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Cornerstones 1-1.indd

Practice-Based Research Syntheses of Child Find, Referral, Early Identifi cation, and Eligibility Practices and Models Educational Outreach (Academic Detailing) The use of an educational outreach procedure called academic detailing for changing physician pre-scribing practices was the focus of this research synthesis. The practice is characterized by brief, repeated, face-to-face, informal educational outreach visits to physicians by knowledgeable profes-sionals (academic detailers) in physicians’ offi ces or other practice settings to provide information and materials to change prescribing behavior. The synthesis included 38 studies of more than 5,000 physicians and other health-care providers. Results showed that a number of academic-detailing characteristics were most associated with hypothesized or expected changes in prescribing prac-tices. Characteristics include collecting baseline information on physicians’ current prescribing prac-tices, establishing a motivation to change, establishing the credibility of the message and messenger, repeating a highly focused message, and providing positive reinforcement for changes in prescribing practices. Implications for using these practice characteristics for child fi nd are described. professionals (academic detailers) in physicians’ offi ces or other practice settings to provide information and The purpose of this practice-based research materials to change prescribing behavior (Soumerai &
synthesis is to assess the effectiveness of an educational outreach practice called academic This particular educational outreach practice was detailing for changing physician prescribing practices. the focus of this research synthesis because the prac- Academic detailing is a well developed and researched Cornerstones is a publication of the Tracking, Re-
practice that has been widely used to improve physi- ferral and Assessment Center for Excellence (TRACE) cians’ decision-making choices that involve prescribing funded by the U. S. Department of Education, Offi ce of medications, diagnostic tests, medical procedures, treat- Special Education Programs (H324G020002). TRACE is ments, etc. (Benincasa et al., 1996; Daly et al., 1993; an organizational unit of the Center for Improving Com- Ofman et al., 2003; Soumerai & Avorn, 1987; Soumerai munity Linkages at the Orelena Hawks Puckett Institute ( All opinions are the responsibility of et al., 1993). This educational outreach practice is char- TRACE and do not necessarily refl ect the views of the acterized by brief, repeated, face-to-face, informal edu- U.S. Department of Education. Copyright 2005 by the cational outreach visits to physicians by knowledgeable Orelena Hawks Puckett Institute. All rights reserved.
Cornerstones | Volume One | Number One 1 tice holds promise as a child fi nd strategy for increas- 1. conducting interviews to investigate baseline ing physician referrals to IDEA Part C early intervention knowledge and motivations for current pre- programs (Dunst & Trivette, 2004). More specifi cally, we examined the features of academic detailing that 2. focusing programs on specifi c categories of were associated with changes in physician prescribing physicians as well as on their opinion leaders, practices with a focus on those characteristics that could 3. defi ning clear educational and behavioral ob- be used as part of child fi nd to promote physician refer- rals of children with or at risk for disabilities to early 4. establishing credibility through a respected or- intervention programs. Physician outreach is a common ganizational identity, referencing authoritative child fi nd practice (see Dunst & Trivette, 2004), but no and unbiased sources of information, and pre- empirical evidence was found regarding the effective- senting both sides of controversial issues, ness of the ways in which this practice is used by early stimulating active physician participation in intervention program providers. We therefore conducted a review and synthesis of studies in health-care settings 6. using concise graphic educational materials, where an evidence base has been amassed about the ef- 7. highlighting and repeating the essential mes- fectiveness of physician prescribing behavior. (For pur- poses of this synthesis, a physician making a referral for 8. providing positive reinforcement of improved treatment was deemed a prescribing practice.) The synthesis was conducted using a characteristics These characteristics were used to develop the 13 aca- and consequences framework (Dunst, Trivette, & Cut- demic-detailing variables listed in Table 1 and to code spec, 2002) where the focus of analysis was the identi- the studies included in the research synthesis. The fi ve fi cation of those particular characteristics of academic Soumerai and Avorn (1990) characteristics that included detailing that were associated with desired changes in multiple elements (Numbers 1, 2, 6, 7 and 8 in the above prescribing practices. This was accomplished by coding list) were subdivided in order to discern which character- different academic detailing characteristics and relating istics were most important. Additionally, we examined the use of the practice characteristics to variations in fi ve structural variables as possible determinants of the study outcomes and as well examined the infl uence of the type of research design on changes in prescribing Background
