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National electronic Library for Medicines Medicines Management Overview January 2013 EFFECT OF EDUCATIONAL OUTREACH (“ACADEMIC DETAILING”) ON PRESCRIBING AND GUIDELINE ADHERENCE: An annotated bibliography Summary Contents Summary 1 Introduction 2 Synopsis 4 References 6 This annotated bibliography with 50 references published from 2007 to the end of 2012 is based on searches of the National Electronic Library for Medicines (NeLM), Medline, Google Scholar and publishers’ websites, and review of reference lists of retrieved papers. W e Educational outreach to prescribers has been i delivered for some thirty years, most often in a g primary care setting, but also in secondary care. h t Where the outcome has been evaluated in terms of mquantitative indicators of interest, the results have a been equivocal. In some cases a marked n improvement in the quality of drug use has been a g found, but in others there was little or no impact. Produced for the National electronic Library for Medicines by: Tom Burnham, Information Specialist, London and South East Medicines Information Service, Guy’s Hospital, London SE1 9RT e mIf educational outreach is to achieve reliably the e favourable results obtained in some cases, careful n consideration (and perhaps more research) is needed t of the exact details of the technique used, and how meducational outreach is combined with other a interventions. Tel: 020 7188 5026 [email protected] n a g e m e n t O s t e o 1 Introduction The practice of educational outreach (“academic detailing”) to prescribers as a means of improving the quality of their drug therapy decisions and reducing unnecessary expenditure was pioneered some thirty years ago. Early advocates of the practice were Dr Jerry Avorn and Dr Stephen Soumerai of Harvard Medical School in the USA, and they have continued to be involved with the field. The concept derives from “detailing”, a marketing technique used by pharmaceutical companies, in which company representatives make one-to-one visits to individual prescribers in order to persuade them to prescribe the company’s products. It is hoped that a personal relationship will develop over a number of visits which will reinforce the effect of the information presented by the representative. Educational outreach aims to employ some of the techniques developed in pharmaceutical marketing to promote prescribing which is rational, evidence-based and adherent to guidelines. It is typically carried out by health professionals (often pharmacists, also doctors or nurses) employed by non-profit organisations. According to Soumerai and Avorn (Avorn and Soumerai, 1983; Soumerai and Avorn, 1990), some of the most important techniques of educational outreach include (1) conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns, (2) focusing programmes on specific categories of physicians as well as on their opinion leaders, (3) defining clear educational and behavioural objectives, (4) establishing credibility through a respected organisational identity, referencing authoritative and unbiased sources of information and presenting both sides of controversial issues, (5) stimulating active physician participation in educational interactions, (6) using concise graphic educational materials, (7) highlighting and repeating the essential messages and (8) providing positive reinforcement of improved practices in follow-up visits. A Cochrane Review, updated to 2007 (O’Brien et al., 2007), concluded that educational outreach visits (EOVs), “with or without additional interventions, can be effective in improving health professional practice. The effects are, for the most part, small to moderate, but potentially important. The effects on prescribing are small and consistent (median 4.8%, interquartile range 3.0% to 6.5%) whereas the effect on other professional behaviours is more variable (median adjusted RD 6%, interquartile range 3.6% to 16%). It is not known to what extent performance is likely to deteriorate or improve over time, or whether multiple visits are worth the additional cost. Long-term performance (beyond one year) should be monitored. Although EOVs are reported to be costly, savings may outweigh costs if targeted at inappropriate prescribing and the effects are enduring. The costs and cost effectiveness of this approach will depend upon targeted behaviours, the comparisons that are made and the context in which the interventions are provided.” This annotated bibliography focuses on publications in this field since 2007, the date of the Cochrane review. References cited in Introduction Improving drug-therapy decisions through educational outreach - a randomized controlled trial of academically based detailing J Avorn, SB Soumerai New England Journal of Medicine 16 Jun 1983;308(24):1457-1463 http://www.nejm.org/doi/full/10.1056/NEJM198306163082406 2 Educational outreach visits: effects on professional practice and health care outcomes O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, Forsetlund L, Bainbridge D, Freemantle N, Davis D, Haynes RB, Harvey E Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD000409. DOI: 10.1002/14651858.CD000409.pub2 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000409.pub2/abstract Principles of educational outreach ('academic detailing') to improve clinical decision making SB Soumerai, J Avorn Journal of the American Medical Association 26 Jan 1990;263(4):549-556 http://jama.ama-assn.org/content/263/4/549.short 3 Synopsis Setting Educational outreach has been reported - as regular practice or as part of a trial in a number of countries, including Australia (Banakh, 2011; Li et al., 2010; McIntosh et al., 2011; Peterson et al., 2012; Pulver et al., 2011; Roberts et al., 2010; Semple and Roughead, 2009), Belgium (Borgermans et al., 2010), Canada (Allen et al., 2007; Bernier et al., 2011; Chui et al., 2011; Graham et al., 2008; Jin et al., 2012), Denmark (Baandrup et al., 2010), England (Eccles et al., 2007; Enriquez-puga et al., 2009; Patel and Afghan, 2009), France (Blanc et al., 2008), Ireland (Naughton et al., 2009), the Netherlands (Smeets et al., 2009), Norway (Frich et al., 2010), Scotland (Lowrie, 2012; Lowrie et al., 2010), South Africa (Zwarenstein et al, 2007; Zwarenstein et al., 2011) and Wales (Butler et al., 2012), besides numerous examples in the United States where the practice started. The professional group targeted is most commonly general practitioners or other primary care physicians, but educational outreach has also been reported to other professional groups, including hospital doctors (Kisuule et al., 2008; Roberts et al., 2010), hospital nurses (Li et al., 2010), staff on hospital orthopaedic wards (Banakh, 2011), emergency department physicians (McIntosh et al., 2011) and psychiatrists (Baandrup et al., 2010; Benjamin et al., 2011). Interventions have addressed the prescribing of a range of drugs, including antibiotics (Blanc et al., 2008; Butler et al., 2012; Enriquez-puga et al., 2009; Kisuule et al., 2008; Linnebur et al., 2011; McIntosh et al., 2011; Naughton et al., 2009; Smeets et al., 2009), antidepressants (Eccles et al., 2007; Enriquez-puga et al., 2009; Patel and Afghan, 2009), antihypertensives (Simon et al., 2007; Stafford et al., 2010), antipsychotics (Baandrup et al., 2010; Benjamin et al., 2011; Hermes et al., 2012), cyclooxygenase-2 inhibitors (Graham et al., 2008; Groves et al., 2010), hypnotics (Simon et al., 2008), proton pump inhibitors (Chui et al., 2011) and statins (Lowrie, 2012; Lowrie et al., 2010; Zillich et al., 2008), in addition to promoting the use of generic drugs (Benjamin et al., 2011; Bhargava et al., 2010; Devine et al., 2009; Hermes et al., 2012), childhood immunisation (Boom et al., 2010), osteoporosis management (Banakh, 2011) and thromboprophylaxis (Bernier et al., 2011; Li et al., 2010). Methods Educational outreach is typically conducted face-to-face at recipients’ sites. It is often delivered by pharmacists, although it has been suggested that physicians may be less willing to receive education from a non-physician (Allen et al., 2007; Chui et al. 2011). It may be reinforced by other techniques such as the provision of printed information, alerts in computerised systems or online education. Face-to-face communication with individuals or small groups is often felt to be an essential component, however (Hartung et al., 2012), although a study in Ireland (Naughton et al., 2009) found that outreach visits by a prescribing adviser were not significantly more effective than a postal bulletin alone in changing the prescribing practices of GPs. Results Of the studies listed which reported the results of educational outreach in terms of measurable changes in prescribing patterns, adherence to guidelines or other objective indicators, just over 60% showed a positive result. Given the likelihood of publication bias, the actual figure may well be lower. However, quantitative analysis is hardly possible as both interventions and outcome measurements vary widely. In some cases the effect was small (Borgermans et al., 2010) and a study targeting thromboprophylaxis (Bernier et al., 2011) found that although the intervention improved 4 clinicians’ practice, it remained sub-optimal. The educational activity was generally well received, and one study (Allen et al., 2007) found that recipients’ attitude to evidencebased practice was improved as a result. Information on the longer term results of educational outreach is limited, but from the studies cited it is possible that the effect can last up to 6 months (Schechter et al., 2010) but rarely for as long as 2 years. The PINCER study in the UK (Avery et al., 2012) and an earlier study in the USA (Simon et al., 2007) concluded that the interventions studied were likely to be cost-effective under some circumstances, but a study in Belgium (Borgermans et al., 2010) did not demonstrate cost-effectiveness. Discussion The studies cited from the period 2007 to 2012 show that educational outreach visits can be an effective technique for improving prescribing and raising the quality of medicines use, but success is by no means guaranteed. Despite considerable investment in educational outreach in a number of countries and many research studies going back some 30 years, it seems that it is not yet possible to identify with certainty the factors contributing to an effective result (Ostini et al., 2009). Aspects that may warrant further investigation include: The profession and training of the educator, and their ability to establish a personal relationship with the clinician; The design of the educational intervention with reference to a specific change model (Kisuule et al., 2008) or to known barriers to change of practice; One-to-one or small group presentations (Simon et al., 2005); Whether educational outreach should be combined with other educational methods or materials, with prompts on electronic systems or with mandatory restrictions on prescribing (e.g. Devine et al., 2009; Lu et al., 2008; Pulver et al., 2011; Roberts et al., 2010; Smeets et al., 2009); The benefits of targeting outreach (Eccles et al., 2007), for example for individual prescribers with poor prescribing habits (Frich et al., 2010) or early prescribers (Groves et al., 2010); The selection of topics which appear relevant and important to clinicians. 5 References Family physicians' perceptions of academic detailing: a quantitative and qualitative study M Allen, S Ferrier, N O'Connor, I Fleming BMC Medical Education 12 Oct 2007;7:36 Background: The efficacy of academic detailing in changing physicians' knowledge and practice has been the subject of many primary research publications and systematic reviews. However, there is little written about the features of academic detailing that physicians find valuable or that affect their use of it. The goal of our project was to explore perceptions of academic detailing of family physicians' (FPs) in Nova Scotia, Canada, and the factors that affect their use of it. Methods: We used two methods to collect data, a questionnaire and semi-structured telephone interviews. We mailed questionnaires to all FPs in the Dalhousie Office of Continuing Medical Education database and analysed responses of non-users and users of academic detailing. After a preliminary analysis of questionnaire data, we conducted semi-structured interviews with 7 FPs who did not use academic detailing and 17 who did use it. Results: Overall response rate to the questionnaire was 33% (289/869). Response rate of non-users of academic detailing was 15% (60/393), of users was 48% (229/476). The 3 factors that most encouraged use of academic detailing were the topics selected, the evidence-based approach adopted and the handout material. The 3 factors that most discouraged the use of academic detailing were spending office time doing CME, scheduling time to see the academic detailer and having CME provided by a non-physician. Users of academic detailing rated it as being more valuable than other forms of CME. Generally, interview data confirmed questionnaire data with the exception that interview informants did not view having CME provided by a non-physician as a barrier. Interview informants mentioned that the evidencebased approach adopted by academic detailing had led them to more critically evaluate information from other CME programmes, pharmaceutical representatives and journal articles, but not advice from specialists. Conclusions: Users of academic detailing highly value its educational value and tend to view information from other sources more critically because of its evidence-based approach. Non-users are unlikely to adopt academic detailing despite its high educational value because they find using office time for CME too much of a barrier. To reach these physicians with academic detailing messages, we will have to find other CME formats. http://www.biomedcentral.com/content/pdf/1472-6920-7-36.pdf A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis AJ Avery, S Rodgers, JA Cantrill, S Armstrong, K Cresswell, et al. Lancet 7 Apr 2012;379(9823):1310-1319 Background: Medication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention. 6 Methods: In this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to researchers and statisticians involved in processing and analysing the data. The allocation was not masked to general practices, pharmacists, patients, or researchers who visited practices to extract data. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; beta-blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-effectiveness analysis. Findings: 72 general practices with a combined list size of 480,942 patients were randomised. At 6 months' follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0.58; 95% CI, 0.38 to 0.89); a betablocker if they had asthma (0.73; 0.58 to 0.91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0.51; 0.34 to 0.78). PINCER has a 95% probability of being cost effective if the decision-maker's ceiling willingness to pay reaches GBP75 per error avoided at 6 months. Interpretation: The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records. Trial Registration: Controlled-Trials.com, number ISRCTN21785299. See also editorial commentary: Lancet 7 Apr 2012;379(9823):1278-1280; and correction: Lancet 16 Jun 2012;379(9833):2242. Protocol described in: Trials 1 May 2009;10:28. