Family physicians' perceptions of academic detailing: a quantitative and qualitative study

Implementation of virtual academic detailing in North America: A qualitative study

RATIONALE

The shift toward virtual academic detailing (AD) was accelerated by the COVID-19 pandemic.

AIMS AND OBJECTIVES

We aimed to examine the role of external, contextual, and intrinsic programme-specific factors in virtual engagement of healthcare providers (HCPs) and delivery of AD.

METHODS

AD groups throughout North America were contacted to participate in semistructured interviews. An interview guide was constructed by adapting the Consolidated Framework for Implementation Research (CFIR). A point of emphasis included strategies AD groups employed for provider engagement while implementing virtual AD programmes. Independent coders conducted qualitative analysis using the framework method.

RESULTS

Fifteen AD groups from Canada (n = 3) and the United States (n = 12) participated. Technological issues and training detailers and HCPs were challenges during the transition to virtual AD visits. Restrictions on in-person activities during the pandemic created difficulties engaging HCPs and fewer AD visits. Continuing education was one strategy to incentivize participation, but credits were often not claimed by HCPs. Groups with established networks and prior experience with virtual AD leveraged connections to mitigate disruptions and continue AD visits. Other facilitators included emphasizing contemporary topics, including opioid education beyond fundamental guidelines. Virtual AD had the additional benefit of expanding geographic reach and flexible scheduling with providers.

CONCLUSIONS

AD groups across North America have shifted to virtual outreach and delivery strategies. This trend toward virtual AD may aid outreach to vulnerable rural communities, improving health equity. More research is needed on the effectiveness of virtual AD and its future implications.

Transitioning to virtual academic detailing amid COVID-19: A case study

BACKGROUND

Coronavirus disease 2019 (COVID-19) public health protocols required medical educators to rapidly move curricula online. This included academic detailing (AD), a form of one-to-one or small group educational outreach for primary care providers (PCPs).

OBJECTIVES

This study aimed to contribute to the sparse evidence base exploring virtual AD by exploring strengths, challenges, and best practices.

METHODS

This case study drew on 3 methods: (1) observations of AD visits (n = 5 sessions), (2) group (n = 6 detailers) and one-on-one interviews (n = 5 PCPs, n = 3 detailing staff), and (3) document analysis of curriculum and policy documents (n = 10 documents).

RESULTS

Our analysis identified several strengths of virtual detailing: (1) inherent benefits of virtual programming, (2) pre-existing strengths in program leadership, (3) global move toward telehealth amid COVID, (4) pre-existing detailing relationships, and (5) pre-existing roles and attributes of pharmacists. Several challenges were also identified: (1) virtual presence in group visits, (2) establishing consistency across modalities, and (3) technological issues.

CONCLUSION

Virtual detailing has posed unique challenges and opportunities for innovation. Our study supports a blended model moving forward-one that balances strengths and challenges of virtual and in-person delivery and considers logistics, efficiencies, environmental impacts, and unique participant needs.

Testing interventions to reduce clinical inertia in the treatment of hypertension: rationale and design of a pragmatic randomized controlled trial

BACKGROUND

Clinical inertia, or failure to intensify treatment when indicated, leads to suboptimal blood pressure control. Interventions to overcome inertia and increase antihypertensive prescribing have been modestly successful in part because their effectiveness varies based on characteristics of the provider, the patient, or the provider-patient interaction. Understanding for whom each intervention is most effective could help target interventions and thus increase their impact.

METHODS

This three-arm, randomized trial tests the effectiveness of 2 interventions to reduce clinical inertia in hypertension prescribing compared to usual care. Forty five primary care providers (PCPs) caring for patients with hypertension in need of treatment intensification completed baseline surveys that assessed behavioral traits and were randomized to one of three arms: 1) Pharmacist e-consult, in which a clinical pharmacist provided patient-specific recommendations for hypertension medication management to PCPs in advance of upcoming visits, 2) Social norming dashboards that displayed PCP's hypertension control rates compared to those of their peers, or 3) Usual care (no intervention). The primary outcome was the rate of intensification of hypertension treatment. We will compare this outcome between study arms and then evaluate the association between characteristics of providers, patients, their clinical interactions, and intervention responsiveness.

