Academic detailing in the Alberta Drug Utilization Program

Dr. Harold Lopatka, Program Director, Alberta Drug Utilization Program

The Alberta Drug Utilization Program runs a multi-faceted educational initiative, with academic detailing as the centrepiece, to improve physician prescribing behaviour in Alberta. Noticeable improvements to clinical practice guidelines have been observed over the three years of its operation. Building and maintaining relationships—between organizations, between physicians and academic detailers, and between physician peers—has been identified as key to the success of this initiative.

Background

The Alberta Drug Utilization Program (ADUP) was established in 1998 to develop, evaluate, and facilitate the implementation of drug use management strategies that promote the health of Albertans.

Academic detailing—an educational intervention for improving professional practice—was identified as one strategy that could improve the prescription and use of drugs in Alberta. The goal of academic detailing is to optimize physician prescribing behaviour by communicating evidence-based, cost-effective and unbiased drug information to providers.

However, approaches such as multi-faceted educational interventions and academic detailing may not be as effective at influencing professional practice as once believed, due to unacknowledged factors.1 In the pharmaceutical industry, for example, significant attention is paid to the role of inter- and intra-organizational and personal relationships in the success of knowledge translation (KT) interventions.2,3 This has not been as well explored in the medical literature.

ADUP was charged with implementing and evaluating a multi-faceted educational initiative, with academic detailing as the centrepiece, through demonstration projects in Alberta's regional health authorities. Our key partner organizations were the Alberta Medical Association, the Alberta College of Physicians and Surgeons, the Alberta College of Pharmacists, the Pharmacists Association of Alberta, The College of Family Physicians of Canada, Alberta's regional health authorities, Alberta Health and Wellness, Alberta Blue Cross, the University of Alberta and the University of Calgary. The project was funded by Alberta Health and Wellness.

The KT initiative

The initiative began in the David Thompson Health Region in late 2001 and is now being launched in the Calgary Health Region. The central goal is to improve family medicine physicians' adherence to provincial and national clinical practice guidelines for rational medication use. Specific topics are chosen by reviewing prescription claims and physician billing data to determine potential care gaps and educational needs. Literature reviews are conducted and the opinions of specialists are obtained when data is not available for selecting topics.

A multi-faceted KT approach, including multidisciplinary continuing education, academic detailing by a pharmacist, distribution of printed education materials, opinion leader consultation and comparative prescribing feedback reports which show how consenting physicians prescribe in relation to peers in the region, is used for each topic. The complete intervention occurs over four to six months.

Medical specialists deliver the continuing education, providing their perspective on important aspects of the clinical practice guideline (e.g. key points, grey areas) and answering questions. The academic detailing occurs after the continuing education, with the detailer conducting a 30-minute visit in the physician's office to talk about the guideline. Some time after the academic detailing visit, a small group session (usually at the physician's clinic) is scheduled with an opinion leader, a specialist, and the detailer to discuss cases. Opinion leaders also provide advice to the detailers about interpreting critical evidence and help them prepare for a topic by allowing them to attend outpatient clinics.

The clinical practice guidelines are produced and validated by the provincial clinical practice guidelines program, Towards Optimal Practice (TOP), which develops new guidelines, validates national guidelines, or updates older guidelines. TOP produces one-page guideline summaries for use in academic detailer and opinion leader visits. After our visits and internal evaluations, we provide feedback from physicians on the guidelines to TOP.

The University of Alberta assists in the organization and delivery of the continuing medical education programs, coordinating promotion activities, registrations, handouts, tele-health broadcasts to rural sites, attendance certificates, and evaluations.

The David Thompson Health Region and the Calgary Health Region also promote and market the initiative. In the Calgary Health Region, it has been embedded structurally within the chronic disease management unit, and physicians participating in the chronic disease management program are also recruited for academic detailing.

We evaluated the success of the initiative through monitoring of academic detailer activities, physician satisfaction and opinion surveys and through retrospective review of prescription drug claims (to assess adherence to clinical practice guidelines).

Results of the KT experience

We attribute our success to our ability to build relationships with increasing numbers of physicians, and to foster in-depth relationships with physicians participating in the initiative.

Overall, 250 visits were conducted by our pharmacist detailer on four broad topics by the end of 2004. Physician participation increased from 10 physicians for the first topic to over 55 for a later topic, and the regional centres (cities and towns) we covered increased from two to 15. The initiative has been accepted by local physicians (high levels of satisfaction have been reported by participants) and has been successful in improving adherence to clinical practice guidelines (10-13% improvements have been recorded in adherence to two guidelines).

