Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat

In the paper by Flottorp et al [1] reporting on a cluster randomised
controlled trial of a multifaceted intervention two messages are brought
forward. First, the authors conclude that a passively delivered
intervention has little effect on changing the management of UTI in women
and sore throats. Second, they advocate the use of adequately sized
cluster randomised controlled trials to evaluate interventions aimed at
implementating guidelines. As it happens, a number of rigorous trials
using hierachical models has been conducted to evaluate interventions to
implement guidelines for urinary tract infections as part of the European
Drug Education Project.[2-4] Only one of these studies is mentioned and
its findings are not adequately discussed, thereby missing the opportunity
to compare the intervention methods and to learn more about why some
interventions work better than others.

In the European Drug Education Project an active intervention
strategy was used to improve the management of urinary tract infections in
women. Small groups of general practitioners (GPs) received feedback on
their management decisions and discussed this with each other and a
(local) pharmacist in the light of specific guideline recommendations.
This type of educational programme mainly addresses the barriers relating
to competence, motivation and attitudes of the GPs, and not the logistic
or organisational barriers for implementing guidelines. Since the GPs are
actively involved in the programme and receive individual feedback, it is
tailored to their needs. The main focus of the educational programme
differed somewhat in the participating countries, since the clinically
relevant issues were found not to be identical. In Sweden [2] the focus
was on prescribing first choice drugs, whereas in the Netherlands [3] and
Norway [4] it was on the duration of treatment. The programme had effects
in the intervention group relative to the control group ranging from 12%
in Norway to 31% the Netherlands.[2-4] In comparison, this active approach
focussing on specific barriers and needs at the level of the GPs seems
more effective than the passive broad approach that tries to overcome
several possible barriers at many different levels at once.

It is important to note that our active approach was a group approach
in which support is given to encourage internal discussion and
implementation of guidelines in peer groups. Supporting local peer groups
needs less resources than supporting all practices with individual
outreach visits. In the Netherlands, there is a nationwide network of
local groups of GPs and pharmacists that discuss pharmacotherapy on a
regular basis. This familiarity with the peer group approach may explain
why the effects of the European Drug Education Project were largest is
this country.[2-5]

1. Flottorp S, Oxman AD, Havelsrud K, Treweek S, Herrin J. Cluster
randomised controlled trial of tailored interventions to improve the
management of urinary tract infections in women and sore throat. BMJ 2002;
325: 367-370

2. Stalsby Lundborg C, Wahlström R, Oke T, Tomson G, Diwan VK.
Influencing prescribing for urinary tract infection and asthma in primary
care in Sweden: a randomized controlled trial of an interactive
educational intervention. J Clin Epidemiol 1999; 52: 801-812

3. Veninga CCM, Denig P, Zwaagstra R, Haaijer-Ruskamp FM. Improving
drug treatment in general practice. J Clin Epidemiol 2000; 53: 762-772

4. Lagerlov P, Loeb M, Andrew M, Hjortdahl P. Improving doctors'
prescribing behaviour through reflection on guidelines and prescription
feedback: a randomised controlled study. Qual Health Care 2000; 9: 159-165

5. Veninga CCM, Lagerlov P, Wahlström R, et al. Evaluating an
educational intervention to improve the treatment of asthma in four
European countries. Am J Resp Crit Care Med 1999; 160: 1254-1262.