Evaluating, improving and monitoring generic drug prescription

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JM Bernal Montañés, JF Sánchez Ruiz" "autores" => array:4 [ 0 => array:3 [ "Iniciales" => "JJ" "apellidos" => "López-Picazo Ferrer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "JA" "apellidos" => "Sanz Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] 2 => array:3 [ "Iniciales" => "JM" "apellidos" => "Bernal Montañés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 3 => array:3 [ "Iniciales" => "JF" "apellidos" => "Sánchez Ruiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Physician, Family Medicine Specialist. Quality, Pharmacy and Informatics Unit, Gerencia de Atención Primaria, Instituto Nacional de Salud (INSALUD), Murcia, Spain" "etiqueta" => "a" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Pharmacist, Hospital Pharmaceutics Specialist. Quality, Pharmacy and Informatics Unit, Gerencia de Atención Primaria, Instituto Nacional de Salud (INSALUD), Murcia, Spain" "etiqueta" => "b" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "D. Pharm, Hospital Pharmaceutics Specialist. Quality, Pharmacy and Informatics Unit, Gerencia de Atención Primaria, Instituto Nacional de Salud (INSALUD), Murcia, Spain" "etiqueta" => "c" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Informatics Engineer, Associate Professor, University of Murcia, Murcia, Spain." "etiqueta" => "d" "identificador" => "affd" ] ] ] ] "textoCompleto" => "Introduction<hr></hr>Drug prescription, a decision-making process that physicians must often perform,1 is one of the largest items of health resource consumption in the Spanish National Health System.2 The analysis of prescribing practices--which vary widely--is not a simple task,3,4 as it involves issues of effectiveness and efficiency, as well as consideration of the patients´ needs and expectations.5According to the World Health Organization, the continuous evaluation of prescribing behavior should be customary practice to guarantee the quality of treatment and control iatrogenic risks.6 In addition, the use of drugs satisfies all three characteristics that have been suggested for measures that require evaluation and monitoring (high frequency, high risk and tendency to create problems).7 Monitoring of drug use can be approached from three standpoints, which Saturno8 has called pharmacologic (efficacy and effectiveness of drugs), economic (efficiency and optimization of use) and structural rationality. This systematic analysis has become a necessity in efforts to improve drug use.9However, this approach (measuring what is done accompanied by interventions to do it better) is not the most widely known one. In Spain the health system provides mainly quantitative information aimed at controlling costs,10 although information from a qualitative viewpoint is becoming more commonplace11,12 (possibly because of an awareness that better prescribing practices lead, in the long run, to cost savings).13 However, qualitative information seems at present to be insufficient in itself to improve practices. As a result the World Organization of family doctors developed five steps to be followed to attain and maintain improvements in the use of medications.14The present study reports the results of a specially-designed intervention to evaluate and improve the prescribing behavior of family physicians (FP) in a regional primary care district in Spain.<hr></hr>Material and methods<hr></hr>The regional primary care district of Murcia comprises four of the six health areas in the autonomous region of Murcia, in southeastern Spain. In 1998, when the study was begun, it employed 339 FP organized in 45 primary care teams, who provided medical care to 670 287 inhabitants.Choice of indicatorData on the prescriptions dispensed in the regional primary care district were obtained from the monthly reports of prescriptions sent to the Official College of Pharmacists. These lists detailed the medications prescribed by each FP that are covered by the national health system and which were dispensed through pharmacies, but did not identify the patients for whom the medications were prescribed. Of all potential indicators, we chose the percent proportion of prescriptions for generic drugs relative to the total number of prescriptions dispensed during a given month, for those medications that had a generic alternative (percentage of generic prescriptions, PGP). We defined generic drug to mean a medication marketed under its international nonproprietary name and the name of the manufacturer, which had documented therapeutic equivalence to the reference (brand name) medication, and which cost less than the reference medication. In Spain generic drugs are designated EFG (especialidad farmacéutica genérica).15Implementation of the interventionFrom October 1998 to March 2000 the office of management of the regional primary care district ran a program aimed at facilitating improvements in drug prescribing practices. The program consisted of the following actions:1. Each FP received an individual monthly report of his or her prescribing practices, in which changes in PGP over time since January 1998 were graphed. Information about the changes in PGP for the physician´s primary care team and for the entire primary health care district over the same period was also provided. Physicians and pharmacies were still required to submit monthly reports of prescriptions and pharmaceutical costs.2. Each semester all FP received a personal letter and a specially-printed card listing the generic drugs available and their pharmaceutical forms, grouped according to indication (anti-infectives, neuropsychiatric drugs, cardiovascular drugs, digestive system drugs, analgesics, anti-inflammatories, miscellaneous) and arranged in alphabetical order. The cards were updated every six months to include new generics on the market, which were highlighted. Each card was sent together with a personal letter from the head of the office of management to all FP in the regional primary care district and to all physicians under temporary contract with the regional public health system. The cards were designed to be esthetically pleasing, and were printed on heavy, durable stock, then laminated. Different groups of drugs were highlighted with different colors. The cards were sized (165 x 100 mm) to fit