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Janette Randall, Australasian Cochrane Symposium



NPS: using evidence to frame messages

NPS: using evidence to frame messages
Presented by Janette Randall, Chair, National Prescribing Service Board, at the Australasian Cochrane Symposium, Melbourne, 1 July 2011



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  • Company Ltd by guarantee, head office in Sydney, plus Canberra, Melbourne and Brisbane; started in 1998, grown to 185 staff and annual income this year of around $45million which will grow to $50mil next year
  • Fortunate in Australia to have a strong evidence based Medicines policy; 4 key elements are industry, TGA, PBAC and NPS; Aust govt needs to be congratulated for their strategic and continuing investment in
  • QUM is an integral part of the NMP and NPS is theeffector arm for the policy; our core business is quality use of medicines; note that consumers are central to the NMP and the work of NPS is very consumer centric
  • In a nutshell, QUM is these three things; can be a difficult concept to grasp and so we have to make it meaningful for all of our audiences
  • NPS began its work with a focus on prescribing in General Practice for a number of reasons. GPs deliver a substantial amount of health care and are front line as these stats show
  • Medicines are expensive and we need to ensure value for money from our investment in medicines – both as a society and also as individuals
  • There exists a reasonable evidence base to suggest that prescribing is not always optimal and results in adverse outcomes for consumers and unnecessary use of health resources; hence NPS spent its formative years developing programs to change the prescribing behaviour of GPs ; but QUM is much broader than this and so NPS has expanded its scope and remit over time to try and influence many factors that contribute to QUM
  • Some of these high level shifts in our focus are described here
  • There are a number of ways in which we conceptualise our work. The following few slides show some of the different frameworks that we use to think about medicines and diagnostics, and to identify potential problems or gaps that need to be addressed. This slide is very comprehensive but captures all the key elements in terms of health and disease spectrum. For each disease specific state, we recognise that there is a disease progression and that as the disease severity increases, the percent of the population that this disease state applies to decreases. At all stages, a focus is required to be maintained on general health promotion and this is underpinned by such skills as health literacy and building community capacity. Medical tests and related technologies for diagnosis disease and testing for presence of risk factors, or disease monitoring also underpins each stage of the process. Importantly, at each stage in the spectrum, communication is paramount. The target audiences, key messages and means of delivery may be different at each stage.
  • We also consider QUM in the context of the life journey for consumers and the multiple points at which QUM becomes important for them; the way we frame and deliver messages very much depends on where people are at in their life journey
  • We also use the medicines management cycle to look at systems change and the possible points of intervention where we may be able to influence.
  • There are any number of interventions that can be delivered to influence different parts of the medication management cycle.
  • Because we are fundamentally interested in changing behaviour, once we have decided that a QUM (or QUD) problem exists, we first try to understand the barriers to change across a number of domains (on the left) – some of the information sources that we use to analyse problems are listed here.
  • Once we understand the barriers, then we map these against a possible suite of interventions. This slide relates particularly to HP behaviour change because we have much more evidence and experience in our work with health professionals, much less in consumer work. We know that these interventions work to varying degrees in changing health professional knowledge, beliefs and ultimately behaviours. There are opportunities to explore innovative interventions where evidence is lacking, and if necessary undertake our own research to confirm the benefits of these new interventions. For example the GP data project – RCT type design.
  • Here is a simple example of how the process can work in real life and relates to a previous common colds campaign that we ran a few years ago.
  • In addition to the HP interventions that I have already mentioned, there are a number of otherways in which we get our messages out to our target audiences
  • We also see that we have an important role in contributing to the evidence base, particularly when there are gaps. NPS has a very strong evaluation culture and we invest a lot of resources in this area. We feed the learnings back into our own work, but also seek to share it with others. Here are some of our recent publications. NPS also undertakes some research, often in partnership with others.
  • In recent years, our efforts to engage the wider community have increased in an attempt to build health and medicines literacy, and help to empower consumers with information and resources. We use a social marketing framework to identify priorities and develop messages based on what we want to achieve.
  • All of our consumer work is based on these three key elements of learn, discuss and manage – again linking back to our mission which is to enable people to make better choices
  • We have developed a reasonable amount of expertise now in framing consumer messages and delivering them in ways which are relevant and meaningful. Here are some of our written resources.
  • From March to June of this year, we delivered a comprehensive multimedia strategy which we called the Medicinewise campaign. This was delivered across print, radio, TV and electronic media include social media. Partnership with the 7 network was very effective and enabled much greater reach for our resources. Challenge now is to sustain the message.
  • New multimedia delivery mechanisms are not yet well evaluated and represent an area of innovation for NPS; technology is moving so quickly that best guess rather than evidence based decisions are required – this has been a challenge for an organisation like NPS

