Academic Detailing

Improving Patient Safety Through Informed Medication Prescribing and Disposal Practices

Portland ME

October 2007

Michael Allen MD

Dalhousie University Continuing Medical Education

3

Outline

• Definition

• Evidence - general

• Evidence - specific

• Dalhousie program

• Canadian academic detailing

• US academic detailing

4

Academic Detailing

• One-on-one educational intervention provided to physicians in their office by a trained health care professional

• Evidence-based

• Information for clinical decisions

6

Evidence – general O’Brien et al Cochrane Oct 2007

Intervention in which AD is a component vs no intervention +/- printed materials

Median effect size

AbsIQR RelIQR

• Overall 6%3% to 10% 21%11 to 41%

– Prescribing 4.8% 3% to 6.5%

– Others 7.2% 4% to 16%

7

Evidence – general Grimshaw J et al 2004

Multifaceted interventions including academic detailing vs no interventions

Median effect sizeAbs Range

Academic detailing 6% -4 to 17%

Patient mediated21% 10 to 25%Reminders 14% -1 to 34%

Health Technol Assess 2004;8(6)

8

Evidence – specificBenzodiazepines Zwar, Aus Fam Physician, 2000

• 20 minute visit to 79 GP-registrars re gradual withdrawal of benzos for anxiety or insomnia if indicated

• Management guidelines – gradual withdrawal • Patient education aids re relaxation • Prescribing evaluated by 3 practice-activity

surveys of 110 consecutive patients at 6 mos intervals

• Both groups decreased prescribing – no diff• Need to involve patients, family, nursing staff

9

Evidence – specificBenzodiazepines de Burgh Aus J Pub Health 1995

• ~142 FPs in New South Wales in control and intervention groups

• Baseline survey of 110 consecutive patients• 20 minute academic detailing visit

– Indications for benzos– Patient education material for sleep– Approach to management of long-term users– Asked to review 5 patients on long-term benzos with

review card– Follow-up phone call to assess docs reaction

• Survey 110 consecutive patients 5 months later

10

Evidence – specificBenzodiazepines de Burgh Aus J Pub Health 1995

Overall decrease 4.93.8 Rx/100 encounters - NS

Initial benzo prescribing per 100 encountersNew anxiety diagnosesControl 23.0 28.4Intervention 22.5 22.5

New insomnia diagnosesControl 68.9 64.3Intervention 84.7 48.3

OR 0.75 (0.26 to 2.15)

OR 0.18 (0.04 to 0.73)

11

Evidence – specificBenzodiazepines Berings Euro J Clin Pharmacol 1994

• FPs – 3 groups – N~43 each group– Written material + academic detailing– Written material– Control – no information

• Written material similar to drug ads– Rational and short-term use of benzos– Limited long-term benefit of benzos– Cognitive and emotional side effects of benzos– Importance of habituation and dependence

12

Evidence – specificBenzodiazepines Berings Euro J Clin Pharmacol 1994

• Data collected by surveys before and 4 weeks after interventions

• 85% repeat users, 15% new prescriptions

• # packs of benzos per 100 patient contacts– Written material + AD 14.1 10.8 ↓24%– Written material 13.0 11.2 ↓14%– Control 14.7 14.2 ↓3%

ANOVA F=4.7, df 2 P<0.05

13

Evidence – specificAntidepressants van Eijk BMJ 2001

• Individual vs group vs control ~ 40 docs 14 pharms per group

• 2 visits 4 mos apart– Content then prescribing profile

• Data collected from pharmacy reimbursement databases

14

Evidence – specificAntidepressants van Eijk BMJ 2001

• Highly anticholinergic RR 95% CI – Individual 0.68 0.39 – 1.18– Group 0.56 0.28 –

1.15

• Less anticholinergic RR 95% CI – Individual 2.02 1.24 – 3.30– Group 1.66 0.97 –

2.85

15

Evidence – specificPsychoactive drugs in nursing homes Avorn NEJM 1992

• 6 pairs of nursing homes in Massachusetts

• Targeted heavy prescribers – 3 visits

• Nursing staff had group sessions

• After 5 month program, percent of patients: antipsychotics 32% vs 14%– D/C long acting benzos 20% vs 9%– D/C antihistamine hypnotics 45% vs 21%

• Could prescribe short acting benzos

16

Suggestions

• Changing psychotrophic prescribing complex and difficult.