inside the breast pocket of a lab coat or to be affixed to the computerized prescription label printer.3. One to three (mode, two) face-to-face clinical outreach sessions were held with each primary care team. These meetings were called by the team member responsible for quality control, and were held during working hours. During these meetings, members of the primary care team discussed the most recent report on generic drug prescribing behavior and the best generics available as alternatives to brand-name medications.4. Specific prescribing goals for the PGP were set for the years 1999 (12.0%) and 2000 (20.0%), and incentives to attain the goals were included in the terms of the contract for clinical services signed between the office of management of the regional primary care district and each primary care team. These contracts were signed by each FP on the primary care team, and a salary bonus of 250 000 pesetas (about 1500 euros) per practitioner was stipulated if the goals were met. The final amount of the payment for each primary care team was determined by the specific goals met with regard to (in addition to the PGP) the results for services provided, remaining within budgetary allowances for staff substitutions, drug costs, accessibility and waiting periods, and user satisfaction surveys. Payments were distributed among members of the primary care team who signed the clinical services contract on the basis of agreed-upon criteria which were ratified by the office of management.Evaluation of effectivenessThe effectiveness of the program was evaluated in two ways. Improvements in prescribing behavior were tracked by calculating the absolute and relative differences in PGP between the 3-month period immediately preceding the program (July to September 1998) and the 3 months immediately after the program (January to March 2000). To calculate relative improvement, absolute improvement was divided by total potential improvement.In addition, we monitored PGP with statistical quality control methods.16 Essentially, variability of the indicator was graphed to judge whether the indicator showed stable behavior; this analysis was done with methods similar to those traditionally used to compare hypotheses. According to the null hypothesis the indicator would remain stable. The alternative hypothesis--that the indicator would show variability--was confirmed by visual analysis of the shape of the curve. We monitored PGP with control charts.17 Changes in PGP about an average value were plotted with limits at ± 3 standard deviations (SD), which represented a risk of * error <0.01. We also defined three zones above and below the average (A, B and C), delimited by ±1, ±2 and ±3 SD, to facilitate the visualization of patterns of distribution of the indicator that might suggest variability, and to increase the sensitivity of the graph. The distribution patterns were based on those described by Kume17 and Farnum18 as adapted by Saturno.16 The same technique was used to check stability of the indicator before and after the intervention. For the pre-intervention analysis we used PGP values for the period from January to September 1998, and for the post-intervention analysis the values were those for the period from January 2000 to March 2001.<img src="27v29n07-13031954tab01.gif"></img>Results<hr></hr>Prescribing practices for all FP in the Murcia regional primary care district were analyzed. A total of 24 466 872 packages of medications were dispensed, for a mean of 827 816 packages per month (maximum 1 035 132, minimum 668 042, SD 86 904).The pre-intervention PGP was 2.79%, and the post-intervention figure was 17.63%. Absolute improvement was therefore 14.84%, and relative improvement was 15.27%. Monthly PGP values ranged from 1.77% to 27.97%, with a mean of 13.08% and an SD of 7.54%. In the pre-intervention period (before October 1998) mean PGP was 3.12%. During the intervention (October 1998 to December 1999), mean PGP was 11.90%, and after the intervention (January 2000 to March 2001), mean PGP was 20.25%. Table 1 shows the changes in PGP and in the number of packages of drugs prescribed in each phase. The control charts for each phase are shown in Figures 1 to 3. We saw no signs of significant variability in the pre- and post-intervention phases based on the criteria used in this study. In the intervention phase we noted a sequence indicating significant variability, which consisted of five successively increasing values from June 1999 onward.<img src="27v29n07-13031954tab02.gif"></img>Discussion<hr></hr>The choice of indicatorThe development and choice of indicators is an activity that is basic to monitoring and quality assurance programs.19 The indicators used to measure drug prescribing or dispensation should show adequate validity and reliability, and should also be specifically focused.20 In this regard, indicators developed from user reports appear to represent one of the best choices,21 as they have been shown to have appropriate levels of validity22,23 and to provide information that cannot be obtained from any other source,24 because they shift the center of attention from the drug25 to the patient, which then becomes the preferential unit of study.26,27However, the factor most often used to decide which indicator to use has traditionally been availability of the data and ease in obtaining them.8 This approach, which we used here in the form of the monthly reports of packages of drugs sold through the pharmacies, may appear less than ideal as it provides indicators whose focus is global or related with efficiency.10 Nonetheless, a high rate of generic prescribing has been related with improvements in drug use,8 and many examples of this association have been published.28-32 There is also a recognized relationship between generic prescribing and improvements in efficiency,33,34 one of the quality dimensions recognized by most authors. Because of its validity and because of the accessibility of the data, we decided to use generic drug prescribing as an indicator to evaluate, enhance and monitor drug use, although we were aware of the existence of other features of prescribing behavior not considered here but known to be involved in the rational use of drugs.The choice of the PGP indicator proposed by the Spanish National Institute of Health (INSALUD) on in its program for improving