The effect of registry-based performance feedback via short text messages and traditional postal letters on prescribing parenteral steroids by general practitioners—A randomized controlled trial

https://doi.org/10.1016/j.ijmedinf.2015.12.008Get rights and content

Highlights

  • Sending feedback about recent steroid prescription to general practitioners reduced parenteral steroids prescription rate by about one-third.

  • Feedback in the form of short text messages was demonstrated to be at least as effective as postal letters, and much cheaper.

  • Reduction in this outcome was unrelated to gender and age but it was associated with the number of feedback messages sent.

Abstract

Background

It is conjectured that providing feedback on physicians’ prescribing behavior improves quality of drug prescriptions. However, the effectiveness of feedback provision and mode of feedback delivery is not well understood. The objective of this study was to assess and compare the effect of traditional paper letters (TPL) and short text message (STM) feedback on general practitioners’ prescribing behavior of parenteral steroids (PSs).

Methods

In a single-blind randomized controlled trial, 906 general practitioners (GPs) having at least 10 monthly prescriptions were randomly recruited into two interventions and one control study arms with 1:1 allocation, stratified by percentage of prescriptions. The intervention was the provision of 3 feedback messages containing prescribing indices in TPL and STM (in the first two arms) versus the control arm (CG) with an interval of 3 months between these messages. We calculated the PS Defined Daily Dose (DDD) for every GP, every month, and compared between the 3 arms, before and after the interventions. The expected primary outcome was to reduce prescription of parenteral steroids by participants. The study was performed in the Kerman Social Security Organization in Iran.

Results

A total of 906 GPs were selected for the trial, but only 721 of them (TPL = 191, STM = 228, CG = 302) were recruited for the 1st feedback. The mean age of GPs was 44 and 59% of them were male. The prescribed parenteral steroid DDDs at baseline were similar (TPL = 121.62, STM = 127.49, CG = 115.68, P > 0.5). At the end of the study, DDDs in the TPL and STM arms were similar (TPL = 104.38, STM = 101.90, P > 0.9) but DDDs in each intervention arm was statistically significantly lower than in CG (CG = 156.17, P < 0.0001). Being in TPL and STM arms resulted in 36.1 and 41.7 units of decrease in DDD respectively, compared to the control arm (P < 0.02 and P < 0.005) after the one-year duration of the study.

Conclusion

Feedback by TPLs and STMs on prescribing performance effectively reduced prescribing PSs by GPs. STM, being a cheap and fast tool, is potentially powerful and efficient for drug prescription rationalization.

Introduction

Rational use of drugs is an important topic in medicine. Physicians’ prescribing is one of the most frequent medical interventions affecting care outcomes and costs [1], [2], [3]. Several studies have focused on physicians’ prescribing behavior. Audit and feedback have the potential to improve prescribing behavior but studies showed they have little to moderate effect on improving professional practice [3], [4], [5], [6], [7]. According to a Cochrane Review, audit and feedback are defined as providing a summary of the clinical performance of healthcare provider(s) over a specified period of time [6]. Yet, evidence about the feedback effect is inconclusive due to contradictory results [8], [9], [10], [11]. In addition, absolute effects of audit and feedback are likely to be larger when baseline adherence to recommended practice is low and intensity of audit and feedback is high [4], [8].

Several reports in Iran have shown inappropriate prescribing and usage of corticosteroid drugs in the last decade. Corticosteroid prescribing was reported to have an incidence ranging between ten to fifty percent according to publications from different regions of Iran [5], [12], [13]. It increased nationwide from 12.7% in 1998 to 23% in 2007 [14], based on about 100 million prescriptions [14]. Among steroids, Dexamethasone Phosphate Ampule (8 mg/2 ml) was prescribed in roughly 12% of about 85 million prescriptions in Iranian patients. It has also been placed in the top ten prescribed drugs of any type in Iran over recent years. When not adequately monitored, usage of these drugs may lead to unsafe side effects. Both governmental and other health care organizations are putting much effort in improving the quality of prescriptions.

To ensure the appropriateness of prescription drug use, third party payers widely use retrospective drug utilization reviews [9]. Kerman is the largest province in Iran with around three million people living in its cities and villages. About half of these are covered by insurance via the Kerman Social Security Organization (SSO). More than 1800 general practitioners practice in the province and work together with the SSO. The SSO has a special office called Medical Documents Audit Office (MDAO). In MDAO, the Research and Scientific Council (RSC), run by official staff members, specialists and honorary members, focuses on checking the validity and correctness of diverse medical documents from all medical sections, e.g., medical labs, pharmacies, hospitals, private offices, governmental and private clinics. The main aim of MDAO and RSC is minimizing and preventing prescription drug violations and errors in medical documenting procedures.