For purposes of this synthesis, studies were includ- Academic detailing has its roots in communications ed if the academic-detailing procedure was done face- theory and social marketing (see Smith, 1991; Soume- to-face in physicians’ practices or another health-care or rai & Avorn, 1990). It has been used by pharmaceuti- medical setting (e.g., hospitals). Studies that implement- cal manufacturers for more than 50 years for infl uencing ed and evaluated the practice by mail, telephone, or other physicians’ prescriptions of the manufacturers’ products non-face-to-face methods were excluded (e.g., McPhee, (Caplow, 1952; Hawkins, 1959; Hubbard, 1955). In Bird, Fordham, Rodnick, & Osborn, 1991; Sweet, 1996). 1949, at the point in time where academic detailing was Additional exclusion criteria are described in the Selec- recognized as a profession, the U.S. Department of Labor described an academic detailer as a person who “intro-duces new pharmaceutical products and their methods of Search Strategy
use to physicians, dentists, hospitals, and public-health offi cials, promoting the use of the product rather than Search Terms
selling it” (cited in Hawkins, 1959, p. 215).
An initial search was done using physician outreach, marketing or marketing strategies, and educational out- Description of the Practice
reach as search terms. Once academic detailing was There have been various attempts to defi ne academic identifi ed as the limiting term used for educational out- detailing and describe the key characteristics of the prac- reach to physicians, the search for relevant studies was tice (e.g., Allen, 2004; Dietrich et al., 1992; Klein, 1983; done using different variations of academic detailing (ac- Pathak, 1983). Stephen Soumerai and his colleagues by ademic detail,* academic and detail*) as search terms. far have been the leaders in attempting to disentangle, unpack, and identify the principles and components of The following databases were searched for relevant the practice (e.g., Soumerai, 1998; Soumerai & Avorn, studies: Psychological Abstracts online (PsycINFO), 1990). According to Soumerai and Avorn (1990), aca- Social Sciences Citation Index, Educational Resources Information Center (ERIC), MEDLINE, Cumulative In- 2 Cornerstones | Volume One | Number One dex to Nursing and Allied Health Literature (CINAHL), in the experimental or intervention groups and 2,435 in Health Source: Nursing/Academic Edition, The Co- the control or comparison groups. The number of partici- chrane Library, Academic Search Elite, Dissertation pants in two studies (Avorn et al., 1992; Landgren et al., Abstracts International, OCLC PapersFirst, ABI Inform 1988) were not reported (see footnote b in Table 2 for an (ProQuest), Ingenta, Business Source Elite, and World- Cat. Hand searches were conducted of relevant review The majority of participants were physicians (86%). articles, book chapters, books, and a Cochrane review The remaining participants were nurse practitioners (O’Brien et al., 2001) to locate additional studies. In ad- (5%), residents (5%), physician assistants (2%), and in- dition, the reference lists of the studies identifi ed through the above searches were also examined.
Participant ages were reported in only six studies and averaged between 38 and 51 years. Years of experi- Selection Criteria
ence of the study participants was reported in only four Studies were included if at least three of the eight studies and averaged between 13 and 40 years. In the 11 Soumerai and Avorn (1990) academic detailing char- studies that reported the gender of the study participants, acteristics were described, mentioned, or could be dis- cerned, and Cohen’s d effect sizes (Dunst, Hamby, & Trivette, 2004) could be calculated for pretest/posttest Settings
or experimental vs. comparison group differences. In a The academic-detailing interventions were imple- number of instances, the data presented in the research mented in physicians’ practices (61%), HMOs, MCOs, reports were reanalyzed to produce fi ndings that were di- or clinics (21%), hospitals (13%), or nursing homes rectly comparable across studies. In so doing, there were (5%). In all cases, the interventions were implemented cases where the study investigators reported positive on a face-to-face basis with an individual study partici- fi ndings but our analyses found small effects. In other pant (76%) or with a small group of participants all prac- cases, study investigators reported no signifi cant results but our analyses found large effect sizes.
