A multifaceted intervention to reduce guideline non-adherence among prescribing physicians in Dutch hospitals

Int J Clin Pharm (2017) 39:1211–1219 DOI 10.1007/s11096-017-0553-0 RESEARCH ARTICLE A multifaceted intervention to reduce guideline non‑adherence among prescribing physicians in Dutch hospitals Jacqueline M. Bos1 · Stephanie Natsch2 · Patricia M. L. A. van den Bemt3 · Johan L. W. Pot4 · J. Elsbeth Nagtegaal4 · Andre Wieringa5 · Gert Jan van der Wilt6 · Peter A. G. M. De Smet2,7 · Cornelis Kramers1,8 Received: 30 April 2017 / Accepted: 23 October 2017 / Published online: 3 November 2017 © The Author(s) 2017. This article is an open access publication Abstract Background Despite the potential of clinical practice guidelines to improve patient outcomes, adherence to guidelines by prescribers is inconsistent. Objective The aim of the study was to determine whether an approach of introducing an educational programme for prescribers in the hospital combined with audit and feedback by the hospital pharmacist reduces non-adherence of prescribing physicians to key pharmacotherapeutic guidelines. Setting This prospective intervention study with a before–after design evaluated patients at surgical, urological and orthopaedic wards. Method An educational program covering pain management, antithrombotics, fluid and electrolyte management, prescribing in case of renal insufficiency, application of * Jacqueline M. Bos 1 Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands 2 Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands 3 Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands 4 Department of Clinical Pharmacy, Meander Medical Centre, Amersfoort, The Netherlands 5 Department of Clinical Pharmacy, Isala Hospital, Zwolle, The Netherlands 6 Department of Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands 7 8 Department Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands Department of Clinical Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, The Netherlands radiographic contrast agents and surgical antibiotic prophylaxis was presented to prescribers on the participating wards. Hospital pharmacists performed medication safety consultations, combining medication review of patients who are at risk for drug related problems with visits to ward physicians. Main outcome measure The outcome measure was the proportion of the admissions of patients in which the physician did not adhere to one or more of the included guidelines. Difference was expressed in odds ratios (OR) with 95% confidence intervals (CI). Multivariable logistic regression analysis was performed. Results 1435 Admissions of 1378 patients during the usual care period and 1195 admissions of 1090 patients during the intervention period were included. Non-adherence was observed significantly less often during the intervention period [21.8% (193/886)] as compared to the usual care period [30.5% (332/1089)]. The adjusted OR was 0.61 (95% CI 0.49–0.76). Conclusion This study shows that education and support of the prescribing physician can reduce guideline non-adherence at surgical wards. Keywords Education · Guideline adherence · Medication review · Patient safety · Prescribing · The Netherlands Impacts on practice • Pharmacotherapeutic guidelines seem to be poorly imple- mented in daily clinical practice in Dutch hospitals. • Hospital pharmacists can play a leading role in the imple- mentation of key pharmacotherapeutic guidelines. • Education on guidelines and support of the prescribing physician by the hospital pharmacist are an effective way to improve guideline adherence. 13 Vol.:(0123456789) 1212 Introduction Preventable, clinically relevant problems due to complex pharmacotherapy are common among hospitalised patients [1–4]. Examples are haemorrhage, arterial or venous thrombosis, drug intoxication in renal insufficiency, delirium and faecal impaction. Many of these problems derive from prescribing errors that lead to potentially preventable morbidity, mortality and costs [5]. The majority of these are caused by pain medication, antithrombotics, antibacterial drugs, cardiovascular drugs, and drugs that are renally excreted [1–3, 6–9]. Different strategies, including introduction of computerized physician order entry (CPOE), pharmacist involvement on the ward, educational programs and support systems for clinical decision making (CDS) have been studied to address this problem and to improve clinician prescribing in hospitalized patients [10–12]. Clinical practice guidelines with evidence-based recommendations for physicians have been developed to assist doctors and to improve patient outcomes. In routine daily practice however, it appears to be difficult to implement key recommendations and guidelines seem to have limited impact on physician prescribing behaviour. Most clinicians can barely keep pace with the rapid advances in pharmacotherapy. And even if doctors are aware of the guidelines and are willing to change, to alter well established patterns of prescribing is difficult [13]. Earlier research showed that non-compliance to several guidelines by prescribers varies between 33 and 70% [14–16]. Several determinants of practice that prevent or enable guideline adherence, have been described. Guideline factors, such as quality of evidence and accessibility of the guideline, organizational factors and resources, such as the information system, frequent rotations of physicians on the ward and workload, patient factors such as increasingly complex multi-morbidity and also individual health professional factors, such as knowledge and skills, awareness and professional behaviour play a role [17, 18]. When these factors are taken into account in the development of strategies to improve guideline adherence, the quality of the treatment of hospitalised patients improves [19, 20]. Education is one of the possible strategies to tackle several of these determinants for non-adherence. Education of prescribers is most effective when it is interactive and continuous, includes discussion of evidence and local consensus and when it is followed by feedback on performance. This way of professional development needs to be built into patient care as much as possible, and should preferably take place in real time with clinical decision-support tools and patient-specific reminders to help doctors make the best decisions [21]. 13 Int J Clin Pharm (2017) 39:1211–1219 The P-REVIEW study is a prospective, multicentre, open intervention study, designed to investigate if an approach of introducing an educational programme for prescribers in the hospital combined with audit and feedback by the hospital pharmacist can lead to a clinically relevant benefit for patients at surgical wards [22]. The educational program teaches the prescriber the pharmacological aspects of using (...truncated)