1. Study identification
EU PAS Register NumberEUPAS5149
Official titleAn open cluster-randomized, 18 month trial to compare the effectiveness of educational outreach visits with usual guideline dissemination to improve family physician prescribing
Study title acronymTEP (Trial Educational outreach Prescribing)
Study typeOther: Clinical Trial with no Human Medicine (Behavior Intervention)
Brief description of the studyBackground: The Portuguese National Health Directorate has issued guidelines on prescription of anti-inflammatory drugs, acid suppressive therapy, and antiplatelets. However, their effectiveness in changing actual practice is unknown. Methods: The study will compare the effectiveness of educational outreach visits regarding the improvement of clinical guidelines compliance with 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 months 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.
Discussion: This 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 in Portugal.
Was this study requested by a regulator?No
Is the study required by a Risk Management Plan (RMP)?
Regulatory procedure number (RMP Category 1 and 2 studies only)
Other study registration identification numbers and URLs as applicable
2. Research centres and Investigator details
Coordinating study entity
Department/Research groupCEDOC - Chronic Diseases Research Center of the Faculdade de Ciências Médicas da Universidade Nova de Lisboa
Organisation/affiliationFaculdade Ciências Médicas Univ. Nova Lisboa
Details of (Primary) lead investigator
Title Professor
Last name Caetano
First name Pedro
Is this study being carried out with the collaboration of a research network?
No
Other centres where this study is being conducted
Not applicable (single centre)
Countries in which this study is being conducted
National study
Portugal
3. Study timelines: initial administrative steps, progress reports and final report
PlannedActual
Date when funding contract was signed11/04/2012
Start date of data collection29/11/201301/01/2014
Start date of data analysis30/06/201430/06/2014
Date of interim report, if expected
Date of final study report31/03/2016
4. Sources of funding
Please provide estimates of the percentage of funding by source for this study
Names(s)Approximate % funding
Pharmaceutical companies
Charities
Government bodyMinistério da Saúde, INSA, I.P.100
Research councils
EU funding scheme
5. Contact details for enquiries
Scientific Enquiries
Title Professor
Last name Caetano
First name Pedro
Address line 1Grupo de Informação Académica Independente
Address line 2CEDOC da Faculdade de Ciências Médicas - UNL
Address line 3Ed. CEDOC I, Rua do Instituto Bacteriológico, n.º 5, 5-A e 5-B, 2º piso, sala 2.20
CityLisbon
Postcode1150-190
CountryPortugal
Phone number (incl. country code)00351218803101
Alternative phone number
Fax number (incl. country code)
Public Enquiries
Title Mrs
Last name Gomes
First name Ines
Address line 1Grupo de Informação Académica Independente
Address line 2CEDOC da Faculdade de Ciências Médicas - UNL
Address line 3Ed. CEDOC I, Rua do Instituto Bacteriológico, n.º 5, 5-A, 5-B, 2º piso, sala 2.11
CityLisbon
Postcode1150-190
CountryPortugal
Phone number (incl. country code)351218803101
Alternative phone number
Fax number (incl. country code)
6. Study drug(s) information
Not applicable (disease/epidemiology study)
7. Medical conditions to be studied
Medical condition(s)Yes
Gastrooesophageal reflux disease
Gastrointestinal disorder
Cardiovascular disorder
Pain
8. Population under study
Age
Adults (18 - 44 years)
Adults (45 - 64 years)
Sex
Male
Female
9. Number of subjects
Estimated total number of subjects220
Additional information
Assuming a mean cluster size of 6 physicians per unit, a 1:1 allocation ratio of controls per intervention unit, an alpha type error of 0.025, and a dropout rate of about 15%, then a sample of 110 physicians per group will allow for 80% power to demonstrate 5% absolute increase in omeprazole proportion and 5% absolute decrease in COX-2 inhibitors. 38 primary care units (clusters) will be required.
10. Source of data
Is this study being carried out with an established data source?No
Sources of data
Prescription event monitoring
Administrative database, e.g. claims database
Routine primary care electronic patient registry
11. Scope of the study
What is the scope of the study?
Drug utilisation study
Primary scope : Drug utilisation study
12. Main objective(s)
What is the main objective of the study?
This trial aims to assess whether educational outreach visits are superior to usual implementation of guidelines regarding the reduction of inappropriate prescribing (compliance with prescription guidelines by family physicians). This for prescriptions of NSAIDs, Proton Pump Inhibitors, and anti platelets. The trial will also determine the cost-benefit of educational outreach visits.
Are there primary outcomes?Yes
Two primary outcomes at physician´s level: The proportion of COX-2 inhibitors (anatomical therapeutic classification [ATC] M01AH) prescribed within the entire NSAID class (ATC M01A) in defined daily doses 18 months after the intervention. The proportion of omeprazole (ATC A02BC01) within the entire proton pump inhibitors class (ATC A02BC) in defined daily doses 18 months after the intervention.
Are there secondary outcomes?Yes
There are seven secondary outcomes, also measured at the physician´s level: The proportion of COX-2 inhibitors within the NSAID class at 1 and 6 months; the proportion of omeprazole within the proton pump inhibitors class at 1 and 6 months; and the number of defined daily doses of clopidogrel prescribed per 1000 registered patients at 1, 6 and 18 months.
13. Study design
What is the design of the study?
Prescription event monitoring
Drug utilisation study
Randomised controlled trial
14. Follow-up of patients
Will patients be followed up?Not applicable/no follow-up
15. Data analysis plan
Please provide a brief summary of the analysis method
Researchers will have access to prescription data through a data monitoring system operated by the Lisbon (Portugal) Regional Health Administration. Data will be collected and provided by employees from this Administration according to researcher defined specifications. Importantly, researchers will not be directly involved in data collection. This information arrives with a two month delay from the date the prescription is dispensed. Data of prescribing
physicians will be analyzed according to their randomly allocated group regardless of adherence to the intervention (intention to treat analysis). Both groups will be compared on primary outcomes using generalized mixed-effects models. The ratio of COX-2 inhibitors to the entire NSAIDs class and the ratio of omeprazole to the entire proton pump inhibitors class and respective 95% confidence intervals will be calculated. Statistical significance will be assumed for a p-value less than 0.025.