The BMJ ( IF 105.7 ) Pub Date : 2019-10-02 00:00:00 , DOI: 10.1136/bmj.l5205 Alex J Walker , Felix Pretis , Anna Powell-Smith , Ben Goldacre
Objectives To determine how clinicians vary in their response to new guidance on existing or new interventions, by measuring the timing and magnitude of change at healthcare institutions.
Design Automated change detection in longitudinal prescribing data.
Setting Prescribing data in English primary care.
Participants English general practices.
Main outcome measures In each practice the following were measured: the timing of the largest changes, steepness of the change slope (change in proportion per month), and magnitude of the change for two example time series (expiry of the Cerazette patent in 2012, leading to cheaper generic desogestrel alternatives becoming available; and a change in antibiotic prescribing guidelines after 2014, favouring nitrofurantoin over trimethoprim for uncomplicated urinary tract infection (UTI)).
Results Substantial heterogeneity was found between institutions in both timing and steepness of change. The range of time delay before a change was implemented was large (interquartile range 2-14 months (median 8) for Cerazette, and 5-29 months (18) for UTI). Substantial heterogeneity was also seen in slope following a detected change (interquartile range 2-28% absolute reduction per month (median 9%) for Cerazette, and 1-8% (2%) for UTI). When changes were implemented, the magnitude of change showed substantially less heterogeneity (interquartile range 44-85% (median 66%) for Cerazette and 28-47% (38%) for UTI).
Conclusions Substantial variation was observed in the speed with which individual NHS general practices responded to warranted changes in clinical practice. Changes in prescribing behaviour were detected automatically and robustly. Detection of structural breaks using indicator saturation methods opens up new opportunities to improve patient care through audit and feedback by moving away from cross sectional analyses, and automatically identifying institutions that respond rapidly, or slowly, to warranted changes in clinical practice.
中文翻译:
NHS临床医生对有保证的行为改变的反应性差异:纵向处方数据中改变检测方法的新颖实现
目的通过测量医疗机构变更的时机和幅度,确定临床医生对现有或新干预措施的新指南的反应方式如何变化。
设计纵向处方数据中的自动更改检测。在英语初级保健中
设置处方数据。
参加者英语通用练习。
主要观察指标在每种实践中,都测量了以下内容:最大变化的时机,变化斜率的陡度(每月比例的变化)以及两个示例时间序列的变化幅度(2012年Cerazette专利到期,从而使价格更便宜)通用的去氧孕烯替代品上市; 2014年后抗生素处方指南发生变化,在无并发症的尿路感染(UTI)中,呋喃妥因优于甲氧苄氨嘧啶。
结果机构之间在变化的时机和变化的陡度上都存在很大的异质性。实施更改之前的时间延迟范围较大(Cerazette的四分位间距为2-14个月(中位数为8),UTI的时间间隔为5-29个月(18岁))。在检测到变化之后,在坡度上也观察到了很大的异质性(Cerazette,每月四分位间距的绝对减少量为2-28%(中位数为9%),UTI的幅度为1-8%(2%))。实施更改后,更改的幅度显示出异质性大大降低(Cerazette的四分位间距为44-85%(中位数为66%),UTI的四分位间距为28-47%(38%))。
结论观察到个别NHS一般实践对临床实践中有根据的变化做出反应的速度存在显着差异。处方行为的变化可以自动而可靠地检测到。使用指标饱和度方法检测结构性断裂开辟了新的机会,可通过脱离横截面分析并自动识别对临床实践中需要快速或缓慢响应的机构,通过审核和反馈来改善患者护理。