Information and interaction : influencing drug prescribing in Swedish primary care

University dissertation from Stockholm : Karolinska Institutet, Department of Public Health Sciences

Abstract: Aim The studies concern drug information and continuing education on drug treatment, focusing on doctors' prescribing in primary care in Sweden. The long-term aim has been to develop educational models accepted by the doctors, and to develop and apply means of evaluating the education. Methods Data have been collected from the study populations mainly through questionnaires and dispensed prescriptions, i.e., quantitative data. In addition, qualitative interview data were included. The studies were; (i) a population based cross-sectional descriptive study (202 doctors, in one county) including development of an educational outreach model, with drug information visits to peer groups (150 doctors, part of the 202, in one county); (ii) a study with a phenomenographic approach focusing on General Practitioners' (GPs) ways of experiencing asthma management (20 GPs, in seven counties); and (iii) a randomised parallel trial, of a new educational model (36 GP groups, totally 204 GPs, in seven counties). The content of national guidelines was used as a basis for this education. The model included externally facilitated (GP + pharmacist) discussions in peer groups on the participants' individual feedback, related to the guideline content. The two study arms, education on uncomplicated urinary tract infection (UTI) respectively asthma, were each other's controls. Data were collected before and after the intervention. Using this rigorous evaluation model, potential effects could be attributed to the education itself and not to the attention effect. The education was evaluated regarding the participants' acceptance, knowledge and attitudes, and prescribing, the latter measured through developed prescribing indicators. Results Lack of verbal non-commercial drug information sources was reported (61%) in the first study. GPs reported a variation in adoption patterns of drugs depending on category. One educational model was developed, which has been sustainable for more than 10 years. The results of a prescribing survey (2469 norfloxacin prescriptions) within this educational model indicated that a combination of oral and written information influences prescribing more (in line with recommendations) compared to written information only. About 10% of the prescribers had prescribed >50% of the prescriptions. In the qualitative interview study, four different ways of GPs' ways of experiencing asthma management were found. The new educational model was effective in improving drug treatment for UTI, measured as knowledge (p=0.028) and prescribing (p<0.001) in accordance with guideline recommendations. For asthma, no significant improvements were seen although positive trends were recorded in the prescribing of inhaled steroids. A total of 8,114 prescriptions were analysed for UTI and 15,694 for asthma. The use of feedback was considered important by 86% of the participants, and 87% would like to receive education concerning other conditions, using the same model. Conclusions It was found that GPs appreciated the types of non-commercial education on drug treatment developed in this work, i.e., education in small peer groups, facilitated by an external team of one GP and one pharmacist. The results indicate that individualised educational strategies depending on the disease condition seem necessary. In this work, effects were seen on knowledge and behaviour for clear messages concerning UTI, a short-term treatment, but not for asthma, a chronic treatment.

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