Educational outreach/academic detailing
3.4. Educational outreach/academic detailing
Face-to-face detailing has been used by the pharmaceutical industry for many years to market its products to physicians. The studies in this section use similar methods of detailing physicians regarding appropriate prescribing. The detailers in these studies were either clinical or research pharmacists or medical doctors. In some studies the effectiveness of different types of detailers are com- pared. This method is attractive for appropriate prescribing education as it has been used very successfully by the pharmaceutical industry, possibly because of the one-on-one attention paid to the prescriber. Materials discussed in the ses- sions include the review of audit material from the physician’s own practice.
In this section, there were eight studies (Avorn and Soumerai, 1983; De Santis et al., 1994; Dolovich et al., 1999; Font et al., 1991; Ilett et al., 2000; McConnell et al., 1982; Peterson et al., 1997; Ray et al., 1985; long term fol- low-up data for Schaffner et al., 1983) (see Table 4). The two cluster RCTs,
Table 4. Educational outreach visits Study citation Design Analysis
Outcome measure Results as reported in the study Dolovich
Mean percent change in market et al. (1999)
Cluster Controlled
Increased
RCT for location
share for amoxicillin in of pre-
prescribing of
intervention region 0.63 compared scriber in
first-line agents
(amoxicillin) for with ⫺0.72 in controls ( p ⫽ 0.15). multivariable acute otitis media analysis
De Santis Cluster No cluster
Increase in proportion of et al.
Increase
prescriptions that are pencillin or (1994)
RCT analysis
prescribing of
erythromycin from pre to post erythromycin for intervention in both groups— tonsillitis
penicillin and
60.5% to 8 7.7% in intervention, 52.9% to 71.7% in controls.
Avorn Cluster No cluster Reduction in use Mean difference from controls and Soumerai RCT
between pre and post intervention (1983)
analysis
of cephalexin
periods ⫺382 (mean number of units prescribed) ( p ⫽ 0.0006).
Ilett et al. RCT No cluster
Significant increase in prescribing (2000)
Increase
analysis
prescribing of
of amoxicillin from median 293
first-line agents
prescriptions per physician to 594 for UTI, bacterial ( p ⬍ 0.05) and doxycycline from tonsillitis, otitis
median 235 prescriptions per
media, bacterial
physician to 865 ( p ⬍ 0.05) (within
bronchitis, mild
group comparison only). Both
pneumonia
recommended first-line agents for otitis media and pneumonia, respectively.
508 Sandra L. Arnold
Table 4. Continued Study citation Design Analysis
Outcome measure Results as reported in the study McConnell
Average number of tetracycline et al. (1982)
RCT No cluster
Reduction in
analysis
prescribing of
prescriptions per provider dropped
tetracycline
from 12.6 to 1.8 ( p ⬍ 0.001) in intervention group and 7.6 to 3.2 ( p ⬍ 0.001) in controls.
Font et al. RCT No cluster
Median number of prescriptions (1991)
Reduction in
analysis
prescribing of
per month for combination agents
antibiotics
fell from 86.53 to 75.89 ( p ⬍ 0.001)
combined with
for intervention group, 98.55 to
symptomatic
91.96 for controls ( p ⬍ 0.001)
drugs, injectable
between group comparison
cephalosporins
significantly different ( p ⬍ 0.01);
and injectable
for oral cephalosporins 4.97 to
penicillin/
5.36 (p ⬍ 0.05), 6.43 to 5.98 (NS),
streptomycin
between group comparison
combination,
( p ⬍ 0.01); injectable
increase in oral
cephalosporins no reduction;
cephalosporins
penicillin/streptomycin between group comparison NS.
Peterson CBA No cluster
Relative prescribing of first-line et al. (1997)
Increase
analysis
prescribing of
agents for UTI higher in
first-line agents
intervention than control region
for UTI
compared with baseline
(amoxicillin
( p ⬍ 0.0001)—ratio of
clavulanic acid,
recommended to non
cephalexin,
recommended antibiotics
trimethoprim)
increased from 2.77 to 5.43 in intervention region and 4.29 to
4.92 in control region. Schaffner
Relative reduction in number of et al. (1983)
CBA No cluster
Reduction in use
analysis of contraindicated prescriptions for contraindicated antibiotics and
antibiotics of 67%, 85%, and
cephalosporins
41% in pharmacist detailer, physician detailer, and control groups, respectively; for oral cephalosporins, corresponding changes were 35%, 50%, and 33% reduction.
randomized by geographic region, examined changes in the prescribing of first-line agents for acute otitis media (Dolovich et al., 1999) and tonsillitis (De Santis et al., 1994) in response to academic detailing by a pharmacist. Three of the physician randomized RCTs examined the effectiveness of academic detailing on reducing the use of particular antibiotics, oral
Interventions to Improve Antibiotic Prescribing 509 1982), and antibiotics combined with symptomatic medications, oral and
injectable cephalosporins, and an injectable combination of penicillin and streptomycin (Font et al., 1991). Another RCT used academic detailing to pro- mote the use of certain first-line agents for a variety of community-acquired bacterial infections (UTI, bacterial tonsillitis, otitis media, bacterial bronchitis, and mild pneumonia) (Ilett et al., 2000).
The two cluster RCTs combined mailed educational materials with acade- mic detailing by a pharmacist (De Santis et al., 1994) or a traditional pharma- ceutical industry detailer (Dolovich et al., 1999) which focused on the content of the previously mailed materials. One of these studies demonstrated a small but significant benefit from academic detailing (De Santis et al., 1994) while the other study showed not benefit (Dolovich et al., 1999). Among the physi- cian randomized studies, two demonstrated a reduction in the use of specific classes of antibiotics (cephalexin [Avorn and Soumerai, 1983] and tetracy- clines [McConnell et al., 1982]) compared with controls and printed educa- tional materials alone (Avorn and Soumerai, 1983). In the third study (Ilett et al., 2000), very small changes in the prescribing of recommended first-line agents were achieved; however, the large number of outcomes measured (many antibiotics examined) raises concerns regarding multiple comparisons and the possibility that small, significant results may be due to chance alone.
In the three CBA studies, academic detailing was successful in reducing inappropriate antibiotic use as defined by the individual studies. One group suc- cessfully increased the number of prescriptions for first-line agents in UTIs (Peterson et al., 1997). The remaining two studies aimed to reduce the use of cer- tain antimicrobials considered to be contraindicated for use in general practice. Physicians prescribed fewer antibiotics in combination with symptomatic med- ication and fewer courses of injectable cephalosporins in Barcelona following academic detailing by a pharmacist (Font et al., 1991). The Tennessee statewide intervention mentioned previously used pharmacist or physician detailers and reduced the use of certain agents considered to be contraindicated with a greater reduction seen with physician detailers than pharmacists (Schaffner et al., 1983). This reduction was sustained after two years (Ray et al., 1985).
The effect of academic detailing on improving antibiotic prescribing appears to be moderate in the best cases. Most of the studies utilized pharma- cist detailers and thus, it is difficult to generalize about the differences between pharmacist and physician detailers. In the one study comparing the two types of detailing, physician detailing clearly had a more substantial effect on changing prescribing behavior (Ray et al., 1985; Schaffner et al., 1983). The one study utilizing traditional pharmaceutical representatives (Dolovich et al., 1999) to provide education did not demonstrate a significant impact. The overall success of these studies may, in part, be due to the fact that the primary goal in most of these studies was to reduce prescribing of certain agents and/or
510 Sandra L. Arnold sought to reduce overall use of antibiotics for inappropriate indications which
appears to be a much more difficult task.