• May be easier to affect new prescribing

• Insomnia may be easier than anxiety

• May need to involve more than MDs

• Academic detailing may not be enough

• Review these and other papers

18

Dalhousie Academic Detailing Service

• Started fall 2001

– 3 academic detailers

• 2 pharmacists, 1 nurse

• Advisory committee

– 4 family physicians

– Content expert

19

Dalhousie Academic Detailing Service

• Each topic see ~ 350 FPs +

–Nurse practitioners

–Medical students/residents

–Nurses

–Pharmacists

20

Dalhousie Academic Detailing Service

• Handout

– 30-40 page booklet

– Summary statements

– Double-sided laminate

22

Canadian Academic Detailing Collaboration (CADC)

• British Columbia (est. 1993)– BC Community Drug Utilization Program– 50-60 general practitioners in North/West Vancouver– www.cdup.org

• Alberta (est. 2001, then 2006)– Academic Detailing – Calgary Health Region – 150 urban physicians– www.calgaryhealthregion.ca

• Saskatchewan (est. 1997)– RxFiles Academic Detailing Program– 400 physicians and other HCPs in SK– www.rxfiles.ca

• Manitoba (est. 2003)– Prescription Information Services of Manitoba– 70 general practitioners– www.prisminfo.org

• Nova Scotia (est. 2001)– Dalhousie Academic Detailing Services– 350 physicians and other HCPs in Nova Scotia– http://cme.medicine.dal.ca/ADS.htm

23

25

1. Outcomes evaluation – BC

2. Use of technology in ADing – BC

3. Canadian/international experience with ADing

4. Evaluate printed educational materials – AB

5. Time and motion study – SK

6. Needs assessment – MB

7. Physicians’ perceptions of ADing – NS

Research

26

Physician education beyond ADing

• Grand Rounds– U of SK internal med, neurology, geriatrics– Dalhousie - cardiology, respirology, geriatrics

• Anti-infective and antihypertensive courses in SK and at national Family Medicine Forum

• Conference presentations

• PowerPoint slides and printed materials

• Collaboration with the CMA

27

Educating other health professionals

• Medical students• Residents • Pharmacy students:

– PharmD, MSc Undergrad

– Applying EBM to drug decisions

• Pharmacists• Nurses• Nurse practitioners• Psychologists• Physiotherapists• Diabetes educators

Students Other HCPs

29

Guidelines development & review

• Hypertension – Review Panel (Toronto-MUMs)

– Canadian Consensus input

• Health Quality Council – SK– Post-MI drugs

• Acute coronary syndrome• STEMI• COMPUS Expert Review Committee

NS

30

Commentaries/publications

• RxFiles Drug Comparison Chart Book – 6th edition (current CMA best-seller)– All SK physicians, pharmacies & 3000+

nationally

• Measuring prescribing improvements– Basic & Clinical Pharmacology &

Toxicology 2006; 98, 243-52.

31

Commentaries/publications

• Coxibs– CMAJ 2005;173:83

• Statin guidelines– Can J Cardiol 2007– AFP 2006;73:973-4

33

34

Academic Detailing in USA

• Kentucky– Frank May frank149@bigpond.net.au

• Pennsylvania – Independent Drug Information Service– Michelle Spetman mspetman@partners.org

• Vermont– Charles Maclean

Charles.Maclean@vtmednet.org– http://www.med.uvm.edu/ahec/TB1+BL.asp?SiteAreaID=290

35

Michael Allen

michael.allen@dal.ca

cme.medicine.dal.ca/ADS.htm