The effect of computer reminders on GPs’ prescribing behaviour: A cluster-randomised trial

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Abstract

Objective

It is difficult to control drug-prescribing behaviour in general practice, despite the development and distribution of guidelines. The purpose of this study was to assess the effect on drug-prescribing behaviour of implementing prescribing guidelines by means of a reactive computer reminder system (CRS).

Design

Cluster-randomised controlled trial with an incomplete block design in the south of the Netherlands: 25 GPs (7 GP practices) received reminders about antibiotics and asthma/COPD prescriptions, 28 GPs (7 GP practices) received reminders about cholesterol prescriptions. Prescription guidelines were integrated into the computerised GP information system.

Measurements

Both performance indicators and prescription volumes were calculated as the main outcome measures. Next to individual volume measure, sum scores were constructed on the volume measures per drug group (antibiotics, asthma/COPD and cholesterol).

Results

Variation between GPs turned out to be larger and more skewed than expected. No differences between groups were found for indicators and volumes related to recommendations advocating certain drugs. Although there was a tendency towards clinically relevant results for prescription volumes that were supposed to drop, the difference in sum score between the groups was not significant. For antibiotic prescriptions that were supposed to drop, the sum score for the intervention group was 28.2 (95% CI: 20.8–44.5) prescriptions per 1000 patients per GP, while this was 39.7 (95% CI: 29.7–64.1) for the control group (p 0.2). For prescriptions asthma/COPD that were supposed to drop, the sum score for the intervention group was 1.1 (95% CI: 0.6–2.6) prescriptions per 1000 patients per GP, while this was 2.2 (95% CI: 1.4–4.3) for the control group (p 0.1). On three specific recommendations (on quinolones for cystitis, corticosteroids for CPOD, and antibiotics for acute sore throat) significant differences were found.

Conclusions

This study turned out to be underpowered due to high inter doctor variation in prescribing behaviour. Nevertheless, computerised reminders sometimes have a favourable effect on restricting certain drugs that are not or no longer indicated in general practice.

Section snippets

Background

Healthcare expenditure in the Netherlands increases each year, as it does in other European countries. Drug prescribing is an important contributor to this increase in costs [1], [2], [3]. Medication is not always prescribed effectively: drugs may be prescribed unnecessarily and lower cost alternatives are not always taken into consideration. Inappropriate drug prescription can be attributed to demographic factors (growth and ageing of the population), the trend towards new but usually more

Design and participants

A cluster-randomised controlled trial (RCT) with an incomplete block design was conducted in the very South of the Netherlands. Randomisation took place on practice level into two blocks. Clusters thus consisted of GPs per practice. Therefore, in this block design the participants were only intervened on part of the underlying guidelines (incomplete block). With the block design, we tried to control for the Hawthorne effect by comparing the complete intervention in both arms on either reminders

Results

Fifty-three GPs out of 77 GPs agreed to participate. Twenty-five GPs received reminders about antibiotics and asthma/COPD prescriptions, 28 GPs received reminders about cholesterol prescriptions (Fig. 3). Five GPs dropped out during the intervention period because of technical problems, leaving datasets from 48 GPs available for analysis. The reasons for dropping out were: technical problems because of general IT problems in the GP practice (2 GPs), many updates to the GP information system (2

Discussion

No favourable effects were found for computerised reminders with the message to prescribe certain drugs. On the other hand, computerised reminders with the message not to prescribe certain drugs sometimes positively influence the prescribing behaviour of GPs.

Our reminders were applicable in daily practice: the CRS did not interfere with the GP information system as long as the GP did not deviate from the guideline. So, the CRS did not interrupt the GP. Furthermore, the CRS interfered at the

Conclusion

The implementation of a reactive CRS is sometimes effective in improving GPs’ rational drug-prescribing behaviour, concerning reminders not to prescribe certain drugs. There was no effect of reminders on first choice prescriptions for certain diagnoses.

Acknowledgements

We thank the Dutch insurance companies VGZ and CZ for providing financial support and data for this study. We thank Mr. F. Kessels (M.Sc.) for performing the power calculation for the study. We own acknowledgements to Dr. F. Haaijer-Ruskamp for her examination on the methods section and on the formulation of the prescribing indicators. The views expressed in this paper are the authors’ responsibility as well as any possible remaining errors.

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