prescription practices,11 as opposed to other indicators traditionally used in studies of generic prescribing26-32 (absolute percentage of generic drugs prescribed, prescriptions adjusted for population, daily doses per 1000 inhabitants, choice of active principles, cost savings, ect.), was motivated by the rapid appearance of new products and active principles in the form of generics during the study period. An indicator unable to take these new products into account might have shown an artificial tendency toward improved prescribing practices by greatly increasing the number of prescriptions for which a generic alternative was available.The interventionThe measures that can be taken to improve drug utilization are many and varied. They appear to be more effective when accompanied by quality control methods, when they are preferentially internal in nature, and when they are implemented in small groups, ideally in face-to-face meetings.35,36 According to some authors, measures aimed at training are the most useful;37 however, such interventions cannot be used limitlessly, as studies have shown that such measures lose their effectiveness if they are used more than two or three times a year.38 Educational measures that emphasize information about prescribing practices have also been shown effective,39,40 and their effectiveness is maintained with time.41 Effectiveness is influenced to a great extent by the type of indicators contained in the available information. For example, those that monitor features of prescribing-on which there is no clear consensus among FPs-or those that simply reflect prescribing patterns,42 do not seem able to significantly improve prescribing quality. The use of generics, ie, the indicator we chose in the present study, is not among this group of indicators, and has been found useful on other occasions.28,39Our intervention was intended to include characteristics that have been shown to be associated with greater effectiveness. The most important of these features are: a) personalized information about prescribing behavior and proposals to improve prescribing rates (pocket card listing generic drugs); b) control charts and graphically-presented information used to make information more attractive and readily assimilated by FPs; c) face-to-face sessions with FPs to take advantage of positive peer pressure in favor of changing prescribing habits; d) information provided twice yearly on how to attain further improvements, supplied on pocket cards; e) use of specific goals to be reached, identifiable with the desired quality standard, and f) involving FPs in the design of incentives, which required explicit commitments from the practitioners.Proven effectivenessThe results we obtained reflected an increase in generic prescribing both in percentage terms and as seen in the control charts (Table 1). Because we used complete records of prescriptions dispensed through the pharmacies to calculate PGP (ie, the figures reflected prescriptions actually dispensed, not estimates, for the entire regional primary care district ), it was not necessary to use tests of statistical significance to document improvements. On the other hand, statistical quality control techniques showed that the indicator was stable before and after the intervention (Figures 1 and 3) and varied significantly toward improvement during the intervention (Figure 2). This is evidence that the program we designed was responsible for the improvements.<img src="27v29n07-13031954tab03.gif"></img><img src="27v29n07-13031954tab04.gif"></img><img src="27v29n07-13031954tab05.gif"></img>We should note that the INSALUD reported an overall increase in the use of generics for the period when our study was carried out.10 This situation was expected in the light of the increasing number of generic drugs on the market in Spain. However, the use of raw percentages of prescriptions in the INSALUD reports means that these improvements may represent «false positives» induced by the increased availability of generics. We tried to avoid this pitfall by using the PGP, which «standardizes» the actual number of prescriptions against the number of generic drugs available.It should be recalled, however, that this study centered on evaluating and improving prescription behavior, and was not designed explicitly to evaluate the effectiveness of our intervention. The evidence we provide is therefore insufficient to state that the improvement observed was a direct consequence of our program. Such proof will require further studies designed to compare the present results with those obtained in a control group; no such group was used here, as we included in our program all FPs in the regional primary care district under study. As in the present report, many other earlier studies also lacked a control group, and as several authors have noted,28,43 the effectiveness of the interventions they studied should be interpreted with caution.The statistical control techniques we used were shown to be useful, and would appear to be indispensable for the efficient monitoring of change in prescribing practices. These techniques make it possible to promptly detect opportunities for improvement (unfavorable trends) and take appropriate measures.<img src="27v29n07-13031954tab06.gif"></img>Acknowledgments<hr></hr>The present study was made possible thanks to the teachings and advice of Dr. Pedro J. Saturno of the Preventive Medicine Teaching Unit at the University of Murcia. The training and support provided through the EMCA program of the Health Council of the Region of Murcia were also fundamental for the performance of this study. " "pdfFichero" => "27v29n07a13031954pdf001.pdf" "tienePdf" => true "tieneResumen" => true "resumen" => array:1 [ "en" => array:1 [ "resumen" => "Objective. To evaluate and improve generic drug prescription by family physicians in a regional primary care district with a specially-designed intervention. Design. Uncontrolled study of an intervention, based quality evaluation and improvement methods. We selected an indicator that could be constructed with the available data (monthly reports of prescriptions dispensed through the public national health system) and determined the proportion of prescriptions for generic drugs to the total number of prescriptions dispensed, for those medications that had a generic alternative (percentage