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61817-5/fulltext Teaching clinicians about drugs - 50 years later, whose job is it? J Avorn New England Journal of Medicine 31 Mar 2011;364(13):1185-1187 This article notes that 2011 is the 50th anniversary of the pivotal 1961 debate introduced by Senator Estes Kefauver that transformed prescription drug approval and use in the USA. At that time, what physicians knew about prescription drugs was shaped predominantly by the claims their manufacturers made about them, and the evidence base underlying such claims was often rudimentary, or worse. Closely related to the thinness of the science was the question of how information about a drug's benefits and risks should be evaluated and communicated to physicians - and by whom. Then as now, pharmaceutical companies mounted aggressive promotional campaigns for their products. No mechanism existed for robust, arm's-length governmental determination of a drug's efficacy and for the dissemination of such data. As a result, practitioners were often left with little disinterested guidance about the usefulness or safety of new medications in comparison with their alternatives. Among other things, the Kefauver legislation sought to have the federal government provide a more even-handed, public source of drug education for physicians: a 7 leaflet that would accompany every prescription medication describing 'all the information about the activity, uses and untoward effects of the drug'; a compendium of such information for all products 'in convenient and readable form' to be distributed widely; and an annual list of medications with high potential for serious side effects. Fifty years later, these issues are even more relevant, and the need to provide reliable drug information to physicians is even more pressing. An emerging answer may be public–nonprofit collaborations for which the government provides funding but profession-based nongovernmental entities with no ties to industry generate the scientific content. One illustration is the growth of support for 'academic detailing' educational outreach programmes in which independent researchers and clinicians systematically review data for a given therapeutic area and develop noncommercial, evidence-based recommendations about treatment choices. Pharmacists, nurses and physicians are then sent to visit practitioners in their offices to present these findings, drawing on the successful marketing strategies of industry but without its sales-oriented spin. Several US states, insurers, and federal programmes currently fund academic detailing programs based on content developed by nonprofit organisations free of industry ties. As concerns grow about the safety, complexity and affordability of our expanding pharmacopoeia, demand for these programmes increases. http://www.nejm.org/doi/pdf/10.1056/NEJMp1011713 'Bench to behavior': translating comparative effectiveness research into improved clinical practice J Avorn, M Fischer Health Affairs Oct 2010;29(10):1891-1900 The new emphasis on comparative effectiveness research in the USA is likely to generate an unprecedented volume of new findings. It is essential to anticipate the obstacles that front-line health care professionals will face in translating these results into better clinical decision making. We review the current barriers to the dissemination of evidence-based clinical recommendations, including problems with continuing medical education, provider incentives and quality assurance . We then propose solutions, including more effective educational outreach programmes, requirements for practitioners to master important findings and alignment of incentives to encourage evidence-based practice. Such strategies can lead to policies that could encourage the uptake of new comparative effectiveness data and encourage their translation into better clinical practice. http://content.healthaffairs.org/content/29/10/1891.abstract Evaluation of a multifaceted intervention to limit excessive antipsychotic co-prescribing in schizophrenia out-patients L Baandrup, P Allerup, H Lublin, M Nordentoft, L Peacock, B Glenthoj Acta Psychiatrica Scandinavica Nov 2010;122(5):367-374 Objective: To evaluate the effect of a multifaceted educational intervention on the frequency of antipsychotic co-prescribing in adult schizophrenia outpatients. Method: Controlled quasi-experimental study performed in two Danish municipalities matched for baseline prevalence of antipsychotic polypharmacy, socioeconomic status and functional level of patients. The intervention was aimed at psychiatric healthcare providers and consisted of 1 day of didactic lectures, six 3-hour educational outreach visits and an electronic reminder during drug prescribing. 8 Results: Between-group use of antipsychotic polypharmacy was compared at baseline (intervention group, N = 232/control group, N = 351) and after 1 year of intervention (intervention group, N = 216/control group, N = 386). The prevalence of antipsychotic polypharmacy at follow-up was not significantly different between treatment settings when adjusting for differences in case-mix (P = 0.07). Conclusions: This multifaceted educational intervention failed to reduce the frequency of antipsychotic co-prescribing, but it suggested that future efforts to improve prescribing practice should address organisational barriers to implementation. http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.2010.01553.x/abstract PRO-OSTEO Project (improving osteoporosis management in the acute hospital setting): a pilot single-centre study I Banakh Archives of Osteoporosis Dec 2011;6(1-2):157-165 Objectives: Osteoporosis is an inadequately managed condition around the world with high mortality and morbidity resulting from major fractures. Assessment and treatment rates for this condition are low, including hospital settings after minimal trauma fractures. The PRO-OSTEO project was set up to improve assessment and treatment rates of osteoporosis in patients admitted to the orthopaedic ward of Frankston Hospital (Peninsula Health, Victoria, Australia) with minimal trauma fractures. Methods: An osteoporosis assessment and treatment algorithm was introduced into inpatient practice in Mar 2010. This was accompanied by a multifaceted intervention, which included posters, presentations promoting the project and one on one academic detailing to ward pharmacists, orthopaedic, endocrinology and aged care junior medical staff. Three time periods were retrospectively reviewed to determine assessment and treatment rates, before and after the introduction of the algorithm, as well as 3 months following the introduction of the algorithm, to observe the sustainability of the intervention in a new group of doctors who had not received academic detailing. Results: Initially, the introduction of the algorithm increased treatment and assessment rates from 19.7% and 50% at baseline to 71.6% and 87.8%, respectively (p less than 0.0005), with the results declining in the following period, 3 months after initial intervention and after medical/surgical staff change over, to 47.8% and 54.3%, respectively (p less than 0.0005). Conclusions: An algorithm-based approach linked with academic detailing and education of the multidisciplinary team in acute hospital environment provides a clinically significant and effective strategy to improve osteoporosis management of patients with minimal trauma fractures. http://www.springerlink.com/content/k3408m0363g4k648/ The impact of evidence-based education on prescribing in a psychiatry residency D Benjamin, M Swartz, L Forman Journal of Psychiatric Practice Mar 2011;17(2):110-117 Objective: Recent clinical trials comparing the effectiveness of antipsychotics have found no advantage for second-generation antipsychotics over older first-generation agents. However, the former are much more commonly used despite their significantly higher cost and potential for contributing to the metabolic syndrome. To date, educational interventions have been unsuccessful in influencing this pattern. 9 The Duke University Medical Center Department of Psychiatry began a programme based on principles of academic detailing designed to educate psychiatry residents about generic psychotropics. To encourage residents to gain experience with these medications, samples of selected generic drugs were provided. To assess the initiative's impact, the authors measured the prescribing patterns of residents. Methods: We measured the amount of generic drug use 6 months after the programme began and compared it with data from a 6-month control period. The data were analysed based on overall psychotropic use, class of medication, site and diagnosis. Results: We found a consistent increase in generic use across analyses. There was an increase in overall generic prescribing from 55.8% to 58.6% (X = 10.37, odds ratio (OR) = 1.12, P = 0.0013) and a particularly large increase in prescribing of generic antipsychotic medications from 39.5% to 47.7% (X = 36.12, OR = 1.39, P less than 0.0001). Conclusions: The implementation of this educational programme was correlated with increasing use of generic medications and brought antipsychotic prescribing into concordance with the new evidence. This is the first such study in a psychiatry residency programme and has implications for promoting cost-effective care while preserving patient choice in the mental health system. The findings from this study also suggest potential techniques for expanding residents' prescribing skills across specialties. http://journals.lww.com/practicalpsychiatry/Abstract/2011/03000/The_Impact_of_Evidence _Based_Education_on.5.aspx Implementation and evaluation of a pharmacy-led thromboprophylaxis campaign in a community hospital MC Bernier, K Desjardins, J Filiatrault, MA Sauriol, J Martineau, E Gilbert, S Caron, L Lalonde Journal of Thrombosis and Thrombolysis Nov 2011;32(4):431-438 In hospitalised patients, venous thromboembolism (VTE) is an important cause of morbidity and mortality. Despite evidence demonstrating efficacy and safety of pharmacological thromboprophylaxis in the prevention of VTE, its use remains low. The aim of this study is to compare the incidence of use of thromboprophylaxis before and after a pharmacy-led thrombosis prevention campaign in medical patients hospitalised in a community hospital in Canada. A pharmacy-led multifaceted thromboprophylaxis campaign including continuing education activities for physicians and pharmacists and individualised academic detailing activities supported by clinical tools were implemented over an 8-week period. In a quasiexperimental study, the incidence of pharmacological thromboprophylaxis was evaluated using a retrospective chart review and compared before and after the campaign in medical patients at high and non-high risk of VTE as defined by the American College of Chest Physicians criteria. The medical charts of 461 patients were reviewed; 66 and 58 patients were at high-risk of VTE prior to and after the campaign, respectively. After the campaign, thromboprophylaxis ordering in high-risk patients increased from 15.2 to 43.1% (adjusted OR: 6.8; 95% CI, 2.5 to 18.0). Thromboprophylaxis ordering in non-high risk patients was 1.8% before the campaign and 6.0% after. This increase was not statistically significant (adjusted OR: 4.6; 95% CI, 1.0 to 20.4). Concludes that the incidence of pharmacological thromboprophylaxis in hospitalised medical patients at high-risk of VTE increased significantly after the campaign but remained suboptimal. Longer or a different campaign may be needed to ensure long-term optimal thromboprophylaxis use. 10 http://www.springerlink.com/content/q085338k78263045/ Addition of generic medication vouchers to a pharmacist academic detailing program: effects on the generic dispensing ratio in a physician-hospital organization V Bhargava, ME Greg, MC Shields Journal of Managed Care Pharmacy Jul-Aug 2010;16(6):384-392 Background: Generic dispensing ratio (GDR) is an important measure of efficiency in pharmacy benefit management. A few studies have examined the effects of academic detailing or generic drug samples on GDR. On 1 Jul 2007, a physicianhospital organisation (PHO) with a pay-for-performance incentive for generic utilisation initiated a pilot generic medication voucher programme that augmented its existing pharmacist-led academic detailing efforts. No published studies have examined the role of generic medication vouchers in promoting generic drug utilisation. Objective: To determine if supplementing an existing academic detailing initiative in a PHO with a generic medication voucher programme would be more effective in increasing the GDR compared with academic detailing alone. Methods: The intervention took place over the 9-month period from 1 Jul 2007 to 31 Mar 2008. Vouchers provided patients with the first fill of a 30-day supply of a generic drug at no cost to the patient for 8 specific generic medications obtained through a national community pharmacy chain. The study was conducted in a PHO composed of 7 hospitals and approximately 2900 physicians in t5he Chicago region of the USA (900 primary care providers (PCPs) and 2000 specialists). Of the approximately 300 PCP practices, 21 practices with at least 2 physicians each were selected on the basis of high prescription volume (more than 500 pharmacy claims for the practice over a 12-month pre-baseline period) and low GDR (practice GDR less than 55% in the 12-month pre-baseline period). These 21 practices were then randomised to a control group of academic detailing alone or the intervention group that received academic detailing plus generic medication vouchers. One of 10 intervention groups declined to participate, and 2 of 11 control groups dropped out of the PHO. GDR was calculated monthly for all pharmacy claims including the 8 voucher medications. GDR was defined as the ratio of the total number of paid generic pharmacy claims divided by the total number of paid pharmacy claims for 108 prescriber identification numbers (Drug Enforcement Administration (DEA) or National Provider Identifier (NPI)) for 9 intervention groups (n = 53 PCPs) and 9 control groups (n = 55 PCPs)). For both intervention and control arms, the GDR for each month from Jul 2007 (start of 2007 Q3, intervention start date) up to Sep 2008 (end of 2008 Q3, 6 months after intervention end date) was compared with the same month in the previous year. A descriptive analysis compared a 9-month baseline period from 2006 Q3 to 2007 Q1 with a 9-month voucher period from 2007 Q3 to 2008 Q1. A panel data regression analysis assessed GDR for 18 practices over 27 months (12 months pre-intervention and 15 months post-intervention). Results: A total of 656 vouchers were redeemed over the 9-month voucher period from 1 Jul 2007 to 31 Mar 2008, for an average of about 12 vouchers per participating physician; approximately one-third of the redeemed vouchers were for generic simvastatin. The GDR increase for all drugs, including the 8 voucher drugs, was 7.4 points for the 9 PCP group practices with access to generic medication vouchers, from 53.4% in the 9-month baseline period to 60.8% in the 9-month voucher period, compared with a 6.2 point increase for the control group from 55.9% during baseline to 62.1% during the voucher period. The panel data 11 regression model estimated that the medication voucher programme was associated with a 1.77-point increase in overall GDR compared with academic detailing alone (P = 0.047). Conclusions: Compared with academic detailing alone, a