Janette Randall, Australasian Cochrane Symposium Janette Randall, Australasian Cochrane Symposium Presentation Transcript

  • NPS: Using Evidence to Frame Messages
    Dr Janette Randall
    Chair, NPS Board
    NPS – who we are and what do we do; putting evidence into practice
    The shift from “National Prescribing Service” to “NPS: Better Choices, Better Health”
    Use of evidence in deciding priorities and framing messages
    Evidence based interventions to deliver messages
    Health professionals
    Mass audience / population based
    Independent, not-for-profit, Company Ltd by guarantee
    Our mission - NPS enables better decisions about medicinesand medical tests
    Funded by the Australian Government Department of Health and Ageing
    Strongly focused on primary care
    • Timely access to necessary medicines at affordable cost - PBAC
    • Medicines meeting appropriate standards of quality, safety and efficacy - TGA
    • Quality use of medicines - NPS
    • Maintaining a responsible and viable medicines industry
    The term “medicine” includes prescription and non-prescription medicines, including complementary healthcare products.
  • QUM is integral part of the National Medicines Policy
  • Quality use of medicines
    Selecting management options wisely - including non medicine options
    Choosing suitable medicines if a medicine is considered necessary
    Using medicines safely and effectively
  • WHY GPs?(Evidence for initial focus on GP delivery)
    • Besides hospitals, General practitioner visits provide the other major intervention (good or service) to address health/ill-health 1
    • 112 million general practice consultations paid for by Medicare in 3/2008-4/2009 2
    • 81% or 11.4 million people seen GP >1 in past year
    • <75years – majority visited a GP 2-3 times in the past year 1
    • >75 years
    • 70% saw a GP ≥ 4 times in past year
    • 24% saw a GP 12 or more times in the year 1
    1. http://www.abs.gov.au/ausstats/abs@.nsf/0/67FC076DC701E9AACA257773000E9296?opendocument
    2. http://www.aihw.gov.au/publications/gep/gep-26-11014/gep-26-11014.pdf
    14.3% of health “goods and services” expenditure of $80bil in 2005-6 on MEDICINES ($11.4 billion)
    Frequent option (>120million PBS scripts per year)
    Costly option
    >$7.6793 billion in PBS costs 2008-9 3
    $1.309billion in patient co-contributions (co-payments)
    >$1.6billion hospital / state funded medicines
    >$1billion Complementary and alternative medicines
    3. http://www.health.gov.au/internet/main/publishing.nsf/Content/696CBFCEB2FFD713CA257679000EABCA/$File/0212%20Summary%202009.pdf
    Elderly Patients Prescribed Inappropriate Medications at 8 Percent of Doctor Visits (February 9, 2004)
     Inappropriate Medication Prescribing for Elderly Ambulatory Care Patients, Archives of Internal Medicine. Journal of the American Medical Association, Volume 164. February 9, 2004
    Inappropriate usage
    Not in alignment with guidelines
    Guidelines don’t exist
  • 10 YEARS AND BEYOND- our focus has broadened over time
    10 years as National Prescribing Service
    Changing focus
    From “prescribing” to
    whole medicines management cycle (dispensing, administration, concordance, monitoring use of medicines)
    From General Practitioners and Community Pharmacists to
    Other prescribers, other practitioners
    From treatment with medicines to
    Diagnosis and monitoring
    From consumers receiving services to
    Consumers as change agents
    Consumers delivering messages
    Motivation for change for consumer
    Health practitioner involvement
    Medicine use intensity
    Intensity of strategies
    Communication – strategies, target groups and priority groups
    Disease severity
    % of population
    (inc Environ- mental health etc)
    promotion and prevention
    Acute / Symptomatic treatment
    Palliation / end of life management
    Chronic disease management
    Disease state specific
    Diagnosis, testing, monitoring
    Health promotion - Community capacity building, health literacy
    The healthy
    To stay healthy, lifestyle, complementary medicines, immunisation
    The acutely ill
    Often self-limiting, benefits and harms, duration
    The chronically ill
    Non-drug, information and skills, monitoring and review of goals
    The severely ill
    Frequent changes, adverse events
    The very frail
    Cessation, continuum of care
    The dying
    Dignity at end of life, evidence, symptoms management
    Weekes LM. Quality use of medicines and the life journey. J PharmPract Res. 2009 September;39(3):172-3.
    Guiding principles to achieve continuity in medication management APAC, adapted from:
    Australian Council for Safety and Quality in Health Care (2002). Second national report on patient safety: improving medication safety. July 2002. Canberra. www.safetyandquality.org/articles/publications/med_saf_rept.pdf