of generic prescriptions, PGP). After these data were evaluated, an intervention was implemented to increase generic prescriptions. Prescribing behavior was again evaluated and monitored at the end of the intervention period. Setting. Forty-five primary care teams in the Murcia (Southeast Spain) regional primary care district. Participants. A total of 339 family physicians. Interventions. During 15 months, individual reports of prescribing practices, in which changes over time were graphed, were sent to each participating prescriber. Each semester the physicians received a personal letter and a specially-printed, updated card showing the generic medications available and their pharmaceutical forms. One to three face-to-face clinical outreach sessions were held with each primary care team. Specific prescribing goals for the PGP were set and incentives to attain the goals were included in the terms of the contract for clinical services signed between the regional office of primary care management and each primary care team. Main outcome measures. The PGP increased from a pre-intervention rate of 2.7% to a post-intervention rate of 17.63%. Absolute improvement was therefore 14.84%, and relative improvement was 15.27%. Variability was monitored and analyzed with control charts. There was no significant variability within the pre- and post-intervention phases, whereas variability increased significantly (indicating improvement) during the intervention phase. Conclusions. The increase in PGP showed that prescribing for generic preparations improved. Statistical quality control tests were useful in evaluating and tracking the results of the intervention, and were indispensable for monitoring and promptly detecting opportunities to improve prescribing behavior and take appropriate measures." ] ] "multimedia" => array:12 [ 0 => array:6 [ "identificador" => "tbl1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v29n07-13031954tab01.gif" "imagenAlto" => 802 "imagenAncho" => 366 "imagenTamanyo" => 21004 ] ] ] ] ] ] 1 => array:6 [ "identificador" => "tbl2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v29n07-13031954tab02.gif" "imagenAlto" => 925 "imagenAncho" => 765 "imagenTamanyo" => 26254 ] ] ] ] ] ] 2 => array:6 [ "identificador" => "tbl3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v29n07-13031954tab03.gif" "imagenAlto" => 386 "imagenAncho" => 730 "imagenTamanyo" => 26783 ] ] ] ] ] ] 3 => array:6 [ "identificador" => "tbl4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v29n07-13031954tab04.gif" "imagenAlto" => 422 "imagenAncho" => 730 "imagenTamanyo" => 30749 ] ] ] ] ] ] 4 => array:6 [ "identificador" => "tbl5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v29n07-13031954tab05.gif" "imagenAlto" => 356 "imagenAncho" => 730 "imagenTamanyo" => 31570 ] ] ] ] ] ] 5 => array:6 [ "identificador" => "tbl6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v29n07-13031954tab06.gif" "imagenAlto" => 626 "imagenAncho" => 366 "imagenTamanyo" => 27888 ] ] ] ] ] ] 6 => array:5 [ "identificador" => "tbl7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 7 => array:5 [ "identificador" => "tbl8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 8 => array:5 [ "identificador" => "tbl9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 9 => array:5 [ "identificador" => "tbl10" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 10 => array:5 [ "identificador" => "tbl11" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 11 => array:5 [ "identificador" => "tbl12" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:43 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "General practitioners for rational use of drugs. 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Evaluating, improving and monitoring generic drug prescription

JJ. López-Picazo Ferrera, JA. Sanz Morenob, JM. Bernal Montañésc, JF. Sánchez Ruizd

a Physician, Family Medicine Specialist. Quality, Pharmacy and Informatics Unit, Gerencia de Atención Primaria, Instituto Nacional de Salud (INSALUD), Murcia, Spain

b Pharmacist, Hospital Pharmaceutics Specialist. Quality, Pharmacy and Informatics Unit, Gerencia de Atención Primaria, Instituto Nacional de Salud (INSALUD), Murcia, Spain

c D. Pharm, Hospital Pharmaceutics Specialist. Quality, Pharmacy and Informatics Unit, Gerencia de Atención Primaria, Instituto Nacional de Salud (INSALUD), Murcia, Spain

d Informatics Engineer, Associate Professor, University of Murcia, Murcia, Spain.

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    "textoCompleto" => "<p class="elsevierStylePara">Introduction</p><hr></hr><p class="elsevierStylePara">Drug prescription&#44; a decision-making process that physicians must often perform&#44;<span class="elsevierStyleSup">1</span> is one of the largest items of health resource consumption in the Spanish National Health System&#46;<span class="elsevierStyleSup">2</span> The analysis of prescribing practices--which vary widely--is not a simple task&#44;<span class="elsevierStyleSup">3&#44;4</span> as it involves issues of effectiveness and efficiency&#44; as well as consideration of the patients&#180; needs and expectations&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">According to the World Health Organization&#44; the continuous evaluation of prescribing behavior should be customary practice to guarantee the quality of treatment and control iatrogenic risks&#46;<span class="elsevierStyleSup">6</span> In addition&#44; the use of drugs satisfies all three characteristics that have been suggested for measures that require evaluation and monitoring &#40;high frequency&#44; high risk and tendency to create problems&#41;&#46;<span class="elsevierStyleSup">7</span> Monitoring of drug use can be approached from three standpoints&#44; which Saturno<span class="elsevierStyleSup">8</span> has called pharmacologic &#40;efficacy and effectiveness of drugs&#41;&#44; economic &#40;efficiency and optimization of use&#41; and structural rationality&#46; This systematic analysis has become a necessity in efforts to improve drug use&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">However&#44; this approach &#40;measuring what is done accompanied by interventions to do it better&#41; is not the most widely known one&#46; In Spain the health system provides mainly quantitative information aimed at controlling costs&#44;<span