Studies were excluded from the synthesis if too Academic Detailers
few academic-detailing characteristics could be dis- The 38 studies employed 48 individuals as interven- cerned (e.g, Kim et al., 1999; van Eijk, Avorn, Porsius, tionists. The persons implementing the academic-detail- & de Boer, 2001; Zwar, Wolk, Gordon, & Sanson-Fisher, ing interventions were mostly physicians (41%) or phar- 2000), the outcomes in a study did not include a measure macists (41%) (Table 3). In eight instances (16%), the of physician prescribing behavior (e.g., Gorin et al., 2000; profesional backgrounds of the academic detailers were Hearnshaw, Khunti, & Robertson, 2000; Ross-Degnan et al., 1996), the intervention was not done on a one-on-one or small group basis (e.g., Bernal-Delgado, Galeote- Research Designs
Mayor, Pradas-Arnal, & Peiro-Moreno, 2002; Ferguson Table 3 shows the research designs used by the in- et al., 2003; Mahloch, Taylor, Taplin, & Urban, 1993), vestigators and the types of analyses performed on the the intervention was called academic detailing but the data. The majority of the investigations were random- description of practice did not match the academic-de- ized clinical trials (60%) or other types of controlled trial tailing characteristics in Table 1 (e.g., Blackstien-Hirsch, studies (29%). The remaining four studies (10%) used Anderson, Cicutto, McIvor, & Norton, 2000; Markey & Schattner, 2001; McCormick et al., 1999) or effect sizes In the largest number of cases, the investigators col- could not be calculated from the data included in the re- lected both pretest and posttest measures of physician search reports (e.g., Benincasa et al., 1996; Daly et al., prescribing behavior or practices (84%). In six studies (16%), only posttest data were collected.
Search Results

The 38 studies included nine different types of pre- Thirty eight (38) studies met the inclusion criteria scribing practices (see Table 3). In most of the studies for the synthesis. Table 2 shows selected characteristics (60%), the outcome was a change in prescribing some of the study participants and the settings where the edu- type of drug or medication. Prescribing patient treat- ments (18%) or diagnostic tests or screenings (18%) were the second most frequent outcomes. In two studies Participants
(5%), referrals to other professionals or programs were The 38 studies included 5,102 participants, 2,667 Cornerstones | Volume One | Number One 3 The outcomes were considered either targeted tors may have conducted pretest/posttest differences for (26%) or nontargeted (74%). Outcomes were considered the experimental and comparison groups separately. In targeted if hypothesized or expected change in prescrib- the majority of studies (79%) we were able to compute ing practices was focused and precise (e.g., decreasing the posttest difference effect sizes.
