Safer prescribing: a trial of education, informatics, and financial incentives.

Dreischulte, Tobias; Donnan, Peter; Grant, Aileen; Hapca, Adrian; McCowan, Colin; Guthrie, Bruce

Abstract

High-risk prescribing and preventable, drug-related complications are common in primary care. We evaluated whether the rates of high-risk prescribing by primary care clinicians and the related clinical outcomes would be reduced through a complex intervention. This cluster-randomized, stepped-wedge trial was conducted in Tayside, Scotland. In the trial, we randomly assigned participating primary care practices to various start dates for a 48-week intervention, comprising professional education, informatics to facilitate review, and financial incentives for practices that aimed to encourage the review of patients' charts in order to assess appropriateness. The primary outcome was patient-level exposure to any of nine possible measures for high-risk prescribing of nonsteroidal, antiinflammatory drugs (NSAIDs), or selected antiplatelet agents. For example, NSAID prescription in a patient with chronic kidney disease, or co-prescription of an NSAID and an oral anticoagulant without gastroprotection. Pre-specified secondary outcomes included the incidence of related hospital admissions. Analyses were performed according to the intention-to-treat principle, with the use of mixed-effect models to account for clustering in the data. A total of 34 practices underwent randomization, 33 of which completed the study. Data were analyzed for 33,334 patients who were at risk at one or more points in the pre-intervention period, and for 33,060 patients who were at risk at one or more points in the intervention period. Targeted high-risk prescribing was significantly reduced, from a rate of 3.7% (1102 of 29,537 patients at risk) immediately before the intervention, to 2.2% (674 of 30,187) at the end of the intervention (adjusted odds ratio, 0.63; 95% confidence interval [CI], 0.57 to 0.68; P < 0.001). The rate of hospital admissions for gastrointestinal ulcer or bleeding was significantly reduced from the pre-intervention period to the intervention period (from 55.7 to 37.0 admissions per 10,000 person-years; rate ratio, 0.66; 95% CI, 0.51 to 0.86; P = 0.002), as was the rate of admissions for heart failure (from 707.7 to 513.5 admissions per 10,000 person-years; rate ratio, 0.73; 95% CI, 0.56 to 0.95; P = 0.02). However, admissions for acute kidney injury were not (101.9 and 86.0 admissions per 10,000 person-years, respectively; rate ratio, 0.84; 95% CI, 0.68 to 1.09; P = 0.19).

Citation

DREISCHULTE, T., DONNAN, P., GRANT, A., HAPCA, A., MCCOWAN, C. and GUTHRIE, B. 2016. Safer prescribing: a trial of education, informatics, and financial incentives. New England journal of medicine [online], 374(11), pages 1053-1064. Available from: https://doi.org/10.1056/NEJMsa1508955

• Journal Article Type: Article
• Acceptance Date: Mar 6, 2016
• Online Publication Date: Mar 17, 2016
• Publication Date: Mar 17, 2016
• Deposit Date: Feb 13, 2018
• Publicly Available Date: Feb 13, 2018
• Journal: New England journal of medicine
• Print ISSN: 0028-4793
• Electronic ISSN: 1533-4406
• Publisher: Massachusetts Medical Society
• Peer Reviewed: Peer Reviewed
• Volume: 374
• Issue: 11
• Pages: 1053-1064
• DOI: https://doi.org/10.1056/NEJMsa1508955
• Keywords: High risk prescribing; Primary care; Tayside; Intervention
• Public URL: http://hdl.handle.net/10059/2745