class="elsevierStyleSup">10</span> although information from a qualitative viewpoint is becoming more commonplace<span class="elsevierStyleSup">11&#44;12</span> &#40;possibly because of an awareness that better prescribing practices lead&#44; in the long run&#44; to cost savings&#41;&#46;<span class="elsevierStyleSup">13</span> However&#44; qualitative information seems at present to be insufficient in itself to improve practices&#46; As a result the World Organization of family doctors developed five steps to be followed to attain and maintain improvements in the use of medications&#46;<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">The present study reports the results of a specially-designed intervention to evaluate and improve the prescribing behavior of family physicians &#40;FP&#41; in a regional primary care district in Spain&#46;</p><hr></hr><p class="elsevierStylePara">Material and methods</p><hr></hr><p class="elsevierStylePara">The regional primary care district of Murcia comprises four of the six health areas in the autonomous region of Murcia&#44; in southeastern Spain&#46; In 1998&#44; when the study was begun&#44; it employed 339 FP organized in 45 primary care teams&#44; who provided medical care to 670 287 inhabitants&#46;</p><p class="elsevierStylePara">Choice of indicator</p><p class="elsevierStylePara">Data on the prescriptions dispensed in the regional primary care district were obtained from the monthly reports of prescriptions sent to the Official College of Pharmacists&#46; These lists detailed the medications prescribed by each FP that are covered by the national health system and which were dispensed through pharmacies&#44; but did not identify the patients for whom the medications were prescribed&#46; Of all potential indicators&#44; we chose the percent proportion of prescriptions for generic drugs relative to the total number of prescriptions dispensed during a given month&#44; for those medications that had a generic alternative &#40;percentage of generic prescriptions&#44; PGP&#41;&#46; We defined generic drug to mean a medication marketed under its international nonproprietary name and the name of the manufacturer&#44; which had documented therapeutic equivalence to the reference &#40;brand name&#41; medication&#44; and which cost less than the reference medication&#46; In Spain generic drugs are designated EFG <span class="elsevierStyleItalic"> &#40;especialidad farmac&#233;utica gen&#233;rica&#41;&#46;</span><span class="elsevierStyleSup">15</span></p><p class="elsevierStylePara">Implementation of the intervention</p><p class="elsevierStylePara">From October 1998 to March 2000 the office of management of the regional primary care district ran a program aimed at facilitating improvements in drug prescribing practices&#46; The program consisted of the following actions&#58;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">1&#46;</span> Each FP received an individual monthly report of his or her prescribing practices&#44; in which changes in PGP over time since January 1998 were graphed&#46; Information about the changes in PGP for the physician&#180;s primary care team and for the entire primary health care district over the same period was also provided&#46; Physicians and pharmacies were still required to submit monthly reports of prescriptions and pharmaceutical costs&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">2&#46;</span> Each semester all FP received a personal letter and a specially-printed card listing the generic drugs available and their pharmaceutical forms&#44; grouped according to indication &#40;anti-infectives&#44; neuropsychiatric drugs&#44; cardiovascular drugs&#44; digestive system drugs&#44; analgesics&#44; anti-inflammatories&#44; miscellaneous&#41; and arranged in alphabetical order&#46; The cards were updated every six months to include new generics on the market&#44; which were highlighted&#46; Each card was sent together with a personal letter from the head of the office of management to all FP in the regional primary care district and to all physicians under temporary contract with the regional public health system&#46; The cards were designed to be esthetically pleasing&#44; and were printed on heavy&#44; durable stock&#44; then laminated&#46; Different groups of drugs were highlighted with different colors&#46; The cards were sized &#40;165 x 100 mm&#41; to fit inside the breast pocket of a lab coat or to be affixed to the computerized prescription label printer&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">3&#46;</span> One to three &#40;mode&#44; two&#41; face-to-face clinical outreach sessions were held with each primary care team&#46; These meetings were called by the team member responsible for quality control&#44; and were held during working hours&#46; During these meetings&#44; members of the primary care team discussed the most recent report on generic drug prescribing behavior and the best generics available as alternatives to brand-name medications&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">4&#46;</span> Specific prescribing goals for the PGP were set for the years 1999 &#40;12&#46;0&#37;&#41; and 2000 &#40;20&#46;0&#37;&#41;&#44; and incentives to attain the goals were included in the terms of the contract for clinical services signed between the office of management of the regional primary care district and each primary care team&#46; These contracts were signed by each FP on the primary care team&#44; and a salary bonus of 250 000 pesetas &#40;about 1500 euros&#41; per practitioner was stipulated if the goals were met&#46; The final amount of the payment for each primary care team was determined by the specific goals met with regard to &#40;in addition to the PGP&#41; the results for services provided&#44; remaining within budgetary allowances for staff substitutions&#44; drug costs&#44; accessibility and waiting periods&#44; and user satisfaction surveys&#46; Payments were distributed among members of the primary care team who signed the clinical services contract on the basis of agreed-upon criteria which were ratified by the office of management&#46;</p><p class="elsevierStylePara">Evaluation of effectiveness</p><p class="elsevierStylePara">The effectiveness of the program was evaluated in two ways&#46; Improvements in prescribing behavior were tracked by calculating the