generic medication voucher programme providing a 30-day supply of 8 specific medications in addition to academic detailing in PCP groups with low GDR and high prescribing volume in an outpatient setting was associated with a small but statistically significant increase in adjusted overall GDR. http://www.amcp.org/data/jmcp/384-392.pdf ‘Antibiotics only when necessary’ campaign in the Alpes-Maritimes district: no impact on invasive respiratory bacterial infections in children in the community 1998-2003 (Campagne ‘Antibios quand il faut’ dans les Alpes-Maritimes: absence d’impact sur l’incidence des infections invasives dues aux bactéries respiratoires communautaires chez l’enfant, 1998-2003) V Blanc, P Bruno-Bazureault, A Malicki, F Berthier, B Dunais, P Touboul, P Hofliger, T Fosse, C Pradier, P Dellamonica Presse Medicale Dec 2008;37(12):1739-1745 Objectives: A multidisciplinary group (for the study and prevention of infections in children, GEPIE) conducted a local public health campaign to improve antibiotic prescribing in paediatric outpatient care in the Alpes-Maritimes district of France. This campaign included peer-conducted academic detailing (educational outreach) visits in 2000 and 2003. Practitioners often report during both focus groups and the GEPIE visits that they prescribe antibiotics because of a fear of subsequent complications. This study therefore sought to explore the trends in invasive diseases related to bacterial respiratory pathogens. Methods: A retrospective survey examined the incidence in the district of invasive infections due to Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes and Neisseria meningitidis from 1998 to 2003 among children aged 1 month to 15 years. All local laboratories were asked for all reports of blood cultures (as well as spinal, synovial, pericardiac, peritoneal and pleural fluid cultures) positive for these bacteria in the study population over the study period. Resistance and serotype data were recorded. Results: Over the 6-year study period, there were 113 cases of invasive infections: 64% due to S. pneumoniae, 26% to N. meningitidis, 6% to H. influenzae and 4% to S. pyogenes. There was no statistically significant difference in the annual average incidence rate before and during the campaign. The overall incidence rate was 11.2 cases per 100,000; meningitis accounted for 4.2 and invasive pneumococcal diseases 7.2 (42.7 per 100,000 children younger than 2 years). Pneumococcal resistance rates to penicillin and erythromycin did not change significantly. Discussion: Two local cross-sectional studies at daycare centres in 1999 and 2002 showed a 9% reduction in the proportion of children who received antibiotics. The stability of invasive infection in children and of bacterial resistance during the campaign is reassuring. The campaign's risk/benefit ratio appears positive. Conclusions: These results encourage continuing promotion of rational antibiotic prescribing and ought to allay practitioners' fears about the consequences of prescribing antibiotics less often. http://www.em-consulte.com/article/193841/alertePM 12 Utilizing peer academic detailing to improve childhood immunization coverage levels JA Boom, CS Nelson, AE Kohrt, CA Kozinetz Health Promotion Practice May 2010;11(3):377-386 Interventions that utilise academic detailing to improve childhood immunisation have been implemented across the USA. This study evaluates the effectiveness of an academic detailing intervention to increase childhood immunisation rates in paediatric and family medicine practices in a major metropolitan area. Educational teams of one physician, nurse and office manager delivered 83 peer education sessions at practices in the intervention group. Post-intervention immunisation rates for children 12-23 months of age increased 1% in the intervention group and decreased 3% in the control group. Post-intervention coverage levels for children 12-23 months of age did not differ between the intervention and control groups. Results indicated this office-based intervention was not sufficient to effect measurable changes in immunization coverage levels after 1 year of participation. Future interventions need to provide initial feedback regarding practice immunisation coverage levels prior to the educational interventions and include multiple encounters. http://hpp.sagepub.com/content/11/3/377.abstract Impact of academic detailing on primary care physicians L Borgermans, C Dubois, S Rieppi, S Vanhaeren, N Geukens, C Fallon, F Claisse, C Massart, S Brunet, L Kohn, J Pierart, D Paulus Brussels: Belgian Health Care Knowledge Centre (KCE). 2010. KCE Reports 125C. D/2010/10.273/16, 112pp. Background: Since 1998, the Belgian Federal Agency for Medicines and Health Products has supported an academic detailing (AD) programme with visits to general practitioners (GPs), which is performed by the non-profit-making organisation ‘Farmaka’ at an annual cost of Euro 1,121,193 (2009). Objective: The objective of this project is to analyse the impact of AD on the practice of GPs in Belgium, based on a review of gray and published literature, a Delphi survey of Belgian GPs, and a study of changes in the prescription behaviour of Belgian GPs after the visit of an academic detailer. Methods: A literature review included two parts. First a search of the grey literature analysed the organisation of eight AD programmes in other countries (e.g. 3 in the USA and 2 in Australia). Secondly, a systematic literature review was performed in the indexed literature (Medline, Embase, Cochrane Database of Systematic Reviews, Eric, Psychinfo and Econlit) to identify the potential effectiveness and costeffectiveness of AD. The search focused on the systematic reviews (n=16) and primary studies of high quality (87 studies). The results of both literature analyses have been merged in the results section. A qualitative study was conducted among GPs who were offered an AD visit in relation to diabetes and/or dementia. Farmaka first sent 1498 letters to ask the written consent of these GPs . Unfortunately only 19.8% of the this target population answered positively (n=297). Finally, 126 GPs participated effectively in a Delphi survey i.e., 8.4% of the initial target population. This study used the so-called ‘Mesydel’ technique i.e. a Delphi technique in two rounds using an internet tool. A quantitative study analysed the prescriptions of the same GPs to detect a possible effect of the AD visit on the prescriptions of diabetes and dementia medications. The analyses used Pharmanet data from the Intermutualistic agency (medications 13 purchased by patients). The evolution of their prescriptions across semesters was compared the those of the Belgian GP population to identify the effects of concurrent interventions. Results: Literature review on academic detailing - Most papers from the indexed literature (77 out of 87) reported on the effectiveness of AD, using mainly process indicators (e.g. prescriptions). Most of them (n = 67) reported a positive effect of AD on some outcomes, although 10 studies reported no effect of the intervention. A systematic review estimated a limited effect of AD on the compliance with an improvement towards the desired practice of about 5% only. However, systematic reviews conclude that AD within multifaceted interventions is generally effective in improving appropriate care and prescribing. Ten papers also reported economic outcomes. Seven of them were full economic evaluations, mostly cost-minimisation or costeffectiveness analyses. However, their results are contradictory and do not allow conclusions about the cost-effectiveness of AD. The review of initiatives in other countries shows a lack of evaluations. They involve annual costs that range from US$ 50,000 (for a limited intervention) to US$1 million. This last figure is similar to the current investment in Belgium for AD. Nevertheless these budgets are by no means comparable to the huge investments by the pharmaceutical industry in detailing interventions. Qualitative study among GPS in Belgium - A perplexing finding is that many GPs who participated to this survey did not remember the AD visit and/or its content. When they remembered it, this visit was considered as having a scientific content, sometimes too dense. The background of the visitor (e.g. physician or not) had little influence on the perception, as long as he/she had the necessary scientific knowledge for fruitful discussions. The role of the state in the provision of information for physicians raised contradictory reactions: most interviewees acknowledged that the state’s intervention was necessary and offered a counterbalance to the pharmaceutical industry. The GPs stated that the AD visits delivered a message oriented towards more considered prescribing behaviour but the messages also related to non-drug treatments. GPs who participated to the study made a number of suggestions to improve the programme. Analysis of prescription data - Due to serious limitations in the available data, very few meaningful conclusions could be drawn on the effect of the AD visits in the Belgian context on diabetes care, and no conclusions on dementia care. Conclusions: Most studies reported in the literature show an effect of AD on the targeted care processes but the size of the effect is usually small. Cost-effectiveness has not been demonstrated. The available Belgian prescription data allowed hardly any conclusions on the effect of the AD intervention on the prescriptions of a sample of GPs. The main reasons were the limitations of the GP sampling and of the data, and the high concordance of prescribing with the Farmaka recommendations even before the AD visit. https://kce.fgov.be/sites/default/files/page_documents/d20101027316_0.pdf Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial CC Butler, SA Simpson, F Dunstan, S Rollnick, D Cohen, D Gillespie, M R Evans, MF Alam, M-J Bekkers, J Evans, L Moore, R Howe, J Hayes, M Hare, K Hood British Medical Journal 2012;344:doi: 10.1136/bmj.d8173 (published 2 Feb 2012) 14 Objective: To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care. Design: Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation. Setting: 68 general practices with about 480 000 patients in Wales, United Kingdom. Participants: 34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed. Interventions: Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice-based seminar reflecting on the practice’s own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care. Main Outcome Measures: Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year’s dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes and costs. Results: The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% CI, 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P = 0.02). Reductions were found for all classes of antibiotics other than penicillinaseresistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was GBP 2923 (Euro 3491, US$ 4572) per practice (SD GBP 1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (-0.4% to 11.4%), equivalent to a reduction of about GBP 830 a year for an average intervention practice. Conclusions: The STAR educational programme led to reductions in all-cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations or costs. Trial Registration: ISRCT No 63355948. http://www.bmj.com/content/344/bmj.d8173.pdf%2Bhtml Impact of academic detailing on proton pump inhibitor prescribing behaviour in a community hospital D Chui, F Young, AM Tejani, EC Dillon Canadian Pharmacists Journal Mar 2011;144(2):66-71 A before-and-after study in order to determine if a simple academic detailing (AD) intervention could reduce inappropriate PPI prescribing in a 267-bed community hospital in British Columbia, Canada, and optimise prescribing practices. During the AD, a clinical research and drug information pharmacist conducted a 10minute presentation and provided the pocket card to the physician. The physician was allowed to ask questions and was offered copies of the reference material used 15 to put together the AD intervention. The pocket card provided to the physicians contained information pertaining to PPI indications for which there was evidence of ineffectiveness and for which there was weak or absent evidence. It also contained information about possible adverse effects of PPIs. The pharmacist then set up appointments to perform the 10-minute AD presentations with individual physicians and organised a group presentation for the surgeons in the time period of Nov to Dec 2007. A post-intervention retrospective chart review was conducted from Feb to Mar 2008. The AD intervention was given to 31 out of 45 possible physicians. Based on a review of 100 charts in the pre-intervention group, the top 3 situations in which PPIs were prescribed inappropriately included double-dosing, postsurgical prophylaxis and anaemia. There was no statistically significant difference in inappropriate PPI prescribing between the pre-intervention (53%) and postintervention (61%) groups (Pearson chi-squared p = 0.253). However, it is important to note that not all physicians who prescribed PPIs in the postintervention phase received the AD intervention. This study was unable to show an improvement in physicians' prescribing behaviour following the AD intervention. There are several possible reasons for this: Firstly, all patients were included in the study regardless of hospital or community initiation of the PPI. The results showed that almost half the patients included in the study were started on PPIs in the community and a significant proportion (32% to 43%) of those PPIs was inappropriately prescribed. When questioned at the time of the AD, many physicians indicated that they would be reluctant to change an inappropriate PPI order started in the community. Secondly, a limited amount of time may have had an effect on the success of the AD intervention. The AD in the current study was approx 10 minutes, which limits the amount of evidence-based information that can be provided. Lastly, the academic detailers in a cited study by Liberman and Whelan were physicians, while the academic detailer in the present study was a pharmacist. The authors suggest that physicians may be more receptive to the AD information if they receive it from other physicians rather than from a pharmacist, which may be another reason for the lack of effect in this study. http://www.cpjournal.ca/doi/pdf/10.3821/1913-701X-144.2.66 Strategies to optimize medication use in the physician group practice: the role of the clinical pharmacist EB Devine, S Hoang, AW Fisk, et al. Journal of the American Pharmacists Association Mar-Apr 2009;49(2):181-191 This paper (1) describes the role of clinical pharmacists in providing populationbased pharmaceutical care as employees of a community-based, multispecialty, physician group practice located in the north Puget Sound area of Washington state, USA, between 2003 and 2007, (2) describes the strategies used by pharmacists to optimise medication use, (3) quantifies improvements in care and (4) illustrates the calculations used to quantify cost savings. Using four cornerstones (evidence-based medicine, therapeutic interchange, academic detailing, and a local pharmacy and therapeutics committee), the pharmacists provided population-based pharmaceutical care, leading generic switches, target drug programmes and prescription to over-thecounter medication switches. They also led disease management