RESULTS

Forty-five primary care providers were enrolled and randomized: 16 providers and 173 patients in the social norming dashboards arm, 15 providers and 143 patients in the pharmacist e-consult arm, and 14 providers and 150 patients in the usual care arm. On average, the mean patient age was 64 years, 47% were female, and 73% were white. Baseline demographic and clinical characteristics of patients were similar across arms, with the exception of more Hispanic patients in the usual care arm and fewest in the pharmacist e-consult arm.

CONCLUSIONS

This study can help identify interventions to reduce inertia in hypertension care and potentially identify the characteristics of patients, providers, or patient-provider interactions to understand for whom each intervention would be most beneficial.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT, Registered: NCT04603560).

Perspectives of primary care physicians on academic detailing for antimicrobial stewardship: feasibility and impact assessment

OBJECTIVE

To understand primary care physicians' perspectives on academic detailing from an antimicrobial stewardship team to combat antibiotic overuse for upper respiratory infections and bronchitis in the COVID-19 era, which will help prevent avoidable outpatient visits.

METHODS

In this prospective study, 14 female Croatian physicians completed standardized qualitative interviews using a semi-structured guide. The data were analyzed using inductive methodology based on reflexive thematic analysis. We used a theoretically informed approach based on a conceptual framework of healthcare intervention implementability focused on three domains: acceptability, fidelity, and feasibility.

RESULTS

We identified six key themes highlighting barriers to changing prescribing practices, with patient pressure and specialist recommendations having an impact on the effectiveness of academic detailing. Despite challenges, primary care physicians described appreciation of direct interaction with evidence-based practices and reported usefulness, effectiveness, and further need for academic detailing.

CONCLUSION

This study highlights the complex dynamics involved in implementing healthcare interventions and provides valuable insights for enhancing strategies directed at improving antibiotic prescribing practices. Specifically, our findings emphasize factors influencing behavior changes in physicians' antibiotic prescribing. The authors advocate for a collaborative approach involving community and hospital-based professionals to provide tailored guidance and address questions, ultimately improving prescribing practices.

A realist synthesis of educational outreach visiting and integrated academic detailing to influence prescribing in ambulatory care: why relationships and dialogue matter

BACKGROUND

Many quality improvement initiatives in healthcare employ educational outreach visits, integrating academic detailing to bridge evidence-practice gaps and accelerate knowledge translation. Replicability of their outcomes in different contexts varies, and what makes some visiting programmes more successful than others is unclear.

OBJECTIVE

We conducted a realist synthesis to develop theories of what makes educational outreach visiting integrating academic detailing work, for whom, under which circumstances and why, focusing on the clinician-visitor interaction when influencing prescribing of medicines in ambulatory care settings.

METHODS

The realist review was performed in accordance with RAMESES standards. An initial programme theory was generated, academic databases and grey literature were screened for documents with detail on contexts, intervention and outcomes. Using realist logic of analysis, data from 43 documents were synthesised in the generation of a refined programme theory, supported by additional theoretical frameworks of learning and communication.

RESULTS

Twenty-seven interdependent context-mechanism-outcome configurations explain how clinicians engage with educational outreach visits integrating academic detailing through programme design, what matters in programme design and the educational visitor-clinician interaction and how influence extends beyond the visit. They suggest that in addition to relevance, credibility and trustworthiness of a visit's contents, communication and clinical skills of educational visitors, the relationship between the educational visitor and clinician, built on a dialogue of learning from and sense-making with each other, creates conditions of critical thinking which are conducive to facilitating prescribing practice change when necessary.

CONCLUSION

This realist synthesis elucidates that the quality of clinician-educational visitor interactions is pivotal to educational outreach visiting programmes. Building and sustaining relationships, and establishing an open dialogue are important; neglecting these undermines the impact of visits. Educational visitors can facilitate clinicians' reflection on practice and influence their prescribing. Clinicians value the discussion of individualised, tailored information and advice they can translate into their practice.

PROSPERO REGISTRATION NUMBER

CRD42021258199.

