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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

AbsIQR RelIQR

  • Overall 6%3% to 10% 21%11 to 41%
    • Prescribing 4.8% 3% to 6.5%
    • Others 7.2% 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

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)

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 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
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 hypnotics 45% 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
slide28
Michael Allen

[email protected]

cme.medicine.dal.ca/ADS.htm

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