programmes, managed drug recalls, implemented electronic health records, negotiated budgets with health plans, and led patient assistance programmes and prior authorisation programmes to improve patient satisfaction. In 2006-2007, 71% of the practice's 16 hypertensive patients received generic agents compared with a network average for receiving generic agents of 43%, while the proportion of patients with controlled blood pressure increased from 45% to 60%. The practice saved US$450,000 in inpatient costs for deep venous thrombosis. Concludes that clinical pharmacists employed in a physician group practice can optimise medication use, improve care and reduce costs. http://japha.org/article.aspx?doi=10.1331/JAPhA.2009.08009 Is untargeted educational outreach visiting delivered by pharmaceutical advisers effective in primary care? A pragmatic randomized controlled trial MP Eccles, IN Steen, PM Whitty, L Hall Implementation Science 26 Jun 2007;2:23 Background: There is increasing evidence that clinical guidelines can lead to improvements in clinical care. However, they are not self-implementing. While educational outreach visits may improve prescribing behaviour, the effectiveness of routine delivery of these visits by existing pharmaceutical advisers is unknown. Methods: Within a pragmatic randomised controlled trial, involving all general practices in two primary care trusts (PCTs), routine methods were used to distribute guidelines for the choice of antidepressants for the management of depression. Intervention practices were offered two visits (most accepted only one) by their PCT pharmaceutical adviser who had been trained in the techniques of outreach visiting. Intervention practices were visited regardless of whether they had prior problems with prescribing ('untargeted' visits). The intervention was evaluated using level three prescribing analysis and cost (PACT) data for antidepressant drugs for the 6 months during which the intervention was delivered and the subsequent 12 months. Results: Across the 72 study practices there was no significant impact of the intervention on usage of any group of antidepressant drugs. Conclusions: The routine use of untargeted educational outreach visiting delivered by existing pharmaceutical advisers may not be a worthwhile strategy. Trial registration: ClinicalTrials.gov NCT00393536. http://www.implementationscience.com/content/pdf/1748-5908-2-23.pdf Effect of educational outreach on general practice prescribing of antibiotics and antidepressants: a two-year randomised controlled trial A Enriquez-puga, R Baker, S Paul, R Villoro-Valdes Scandinavian Journal of Primary Health Care Dec 2009;27(4):195-201 Objective: Prescribing of broad spectrum antibiotics and antidepressants in general practice often does not accord with guidelines. The aim was to determine the effectiveness of educational outreach in improving the prescribing of selected antibiotics and antidepressants, and whether the effect is sustained for 2 years. Design. Single blind randomised trial. Setting: 28 general practices in Leicestershire, England. Intervention: Educational outreach visits were undertaken, tailored to barriers to change, 14 practices receiving visits for reducing selected antibiotics and 14 for improving antidepressant prescribing. Main Outcome Measures: Number of items prescribed per 1000 registered patients for amoxicillin with clavulanic acid (co-amoxiclav) and quinolone antibiotics, and 17 average daily quantities per 1000 patients for lofepramine and fluoxetine antidepressants, measured at the practice level for 6-month periods over 2 years. Results: There was no effect on the prescribing of co-amoxiclav, quinolones, or fluoxetine, but prescribing of lofepramine increased in accordance with the guidelines. The increase persisted throughout 2 years of follow-up. Conclusions: A simple, group-level educational outreach intervention, designed to take account of identified barriers to change, can have a modest but sustained effect on prescribing levels. However, outreach is not always effective. The context in which change in prescribing practice is being sought, the views of prescribers concerning the value of the drug, or other unrecognised barriers to change may influence the effectiveness of outreach. http://informahealthcare.com/doi/abs/10.3109/02813430903226530 Academic detailing can play a key role in assessing and implementing comparative effectiveness research findings MA Fischer, J Avorn Health Affairs Oct 2012;31(10):2206-2212 Comparative effectiveness research evaluates the relative effectiveness, safety and value of competing treatment options in clinically realistic settings. Such evaluations can be methodologically complex and difficult to interpret. There will be a growing need for critical evaluation of comparative effectiveness studies to assess the adequacy of their design and to put new information into a broader context. Equally important, this knowledge will have to be communicated to clinicians in a way that will actually change practice. We identify three challenges to effective dissemination of comparative effectiveness research findings: the difficulty of interpreting comparative effectiveness research data, the need for trusted sources of information and the challenge of turning research results into clinical action. We suggest that academic detailing - direct outreach education that gives clinicians an accurate and unbiased synthesis of the best evidence for practice in a given clinical area - can translate comparative effectiveness research findings into actions that improve health care decision making and patient outcomes. http://content.healthaffairs.org/content/31/10/2206.abstract General practitioners and tutors' experiences with peer group academic detailing: a qualitative study JC Frich, S Hoye, M Lindbaek, J Straand BMC Family Practice 12 Feb 2010;11:12 Background: The Prescription Peer Academic Detailing (Rx-PAD) project is an educational intervention study aiming at improving GPs' competence in pharmacotherapy. GPs in CME peer groups were randomised to receive a tailored intervention, either to support a safer prescription practice for elderly patients or to improve prescribing of antibiotics to patients with respiratory tract infections. The project was based on the principles of peer group academic detailing, incorporating individual feedback on GPs' prescription patterns. We did a study to explore GPs and tutors' experiences with peer group academic detailing, and to explore GPs' reasons for deviating from recommended prescribing practice. Methods: Data was collected through nine focus group interviews with a total of 39 GPs and 20 tutors (experienced GPs) in Norway. Transcripts from the interviews were analysed by two researchers according to a procedure for thematic content analysis. 18 Results: A shared understanding of the complex decision-making involved in prescribing in general practice was reported by both GPs and tutors as essential for an open discussion in the CME groups. Tutors experienced that CME groups differed regarding structure and atmosphere, and in some groups it was a challenge to run the scheme as planned. Individual feedback motivated GPs to reflect on and to improve their prescribing practice, though feedback reports could cause distress if the prescribing practice was unfavourable. Explanations for inappropriate prescriptions were lack of knowledge, factors associated with patients, the GP's background, the practice, and other health professionals or health care facilities. Conclusions: GPs and tutors experienced peer group academic detailing as a suitable method to discuss and learn more about pharmacotherapy. An important outcome for GPs was being more reflective about their prescriptions. Disclosure of inappropriate prescribing can cause distress in some doctors, and tutors must be prepared to recognise and manage such reactions. http://www.biomedcentral.com/content/pdf/1471-2296-11-12.pdf Effect of an academic detailing intervention on the utilization rate of cyclooxygenase-2 inhibitors in the elderly SD Graham, AG Hartzema, IS Sketris, AG Winterstein Annals of Pharmacotherapy Jun 2008;42(6):749-756 Background: Osteoarthritis is prevalent in the elderly. Nova Scotia (Canada) general practitioners (GPs) identified the need for an academic detailing (AD) intervention aimed at optimising the management of osteoarthritis. AD was provided by Dalhousie University Continuing Medical Education in a face-to-face encounter employing evidence-based information. GP participation was voluntary. Objective: To evaluate the effect of a GP-targeted osteoarthritis AD intervention on a reduction in the prescribing of cyclooxygenase-2 (COX-2) inhibitors, as well as examine the intervention effect on the utilisation rates of gastroprotective agents and medical services. Methods: A retrospective cohort study design employing administrative data was used. Differences in utilisation rates between intervention and control groups were evaluated using generalised estimating equations analysis for longitudinal data over four 90-day postintervention periods. Confounding was addressed using propensity scores to adjust for between-group bias on the measured covariates. Results: The between-group difference for change in COX-2 utilisation rates was 0.76 defined daily doses/patient (p = 0.040; 95% CI, 0.037 to 1.48) for the 3-month period following the intervention, with lower COX-2 utilisation in the AD intervention group than in the control group. The intervention group showed a significant decrease in the within-group utilisation rate between the pre- and post-intervention periods (z = -2.34; p = 0.019). The between-group difference for change in GP office visit rates was 0.40 visits/patient (p = 0.028; 95% CI, 0.046 to 0.79) with the intervention group, showing higher visit rates compared with the control group. Conclusions: The osteoarthritis AD intervention was associated with a significant decrease (23%) in COX-2 utilisation rates in the 3-month period immediately following the intervention. The only secondary outcome to show a significant between-group effect was the GP office visit rate, which was higher for the intervention group in the second 3-month post-intervention period. http://www.theannals.com/content/42/6/749.long Identifying early prescribers of cycloxygenase-2 inhibitors (COX-2s) in Nova Scotia, Canada: considerations for targeted academic detailing 19 KEM Groves, T Schellinck, IS Sketris, NJ MacKinnon Research in Social and Administrative Pharmacy Sep 2010;6(3):257-267 Background: Expenditures on prescribed drugs in Canada are now well past those for all services provided by outpatient physicians (Can$26.9 billion vs $21.5 billion in 2007). Government has the opportunity to dedicate resources to continuing medical education of physicians, and effective profiling would assist in the allocation of these educational resources. Objective: The purpose of this study was to evaluate physician prescribing patterns and establish criteria by which various prescribing profiles may be segmented and identified, so as to better target detailing and continuing medical education resources. Methods: A sample of 925 physicians practising in Nova Scotia (NS) was characterized by age, sex, rural/urban nature of their practice and specialty. They were subsequently evaluated relative to all prescriptions filled by their patients who were beneficiaries of the NS Department of Health's senior's Pharmacare drug insurance programme. The adoption of COX-2 inhibitors (e.g. Vioxx and Celebrex) and their substitution for NS-NSAIDs (non-specific non-steroidal anti-inflammatory drugs, e.g. Motrin) from 1999 to 2003 were examined. Results: This analysis established the profiles of 2 key groups of physicians. The first consisted of those most likely to comprise the early, high volume COX-2-prescribing universe (profiles based on the absolute number of prescriptions written over a given period). These individuals were likely to be older, more experienced, male general practitioners operating in a rural practice. The second group consisted of those most likely to comprise the early, high-relative, COX-2-prescribing universe (prescribing of COX-2s relative to non-selective, non-steroidal anti-inflammatory drugs (NSNSAIDs)). These individuals were likely to be younger, less experienced female general practitioners, operating in an urban practice. Conclusions: This research moves us closer to identifying unique physician segments that account for either the largest volume of prescriptions for new drugs, or the largest relative volume of prescriptions. Use of these physician groups can help continuing medical education providers target specific prescribers with information to assist them in examining and improving their prescribing. http://dx.doi.org/10.1016/j.sapharm.2009.09.003 A pilot study evaluating alternative approaches of academic detailing in rural family practice clinics DM Hartung, A Hamer, L Middleton, D Haxby, LJ Fagnan BMC Family Practice 31 Dec 2012;13:129 Background: Academic detailing is an interactive, convenient and user-friendly approach to delivering non-commercial education to healthcare clinicians. While evidence suggests academic detailing is associated with improvements in prescribing behaviour, uncertainty exists about generalisability and scalability in diverse settings. Our study evaluates different models of delivering academic detailing in a rural family medicine setting. Methods: We conducted a pilot project to assess the feasibility, effectiveness and satisfaction with academic detailing delivered face-to-face as compared to a modified approach using distance-learning technology. The recipients were four family medicine clinics within the Oregon Rural Practice-based Research Network (ORPRN) in the USA. Two clinics were allocated to receive face-to-face detailing and two received outreach through video conferencing or asynchronous web-based outreach. 