Addressing Unhealthy Alcohol Use and the HIV Pre-exposure Prophylaxis Care Continuum in Primary Care: A Scoping Review

Individuals with unhealthy alcohol use are at increased risk for HIV acquisition and may benefit from receiving HIV pre-exposure prophylaxis (PrEP) in primary care settings. To date, literature synthesizing what is known about the impact of unhealthy alcohol use on the PrEP care continuum with a focus on considerations for primary care is lacking. We searched OVID Medline and Web of Science from inception through March 19, 2020, to examine the extent, range, and nature of research on PrEP delivery among individuals with unhealthy alcohol use in primary care settings. We identified barriers and opportunities at each step along the PrEP care continuum, including for specific populations: adolescents, people who inject drugs, sex workers, and transgender persons. Future research should focus on identification of candidate patients, opportunities for patient engagement in novel settings, PrEP implementation strategies, and stigma reduction.

Influence of pharmaceutical promotion on prescribers in Jordan

Background Pharmaceutical promotion efforts should facilitate excellent quality patient care. However, there has been substantial debate about ethical principles related to pharmaceutical promotions. Objectives This study aimed to evaluate (i) attitudes toward pharmaceutical promotion among physicians in the private sector in Jordan, (ii) the impact of pharmaceutical promotion in influencing physicians' prescribing practices, and (iii) the prospect of academic detailing on this issue in Jordan. Setting The private health care sector in Jordan. Methods In this cross-sectional study, a self-administered questionnaire was distributed to a sample of physicians from the private health sector in Jordan during the period from December 2018 to March 2019. Descriptive statistics were conducted to describe physicians' attitudes toward pharmaceutical promotions, factors affecting prescribing practices, and perceptions toward academic detailing. Logistic regression models were performed to investigate predictors of acceptance and skepticism attitudes toward pharmaceutical promotion. Eisenberg model of physician decision-making was applied to evaluate factors influencing physicians' prescribing practice of promoted pharmaceutical products. Main outcome measure Attitudes toward pharmaceutical promotions, exposure to promoted pharmaceutical products, factors affecting physicians' prescribing practice of promoted pharmaceutical products, and their perceptions toward academic detailing and expected challenges. Results A total of 310 physicians completed the survey. The majority of physicians (73%) agreed that pharmaceutical companies provide valuable education on new pharmaceutical products. However, 66% of physicians agreed that lectures that are sponsored by pharmaceutical companies are often biased in favor of their products. Ninety-two percent of physicians agreed that drug samples were the most commonly offered promotional products by pharmaceutical companies. Being educated about the ethical principles related to pharmaceutical promotions among physicians was associated with higher likelihood of being skeptic about pharmaceutical promotional activities. Physicians' years of experience, payers' factors, environmental factors and participation in drug committees were significantly associated with high impact of marketing activities on physicians' prescribing practices (ORs of 1.2, 1.2, 1.49 and 0.43, respectively). The majority of participants in the current study reported positive attitudes toward applying academic detailing services in the future. Conclusions Education seems to play a crucial role in physicians' attitudes toward pharmaceutical promotion. Academic detailing is a promising strategy to counteract unethical marketing practice.

Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease

Background:

As the burden of chronic kidney disease (CKD) continues to increase, many geographically dispersed Canadians have limited access to specialist nephrology care, which tends to be centralized in major urban areas. As a result, many rural/remote-dwellers in Canada experience poor quality of care and related adverse outcomes. It is imperative to develop alternative care delivery mechanisms to ensure optimal health outcomes for all Canadians.

Objective:

To investigate the feasibility and effectiveness of electronic consultation (eConsult) as a new model for interactions between specialists and primary care providers (PCPs) to improve access to care for patients with CKD.

Design:

This is a sequential, mixed methods study that will be conducted in 3 phases.

Setting:

The study will be conducted across the entire province of Alberta, supported by Alberta Kidney Care (formerly, Northern and Southern Alberta Renal Programs [NARP/SARP]).

Patients:

Patients suffering from CKD will be included in the study.

Measurements:

We will assess the barriers and enablers of implementation and adoption of an e-consultation protocol to facilitate access to care for patients with CKD in Alberta with a focus on rural/remote-dwellers with CKD. We will also evaluate the impact of the eConsult system (eg, improved access to specialist care, reduction in care gaps), assess the feasibility of province-wide implementation, and compare eConsult with practice facilitation versus eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Methods:

The study will be conducted in 3 phases. In phase 1, we will assess the perceptions of stakeholders (ie, PCPs, nephrologists, patients, policymakers, and other care providers) to improve CKD care delivery, quality, and outcomes in Alberta with focus groups and semistructured interviews. Phase 2 will engage specific family physicians for their input on key factors and logistical issues affecting the feasibility of implementing eConsult for the care of patients with CKD. Phase 3 will provide academic detailing including practice facilitation to clinics in Alberta to assess how eConsult with practice facilitation compares with eConsult alone in terms of access to specialist care, quality of care, and related outcomes.