the use of the antibiotic tetracycline for treating respira- Ninety three (93) effect sizes were computed from tory infections). Outcomes were considered nontargeted the fi ndings in the 38 studies. Effect sizes were calculat- if the hypothesized or expected changes in prescribing ed only on outcomes that were hypothesized or expected practices included both increases and decreases of two to change as a result of the interventions. In all cases, or more prescribing behaviors (e.g., increasing prescrip- these included the prescribing practices of the study tions for beta-blockers and decreasing prescriptions for participants. Effect sizes were not computed on study ace-inhibitors) or included two or more conditions con- participants’ nonprescribing practices (e.g., physician stituting the focus of intervention (e.g., decreasing pre- requests for information), patient outcomes (e.g., blood scriptions for treating hypertension or depression). pressure), or for prescriptions that were not the targets of The sources of the outcome data were either the the interventions. In a number of studies, the investiga- direct observation or measurement of the study partici- tors reported results for individual prescriptions and for pants’ prescribing practices (50%) or changes in pre- all prescriptions combined. The latter were not included scription counts or rates found in databases including the in our analyses to reduce confounds associated with du- physicians’ prescriptions (50%). Direct observation or measurement included, for example, the number of times Table 5 summarizes the expected and observed ef- a physician in a study prescribed or did not prescribe a fects in the 38 studies. The table includes the targets of targeted drug. Indirect outcome measures included, for the study participants prescribing practices, the outcome example, average daily doses of prescriptions from an measures constituting the focus of investigation, the hypothesized or expected increase or decrease in pre-scriptions, and the effect sizes for the pretest/posttest or Interventions
posttest group differences. The effect size signs show the Table 4 shows the particular academic-detailing direction of effect of the independent variables on the characteristics that were part of the interventions con- dependent variables (e.g., if there was a hypothesized stituting the focus of investigation. The presence of each decrease in prescriptions and this was found, the result is characteristic was discerned by descriptions included in the research reports and checked by two or more of the authors of this synthesis. Individual studies included an shown in Table 6. Because the posttest comparison average of 5.60 characteristics (SD = 2.29, Range = 3 to group studies produced more effect sizes, they are used 13). The use of an opinion leader to implement the inter- as the principle fi ndings for interpretative purposes. The ventions was used in the fewest studies (11%), and the academic-detailing characteristics are ordered (for the provision of concise educational materials to the study posttest group difference analyses) from the largest to participants was done in the majority of studies (89%).
smallest average size of effect. The confi dence intervals The interventions themselves occurred during a sin- (CI) for the effect sizes are also included and provide a gle session (45%) or had one or more follow-up contacts basis for ascertaining the relative importance of the aca- (55%). The number of follow-up contacts ranged from demic-detailing characteristics and structural variables. as few as one or two (47%) to as many as four or fi ve (For interpretative purposes, if the lower bound is at least .25, then the true effect may be considered at least this large.) Synthesis Findings
Academic Detailing
The relationship between both the academic-detail- All of the academic-detailing characteristics, except ing characteristics (Tables 1 and 4) and the study struc- the use of an opinion leader as an interventionist, have tural variables (Tables 1) and the study participant pre- average effect sizes greater than .25 for the pretest/post- scribing practices (Table 3) was ascertained by calculat- test comparisons. Seven characteristics emerged as rela- ing effect sizes for either pretest/posttest differences or tively more important as evidenced by lower bound con- posttest differences between the experimental/interven- fi dence levels being about .25 or larger. These charac- tion groups and control/comparison groups (Dunst et al., teristics are collecting baseline prescribing information, 2004). In the latter studies, information available in the establishing credibility, repeating the intended message, research reports was used to calculate the posttest differ- providing positive reinforcement, establishing a motiva- ences between groups even though the study investiga- tion to change, having clear intervention objectives, and 4 Cornerstones | Volume One | Number One using concise educational materials for reinforcing the with relatively small differences for the within variable intended change or desire to change.
contrasts. These results indicate that where, who, and A comparison of the average effect sizes from the how academic detailing is done matters less than what is two different types of analyses (posttest vs. pretest/post- test) shows, with a few exceptions, similar results. Al- In contrast to the fi ndings for the practice-related though the magnitude of effect is generally smaller for structural variables, both outcome-related variables were pretest/posttest studies compared to the posttest group associated with differences in the average effect sizes comparison studies. The exception is the single study where the patterns were identical for both types of analy- that yielded an average effect size of .82 for three aca- ses. Measuring the prescribing practices of the study par- demic-detailing characteristics, which should be inter- ticipants directly produced an average effect size almost preted with caution. The fi ndings taken together indicate twice as large as when the effects of the interventions that a combination of academic-detailing characteristics were discerned using indirect or unobtrusive measures. are associated with desired changes in prescribing prac- This was expected because the use of a larger database as a source of outcome data includes prescriptions of physi- Exploratory cluster and factor analyses were per- cians who were not participants in the studies.
