Challenges in recruiting primary care doctors for a randomized controlled trial to study change in prescription practices due to our educational intervention Dr. Monica Barne1, Dr. Sharad Agarkhedkar2, Dr. Avinash Bhondawe3, Priyanka Thakare1, Noopur Hedawoo1, Sapna Madas1, Dr. Aarti Nagarkar4, Dr. Sundeep Salvi1 1Chest Research Foundation, 2Dr. D. Y. Patil Medical College, 3Indian Medical Association, 4Savitribai Phule Pune University

Background India: A country of increasing Asthma Prevalence India: A country of misdiagnosis/under diagnosis of Asthma India: A country of inappropriate management of Asthma India needs effective knowledge up-gradation of correct Asthma practices amongst medical practitioners

Aim of our study To recruit doctors to participate in a study to find out if our one day training programme in Asthma, ‘CHAMPS’ has any impact in improving the prescription practices, knowledge and attitude of primary care practitioners in Pune city in India.

Methodology Randomized, controlled single blinded interventional study In collaboration with the Indian Medical Association and College of General Practitioners in Pune, India.

Inclusion Criteria Primary Health care doctors Age: 25 to 50 years Gender: Males and Females Qualified primary care practitioners. MBBS, MD (General Medicine), DNB (Med), MD (Pediatrics), DNB (Pediatrics), MBBS (DCh) In private practice for > 2 years Having independent private clinic Doctors not managing Asthma according to the GINA guidelines. Willing to participate in the study after informed consent. Data obtained from the records of the Indian Medical Association

Keep carbon copy of all respiratory prescriptions x 1 month Screening To identify a pool of doctors non adherent to GINA guidelines as gold standard for correct practices in Asthma Included in study and Randomized into Prescription scoring will done for adherence to GINA guidelines All doctors included in screening Keep carbon copy of all respiratory prescriptions x 1 month Scores 1 and 2 Study group Control group Scores 3 and 4 Exclude from study

Scoring system for analyzing the prescriptions Criteria Score Doctors prescribing appropriate GINA guideline based inhalation therapy 4 Doctors using Inhaled Corticosteroids and bronchodilators or Leukotriene antagonists as add on therapy. 3 Prescribing only bronchodilator inhalers or inappropriate combinations of inhalers or Leukotriene antagonists as monotherapy 2 Prescribing oral medications (Oral beta agonists, theophyllines, steroids, mucolytics syrups, anti-histamines, expectorants etc)/ Using frequent nebulizations/ Using injectable Aminophyllines. 1 Doctors who score 2 or 1 (IN > 50% of their Asthma prescriptions) will be invited to attend CHAMPS.

Intervention Study Group Control group Attend CHAMPS Do not Attend CHAMPS Both fill in a pre and a post workshop questionnaire on the day of CHAPMS Intervention Both keep a prescription record for 1 month after the training programme

Results:-Outcome of the enrollment process Screening calls to 907 doctors 118 (12%) agreed to participate and received prescription pads 52 (44%) gave us the recorded prescription pads 44 (84.6%) Doctors fulfilled the inclusion criteria 22-Control group 22-Study Group Out of the 22 in study group, only 13 came for the training 1 dropped out after the training leaving only 12 in the study group.

Reason for poor outcomes of the prescription records from enrolled doctors

Conclusion It is a real world challenge to enroll primary care doctors in a randomized controlled study involving them keeping prescription records and attending a training on Asthma. We need alternate, more simple methods to evaluate the impact of our training programmes.

Discussion Despite a stringent telephonic follow up and visits by the study team, it has been difficult to get doctors to participate in this research study. Despite we having arranged for the travel of the doctors and getting the programme CME points, the target audience who is actually in need of this practice up gradation showed a very poor attendance. The policy making bodies for practicing doctors needs to initiate and set up systems to ensure knowledge and practice up-gradation.