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Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial.

ABSTRACT: Importance:Strategies to reduce the inappropriate prescription of antipsychotics have been the focus of recent attention but have shown considerable variation in their effectiveness. Objective:To evaluate the effectiveness of academic detailing in nursing homes targeting appropriate prescribing of antipsychotics. Design, Setting, and Participants:We conducted a pragmatic, cluster randomized clinical trial comparing the effect of academic detailing vs usual care on prescribing antipsychotics in 40 nursing homes with 5363 residents in Ontario, Canada. Data were collected from October 2015 to March 2016 and analyzed from April to August 2018. Primary analyses were conducted using intention to treat. Intervention:Academic detailing delivered by health professionals (eg, nurses or pharmacists) who arranged meetings (with administrators, physicians, pharmacists, nurses, and support workers), presentations, group visits (with 2-6 clinicians), and 1-on-1 visits (traditional academic detailing visits). Academic detailers had direct and ongoing contact with the nursing homes from the time of launch. Main Outcomes and Measures:The primary outcome, defined at the level of the resident, was whether continuous antipsychotics were dispensed in the past week. Secondary outcomes included prescribing of other psychotropic medications and clinical outcomes and scores. Prescribing outcomes were assessed at baseline and at 3, 6, and 12 months, and clinical outcomes and scores were assessed at baseline and 3 and 6 months. Results:A total of 40 nursing homes with 5363 residents were randomized, with 18 intervention homes (45.0%; 2303 [42.9%] residents) and 22 control homes (55.0%; 3060 [57.1%] residents). Participants in the intervention and control groups had similar median (interquartile range) age (86 [79-91] years vs 85 [78-90] years) and sex (674 [29.3%] men vs 970 [31.7%] men). At 12 months, there was no statistically significant difference in the frequency of daily antipsychotic use (intervention: 569 patients [25.2%]; control: 769 [25.6%]; odds ratio, 1.06; 95% CI, 0.93-1.20; P?=?.49). There were no significant differences in the rates of health care utilization, but the intervention group did experience a statistically significant reduction in pain compared with the control group (mean [SD] pain score, 0.30 [0.59] vs 0.38 [0.66]; P?

SUBMITTER: Tadrous M

PROVIDER: S-EPMC7251442 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial.

Tadrous Mina M Fung Kinwah K Desveaux Laura L Gomes Tara T Taljaard Monica M Grimshaw Jeremy M JM Bell Chaim M CM Ivers Noah M NM

JAMA network open 20200501 5

<h4>Importance</h4>Strategies to reduce the inappropriate prescription of antipsychotics have been the focus of recent attention but have shown considerable variation in their effectiveness.<h4>Objective</h4>To evaluate the effectiveness of academic detailing in nursing homes targeting appropriate prescribing of antipsychotics.<h4>Design, setting, and participants</h4>We conducted a pragmatic, cluster randomized clinical trial comparing the effect of academic detailing vs usual care on prescribi ...[more]

PMID: 32453383

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Project description:In 2014, nursing home administration and government officials were facing increasing public and media scrutiny around the variation of antipsychotic medication (APM) prescribing across Ontario nursing homes. In response, policy makers partnered to test an academic detailing (AD) intervention to address appropriate prescribing of APM in nursing homes in a cluster-randomized trial. This mixed-methods study aimed to explore how and why the AD intervention may have resulted in changes in the nursing home context. The objectives were to understand how the intervention was implemented, explore contextual factors associated with implementation, and examine impact of the intervention on prescribing.Administrative data for the primary outcome of the full randomized trial will not be available for a minimum of 1 year. Therefore, this paper reports the findings of a planned, quantitative interim trial analysis assessed mean APM dose and prescribing prevalence at baseline and 3 and 6 months across 40 nursing homes (18 intervention, 22 control). Patient-level administrative data regarding prescribing were analyzed using generalized linear mixed effects regression. Semi-structured interviews were conducted with nursing home staff from the intervention group to explore opinions and experiences of the AD intervention. Interviews were analyzed using the framework method, with constructs from the Consolidated Framework for Implementation Research (CFIR) applied as pre-defined deductive codes. Open coding was applied when emerging themes did not align with CFIR constructs. Qualitative and quantitative findings were triangulated to examine points of divergence to understand how the intervention may work and to identify areas for future opportunities and areas for improvement.No significant differences were observed in prescribing outcomes. A total of 22 interviews were conducted, including four academic detailers and 18 nursing home staff. Constructs within the CFIR domains of Outer Setting, Inner Setting, and Characteristics of Individuals presented barriers to antipsychotic prescribing. Intervention Source, Evidence Strength and Quality, and Adaptability explained participant engagement in the AD intervention; nursing homes that exhibited a Tension for Change and Leadership Engagement reported positive changes in processes and communication.Participants described their experiences with the intervention against the backdrop of a range of factors that influence APM prescribing in nursing homes that exist at the system, facility, provider, and resident levels. In this context, the perceived credibility and flexibility of the intervention were critical features that explained engagement with and potential impact of the intervention. Development of a common language across the team to enable communication was reported as a proximal outcome that may eventually have an effect on APM prescribing rates. Process evaluations may be useful during early stages of evaluation to understand how the intervention is working and how it might work better. Qualitative results suggest the lack of early changes observed in prescribing may reflect the number of upstream factors that need to change for APM rates to decrease.ClinicalTrials.gov, NCT02604056.

