A cluster-randomized educational intervention to reduce inappropriate prescription patterns for elderly patients in general practice--The Prescription Peer Academic Detailing (Rx-PAD) study [NCT00281450]

Abstract

Background: Age-related alterations in metabolism and excretion of medications increase the risk of adverse drug events in the elderly. Inappropriate polypharmacy and prescription practice entails increased burdens of impaired quality of life and drug related morbidity and mortality. The main objective of this trial is to evaluate effects of a tailored educational intervention towards general practitioners (GPs) aimed at supporting the implementation of a safer drug prescribing practice for elderly patients > or = 70 years.

Methods/design: Approximately 80 peer continuing medical education (CME) groups (about 600 GPs) in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. The control group will not receive any intervention towards prescription patterns in elderly, but will be the target of an educational intervention for prescription of antibiotics for respiratory tract infections. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, a set of quality indicators (QIs), i.e. explicit recommendations for safer prescribing for elderly patients, will be presented and discussed. Software will be handed out for installation in participants' practice computers to enable extraction of pre-defined prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Feedback reports will include QI-scores on individual- and group levels, before and after the intervention. The main outcome of this trial is the change in proportions of inappropriate prescriptions (QIs) for elderly patients > or = 70 years following intervention, compared to baseline levels.

Discussion: Improvement of prescription patterns in medical practice is a challenging task. Evidence suggests that a thorough evaluation of diagnostic indications for drug treatment in the elderly and/or a reduction of potentially inappropriate drugs may impose significant clinical benefits. Our hypothesis is that an educational intervention program will be effective in improving prescribing patterns for elderly patients in GP settings.

Trial registration: ClinicalTrials.gov NCT00281450.

Figure 1

Flow of practices through The Rx-PAD Study. *Electronic Patient Record, **Norwegian Prescription Database, ***Prescription Peer Academic Detailer

Figure 2

Logistics of data collection. Flow-chart of merging process of prescription data provided by the Norwegian Prescription Database (NorPD) and data from the electronic patient record (EPR) systems. Patients' Civil Personal Registration (CPR) numbers are unique Norwegian residents' identification keys. Health Personnel Registration (HPR) numbers are unique Norwegian health personnel registration keys. Identifiable data will be deleted from the research database when the merge is completed, as the de-identified personal IDs will be sufficient for the subsequent data analysis. Statistics Norway, which is the public institution in Norway responsible for collecting, analyzing and disseminating official statistics, will provide CPR and HPR pseudonyms making it possible to merge the two data sources.