J Pharm Pharm Sci (www.cspsCanada.org) 16(4) 511 - 529, 2013 Effectiveness of Academic Detailing to Optimize Medication Prescribing Behaviour of Family Physicians Harpreet Chhina1,2, Vidula M.Bhole1,3, Charles Goldsmith1,4, Wendy Hall5, Janusz Kaczorowski6, Diane Lacaille1,7 1Arthritis Research Centre of Canada Vancouver, BC, Canada; 2Department of Experimental Medicine, Faculty of Medicine, University of British Columbia, Vancouver BC; 3Epi Solutions Consultancy Services, Thane, India; 4Faculty of Health Science, Simon Fraser University, Burnaby , BC Canada; 5School of Nursing, University of British Columbia, 6Department of Family and Emergency Medicine and CRCHUM, University of Montreal, 7Division of Rheumatology, Faculty of Medicine, University of British Columbia, Vancouver BC. Received, August 6, 2013; accepted, August 23, 2013; published, August 25, 2013. ABSTRACT – PURPOSE. To synthesize current knowledge about the effectiveness and the magnitude of the effect, of Academic Detailing (AD), as a stand-alone intervention, at modifying drug prescription behavior of Family Physicians (FPs) in primary care settings. METHODS. A search of MEDLINE, EMBASE, CENTRAL, and Web of Science databases of all English language articles between January 1983 and July 2010 was conducted. We hand-searched the bibliographies of articles retrieved from the electronic search to identify additional studies. Inclusion criteria were: full-length articles describing original research; randomized controlled trial (RCT), or observational study design with a control group; studies of AD delivered to FPs; AD as a stand-alone intervention; drug prescription as the target behavior. Data extraction was done independently by two reviewers. Outcomes evaluated were: the difference in relative change in prescription rate between the intervention and control groups; the difference in absolute change in prescription rate between the intervention and control groups; and effect size, calculated as the standardized mean difference. RESULTS. 11 RCTs and 4 observational studies were included. Five RCTS described results showing effectiveness, while 2 RCTs reported a positive effect on some of the target drugs. Two observational studies found AD to be effective, while 2 did not. The median difference in relative change among the studies reviewed was 21% (interquartile range 43.75%) for RCTs, and 9% (interquartile range 8.5%) for observational studies. The median effect size among the studies reviewed was - 0.09 (interquartile range 2.73). CONCLUSION. This systematic review demonstrates that AD can be effective at optimizing prescription of medications by FPs. Although variable, the magnitude of the effect is moderate in the majority of studies. This systematic review also provides evidence supportive of the use of AD as a strategy to promote evidence based prescription of medications or incorporation of clinical guidelines into clinical practice. This article is open to POST-PUBLICATION REVIEW. Registered readers (see “For Readers”) may comment by clicking on ABSTRACT on the issue’s contents page. __________________________________________________________________________________________ INTRODUCTION audit/feedback, academic detailing and reminders, have been shown to be effective for changing Gaps between research, policy and practice have physician behaviour or healthcare outcomes[3]. been identified globally, with attention focused on Academic detailing (AD), or educational making research-based evidence easily available so outreach visits, is a form of CME in which a trained that it can facilitate change in the behaviours of health care professional, such as a physician or health practitioners. Clinicians and family pharmacist, visits physicians in their offices to physicians (FPs) in particular, are faced with provide evidence-based information on a selected burgeoning scientific literature on a variety of topic [4-6]. Some of the important elements of AD topics, making it difficult to stay up to date. are: a) identifying and defining the problem and Current evidence suggests that dissemination of specific behaviours to be promoted or discouraged; research results through peer-reviewed publications ___________________________________________________ alone and conventional continuing medical Corresponding Author: Harpreet Chhina, Arthritis Research education (CME) techniques have little effect[1, 2] Centre of Canada, 5591 No. 3 Rd, Vancouver, BC, Canada; while interactive techniques, such as Email: [email protected] 511 J Pharm Pharm Sci (www.cspsCanada.org) 16(4) 511 - 529, 2013 b) examining baseline knowledge and motivations more focused evaluation of the effectiveness of AD for current practice patterns; c) defining clear among a select group