gms | German Medical Science

20th Annual Meeting of the German Drug Utilisation Research Group (GAA)

Gesellschaft für Arzneimittelanwendungsforschung und Arzneimittelepidemiologie

05.12. - 06.12.2013, Düsseldorf

Change of prescription behaviour in patients with heart failure after a continued medical education intervention followed by repeated feedback

Meeting Abstract

  • corresponding author presenting/speaker Bernd Hagen - Zentralinstitut für die kassenärztliche Versorgung in Deutschland, Köln, Germany
  • Reinhard Griebenow - Kliniken der Stadt Köln, Krankenhaus Merheim, Köln, Germany
  • Ines Schwang - St. Marien-Hospital, Hamm, Germany
  • Lutz Altenhofen - Zentralinstitut für die kassenärztliche Versorgung in Deutschland, Köln, Germany

Gesellschaft für Arzneimittelanwendungsforschung und Arzneimittelepidemiologie e.V. (GAA). 20. Jahrestagung der Gesellschaft für Arzneimittelanwendungsforschung und Arzneimittelepidemiologie. Düsseldorf, 05.-06.12.2013. Düsseldorf: German Medical Science GMS Publishing House; 2013. Doc13gaa07

doi: 10.3205/13gaa07, urn:nbn:de:0183-13gaa070

Published: November 25, 2013

© 2013 Hagen et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.



Background: The aim of the study was to investigate whether introducing targeted CME into a regular feedback system being part of a disease management programme (DMP) will improve prescription behaviour, and if yes, how long it will take to demonstrate this effect and what the magnitude of such an effect could be.

Materials and Methods: Beginning in 2006 a series of written CME texts were disseminated focusing the prescription of medications recommended by current clinical guidelines for patients suffering from heart failure. They accompanied the regular feedback reports which are send to all physicians (mostly general practitioners) who took part in the DMP coronary artery disease in the North Rhine region, Germany. Feedback reports in the DMP compare primarily rates in a set of defined quality of care indicators between the individual practice addressed and all other practices in the region. Control group data were collected in the neighbourhood region Westphalia-Lippe, where only a short feedback and no CME texts were given out. From 2005 until 2011 changes in prescription of ACE inhibitors, beta blockers, and calcium channel blockers (until 2008) were analysed in the three cohorts of patients of physicians who actively took part in the first CME intervention vs. physicians who did not took part vs. physicians in the control group.

Results: 428 physicians took part, 3,067 did not respond. The participants took care of 1,141 patients with heart failure of NYHA class II or III (nonparticipants: 6,310 patients). Control group consisted of 3,295 physicians and 7,614 patients. Mean age of patients differed from 73.3 ± 8.8 to 73.8 ± 9.2 years, rate of male patients from 58.6 to 60.8%. Baseline characteristics of the patient groups with regard age, sex, concomitant diseases, and smoking status were almost the same; however patients of participants showed lower blood pressure levels. Dropout rates of patients until the end of observation period differed insignificantly between 59.5 to 61.8%.

Baseline prescription rates of ACE inhibitors (ACE-I) were higher among the patients of nonparticipants, whereas rates of beta blocker (BB) prescription were higher among patients of participants. From 2005 till 2011 changes in the prescription of ACE-I (–0.2 to +6.6%) and BB (+5.5 to +8.0%) could be seen in all three patient cohorts. They were most pronounced with regard to an additional prescription of ACE inhibitors in patients who received only beta blockers at baseline (+46.0 to 53.2%) (Table 1 [Tab. 1]). On the other hand prescription of calcium channel blockers (CCB) remained rather unchanged during observation period. Significant changes of prescription behaviour favouring patients of CME participants could first be demonstrated approximately three years after the first CME. Results among nonparticipant patients and control group patients were nearly identical.

Conclusion: A first CME activity (delivered as print CME) is able to trigger a strategy towards improved guideline compliance. To influence prescription behaviour a series of CME interventions as well as regular feedback on specific quality of care indicators seems inevitable. Contrasting the results from the nonparticipants where at least a passive CME reception was possible and the control group which did not receive any CME demonstrates clearly the effect of an active examination of the CMEs and feedback reports. But in order to reach maximum effects it took years in our study.