formed on the use/nonuse of the academic-detailing fi ndings for the targeted vs. nontargeted out- characteristics (Table 4) to discern if there were unique comes were unexpected inasmuch as one would predict combinations of practice characteristics. The cluster and a larger size of effect for prescriptions that were specifi - factor analyses were done for all 38 studies combined cally the focus of behavior change. The results suggest and for the pretest/posttest and the experimental vs. com- that the effects of the interventions were broader based parison group studies separately. A consistent pattern of fi ndings emerged (regardless of type of analysis or set of data) showing there were four clusters or groupings of Conclusion
Building rapport and credibility by establishing Findings from this practice-based research synthe- physician baseline knowledge, ascertaining the sis indicate that most of the academic detailing charac- motivation to change prescribing practices, and teristics constituting the focus of analysis are associated establishing credibility and delivering a cred- with expected or hypothesized changes in the study par- ticipants’ prescribing behavior and that a combination • Fostering change by establishing specifi c behav- of the practice characteristics best represented the key ioral objectives, highlighting and repeating the features and components of the practice. Results also reason(s) why a change in prescribing practices show that the practice-related structural variables con- is warranted, actively involving the physicians stituting the focus of analysis were not confounds and in the change process, and reinforcing the phy- that academic detailing is similarly effective regardless sicians for changing their practices.
of setting, interventionist, or the type of intervention • Using explanatory materials by using concise and (see Table 6). Moreover, the patterns of fi ndings of the graphic written materials for describing and ex- structural variable analyses are nearly the same for the plaining the benefi ts of changing prescribing posttest group comparison and pretest/posttest studies. Results from this practice-based research synthesis are • Maintaining change by making repeated follow- similar to those reported elsewhere (e.g., Davis, Thom- up visits to answer questions, reinforcing be- son, Oxman, & Haynes, 1995; Smith, 2000).
havior change, and providing additional infor-mation.
Implications for Practice
The reader is referred to Moser, Dorsch, and Kellerman The educational outreach practice constituting the (2004) for a similar categorization of academic-detailing focus of this Cornerstones was targeted for review and synthesis because it holds promise as a child fi nd strat-egy for increasing physician referrals of infants and tod- Structural Variables
dlers with disabilities or at risk for developmental delays The structural variables constituting the focus of to early intervention programs. The current landscape of analysis included three practice-related factors (setting, health-care practices makes it very diffi cult for physi- academic detailer, and type of session) and two out- cians to take time out of their busy schedules to attend come-related factors (type and source of outcome data). training sessions promoting their understanding of early All three practice-related factors have average effect intervention and the benefi ts to their patients and them- sizes of .27 or higher for the posttest comparison studies selves. Because of its brief and highly focused emphasis Cornerstones | Volume One | Number One 5 on communicating a credible message, features of aca- & Fields, D. (1992). A randomized trial of a pro- demic detailing would seem especially useful for im- gram to reduce the use of psychoactive drugs in proving the effectiveness of child fi nd.
nursing homes. New England Journal of Medicine, Physician outreach is a commonly used strategy for promoting referrals to early intervention (Dunst & Baran, R. W., Duchane, J., Parker, L., Cornwell, S., Trivette, 2004). The extent to which outreach to phy- Franic, D., & Erwin, W. G. (1996). Effectiveness sicians is likely to be effective can be strengthened by of academic detailing in the managed care envi- considering key characteristics of academic detailing as ronment: Improving prescribing of lipid-lowering part of planning and implementing child fi nd activities. agents. Journal of Managed Care Pharmacy, 2, The use of academic detailing as a child fi nd strategy in- dicates a need to include a reason (motivation) for mak- Benincasa, T. A., King, E. S., Rimer, B. K., Bloom, H. ing a referral (prescription) to early intervention with an S., Balshem, A., James, J., & Engstrom, P. F. (1996). explicit focus (message) on the benefi ts to a physician Results of an offi ce-based training program in clini- and his or her patients. The message needs to be clear, cal breast examination for primary care physicians. concise, and credible, as well as highly focused. Estab- Journal of Cancer Education, 11, 25-31. lishing the credibility of the message and messenger is Bernal-Delgado, E., Galeote-Mayor, M., Pradas-Arnal, accomplished by reference to relevant and respected F., & Peiro-Moreno, S. (2002). Evidence based edu- sources (e.g., the American Academy of Pediatrics for cational outreach visits: Effects on prescriptions of pediatricians and the American Academy of Family non-steroidal anti-infl ammatory drugs. Journal of Physicians for family physicians). The message needs Epidemiology & Community Health, 56, 653-658. to be communicated orally during visits to physicians’ Blackstien-Hirsch, P., Anderson, G., Cicutto, L., McIvor, practices, reinforced using concise and graphic written A., & Norton, P. (2000). Implementing continuing materials (e.g., brochures) left with the physicians, and education strategies for family physicians to en- repeated during regularly scheduled follow-up visits to hance asthma patients’ quality of life. Journal of the physicians offi ces. To be maximally effective, con- sistent, relevant, and timely feedback needs to be pro- Brown, J. B., Shye, D., McFarland, B. H., Nichols, G. vided to maintain physician referrals (Smith, 2000).