Results:

We will assess stakeholder perceptions about potential barriers to and enablers of a new eConsult and decision support system strategy, focusing on elements that are most important for the design of a feasible and implementable intervention. We will develop, pilot test, and assess the impact of the eConsult model in improving access to specialist nephrology care and the feasibility of province-wide implementation. The final phase of the project will address key challenges for optimal care for patients with CKD living in rural, remote, and underserved areas of Alberta, particularly timely referral and disease management as well as the cost-effective benefits of eConsult.

Limitations:

Lack of high-speed Internet in many rural and remote areas of Alberta may lead to more time spent in completing the eConsult request online versus faxing a referral the traditional way. Allied health care staff (referral coordinators, administrative staff) require training to the eConsult system, and physicians at many remote sites do not have adequate staff to handle eConsult as an added task.

Conclusions:

Implementation of eConsult can favorably influence referral patterns, access to care, care quality, patient outcomes, and health care costs for people with CKD. Results of this study will inform the optimization of care for rural/remote-dwellers with CKD and will facilitate future partnerships with policymakers and provincial renal programs in Alberta to ensure optimal kidney health for all residents.

Trial registration:

Not required.

Educational outreach visits to improve knee osteoarthritis management in primary care

BACKGROUND

Knee osteoarthritis is a common problem, but often underdiagnosed and undertreated in primary care as compared to evidence-based guidelines. Educational outreach visits are an effective strategy to improve guideline adherence, but its contribution to knee osteoarthritis management is largely unknown. The aim of this study was to evaluate the overall effectiveness of educational outreach visits on process quality indicators for knee osteoarthritis management, more specifically on the referral for physical therapy.

METHODS

An educational intervention study, non-randomized and controlled, was designed for general practitioners (GPs) in Belgium. During four months, 426 GPs were visited by academic detailers and allocated to the intervention group. The control group was selected from GPs not visited by academic detailers during the study period. Six months post-intervention, both groups received a questionnaire with two case-vignettes to measure the effectiveness of the educational outreach. Outcomes were assessed with a Belgian set of quality indicators for knee osteoarthritis management and focused on the number of prescriptions for appropriate physical therapy (i.e. muscle strengthening, aerobic, functional or range of motion exercises) and the adherence to eight additional quality indicators related to knee osteoarthritis management. For the analysis, multivariable logistic regression models were used and Generalized Estimating Equations to handle the correlation between the multiple results per GP.

RESULTS

The intervention group showed a tendency to prescribe more frequently at least one appropriate physical therapy for a case (43.8%), compared to the control group (31.3%, p = 0.057). Muscle strengthening exercises were the most frequently prescribed therapy with 37.0% in the intervention versus 26.9% in the control group. The adherence to the other quality indicators showed no significant difference between the intervention and control group and varied between 8.9 and 100% in the intervention group.

CONCLUSIONS

This intervention did not alter significantly the adherence to quality indicators and in particular the probability of prescribing physical therapy. To change general practitioners' prescription behavior, more extensive or combined interventional approaches seem warranted.

Academic detailing as a method of continuing medical education

INTRODUCTION

Academic detailing is an interactive educational outreach to prescribers to present unbiased, non-commercial, evidence-based information, mostly about medications, with the goal of improving patient care. Academic detailing in Norway is an approach for providing continuing medical education to general practitioners (GPs). The basis of academic detailing is a one-to-one discussion between a trained health professional (the academic detailer) and the GP at the GP's workplace.

METHOD

Our first campaign was named "Better use of non-steroidal anti-inflammatory drugs (NSAIDs)", which aim was to reduce the use of diclofenac due to the risk of serious cardiovascular adverse events. At the same time we advised the GPs to use naproxen as the drug of choice if an NSAID was needed. We did a one-to-one intervention in two cities, where a trained academic detailer met the GP during office hours. A total of 247 GPs were invited to participate and 213 visits (86%) were completed. This article reviews the theoretical framework underlying the method and describes the development and implementation of academic detailing to GPs in Norway.