Project description:Objective: Determine the accuracy of nursing home self-reported antipsychotic prescribing before and after implementation of a Medicare campaign to reduce use.Methods: Quasi-experimental study comparing trends in self-reported antipsychotic prescribing relative to claims-based prescribing. Setting is a nationwide sample of 11,912 facilities, 2011-2013. Participants are long-stay nursing home residents (n = 586,281) with prescribing data in Medicare Minimum Data Set 3.0 and Medicare Part D claims database. Verified with a pharmacy dispensing database. Main outcomes are the discrepancies in quarterly prevalence of antipsychotic prescribing between nursing home self-reports and claims data and the characteristics of facilities and residents where discrepancies were identified.Results: Nursing homes underreport their antipsychotic prescribing levels, on average, by 1 percentage point per quarter relative to Medicare Part D claims (0.013, 95% confidence interval (CI), 0.012-0.015; p<.001). After the Medicare campaign, the underreporting gap increased by another half a percentage point (0.004, 95% CI .003-.005; p = .012). Nursing home residents with dementia, Alzheimer's disease or bipolar disorders were at the highest risk for underreported antipsychotic prescribing before the campaign (Adjusted Odds ratio (AOR) 1.385, 95% CI: 1.330-1.444; AOR 1.234, 95% CI: 1.172-1.300; AOR 1.574, 95% CI: 1.444-1.716, respectively) and afterwards. After the launch of the Medicare campaign, underreported antipsychotic prescribing occurred most in for-profit nursing homes (AOR 1.088, 95% CI: 1.005-1.178) and facilities in the US South (AOR 1.262, 95% CI: 1.145-1.391). Agreement was high between claims and dispensing data (99.7%).Conclusion: Nursing homes did not identify up to 6,000 residents per calendar quarter as having received antipsychotics despite these prescriptions being paid by Medicare and dispensed by a pharmacy. Nursing home rates of antipsychotic prescribing from self-reported data may be biased.

Project description:BACKGROUND:In Belgium, the debate about the effect of the national academic detailing service (ADS) on prescribing quality in general practice is ongoing. In order to evaluate both the implementation strategies of the ADS and its effectiveness on appropriate prescribing of pain relief medication, we conducted a real-world cluster randomized controlled trial (cRCT). METHODS:In a pragmatic cRCT, all Belgian general practices previously visited by Farmaka were assessed for eligibility and randomized. Only practices randomized to the intervention group were invited for an academic detailing visit on appropriate prescribing of pain relief medication. GPs were unaware of the study, ensuring the production of real-world evidence but were given the option to opt out from the analysis. An objective outcome assessment was obtained using routinely collected reimbursement data. Primary outcomes were the proportion of patients reimbursed for an analgesic or NSAID, the defined daily dose of paracetamol per patient per month, the proportion of patients reimbursed for a recommended NSAID among those reimbursed for any NSAID and the proportion of patients reimbursed for both an NSAID and a proton pump inhibitor among those reimbursed for an NSAID. The impact of practice, GP and academic detailer characteristics were also assessed. RESULTS:Three thousand five hundred twenty-nine general practices (4530 GPs) were eligible and randomized. One thousand six hundred ninety-eight practices (2171 GPs) in the intervention group and one thousand seven hundred three (2163 GPs) in the control group were included in the analysis. The intervention had a significant impact on the proportion of patients reimbursed for a recommended NSAID among those reimbursed for any NSAID (increase in odds (95% CI): 19% (10-29%)). A clear impact on other outcomes could not be detected. Additionally, we showed that the characteristics of the academic detailers might impact the effectiveness of the visit. CONCLUSIONS:National implementation of academic detailing in Belgian general practices provided by Farmaka significantly improved the proportion of recommended NSAIDs prescribed by GPs, but not other outcomes related to appropriate prescribing of pain relief medication. TRIAL REGISTRATION:NCT01761864 . Registered 2 January 2013.