A., Mullooly, J. P., & Johnson, R. E. (2000). Con- Findings from this practice-based research synthe- trolled trials of CQI and academic detailing to im- sis are being used to develop practice guidelines that plement a clinical practice guideline for depression. describe the process and procedures for using academic- Joint Commission Journal on Quality Improvement, detailing characteristics for improving child fi nd. The reader is referred to a nontechnical summary of this Caplow, T. (1952). Market attitudes: A research report synthesis (Endpoints, Volume 1, Number 1) for a brief from the medical fi eld. Harvard Business Review, description of the practice guidelines. Interested readers should see especially Cutts and LaCaze (2003) for a de- Cockburn, J., Ruth, D., Silagy, C., Dobbin, M., Reid, Y., scription of the principles, benefi ts, and application of Scollo, M., & Naccarella, L. (1992). Randomised trial of three approaches for marketing smoking ces-sation programmes to Australian general practitio- References
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M., Stanton, L. A., Bergin, J. K., & Chap- outreach service for community medical practitio- man, G. A. (1997). Improving the prescribing of an- ners: Non-steroidal anti-infl ammatory drugs. Medi- tibiotics for urinary tract infection. Journal of Clini- cal Journal of Australia, 170, 471-474. cal Pharmacy and Therapeutics, 22, 147-153. McConnell, T. S., Cushing, A. H., Bankhurst, A. D., Peterson, G. M., & Sugden, J. E. (1995). Educational Healy, J. L., McIlvenna, P. A., & Skipper, B. J. (1982). program to improve the dosage prescribing of allo- Physician behavior modifi cation using claims data: purinol. Medical Jounal of Australia, 162, 74-77. Tetracycline for upper respiratory infection. Western Raisch, D. W., Bootman, J. L., Larson, L. N., & McGhan, Journal of Medicine, 137, 448-450. W. F. (1990). Improving antiulcer agent prescribing McCormick, R., Adams, P., Powell, A., Bunbury, D., Pa- in a health maintenance organization. American ton-Simpson, G., & McAvoy, B. (1999). 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The RAFT approach to academic detailing with precep- Reeve, J. F., Peterson, G. M., Rumble, R. H., & Jaffrey, tors. Family Medicine, 36, 316-318. R. (1999). Programme to improve the use of drugs Newton-Syms, F. A. O., Dawson, P. H., Cooke, J., Feely, in older people and involve general practitioners in M., Booth, T. G., Jerwood, D., & Calvert, R. T. community education. Journal of Clinical Pharma- (1992). The infl uence of an academic representa- cy and Therapeutics, 24, 289-297. tive on prescribing by general practitioners. British Ross-Degnan, D., Soumerai, S. B., Goel, P. K., Bates, J., Journal of Clinical Pharmacology, 33, 69-73. Makhulo, J., Dondi, N., Sutoto, Adi, D., Ferraz-Tabor, Nilsson, G., Hjemdahl, P., Hassler, A., Vitols, S., Wallen, L., & Hogan, R. (1996). The impact of face-to-face N. H., & Krakau, I. (2001). Feedback on prescribing educational outreach on diarrhoea treatment in phar- rate combined with problem-oriented pharmaco- macies. Health Policy and Planning, 11, 308-318. therapy education as a model to improve prescribing Schaffner, W. (1983). Improving