Lessons learned

We attribute the success of the initiative to the attention given to building and maintaining relationships at both the system and front line levels. At the system level, relationships with our key provincial partner organizations, such as the health regions, Alberta Blue Cross, the University of Alberta, and TOP, were critical for the delivery of our program. As a general operating principle, we work on the premise that our activities should focus on front line delivery of services and should not duplicate activities performed by other organizations.

At the front-line level, we attribute our success to our ability to build relationships with increasing numbers of physicians, and to foster in-depth relationships with physicians participating in the initiative. For example:

The involvement of a highly supportive local champion has made a significant difference in physician recruitment and participation.

  • We recruited local physician champions to increase acceptance of the initiative by their peers. As participation in the program is voluntary, the involvement of a highly supportive local champion has made a significant difference in physician recruitment and participation. In regional centres where a local champion is present, physician participation in topics has been as high as 100%. In centres without a local champion, or if the centre is too large for a local champion to have an effect, participation is approximately 10%.
  • We hired local community pharmacists as academic detailers to improve efficiency and increase physician participation. Initially, we began with one Edmonton-based academic detailer. But the David Thompson Health Region spans a very large geographic area and significant time was spent traveling. So two local community pharmacists were hired to provide detailing services. Their local familiarity and established relationships also allowed them to gain access to physicians who had previously resisted participation in the initiative. One pharmacist increased physician participation by more than 100% in one centre.
  • Opinion leaders helped improve the credibility of the initiative. Our initial plan was to co-opt local physicians to serve as opinion leaders and to have them consult with their peers about the guidelines. However, we encountered difficulties in finding local opinion leaders and instead recruited an opinion leader from Edmonton, an internal medicine specialist. This has proved to be a popular learning approach with participating physicians. In Calgary, we have employed a different model, using topic-specific opinion leaders.
  • We offer physicians the opportunity to trial or sample the initiative before making a full commitment. For example, newly recruited physicians can receive academic detailing and/or opinion leader consultation, but not continuing education or comparative prescribing feedback reports. Approximately 10% of physicians receive sample or trial detailing visits.
  • We foster long-term, individual relationships. As the relationships between detailers and individual physicians mature beyond basic information exchange, and comfort levels increase, discussions became more meaningful. Detailers are able to identify common uncertainties in family medicine practice and specific educational needs relating to the clinical practice guidelines.

As the relationships between detailers and individual physicians mature beyond basic information exchange, discussions became more meaningful.

Considerable time and effort is required to create and maintain relationships, but this was identified as critical to the success of our early KT activities. As our initiative continues to mature and expand, it is expected that additional challenges will need to be addressed at both the system and front line levels. We need to know more about the optimal structures and processes for effective relationship building, and we need to be able to determine if the interventions produce better outcomes when they are conducted in settings where established relationships exist. We also need to know if specific KT activities are more effective than others where established relationships exist.

Conclusions and implications

Several encouraging developments suggest that our initiative will have broader uptake. First, another government drug plan manager, Health Canada (First Nations and Inuit Health Branch-Alberta region), has joined our group of key stakeholders because of their interest in the project. Second, five provinces conducting academic detailing initiatives have joined forces to create the Canadian Academic Detailing Collaborative. This group has secured funding from Health Canada to evaluate processes and outcomes resulting from national collaboration. Third, the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) has been created by the Canadian Coordinating Office for Health Technology Assessment to coordinate evidence-based reviews and the development of change management tools. As COMPUS becomes operational it will enhance our capacity to conduct KT activities by making tools available for KT, assessing KT strategies relating to appropriate medication use, and reviewing methods for evaluating KT activities like academic detailing. Fourth, at least two Alberta local primary care networks have integrated academic detailing as a service for primary care physicians. In a recent external program evaluation of ADUP, an accelerated expansion of the initiative was identified as a major strategic activity for our future plans.


References

1 Grimshaw, J. M., R. E. Thomas, G. MacLennan, C. Fraser, C. R. Ramsay, L. Vale, P. Whitty, et al. 2004. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 8 (6): 1-72.
2 Weitz, B. A., and K. D. Bradford. 1999. Personal selling and sales management: A relationship marketing perspective. J Acad Market Sci 27:241-54.
3 Prounis, C. 2003. What doctors want. Pharmaceutical Executive, May (Suppl).

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