RESULTS

More than 90% the participating GPs considered academic detailing a suitable method for providing up-to-date evidence-based, manufacturer-independent information, and nearly all would most likely or probably welcome another visit. After the intervention there was a reduction of diclofenac prescribing of 16% and 18%, respectively, in the two cities.

CONCLUSION

We consider that academic detailing is a suitable method to bring the best available evidence to the point at which care is delivered, to achieve the best for the patients. According to the Norwegian GPs' evaluation, it is a key supplement to other methods of continuing medical education. To have maximum impact, it is important that academic detailing is practiced according to the consensus that has evolved in the USA and Australia.

Academic detailers' and general practitioners' views and experiences of their academic detailing visits to improve the quality of analgesic use: process evaluation alongside a pragmatic cluster randomized controlled trial

Background

Continuous medical education strategies, including academic detailing (AD), have mixed effects on the quality of prescribing in general practice. Alongside a cluster-randomized controlled trial (cRCT) to assess the effectiveness of AD visits (on appropriate prescribing of analgesics for chronic pain in osteoarthritis) by Farmaka, an independent drug information center, we performed a process evaluation to identify possible barriers and success factors to improve these AD visits, both from the perspective of the academic detailers delivering the visits and the general practitioners (GPs) receiving them.

Methods

We performed semi-structured interviews with 20 GPs who participated in the cRCT and 13 academic detailers. The interviews were transcribed verbatim and analysed using thematic analysis.

Results

GPs viewed AD visits as a practical and useful CME strategy, that is less time consuming than other CME activities, and the visitors as providers of objective and independent information relevant to their daily practice with whom they can have meaningful discussion. Academic detailers saw themselves as content experts, mainly informing GPs about the topic and not emphasizing on behavior change. Both GPs and academic detailers believed that the AD visits could have better interaction and discussion if performed in small groups. According to the GPs, the visits on analgesic use provided some new and relevant information as well as clarifying some misconceptions. They increased awareness of the disadvantages of particular non-steroidal anti-inflammatory drugs and of the lower doses of paracetamol that should be prescribed for chronic use, which may have changed their beliefs and/or attitudes towards more appropriate prescribing for osteoarthritis. However, the transfer of knowledge into practice was seen as not so straightforward.

Conclusions

GPs view AD visits as a credible and interesting way of CME that enhances their knowledge and increases reflection on their prescribing behavior.

Academic detailing among psychiatrists - feasibility and acceptability

Purpose Research has shown that academic detailing (AD), which includes repeated in-person educational messages in an interactive format in a physician's office, is among the most effective continuing medical education (CME) forms for improving prescribing practices and reducing drug costs. The purpose of this paper is to investigate AD's feasibility and acceptability as an educational tool among psychiatrists and its ability to facilitate positive changes in antipsychotic prescribing. Design/methodology/approach All psychiatrists practicing in Southwestern Ontario, Canada were invited to participate. Participants (32/299(10.7 percent)) were provided with two educational sessions by a healthcare professional. Participants evaluated their AD visits and completed a pre- and post-AD questionnaire measuring various prescribing practice aspects. Findings A total of 26 out of 32 (81.3 percent) participants completed the post-AD evaluation; most of them (61.5 percent, n=16) felt that AD gave noteworthy information on tools for monitoring side-effects and 50.0 percent ( n=13) endorsed using these in practice. In total, 13 participants (50.0 percent) felt that the AD sessions gave them helpful information on tools for documenting polypharmacy use, which 46.2 percent ( n=12) indicated they would implement in their practice. No significant differences were found between participants' pre- and post-assessment prescribing behaviors. Practical implications There is great need for raising AD program's awareness and improving physician engagement in this process locally, provincially and nationally. Originality/value To the authors' knowledge, this is the first AD program in Canada to target specialists solely. Participant psychiatrists accepted the AD intervention and perceived it as a feasible CME method.

Program evaluation of neuroscience competency programs to implement evidence-based practices

RATIONALE

Program evaluation is essential to help determine the success of an evidence-based practice program and assist with translating these processes across settings.