    Audit Commission UK. (2002). A spoonful of sugar: medicines management in NHS hospitals. UK. www2.audit-commission.gov.uk/itc/medman.shtml
    Lynne T (Ed.) (2003) Queensland Health Medication Management Manual. Queensland Health, Brisbane. www.health.qld.gov.au/quality/publications.asp (currently under review)
    - Non-medicines options
    - Appropriate option
    Opportunity to
    influence others
    Consumers as an intervention
    Opportunity to
    Influence use of tests, monitoring for ADEs, reminders to review, de-prescribing, etc
    Appropriate medicine
    choice in
    appropriate regimen
    Opportunity to influence
    choice and regimen with EDS
    Safe and effective administration and recording
    Opportunity to
    stockpiling, expiry
    Nursing Home medicines management
    Opportunity to review
    Appropriateness of
    Medicines choice and
    Opportunity to influence
    Opportunity for
    self-improvement / QI
    Analysis of needs and barriers
    • Literature
    • Questionnaires
    • Key informants
    • Advisory groups
    • Audits / observation
    • Phone lines
    • Practice research
    • Evaluation results
    Awareness, knowledge
    Beliefs, attitudes
    Motivation, readiness for change
    Systems, practicalities
    External environment
    Educational materials
    Map barriers to interventions, considering:
    • What needs to change
    • Evidence for interventions
    • Active v/s passive engagement
    • Multi-faceted approach
    • What will work in general practice
    Educational meetings
    Educational visiting
    Clinical audit & feedback
    Opinion leaders
    Reminder systems
    Patient mediated strategies
  • Reaching people in different ways, including...
    Collaborative community based education programs – COTA, FECCA and others
    Train the trainer models – ACHS model
    Multi-platform national awareness campaigns
    Respected publications like Australian Prescriber and NPS RADAR – also available on line
    Medical school curriculum and online education (evidence vs hype)
    E-health applications and tools – e audits, decision support, pop ups, smart phone apps
    Online resources including www.nps.org.au
    Contributing to the evidence –
    NPS Research & Development function
    Recent publications
    Moxey A, Robertson J, Newby D, Hains I, Williamson M, Pearson S-A. Computerized clinical decision support for prescribing: provision does not guarantee uptake. Journal of the American Medical Informatics Association2010 ;17(1):25-33.
    Sweidan M, Williamson M, Reeve JF, Harvey K, O’Neill JA, Schattner P, Snowdon T. Evaluation of features to support safety and quality in general practice clinical software. BMC Medical Informatics and Decision Making 2011, 11:27
    McIntosh KA, Maxwell DJ, PulverLK,Horn F, Robertson MB, Kaye KI, Peterson GM, Dollman WB, Wai A, Tett SE. A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments. Int J Qual Health Care 2011; 23(2):142-50.
    Wai A, Pulver L, Oliver K, Thompson A. Current Discharge Management of Acute Coronary Syndromes: Baseline results from a national quality improvement initiative. Internal Medicine Journal (Published online July 2010).
    Pirotta M, Kotsirilos V, Brown J, Adams J, Morgan T, Williamson M. Complementary medicine in general practice: A national survey of GP attitudes and knowledge. Australian Family Physician 2010;39(12):946-950.
  • SOCIAL MARKETING FRAMEWORK: Selling an idea for public good
    Understand the nature and scale of the problem
    Evidence-practice gap
    Burden of illness / harm
    Economic burden
    Decide what we want to achieve and who we want to influence
    Raise awareness
    Change behaviour (need to segment audience)
    Sustain or enhance a previous change
    Monitor the problem or change
    Consider resources available
    $, people, time
    Consumer Publications
    Medicine Update, reviews new medicines listed on the PBS
    MedicinesTalk, written by consumers for consumers
    Community Update
    Be Medicinewise Mass Media campaign
    Tools and Resources
    NPS website
    National “Be medicinewise” campaign introduces the term ‘medicinewise’ as shorthand for quality use of medicines and medical tests
    “Why?” is the central theme of the campaign
    Being medicinewise means having the knowledge about medicines and medical tests to make informed decisions
    NPS wants all Australians to make better medicines decisions
    We can provide the right tools and resources to encourage informed discussions with health professionals to make the right decisions
    From paper to web to smart phones
    Phoneline – 1300 MEDICINE
    NPS use of evidence in:
    Identifying and prioritising issues
    Selecting interventions
    Developing key messages
    Optimal delivery mechanisms
    Supporting our field force
    Informing consumers