Academic Detailing

1. Academic Detailing Michael Allen MD Dalhousie University Continuing Medical Education Improving Patient Safety Through Informed Medication Prescribing and Disposal Practices Portland ME October 2007

2. Outline • Definition • Evidence - general • Evidence - specific • Dalhousie program • Canadian academic detailing • US academic detailing

3. 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

4. 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%

5. Evidence – general Grimshaw J et al 2004 Multifaceted interventions including academic detailing vs no interventions Median effect size Abs Range Academic detailing 6% -4 to 17% Patient mediated 21% 10 to 25% Reminders 14% -1 to 34% Health Technol Assess 2004;8(6)

6. 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

7. Evidence – specificBenzodiazepines de BurghAus 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

8. Evidence – specificBenzodiazepines de BurghAus J Pub Health 1995 Overall decrease 4.93.8 Rx/100 encounters - NS Initial benzo prescribing per 100 encounters New anxiety diagnoses Control 23.0  28.4 Intervention 22.5  22.5 New insomnia diagnoses Control 68.9  64.3 Intervention 84.7  48.3 OR 0.75 (0.26 to 2.15) OR 0.18 (0.04 to 0.73)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Started fall 2001 3 academic detailers 2 pharmacists, 1 nurse Advisory committee 4 family physicians Content expert Dalhousie Academic Detailing Service

16. Each topic see ~ 350 FPs + Nurse practitioners Medical students/residents Nurses Pharmacists Dalhousie Academic Detailing Service

17. Handout 30-40 page booklet Summary statements Double-sided laminate Dalhousie Academic Detailing Service

18. 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

20. Outcomes evaluation – BC Use of technology in ADing – BC Canadian/international experience with ADing Evaluate printed educational materials – AB Time and motion study – SK Needs assessment – MB Physicians’ perceptions of ADing – NS Research

21. 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

22. Medical students Residents Pharmacy students: PharmD, MSc Undergrad Applying EBM to drug decisions Pharmacists Nurses Nurse practitioners Psychologists Physiotherapists Diabetes educators Educating other health professionals Other HCPs Students

23. 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

24. 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.

25. Commentaries/publications • Coxibs • CMAJ 2005;173:83 • Statin guidelines • Can J Cardiol 2007 • AFP 2006;73:973-4

27. 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

28. Michael Allen michael.allen@dal.ca cme.medicine.dal.ca/ADS.htm