of professionals, this objectives for behaviour change; d) establishing systematic review aims to synthesise current credibility of the information provided by knowledge about the effectiveness, and the referencing unbiased information sources; e) magnitude of the effect of AD as a stand-alone providing interactive and short sessions with intervention at modifying drug prescription opportunity for discussion; f) highlighting and behaviour of FPs. reinforcing key messages with concise graphic information; and g) providing positive METHODS reinforcement through follow-up visits [4]. Despite originating in 1983 [7] , adoption of Literature Search Strategy: We conducted a AD by health policy planners as a health service search of MEDLINE, EMBASE, CENTRAL, and intervention is fairly new. In Canada, AD was first Web of Science databases of all English language systematically introduced in Nova Scotia in 2001 articles between January 1983 and July 2010. We [5]and is now implemented in six provinces [8, 9]. used terms that mapped to Medical Subject Although the effectiveness of AD to influence the Headings (MeSH) in combination with keyword knowledge and practice of various health care terms as described in Table 1. We also hand- professionals has been demonstrated in previous searched the bibliographies of articles retrieved reviews [2, 3, 10, 11], its effectiveness as a stand- from the electronic search to identify additional alone intervention targeted at family physicians studies. (FP) to optimize their medication prescribing behaviour has not been previously evaluated, as far Selection of Studies: Two authors (HC and VB) as we know, in a systematic review. Focusing on reviewed all titles and abstracts identified to select medication prescription by FPs is particularly studies which met the following inclusion criteria: important because they are responsible for most 1) Full-length articles describing original research; medication prescriptions. In Canada, FPs prescribe 2) Randomized controlled trial (RCT), or drugs at about 50% of office visits and are observational studies with a control group; 3) accountable for the majority of the prescriptions Studies of AD delivered to FPs; 4) AD as the sole dispensed annually [12]. Given rising health care intervention; 5) Drug prescription as the target costs, with drugs (prescription and non- behaviour of AD (Table 2). Figure 1 illustrates the prescription) ranking as the second major flow of study inclusions/exclusions. The two contributor to healthcare spending[13, 14], reviewers also independently reviewed the selected facilitating and supporting evidence-based studies for quality assessment and data abstraction. prescribing patterns is very important. To provide a Any discrepancies were discussed and resolved by consensus. Table 1. Medical Subject Headings (MeSH) terms and keywords used in electronic search strategy Concept MeSH Terms Keywords Academic Detailing Education, Medical, Continuing Academic detailing, academically based detailing, continuing medical education, public interest detailing, educational outreach Family Physicians Physician Physicians, general practitioner, family practice, family doctor, primary health care provider, general practice, primary Health Care Practice Patterns Physician practice patterns Practice pattern, drug prescription, antibiotic prescribing, drug dose calculation 512 J Pharm Pharm Sci (www.cspsCanada.org) 16(4) 511 - 529, 2013 Table 2. Inclusion and exclusion criteria for study selection Inclusion Criteria Exclusion Criteria Study design RCT, observational study with control group Observational study without a control group Participants FPs in primary care setting specialist physicians, other healthcare professionals Intervention AD as a single intervention (not as part of a other CME , educational intervention, multifaceted intervention) multifaceted interventions Target behavior Drug prescription other physician practice pattern Records identified through search strategy (n = 6166) Excluded by title review due Duplicates removed to lack of relevance (n = 151) (n= 5895) Abstracts Selected for review (n = 120) Abstracts excluded: Abstracts excluded: Meeting abstracts, Special AD aimed at practice change Reports, Editorials, and two other than drug prescription, publications from same study (n =52) (n=15) AD not in a primary care setting Abstracts excluded: (hospital setting and directed Multifaceted interventions at residents, interns, sub‐ (n=19), Intervention not AD speciality fellows, surgeons, and directed at patients only and other hospital staff) (n = 1) (n=6) Full‐text articles selected for review of eligibility (n = 27) Full‐text articles excluded: AD aimed at pharmacists, publication of study protocol Observational