Department of Epidemiology and Biostatistics, Western Centre for Public Health and Family Medicine, 1465 Richmond St., London, ON, N6G 2M1, Canada.
ICES, Toronto, ON, Canada.
BMC Fam Pract. 2021 Dec 11;22(1):243. doi: 10.1186/s12875-021-01592-9.
Printed educational materials (PEMs) have long been used to inform clinicians on evidence-based practices. However, the evidence for their effects on patient care and outcomes is unclear. In Ontario, despite widely available clinical practice guidelines recommending antihypertensives and cholesterol-lowering agents for patients with diabetes, prescriptions remain low. We aimed to determine whether PEMs can influence physicians to intensify prescribing of these medications.
A pragmatic, 2 × 2 factorial, cluster randomized controlled trial was designed to ascertain the effect of two PEM formats on physician prescribing: a postcard-sized message ("outsert") or a longer narrative article ("insert"). Ontario family physician practices (clusters) were randomly allocated to receive the insert, outsert, both or neither. Physicians were eligible if they were in active practice and their patients were included if they were over 65 years with a diabetes diagnosis; both were unaware of the trial. Administrative databases at ICES (formerly the Institute for Clinical Evaluative Sciences) were used to link patients to their physician and to analyse prescribing patterns at baseline and 1 year following PEM mailout. The primary outcome was intensification defined as the addition of a new antihypertensive or cholesterol-lowering agent, or dose increase of a current drug, measured at the patient level. Analyses were by intention-to-treat and accounted for the clustering of patients to physicians.
We randomly assigned 4231 practices (39% of Ontario family physicians) with a total population of 185,526 patients (20% of patients with diabetes in Ontario primary care) to receive the insert, outsert, both, and neither; among these, 4118 practices were analysed (n = 1025, n = 1037, n = 1031, n = 1025, respectively). No significant treatment effect was found for the outsert (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.98 to 1.04) or the insert (OR 0.99, 95% CI 0.96 to 1.02). Percent of intensification in the four arms was similar (approximately 46%). Adjustment for physician characteristics (e.g., age, sex, practice location) had no impact on these findings.
PEMs have no effect on physician's adherence to recommendations for the management of diabetes-related complications in Ontario. Further research should investigate the effect of other strategies to narrow this evidence-to-practice gap.
ISRCTN72772651 . Retrospectively registered 21 July 2005.
印刷教育材料（PEMs）长期以来一直被用于向临床医生提供循证实践信息。然而，其对患者护理和结局的影响证据尚不清楚。在安大略省，尽管有广泛可用的临床实践指南推荐使用抗高血压药和降胆固醇药物治疗糖尿病患者，但处方仍然很低。我们旨在确定 PEM 是否可以影响医生加强这些药物的处方。
一项实用的、2×2 析因、群组随机对照试验旨在确定两种 PEM 格式对医生处方的影响：明信片大小的信息（“插页”）或较长的叙述性文章（“插入物”）。安大略省家庭医生诊所（群组）被随机分配接受插入物、插页、两者或两者都不接受。如果他们在积极实践中，并且他们的患者符合以下条件，则医生有资格参加：年龄超过 65 岁且有糖尿病诊断；两者都不知道试验。ICES（以前称为临床评估研究所）的管理数据库用于将患者与其医生联系起来，并分析 PEM 邮件发送前后的处方模式。主要结局是通过衡量患者水平的添加新的抗高血压药或降胆固醇药或增加当前药物的剂量来定义的强化治疗。分析采用意向治疗，并考虑了患者到医生的聚类。
我们随机分配了 4231 个实践（安大略省家庭医生的 39%），总共有 185526 名患者（安大略省初级保健中 20%的糖尿病患者）接受了插入物、插页、两者或两者都不接受；其中，4118 个实践被分析（n=1025，n=1037，n=1031，n=1025，分别）。插页（比值比（OR）1.01，95%置信区间（CI）0.98 至 1.04）或插入物（OR 0.99，95%CI 0.96 至 1.02）均未发现治疗效果显著。四个组的强化治疗比例相似（约 46%）。调整医生特征（例如年龄、性别、实践地点）对这些发现没有影响。
PEM 对安大略省医生遵守糖尿病相关并发症管理建议没有影响。应进一步研究其他策略的效果，以缩小这一证据与实践之间的差距。
ISRCTN72772651。回顾性注册于 2005 年 7 月 21 日。
