The ROAD pilot project of alternative approaches to delivering academic detailing was well received by participating family medicine clinics. Survey data overwhelmingly indicate clinicians were satisfied with the content and approaches used. The component with the highest reported satisfaction involved the specific content covered during the outreach. The component achieving the lowest level of reported satisfaction was our Medicaid prescribing profile. This finding is not entirely surprising. While we intended our prescribing reports to inform clinicians about their own current prescribing practices, the number of claims identified for each prescribing indicator was generally small and highly variable. Nevertheless, participating clinicians uniformly indicated they would likely or had already changed behavior related to several of the educational messages delivered. On average 60% to 75% of respondents indicated their willingness to change behavior. Clinicians indicated the least likelihood for changing the use of generic SSRI antidepressants as the initial choice for treating depression. This was unexpected because prevailing evidence shows only modest differences in effectiveness between commonly used SSRI antidepressants . One possible explanation is that nearly 75% of current prescribing is already for generic SSRI antidepressants leaving little room for changes in practice to occur.
While satisfaction between the face-to-face and distance detailing approaches were similar, clinicians’ perceptions of impact seemed to favor the face-to-face encounter over the distance approach. Clinicians who received in–person outreach rated their likelihood of changing as qualitatively higher for 5 of 7 categories. While virtually all participants indicated their willingness to continue future participation in the program, enthusiasm for the outreach was diminished for distance approaches such as asynchronous web modules and teleconference. Unstructured responses solicited from the participants confirm the bias towards in-person detailing, with several individuals suggesting the teleconference approach was not effective. Many in the field strongly advocate that academic detailing requires a face-to-face interaction for the purpose of relationship building, establishing credibility, and facilitating two-way communication between the clinician and the detailer . In theory, much of this communication could potentially be accomplished through video conferencing. In practice, however, it was our impression that barriers to open dialog still exist with such an approach, such as the diminished ability to recognize body language. Future programs might benefit from a hybrid approach where less frequent visitations are coupled with online or other distance technologies. Also, our program used an approach where clinicians engaged with the clinical pharmacist in small groups (versus one-on-one). We used this model because of the logistical difficulties anticipated with individual clinician meetings and because preliminary focus group suggested a preference for it. Although much of what has been described in the literature consists of a one-on-one detailing model, some evidence exists showing that small group detailing is an effective alternative to individual encounters .
Project resources allowed for only a small amount of clinical pharmacist (detailer) time to deliver education and to assist in content development. Content development and generation of provider prescribing profiles was resource-intensive, requiring significant time for research, programming and design. We question the ultimate return on investment for developed reports given the limitations and narrow population scope of the summarized data. In developing other educational tools, we attempted to leverage existing evidence-based products. For example, we used the clinician handout for treatment of depression developed by the AHRQ Effective Healthcare Program. We also explored the existence of materials on academic detailing websites in Canada, Australia, and the Harvard program which operates in Pennsylvania (http://www.rxfacts.org). Unfortunately, at the time there was a scarcity of material on many of the mental health topics we elected to detail on, such as treatment-resistant depression.
Our findings are tempered by several limitations. First, while the response rate from our survey was moderate, the overall response was low and likely not adequately powered to detect significant differences between the two detailing approaches. Initially, we explored using Medicaid pharmacy data to both generate prescribing profiles and to measure changes in behavior following our intervention. It became clear during the design of these profiles that the number of patients, and ultimately pharmacy claims, associated with each clinician was very small. As a result, our prescribing profiles were likely of little value. Similarly, the use of pharmacy claims to quantify changes in behavior was highly variable and unreliable.
Each clinic was given a $1000 honorarium for participating in the ROAD project. Our intent was to provide clinics with a gesture of gratitude for time spent with research-related activities, such as filling out surveys and participating in the focus group, rather than as an incentive to receive the detailing itself. It is unclear if clinics would be as willing to participate in future efforts if the financial reimbursement was eliminated. While Medicaid data limitations curtailed our ability to document changes in prescribing behavior, the outreach was well received and helpful to clinicians. In the near future, the State of Oregon is rolling out an all–payer, all-claims dataset that will serve as a repository for medical and pharmacy claims for private (group and self-insured) and public (Medicaid and Medicare) insured individuals (~3 million covered lives per year) in the state. The implementation of Oregon’s all–payer, all-claims dataset is a promising development that could assist in generating more accurate and comprehensive prescribing profiles, targeting specific providers, and enhance our ability to evaluate future programs.
While many academic medical centers have taken steps to curtail influence of the pharmaceutical industry on the continuing education of their clinicians, family physicians in small independent practices may continue to rely on industry for prescribing information as well as the provision of drug samples [10, 19]. The Institute of Medicine’s consensus report entitled “Conflict of Interest in Medical Research, Education, and Practice” published in 2009 recognizes the information needs of clinicians and proposes that academic detailing programs may be an attractive alternative for clinicians to obtain non-commercial prescribing information . In the US, academic detailing activities have primarily been localized state programs, although AHRQ is currently funding a national effort focused on dissemination and translation of its Effective Health Care products to primary care clinicians . Several lessons emerge from this project that will assist in informing a longer-term more sustained effort in the state. First and foremost, the distance approach, as formulated in this project, was not viewed as favorably as outreach delivered in person. This is consistent with the theoretical framework of detailing which stresses the importance of relationship building and credibility on affecting change [4, 22]. Future work should either abandon this approach or supplement it with individual interaction. At the very least, if a similar approach is used, it will be important to actively assess and incentivize provider engagement, as well as knowledge attainment and retention with the distance modules. Video conferencing may still be a viable option if it can be configured in a way that facilitates the personal connection between the detailer and provider. Also, it is unclear at what interval or intensity of engagement needs to occur in order to achieve a desired change. Understanding this will be critical for sustaining programs that cover geographically distant areas. Finally, the effort required to synthesize evidence into usable clinical practice recommendations it not a trivial matter. Although a variety of organizations have built a sizable library of material that can be used in academic detailing efforts, gaps remain. The work of packaging evidence syntheses for clinical use will grow substantially as evidence from the US comparative effectiveness research enterprise accumulates.