Monday, December 30, 2019

Changing physician behavior to avoid unnecessary steroid prescriptions

- Jennifer Middleton, MD, MPH

"Short-Term Systemic Corticosteroids: Appropriate Use in Primary Care," e-published ahead of print this past week, reviews several diagnoses that steroids are commonly prescribed for along with the evidence base - or lack thereof - to support their use. Regarding the latter, Drs. Dvorin and Ebell review the evidence against short-term steroid use in allergic rhinitis, acute sinusitis, carpal tunnel syndrome, and acute bronchitis (in the absence of an underlying asthma or COPD diagnosis). Besides not improving patient-oriented outcomes for these conditions, the risks of a short-term course of steroids are not negligible. Changing treatment habits can be challenging for physicians, but implementing strategies that do successfully promote physician behavior change may be one worthwhile resolution to make for the upcoming new year.

Two recent articles provide guidance regarding the promotion of physician behavior change. The first, a comprehensive review published in 2017, found that "[c]ollaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective:" 
"Interactive and multifaceted continuous medical education programs including training with audit and feedback, and clinical decision support systems were found to be of benefit in improving knowledge, optimizing prescriptions...enhancing patient outcomes, and reducing adverse events." 
Interestingly, financial incentives were not found to meaningfully effect long-term behavior change regarding physician prescribing and/or treatment habits.

The second article, a rapid review conducted in Australia, specifically examined "changing prescribing behaviors with educational outreach:"
"Educational outreach involves a trained facilitator delivering a face-to-face program in a health professional’s setting (e.g. GP clinic) with the aim to change clinician behaviour, such as prescribing behaviours [sic]. Educational outreach programs can focus largely on education...or include a variety of supplemental or additional strategies like providing reminder letters or audit and feedback." 
This review found that educational outreach can be effective, but it was most effective when it focused on "specifically targeting barriers" to change. Semi-structured interviews of physicians included in the review additionally suggested that the "[c]ontent of EO visits needs to be practical, skills-focused and engaging to facilitate participation and uptake, as opposed to didactic or lecture-based."

These studies found that simple interventions, such as financial incentives and generic didactic content, were not effective, while more complex solutions, such as involving interdisciplinary teams in crafting policy change and tailoring educational outreach, were effective. If healthcare leaders and organizations want to promote meaningful change in physician behavior, then investment in these more complex solutions may be worth the effort.

The transition to a new year is often a time for resolutions regarding behavior change; in addition to avoiding unnecessary steroid prescriptions, perhaps you might also consider resolving to expand how you access AFP's content, such as using the Favorites feature on the homepage, listening to the podcast, viewing our YouTube videos, or following us on Twitter.