Return to PJ Online Home Page
The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR27

Educational outreach and guideline implementation in general practice: a randomised controlled trial

By M. C. Watson, D. J. Gunnell* and D. J. Sharp*

Introduction General medical practitioners (GPs) in the United Kingdom are modest prescribers compared with their European colleagues.1 However, there is scope to further improve prescribing behaviour.
The traditional method of providing prescribing information and advice to GPs in the UK is the dissemination of printed educational materials, a method shown to be relatively ineffective in producing behaviour change.2 Evidence-based guidelines can be effective in influencing health care but further evaluation of implementation strategies for guidelines in general practice is required.3 Educational outreach or academic-detailing visits from pharmaceutical industry representatives have been used for decades to influence prescribing behaviour.
Pharmacists are society's experts on drugs.4 Community pharmacists are members of the primary health care team, but they are an underutilised source of influence on GP prescribing.
The suitability and potential of community pharmacists as a source of influence on GP prescribing has not gone unrecognised.5 The effect of educational outreach visits from community pharmacists as an implementation strategy for prescribing guidelines has not previously been evaluated in the UK.

Method A randomised controlled trial was conducted to compare the effectiveness of educational outreach visits from community pharmacists with printed guideline materials on GPs' non-steroidal anti-inflammatory drug (NSAID) prescribing.
Twenty general practices from the former Avon health authority participated in the trial. The practices were randomised to three groups: control (n=7) - no intervention; mass media (n=6) - printed materials only; and educational outreach (n=7). GPs in the outreach group received two one-to-one educational outreach visits from community pharmacists during the first six months of the trial.
Prescribing analysis and cost (PACT) data were used to measure the effect of the interventions on the volume, cost and quality of NSAID prescribing. The purpose of the guidelines was to promote awareness of GPs regarding the issues associated with using NSAIDs.
The outcomes that were desired as a result of the guidelines and their implementation strategies were reductions in overall NSAID prescribing volume and costs, reductions in the volume of azapropazone prescribing, increased ibuprofen use as a proportion of total NSAID prescribing, and increases in the quality measures of NSAID prescribing.

Focal points

  • The use of printed guideline materials did not achieve behavioural change among prescribers
  • Educational outreach visits from community pharmacists were well received by general medical practitioners
  • Changes in NSAID prescribing were achieved following educational outreach visits from community pharmacists
  • Educational outreach visits from community pharmacists may be effective as an implementation strategy for prescribing guidelines in general practice but their costs may outweigh their benefits

Results The visits were well received by the GPs. The results were generated using analysis of covariance (ANCOVA), which adjusted for baseline. The results are presented as the group difference (with the 95 per cent confidence interval).
No significant effect was shown with the mass media strategy. A statistically significant increase of 2.2 per cent (0.9 to 3.6 per cent) for the top five NSAIDs as a percentage of total NSAID prescribing was shown for the educational outreach group. Reductions in the total volume (-72 [-141 to -3[ DDDs [defined daily dose[ per 1,000 STARPUs [specific therapeutic group age-sex related prescribing units]) and cost (-£19.74 [-£37.64 to -£1.84] per 1,000 STARPUs) of NSAID prescribing and the volume of azapropazone prescribing (-3.8 ]-7.4 to -0.2] DDDs per 1000 STARPUs) compared with control, were also demonstrated.
Each outreach visit cost £66.31 (including training and material costs).

Discussion Guidelines are used increasingly in health care but there has been little evaluation of strategies for their implementation. In this trial, the traditional method of disseminating printed materials to influence GP prescribing was shown to be ineffective in achieving substantial behaviour change. Educational outreach visits from community pharmacists produced changes in the desired direction for the majority of outcomes evaluated.
Despite failing to achieve conventional levels of statistical significance, these results suggest that educational outreach visits may be an effective, if expensive, strategy for achieving change in prescribing behaviour.

Department of general practice and primary care, University of Aberdeen; *department of social medicine, University of Bristol

References

1. Compendium of health statistics. London: Office of Health Economics; 1997
2. Freemantle N, Harvey EL, Wolf F, Grimshaw JM, Grilli R, Bero LA. Printed educational materials: effects on professional practice and health care outcomes (Cochrane Review). In: The Cochrane Library, Issue 1, 2000. Oxford: Update Software; 2000.
3. Grimshaw J, Freemantle N, Wallace S, Russell I, Hurwitz B et al. Developing and implementing clinical practice guidelines. Quality in Health Care 1995;4:55-64.
4. Barber N, Smith F, Anderson S. Improving quality of care: the role of the pharmacist. Quality in Health Care 1994;3:153-8.
5. NHS Executive. Primary care: the future. London: Department of Health; 1996.