Transcript Academic Detailing - University of New England

Academic Detailing
Michael Allen MD
Dalhousie University Continuing Medical Education
Improving Patient Safety Through Informed Medication
Prescribing and Disposal Practices
Portland ME
October 2007
Outline
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Definition
Evidence - general
Evidence - specific
Dalhousie program
Canadian academic detailing
US academic detailing
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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
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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
– Prescribing
– Others
6%3% to 10%
21%11 to 41%
4.8% 3% to 6.5%
7.2% 4% to 16%
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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)
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Evidence – specific
Benzodiazepines 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
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Evidence – specific
Benzodiazepines 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
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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
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Evidence – specific
Benzodiazepines de Burgh Aus 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
OR 0.75 (0.26 to 2.15)
Intervention
22.5  22.5
New insomnia diagnoses
Control
68.9  64.3
Intervention
84.7  48.3
OR 0.18 (0.04 to 0.73)
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Evidence – specific
Benzodiazepines 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
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Evidence – specific
Benzodiazepines 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
– Written material
13.0  11.2
– Control
14.7  14.2
ANOVA F=4.7, df 2 P<0.05
↓24%
↓14%
↓3%
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Evidence – specific
Antidepressants 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
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Evidence – specific
Antidepressants van Eijk BMJ 2001
• Highly anticholinergic RR
– Individual
– Group
• Less anticholinergic
– Individual
– Group
95% CI
0.68
0.56
0.39 – 1.18
0.28 – 1.15
RR
95% CI
2.02
1.66
1.24 – 3.30
0.97 – 2.85
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Evidence – specific
Psychoactive drugs in nursing homes Avorn NEJM 1992
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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
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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
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Dalhousie Academic Detailing
Service
• Started fall 2001
– 3 academic detailers
• 2 pharmacists, 1 nurse
• Advisory committee
– 4 family physicians
– Content expert
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Dalhousie Academic Detailing
Service
• Each topic see ~ 350 FPs +
–Nurse practitioners
–Medical students/residents
–Nurses
–Pharmacists
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Dalhousie Academic Detailing
Service
• Handout
– 30-40 page booklet
– Summary statements
– Double-sided laminate
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Canadian
Academic Detailing Collaboration (CADC)
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British Columbia (est. 1993)
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Alberta (est. 2001, then 2006)
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RxFiles Academic Detailing Program
400 physicians and other HCPs in SK
www.rxfiles.ca
Manitoba (est. 2003)
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Academic Detailing – Calgary Health Region
150 urban physicians
www.calgaryhealthregion.ca
Saskatchewan (est. 1997)
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BC Community Drug Utilization Program
50-60 general practitioners in North/West Vancouver
www.cdup.org
Prescription Information Services of Manitoba
70 general practitioners
www.prisminfo.org
Nova Scotia (est. 2001)
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Dalhousie Academic Detailing Services
350 physicians and other HCPs in Nova Scotia
http://cme.medicine.dal.ca/ADS.htm
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Research
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
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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
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Educating other health
professionals
Other HCPs
Students
• Medical students
• Residents
• Pharmacy students:
– PharmD, MSc
Undergrad
– Applying EBM to
drug decisions
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Pharmacists
Nurses
Nurse practitioners
Psychologists
Physiotherapists
Diabetes educators
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Guidelines development &
review
• Hypertension
– Review Panel (Toronto-MUMs)
– Canadian Consensus input
• Health Quality Council – SK
– Post-MI drugs
• Acute coronary syndrome
• STEMI
NS
• COMPUS Expert Review Committee
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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.
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Commentaries/publications
• Coxibs
– CMAJ 2005;173:83
• Statin guidelines
– Can J Cardiol 2007
– AFP 2006;73:973-4
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Academic Detailing in USA
• Kentucky
– Frank May [email protected]
• Pennsylvania – Independent Drug
Information Service
– Michelle Spetman [email protected]
• Vermont
– Charles Maclean
[email protected]
– http://www.med.uvm.edu/ahec/TB1+BL.asp?SiteAreaID=290
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Michael Allen
[email protected]
cme.medicine.dal.ca/ADS.htm
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