Intervention Providing Feedback to Physicians and Pharmacists to Improve Drug Use

Key Implications for Decision Makers

To promote optimal drug use, it might be useful to send pharmacists the profile of drugs used by their patients.

The profiles should provide the name of each patient as well as the specific information about that patient (for example, type of drug, amount, purchase date).

The drug profiles should include an assessment of each prescription in terms of its compliance with evidence-based recommendations for correct use.

It would be desirable to attach a document to the drug profiles that presents in simple, summarized form evidence-based recommendations for the correct use of drugs.

It is not certain that sending drug profiles to physicians is effective in improving use. This will probably depend on the characteristics of these profiles. For example, it appears to be important that the profiles provide individualized data on each patient, including the patient's name, so physicians can intervene with them.

It is important that the drug profiles prepared for healthcare professionals be sent to them with a view to improving the quality of care, not monitoring their professional practice.

Executive Summary

Asthma is a disease that affects a growing number of people. Treatment costs and the costs associated with lost days of work are considerable. Several studies have shown that the drugs prescribed to treat this disease are not used in the most effective way. Some types of drugs, called inhaled short-acting ß2 agonists, which quickly relieve acute respiratory symptoms, are often over-used but do not control the asthma. In turn, other drugs, which treat the bronchial inflammation underlying respiratory problems and are recommended to control asthma (such as inhaled corticosteroids), are underused.

Physicians and pharmacists treating asthma patients are quite familiar with the various types of drugs, and have access to guides on the correct use of these drugs based on scientific studies. Given their expertise, these professionals can play an important role in helping their patients make better use of asthma drugs and control their condition. Yet physicians and pharmacists do not always have the necessary tools to intervene with their patients and correct inappropriate use of asthma drugs. For example, a physician may prescribe a drug for fast relief of asthma attack symptoms as well as a corticosteroid to maintain good control of the disease, but the patient may decide to buy only the first. Since the physician does not know that the patient has not had the corticosteroid prescription filled, it will be hard to intervene with the patient to correct the situation. In turn, pharmacists usually have all the information in their computer on drugs purchased by asthma patients. Yet this information is not always organized to indicate whether a patient's use is appropriate or not. In fact, the simple list of drugs does not quickly indicate to the pharmacist whether a given drug is being over-used while another is being under-used.

If physicians and pharmacists had clear information about the drugs purchased by their patients, indicating whether their use was consistent with guides for correct use, they might be able to intervene with their patients to promote optimal use of asthma drugs. This is precisely the assumption our study attempted to verify.

The findings of this study show that when pharmacists are sent the list of asthma drugs purchased by each of their patients (with the patient's name), use tends to approach that recommended for correct use based on the Canadian Asthma Consensus. This trend applies to short-acting ß2 agonists and long-acting ß2 agonists. We are talking about trends rather then final results, since the usual threshold for statistical significance of 0.05 has not been reached; the thresholds obtained are 0.09 for both types of drugs. However, the recommendation to use corticosteroids at the same time as long-acting ß2 agonists has not been better monitored after the profiles were sent to pharmacists. In turn, sending physicians the profiles of asthma drugs purchased by their patients has not actually changed the use of these drugs.

The study proceeded as follows. Physicians and pharmacists who, according to the data from Quebec's public drug insurance plan managed by the Régie de l'assurance maladie du Québec, had prescribed or dispensed asthma drugs to at least 10 patients five to 45 years of age over the past year were invited to take part in the study. Those who accepted (71 physicians and 60 pharmacists) were randomly divided between two groups: a test group and a control group.

The professionals in the test group received, on three occasions over a nine-month period, the profiles of asthma drugs purchased by their patients over the past year, with an indication specifying whether the prescriptions were consistent with the Canadian Asthma Consensus recommendations; a guide to correct use that inspired the recommendations by this consensus was also enclosed with the profiles. The control group received nothing during this period.

The pharmacists received a general profile for all patients who had purchased drugs in their pharmacy and specific profiles for each patient, accompanied by the patient's name. The physicians received general profiles and specific profiles for patients from whom they had obtained consent (only a few).

Another aspect of the study was intended to survey physicians' and pharmacists' opinions on the profiles and the guide to correct use sent to them. Three months after the last profiles were sent to physicians and pharmacists in the test groups, we sent them a brief questionnaire about this. The response rate was 56 percent for physicians (n=20) and 78 percent for pharmacists (n=21). The vast majority of physicians (89 percent) and all pharmacists found the profiles easy or very easy to understand. Almost all pharmacists (95 percent), but only half of the physicians, found the profiles and guide to correct use somewhat or very useful. More pharmacists (81 percent) than physicians (50 percent) stated that the profiles and guides led them to change the care they provide to their patients. For example, 71 percent of pharmacists reported taking more time to explain to their patients the role of the different asthma drugs and their appropriate use. More than half of pharmacists (57 percent) indicated that the profiles and guides allowed them to target their interventions with asthma patients more effectively. Among physicians, the main change was to spend more time educating their patients about the role of the different drugs and their appropriate use, but this was reported by only 35 percent of physicians. Interest in continuing to receive this type of profile on asthma drugs is much greater among pharmacists (95 percent) than physicians (40 percent). Finally, more pharmacists (71 percent) than physicians (39 percent) would like to receive drug profiles for other health problems.

In brief, sending drug profiles to pharmacists appears to show promise for improving some aspects of the use of asthma drugs, but we cannot truly conclude that these profiles, as designed in this study, have an impact on physicians. The fact that pharmacists received individualized profiles for all their patients, including their names, probably made these profiles more interesting and more effective.