One-to-one versus Group Sessions to Improve Prescribing in Primary Care: Is a Twosome Better than a Herd Approach?

Original Citation

One-to-one versus group sessions to improve prescription in primary care: a pragmatic randomized controlled trial. Figueiras A, Sastre I, Tato F, Rodriguez C, Lado E, Caamano F, Gestal-Otero JJ.

Overall Study Question

The primary objective of the study was to evaluate the effectiveness of one-to-one education and group education of physicians with the intent of improving the prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) in primary care.  The secondary objectives were to assess the duration of the education effect on prescribing, and determine whether or not printed materials (i.e. a reminder) increases the overall effectiveness of the educational strategies.

The study population involved general and family practice physicians in Galacia, Spain (population 2.7 million).  Physicians in the one-to-one education group received a 20-minute outreach visit from 1 of 2 doctoral level pharmacists.  Those physicians receiving group education attended a 45-minute session conducted by the same pharmacists.  All subjects in both groups were provided with copies of relevant articles. In addition, some physicians in each education group were provided with an additional reminder (brief glossy printed material). The educational message for both groups included the recommendation that ibuprofen, naproxen and diclofenac are considered non-steroidal anti-inflammatory  drugs (NSAIDs) of first choice for the treatment of osteoarthritis with inflammation.

The effect of the educational interventions was assessed by calculating the rate of prescribed units of the recommended NSAIDs relative to the total NSAIDs prescribed on a monthly basis for 2 years (15 months pre-education and 9 months post-education).  ASA was excluded as it is seldom used as an NSAID in Spain.

Are the Results of the Study Valid?

Was assignment of patients randomized?

Yes.  The Galacia region was divided into 15 spatial clusters which were then randomly allocated into 3 study groups:

1) one-to-one education;

2) group education and;

3) control group.

Within the 5 clusters allocated to the one-to-one education group, 98 physicians were randomly selected.  Within the 5 clusters allocated to group education, 92 physicians from 8 health centres were selected.  The control group included all physicians (n=405) from the remaining 5 clusters.  Physicians were randomized by geographic areas rather than as individual prescribers to avoid intergroup cross-contamination.

In addition, some physicians in each of the educational groups were selected to receive glossy printed materials (i.e. reminders) to determine if these materials would increase the effectiveness of the intervention.  How the physicians were allocated to the reminder or no reminder strata is unclear.  In the one-to-one educational group, this was done ‘systematically’ (by weekday) such that 82% received the reminder.  Two of the 8 centres receiving group education were allocated to not receive the reminder, however , 11 physicians at one of these centres did receive the reminder when they requested it.

Were all patients who entered the trial properly accounted for and attributed at its conclusion?

Yes.  Ninety-four of the 98 physicians selected for one-to-one education took part in this intervention. Of the 92 physicians selected for group education, only 59 attended the educational session.  While no explanation is provided for the non-participation, the statistical analysis was done by intention-to-treat.

Were patients, their clinicians, and study personnel ‘blind’ to treatment?
No.  Prior to the start of the study, physicians in the one-to-one education group received a letter from the university conducting the study describing the study’s objectives, source of funding (a government agency) and that a doctoral level pharmacist would contact them to arrange a meeting.  The coordinators at each of the health centres where the physicians received group education received a similar letter. Researchers were blind to which physician had written which prescription.
Were the groups similar at the start of the trial?

Unable to determine.  Only general and family practice physicians were included in the study. No other demographic information is provided.

Aside from the experimental intervention, were the groups treated equally?

No.  While the introduction letter was sent to all physicians in the one-to-one education group, it was only sent to the coordinator of the health centre where the group education was taking place. Therefore, it is uncertain if all of the physicians in both groups had the same information about the study prior to its start.  In addition, one group of 11 physicians receiving group education who initially were allocated to the non-reminder group received the printed material when they requested it.

Overall, are the results of the study valid?
Partially.  The study results are valid in demonstrating that one-to-one education is more effective than group education on modifying the prescribing practices of physicians.  Unfortunately, the results assessing the impact of using a printed reminder to enhance the effectiveness of the educational interventions is not valid as the randomization process is unclear and the results are only reported for one of the 2 educational strategies.

What were the Results?

How large was the treatment effect? 

During the 9 months of follow-up, the physicians who received one-to-one education increased their rate of prescribing of the recommended NSAIDs by 6.5% in comparison to the control group (p<0.001).  The physicians who received group education increased the prescribing of the recommended NSAIDs by 2.4% in comparison to the control group (p<0.05).  One-to-one education was more effective than group education even after adjusting for the intended sample versus the actual sample (6.5% vs. 3.7%, p<0.05).

In the one-to-one education group, the researchers report that the physicians who received the reminder prescribed significantly more of the recommended NSAIDs than the physicians that did not receive the reminder although the relative changes are not reported.  The effect of the reminder in the group receiving group education was not reported.

2. How precise was the estimate of the treatment effect?

Unknown.  No information is provided.

Will the Results Help Me in Caring for My Patients?

 

Can the results be applied to my patient care?

Not applicable.

2. Were all clinically important outcomes considered?

NSAIDs were selected as the focus of the educational interventions because the investigators felt that promoting the use of NSAIDs with lower gastrointestinal risk (i.e. ibuprofen, naproxen, diclofenac) could reduce the incidence of gastric lesions.  While the study demonstrates that the educational strategies did increase the prescribing of these NSAIDs, it would have been interesting to see if there was a reduction in NSAID-associated adverse events (e.g. ulcers, bleeding, perforation, hospitalizations).

3. Are the likely treatment benefits worth the potential harms and costs?

No information is provided on the cost of conducting the educational interventions.

Commentary

The results of this study support previous reports that demonstrate that one-to-one education is effective in altering prescribing practices and the effect is sustained for at least 9 months (i.e. the duration of follow-up in this study).  The comparison of one-to-one education to group education provides new information demonstrating that although group education is also effective at changing prescribing practices, one-to-one education is comparatively more effective.  Although the investigators report that a reminder was effective in enhancing one-to-one education, it is unclear as to how the physicians were assigned to the reminder versus no reminder strata.  The imbalance between the strata suggests that it was not randomized.  As well, no analysis was conducted on the effect of the reminder on physician who received group education presumably because those physicians allocated to receive no reminder did receive the reminder.  Accordingly, we should not attempt to draw any conclusions from this study regarding the ability of a printed reminder to enhance the effectiveness of one-to-one or group education on modifying prescribing behaviour.

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