Project description:Antipsychotic medications are routinely prescribed in nursing homes to address the behavioral and psychological symptoms of dementia. Unfortunately, inappropriate prescribing of antipsychotic medications is common and associated with increased morbidity, adverse drug events, and hospitalizations. Multifaceted interventions can achieve a 12-20 % reduction in antipsychotic prescribing levels in nursing homes. Effective interventions have featured educational outreach and ongoing performance feedback.This pragmatic, cluster-randomized control trial and embedded process evaluation seeks to determine the effect of adding academic detailing to audit and feedback on prescribing of antipsychotic medications in nursing homes, compared with audit and feedback alone. Nursing homes within pre-determined regions of Ontario, Canada, are eligible if they express an interest in the intervention. The academic detailing intervention will be delivered by registered health professionals following an intensive training program including relevant clinical issues and techniques to support health professional behavior change. Physicians in both groups will have the opportunity to access confidential reports summarizing their prescribing patterns for antipsychotics in comparison to the local and provincial average. Participating homes will be allocated to one of the two arms of the study (active/full intervention versus standard audit and feedback) in two waves, with a 2:1 allocation ratio. Homes will be randomized after stratifying for geography, baseline antipsychotic prescription rates, and size, to ensure a balance of characteristics. The primary outcome is antipsychotic dispensing in nursing homes, measured 6 months after allocation; secondary outcomes include clinical outcomes and healthcare utilization.Policy-makers and the public have taken note that antipsychotics are used in nursing homes in Ontario far more than other jurisdictions. Academic detailing can be an effective technique to address challenges in appropriate prescribing in nursing homes, but effect sizes vary widely. This opportunistic, policy-driven evaluation, embedded within a government-initiated demonstration project, was designed to ensure policy-makers receive the best evidence possible regarding whether and how to scale up the intervention.ClinicalTrials.gov NLM Identifier: NCT02604056 .

Project description:BackgroundAntipsychotic medication use in nursing homes is associated with potential for harms. In Ontario, Canada, an agency of the provincial government offers nursing home physicians quarterly audit and feedback on their antipsychotic prescribing. We compared the characteristics of physicians who did and did not engage with the intervention, and assessed early changes in prescribing.MethodsThis population-level, retrospective cohort study used linked administrative databases to track prescribing practices in nursing homes pre-intervention (baseline), immediately post-initiative (3 months), and at follow-up (6 months). Exposure variables identified whether a physician signed up to participate (or not) or viewed the feedback following sign up (or not). Differences in the proportion of days that residents received antipsychotic medications at 6 months compared to baseline by exposure(s) were assessed using a linear mixed effects regression analysis to adjust for a range of resident, physician, and nursing home factors. Benzodiazepine and statin prescribing were assessed as a balance and tracer measures, respectively.ResultsOf 944 eligible physicians, 210 (22.3%) signed up to recieve the feedback report and 132 (13.9%) viewed their feedback. Physicians who signed up for feedback were more likely to have graduated from a Canadian medical school, work in urban nursing homes, and care for a larger number of residents. The clinical and functional characteristics of residents were similar across physician exposure groups. At 6 months, antipsychotic prescribing had decreased in all exposure groups. Those who viewed their feedback report had a signicantly greater reduction in antipsychotic prescribing than those who did not sign up (0.94% patient-days exposed; 95% CI 0.35 to 1.54%, p = 0.002). Trends in prescribing patterns across exposure groups for benzodiazepines and statins were not statistically significant.InterpretationAlmost a quarter of eligible physicians engaged early in a voluntary audit and feedback intervention related to antipsychotic prescribing in nursing homes. Those who viewed their feedback achieved a small but statistically significant change in prescribing, equivalent to approximately 14,000 fewer days that nursing home residents received antipsychotic medications over 6 months. This study adds to the literature regarding the role of audit and feedback interventions to improve quality of care.

