Svetlana V. DoubovaDolores Mino-LeonHortensia Reyes MoralesSergio Flores-HernándezRicardo Pérez-Cuevas

Svetlana V. DoubovaDolores Mino-LeonHortensia Reyes MoralesSergio Flores-HernándezRicardo Pérez-Cuevas

There is a high frequency of prescription of non-opioid analgesics (NOAs), second only to cardiovascular drugs.

Several studies have reported that medical doctors do not prescribe properly and patients do not use the NOAs appropriately.

This finding is evidenced by overutilization rates of up to 41%

and by the frequent appearance of preventable adverse events.-42% of the medical doctors are unaware of the adverse events

that NOAs cause.

-34% of patients are unsure about the proper method of taking NOAs, despite the fact that these are among the most common self-medicated drugs.

To develop and test two educational programs (interactive and passive) aimed at improving family doctors’ (FDs) prescribing practices and patient’s knowledge and use of NOAs.

Methods: The educational programs were conducted in two

family medicine clinics belonging to the Mexican Institute of Social Security in Mexico City.

The study was performed in three stages: 1) Baseline evaluation 2) Implementation of educational activities3) Post-program evaluation.

EDUCATIONAL PROGRAMS

INTERACTIVE (IEP) PASSIVE (PEP)

FAMILY DOCTORS

WORKSHOPS, DISCUSSION

GROUPS, IN-SERVICE TRAINING

1 MOUNTH

PATIENTS

VIDEO, LIFLET,INTERACTIVE EDUCATIONAL

SESSION

1 OCASION PER PATIENTE

FAMILY DOCTORS

CLINICAL GUIDELINE

1 OCASION

PATIENTS

LIFLET

1 OCASION

All FDs working at the clinics were invited to participate in the programs, and most (99%) of them accepted the invitation.

There were 58 FDs in the IEP group and 52 FDs in the PEP group.

The eligibility criteria for patients were: age ≥ 50 years, suffered from non-malignant pain

syndrome, had received at least one NOA prescription for a period of ≥ 7 days, were under the care of the participating FDs, and were able to answer the questions posed during the interview.

The baseline and post-program evaluations included 300 patients by group.

The effect of the programs: on the FDs was measured through the

appropriateness of prescriptions of NOA and analyzed using the differences-in-differences estimator (D-in-D)

on patients through changes in self-medication and in their knowledge about the proper use and adverse events by analyzing the inter- and intra-group differences before and after the programs.

Baseline evaluation stage

Post-programs evaluation stage

IEP

n=58

Average proportion

PEP

n=52

Average proportion

IEP

n=58

Average proportion

PEP

n=52

Average proportion

Paracetamol 35.2 36.4 57.4* 42.9NSAIDs*** 89.7 87.2 76.6 81.4NSAIDs contraindicated in the elderly 31.3 24.4 15.6* 24.0Simultaneous prescription of multiple NSAIDs 10.1 6.6 1.2 2.8NSAID prescribed to patients with chronic renal failure 1.3* 4.6 1.4 2.4Prescription of NSAID without gastric protectors to patients in risk of gastrointestinal adverse effects

3.8* 10.3 1.6 2.9

*p<0.05 *p<0.05 between groupsbetween groupsA comparison of data from the IEP and PEP groups (i.e., baseline and

post-program evaluation data) revealed that prescription of paracetamol increased and NSAIDs decreased in the IEP group (p < 0.05), particularly with regard to prescriptions for elderly patients.

IEPn= 58

PEPn=52

Pre-intervention stage Average proportion 95% confidence interval

65.2(59.5 – 71.0)

62.0(56.1 – 67.9)

Post-intervention stageAverage proportion95% confidence interval

82.6( 78.0 – 87.2)

68.0(62.8 – 73.2)

Difference in the average proportion95% confidence interval

17.4 **(11.0 – 23.7)

6.0(-2.3 – 14.3)

Differences-in-differences estimate*95% confidence interval

15.0 † (14.4 - 16.3)

*The model was adjusted according to baseline evaluation data and seniority of the family *The model was adjusted according to baseline evaluation data and seniority of the family doctors.doctors. **p < 0.0001 between pre- and post-intervention stages, within groups.**p < 0.0001 between pre- and post-intervention stages, within groups.††p < 0.0001 between IEP and PEP. p < 0.0001 between IEP and PEP.

In the IEP group, the mean difference in the proportion of appropriately prescribed NOAs between the baseline and post-intervention stages was 17.8% (p < 0.05), whereas the mean

difference in the PEP group was 6.0% (p > 0.05).

In the IEP group, the mean difference in the proportion of appropriately prescribed NOAs between the baseline and post-intervention stages was 17.8% (p < 0.05), whereas the mean

difference in the PEP group was 6.0% (p > 0.05).

Table 3. Effect of educational programs on patients’ use of non-opioid analgesics.

IEPn= 622

PEPn=607

Self-medication* Absolute percent difference 95% confidence interval

-9.1(-11.4 - -6.8)

-13.4(–16.1- -10.7)

Knowledge about the proper way in which NOAs should be taken Absolute percent difference 95% confidence interval

8.5(6.3 – 10.7)

8.5(6.3 – 10.7)

Knowledge about NOA adverse events* Absolute percent difference95% confidence interval

39.6(37.6 – 41.6)

9.2(8.0-10.4)

*Abbreviation: NOA, non-opioid analgesics.* p < 0.05.

The percent differences in IEP and PEP patients reporting self-medication were –9.1% and –13.4%, respectively. The percent difference in knowledge of proper NOA administration was 8.5% in both groups,

while awareness of adverse events was 39.6% in the IEP group and 9.2% in the PEP group

The IEP aimed at patients and family doctors are superior to PEP in improving family doctors’ prescribing patterns and enhancing patients’ knowledge of NOA-associated adverse events.

Our findings suggest that programs aimed at improving medication use should focus on interactive educational activities.

The IEP had a positive effect on patients’ awareness of NOA-associated adverse events even though the intervention did not improve the ability of patients to identify gastrointestinal adverse events.

The IEP should be improved in this aspect, and novel programs should be developed to specifically educate patients about NOAs gastrointestinal adverse events.