Academic Detailing

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Academic Detailing
Michael Allen MD Dalhousie University Continuing
Medical Education

• Improving Patient Safety Through Informed
  Medication Prescribing and Disposal Practices
• Portland ME
• October 2007

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Outline

• 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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Features

• Assess current practice and barriers to change
• Target physicians and opinion leaders
• Develop educational objectives
• Establish credibility
• Encourage interaction
• Use concise educational materials
• Repeat key messages
• Provide reinforcement through repeated visits

Soumerai JAMA 1990, 263 549-556
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Evidence general OBrien et al Cochrane Oct
2007

• Intervention in which AD is a component vs no
  intervention /- printed materials
• Median effect size
• AbsIQR RelIQR
• Overall 63 to 10 2111 to 41
• Prescribing 4.8 3 to 6.5
• Others 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 20048(6)

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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

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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

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Evidence specificBenzodiazepines 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
• 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)
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Evidence specificBenzodiazepines Berings Euro
J Clin Pharmacol 1994

• FPs 3 groups N43 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 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 F4.7, df 2 Plt0.05

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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

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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

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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

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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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Evidence specificADR reporting Figuieras JAMA
2006

• Group detailing 1 hour 10 to 20 docs
• Reminder card
• Reporting form
• Intervention/control 1388/5063
• 655 (47) attended intervention
• Intervention 7.6 ?100.2 per 1000 phys-yrs
• Control 11.3 ? 14.5 per 1000 phys-yrs
• Effect greater first 4 mos vs following 9 mos

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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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Dalhousie Academic Detailing Service

• Collaborate with academic detailing programs in
• British Columbia
• Alberta
• Saskatchewan
• Manitoba

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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

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Who are we?

• Mostly pharmacists
• Family physician
• Nurse
• Epidemiologist
• Pharmaceutical policy researcher
• Varying degrees of formal training in critical
  appraisal

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Research

• 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

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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

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

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Errors/clarifications in publications

• Medscape Pharmacist Letter DREAM trial
• Ramipril normoglycemia in IGT given as
  104/1000
• Actual numbers 42.5 vs 38.2 (4.3 or 43/1000)
• Dr. Yusuf I believe you are correct. Medscape
  must have made an error.
• Ann of Int Med ARB dosing in Heart Failure
• HF Target doses for Valiant misquoted etc.
• Finally, we agree with Mr. Regier and Mr. Jensen
  that in our Table, the doses of valsartan and
  captopril in the VALIANT study were reported as
  the target doses from the initial hospitalization
  but should have been the target doses on 3-month
  follow-up, which were twice as high.
  http//www.annals.org/cgi/content/full/142/5/388-
  a

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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
• COMPUS Expert Review Committee

NS
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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 200517383
• Statin guidelines
• Can J Cardiol 2007
• AFP 200673973-4

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Other educational activities

• Clinical significance calculator
• Conference planning
• Influencing Prescribing Behaviour Conference
• Inform physicians about clinical programs
• Support health policies
• New physician prescribing orientation - SK
• including international medical graduates

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Academic Detailing in USA

• Kentucky
• Frank May frank149_at_bigpond.net.au
• Pennsylvania Independent Drug Information
  Service
• Michelle Spetman mspetman_at_partners.org
• Vermont
• Charles Maclean Charles.Maclean_at_vtmednet.org
• http//www.med.uvm.edu/ahec/TB1BL.asp?SiteAreaID
  290

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• Michael Allen
• michael.allen_at_dal.ca
• cme.medicine.dal.ca/ADS.htm