Ho Mei-Jen, Venci Jineane
University of South Florida College of Pharmacy, Tampa, FL 33612, USA.
J Manag Care Pharm. 2012 Oct;18(8):627-49. doi: 10.18553/jmcp.2012.18.8.627.
Educational interventions have long been used as a means of influencing prescribing behavior. Various techniques including educational mailings, academic detailing, prescriber feedback with or without disclosing patient-identifying data, and supplemental patient information have been used to promote appropriate prescribing habits, reduce costs, and optimize patient care. While the effects of educational intervention programs are widely reported, little information is available regarding the effectiveness of various mailed intervention techniques.
To review the effectiveness of mailed intervention programs and identify factors that may promote successful outcomes.
A literature search was conducted via PubMed for reports of mailed intervention programs published through May 2012. Specific search terms included "drug utilization review," "drug utilization," "Medicaid," "prescribing feedback," "mailed physician intervention," and "mailed physician communications." Identified publications that met the following criteria were selected for inclusion: (a) evaluated printed educational materials disseminated via postal mail, (b) occurred in an outpatient setting, and (c) measured intervention impact on prescribing patterns, health care utilization, or economic outcomes. Publications that met all 3 criteria were abstracted for intervention strategy, follow-up period, data source, intervention target, prescriber acceptance of intervention, and effect on prescribing patterns, health care utilization, and economic outcomes.
A total of 40 published reports regarding 39 unique interventions met inclusion criteria. The majority (34/39 [87.2%]) of studies were conducted in state or federally funded programs; only 5 programs involved private insurers. All programs used follow-up periods of ≤12 months after final intervention mailing. A total of 26 of the 39 unique interventions reported a positive impact on at least 1 target outcome. Programs that included a second recipient such as pharmacists (n = 4) reported a greater impact as compared with interventions mailed to prescribers alone. Programs that provided patient-identifying data had a higher success rate than those that supplied prescriber feedback and/or educational materials (21/25 [84.0%] vs. 5/14 [35.7%]); it should be noted that 2 of the 5 successful programs that provided nonpatient-identifying materials also used academic detailing. Programs that sent education material and/or prescriber feedback pertaining to multiple medication classes or disease states had minimal impact on prescribing patterns (n = 4). However, targeting 1 specific disease or medication supported by appropriate evidence resulted in favorable change in a short period of time. Additionally, providing recommendations that were supported by widely accepted clinical guidelines or literature were also associated with a high rate of success. A subset of programs that sought to evaluate health care utilization (n=5) and economic impact (n = 9) observed little change in measured outcomes. Evaluation of prescriber response forms conducted by 7 programs revealed that changes in therapy occurred in approximately 50% of patients with prescribers who intended to accept intervention recommendations.
Though the degree of heterogeneity between articles prevents provision of definite results, it appears that a well-constructed mailed intervention program has the potential to evoke significant changes in prescribing patterns. Prescribers appear to be receptive to mailed interventions; however, there are limited data to determine the association between acceptance and actual prescribing change. Future research should focus on identifying barriers that may prohibit acceptance of recommendations from translating into changes in therapy. Additionally, future projects should include longer assessment periods to determine the duration of impact following final intervention mailing and potential effect on health care and economic outcomes.
长期以来，教育干预一直被用作影响处方行为的一种手段。包括教育邮件、学术推广、提供或不提供患者识别数据的处方者反馈以及补充患者信息等各种技术，已被用于促进合理的处方习惯、降低成本并优化患者护理。虽然教育干预项目的效果已有广泛报道，但关于各种邮寄干预技术有效性的信息却很少。
回顾邮寄干预项目的有效性，并确定可能促进成功结果的因素。
通过PubMed对截至2012年5月发表的邮寄干预项目报告进行文献检索。具体检索词包括“药物利用审查”“药物利用”“医疗补助”“处方反馈”“邮寄给医生的干预措施”以及“邮寄给医生的沟通内容”。选择符合以下标准的已识别出版物纳入研究：（a）评估通过邮政邮件传播的印刷教育材料；（b）在门诊环境中进行；（c）测量干预对处方模式、医疗保健利用或经济结果的影响。符合所有三项标准的出版物被提取出干预策略、随访期、数据来源、干预目标、处方者对干预的接受程度以及对处方模式、医疗保健利用和经济结果的影响。
共有40篇关于39项独特干预措施的已发表报告符合纳入标准。大多数（34/39 [87.2%]）研究是在州或联邦资助项目中进行的；只有5个项目涉及私人保险公司。所有项目在最后一次干预邮件发送后的随访期均≤12个月。39项独特干预措施中共有26项报告对至少1个目标结果有积极影响。与仅邮寄给处方者的干预措施相比，包括第二名接收者（如药剂师）的项目（n = 4）报告的影响更大。提供患者识别数据的项目比提供处方者反馈和/或教育材料的项目成功率更高（21/25 [84.0%] 对 5/14 [35.7%]）；应当指出，提供非患者识别材料的5个成功项目中有2个也采用了学术推广。发送与多种药物类别或疾病状态相关的教育材料和/或处方者反馈的项目对处方模式影响最小（n = 4）。然而，针对有适当证据支持的1种特定疾病或药物在短时间内可产生有利变化。此外，提供得到广泛认可的临床指南或文献支持的建议也与高成功率相关。一部分旨在评估医疗保健利用（n = 5）和经济影响（n = 9）的项目观察到测量结果变化不大。7个项目对处方者回复表的评估显示，在打算接受干预建议的处方者所治疗的患者中，约50%出现了治疗变化。
尽管文章之间的异质性程度使得无法提供确切结果，但精心构建的邮寄干预项目似乎有可能引起处方模式的显著变化。处方者似乎接受邮寄干预；然而，确定接受与实际处方变化之间关联的数据有限。未来的研究应侧重于识别可能阻止建议被接受转化为治疗变化的障碍。此外，未来的项目应包括更长的评估期，以确定最后一次干预邮件发送后的影响持续时间以及对医疗保健和经济结果的潜在影响。
