An automated method for analyzing adherence to therapeutic guidelines: Application in Diabetes

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1 MIE May, Göteborg/Sweden An automated method for analyzing adherence to therapeutic guidelines: Application in Diabetes Massoud Toussi, MD, MSc a,, Vahid Ebrahiminia, MD, PhD a, Philippe Le Toumelin, MD a, Régis Cohen, MD b, and Alain Venot, MD, PhD a a Lim&Bio Laboratoire d informatique médicale et de bioinformatique, University of Paris 13 b Department of Endocrinology, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, France

2 Assessing the quality of prescriptions Indicators of prescribing appropriateness Based on the Summaries of Product Characteristics (SmPCs) The appropriateness of the choice of treatments Based on Clinical Practice Guidelines (CPG) Various studies show controversial results Is this because of practice differences? methods measuring the adherence? 2

3 To develop a simple method To quantify the appropriateness of prescriptions regarding CPGs To analyze easily the situations in which the recommendations are not followed Which can be automated To apply method in type two diabetes 3

French CPGs for type two diabetes The national reference standard Widely available in electronic and paper forms A step-by-step therapeutic strategy (graded) Patient database De-identified

4 French CPGs for type two diabetes The national reference standard Widely available in electronic and paper forms A step-by-step therapeutic strategy (graded) Patient database De-identified demographic, clinical, laboratory, and therapeutic data Ambulatory patients admitted to Avicenne hospital from June 2003 to September 2004 For a periodic visit or because of deregulation Laboratory tests and clinical examination 4

5 Descriptive model of a therapy INN: International non proprietary name 5

6 Calculation of agreement values 6

7 574 patient records included Mean age: 59.9 (sd=11.4) years Mean duration of diabetes: 11.4 (sd=9.2) years Mean body mass index: 29.0 (sd=6.0) kg/m 2 Mean Hb A1C : 7.9 (sd=1.7)% 13 patients excluded Thiazolidinediones in treatment and lack of relevant information in the guideline 7

8 Type of treatment at admission Agreement between prescriptions and recommendations at discharge at three levels Type only n (% in row) Type and class n (% in row) Type, class and dose n (% in row) Number of patients Diet and exercise monotherapy bitherapy tritherapy 18 (62) 18 (62) 18 (62) (86) 117 (79) 109 (74) (82) 112 (77) 105 (72) (11) 4 (11) 4 (11) 38 Insulin alone or combined with oral therapy 205 (96) 197 (92) 160 (75) 213 Total 473 (82) 448 (78) 396 (69) 574 8

9 Type of treatment at admission Agreement between prescriptions and recommendations at discharge at three levels Type only n (% in row) Type and class n (% in row) Type, class and dose n (% in row) Number of patients Diet and exercise monotherapy bitherapy tritherapy 18 (62) 18 (62) 18 (62) (86) 117 (79) 109 (74) (82) 112 (77) 105 (72) (11) 4 (11) 4 (11) 38 Insulin alone or combined with oral therapy 205 (96) 197 (92) 160 (75) 213 Total 473 (82) 448 (78) 396 (69) 574 9

10 Type of treatment at admission Prescribed and recommended types of treatment at discharge Diet and exercise monotherapy bitherapy tritherapy Insulin alone or combined with oral therapy Number of patients Ph CPG Ph CPG Ph CPG Ph CPG Ph CPG Diet and exercise monotherapy bitherapy tritherapy Insulin alone or combined with oral therapy Total Ph: physician's prescription CPG: guideline recommendations 10

11 Type of treatment at admission Prescribed and recommended types of treatment at discharge Diet and exercise monotherapy bitherapy tritherapy Insulin alone or combined with oral therapy Number of patients Ph CPG Ph CPG Ph CPG Ph CPG Ph CPG Diet and exercise monotherapy bitherapy tritherapy Insulin alone or combined with oral therapy Total Ph: physician's prescription CPG: guideline recommendations 11

12 Type of treatment at admission Prescribed and recommended types of treatment at discharge Diet and exercise monotherapy bitherapy tritherapy Insulin alone or combined with oral therapy Number of patients Ph CPG Ph CPG Ph CPG Ph CPG Ph CPG Diet and exercise monotherapy bitherapy tritherapy Insulin alone or combined with oral therapy Total Ph: physician's prescription CPG: guideline recommendations 12

Lack of details in CPGs Comparison convention Reasons of non adherence Extensibility of basic concepts Dose and class: universal concepts Type :

