GPs (both groups) and from the NorPD CME peer group session: Reflection on own performance (individual report achieved effects) Evaluation Research (3 PhD theses) Autumn 05 Jan/March 06 Winter/spring 06 Jan/March >

9 We designed a software for simple extraction of prespecified data from the various EPR-systems Data sources for quality assessment Capured electronic medical record (EPR)-data were linked with corresponding data from the Norwegian Prescription Database (NorPD) Captured data were used for making individual feedback reports to the participating GPs throughout the project. The reports included individual performance data as compared to the total average

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11 Data flowchart Participant s EPR system Statistics Norway Patients data linked to project IDs (de-identified personal IDs) Project IDs linked to patients CPR number and doctors HPR numbers Project ID s linked to pseudonymous CPR and HPR numbers Project site University of Oslo Prescription data linked to project IDs Norwegian Prescription Database - NorPD (Pseudonymous)

12 UNIVERSITY OF OSLO KTV-anbefalinger: kvalitetsindikatorer Eksplisitte kriterier for farmakologisk potensielt uhensiktsmessig legemiddelbruk hos eldre. Viktig del av den pedagogiske intervensjonen. Jørund Straand, 2015 General Practice Research Unit, University of Oslo

13 Personal report to each GP: 1. baseline Based on NorPDdata Reflecting GP s prescription practice before the educational intervention as compared to average figures for all participants (~450)

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16 CME peer group session: GPs reflecting on own performance

17 2. nd report: 1 year later and after a one day course (evidence update course)

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20 UNIVERSITY OF OSLO KTV: 3 ph.d projects 1. Svein Gjelstad: Can antibiotic prescribing in respiratory tract infections be improved? A cluster-randomised educational intervention in Norwegian general practice. The prescription peer academic detaling (Rx-PAD) study (NFR). 2. Sture Rognstad: Prescription peer academic detailing to reduce inappropriate prescribing to older patients. A cluster randomised educational intervention in Norwegian general practice: The Prescription Peer Academic Detailing (Rx-PAD) study. (NFR) 3. Sigurd Høye: Delayed antibiotic prescriptions a feasible strategy to lower antibiotic use for respiratory tract infections in primary care? (AMFF) Jørund Straand, 2015 General Practice Research Unit, University of Oslo

21 UNIVERSITY OF OSLO The Rx-PAD study did alter GPs practice! Jørund Straand, 2013 Department of General Practice, Institute of Health and Society

22 How the number of potentially inappropriate single drug prescriptions (PIPs) went down in the intervention group as compared with control group Single drugs targeted Reduction (95%CI) after intervention Tricyclic antidepressants 17.1 (14.9 to 19.3)% Antihistamines 21.6 (12.4 to 23.9)% Antipsychotics 24.7 ( 21.7 to 27.7)% Long-acting benzodiazepines 5.7 ( 4.7 to 6.7)% Carisoprodol 2.0 ( 0.7 to 3.3)% (withdrawn from market; small figures) Theophylline, tablets Increase: 0.5 (1.3 to 0.3)% (small figures!)

23 How the number of potentially inappropriate drugdrug combinations and total numbers of (PIPs) went down in the intervention group as compared with control group Prescriptions with drug-drug combinations Reduction % (95%CI) Βetablocker + unselective calsium blocker 7.4 ( 3.4 to 11.4)% NSAID + warfarin 32.2 (27.9 to 36.5)% NSAID(Cox-2) + ACE (ARB) 5.1 ( 4.1 to 6.1)% NSAID + SSRI 16.3 (12.8 to 19.8)% NSAID + diuretic 15.2 (13.4 to 17.0)% 3+ psychopharmaceuticals Increase: 0.9 (0.4 to 1.4)% Total number of PIPs (single drugs included) 12.0 (11.5 to 12.6)% Jørund Straand, 2015 Department of General Practice, Institute of Health and Society

24 UNIVERSITY OF OSLO Conclusions elderly trial 1. The cluster-randomised multifaceted intervention study reported here included about 10% of all GPs in Norway. 2. The intervention, carried out by trained GPs in peer CME groups, targeted potentially inappropriate prescriptions for older patients across a wide spectrum of therapeutic areas. 3. Significant improvements were obtained for 12 out of 13 predefined explicit quality indicators for inappropriate prescriptions. 4. The Rx-PAD model may be used on a more regular basis during GPs specialist training and in their CME.

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26 UNIVERSITY OF OSLO Antibiotikastudien - resultater Travle leger forskriver hyppigere ut antibiotika enn ikke-travle leger. Storforskrivere velger oftere bredspektrede antibiotika. Intervensjonen medførte forholdsvis små reduksjoner i AB-forskrivningsrater, men derimot store endringer med å velge vanlig penicillin framfor bredspektrede og mer resistensdrivende antibiotika. (Vente-og-se opsjonen medførte mindre AB-bruk) Jørund Straand, 2015 General Practice Research Unit, University of Oslo

27 UNIVERSITY OF OSLO Will obtained changes persist? Remain stable? Decrease? Increase? We have follow-up data for another 2-3 years. Jørund Straand, 2015 Department of General Practice, Institute of Health and Society

28 UNIVERSITY OF OSLO Rx-PAD Study II ( ) Switching intervention theme between the CMEgroups participating in Rx-PAD I study Objective: to assess long term effects of Rx-PAD I intervention The one day course substituted by a group session including reflection and discussion regarding 4 cases from each participant Improved data extraction methods from EPR system Jørund Straand, 2015 General Practice Research Unit, University of Oslo

29 UNIVERSITY OF OSLO So what? Indirekte følger av KTV-prosjektet Senter for kvalitet i legekontor (SKIL): Legemiddelgjennomganger NorPD diagnosekoder, også på AB-resepter Permanent infrastruktur for klinisk forskning i allmennpraksis: Praksisbasert Forskningsnettverk. Hdir HO21-anbefalinger NFR Hdir=> pilot => ny søknad NFR H2016 Jørund Straand, 2015 General Practice Research Unit, University of Oslo

30 UNIVERSITY OF OSLO The Norwegian Primary care Research Network (NFR application Oct 2014) Assessment of grant application (NFR) Benefit to research infrastructure (6 excellent) This is a well designed proposal that will open up the opportunities currently lacking. high quality international collaborations Overall assessment of the referee/panel This is an excellent application and one that offers a stepchange on delivery of community research in Norway Overall assessment grade: 6 (excellent) Jørund Straand, 2015 Allmennmedisinsk Forskningsenhet og Avdeling for allmennmedisin, UiO

31 Praksisbasert forskningsnettverk er framtiden for klinisk forskning i primærhelsetjenesten Jørund Straand, 2015 General Practice Research Unit, University of Oslo