# Presentation: 499284

## Educational Interventions to Improve Patient Safety

**The Potential Role of Academic Detailing**
*Steven R. Simon, MD, MPH*
*Harvard Medical School and*
*Harvard Pilgrim Health Care*

## Background

- Educational interventions may target knowledge, skills, attitudes, beliefs
- Goal is to change behavior/practice
- In patient safety, objective is to reduce errors of omission and commission

**Notes:**
Htn, or HBP, affects more than 50 million individuals in the US.
Leads to cardiovascular disease morbidity and mortality, as well as tremendous expense.
For more than 25 years, practice guidelines have been widely disseminated, most conspicuously in the form of the JNC, or Joint National Committee’s recommendations for the prevention, detection and treatment of Hypertension.
Despite these guidelines, care for hypertension is suboptimal.
--  Fewer than 1/3 of patients with hypertension have the blood pressure controlled to below 140/90, and even fewer have reached the more rigorous current guidelines.
--And, most patients who are treated for hypertension do not receive diuretics orbeta blockers, the agents consistently indicated as first-line treatment in the JNC guidelines because of their proven benefit in long term controlled trials
Surprisingly, despite these gaps between evidence and practice, there have been few controlled studies of improving the treatment of hyperension, and most of these have focused on enhancing patient adherence with medication regimens, not on physicians’ selection of antihypertensive medications.

## Examples of Target Behaviors

- Increase use of life-saving medications and decrease use of less effective medications in hypertension
- Improve lab monitoring of medications
- Decrease use of potentially inappropriate medications in the elderly
- Decrease drug-drug interactions
- Improve dosing of meds in renal insuff.

## Question

- Can academic detailing be employed to change target behaviors and improve patient safety?

## What is Academic Detailing?

- Consistently successful intervention for improving prescribing (also transfusions, screening)
- Educational outreach intervention
- Adult learning principles
- Professional, simple educational messages and materials from a credible source combine with face-to-face visits
- Initially, all one-on-one
- Recently, group sessions

## Academic Detailing Principles

- Understand _motivation_ behind prescribing
- _Target_ physicians who can benefit most
- Establish _credibility_ through respected sponsor
- Reference authoritative, unbiased _information_
- Present both sides of controversial _issues_
- Stimulate active physician _participation_
- Present visually appealing _graphical_ materials
- Repeat and _reinforce_ desired behaviors

*Soumerai and Avorn, JAMA 1990*

**Notes:**
Educational outreach, or academic detailing, is one intervention that has been consistently proven to improve quality of care, specifically the prescribing behavior of clinicians.  Academic detailing is based on principles of adult learning and social marketing theory.  The approach of academic detailing is to understand the motivation behind prescribing, usually through interviews and other observations of prescribing behavior; target the physicians who can benefit most, namely those whose behavior has the most room to move with change.  Trained educators, or detailers, usually pharmacists or physicians, meet face to face with physicians and establish their credibility through a respected sponsor.  They reference authoritative, unbiased, evidnce-based information in their discussion with physicians and present both sides of controversial issues, often inoculating against anticipated arguments that physicians rae likely to raise.  The detailers are trained to stimulate active physician participation in discussion, supported by the presentation of visually appealing graphical materials.  Throughout the intervention, the detailers repeat and reinforce a small number of desired behaviors.

## 3 Case Studies

- Hypertension prescribing
- Laboratory monitoring of medications
- Enhancing computerized clinical decision support (alerts in CPOE)

## Example 1:  RCT to Reduce Prescribing Errors in HTN

- To compare
- Individual academic detailing
- Group academic detailing
- Mailed practice guidelines (usual care)
- Increase use of diuretics and ***β***-blockers
- Initial pharmacologic treatment of hypertension.

*Funded by AHRQ, #HS012019*

**Notes:**
Our specific objective was To compare the effects of 
Individual academic detailing
Group academic detailing
Mailed practice guidelines (usual care)
In an effort to Increase use of diuretics and β-blockers in the 
initial pharmacologic treatment of hypertension.

## Harvard Community Health Plan

- 47 practice groups

- 9 practice groups randomized

- Individual
- Academic Detailing
- (N=3)

- Group
- Academic Detailing
- (N=3)

- Mailed
- Practice Guidelines
- (N=3)

-  114 Clinicians and
- 1066 HTN patients

- 120 Clinicians and
- 1007 HTN patients

- 133 Clinicians and
- 1619 HTN patients

**Notes:**
This figure shows the study design.  We conducted a group-randomized controlled trial.  At the time of the intervention, the summer of 1995, Harvard Community Health Plan, or HCHP, included 47 practice groups. We selected 9 demographically similar but geograpically separated practice groups and  randomly allocated them to one of 3 interventions:
3 practice groups to the individual academic detailing arm.
3 groups to the group detailing arm,
And 3 groups to receive only mailed practice guidelines, or usual care.
This group randomization resulted in more than 100 clinicians who initiated pharmacologic treatment of hypertension for more than 1000 patients in each study arm in each year.  These numbers show the number of prescribing clinicians and patients with newly diagnosed and treated hypertension in the baseline year, that is the year preceding the intervention.  In each of the succeeding years following the intervention there were similar numbers of patients with newly treated hypertension in each arm.