13 Lack of details in CPGs Comparison convention Reasons of non adherence Extensibility of basic concepts Dose and class: universal concepts Type : common in chronic diseases Existing approaches for measuring adherence Explicit criteria, physican surveys, guideline impact, patient records 13

Our method was automated and used to measure prescribing appropriateness to analyze a CPG for followed / not followed recommendaitons Possible applications Monitoring

14 Our method was automated and used to measure prescribing appropriateness to analyze a CPG for followed / not followed recommendaitons Possible applications Monitoring (automatically) the evolution of adherence over time Making measurements which can be compared with each other for various CPGs Exploring decision-making pathways of medical experts 14

[1] Buetow SA, Sibbald B, Cantrill JA, Halliwell S. Prevalence of potentially inappropriate long term prescribing in general practice in the United Kingdom, 1980-95: systematic literature review. BMJ.

15 [1] Buetow SA, Sibbald B, Cantrill JA, Halliwell S. Prevalence of potentially inappropriate long term prescribing in general practice in the United Kingdom, : systematic literature review. BMJ. 1996;313: [2] Coste J, Sene B, Milstein C, Bouee S, Venot A. Indicators for the automated analysis of drug prescribing quality. Methods Inf Med. 1998;37: [3] Coste J, Venot A. An epidemiologic approach to drug prescribing quality assessment: a study in primary care practice in France. Med Care. 1999;37: [4] Muijrers PE, Janknegt R, Sijbrandij J, Grol PR, Knottnerus JA. Prescribing indicators. development and validation of guideline-based prescribing indicators as an instrument to measure the validation in prescribing behaviour of general practitioners. Eur J Clin Pharmacol. 2004;60: [5] Asch SM, Kerr EA, Lapueta P, Law A, McGlynn EA. A new approach for measuring quality of care for women with hypertension. Arch Intern Med. 2001;161: [6] Balas EA. Trends in hypertensive drug therapy by US office-based physicians. Hypertension. 2001;37:E12. [7] Weiss R, Buckley K, Clifford T. Changing patterns of initial drug therapy for the treatment of hypertension in a medicaid population, Clin Ther. 2002;24: [8] Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR.Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282: [9] Lomas J, Anderson GM, Dominick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med. 1989; 321: [10] Milchak JL, Carter BL, James PA, Ardery G. Measuring adherence to practice guidelines for the management of hypertension: an evaluation of the literature. Hypertension. 2004;44; [11] Aminzadeh F. Adherence to recommendations of community-based comprehensive geriatric assessment programmes. Age Ageing. 2000;29: [12] Stratégie de prise en charge du patient diabétique de type 2 à l'exclusion de la prise en charge des complications. Paris : Agence Nationale d' Accréditation et d' Evaluation en Santé; available from: APEH-3YTFUH?OpenDocument&Defaut=y& [13] WHO Collaborating Centre for Drug Statistics Methodology, ATC Classification index with DDDs Oslo [14] Wolfe RM, Sharp LK, Wang RM. Family physicians' opinions and attitudes to three clinical practice guidelines. J Am Board Fam Pract. 2004;17: [15] Mosca L, Linfante AH, Benjamin EJ, Berra K, Hayes SN, Walsh BW, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111: [16] Milchak JL, Carter BL, Ardery G, Black HR, Bakris GL, Jones DW, et al. Development of explicit criteria to measure adherence to hypertension guidelines. J Hum Hypertens. 2006;16. 15

16 For more information: 16

17 Analysis of the guideline Checking the system Comparison algorithm A more detailed level of comparison 17

18 Comprehension of the CPG decision-making flow HbA1c<6,5% Do not change Diet and exercise monotherapy dose to maximum± Change ATC Class Bitherapy Dose to maximum ± Change ATC class Insulin therapy with oral therapy Insulin therapy dose to maximum Intensive insulin therapy 18

19 19

20 *: If nothing is generated by system consider Yes by convention. 20

21 ATC pharmacotherapeutic class of oral treatment at admission ATC pharamcotherapeutic classes of prescribed or recommended oral treatments at discharge B or B or S or * B S A BS BA SA BSA nothing A Ph CPG Ph CPG Ph CPG Ph CPG Ph CPG Ph CPG Ph CPG Ph CPG CPG CPG Total * B S A BS BA SA BSA Total Ph: physician's prescription CPG: guideline B: biguanides S: Sulfonylurea A: alphaglucosidase inhibitors *: Patients not treated with oral antidiabetic agents (treated with diet and exercise, or insulin). : The guideline allows physicians to choose to combine metformine with insulin therapy or not. : The guideline allows physicians to choose any pharmacotherapeutic class for oral monotherapy 21