Rational Prescribing in Primary care (RaPP): process evaluation of an intervention to improve prescribing of antihypertensive and cholesterol-lowering drugs

BACKGROUND: A randomised trial of a multifaceted intervention for improving adherence to clinical practice guidelines for the pharmacological management of hypertension and hypercholesterolemia increased prescribing of thiazides, butdetected no impact onthe use of cardiovascular risk assessment toolsor achievement of treatment targets. We carried out a predominantly quantitative process evaluation to help explain and interpret the trial-findings. METHODS: Several data-sources were used including: questionnaires completed by pharmacists immediately after educational outreach visits, semi-structured interviews with physicians subjected to the intervention, and data extracted from their electronic medical records. Multivariate regression analyses were conducted to explore the association between possible explanatory variables and the observed variation across practices for the three main outcomes. RESULTS: The attendance rate during the educational sessions in each practice was high; few problems were reported, and the physicians were perceived as being largely supportive of the recommendations we promoted, except for some scepticism regarding the use of thiazides as first-line antihypertensive medication. Multivariate regression models could explain only a small part of the observed variation across practices and across trial-outcomes, and key factors that might explain the observed variation in adherence to the recommendations across practices were not identified. CONCLUSION: This study did not provide compelling explanations for the trial results. Possible reasons for this include a lack of statistical power and failure to include potential explanatory variables in our analyses, particularly organisational factors. More use of qualitative research methods in the course of the trial could have improved our understanding

The Effects of Mandatory Prescribing of Thiazides for Newly Treated, Uncomplicated Hypertension: Interrupted Time-Series Analysis

Atle Fretheim and colleagues found that the prescribing of thiazides in Norway for uncomplicated hypertension more than doubled after a rule requiring their use as first-choice therapy was put into effect

A Televised, Web-Based Randomised Trial of an Herbal Remedy (Valerian) for Insomnia

BACKGROUND: This trial was conducted as part of a project that aims to enhance public understanding and use of research in decisions about healthcare by enabling viewers to participate in research and to follow the process, through television reports and on the web. Valerian is an herbal over-the-counter drug that is widely used for insomnia. Systematic reviews have found inconsistent and inconclusive results about its effects. METHODS: Participants were recruited through a weekly nationally televised health program in Norway. Enrolment and data collection were over the Internet. 405 participants who were 18 to 75 years old and had insomnia completed a two week diary-keeping run-in period without treatment and were randomised and mailed valerian or placebo tablets for two weeks. All participants and investigators were blind to treatment until after the analysis was completed. FINDINGS: For the primary outcome of a minimally important improvement in self-reported sleep quality (> or = 0.5 units on a 7 point scale), the difference between the valerian group (29%) and the placebo group (21%) was not statistically significant (difference 7.5%; 95% CI-0.9 to 15.9; p = 0.08). On the global self-assessment question at the end of the treatment period 5.5% (95% CI 0.2 to 10.8) more participants in the valerian group perceived their sleep as better or much better (p = 0.04). There were similar trends favouring the valerian group for night awakenings (difference = 6.0%, 95% CI-0.5 to 12.5) and sleep duration (difference = 7.5%, 95% CI-1.0 to 16.1). There were no serious adverse events and no important or statistically significant differences in minor adverse events. INTERPRETATION: Based on this and previous studies, valerian appears to be safe, but with modest beneficial effects at most on insomnia compared to placebo. The combined use of television and the Internet in randomised trials offers opportunities to answer questions about the effects of health care interventions and to improve public understanding and use of randomised trials. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN72748991

Effekt av psykologiske tiltak i primærhelsetjenesten for barn og ungdom med alvorlig somatisk sykdom

Barn med alvorlig somatisk sykdom har bedre prognose i dag enn for noen tiår siden, og flere barn lever med kronisk sykdom nå enn tidligere. Studier viser at barn med alvorlig somatisk sykdom har to til tre ganger større risiko for å utvikle psykiske, sosiale og familiære problemer enn friske barn. Derfor er det viktig å identifisere tiltak som kan bidra til bedre psykisk helse hos alvorlig somatisk syke barn. Formålet med denne oversikten over systematiske oversikter er å presentere funn fra systematiske oversikter av høy kvalitet som oppsummerer resultater om effekt av psykologiske tiltak gitt i primærhelsetjenesten til barn med alvorlig somatisk sykdom. Vi inkluderte ti systematiske oversikter som presenterte resultater fra 21 primærstudier som var aktuelle for vår problemstilling. Studiene omhandlet først og fremst psykologiske tiltak til barn med astma og diabetes. Dokumentasjonen viser at: Vi kan ikke si noe sikkert om i hvilken grad psykologiske lavterskeltilbud påvirker psykisk helse, som angst, depresjon, livskvalitet, mestring og psykososial funksjon hos alvorlig somatisk syke barn. En meta-analyse med fire studier viste at psykologiske tiltak som kognitiv atferdsterapi, støtte og rådgivning av psykolog og familiesystemterapi muligens kan bidra til bedre psykisk helse hos barn med type 1 diabetes. Resultatene fra studiene vi har inkludert viste gjennomgående ingen statistisk signifikant forskjell for de ulike tiltakene. At det ikke er dokumentert en forskjell, betyr ikke at det er dokumentert at det ikke er noen forskjell. Kvaliteten på dokumentasjonen er så lav at vi ikke kan trekke sikre konklusjoner. De fleste inkluderte studiene hadde få deltakere og stor variasjon når det gjelder populasjon, tiltak og utfallsmål. Det er behov for mer forskning på feltet for å kunne trekke sikrere konklusjoner om effekt av psykologiske lavterskeltilbud til barn med alvorlig somatisk sykdom

Flow of Practices through Trial

<p>^aFor two of these practices no outreach visit was conducted (one withdrew after randomization and one had technical problems) but data collection was possible.</p