MDAO members monitor the practice of physicians continuously. Important data about any individual prescription is recorded in a web based application when dispensed in pharmacy and all data are collected instantly into the comprehensive registry of SSO. In MDAO, the RSC members have weekly meetings for assessing the prescriptions based on reports extracted from the prescription registry. Based on these reports, the RSC director provides feedback letters about many prescribing indices. These letters may include comparison to other providers and advice or appreciation to the recipient. However, the number of weekly letters did not exceed 20, and there was no effort to evaluate their effect. The MDAO hypothesized that systematically sending feedback letters or face to face visits by inviting physicians to MDAO or even going to their offices are effective measures to change physicians' behavior. They hence sought to scientifically evaluate this hypothesis.

In this study we conducted a randomized controlled trial (RCT) aimed to assess whether registry based feedback to general practitioners (GPs) about their professional practice may affect their prescribing of parenteral steroids (PSs). We considered two types of feedback to improve prescribing behavior for PSs: by traditional postal letters (TPLs) and by short text messages (STMs). Also we compared the efficiency of STMs and TPLs. We hypothesized that STM could be a simple, rapid and effective way for providing actionable feedback in the form of quantitative and qualitative indices to the physicians, while respecting privacy and having low cost. The rationale is that these actions would improve their prescribing quality and hence also healthcare outcome.

Section snippets

Overview and study timeline

In this randomized controlled trial, we evaluate the effect of providing performance feedback by traditional postal letters (TPLs) or mobile short text messages (STMs) compared to the control group (CG) with the normal feedback as usual on physicians’ behavior in prescribing PSs. The study timeline is shown in Fig. 1a.

Recruitment of participants

There were 1886 GPs practicing in Kerman province at the recruitment phase of the study. In order to find an assumed improvement of at least 10% absolute decrease after the

Participant flow and intervention

Nine hundred and six GPs were randomly recruited for the study. The basic characteristics of the participants in all three arms of the trial were similar after randomization (Table 2). The GPs worked in 14 different cities and counties of Kerman Province (39.3% in Kerman city itself, 50.5% in other cities, and 10.2% in the counties) and the male to female ratio was 1.4. According to the official records, the participants had different levels of clinical experience ranging from several months to

Discussion

Our RCT showed that sending feedback about the prescription indices to general practitioners in a large province of Iran reduced parenteral steroids prescription rate by about one-third. Reduction in this outcome was unrelated to gender and age but it was associated with the number of feedback messages sent. Feedback in short text messages was demonstrated to be at least as effective as postal letters. The most frequently prescribed drug was Dexamethasone Phosphate Disodium Ampule (8 mg/2 ml)

Limitations of the study

Some of the physicians, who were randomly assigned to one of the intervention arms, did not receive the letters/STMs. This was due to inaccessibility to their mobile numbers and postal addresses. Also it was probable that some of the participants, who did not have a practice contract with the SSO at the study period, were less susceptible to SSO letters.

It was preferable to run the study for a longer time, but because of budget and time constrains, we set the duration to one year and three

Conclusion

In this single-blind randomized controlled trial, we aimed to assess the effects of registry based performance feedback by short text messages compared to traditional postal letters and care as usual on prescribing PSs. We achieved more than 34% relative decrease in prescribing these drugs in terms of DDDs when compared to care as usual in a similar year-period within two years. STM could be a very simple, cheap and effective way to provide performance feedback for general practitioners to

Author Contribution

SE: conception and design of study, interpretation of data, and supervising the study. ASN: design, data analysis, interpretation of data, and manuscript writing. AAH: design, data analysis, and critical revision. KB: design and critical revision. AA: conception and design, and critical revision. MRF: design and critical revision. All authors read and approved the final manuscript.

Conflict of interest

The authors declare they have no conflict of interest.

Summary points

What was already known before this study:

  • Audit and feedback are known as effective way to promote health care services, whether some studies have controversies about the positive effects in improving professional practice and the characteristics of audit and feedback that lead to greater impact

What this study has added:

  • Using short text message to deliver official and organizational supervising materials could be as effective as

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