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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. Outline. Definition Evidence - general Evidence - specific Dalhousie program

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Academic detailing

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

Outline

  • Definition

  • Evidence - general

  • Evidence - specific

  • Dalhousie program

  • Canadian academic detailing

  • US academic detailing


Academic detailing1

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


Evidence general o brien et al cochrane oct 2007

Evidence – general O’Brien et al Cochrane Oct 2007

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

Median effect size

AbsIQRRelIQR

  • Overall 6%3% to 10%21%11 to 41%

    • Prescribing4.8% 3% to 6.5%

    • Others7.2%4% to 16%


Evidence general grimshaw j et al 2004

Evidence – general Grimshaw J et al 2004

Multifaceted interventions including academic detailing vs no interventions

Median effect size

AbsRange

Academic detailing6%-4 to 17%

Patient mediated21%10 to 25%

Reminders14%-1 to 34%

Health Technol Assess 2004;8(6)


Evidence specific benzodiazepines zwar aus fam physician 2000

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


Evidence specific benzodiazepines de burgh aus j pub health 1995

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


Evidence specific benzodiazepines de burgh aus j pub health 19951

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)


Evidence specific benzodiazepines berings euro j clin pharmacol 1994

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


Evidence specific benzodiazepines berings euro j clin pharmacol 19941

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


Evidence specific antidepressants van eijk bmj 2001

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


Evidence specific antidepressants van eijk bmj 20011

Evidence – specificAntidepressants van Eijk BMJ 2001

  • Highly anticholinergicRR95% CI

    • Individual0.68 0.39 – 1.18

    • Group0.560.28 – 1.15

  • Less anticholinergicRR95% CI

    • Individual2.02 1.24 – 3.30

    • Group1.660.97 – 2.85


Evidence specific psychoactive drugs in nursing homes avorn nejm 1992

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 hypnotics45% vs 21%

  • Could prescribe short acting benzos


Suggestions

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


Dalhousie academic detailing service

Started fall 2001

3 academic detailers

2 pharmacists, 1 nurse

Advisory committee

4 family physicians

Content expert

Dalhousie Academic Detailing Service


Dalhousie academic detailing service1

Each topic see ~ 350 FPs +

Nurse practitioners

Medical students/residents

Nurses

Pharmacists

Dalhousie Academic Detailing Service


Dalhousie academic detailing service2

Handout

30-40 page booklet

Summary statements

Double-sided laminate

Dalhousie Academic Detailing Service


Canadian academic detailing collaboration cadc

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


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

Research


Physician education beyond ading

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


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

Educating other health professionals

Other HCPs

Students


Guidelines development review

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


Commentaries publications

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.


Commentaries publications1

Commentaries/publications

  • Coxibs

    • CMAJ 2005;173:83

  • Statin guidelines

    • Can J Cardiol 2007

    • AFP 2006;73:973-4


Academic detailing in usa

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


Academic detailing

Michael Allen

[email protected]

cme.medicine.dal.ca/ADS.htm


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