AIMS

The purpose of this study was to evaluate the usefulness of 2 competency programs that sought to improve neurocritical care nurses' knowledge of and adherence to evidence-based stroke and spinal cord injury guidelines. These programs consisted of 3 specific implementation strategies, including local opinion leaders, printed educational materials, and educational outreach.

METHODS

A qualitative study using one-on-one interviews with 10 neurocritical care nurses was used. Semi-structured interview questions examined the nurses' perceptions of the competency programs and the implementation strategies used; themes were identified through first-level coding. The transcripts were deductively analyzed and categorized using a predetermined implementation outcomes framework, including the concepts of acceptability, appropriateness, adoption, and sustainability.

RESULTS

Nurses reported that the 3 implementation strategies used for the competency programs were acceptable and appropriate. Further, the nurses perceived that the evidence-based practices reviewed during the programs were being adopted into practice and provided suggestions for sustaining improvements in nursing knowledge of and adherence to these evidence-based practices.

CONCLUSIONS

Findings from this study support the success of the Stroke and Spinal Cord Injury Competency Programs, as well as the usefulness of the 3 implementation strategies used. This study provides insight for improvements for subsequent studies focused on implementing evidence-based practices.

Academic Peer Detailing-The Preparation and Experience of Detailers Involved in a Project to Disseminate a Comparative Effectiveness Module

INTRODUCTION

Academic detailing uses communication skills, relationship building, and feedback to facilitate behavior change. This report, part of a larger initiative to disseminate evidence summaries of systematic reviews, demonstrates the feasibility of disseminating a comparative effectiveness module to physicians using peer detailers and examines the development of faculty for this process. We describe planning and implementation of a train-the-detailer session, detailer reactions to the process, and results of the dissemination project.

METHODS

We recruited 10 experienced primary care clinical faculties in Family and Social Medicine at the Albert Einstein College of Medicine. Detailers attended a 90-minute train-the-detailer session and detailed 150 practitioners at community practices. We evaluated the experiences of the learners and detailers with questionnaires, a focus group, and individual interviews of the detailers.

RESULTS

The experiences of detailing in different contexts were uniformly positive. Learners felt the materials were valuable, and that they would implement them or already had implemented them. In the postsurvey completed by 65 of the 150 detailed learners, 97% percent stated that they changed their practice or had already incorporated the practice change before the detailing. All detailers reported a change in their own practice. Detailers found the teaching materials and detailers' guide helpful. Some initially expressed a concern about not knowing enough, which lessened with detailing experience.

DISCUSSION

Peer detailing seems doable and well received, especially with the availability of high quality, previously prepared, and tested evidence-based content and materials. Detailers were easily recruited and trained to apply their teaching skills in this new format. The amount of time spent in training sessions on detailing training as opposed to content mastery can be adjusted depending on faculty needs.

Not for industry only: medical students and office-based academic detailing the PIVOT (Pregnant women Influenza Vaccine Optimization Team) initiative

Academic detailing is a method of educational outreach that utilizes individualized encounters with physicians to broach specific medical issues in an evidence-based and quality-driven manner. Medical students utilized the matter of influenza vaccination during pregnancy as a lens through which to explore the methods of academic detailing in a community setting. Structured and customized dialogues between North Shore-LIJ affiliated obstetricians and Hofstra North Shore-LIJ medical students were conducted regarding the disparity between the proportion of providers that recommend the vaccine and the percentage of pregnant women being vaccinated annually. Ultimately the project aimed to increase vaccine-carrying rates throughout office based practices in the community, while establishing a viable method for up-to-date information exchange between practicing physicians and academic medicine. While the extent of affected change is currently being quantified, the project proved successful insofar as academic detailing allowed the students to gain access to physicians, and engage in compelling and educational conversations. Both the physicians and students felt these interactions were valuable and well worth continuing. The goal for the future is to expand these practices to other pressing public health issues while continuing to refine the technique.

Patient-specific academic detailing for smoking cessation: feasibility study

OBJECTIVE

To describe and to determine the feasibility of a patient-specific academic detailing (PAD) smoking cessation (SC) program in a primary care setting.

DESIGN

Descriptive cohort feasibility study.

SETTING

Hamilton, Ont.

PARTICIPANTS

Pharmacists, physicians, nurse practitioners, and their patients.

INTERVENTIONS

Integrated pharmacists received basic academic detailing training and education on SC and then delivered PAD to prescribers using structured verbal education and written materials. Data were collected using structured forms.