absolute and relative differences in PGP between the 3-month period immediately preceding the program &#40;July to September 1998&#41; and the 3 months immediately after the program &#40;January to March 2000&#41;&#46; To calculate relative improvement&#44; absolute improvement was divided by total potential improvement&#46;</p><p class="elsevierStylePara">In addition&#44; we monitored PGP with statistical quality control methods&#46;<span class="elsevierStyleSup">16</span> Essentially&#44; variability of the indicator was graphed to judge whether the indicator showed stable behavior&#59; this analysis was done with methods similar to those traditionally used to compare hypotheses&#46; According to the null hypothesis the indicator would remain stable&#46; The alternative hypothesis--that the indicator would show variability--was confirmed by visual analysis of the shape of the curve&#46; We monitored PGP with control charts&#46;<span class="elsevierStyleSup">17</span> Changes in PGP about an average value were plotted with limits at &#177; 3 standard deviations &#40;SD&#41;&#44; which represented a risk of &#42; error &#60;0&#46;01&#46; We also defined three zones above and below the average &#40;A&#44; B and C&#41;&#44; delimited by &#177;1&#44; &#177;2 and &#177;3 SD&#44; to facilitate the visualization of patterns of distribution of the indicator that might suggest variability&#44; and to increase the sensitivity of the graph&#46; The distribution patterns were based on those described by Kume<span class="elsevierStyleSup">17</span> and Farnum<span class="elsevierStyleSup">18</span> as adapted by Saturno&#46;<span class="elsevierStyleSup">16</span> The same technique was used to check stability of the indicator before and after the intervention&#46; For the pre-intervention analysis we used PGP values for the period from January to September 1998&#44; and for the post-intervention analysis the values were those for the period from January 2000 to March 2001&#46;</p><p class="elsevierStylePara"><img src="27v29n07-13031954tab01.gif"></img></p><p class="elsevierStylePara">Results</p><hr></hr><p class="elsevierStylePara">Prescribing practices for all FP in the Murcia regional primary care district were analyzed&#46; A total of 24 466 872 packages of medications were dispensed&#44; for a mean of 827 816 packages per month &#40;maximum 1 035 132&#44; minimum 668 042&#44; SD 86 904&#41;&#46;</p><p class="elsevierStylePara">The pre-intervention PGP was 2&#46;79&#37;&#44; and the post-intervention figure was 17&#46;63&#37;&#46; Absolute improvement was therefore 14&#46;84&#37;&#44; and relative improvement was 15&#46;27&#37;&#46; Monthly PGP values ranged from 1&#46;77&#37; to 27&#46;97&#37;&#44; with a mean of 13&#46;08&#37; and an SD of 7&#46;54&#37;&#46; In the pre-intervention period &#40;before October 1998&#41; mean PGP was 3&#46;12&#37;&#46; During the intervention &#40;October 1998 to December 1999&#41;&#44; mean PGP was 11&#46;90&#37;&#44; and after the intervention &#40;January 2000 to March 2001&#41;&#44; mean PGP was 20&#46;25&#37;&#46; Table 1 shows the changes in PGP and in the number of packages of drugs prescribed in each phase&#46; The control charts for each phase are shown in Figures 1 to 3&#46; We saw no signs of significant variability in the pre- and post-intervention phases based on the criteria used in this study&#46; In the intervention phase we noted a sequence indicating significant variability&#44; which consisted of five successively increasing values from June 1999 onward&#46;</p><p class="elsevierStylePara"><img src="27v29n07-13031954tab02.gif"></img></p><p class="elsevierStylePara">Discussion</p><hr></hr><p class="elsevierStylePara">The choice of indicator</p><p class="elsevierStylePara">The development and choice of indicators is an activity that is basic to monitoring and quality assurance programs&#46;<span class="elsevierStyleSup">19</span> The indicators used to measure drug prescribing or dispensation should show adequate validity and reliability&#44; and should also be specifically focused&#46;<span class="elsevierStyleSup">20</span> In this regard&#44; indicators developed from user reports appear to represent one of the best choices&#44;<span class="elsevierStyleSup">21</span> as they have been shown to have appropriate levels of validity<span class="elsevierStyleSup">22&#44;23</span> and to provide information that cannot be obtained from any other source&#44;<span class="elsevierStyleSup">24</span> because they shift the center of attention from the drug<span class="elsevierStyleSup">25</span> to the patient&#44; which then becomes the preferential unit of study&#46;<span class="elsevierStyleSup">26&#44;27</span></p><p class="elsevierStylePara">However&#44; the factor most often used to decide which indicator to use has traditionally been availability of the data and ease in obtaining them&#46;<span class="elsevierStyleSup">8</span> This approach&#44; which we used here in the form of the monthly reports of packages of drugs sold through the pharmacies&#44; may appear less than ideal as it provides indicators whose focus is global or related with efficiency&#46;<span class="elsevierStyleSup">10</span> Nonetheless&#44; a high rate of generic prescribing has been related with improvements in drug use&#44;<span class="elsevierStyleSup">8</span> and many examples of this association have been published&#46;<span class="elsevierStyleSup">28-32</span> There is also a recognized relationship between generic prescribing and improvements in efficiency&#44;<span class="elsevierStyleSup">33&#44;34</span> one of the quality dimensions recognized by most authors&#46; Because of its validity and because of the accessibility of the data&#44; we decided to use generic drug prescribing as an indicator to evaluate&#44; enhance and monitor drug use&#44; although we were aware of the existence of other features of prescribing behavior not considered here but known to be involved in the rational use of drugs&#46;</p><p class="elsevierStylePara">The choice of the PGP indicator proposed by the Spanish National Institute of Health &#40;INSALUD&#41; on in its program for improving prescription practices&#44;<span class="elsevierStyleSup">11</span> as opposed to other indicators traditionally used in studies of generic prescribing<span class="elsevierStyleSup">26-32</span> &#40;absolute