Academic Detailing Michael Allen MD Dalhousie University Continuing

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 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 Abs. IQR Rel. IQR • Overall – Prescribing – Others 6%3% to 10% 21%11 to 41% 4. 8% 3% to 6. 5% 7. 2% 4% to 16% 6

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) 7

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 8

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 – – 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 9

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 New insomnia diagnoses Control 68. 9 64. 3 Intervention 84. 7 48. 3 OR 0. 18 (0. 04 to 0. 73) 10

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 11

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% 12

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 13

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 14

Evidence – specific Psychoactive 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 15

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 16

Dalhousie Academic Detailing Service • Started fall 2001 – 3 academic detailers • 2 pharmacists, 1 nurse • Advisory committee – 4 family physicians – Content expert 18

Dalhousie Academic Detailing Service • Each topic see ~ 350 FPs + – Nurse practitioners – Medical students/residents – Nurses – Pharmacists 19

Dalhousie Academic Detailing Service • Handout – 30 -40 page booklet – Summary statements – Double-sided laminate 20

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) – Rx. Files 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 22

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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 25

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 • Power. Point slides and printed materials • Collaboration with the CMA 26

Educating other health professionals Other HCPs Students • Medical students • Residents • Pharmacy students: – Pharm. D, MSc Undergrad – Applying EBM to drug decisions • • • Pharmacists Nurse practitioners Psychologists Physiotherapists Diabetes educators 27

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 29

Commentaries/publications • Rx. Files Drug Comparison Chart Book – 6 th edition (current CMA best-seller) – All SK physicians, pharmacies & 3000+ nationally • Measuring prescribing improvements – Basic & Clinical Pharmacology & Toxicology 2006; 98, 243 -52. 30

Commentaries/publications • Coxibs – CMAJ 2005; 173: 83 • Statin guidelines – Can J Cardiol 2007 – AFP 2006; 73: 973 -4 31

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Academic Detailing in USA • Kentucky – Frank May frank 149@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/TB 1+BL. asp? Site. Area. ID=290 34

Michael Allen michael. allen@dal. ca cme. medicine. dal. ca/ADS. htm 35