antibiotic prescribing behaviour among general practitioners. European in offi ce practice. Journal of the American Medical Journal of Clinical Pharmacology, 56, 843-848. O’Brien, M. A. T., Oxman, A. D., Davis, D. A., Haynes, R. Schroy, P. C., Heeren, T., Bliss, C. M., Jr., Pincus, J., B., Freemantle, N., & Harvey, E. L. (2001). Infl uence Wilson, S., & Prout, M. (1999). Implementation of of educational outreach visits on behavioral change in on-site screening sigmoidoscopy positively infl u- health professionals (Cochrane Review). Cochrane ences utilization by primary care providers. Gastro- Library, Issue 4. Oxford: Update Software. 8 Cornerstones | Volume One | Number One Smith, M. C. (1991). Pharmaceutical marketing: Strategy gram directed at physicians treating congestive and cases. New York: Pharmaceutical Products Press. heart failure [Electronic version]. American Journal Smith, W. R. (2000). Evidence for the effectiveness of of Health-System Pharmacy, 57, 747-752. techniques to change physician behavior. Chest, van Eijk, M. E., Avorn, J., Porsius, A. J., & de Boer, A. (2001). Reducing prescribing of highly anticholin- Solomon, D. H., Van Houten, L., Glynn, R. J., Baden, L., ergic antidepressants for elderly people: randomised Curtis, K., Schrager, H., & Avorn, J. (2001). Aca- trial of group versus individual academic detailing. demic detailing to improve use of broad-spectrum British Medical Journal, 322, 654-657. antibiotics at an academic medical center. Archives Watson, M., Gunnell, D., Peters, T., Brookes, S., & of Internal Medicine, 161, 1897-1902. Sharp, D. (2001). Guidelines and educational out- Soumerai, S. B. (1998). Principles and uses of academic reach visits from community pharmacists to im- detailing to improve the management of psychiat- prove prescribing in general practice: A randomised ric disorders. International Journal of Psychiatry in controlled trial. Journal of Health Services Research Soumerai, S. B., & Avorn, J. (1987). Predictors of phy- Young, J. M., D’Este, C., & Ward, J. E. (2002). Improv- sician prescribing change in an educational experi- ing family physicians’ use of evidence-based smok- ment to improve medication use. Medical Care, 25, ing cessation strategies: A cluster randomization trial. Preventive Medicine, 35, 572-583. Soumerai, S. B., & Avorn, J. (1990). Principles of edu- Zwar, N. A., Wolk, J., Gordon, J. J., & Sanson-Fisher, R. cational outreach (‘academic detailing’) to improve W. (2000). Benzodiazepine prescribing by GP reg- clinical decision making. Journal of the American istrars: A trial of educational outreach. Australian Medical Association, 263, 549-556. Soumerai, S. B., Salem-Schatz, S., Avorn, J., Casteris, C. S., Ross-Degnan, D., & Popovsky, M. A. (1993). A controlled trial of educational outreach to improve blood transfusion practice. Journal of the American Patricia W. Clow, M.P.H., R.D., is a Research As-
Medical Association, 270, 961-966. sociate at the Tracking, Referral, and Assessment Center Stevens, S. A., Cockburn, J., Hirst, S., & Jolley, D. for Excellence (TRACE) of the Orelena Hawks Puckett (1997). An evaluation of educational outreach to Institute in Asheville, North Carolina (pclow@puckett.