20 Surveys at midpoint and completion were used to assess effectiveness and satisfaction. Results: Each clinic received four outreach visits over an 8-month period. Topics included treatment-resistant depression, management of atypical antipsychotics, drugs for insomnia and benzodiazepine tapering. Overall, 90% of participating clinicians were satisfied with the programme. Respondents who received in person detailing reported a higher likelihood of changing their behaviour compared to respondents in the distance detailing group for 5 of 7 content areas. While 90%100% of respondents indicated they would continue to participate if the programme were continued, the likelihood of participation declined if only distance approaches were offered. Conclusions: We found strong support and satisfaction for the programme among participating clinicians. Participants favoured in-person approaches to distance interactions. Future efforts will be directed at quantitative methods for evaluating the economic and clinical effectiveness of detailing in rural family practice settings. http://www.biomedcentral.com/content/pdf/1471-2296-13-129.pdf Impact of a program encouraging the use of generic antipsychotics EDA Hermes, M Sernyak, R Rosenheck American Journal of Managed Care Aug 2012;18(8):e307-e314 Objective: Recent research suggests that second-generation antipsychotics (SGAs) may be used more often than clinically warranted. An intervention consisting of academic detailing and a prescriber survey was employed to encourage the reduction of newly prescribed on-patent SGAs. Design: Quasi-experimental quality improvement trial. Methods: Academic detailing consisted of educational lectures and a pocket guide on the latest effectiveness, safety, and cost data for SGAs and first-generation antipsychotics. Detailing was coupled with a required 20-item survey of provider decision making completed prior to prescriptions for on-patent SGAs at a US Veterans Health Administration medical centre between Oct 2007 and May 2009. The survey identified the medication, treated diagnosis, comorbid psychiatric and medical diagnoses, reasons for the medication, prior medications, and provider professional status. The outcome was the number of new SGA prescriptions per month. Results: The sample included 2176 surveys. The Spearman correlation between the number of prescriptions and the intervention month (range = 1 to 18) was 0.25 (P = 0.31), indicating no reduction. The most common medication prescribed was quetiapine (55.8%). The distributions of diagnoses were fairly even among schizophrenia, bipolar disorder, other affective disorders and posttraumatic stress disorder (17.0, 28.2, 25.8 and 20.4%, respectively). The 3 most common reasons for prescribing an SGA were to improve efficacy (49.8%), reduce side effects (29.1%) and increase sleep or sedation (34.5%). Conclusions: Academic detailing coupled with a provider survey did not decrease the rate of new prescriptions for on-patent SGAs. Reasons for prescribing SGAs were not consistent with recent research findings regarding efficacy and side effects. http://www.ajmc.com/articles/Impact-of-a-Program-Encouraging-the-Use-of-GenericAntipsychotics A brief overview of academic detailing in Canada: another role for pharmacists M Jin, T Naumann, L Regier, S Bugden, M Allen, et al. 21 Canadian Pharmacists Journal May 2012;145(3):142-146.e2 Academic detailing or educational outreach (a method of continuing education in which a trained health care professional meets with a prescriber in their practice setting to provide one-on-one evidence-based information) has been shown to improve patient health outcomes, It is currently available throughout the Canadian provinces of British Columbia, Saskatchewan and Nova Scotia, and in parts of Manitoba and Ontario. The role of the pharmacist can include academic detailer, evidence reviewer for topics, developer of key messages and content/supporting tools, developer of the evaluation framework and trainer of other academic detailers. http://www.cpjournal.ca/doi/pdf/10.3821/145.3.cpj142 Improving antibiotic utilization among hospitalists: a pilot academic detailing project with a public health approach F Kisuule, S Wright, J Barreto, J Zenilman Journal of Hospital Medicine Jan-Feb 2008;3(1):64-70 Background: Inappropriate use of antibiotics is a major clinical problem and public health concern. We developed and implemented a pilot hospitalist-delivered academic detailing intervention to improve the patterns of antibiotic prescribing for inpatients. Objective: To improve antibiotic prescribing patterns on the hospitalist service of an academic medical centre. Design, Setting and Participants: Hospitalist practitioners were recruited to participate in this pre- and post-intervention pilot study at Johns Hopkins Bayview Medical Center (JHBMC, Maryland, USA). Public health principles for creating a conceptual framework based on behavioural change theory were used in developing the intervention. Methods: Antibiotic prescribing patterns of 17 hospitalist practitioners were retrospectively reviewed. Antimicrobial prescriptions were classified as appropriate, effective but inappropriate or inappropriate. A profile was assembled for each hospitalist, and an academic detailing intervention session was arranged. The session reviewed inappropriate prescribing practices as well as current practice guidelines. After the detailing meeting, the prescribing patterns of the hospitalists were followed prospectively. Main Outcome Measures: The main outcome measures were the proportions of antibiotics prescribed inappropriately before the intervention, during the detailing period, and after the intervention. Results: 17 hospitalist practitioners who participated in the study. A total of 247 prescriptions were reviewed in the pre-intervention and 129 prescriptions in the post-intervention period. Prior to academic detailing, 43% (95% CI, 37% to 49%) of the prescriptions were appropriate and 57% (95% CI, 51% to 63%) were inappropriate. After the intervention, 74% (95% CI, 65% to 81%) of the prescriptions were appropriate and 26% (95% CI, 19% to 35%) were inappropriate; P less than 0.0001. Conclusions: A carefully planned and methodically executed intervention can result in behaviour change, even among busy hospitalists. The academic detailing intervention, which included a practice-based learning component, improved antibiotic prescribing practices of hospitalists at JHBMC. http://onlinelibrary.wiley.com/doi/10.1002/jhm.278/abstract 22 Testing the effect of a targeted intervention on nurses' compliance with "best practice" mechanical venous thromboembolism prevention F Li, K Waler, E McInnes, J Duff Journal of Vascular Nursing Sep 2010;28(3):92-96 The aim of this study was to examine whether educational outreach visits improve nurses' compliance with applying best practice mechanical venous thromboembolism prophylaxis. The design was as a pretest/posttest study with a 7-week follow-up. It was conducted in a mixed medical/surgical unit in a 250-bed private hospital in Sydney, Australia. The target population was 25 medical/surgical nurses in educational outreach visits (EOVs). The main outcome measures included change in percentage between baseline and endpoint of eligible patients receiving mechanical VTE prophylaxis and all patients having VTE risk documented in their medication charts, as well as nurses' feedback on how supportive and useful they found EOVs. The results showed an overall, but not significant increase (p = 0.201) in the percentage of patients who received mechanical VTE prophylaxis (59.4% baseline to 75% endpoint). There was a significant increase in the percentage of patients having VTE risk status documented in the medication chart (0%-28%) (p = 0.002). Improvements in compliance were more likely for surgical than medical patients (95% and 35%, respectively) and risk documentation (47% and 6%, respectively). Most nurses reported that the EOVs supported them in implementing best practice VTE mechanical prophylaxis. Researchers conclude that improvements in compliance with best practice VTE prevention can be achieved using EOVs which were easily conducted and wellreceived in a busy unit setting. More work is needed to increase the compliance rate with medical patients. http://www.jvascnurs.net/article/S1062-0303(10)00046-4/abstract Educational interventions for implementation of arthritis clinical practice guidelines in primary care: effects on health professional behaviour SC Lineker, JA Husted Journal of Rheumatology Aug 2010;37(8):1562-1569 Objective: The dissemination and adoption of clinical practice guidelines (CPG) has been suggested as one method for improving arthritis care delivery. This article provides a review and synthesis of studies evaluating the influence of educational programmes designed to implement CPG for osteoarthritis (OA) and rheumatoid arthritis (RA) in primary care. Methods: A systematic literature search was conducted to identify relevant educational interventions that reported behavioural outcomes that ensured actual knowledge utilisation in primary care. A standardised approach was used to assess the quality of the individual studies and a modified version of the Philadelphia Panel methodology allowed for grading of studies based on strength of design, clinical relevance, and statistical significance. Results: The search identified 485 articles; 7 studies were selected for review. In OA, peer facilitated workshops with nurse case-management support for patients decreased the number of referrals to orthopaedics by 23%, and educational outreach by trained physicians improved prescribing of analgesics. Interprofessional peer 23 facilitated workshops were successful in increasing referrals to rehabilitation services for people with OA and RA. Conclusions: There was sparse literature on educational programmes for the implementation of arthritis CPG in the primary care environment. Future studies are needed to evaluate which specific organizational, provider, patient and system level factors influence the uptake of arthritis CPG in primary care. http://www.jrheum.org/content/37/8/1562.abstract Impact of a multidisciplinary intervention on antibiotic use for nursing home-acquired pneumonia SA Linnebur, DN Fish, JM Ruscin, TA Radcliff, KS Oman, R Fink, B Van Dorsten, D Liebrecht, R Fish, M McNulty, E Hutt American Journal of Geriatric Pharmacotherapy Dec 2011;9(6):442-450.e1 Background: Academic detailing in nursing homes (NHs) has been shown to improve drug use patterns and adherence to guidelines. Objective: The purpose of this study was to evaluate the impact of a multidisciplinary intervention that included academic detailing on adherence to national nursing home-acquired pneumonia (NHAP) guidelines related to use of antibiotics. Methods: This quasi-experimental study evaluated the effects of a 2-year multifaceted and multidisciplinary intervention targeting implementation of national evidence-based guidelines for NHAP. Interventions took place in 8 NHs in Colorado; 8 NHs in Kansas and Missouri served as controls. Interventions included (1) educational sessions for nurses to improve recognition and timely treatment of NHAP symptoms and (2) academic detailing to clinicians by pharmacists regarding diagnostic and prescribing practices. Differences in antibiotic use between groups were compared after 2 intervention years relative to baseline. Results: A total of 549 episodes of NHAP were evaluated in the intervention group and 574 in the control group. Compared with baseline, 1 facility in the intervention group significantly improved in guideline adherence for optimal antibiotic use (P = 0.007), whereas no facilities in the control group improved. The mean adherence score for optimal antibiotic use in intervention NHs increased from 60% to 66%, whereas the control NHs increased from 32% to 39% (P = 0.3). Mean adherence to guidelines recommending antibiotic use within 4 hours of NHAP diagnosis increased from 57% to 75% in intervention NHs but decreased from 38% to 31% in control NHs (P = 0.0003 for difference). There was no difference between intervention and control NHs for guideline adherence regarding optimal duration of antibiotic use. Conclusions: The ability of this multifaceted study to repeatedly remind nursing staff of the importance of timely antibiotic administration contrasts with its limited academic detailing interaction with clinicians. This difference within the intervention may explain the differential impact of the intervention on antibiotic guideline adherence. http://www.sciencedirect.com/science/article/pii/S1543594611001711 Interventions to optimise prescribing in care homes: systematic review M Loganathan, S Singh, B Dean Franklin, A Bottle, A Majeed Age and Ageing Mar 2011;40(2):150-162 Background: Prescribing for older people is a complex process and can elevate the risk of inappropriate prescribing, with potentially severe consequences. With a growing ageing population, strategies to improve prescribing in care homes are 24 essential. Our aim was to review systematically the effects of interventions to optimise prescribing in care homes. Method: Databases searched were MEDLINE, EMBASE, International Pharmaceutical Abstracts and the Cochrane Library from 1990. Search terms included were 'nursing home', 'residential home', 'inappropriate prescribing', 'education' and 'intervention'. Two independent reviewers undertook screening and methodological quality assessment, using the Downs and Black rating scale. Results: The search strategy retrieved 16 studies that met the inclusion criteria. Four intervention strategies were identified: staff education, multi-disciplinary team (MDT) meetings, pharmacist medication reviews and computerised clinical decision support systems (CDSSs). Complex educational programmes that focused on improving patients' behavioural management and drug prescribing were the most studied area, with 6 of 8 studies highlighting an improvement in prescribing. Mixed results were found for pharmacist interventions. CDSSs were evaluated in two studies, with one showing a significant improvement in appropriate drug orders. Two of three studies examining MDT meetings found an overall improvement in appropriate prescribing. A meta-analysis could not be performed due to heterogeneity in the outcome measures. Conclusions: Results are mixed and there is no one interventional strategy that has proved to be effective. Nevertheless, education including academic detailing seems to show most promise. A multi-faceted approach and clearer policy guidelines are likely to be required to improve prescribing for these vulnerable patients. http://ageing.oxfordjournals.org/content/40/2/150.abstract A cluster randomised controlled trial of pharmacist-led Statin Outreach Support in primary care R Lowrie PhD Thesis, University of Glasgow, Apr 2012, 257pp. Background: Elevated blood lipids (particularly cholesterol and sub-fractions) contribute to the risk of developing cerebral, peripheral and cardiovascular disease and associated complications which are leading causes of morbidity and death. Statins reduce the risk of suffering vascular events, with or without decreasing cholesterol levels. Statin prescribing continues to increase but there is scope to improve prescribing and dosing, particularly in primary care. However, there is insufficient empirical evidence to inform approaches to quality improvement. Methods: Following pilot work, we designed a new model of primary care based pharmacist-led intervention for General Practitioners (GPs) and nurses. The aim of the intervention (called Statin Outreach Support, SOS) was to improve statin prescribing by GPs, in line with recent evidence, targeting patients at highest risk of suffering a vascular event. Eleven trained pharmacists worked in SOS allocated practices one day per week for a year. During this period, the pharmacist met three times with all GPs, all nurses and other practice staff. Between meetings, pharmacists used patient level clinical and prescribing data to identify eligible patients and help practices initiate, up-titrate the dose or switch to simvastatin 40mg where indicated. The effectiveness of SOS was tested in a prospective, single-blind, cluster-randomised controlled trial. Usual care (UC) practices received no pharmacist support during the study. With a mean of 1.7 years follow up, the study had over 90% power (at 5% significance) to detect a difference of 12% in the proportion of patients with controlled cholesterol after practices had received the SOS intervention. 25 Results: 31 practices were recruited from the NHS Glasgow area. At randomisation, 16 practices were allocated to the SOS intervention and 15 to UC with 4040 patients included at baseline. Recruited practices showed few differences compared with invited, non-participating practices. Practices and patients randomised to each arm of the study had similar distributions with respect to age, complications, cholesterol levels and statin prescribing. The mean age was 68 years; 53% male, 45% ischaemic aetiology. 