percentage of generic drugs prescribed&#44; prescriptions adjusted for population&#44; daily doses per 1000 inhabitants&#44; choice of active principles&#44; cost savings&#44; ect&#46;&#41;&#44; was motivated by the rapid appearance of new products and active principles in the form of generics during the study period&#46; An indicator unable to take these new products into account might have shown an artificial tendency toward improved prescribing practices by greatly increasing the number of prescriptions for which a generic alternative was available&#46;</p><p class="elsevierStylePara">The intervention</p><p class="elsevierStylePara">The measures that can be taken to improve drug utilization are many and varied&#46; They appear to be more effective when accompanied by quality control methods&#44; when they are preferentially internal in nature&#44; and when they are implemented in small groups&#44; ideally in face-to-face meetings&#46;<span class="elsevierStyleSup">35&#44;36</span> According to some authors&#44; measures aimed at training are the most useful&#59;<span class="elsevierStyleSup">37</span> however&#44; such interventions cannot be used limitlessly&#44; as studies have shown that such measures lose their effectiveness if they are used more than two or three times a year&#46;<span class="elsevierStyleSup">38</span> Educational measures that emphasize information about prescribing practices have also been shown effective&#44;<span class="elsevierStyleSup">39&#44;40</span> and their effectiveness is maintained with time&#46;<span class="elsevierStyleSup">41</span> Effectiveness is influenced to a great extent by the type of indicators contained in the available information&#46; For example&#44; those that monitor features of prescribing-on which there is no clear consensus among FPs-or those that simply reflect prescribing patterns&#44;<span class="elsevierStyleSup">42</span> do not seem able to significantly improve prescribing quality&#46; The use of generics&#44; ie&#44; the indicator we chose in the present study&#44; is not among this group of indicators&#44; and has been found useful on other occasions&#46;<span class="elsevierStyleSup">28&#44;39</span></p><p class="elsevierStylePara">Our intervention was intended to include characteristics that have been shown to be associated with greater effectiveness&#46; The most important of these features are&#58; <span class="elsevierStyleItalic">a&#41;</span> personalized information about prescribing behavior and proposals to improve prescribing rates &#40;pocket card listing generic drugs&#41;&#59; <span class="elsevierStyleItalic">b&#41;</span> control charts and graphically-presented information used to make information more attractive and readily assimilated by FPs&#59; <span class="elsevierStyleItalic">c&#41;</span> face-to-face sessions with FPs to take advantage of positive peer pressure in favor of changing prescribing habits&#59; <span class="elsevierStyleItalic"> d&#41;</span> information provided twice yearly on how to attain further improvements&#44; supplied on pocket cards&#59; <span class="elsevierStyleItalic">e&#41;</span> use of specific goals to be reached&#44; identifiable with the desired quality standard&#44; and <span class="elsevierStyleItalic">f&#41;</span> involving FPs in the design of incentives&#44; which required explicit commitments from the practitioners&#46;</p><p class="elsevierStylePara">Proven effectiveness</p><p class="elsevierStylePara">The results we obtained reflected an increase in generic prescribing both in percentage terms and as seen in the control charts &#40;Table 1&#41;&#46; Because we used complete records of prescriptions dispensed through the pharmacies to calculate PGP &#40;ie&#44; the figures reflected prescriptions actually dispensed&#44; not estimates&#44; for the entire regional primary care district &#41;&#44; it was not necessary to use tests of statistical significance to document improvements&#46; On the other hand&#44; statistical quality control techniques showed that the indicator was stable before and after the intervention &#40;Figures 1 and 3&#41; and varied significantly toward improvement during the intervention &#40;Figure 2&#41;&#46; This is evidence that the program we designed was responsible for the improvements&#46;</p><p class="elsevierStylePara"><img src="27v29n07-13031954tab03.gif"></img></p><p class="elsevierStylePara"><img src="27v29n07-13031954tab04.gif"></img></p><p class="elsevierStylePara"><img src="27v29n07-13031954tab05.gif"></img></p><p class="elsevierStylePara">We should note that the INSALUD reported an overall increase in the use of generics for the period when our study was carried out&#46;<span class="elsevierStyleSup">10</span> This situation was expected in the light of the increasing number of generic drugs on the market in Spain&#46; However&#44; the use of raw percentages of prescriptions in the INSALUD reports means that these improvements may represent &#171;false positives&#187; induced by the increased availability of generics&#46; We tried to avoid this pitfall by using the PGP&#44; which &#171;standardizes&#187; the actual number of prescriptions against the number of generic drugs available&#46;</p><p class="elsevierStylePara">It should be recalled&#44; however&#44; that this study centered on evaluating and improving prescription behavior&#44; and was not designed explicitly to evaluate the effectiveness of our intervention&#46; The evidence we provide is therefore insufficient to state that the improvement observed was a direct consequence of our program&#46; Such proof will require further studies designed to compare the present results with those obtained in a control group&#59; no such group was used here&#44; as we included in our program all FPs in the regional primary care district under study&#46; As in the present report&#44; many other earlier studies also lacked a control group&#44; and as several authors have noted&#44;<span class="elsevierStyleSup">28&#44;43</span> the effectiveness of the interventions they studied should be interpreted with caution&#46;</p><p class="elsevierStylePara">The statistical control techniques we used were shown to be useful&#44; and would appear to be indispensable for the efficient monitoring of change in prescribing practices&#46; These techniques make it possible to promptly detect opportunities for improvement &#40;unfavorable trends&#41; and take appropriate measures&#46;</p><p class="elsevierStylePara"><img src="27v29n07-13031954tab06.gif"></img></p><p class="elsevierStylePara">Acknowledgments</p><hr></hr><p class="elsevierStylePara">The present study was made possible thanks to the teachings and advice of Dr&#46; Pedro J&#46; Saturno of the Preventive Medicine Teaching Unit at the University of Murcia&#46; The training and support provided through the EMCA program of the Health Council of the Region of Murcia were also fundamental for the performance of this study&#46;</p><p class="elsevierStylePara">&#160;</p>"
