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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.
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e Educational outreach to prescribers has been
i delivered for some thirty years, most often in a
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primary care setting, but also in secondary care.
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Where the outcome has been evaluated in terms of
mquantitative indicators of interest, the results have
a been equivocal. In some cases a marked
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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]
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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
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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
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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
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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