59% had no statin prescribed at baseline; only 51% had cholesterol controlled. Follow-up included 7586 patients in 29 practices (one practice had disbanded between recruitment and randomisation and another practice dropped out). Compared with UC, the SOS intervention achieved the primary endpoint of increasing the proportion of patients prescribed Simvastatin 40mg with controlled cholesterol (SOS 44.9% vs UC 27.9%; odds ratio 1.79; 95% CI, 1.61 to 1.98; p less than 0.001). Secondary endpoints were also improved in the SOS arm practices. The intervention effect was strong and consistent across most subgroups including a positive impact on patients from practices in areas of greater socioeconomic deprivation. Conclusions: A pragmatic, new, complex intervention was developed, tested and shown to be effective in a cluster-randomised, controlled trial with good internal and external validity. If implemented on a wider scale, in practices with comparable characteristics and baseline prescribing, the SOS intervention has the potential to reduce the burden of vascular events for patients with vascular disease. This work provides a convincing evidence base for the role of pharmacists collaborating with primary care practices, to improve statin prescribing and drug based cholesterol management, for patients at highest risk of suffering vascular events. http://theses.gla.ac.uk/3352/01/2012lowriephd.pdf A cluster randomised controlled trial of pharmacist led Statin Outreach Support (SOS) in primary care: design and baseline characteristics R Lowrie, J Morrison, A McConnachie Contemporary Clinical Trials Jul 2010;31(4):303-311 Background: Statins reduce the risk of vascular events, however statin prescribing is often sub optimal and better evidence is needed to inform quality improvements. The Statin Outreach Support (SOS) trial was designed to test the efficacy of pharmacistled educational outreach directed at general practices, aiming to improve statin prescribing for community-dwelling patients with vascular disease. This paper describes the study rationale, design, methods and baseline characteristics of participants. Design: The SOS trial was designed to investigate whether practices receiving SOS improve their statin prescribing and patients achieve reduced cholesterol levels. It was a prospective, single-blind, cluster-randomised, controlled trial with a follow-up period of 5 months minimum post SOS intervention delivery. Results: 31 practices were recruited from the NHS Greater Glasgow and Clyde area. At randomisation, 16 practices were allocated to SOS and 15 to usual care with 4040 patients included at baseline. Participating practices showed few differences compared with non-participating practices; practices and patients randomised to each arm of the study had similar distributions with respect to age, complications, cholesterol levels and statin prescribing. Baseline data compared favourably with landmark, placebo-controlled statin trials. Conclusions: Compared with existing implementation research, SOS trial has more participants, a detailed description of baseline characteristics and over 90% power 26 (at 5% significance) to detect a difference of 12% in the proportion of patients with controlled cholesterol after SOS. http://dx.doi.org/10.1016/j.cct.2010.03.010 Interventions designed to improve the quality and efficiency of medication use in managed care: a critical review of the literature 2001-2007 CY Lu, D Ross-Degnan, SB Soumerai, S-A Pearson BMC Health Services Research 7 Apr 2008;8:75 Background: Managed care organisations use a variety of strategies to reduce the cost and improve the quality of medication use. The effectiveness of such policies is not well understood. The objective of this research was to update a previous systematic review of interventions, published between 1966 and 2001, to improve the quality and efficiency of medication use in the US managed care setting. Methods: We searched MEDLINE and EMBASE for publications from Jul 2001 to Jan 2007 describing interventions targeting drug use conducted in the US managed care setting. We categorised studies by intervention type and adequacy of research design using commonly accepted criteria. We summarised the outcomes of wellcontrolled strategies and documented the significance and magnitude of effects for key study outcomes. Results: We identified 164 papers published during the 6-year period. Predominant strategies were: educational interventions (n = 20, including dissemination of educational materials and group or one-to-one educational outreach); monitoring and feedback (n = 22, including audit/feedback and computerised monitoring); formulary interventions (n = 66, including tiered formulary and patient copayment); collaborative care involving pharmacists (n = 15); and disease management with pharmacotherapy as a primary focus (n = 41, including care for depression, asthma and peptic ulcer disease). Overall, 51 studies met minimum criteria for methodological adequacy. Effective interventions included one-to-one academic detailing, computerised alerts and reminders, pharmacist-led collaborative care and multifaceted disease management. Further, changes in formulary tier-design and related increases in copayments were associated with reductions in medication use and increased out-of-pocket spending by patients. The dissemination of educational materials alone had little or no impact, while the impact of group education was inconclusive. Conclusions: There is good evidence for the effectiveness of several strategies in changing drug use in the managed care environment. However, little is known about the cost-effectiveness of these interventions. Computerised alerts showed promise in improving short-term outcomes but little is known about longer-term outcomes. Few well-designed, published studies have assessed the potential negative clinical effects of formulary-related interventions despite their widespread use. However, some evidence suggests increases in cost sharing reduce access to essential medicines for chronic illness. http://www.biomedcentral.com/1472-6963/8/75 A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments KA McIntosh, DJ Maxwell, LK Pulver, F Horn, MB Robertson, KI Kaye, GM Peterson, WB Dollman, A Wai, SE Tett 27 International Journal for Quality in Health Care Apr 2011;23(2):142-150 Objective: The objective of this study was to improve the concordance of community-acquired pneumonia management in Australian emergency departments with national guidelines through a quality improvement initiative promoting concordant antibiotic use and use of a pneumonia severity assessment tool, the pneumonia severity index (PSI). Design and Interventions: Drug use evaluation, a quality improvement methodology involving data collection, evaluation, feedback and education, was undertaken. Educational interventions included academic detailing, group feedback presentations and prescribing prompts. Setting and Participants: Data were collected on 20 consecutive adult communityacquired pneumonia emergency department presentations by each hospital for each of three audits. Main Outcome Measures: Two process indicators measured the impact of the interventions: documented PSI use and concordance of antibiotic prescribing with guidelines. Comparisons were performed using a Chi-squared test. Results: 37 hospitals, including public, private, rural and metropolitan institutions, participated. 26 hospitals completed the full study (range: 462-518 patients), incorporating two intervention phases and subsequent follow-up audits. The baseline audit of community-acquired pneumonia management demonstrated that practice was varied and mostly discordant with guidelines. Documented PSI use subsequently improved from 30/518 (6%; 95% CI, 4-8) at baseline to 125/503 (25%; 95% CI, 21-29; P less than 0.0001) and 102/462 (22%; 95% CI, 18-26; P less than 0.0001) in audits two and three, respectively, while concordant antibiotic prescribing improved from 101/518 (20%; 95% CI, 16-23) to 132/462 (30%; 95% CI, 26-34; P less than 0.0001) and 132/462 (29%; 95% CI, 24-33; P less than 0.001), respectively. Conclusions: Improved uptake of guideline recommendations for communityacquired pneumonia management in emergency departments was documented following a multi-faceted education intervention. http://intqhc.oxfordjournals.org/content/23/2/142.abstract Experience with academic detailing services for quality improvement in primary care practice F May, D Simpson, L Hart, D Rowett, D Perrier Quality and Safety in Health Care Jun 2009;18(3):225-231 Background: Despite longstanding experimental evidence about effectiveness of academic detailing, transitioning this research-based concept into acceptable primary care quality improvement services has been slow in the USA. The purpose of this study was to describe primary care uptake, retention and response to an academicdetailing-led service in the USA. Exploration of accessible performance indicators of service acceptance, and feasibility of use of an Australian academic detailing service model were secondary objectives. Methods: Over a 29-month period, an academic-detailing-led drug and therapeutics information service was offered to all primary care physicians providing ongoing patient care in Fayette County, Kentucky, USA. Two programmes (on type 2 diabetes management and chronic pain management) incorporating up to four office visits were offered. Results: 102 of 130 (78%) eligible primary care physicians participated in the service, 72% receiving visits for the type 2 diabetes management programme, and 58% the chronic non-malignant pain programme. At all successive encounters, 28 participants expressed a willingness to continue to receive visits. Difficulties were experienced in obtaining appointments for subsequent visits, although on direct enquiry, only one participant explicitly declined further visits. No notable differences existed between physicians accepting visits and those who did not. Across successive visits, passive indicators of satisfaction with the service included: duration of visits, office waiting times, retention of printed materials from one visit to the next, whether physicians wished their extender colleagues to also receive visits, and observed levels of interest and participation within encounters. Conclusions: Ongoing primary care quality improvement services spearheaded by academic detailing can be acceptable to US primary care physicians in practice. http://qualitysafety.bmj.com/content/18/3/225.abstract A RCT evaluating the effectiveness and cost-effectiveness of academic detailing versus postal prescribing feedback in changing GP antibiotic prescribing C Naughton, J Feely, K Bennett Journal of Evaluation in Clinical Practice Oct 2009;15(5):807-812 The aim of this study in Ireland was to evaluate the effectiveness of academic detailing (AD) plus postal prescribing feedback versus postal prescribing feedback alone in reducing: (i) the overall rate of antibiotic; and (ii) the proportion of secondline antibiotic prescribing. In addition, the cost-effectiveness of an outreach prescriber adviser service versus a postal prescribing feedback service was evaluated. Volunteer GP practices (n = 98) were randomised to receive prescribing feedback via postal bulletin (PB) (n = 50) or academic detailing plus postal bulletin (AD) (n = 48). Data analysis was based on the HSE-primary care reimbursement service (HSE-PCRS) prescribing database. Regression (beta) coefficients, indicating proportion change in prescribing per month, and 95% confidence intervals (CIs) are presented. The cost-effectiveness ratio was calculated from the total cost of the intervention divided by percentage change in antibiotic prescribing in AD versus PB group. Immediately post-intervention PB (beta = -0.02; 95% CI, -0.04 to -0.001) and AD (beta = -0.02; 95% CI, -0.03 to -0.001) practices significantly decreased overall antibiotic prescribing. Second-line antibiotic prescribing was also significantly decreased by 2 to 3% in both groups. However, there were no significant differences in antibiotic prescribing between the randomised groups in the immediate or longterm post-intervention period. In the cost-effectiveness analysis a postal prescribing feedback service would cost Euro 88 per percentage change in prescribing practice compared with Euro 778 for a prescriber adviser service. Concludes that prescribing feedback significantly reduced overall and second-line antibiotic prescribing, but academic detailing was not significantly more effective than a postal bulletin in changing antibiotic prescribing practice. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2753.2008.01099.x/abstract Systematic review of interventions to improve prescribing R Ostini, D Hegney, C Jackson, M Williamson, JM Mackson, K Gurman, W Hall, SE Tett Annals of Pharmacotherapy Mar 2009;43(3):502-513 Objective: To update two comprehensive reviews of systematic reviews on prescribing interventions and identify the latest evidence about the effectiveness of the interventions. Data Sources: Systematic searches for English-language reports of experimental and quasi-experimental research were conducted in PubMed (1951-May 2007), EMBASE (1974-Mar 2008), International Pharmaceutical Abstracts (1970-Mar 2008) and 11 29 other bibliographic databases of medical, social science, and business research. Following an initial title screening process and after selecting 6 specific intervention categories (identified from the previous reviews) in community settings, two reviewers independently assessed abstracts and then full studies for relevance and quality and extracted relevant data using formal assessment and data extraction tools. Results were then methodically incorporated into the findings of the two earlier reviews of systematic reviews. Data Selection and Synthesis: 29 of 26,314 articles reviewed were assessed to be of relevant, high-quality research. Audit and feedback, together with educational outreach visits, were the focus of the majority of recent, high-quality research into prescribing interventions. These interventions were also the most effective in improving prescribing practice. A smaller number of studies included a patientmediated intervention; this intervention was not consistently effective. There is insufficient recent research into manual reminders to confidently update earlier reviews and there remains insufficient evidence to draw conclusions regarding the effectiveness of local consensus processes or multidisciplinary teams. Conclusions: Educational outreach as well as audit and feedback continue to dominate research into prescribing interventions. These two prescribing interventions also most consistently show positive results. Much less research is conducted into other types of interventions and there is still very little effort to systematically test why interventions do or do not work. http://www.theannals.com/content/43/3/502.short Effects of an educational outreach campaign (IMPACT) on depression management delivered to general practitioners in one primary care trust B Patel, S Afghan Mental Health in Family Medicine Sep 2009;6(3):155-162 Objective: An educational outreach initiative with general practitioners (GPs) within Walsall, led by pharmacists and aimed at delivering evidence-based guidance on stepped care management of clinical depression. Methods: Standardised educational material was produced with key messages and contributions by experts on prescribing principles and management of clinical depression based on NICE guidance. The primary care pharmacists together with a psychiatrist or other professional delivered the training through initial face-to-face meetings with GP practices and carrying out follow-up visits. Evaluation: Analysis of prescribing data (PACT) on antidepressants, which included prescribing of defined daily doses (DDD) and net ingredient cost (NIC) of commonly prescribed antidepressants for the whole of Walsall teaching Primary Care Trust (tPCT) and comparison with prescribing data for the West Midlands and for England during the period Jun 2000 to Jun 2006. Results: The use of fluoxetine increased slightly and the prescribing of dosulepin continued to fall. The prescribing of escitalopram, which had steadily increased prior to the launch of campaign, showed decline, resulting in savings of over GBP50K in the year 2005 to 2006. This was in comparison to a relative increase in the prescribing for escitalopram for the same time period in the West Midlands and nationally. Prescribing of dosulepin continued to fall. The total cost of prescribing for the four antidepressants fell and these changes were sustained over the following year. Conclusions: The educational outreach campaign successfully influenced prescribing behaviour in terms of adhering to NICE guidance and cost-effective prescribing, and 30 also facilitated improved communication among clinicians at the primary-secondary care interface. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2838650/ Management of acute coronary syndromes at hospital discharge: do targeted educational interventions improve practice quality? GM Peterson, A Thompson, LK Pulver, MB Robertson, D Brieger, A Wai, SE Tett (DMACS Project Group) Journal for Healthcare Quality Jan-Feb 2012;34(1):26-34 Evidence-based guidelines exist for the management of patients with acute coronary syndromes (ACS), yet adherence is suboptimal. The Discharge Management of Acute Coronary Syndrome project used a quality improvement approach, with targeted intervention strategies to optimize: prescription of guideline-recommended medications; education regarding lifestyle modifications, including cardiac rehabilitation (CR); and communication between hospital staff, patients and general practitioners. Hospitals across Australia participated in a quality improvement cycle of audit, feedback, intervention and reaudit. Interventions involved educational meetings, academic detailing and point-of-care reminders and feedback of baseline audit results. Outcome measures included prescription of guideline-recommended medications, referral to CR, and documentation and communication of management plan. At baseline, 49 hospitals recruited 1545 patients, and post-intervention, 45 hospitals remained active in the project and recruited 1589 patients. 3034 hospital staff attended group education or academic detailing sessions. Post-intervention, there was a significant increase in the prescription of all four guideline-recommended medications (69% vs 57%; p less than 0.0001); short-acting nitrates (68% vs 56%; p less than 0.0001); and documented referral to CR (68% vs 57%; p less than 0.0001). There were significant increases in documented discharge medication counselling, smoking cessation counselling and communication of management plans. Targeted educational interventions used as part of a quality improvement cycle can enhance adherence to evidence-based guidelines for the management of patients with ACS. http://onlinelibrary.wiley.com/doi/10.1111/j.1945-1474.2011.00137.x/pdf Implementation and evaluation of a multisite drug usage evaluation program across Australian hospitals - a quality improvement initiative LK Pulver, A Wai, DJ Maxwell, MB Roberston, S Riddell BMC Health Services Research 29 Aug 2011;11:206 Background: With the use of medicines being a broad and extensive part of health management, mechanisms to ensure quality use of medicines are essential. Drug usage evaluation (DUE) is an evidence-based quality improvement methodology, designed to improve the quality, safety and cost-effectiveness of drug use. The purpose of this paper is to describe a national DUE methodology used to improve health care delivery across the continuum through multi-faceted interventions involving audit and feedback, academic detailing and system change, and a qualitative assessment of the methodology, as illustrated by the Acute Postoperative Pain Management (APOP) project. Methods: An established methodology, consisting of a baseline audit of inpatient medical records, structured patient interviews and general practitioner surveys, followed by an educational intervention and follow-up audit, is used. Australian hospitals, including private, public, metropolitan and regional, are invited to 31 participate on a voluntary basis. De-identified data collected by hospitals are collated and evaluated nationally to provide descriptive comparative analyses. Hospitals benchmark their practices against state and national results to facilitate change. The educational intervention consists of academic detailing, group education, audit and feedback, point-of-prescribing prompts and system changes. A repeat data collection is undertaken to assess changes in practice. An online qualitative survey was undertaken to evaluate the APOP programme. Qualitative assessment of hospitals' perceptions of the effectiveness of the overall DUE methodology and changes in procedure/prescribing/policy/clinical practice which resulted from participation were elicited. Results: 62 hospitals participated in the APOP project. Among 23 respondents to the evaluation survey, 18 (78%) reported improvements in the documentation of pain scores at their hospital. 15 (65%) strongly agreed or agreed that participation in APOP directly resulted in increased prescribing of multimodal analgesia for pain relief in postoperative patients. Conclusions: This national DUE programme has facilitated the engagement and participation of a number of acute health care facilities to address issues relating to quality use of medicine. This approach has been perceived to be effective in helping them achieve improvements in patient care. http://www.biomedcentral.com/content/pdf/1472-6963-11-206.pdf Clinical decision support implemented with academic detailing improves prescribing of key renally cleared drugs in the hospital setting GW Roberts, CJ Farmer, PC Cheney, SM Govis, TW Belcher, SA Walsh, RJ Adams Journal of the American Medical Informatics Association May 2010;17(3):308-312 Objective: Lack of dose adjustment for renally cleared drugs in the presence of poor renal function is a common problem in the hospital setting. The absence of a clinical decision support system (CDSS) from direct clinician workflows such as computerised provider order entry (CPOE) hinders the uptake of CDSS. This study in Australia implemented CDSS in an environment independent of CPOE, introduced to prescribers via academic detailing, to address the dosing of renally cleared drugs. Design: GFR+ was designed to automatically calculate and update renal function, doses of key drugs adjusted for renal function, and highlight clinically significant decreases in renal function. Prescribers were made aware of GFR+, its navigation, and surrounding clinical issues, using academic detailing. Measurement: The rate of dosing conformity and management for key renally cleared drugs in hospitalised patients, before and after GFR+ implementation. Results: Improvements were seen in dosing conformity for enoxaparin (from 68% to 86%, p = 0.03), gentamicin (63-87%, p = 0.01), and vancomycin (47-77%, p = 0.07), as well as the appropriate use of gentamicin therapeutic drug monitoring (7090%, p = 0.02). During episodes of acute renal impairment, renally cleared drugs were held on 38% of instances in the pre-intervention period compared with 62% post-intervention (p = 0.01). Conclusion: Clinical decision support implemented with academic detailing improved dosing conformity and management of key renally cleared drugs in a hospitalised population. Academic detailing should be strongly considered to facilitate the introduction of CDSS systems that cannot be placed directly into the clinician workflow. http://171.67.114.118/content/17/3/308.abstract 32 Educational outreach to reduce immunization pain in office settings NL Schechter, BA Bernstein, WT Zempsky, NS Bright, AK Willard Pediatrics Dec 2010;126(6):e1514-e1521 Objective: The goal was to examine the impact of a teaching module on immunisation pain reduction practices in paediatric offices 1 and 6 months after the intervention. Methods: Fourteen practices were selected randomly to receive a 1-hour teaching session on immunisation pain reduction techniques, and 13 completed the study. Before the intervention, telephone interviews were conducted with parents concerning their children's recent immunisation experiences. At 1 and 6 months after the intervention, parents of children who had recent immunisations were interviewed by using the same questionnaires. Clinicians also were surveyed at baseline and at 6 months. Results: A total of 839 telephone interviews and 92 clinician surveys were included. Significant changes from baseline were identified at 1 and 6 months after the intervention. At 1 month, parents were more likely to report receiving information (P = 0.04), using strategies to reduce pain (P less than 0.01), learning something new (P less than 0.01), using a ShotBlocker (P less than 0.01), using sucrose (P less than 0.01) and having higher levels of satisfaction (P = 0.015). At 6 months, all rates remained significantly higher than baseline findings (all P less than 0.01) except for satisfaction. Clinician surveys revealed significant increases in the use of longer needles, sucrose, pinwheels, focused breathing, and ShotBlockers at 6 months. Conclusions: A 1-hour teaching session had measurable effects on the use of painreducing strategies at 1 and 6 months after the intervention. This research supports the hypothesis that small-group teaching sessions at the site of care can be associated with changes in practice behaviours. http://pediatrics.aappublications.org/content/126/6/e1514.long Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008 SJ Semple, EE Roughead Australia and New Zealand Health Policy 22 Sep 2009;6:24 This paper presents Part 2 of a literature review examining medication safety in the Australian acute care setting. This review was undertaken for the Australian Commission on Safety and Quality in Health Care, updating the 2002 national report on medication safety. Part 2 of the review examined the Australian evidence base for approaches to build safer medication systems in acute care. A literature search was conducted to identify Australian studies and programmes, published from 2002 to 2008, which examined strategies and activities for improving medication safety in acute care. Since 2002 there has been significant progress in strategies to improve prescription writing in hospitals with the introduction of a National Inpatient Medication Chart. Systems are also in place to ensure a nationally coordinated approach to the ongoing optimisation of the chart. Progress has been made, with Australian research examining the implementation of computerised prescribing systems with clinical decision support. These studies have highlighted barriers and facilitators to the introduction of such systems that can inform wider implementation. However, Australian studies assessing outcomes of this strategy on medication incidents or patient outcomes are still lacking. In studies assessing education for reducing medication errors, academic detailing has been demonstrated to reduce errors in prescriptions for Schedule 8 medicines and a programme was shown to be 33 effective in reducing error-prone prescribing abbreviations. Published studies continue to support the role of clinical pharmacist services in improving medication safety. Studies on strategies to improve communication between different care settings, such as liaison pharmacist services, have focussed on implementation issues now that funding is available for community-based services. Double-checking versus single-checking by nurses, and patient self-administration in hospital, have been assessed in small studies. No new studies were located assessing the impact of individual patient medication supply, adverse drug event alerts or bar coding. There is still limited research assessing the impact of an integrated systems approach on medication safety in Australian acute care. (70 refs.) http://www.anzhealthpolicy.com/content/pdf/1743-8462-6-24.pdf Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: a cluster-randomized controlled trial SR Simon, SR Majumdar, LA Prosser, S Salem-Schatz, C Warner, K Kleinman, I Miroshnik, SB Soumerai American Journal of Medicine May 2005;118(5):521-528 Purpose: To compare group versus individual academic detailing to increase diuretic or beta-blocker use in hypertension. Methods: We conducted a cluster-randomised controlled trial in a large health maintenance organisation in the USA. Subjects (N = 9820) were patients with newly treated hypertension in the year preceding the intervention (N = 3692), the 9 months following the intervention (N = 3556) and the second year following intervention (N = 2572). We randomly allocated 3 practice sites to group detailing (N = 227 prescribers), 3 to individual detailing (N = 235 prescribers) and 3 to usual care (N = 319 prescribers). Individual detailing entailed a physician-educator meeting individually with clinicians to address barriers to prescribing guidelinerecommended medications. The group detailing intervention incorporated the same social marketing principles in small groups of clinicians. Results: In the first year following the intervention, the rates of diuretic or betablocker use increased by 13.2% in the group detailing practices, 12.5% in the individual detailing practices and 6.2% in the usual care practices. As compared with usual care practices, diuretic or beta-blocker use was more likely in group detailing practices (adjusted odds ratio (OR), 1.40; 95% CI, 1.11 to 1.76) and individual detailing practices (adjusted OR, 1.30; 95% CI, 0.95 to 1.79). Neither intervention affected blood pressure control. Two years following this single-visit intervention, there was still a trend suggesting a persistent effect of individual (OR, 1.22; 95% CI, 0.92 to 1.62), but not group, detailing (OR, 1.06; 95% CI, 0.80 to 1.39), as compared with usual care. Conclusions: Both group and individual academic detailing improved antihypertensive prescribing over and above usual care but may require reinforcement to sustain improvements. http://www.sciencedirect.com/science/article/pii/S0002934305000446 Changing prescriber behavior using academic detailing and computerized decision support SR Simon, RJ Fortuna, FX Campion, AC Feldstein, DH Smith, M Packer, B Cerullo, F Zhang, D Ross-Degnan, JA Finkelstein Clinical Medicine and Research Dec 2008;6(3-4):128 34 Paper presented at the 14th Annual HMO Research Network Conference, 13-16 Apr 2008, Minneapolis, USA, Abstract C-C3-04. Background/Aims: Harvard Pilgrim Health Care (HPHC) is one of 28 US Attorney General Consumer and Prescriber Grant Program