MAIN OUTCOME MEASURES

Five main feasibility criteria were generated based on Canadian academic detailing programs: PAD coordinator time to train pharmacists less than 40 hours; median time of SC education per pharmacist less than 20 hours; median time per PAD session less than 60 minutes for initial visit; percentage of prescribers receiving PAD within 3 months greater than 50%; and number of new SC referrals to pharmacists at 6 months more than 10 patients per 1.0 full-time equivalent (FTE) pharmacist (total of approximately 30 patients).

RESULTS

Eight pharmacists (5.8 FTE) received basic academic detailing training and education on SC PAD. Forty-eight physicians and 9 nurse practitioners consented to participate in the study. The mean PAD coordinator training time was 29.1 hours. The median time for SC education was 3.1 hours. The median times for PAD sessions were 15 and 25 minutes for an initial visit and follow-up visit, respectively. The numbers of prescribers who had received PAD at 3 and 6 months were 50 of 64 (78.1%) and 57 of 64 (89.1%), respectively. The numbers of new SC referrals at 3 and 6 months were 11 patients per FTE pharmacist (total of 66 patients) and 34 patients per FTE pharmacist (total of 200 patients), respectively.

CONCLUSION

This study met the predetermined feasibility criteria with respect to the management, resources, process, and scientific components. Further study is warranted to determine whether PAD is more effective than conventional academic detailing.

Academic detailing and adherence to guidelines for Group B streptococci prenatal screening: a randomized controlled trial

Background

Clinical practice guidelines (CPGs) recommend universal prenatal screening for Group B Streptococcus (GBS) to identify candidates for intrapartum antibiotic prophylaxis to prevent early onset neonatal GBS infection. Interventions to promote physician adherence to these guidelines are imperative. This study examined the effectiveness of academic detailing (AD) of obstetricians, compared with CPG mailshot and no intervention, on the screening of pregnant women for GBS.

Methods

A randomized controlled clinical trial was conducted in the medical cooperative of Porto Alegre, Brazil. All obstetricians who assisted in a delivery covered by private health insurance managed by the cooperative in the 3 months preceding the study (n = 241) were invited to participate. The obstetricians were randomized to three groups: direct mail (DM, n = 76), AD (n = 76) and control (C, n = 89, no intervention). Those in the DM group were sent guidelines on GBS. The AD group received the guidelines and an educational visit detailing the guidelines, which was conducted by a trained physician. Data on obstetrician age, gender, time since graduation, whether patients received GBS screening during pregnancy, and obstetricians who requested screening were collected for all participant obstetricians for 3 months before and after the intervention, using database from the private health insurance information system.

Results

Three months post-intervention, the data showed that the proportion of pregnant women screened for GBS was higher in the AD group (25.4%) than in the DM (15.9%) and C (17.7%) groups (P = 0.023). Similar results emerged when the three groups were taken as a cluster (pregnant women and their obstetricians), but the difference was not statistically significant (Poisson regression, P = 0.108). Additionally, when vaginal deliveries were analyzed separately, the proportion screened was higher in the AD group (75%) than in the DM group (41.9%) and the C group (30.4%) (chi-square, P < 0.001).

Conclusions

The results suggest that AD increased the prevalence of GBS screening in pregnant women in this population.

Integrating evidence-based tobacco cessation interventions in free medical clinics: opportunities and challenges

BACKGROUND

Free medical clinics serve a critical role in health care delivery of America's uninsured population, who are less likely to receive tobacco cessation counseling and 1½ times more likely than the general population to use tobacco. The authors evaluate the opportunities for and challenges to implementing the U.S. Public Health Service Guidelines for tobacco cessation in free clinics.

METHODS

Six free clinics participated in this pilot study. Five objectives were targeted: implementation of a tobacco user identification system, education of all clinic staff and volunteers, dedication of a program champion, use of evidence-based treatment, and creation of a supportive environment that reinforces provider behavior. Key informant interviews and focus group data were used to describe the opportunities and barriers of implementing the Public Health Service Guidelines.

RESULTS

All clinics adopted a user identification system, dedicated a program champion, adopted evidence-based counseling, and created an environment conducive for cessation. Common challenges included getting volunteers to attend on-site training programs, accessing nicotine replacement therapy, and promoting Quit Line usage, all of which are part of evidence-based treatment.

