Evaluating change in professional behaviour: issues in design and analysis

Implementing the findings of research to change the behaviour of health care professionals has become an increasingly prominent issue. However, designing valid studies to evaluate different methods of achieving changes requires considerable care and there are a number of pitfalls evident from published previous work. The various steps in the development of an implementation method and issues arising are explored in this text. Aspects include conceptualisation, essential background work, a structured development process, the relative merits of randomised and non-equivalent group designs, the unit of analysis, the role of multi-level models, block designs, economic analysis, and the content or message to be disseminated. An ongoing, large, randomised trial of educational outreach visits by trained pharmacists is used to illustrate some of the issues.behavioural change, implementation methods, economic evaluation, design of trials

NICEly does it: economic analysis within evidence-based clinical practice guidelines

There is increasing professional and policy interest in the role of clinical guidelines for promoting effective and efficient health care. The NHS Health Technology Assessment Programme identified an urgent need, when such guidelines are produced, to develop a framework and methods for incorporating the best evidence of effectiveness, taking into account information on cost-effectiveness. This paper describes the development of recent evidence-based guidelines, for use in primary care, which were the result of recent work by the North of England Guidelines Development Group. Their specific aim was to incorporate economic analysis into the guideline process and treatment recommendations. The introduction of economic data raised some methodological issues, specifically: in providing valid and generalisable cost estimates; in the grading of cost ‘evidence’; in finding a presentation helpful to clinicians. The approach used was to help clinicians aggregate the various attributes of treatment to make good treatment recommendations, rather than interpret cost-effectiveness ratios. In none of the guideline areas was there adequate information to estimate a cost per quality-adjusted-life-year. In the light of this research, future areas of work are identified and some recommendations are made for the forthcoming National Institute for Clinical Excellence.evidence-based medicine, economic evaluation, clinical guidelines, NICE

Gender differences in survival and the use of primary care prior to diagnosis of three cancers:an analysis of routinely collected UK general practice data

Objective To explore whether there are gender differences in the number of GP recorded cases, the probability of survival and consulting pattern prior to diagnosis amongst patients with three non-sex-specific cancers. Design Cross sectional study. Setting UK primary care. Subjects 12,189 patients aged 16 years or over diagnosed with colorectal cancer (CRC), 11,081 patients with lung cancer and 4,352 patients with malignant melanoma, with first record of cancer diagnosis during 1997–2006. Main outcome measures Cancer cases recorded in primary care; probability of survival following diagnosis; and number of GP contacts within the 24 months preceding diagnosis. Results From 1997–2006, overall rates of GP recorded CRC and lung cancer cases recorded were higher in men than in women, but rates of malignant melanoma were higher in women than in men. Gender differences in survival were small; 49% of men and 53% of women survived at least 5 years following CRC diagnosis; 9% of men and 12% of women with lung cancer, and 77% of men and 86% of women with malignant melanoma. The adjusted male to female relative hazard ratio of death in all patients was 1.20 (95%CI 1.13–1.30), 1.24 (95%CI 1.16–1.33) and 1.73 (95%CI 1.51–2.00) for CRC, lung cancer and malignant melanoma respectively. However, gender differences in the relative risk were much smaller amongst those who died during follow-up. For each cancer, there was little evidence of gender difference in the percentage who consulted and the number of GP contacts made within 24 months prior to diagnosis. Conclusions This study found that patterns of consulting prior to cancer diagnosis differed little between two genders, providing no support for the hypothesis that gender differences in survival are explained by gender differences in consultation for more serious illness, and suggests the need for a more critical view of gender and consultation

The effect of cardiac resynchronization on morbidity and mortality in heart failure

