A Brief Overview of Academic Detailing in Canada: Another Role for Pharmacists

Abstract

Medications are the second largest and fastest growing health care cost in Canada.1 In 2010, there were 499.6 million prescriptions dispensed across Canada, representing a total of $23.3 billion. 2 While medications often produce extensive improvements in patient health and well-being, they have also been associated with many preventable adverse events.3,4 In practice, medications are often used at different dosages, with other medications or for patients or conditions that were not included in clinical trials. These factors reflect the complexity of real-world practice and can result in suboptimal medication use that contributes to drug-related morbidity and mortality.5 In 2000, the cost of drug-related morbidity and mortality resulting from drug-related problems exceeded $177.4 billion US in the United States.6 According to a Canadian study completed in 2000, adverse drug reactions occur frequently (7.5 per 100 hospital admissions),7 are preventable (36.9%)7 and prolong hospital stay by an average of 3.6 days.8 Key points Academic detailing has been shown to improve patient health outcomes. Academic detailing is currently available province-wide in British Columbia, Saskatchewan and Nova Scotia. The role of the pharmacist can include academic detailer, evidence reviewer for topics, developer of key messages and content/supporting tools, developer of the evaluation framework and trainer of other academic detailers. Points cles Il a ete demontre que la visite academique ameliore les resultats pour la sante des patients. La visite academique est actuellement offerte dans l'ensemble de la Colombie-Britannique, de la Saskatchewan et de la Nouvelle-Ecosse. Le role du pharmacien peut varier de celui de formateur en pharmacotherapie a celui d'examinateur des donnees probantes ou de developpeur de messages cles, de contenu ou d'outils de soutien ou encore de cadres d'evaluation des agents de formation des formateurs en pharmacotherapie. There have been a number of strategies evaluated to improve medication prescribing and use. An overview of 41 systematic reviews of interventions to change provider behaviour9 found that passive approaches were unlikely to affect changes in provider behaviour, while academic detailing (AD or educational outreach) was considered to be a promising approach, even when delivered as a single intervention.9 AD is a method of continuing education in which a trained health care professional meets with a prescriber (e.g., family physician or nurse practitioner) in their practice setting to provide one-on-one evidence-based information.10 The information given may include feedback about their performance or may be based on overcoming obstacles to change practice. Academic detailing is frequently provided in multifaceted interventions with written materials, continuing education and feedback. One of the main components of academic detailing is that detailers (mostly pharmacists, sometimes nurses or other physicians) provide well-balanced, objective information; this can be accomplished because they are not employed by the pharmaceutical industry and the academic detailing programs do not have any financial links to the pharmaceutical industry. AD has been employed to effect changes in prescribing practices based on the best available evidence to improve patient health outcomes. Some improvements in the appropriate prescribing by physicians for antibiotics,11–13 benzodiazepines,14–16 NSAIDs,17,18 acid-peptic disease management19 and diuretics for hypertension20 have been observed. AD has also been employed to target behaviours related to the provision of preventive services or the general management of conditions commonly seen in general practice, such as the management of patients with diabetes,21 patients with osteoporosis,22 the provision of smoking cessation advice23 or cancer screening.24,25 A Health Council of Canada report26 corroborated these findings as part of a review of interventions to target suboptimal prescribing. AD was among one of the more highly effective interventions discussed, with some studies showing improvements ranging from 1% to 2%, to improvements as large as 24% to 45%.26 The reason for the large variance is unknown, but factors such as physicians' baseline knowledge of the evidence, number of physicians per AD visit, clinic location, complexity of behaviour change and the make-up of the academic detailing visit have all been considered.27,28 In a Cochrane review, 69 studies showed that academic detailing consistently provided small changes in prescribing that could lead to significant changes, with hundreds of patients being affected.27 Soumerai and Avorn recommend that the following principles of educational outreach be incorporated into academic detailing to improve clinical decision-making:29 Conduct interviews with target audience to investigate baseline knowledge and motivations for current prescribing and practice patterns. Focus programs on specific groups of prescribers and opinion leaders. Define clear educational and behavioural objectives. Establish credibility through a respected organizational identity, referencing authoritative and unbiased sources of information and presenting both sides of controversial issues. Stimulate active physician participation in educational interactions. Use concise graphic educational materials. Highlight and repeat the essential messages. Provide positive reinforcement of improved prescribing practices during follow-up visits. The objectives of this article are to provide a brief overview of academic detailing activity in Canada and describe the role of pharmacists as academic detailers.