Daniel Pinto

An open cluster-randomized, 18-month trial to compare the effectiveness of educational outreach visits with usual guideline dissemination to improve family physician prescribing

BackgroundThe Portuguese National Health Directorate has issued clinical practice guidelines on prescription of anti-inflammatory drugs, acid suppressive therapy, and antiplatelets. However, their effectiveness in changing actual practice is unknown.MethodsThe study will compare the effectiveness of educational outreach visits regarding the improvement of compliance with clinical guidelines in primary care against usual dissemination strategies. A cost-benefit analysis will also be conducted. We will carry out a parallel, open, superiority, randomized trial directed to primary care physicians. Physicians will be recruited and allocated at a cluster-level (primary care unit) by minimization. Data will be analyzed at the physician level. Primary care units will be eligible if they use electronic prescribing and have at least four physicians willing to participate. Physicians in intervention units will be offered individual educational outreach visits (one for each guideline) at their workplace during a six-month period. Physicians in the control group will be offered a single unrelated group training session. Primary outcomes will be the proportion of cyclooxygenase-2 inhibitors prescribed in the anti-inflammatory class, and the proportion of omeprazole in the proton pump inhibitors class at 18 months post-intervention. Prescription data will be collected from the regional pharmacy claims database. We estimated a sample size of 110 physicians in each group, corresponding to 19 clusters with a mean size of 6 physicians. Outcome collection and data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and detailers cannot be blinded.DiscussionThis trial will attempt to address unresolved issues in the literature, namely, long term persistence of effect, the importance of sequential visits in an outreach program, and cost issues. If successful, this trial may be the cornerstone for deploying large scale educational outreach programs within the Portuguese National Health Service.Trial registrationClinicalTrials.gov number NCT01984034.

Initial therapeutic choices for hypertension in the Portuguese Sentinel Practice Network

INTRODUCTION AND OBJECTIVES Finding out which drugs are chosen to treat incident cases of hypertension may help in interpreting prevalent use of antihypertensive agents. We aimed to determine the proportion of patients who begin treatment with each antihypertensive drug class, which physicians initiate treatment and whether family physicians alter prescriptions initiated by others, and to compare the prescribing patterns of family physicians and other specialists. METHODS In this cohort-nested cross-sectional study between 2014 and 2015 within the Portuguese Sentinel Practice Network, family physicians notified incident cases of hypertension, reporting treatment, who issued the initial prescription and whether treatments initiated by other physicians were changed. RESULTS A total of 681 incident cases were notified. The initial prescription was issued by the patients family physician in 86.9% of cases (95% CI: 84.2-89.3%). The most frequently used agents were angiotensin-converting enzyme inhibitors (51.3% of patients, 95% CI: 47.5-55.0%), thiazide and thiazide-like diuretics (32.2%, 95% CI: 28.8-35.8%), and angiotensin receptor blockers (21.4%, 95% CI: 18.5-24.7%). Compared to other specialists, family physicians used less beta-blockers (20.4 vs. 5.9%, p<0.001) and loop diuretics (8.2 vs. 0.8%, p=0.003). Prescriptions initiated by other specialists were changed by family physicians in 11.6% of cases (95% CI: 6.0-19.6%). CONCLUSION Angiotensin-converting enzyme inhibitors were the most frequently prescribed antihypertensive class. Most diagnoses were made by the patients own family physician. Prescriptions initiated by other specialists were usually continued by family physicians. Prescribing patterns were similar between family physicians and other specialists, except for lower use of beta-blockers and loop diuretics.

Effect of European Medicines Agency's regulatory measures on nimesulide utilization in Portugal

Severe hepatic adverse events led the European Medicines Agency to recommend restrictions on nimesulide use. Our aim was to determine their effect on nimesulide dispensing in Portugal.

Effect of European Medicines Agency's restrictions on trimetazidine utilization in Portugal.

Following safety concerns regarding trimetazidine, the European Medicines Agency (EMA) recommended restrictions on its use. Our objective was to determine the impact of regulatory actions on trimetazidine utilization in Portugal.