Assessment of drug prescription in the community: utilization of criterion-based guidelines

Beresford, Kathie L. (1998) Assessment of drug prescription in the community: utilization of criterion-based guidelines. Masters thesis, Memorial University of Newfoundland.

[English] PDF (Migrated (PDF/A Conversion) from original format: (application/pdf)) - Accepted Version Available under License - The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. Download (19MB) [English] PDF - Accepted Version Available under License - The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. (Original Version)

Abstract

Pharmaceuticals are a fundamental component of health care delivery in today's society. Yet the necessity and appropriateness of their prescription is sometimes questionable. We performed two pilot studies to determine the feasibility of: (1) collecting patient specific data from physicians, (2) applying clinical practice guidelines to family physicians' therapeutic decisions and (3) using a trained research team versus an expert panel to measure the appropriateness of these decisions. These studies (a) examined the utilization of drugs for upper gastrointestinal (GI) disorders and (b) antimicrobial agents. In both studies two panels assessed the physicians' diagnostic and treatment decisions. To assess appropriateness of these decisions an expert panel used implicit clinical judgement and a research team applied explicit criterion-based guidelines. Comparisons of the decisions made by these two panels determined that it is feasible for a research team to apply guidelines to patient specific data and make decisions regarding the optimal treatment regime for patients examined. -- The first study examined the use of drugs effective in the treatment of upper GI disorders as prescribed by six family physicians. The treatment decisions made by the physicians and subsequently judged by two panels showed that the panels agreed 95% of the time on the optimality of the physicians' decisions. From the high level of agreement we conclude that it is feasible to assess therapeutic decisions through the application of guidelines by a research team versus by an expert panel. However, the decisions made by the expert panel were used to assess the appropriateness of physicians' therapeutic decisions. Of the four drug categories analyzed, the overutilization and underutilization rates were: proton pump inhibitors 12 and 35%; H2 receptor antagonists 22 and 14%; antibiotics 3 and 55%; and prokinetics 8 and 0% respectively. -- The second study investigated infection-related illnesses and the utilization of antibiotics by four family physicians. Two panels were involved in assessing the necessity for antibiotics and appropriateness of choice, using the Ontario Anti-infective Guidelines for Community-acquired Infections (1997). Patient interviews were performed and the congruency between patient and physicians' description of primary symptoms was 90%. Of the 98 patients included in the assessment, 22 were prescribed an antibiotic. When compared to the expert panel's decisions the subsequent application of the guidelines to the physicians' treatment decisions by a research team was highly sensitive and specific regarding the necessity for antibiotics but there was less agreement regarding the appropriateness of the type of antibiotic prescribed. -- We conclude from both studies that it is feasible to collect patient specific data from physicians sufficient to assess therapy using a research team versus an expert panel and for the research team to judge prescribing appropriateness by applying explicit criterion-based guidelines. As a result of these pilot studies, two studies were designed to identify inappropriate prescription in the community, and to assess the impact of educational interventions on improving the prescribing practices of family physicians.

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