CONCLUSION

With more than 1,200 free clinics nationwide, it is very important to understand the opportunities and barriers of implementing tobacco cessation services and systems in free clinics.

The landscape of postgraduate education in palliative care for general practitioners: results of a nationwide survey in Flanders, Belgium

OBJECTIVE

To describe the offer of continuing medical education (CME) in palliative care in Flanders, Belgium and to explore the way providers of CME address the preferences of general practitioners (GP's) towards CME.

METHODS

Questionnaire-survey among official providers of formal CME.

RESULTS

The response rate was 43%, equally distributed over all 5 provinces of Flanders. Data show large content gaps, an under usage of appropriate educational techniques and an absence of evaluation of the impact of CME on clinical practice. Providers of CME explain how they take the preferences of GP's concerning education in palliative care into account.

CONCLUSIONS

The present offer of CME is insufficient to educate GP's in palliative care. The absence of quality criteria and the lack of coordination between different providers results in an unattractive labyrinth of courses leaving GP's and their patients in the cold.

PRACTICE IMPLICATIONS

A comprehensive offer of CME sessions should be installed in a coordination between all providers. This could render the use of means (logistics and speakers) more efficient. Further research could look into other ways of acquiring palliative care competences such as evaluating the learning effect of GP's working together with specialized palliative home care teams.

Improving identification and management of partner violence: examining the process of academic detailing: a qualitative study

BACKGROUND

Many physicians do not routinely inquire about intimate partner violence.

PURPOSE

This qualitative study explores the process of academic detailing as an intervention to change physician behavior with regard to intimate partner violence (IPV) identification and documentation.

METHOD

A non-physician academic detailer provided a seven-session modular curriculum over a two-and-a-half month period. The detailer noted written details of each training session. Audiotapes of training sessions and semi-structured exit interviews with each physician were recorded and transcribed. Transcriptions were qualitatively and thematically coded and analyzed using Atlas ti®.

RESULTS

All three study physicians reported increased clarity with regard to the scope of their responsibility to their patients experiencing IPV. They also reported increased levels of comfort in the effective identification and appropriate documentation of IPV and the provision of ongoing support to the patient, including referrals to specialized community services.

CONCLUSION

Academic detailing, if presented by a supportive and knowledgeable academic detailer, shows promise to improve physician attitudes and practices with regards to patients in violent relationships.

Evaluation of academic detailing for primary care physician dementia education

The objective of this evaluation study was to assess the effect of academic detailing (AcD) as a strategy to increase early detection of dementia in primary care practice and to improve support and management of Alzheimer's disease and other dementia disorders by increasing communication and referrals to local community agencies. As designed for dementia education, AcD consisted of 15-minute educational sessions delivered in primary care practice offices. Twenty-nine visits were conducted by trained teams comprised of a physician and representatives of the Alzheimer's Association (AA) and Area Agency on Aging (AAA). A key outcome of the visits was increased knowledge of the specific programs and services available. In all, 77.4% rated the visit very effective, and follow-up evaluation suggests visits led to an increase in referral to these agencies (55%) and potentially enhanced early detection of dementia by physicians as measured by 35% making changes in the way they identify at-risk patients.

Educating pediatricians and family physicians in children's oral health

Publication of Oral Health in America: A Report of the Surgeon General (SGROH) alerted the public and health professionals to the importance of oral health and the vulnerability of poor and underserved children to dental disease. In response, the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the Society of Teachers of Family Medicine (STFM) have initiated training programs for residents and practicing physicians, allowing them to conduct oral health screenings, apply preventive strategies, and facilitate appropriate referrals to dentists. Training programs are increasingly available on the Web, but their quality and effectiveness are rarely assessed. To ensure greater inclusion of oral health in graduate medical education, voluntary curricular guidelines have been developed, and education in oral health is mandated in family medicine residency programs. Several initiatives engaging practicing physicians in oral health activities have demonstrated improved access and reduced dental disease in children, but evaluation of all programs is essential to determine cost effectiveness and outcomes. The actions of AAP, AAFP, STFM, and other large-scale initiatives have helped break down the traditional separation between medicine and dentistry. Collaboration between physicians and dentists should be encouraged at all levels of education to ensure improvement of the oral health of America's children.