Effect of changes in antibiotic prescribing on patient outcomes in a community setting: A natural experiment in Australia

© 2002 by the Infectious Diseases Society of America.This study examined whether a significant change in antibiotic use caused by an Australian government directive targeted at amoxicillin with clavulanic acid (AC) was associated with changes in prescription share, health care costs, and patient outcomes. We used an integrated database of computerized general practice medical records, which included data regarding 34,242 patients and 318,234 recorded patient visits. There were 15,303 antibiotic prescriptions provided to 9921 patients during a 4-year period, with AC prescribed for 1453 (14.6%) of these patients. A total of 5125 patient outcomes were identified. There was a shift away from best-practice antibiotic prescribing, and a significant association was identified between the rate and cost of process-of-care and patient outcomes and the decrease in AC-prescription share. This policy initiative created unintended changes in prescribing behavior, increased costs to the government, and a trend toward poorer patient outcomes. Detailed analyses are required before instigating initiatives aimed at changing clinicians' prescribing behavior.Justin Beilby, John Marley, Don Walker, Nicole Chamberlain, and Michelle Burke for the FIESTA Study Grou

A methodological framework for model selection in interrupted time series studies.

Interrupted time series (ITS) is a powerful and increasingly popular design for evaluating public health and health service interventions. The design involves analyzing trends in the outcome of interest and estimating the change in trend following an intervention relative to the counterfactual (the expected ongoing trend if the intervention had not occurred). There are two key components to modeling this effect: first, defining the counterfactual; second, defining the type of effect that the intervention is expected to have on the outcome, known as the impact model. The counterfactual is defined by extrapolating the underlying trends observed before the intervention to the postintervention period. In doing this, authors must consider the preintervention period that will be included, any time-varying confounders, whether trends may vary within different subgroups of the population and whether trends are linear or nonlinear. Defining the impact model involves specifying the parameters that model the intervention, including for instance whether to allow for an abrupt level change or a gradual slope change, whether to allow for a lag before any effect on the outcome, whether to allow a transition period during which the intervention is being implemented, and whether a ceiling or floor effect might be expected. Inappropriate model specification can bias the results of an ITS analysis and using a model that is not closely tailored to the intervention or testing multiple models increases the risk of false positives being detected. It is important that authors use substantive knowledge to customize their ITS model a priori to the intervention and outcome under study. Where there is uncertainty in model specification, authors should consider using separate data sources to define the intervention, running limited sensitivity analyses or undertaking initial exploratory studies

Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study

Objective To assess the impact of a pay for performance incentive on quality of care and outcomes among UK patients with hypertension in primary care

Resident physician and hospital pharmacist familiarity with patient discharge medication costs

Objective Cost-related medication non-adherence is associated with increased health-care resource utilization and poor patient outcomes. Physicians-in-training generally receive little education regarding costs of prescribed therapy and may rely on hospital pharmacists for this information. However, little is documented regarding either of these health care providers’ familiarity with out-of pocket medication expenses borne by patients in the community. The purpose of this study was to evaluate and compare resident physician and hospital pharmacist familiarity with what patients pay for medications prescribed once discharged. Setting A major tertiary patient care and medical teaching centre in Canada. Method Internal medicine residents and hospital pharmacists within a specific health care organization were invited to participate in an online survey. Eight patient case scenarios and associated discharge therapeutic regimens were outlined and respondents asked to identify the costs patients would incur when having the prescription filled once discharged. Main Outcome Measure Total number and proportion of estimates above and below actual cost were calculated and compared between the groups using χ2 tests. Responses ±10% of the true cost were considered correct. Mean absolute values and standard deviation estimated costs, as well as cost increments above and below 10%, were calculated to assess the magnitude of the discrepancy between the respondent estimates and the actual total cost. Results Forty-four percent of physician residents and 26% of hospital pharmacists accessed the survey. Overall 39% and 47% of medication costs were under-estimated, 32% and 33% were overestimated, and 29% and 21% were correctly estimated by residents and pharmacists, respectively (P = NS). Incorrect estimates were evident across all therapeutic classes and medical indications presented in the survey. The greatest absolute cost discrepancy for both groups was under-estimation of linezolid ($800 and$400) and over-estimation of clopidogrel ($80) and bisoprolol therapy ($22) by residents and pharmacists, respectively. Conclusion Resident physicians and hospital pharmacists are unfamiliar with what patients must pay for drug therapy once discharged

Family physicians' perceptions of academic detailing: a quantitative and qualitative study

<p>Abstract</p> <p>Background</p> <p>The efficacy of academic detailing in changing physicians' knowledge and practice has been the subject of many primary research publications and systematic reviews. However, there is little written about the features of academic detailing that physicians find valuable or that affect their use of it. The goal of our project was to explore family physicians' (FPs) perceptions of academic detailing and the factors that affect their use of it.</p> <p>Methods</p> <p>We used 2 methods to collect data, a questionnaire and semi-structured telephone interviews. We mailed questionnaires to all FPs in the Dalhousie Office of Continuing Medical Education database and analyzed responses of non-users and users of academic detailing. After a preliminary analysis of questionnaire data, we conducted semi-structured interviews with 7 FPs who did not use academic detailing and 17 who did use it.</p> <p>Results</p> <p>Overall response rate to the questionnaire was 33% (289/869). Response rate of non-users of academic detailing was 15% (60/393), of users was 48% (229/476). The 3 factors that most encouraged use of academic detailing were the topics selected, the evidence-based approach adopted, and the handout material. The 3 factors that most discouraged the use of academic detailing were spending office time doing CME, scheduling time to see the academic detailer, and having CME provided by a non-physician. Users of academic detailing rated it as being more valuable than other forms of CME. Generally, interview data confirmed questionnaire data with the exception that interview informants did not view having CME provided by a non-physician as a barrier. Interview informants mentioned that the evidence-based approach adopted by academic detailing had led them to more critically evaluate information from other CME programs, pharmaceutical representatives, and journal articles, but not advice from specialists.</p> <p>Conclusion</p> <p>Users of academic detailing highly value its educational value and tend to view information from other sources more critically because of its evidence-based approach. Non-users are unlikely to adopt academic detailing despite its high educational value because they find using office time for CME too much of a barrier. To reach these physicians with academic detailing messages, we will have to find other CME formats.</p

Changes in Drug Utilization during a Gap in Insurance Coverage: An Examination of the Medicare Part D Coverage Gap

Jennifer Polinski and colleagues estimated the effect of the "coverage gap" during which US Medicare beneficiaries are fully responsible for drug costs and found that the gap was associated with a doubling in discontinuing essential medications