Improving Private Practitioners' Adherence to Clinical Practice Guidelines: A Quasi- Experimental Study in the Philippines Saniel MC, Acuin CS, Arciaga RS, Lansang MD, NaidasOD, Sevilleja JE, Bustos MV, Balis AC, Ross-Degnan D

Problem Statement  The effectiveness of different strategies for disseminating clinical practice guidelines to private practitioners has been well studied in developed countries but rarely in developing countries

Urinary Tract Infections Clinical Practice Guideline Task Force on UTI, Philippine Practice Guidelines Group in Infectious Diseases. Urinary Tract Infections: Clinical Practice Guideline. PPGG-ID Philippine Society for Microbiology and Infectious Diseases Volume 1 No. 1 Quezon City, Philippines. Task Force on UTI, Philippine Practice Guidelines Group in Infectious Diseases. Urinary Tract Infections: Clinical Practice Guideline. PPGG-ID Philippine Society for Microbiology and Infectious Diseases Volume 1 No. 1 Quezon City, Philippines.

Objective  To compare the effectiveness of problem based-lecture discussion (LD) versus interactive case-oriented session (ICS), each combined with feedback discussions (FD) of practice data, as strategies for improving diagnostic and antibiotic prescribing practices of private physicians for acute cystitis

Baseline Measurement of Prescribing Behavior Problem-Based Lecture Discussion Second Measurement of Prescribing Behavior Baseline Measurement of Prescribing Behavior Interactive Case- Oriented Session Second Measurement of Prescribing Behavior Study Design

Methods Description of Interventions A. Problem based lecture discussion  45-minute problem based lecture on guideline recommendations by an expert in the field followed by an open forum B. Interactive case-oriented session  Participants responded to questions about diagnosis and management of 5 Acute UTI cases using electronic keypads  Aggregate responses were displayed and discussed with an expert panel

Methods Description of Interventions C. Feedback session  Individual prescription data over a 6 month period were aggregated and presented to participating MDs as part of a group discussion of issues on adherence to the CPGs

Methods  Pre- and post- quasi experimental design  Outcomes assessed: percentage of prescriptions that adhered to CPG recommendations for acute cystitis in terms of  antibiotic choice, dosage, and duration  use of laboratory tests  Statistical analyses:  descriptive statistics and bivariate analysis  multivariate analysis using hierarchical cluster models for logistic outcomes (Glimmix, SAS v.9)

Non-PregnantPregnant Prescribe recommended antibiotic and dosage Duration – 3 daysDuration – 7 days No lab work-upOrder urinalysis, urine culture Recommended Prescribing Practices for Uncomplicated UTI (Acute Cystitis)

Results OR=95 (11,817) * OR=140 (16,1205) % adherence OR=4 (1,18) OR=57 (16,206) n=384n=378n=307n=316n=309n=516 Adherence to recommended antibiotic regimen at baseline and after the dissemination strategies (Acute Cystitis, Non-Pregnant) Group AGroup B * Numbers in parentheses are 95% CIs

Results OR=0.5 (0.3,1.0) * OR=2.2 (1.3,3.9) % adherence OR=0.7 (0.4,1.1) OR=0.7 (0.4,1.2) n=145n=129n=118n=130n=175n=162 Group AGroup B * Numbers in parentheses are 95% CIs Adherence to recommended antibiotic regimen at baseline and after the dissemination strategies (Acute Cystitis, Pregnant)

 Private practitioners in developing countries can be motivated to change prescribing behavior given evidence- based guidelines  Educational strategies that allow interactive discussion and feedback are more likely to change behavior than one-way communication strategies Key Lessons

 Combined multifaceted strategies are more effective than a single intervention in changing behavior  Other interventions that address specific obstacles to targeted behavior (ex. test ordering) may be necessary to complement CPGs Key Lessons

 Professional societies and other organizations in developing countries should incorporate effective multifaceted strategies for CPG dissemination, such as interactive educational sessions and performance feedback, in their CME programs  Health facilities and other institutions should likewise adopt these strategies in improving drug use Implications and Recommendations

 Feedback of physician’s performance necessitates measurements  Measurement: a challenge especially in private clinics where records are often inadequate  Develop innovative schemes for data collection that are acceptable to physicians  Evaluate surrogate quality indicators (e.g., admission rates for UTI) Implications and Recommendations

 Economic assessment of dissemination strategies  Impact on patient outcomes (cost- effectiveness)  Sustainability of strategies in eliciting behavior change  Effectiveness of alternative strategies to improve adherence to CPG recommendations on diagnostic tests Future Research