grantees. Four HMORN CERTs sites, including HPHC, received grants. An overall goal of the programme is to identify best practices for educating clinicians about the influences on their prescribing and for changing their prescribing behaviours. At HPHC, our aim was to test the effectiveness of computerised clinical decision support (alerts), alone and in combination with group academic detailing, to reduce the use of heavily marketed hypnotic medications at Harvard Vanguard Medical Associates (HVMA), a 14-site group practice that uses the Epic electronic health record. Methods: We randomly allocated the 14 practices to three study groups: 1. Alerts Only (n=5 practices), 2. Alerts plus Detailing (n=5), and 3. Usual Care (n=4). Internal medicine clinicians in both the Alerts groups received prescribing alerts when initiating new prescriptions for eszopiclone (Lunesta), zaleplon (Sonata), ramelteon (Rozerem) and controlled-release zolpidem (Ambien CR) between Mar and Dec 2007. We carried out group academic detailing sessions in Jun and Jul 2007 followed by an educational mailing in the fall. Results: A pre-planned interim data analysis (Aug 2007) demonstrated that hypnotic study alerts were triggered on 98 separate occasions. After receiving an alert, 30% (95% CI, 21% to 40%) of clinicians changed the prescription to an alternative recommended medication. We plan to extract post-intervention data in Jan 2008 and will present findings of the intervention at the HMORN meeting. In addition, we carried out pre-intervention and post-intervention surveys of all clinicians at HVMA in 2006 and 2007 which assessed clinicians’ perceptions of the influences on their prescribing, with special attention to the role of direct-to-consumer marketing. We will present the results of these surveys, as well. Conclusions: Developing interventions using health information technology and group detailing to improve the use of medications is a high priority for many HMORN organizations. The results of this study should be generalisable to many HMORN sites, including but not limited to the many organisations that have deployed the Epic electronic health record. http://www.clinmedres.org/content/6/3-4/128.1.abstract Economic analysis of a randomized trial of academic detailing interventions to improve use of antihypertensive medications SR Simon, HP Rodriguez, SR Majumdar, K Kleinman, C Warner, S Salem-Schatz, I Miroshnik, SB Soumerai, LA Prosser Journal of Clinical Hypertension Jan 2007;9(1):15-20 The authors estimated the costs and cost savings of implementing a programme of mailed practice guidelines and single-visit individual and group academic detailing interventions by a physician in a randomised controlled trial to improve the use of antihypertensive medications. Analyses took the perspective of the payer. The total costs of the mailed guideline, group detailing and individual detailing interventions were estimated at US$1000, $5500 and $7200, respectively, corresponding to changes in the average daily per person drug costs of -$0.0558 (95% CI, -$0.1365 to $0.0250) in the individual detailing intervention and -$0.0001 (95% CI, -$0.0803 to $0.0801) in the group detailing intervention, compared with the mailed intervention. For all patients with incident hypertension in the individual detailing 35 arm, the annual total drug cost savings were estimated at $21,711 (95% CI, $53,131 savings to $9709 cost increase). Authors conclude that information on costs of academic detailing could assist with health plan decision making in developing interventions to improve prescribing. http://onlinelibrary.wiley.com/doi/10.1111/j.1524-6175.2006.05684.x/pdf Intervention with educational outreach at large scale to reduce antibiotics for respiratory tract infections: a controlled before and after study HM Smeets, MM Kuyvenhoven, AE Akkerman, I Welschen, GP Schouten, GA van Essen, TJM Verheij Family Practice Jun 2009;26(3):183-187 Background: A multiple intervention targeted to reduce antibiotic prescribing with an educational outreach programme had proven to be effective in a randomised controlled trial in 12 peer review groups, demonstrating 12% less prescriptions for respiratory tract infections. Objective: To assess the effectiveness of a multiple intervention in primary care at a large scale. Methods: A controlled before and after study in 2006 and 2007 was designed. Participants were from general practices within a geographically defined area in the central region of the Netherlands. Participants were GPs in 141 practices in 25 peer review groups. A control group of GP practices from the same region, matched for type of practice and mean volume of antibiotic prescribing. The multiple intervention consisted of the following elements: (i) group education meeting and communication training; (ii) monitoring and feedback on prescribing behaviour; (iii) group education for GPs and pharmacists assistants and (iv) patient education material. The main outcome measures are as follows: (i) number of antibiotic prescriptions per 1000 patients per GP and (ii) number of second-choice antibiotics, obtained from claims data from the regional health insurance company. The associations between predictors and outcome measurements were assessed by means of a multiple regression analyses. Results: At baseline, the number of antibiotic prescriptions per 1000 patients was slightly higher in the intervention group than in the control group (184 vs 176). In 2007, the number of prescriptions had increased to 232 and 227, respectively, showing no difference between the intervention and control groups. Conclusions: The implementation of an already proven effective multiple intervention strategy at a larger scale showed no reduction of antibiotic prescription rates. The failure might be attributed to a less tight monitoring of intervention and audit. Inserting practical tools in the intervention might be more successful and should be studied. http://fampra.oxfordjournals.org/content/26/3/183.short Impact of the ALLHAT/JNC7 dissemination project on thiazide-type diuretic use RS Stafford, LK Bartholomew, WC Cushman, JA Cutler, et al. (ALLHAT Collaborative Research Group) Archives of Internal Medicine 24 May 2010;170(10):851-858 Background: Strategies are needed to improve the translation of clinical trial results into practice. We assessed the impact of the ALLHAT/JNC7 Dissemination Project's academic detailing component on thiazide-type diuretic prescribing (ALLHAT indicates Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack 36 Trial; JNC7 indicates the Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure). Methods: We used 2 national databases available from IMS Health: a physician survey of medications reported for hypertension and a pharmacy dispensing database on antihypertensive medications. At a county level, we correlated medication data with Dissemination Project intensity. Practices before the Dissemination Project in 2004 were compared with those after its completion in 2007. We also examined 2000-08 national trends. Results: Academic detailing reached 18,524 physicians in 1698 venues via 147 investigator-educators. We noted an association between ALLHAT/JNC7 academic detailing activities and increased prescribing of thiazide-type diuretics. Physician survey data showed that the percentage of hypertension visits where the physician recorded a thiazide-type diuretic increased the most in counties where academic detailing activity was the highest (an increase of 8.6%, from 37.9% to 46.5%) compared with counties where activity was moderate (an increase of 2%) or low (a decrease of 2%), or where there was none (an increase of 2%; P value for trend, less than 0.05). Pharmacy dispensing data showed that thiazide-type diuretic prescribing increased by 8.7% in counties with Dissemination Project activities compared with 3.9% in those without activities (P less than 0.001). Nationally, thiazide-type diuretic use did not increase between 2004 and 2008. Conclusions: The ALLHAT/JNC7 Dissemination Project was associated with a small effect on thiazide-type diuretic use consistent with its small dose and the potential of external factors to diminish its impact. Academic detailing may increase physicians' implementation of clinical trial results, thereby making prescribing more consistent with evidence. http://archinte.jamanetwork.com/data/Journals/INTEMED/5767/ioi90180_851_858.pdf An evaluation of educational outreach to improve evidence-based prescribing in Medicaid: a cautionary tale AJ Zillich, RT Ackermann, TE Stump, RJ Ambuehl, SM Downs, AM Holmes, B Katz, TS Inui Journal of Evaluation in Clinical Practice Oct 2008;14(5):854-860 Rationale, Aims and Objectives: Evidence suggests that educational outreach (‘academic detailing’) improves evidence-based prescribing. We evaluated the impact of an academic detailing programme intended to increase new statin prescriptions. Methods: In a 2x2 factorial design we evaluated the effect of an academic detailing programme with/without telephonic care management for patients. Eligible patients were continuously enrolled Medicaid members at high risk for cardiovascular disease utilisation who were not receiving statin medication in the 18 months prior to the intervention. All primary care prescribers assigned to these patients were randomised by clinic to academic detailing. Two trained nurses provided the detailing to prescribers, including specific discussion about the use of statins in this high-risk patient population. Nurses left the prescribers with a summary of clinical practice guidelines, a one-page detailing sheet and a list of patients under the care of the prescriber who were candidates for statins. The primary outcome was the incidence of a new statin prescription claim during the 6-month intervention period and the subsequent 6 months. Logistic regression models were used to estimate main effects of the interventions and to adjust for potential confounding variables in the study. Results: 48 clinics were randomised, effectively randomising a total of 284 patients and 128 prescribers. Among the 284 patients, 46 (16%) received a new statin claim during the evaluation period. Controlling for significant bivariate associations, the 37 academic detailing intervention had no significant effect on new statin prescriptions compared with the control group (odds ratio = 0.8; 95% CI, 0.4 to 1.6; P = 0.5). Conclusions: Among this Medicaid population at high risk for cardiovascular events, an academic detailing programme to increase statin prescriptions was not effective. To assist others to learn from our failed effort, we identify and discuss critical elements in the design and implementation of the programme that could account for these results. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2753.2008.01035.x/abstract Educational outreach to general practitioners reduces children's asthma symptoms: a cluster randomised controlled trial M Zwarenstein, A Bheekie, C Lombard, G Swingler, R Ehrlich, M Eccles, M Sladden, S Pather, J Grimshaw, AD Oxman Implementation Science 24 Sep 2007;2:30 Background: Childhood asthma is common in Cape Town, a province of South Africa, but is underdiagnosed by general practitioners (GPs). Medications are often prescribed inappropriately, and care is episodic. The objective of this study is to assess the impact of educational outreach to GPs on asthma symptoms of children in their practice. Methods: This is a cluster randomised trial with general practices as the unit of intervention, randomisation, and analysis. The setting is Mitchells Plain (population 300,000), a dormitory town near Cape Town. Solo GPs, without nurse support, operate from storefront practices. Caregiver-reported symptom data were collected for 318 eligible children (2 to 17 years) with moderate to severe asthma, who were attending GPs in Mitchells Plain. One year post-intervention follow-up data were collected for 271 (85%) of these children in all 43 practices. Practices randomised to intervention (21) received two 30-minute educational outreach visits by a trained pharmacist who left materials describing key interventions to improve asthma care. Intervention and control practices received the national childhood asthma guideline. Asthma severity was measured in a parent-completed survey administered through schools using a symptom frequency and severity scale. We compared intervention and control group children on the change in score from pre-to one-year postintervention. Results: Symptom scores declined an additional 0.84 points in the intervention vs control group (on a 9-point scale. p = 0.03). For every 12 children with asthma exposed to a doctor allocated to the intervention, one extra child will have substantially reduced symptoms. Conclusions: Educational outreach was accepted by GPs and was effective. It could be applied to other health care quality problems in this setting. http://www.implementationscience.com/content/pdf/1748-5908-2-30.pdf Outreach education for integration of HIV/AIDS care, antiretroviral treatment, and tuberculosis care in primary care clinics in South Africa: PALSA PLUS pragmatic cluster randomised trial M Zwarenstein, LR Fairall, C Lombard, P Mayers, A Bheekie, RG English, S Lewin, MO Bachmann, E Bateman British Medical Journal 21 Apr 2011;342:d2022 Objective: To investigate whether PALSA PLUS, an on-site educational outreach programme of non-didactic, case based, iterative clinical education of staff, led by a trainer, can increase access to and comprehensiveness of care for patients with HIV/AIDS. 38 Design: Cluster randomised trial. Setting: Public primary care clinics offering HIV/AIDS care, antiretroviral treatment (ART), tuberculosis care, and ambulatory primary care in Free State province, South Africa. Participants: Fifteen clinics all implementing decentralisation and task shifting were randomised. The clinics cared for 400,000 general primary care patients and 10,136 patients in an HIV/AIDS/ART programme. There were 150 nurses. Intervention: On-site outreach education in 8 clinics; no such education in 7 (control). Main Outcome Measures: Provision of co-trimoxazole prophylaxis among patients referred to the HIV/AIDS/ART programme, and detection of cases of tuberculosis among those in the programme. Proportion of patients in the programme enrolled through general primary care consultations. Results: Patients referred to the HIV/AIDS programme through general primary care at intervention clinics were more likely than those at control clinics to receive cotrimoxazole prophylaxis (41%, (2253/5523) vs 32% (1340/4210); odds ratio 1.95; 95% CI, 1.11 to 3.40), and tuberculosis was more likely to be diagnosed among patients with HIV/AIDS/ART (7% (417/5793) vs 6% (245/4343); 1.25; 1.01 to 1.55). Enrolment in the HIV/AIDS and ART programme through HIV testing in general primary care was not significantly increased (53% vs 50%; 1.19; 0.51 to 2.77). Secondary outcomes were similar, except for weight gain, which was higher in the intervention group (2.3 kg vs 1.9 kg, P less than 0.001). Conclusions: Though outreach education is an effective and feasible strategy for improving comprehensiveness of care and wellbeing of patients with HIV/AIDS, there is no evidence that it increases access to the ART programme. It is now being widely implemented in South Africa. Trial Registration: Current Controlled Trials ISRCTN 24820584. http://www.bmj.com/content/342/bmj.d2022?view=long&pmid=21511783 39