Background: Cardiac resynchronization reduces symptoms and improves left ventricular function in many patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. We evaluated its effects on morbidity and mortality. Methods: Patients with New York Heart Association class III or IV heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony who were receiving standard pharmacologic therapy were randomly assigned to receive medical therapy alone or with cardiac resynchronization. The primary end point was the time to death from any cause or an unplanned hospitalization for a major cardiovascular event. The principal secondary end point was death from any cause. Results: A total of 813 patients were enrolled and followed for a mean of 29.4 months. The primary end point was reached by 159 patients in the cardiac-resynchronization group, as compared with 224 patients in the medical-therapy group (39 percent vs. 55 percent; hazard ratio, 0.63; 95 percent confidence interval, 0.51 to 0.77; P<0.001). There were 82 deaths in the cardiac-resynchronization group, as compared with 120 in the medical-therapy group (20 percent vs. 30 percent; hazard ratio 0.64; 95 percent confidence interval, 0.48 to 0.85; P<0.002). As compared with medical therapy, cardiac resynchronization reduced the interventricular mechanical delay, the end-systolic volume index, and the area of the mitral regurgitant jet; increased the left ventricular ejection fraction; and improved symptoms and the quality of life (P<0.01 for all comparisons). Conclusions: In patients with heart failure and cardiac dyssynchrony, cardiac resynchronization improves symptoms and the quality of life and reduces complications and the risk of death. These benefits are in addition to those afforded by standard pharmacologic therapy. The implantation of a cardiac-resynchronization device should routinely be considered in such patients

A cross-sectional study of blood cultures and antibiotic use in patients admitted from the Emergency Department: missed opportunities for antimicrobial stewardship

BACKGROUND: Early review of antimicrobial prescribing decisions within 48 h is recommended to reduce the overall use of unnecessary antibiotics, and in particular the use of broad-spectrum antibiotics. When parenteral antibiotics are used, blood culture results provide valuable information to help decide whether to continue, alter or stop antibiotics at 48 h. The objective of this study was to investigate the frequency of parenteral antibiotic use, broad spectrum antibiotic use and use of blood cultures when parenteral antibiotics are initiated in patients admitted via the Emergency Department. METHODS: We used electronic health records from patients admitted from the Emergency Department at University Hospital Birmingham in 2014. RESULTS: Six percent (4562/72939) of patients attending the Emergency department and one-fifth (4357/19034) of those patients admitted to hospital were prescribed a parenteral antimicrobial. More than half of parenteral antibiotics used were either co-amoxiclav or piperacillin-tazobactam. Blood cultures were obtained in less than one-third of patients who were treated with a parenteral antibiotic. CONCLUSIONS: Parenteral antibiotics are frequently used in those admitted from the Emergency Department; they are usually broad spectrum and are usually initiated without first obtaining cultures. Blood cultures may have limited value to support prescribing review as part of antimicrobial stewardship initiatives

In the pool: dilution or drowning?

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Promoting cost-effective prescribing in the UK National Health Service

Pharmaceutical prescribing currently represents around 10% of total National Health Service expenditure, and is one of the most inflationary elements of spending (Parliamentary Office of Science and Technology 1993). Between 1980 and 1990, the overall cost of a prescription increased by 19%. Pharmaceuticals are one of the most commonly used and important interventions available to doctors in clinical practice, and their appropriate use can reduce mortality, morbidity and costs falling on other parts of the health care system. However, evidence from systematic reviews demonstrates that current prescribing may not always be effective or cost-effective (Effective Health Care, 1993). A number of policy initiatives have been introduced which attempt to contain prescribing costs. These include provision of Prescribing Analysis and Cost (PACT) data; the limited list; the indicative prescribing scheme and GP fundholding. However, these schemes have had limited impact and tend to focus on cost containment rather than cost-effectiveness in prescribing. Confusion remains concerning current knowledge and good practice in cost-effective prescribing. This confusion could be reduced with appropriate research making use, where possible, of the valid and reliable routinely collected activity data available on prescribing in the UK. In other countries, particularly Australia and Canada, policies have been introduced to limit the introduction of new drugs to those which demonstrate cost-effectiveness. Other countries, including European countries and the United States, are encouraging provision of economic evaluations of pharmaceuticals and have introduced varying initiatives to control prescribing costs and increase cost-effectiveness. UK policy initiatives should be informed by the experience of other countries. There is a considerable inertia in prescribing habits, and evidence of effectiveness and cost-effectiveness, when it exists, is not always used. A number of organisations are attempting to improve this situation. The NHS Centre for Reviews and Dissemination, at The University of York, produces and commissions systematic reviews of specific health-related questions, and disseminates these findings throughout the NHS. The Cochrane Collaboration, at the UK Cochrane Centre in Oxford and around the world, aims to produce systematic reviews of randomised controlled trials. The Cochrane Collaboration for Effective Professional Practice, an international collaboration with an editorial office at The University of York, conducts systematic reviews of initiatives aimed at changing professional behaviour. These and other organisations all attempt to improve the process of getting good evidence about health care interventions (including prescribing) into practice.prescribing, pharmaceuticals, PACT, cost-effectiveness