Project description:IntroductionSocial distancing requirements during COVID-19 pose a challenge to conducting traditional academic detailing, which typically involves in-person peer education visits to improve patient outcomes. The main alternative is to conduct virtual academic detailing delivered through web-based technology, but this approach is fraught with many challenges. This study aimed to examine the feasibility and acceptability of a virtual academic detailing program implemented among health care providers.MethodsThe academic detailing program focused on appropriate opioid prescribing and chronic non-cancer pain management among a sample of providers. An initial in-person visit was followed by a virtual visit up to 8 weeks later. Videoconferencing was used to conduct the virtual visit with telephone as a backup. Feasibility was assessed whether the virtual visits could happen, and acceptability was assessed by provider satisfaction. Validated measures of Provider Satisfaction with Academic Detailing (PSAD) and Detailer Assessment of Visit Effectiveness (DAVE) with a 5-point Likert-type scale were used. Higher scores corresponded to higher satisfaction and greater perceived effectiveness. Non-parametric and parametric statistical tests were used to compare instrument summary scores across visits and between groups. Pairwise analyses across visits only included instrument responses for providers who participated in both visits and completed both surveys in their entirety.ResultsThere were 127 (90 %) initial in-person visits completed out of 141 visits scheduled, with a survey response rate of 96 %. Out of 120 virtual follow-up visits scheduled, 92 (77 %) were conducted, and 56 surveys (61 %) were collected. There was a high level of satisfaction with the initial and follow up virtual academic detailing visits, though, among providers who participated in both visits and had completed surveys (n = 50), initial visits had slightly higher scores (mean difference = -2.94 [95 % Confidence intervals: -4.38, -1.50], p < 0.001). There was no significant difference in detailer perception across the two visits as seen in the scale summary score (0.05 [-0.56, 0.66], p = 0.86) and two individually reported items related to feasibility (0.07 [-0.29, 0.42], p = 0.72) and conversation (-0.05 [-0.28, 0.17], p = 0.63). Forty-one (44.6 %) virtual visits were conducted using WebEx, where video and screen sharing of visit content was possible, while the remaining 51 (55.4 %) were conducted using a telephone. There was no significant difference in provider satisfaction between WebEx vs. telephone visits (-1.47 [-4.99, 2.05], p = 0.82). Provider satisfaction was also not impacted by any technical difficulties as reported by the detailer (-0.04 [-3.30, 3.38], p = 0.98).ConclusionThe results slightly favor in-person visits and suggest that virtual detailing visits need to incorporate strategies that minimize technical difficulties and prevent participants from defaulting to less favorable technology. Future research opportunities include evaluating the effectiveness of a virtual versus in-person delivery of AD program on outcomes such as providers' opioid prescribing behavior.

Project description:ImportanceIn an effort to regulate physician conflicts of interest, some US academic medical centers (AMCs) enacted policies restricting pharmaceutical representative sales visits to physicians (known as detailing) between 2006 and 2012. Little is known about the effect of these policies on physician prescribing.ObjectiveTo analyze the association between detailing policies enacted at AMCs and physician prescribing of actively detailed and not detailed drugs.Design, setting, and participantsThe study used a difference-in-differences multivariable regression analysis to compare changes in prescribing by physicians before and after implementation of detailing policies at AMCs in 5 states (California, Illinois, Massachusetts, Pennsylvania, and New York) that made up the intervention group with changes in prescribing by a matched control group of similar physicians not subject to a detailing policy.ExposuresAcademic medical center implementation of policies regulating pharmaceutical salesperson visits to attending physicians.Main outcomes and measuresThe monthly within-drug class market share of prescriptions written by an individual physician for detailed and nondetailed drugs in 8 drug classes (lipid-lowering drugs, gastroesophageal reflux disease drugs, diabetes drugs, antihypertensive drugs, hypnotic drugs approved for the treatment of insomnia [sleep aids], attention-deficit/hyperactivity disorder drugs, antidepressant drugs, and antipsychotic drugs) comparing the 10- to 36-month period before implementation of the detailing policies with the 12- to 36-month period after implementation, depending on data availability.ResultsThe analysis included 16 121 483 prescriptions written between January 2006 and June 2012 by 2126 attending physicians at the 19 intervention group AMCs and by 24 593 matched control group physicians. The sample mean market share at the physician-drug-month level for detailed and nondetailed drugs prior to enactment of policies was 19.3% and 14.2%, respectively. Exposure to an AMC detailing policy was associated with a decrease in the market share of detailed drugs of 1.67 percentage points (95% CI, -2.18 to -1.18 percentage points; P < .001) and an increase in the market share of nondetailed drugs of 0.84 percentage points (95% CI, 0.54 to 1.14 percentage points; P < .001). Associations were statistically significant for 6 of 8 study drug classes for detailed drugs (lipid-lowering drugs, gastroesophageal reflux disease drugs, antihypertensive drugs, sleep aids, attention-deficit/hyperactivity disorder drugs, and antidepressant drugs) and for 9 of the 19 AMCs that implemented policies. Eleven of the 19 AMCs regulated salesperson gifts to physicians, restricted salesperson access to facilities, and incorporated explicit enforcement mechanisms. For 8 of these 11 AMCs, there was a significant change in prescribing. In contrast, there was a significant change at only 1 of 8 AMCs that did not enact policies in all 3 areas.Conclusions and relevanceImplementation of policies at AMCs that restricted pharmaceutical detailing between 2006 and 2012 was associated with modest but significant reductions in prescribing of detailed drugs across 6 of 8 major drug classes; however, changes were not seen in all of the AMCs that enacted policies.

Dataset Information

Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial.

Publications

Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial.

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