## Academic Detailing Interventions

- Single educational outreach visit
- Trained local physician-detailers
- Credible messenger
- Objective
- Address and overcome barriers to prescribing diuretics and beta blockers
- Unbiased, evidence-based information
- Individual or small group (N=6-8) visits

**Notes:**
The academic detailing interventions in this study consisted of a single educational outreach visit.  We trained 3 physician detailers, chosen from among the practicing physicians in each treatment arm, to be a credible messenger.  These detailers led the educational outreach sessions with the objective of addressing and overcoming barriers to prescribing diuretics and beta blockers for the initial pharmacologic treatment of hypertension.  In the individual detailing arm, detailers met one-on-one with clinicians for a brief discussion lasting approximately 15 minutes.  In the group detailing arm, the detailer led small group discussions usually attended by 6-8 prescribing clinicians.

## Absolute increases in unadjusted rates of use of diuretics or β-blockers among patients with incident hypertension

**Year 1****	****	****          Year 2**

**Baseline Rates**** (58%)     (59%)     (58%)                          (58%)     (59%)    (58%)**

*Simon et al, Am J Med 2005*

**Notes:**
These are the key results of the study, showing the increases in unadjusted rates of use of diuretics or beta-blockers among patients with incident hypertension, one year and two years following the intervention.  Along the bottom, I remind you of the baseline rates of use of diuretics or beta blockers in each of the 3 treatment arms, which are essentially identical. This bar chart shows the increase in use of these agents in each treatment arm in Year 1 and Year 2, as compared with the pre-intervention baseline rate.

After the first year in each of the academic detailing intervention arms, there was an absolute increase of about 13% over baseline in the percentage of patients receiving diuretics or beta blockers, as compared with a 6.2% increase in the mailed information group, in which the physicians received the practice guidelines by mail only.  In the 2nd year after the intervention, the increase over baseline in the rate of use of the guideline recommended drugs was about 15% in the individual detailing arm, 11% in the group detailing arm, and 10% in the usual care arm. 

## Example 2:The Evaluation of Physician Group Academic Detailing as a Method to Increase Laboratory Monitoring

*An intervention study conducted by:*
-  Henry Ford Health Sciences, Detroit, MI
- Kaiser Permanente Northern California, Oakland, CA
- Lovelace Clinic Foundation, Albuquerque, NM
- Harvard Pilgrim Health Care, Boston MA
- University of California, Berkeley, CA
*Part of the CERT Prescribing Safety study*
* **funded by AHRQ*

**Notes:**
Henry Ford has changed its name to Henry Ford Health Sciences

## Intervention Methods

- 38 primary care clinics across 3 HMOs were randomly assigned to intervention and control groups
- Pre/post, intervention/control study design
- Changes in error rates (failure to lab monitor) assessed at the clinic, provider and patient levels
- Intervention: two group-detailing sessions
- Data Source: Administrative healthcare utilization and pharmacy claims data

**Notes:**
Randomization based on  income (in surrounding zip code area), number of health plan members over the age of 18, number of adult primary care physicians, and baseline period medication error rates. 

Error rates will be studied at baseline and annually

Variables to be studied: 
Pre/Post
Treatment/Control
Patient age, sex, Charlson score, chronic disease score
Physician, Clinic, HMO
Error rate; ACE-I, ARB, diuretics, Digoxin

## Reductions in Failure-to-Monitor Rates in 
12 Months after Group Academic Detailing

- 12 Months after Group Academic Detailing

**Percent reduction**

_**Initial Monitoring        Ongoing Monitoring**_

*Note:  Rates are adjusted for patient age & sex, and doctor- & clinic-level effects (in hierarchical models).*

**Baseline Rates:**** (43%)           (46%)               (39%)        ****(41%) (38%)**

## Example 3: Effect of Group AD to enhance CPOE/CDSS

- New prescribing safety alerts in EHR
- Patient-specific, occur at time of ordering
- Offer alternatives or dose adjustment
- Alerts in 3 domains:
- Medications (generally) to avoid in the elderly
- Dose adjustment for renal insufficiency
- Drug-drug interactions

***Co-Led by Smith D and Feldstein A, Kaiser Northwest, as part of the CERT Prescribing Safety study, funded by AHRQ***

## {Group Academic Detailing}			{Usual Care}

*(And all practices receive new prescribing alerts)*

***{Group Academic Detailing}******	******	******	******{Usual Care}***

## Slide 17

## Summary

- (Group) academic detailing appears effective in
- Increasing the use of safe medications
- Increasing laboratory monitoring
- Appears _not_ effective as adjunct to roll out of new computerized alerts to improve prescribing safety

## Implications

- Role for AD in systems without EHRs/CPOE?
- Why AD not effective as adjunct to CPOE?

## Slide 20