Abstract
There is a general trend to work towards a more evidence based medical practice. An
increasing number of guidelines are being developed to translate new evidence to
medical practice. The implementation of guidelines, however, is a complex process.
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This thesis compares two methods of continuing medical education (CME).
Reimbursement data were used to provide quantitative information to support the
methods. We used the regionally organized, typically Dutch, peer review groups
(PRGs) of primary care physicians and pharmacists to address professionals. In
addition we included patient outcome measures to evaluate the effect of our program
patients' well being. Chapter 1 describes the state of the art in the diffusion of
innovations, the use of reimbursement data for research, and how to define -and how
measure- the quality of prescribing and how to measure patient outcomes. Chapter 2
is about the assessment of the quality and suitability of our data. We describe a
systematic tool to test the appropriateness of a given database for specific research
questions. It gives insight into data collecting and data quality, relevant for both
researchers and readers. We describe in particular the potency and the pitfalls of
reimbursement data and express our belief that these data need to be protected and
valued more. Chapter 3 describes how we used reimbursement data to assess the
quality of prescribing. Chapter 4 compares the prevalence of complaints mentioned
by users of anticholinergic antidepressants to a control group of former users in a
population of ambulant elderly. In Chapter 5 we compared several rating scales to
assess depression, since inclusion criteria are an essential element of good guidelines.
Chapter 6 describes qualities of the PRGs in the area. We selected and evaluated
characteristics of PRGs that were thought to be relevant for the effect of our outreach
program. Chapter 7 describes the intervention we undertook to reduce the
prescribing of highly anticholinergic antidepressants in the elderly and its effect on
incident prescribing. The intervention was designed following insights usually
referred to as academic detailing. We added a group versus individual approach
design. Addressing groups may be an important tool to support acceptance of new
guidelines. More research in group-learning processes is needed to improve our
understanding of CME. Chapter 8 compares the questionnaires of users, living in the
intervention and control areas. Chapter 9 includes some final considerations, in
which we speculate on what CME might look like in the future. What will be the role
of very large medical databases in diffusion of innovations, quality assessment and
improvement? What actually is to be defined as optimal prescribing? How do we
maintain large medical databases without jeopardizing privacy? It aims at stimulating
to think ahead -and to take action- on employing ICT (Information and
Communication Technology) for the benefit of health care. Please enjoy my
unfinished thoughts.
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