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Saniel MC, Acuin CS, Arciaga RS, Lansang MD, NaidasOD,

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.

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Saniel MC, Acuin CS, Arciaga RS, Lansang MD, NaidasOD,

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  1. 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

  2. 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

  3. 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.

  4. 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

  5. Study Design

  6. MethodsDescription 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

  7. MethodsDescription 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

  8. 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)

  9. Recommended Prescribing Practices for Uncomplicated UTI (Acute Cystitis)

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

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

  12. Key Lessons • 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

  13. 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

  14. Implications and Recommendations • 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

  15. 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)

  16. Future Research • 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

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