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        "resumen" => "Objective&#46; To evaluate and improve generic drug prescription by family physicians in a regional primary care district with a specially-designed intervention&#46; Design&#46; Uncontrolled study of an intervention&#44; based quality evaluation and improvement methods&#46; We selected an indicator that could be constructed with the available data &#40;monthly reports of prescriptions dispensed through the public national health system&#41; and determined the proportion of prescriptions for generic drugs to the total number of prescriptions dispensed&#44; for those medications that had a generic alternative &#40;percentage of generic prescriptions&#44; PGP&#41;&#46; After these data were evaluated&#44; an intervention was implemented to increase generic prescriptions&#46; Prescribing behavior was again evaluated and monitored at the end of the intervention period&#46; Setting&#46; Forty-five primary care teams in the Murcia &#40;Southeast Spain&#41; regional primary care district&#46; Participants&#46; A total of 339 family physicians&#46; Interventions&#46; During 15 months&#44; individual reports of prescribing practices&#44; in which changes over time were graphed&#44; were sent to each participating prescriber&#46; Each semester the physicians received a personal letter and a specially-printed&#44; updated card showing the generic medications available and their pharmaceutical forms&#46; One to three face-to-face clinical outreach sessions were held with each primary care team&#46; Specific prescribing goals for the PGP were set and incentives to attain the goals were included in the terms of the contract for clinical services signed between the regional office of primary care management and each primary care team&#46; Main outcome measures&#46; The PGP increased from a pre-intervention rate of 2&#46;7&#37; to a post-intervention rate of 17&#46;63&#37;&#46; Absolute improvement was therefore 14&#46;84&#37;&#44; and relative improvement was 15&#46;27&#37;&#46; Variability was monitored and analyzed with control charts&#46; There was no significant variability within the pre- and post-intervention phases&#44; whereas variability increased significantly &#40;indicating improvement&#41; during the intervention phase&#46; Conclusions&#46; The increase in PGP showed that prescribing for generic preparations improved&#46; Statistical quality control tests were useful in evaluating and tracking the results of the intervention&#44; and were indispensable for monitoring and promptly detecting opportunities to improve prescribing behavior and take appropriate measures&#46;"
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Article information

ISSN: 02126567
Original language: English

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Year/Month	Html	Pdf	Total

2024 November	6	0	6
2024 October	33	2	35
2024 September	39	4	43
2024 August	28	5	33
2024 July	31	8	39
2024 June	47	5	52
2024 May	24	6	30
2024 April	35	6	41
2024 March	63	11	74
2024 February	69	13	82
2024 January	77	9	86
2023 December	65	6	71
2023 November	65	7	72
2023 October	95	18	113
2023 September	63	1	64
2023 August	70	10	80
2023 July	48	6	54
2023 June	59	12	71
2023 May	70	11	81
2023 April	52	9	61
2023 March	49	7	56
2023 February	47	13	60
2023 January	66	18	84
2022 December	45	12	57
2022 November	82	14	96
2022 October	51	11	62
2022 September	60	5	65
2022 August	47	14	61
2022 July	44	8	52
2022 June	46	6	52
2022 May	46	28	74
2022 April	53	11	64
2022 March	63	12	75
2022 February	36	11	47
2022 January	41	9	50
2021 December	103	11	114
2021 November	71	7	78
2021 October	86	11	97
2021 September	43	16	59
2021 August	47	9	56
2021 July	26	9	35
2021 June	45	7	52
2021 May	40	13	53
2021 April	102	23	125
2021 March	57	8	65
2021 February	25	7	32
2021 January	53	9	62
2020 December	46	8	54
2020 November	44	9	53
2020 October	56	9	65
2020 September	47	10	57
2020 August	61	7	68
2020 July	38	9	47
2020 June	75	14	89
2020 May	40	9	49
2020 April	34	5	39
2020 March	62	7	69
2020 February	73	9	82
2020 January	46	4	50
2019 December	56	10	66
2019 November	40	6	46
2019 October	57	7	64
2019 September	67	2	69
2019 August	35	2	37
2019 July	45	9	54
2019 June	78	13	91
2019 May	165	6	171
2019 April	85	15	100
2019 March	28	7	35
2019 February	25	5	30
2019 January	21	1	22
2018 December	26	8	34
2018 November	48	6	54
2018 October	28	16	44
2018 September	19	8	27
2018 August	8	2	10
2018 July	8	1	9
2018 June	14	0	14
2018 May	14	4	18
2018 April	5	9	14
2018 March	9	0	9
2018 February	8	3	11
2018 January	11	0	11
2017 December	12	2	14
2017 November	14	0	14
2017 October	14	8	22
2017 September	14	4	18
2017 August	15	4	19
2017 July	10	0	10
2017 June	29	4	33
2017 May	24	4	28
2017 April	12	5	17
2017 March	16	9	25
2017 February	25	4	29
2017 January	19	4	23
2016 December	27	6	33
2016 November	25	3	28
2016 October	40	7	47
2016 September	29	1	30
2016 August	23	3	26
2016 July	18	7	25
2016 June	22	11	33
2016 May	13	14	27
2016 April	12	2	14
2016 March	13	6	19
2016 February	13	1	14
2016 January	13	5	18
2015 December	17	4	21
2015 November	15	1	16
2015 October	28	5	33
2015 September	26	3	29
2015 August	4	1	5
2015 July	19	5	24
2015 June	2	2	4
2015 May	9	1	10
2015 April	20	10	30
2015 March	17	6	23
2015 February	11	2	13
2015 January	25	3	28
2014 December	19	4	23
2014 November	21	1	22
2014 October	26	1	27
2014 September	25	0	25
2014 August	27	3	30
2014 July	28	2	30
2014 June	34	4	38
2014 May	17	0	17
2014 April	17	0	17
2014 March	20	0	20
2014 February	19	0	19
2014 January	12	0	12
2013 December	8	1	9
2013 November	14	1	15
2013 October	18	2	20
2013 September	11	2	13
2013 August	17	1	18
2013 July	9	0	9
2002 April	692	0	692

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