Improving Primary Care Pharmaceutical Use
the reasons underlying a particular practice before trying to change it; and the need to test well-targeted, multi-faceted approaches to solutions. Furthermore, interventions were likely to be culturally mediated, and what worked in one environment might not in another. To date there has been no systematic review to summarize the last decade=s experience about changing drug use in developing countries.
Experiences from Developed Countries
A number of reviews of interventions to improve prescribing have been undertaken in developed countries. In a 1984 review of hospital-based interventions, Soumerai and Avorn identified 31 studies that met minimum study design criteria.(Soumerai 1984) In 1989, the same authors reviewed published experience in primary care interventions, and 44 reports of educational, managerial and regulatory approaches were identified.(Soumerai 1989) These two reports concluded that printed educational materials may change knowledge, but do not change practice. They described limited evidence for the effectiveness of group lectures and discussion. Routine reminder systems linked to prescribing were found to have some effect, as was ongoing feedback of physician performance. The most effective interventions were those based on face-to-face educational visits. The authors commented on the need for better designed controlled or quasi-experimental design studies to clarify which are the effective interventions.
Raisch in 1990 categorized methods used to influence prescribing into direct methods, with individual and practice factors, indirect methods, and continuing education.(Raisch 1990a, 1990b). While agreeing that one-on-one interactions were effective, he reported that the positive effects of printed individual feedback may not be sustained. Grimshaw and Russell in 1993 reviewed studies of clinical guidelines, many involving recommendations about drug therapies.(Grimshaw 1993) Using rigorous criteria, they identified 59 published evaluations, and found significant improvements in all but four studies. They concluded that standard treatment guidelines can improve performance when introduced within an audit system where adherence to guidelines is systematically reviewed.
In 1995 Davis and others published a large review of continuing medical educational (CME) strategies.(Davis 1995) Based on 99 trials with 160 interventions, they reported that in about two-thirds of the