general practitioners as part of a statewide cervi- org). Carl J. Dunst, Ph.D., is Co-Principal Investigator
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Sweet, B. (1996). Academic detailing: Methods and suc- Trivette, Ph.D., is Co-Principal Investigator at TRACE
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Turner, C. J., Parfrey, P., Ryan, K., Miller, R., & Brown, by, M.P.H., is a Research Analyst at the Orelena Hawks
A. (2000). Community pharmacist outreach pro- Puckett Institute, Morganton (
Cornerstones | Volume One | Number One 9 Table 1 Characteristics and Variables Coded for Each Study Included in the Synthesis Collect baseline information about the physicians’ knowledge influencing current practices. Explicit effort made to identify physicians’ motives for the practice targeted for change. Intervention targets specific category of physicians. Use an opinion leader to introduce the targeted prescribing practice. Opinion leader conducts the academic-detailing session(s). Clear behavioral objectives are established for changing physician prescribing practices. Establish credibility for targeted practice change with reference to respected and Physicians are actively involved in the “change process.” Concise written materials about the targeted practice are used to increase knowledge. Graphic materials include explicit description of practice benefits. Intervention highlights and repeats a focused message. Physicians are reinforced for their responsiveness and willingness to change their Academic detailer makes follow up visit to reinforce message delivered during initial One-on-one or a group of physicians in the same practice Physician practice (including HMOs, MCOs, clinics) vs. hospital or nursing home Individual physicians prescribing vs. data in a larger database Pretest/posttest or experimental vs. comparison group a Developed based on descriptions in Soumerai and Avorn (1990). 10 Cornerstones | Volume One | Number One Table 2 Selected Characteristics of Study Participants Cornerstones | Volume One | Number One 11 aType of setting: HMO = health maintenance organization, MCO = managed care organization, Practice = private or group practice, Clinic = health-care center or county clinic. bIndividual number of physicians receiving academic detailing intervention is not reported. Numbers are for cNumber of participants in the experimental and control groups is not reported. Numbers are estimates of indi- dMedian age of participant reported. eNR = Not reported. 12 Cornerstones | Volume One | Number One Table 3 Research Designs and Outcome Measures Used in the Studies follow-up care for patients with depression Number of physicians report- Use of smoking cessation Drugs prescribed Prescribing antibiotics New diagnoses of depression Diagnosis of depression Cornerstones | Volume One | Number One 13 Peterson & Sugden (1995) Controlled trial Pre Post Prescribing of non-steroidal anti-inflammatory drugs and paracetamol Prescribing of antibiotics for urinary tract infection drugs, non-steroidal anti-inflammatory drugs, procholorperazines Avorn & Soumerai (1983) ontrolled trial 14 Cornerstones | Volume One | Number One Table 4 Characteristics of Academic Detailing Constituting the Focus of Intervention Cornerstones | Volume One | Number One 15 Table 5 Outcome Measures and Major Findings of the Studies Lipid lowering drugs (overall prescribing rate) Medication for treatment of depression (average daily dose) Screening for (DES) cancer risk (double intervention) Screening for (DES) cancer risk (single intervention) Patient care following hypertension guidelines Use of guidelines to treat patients with aspirin as anti-platelet Use of guidelines to treat patients with NSAIDs for pain Overall - patient treated according to guidelines Patient treated according to guidelines (small practices) Patient treated according to guidelines (large practices) Physicians requests excessive alcohol use screening kit: Academic detailing vs. mail/phone intervention Physicians uses >1 AUDIT kit: Academic detailing 16 Cornerstones | Volume One | Number One Adequate antidepressant drug intervention: Heliocobacter testing for ulcer diagnosis Drugs for gout and kidney stones treatment Number of patients with long term diazepam use Total number of patients with antipsychotics Cornerstones | Volume One | Number One 17 Compliance with guidelines for sigmoidoscopy Average number of days of unnecessary antibiotics Antibiotic (cephalexin), Vasodialators, and pain management drug propoxyphene (darvon) (prescribing of Transfusions ordered compliant with guidelines Transfusions ordered non-compliant with guidelines ACE inhibitors per guidelines for heart failure Smoking patients’ medical records document Patients medical records indicate physician a SMA-12 = Sequential Multiple Analysis lab test panel for 12 measures used to screen patients. b SMA-6 = Sequential Multiple Analysis lab test panel for 6 measures used to monitor patients. c CBC = Complete blood count test. 18 Cornerstones | Volume One | Number One Table 6 Average Effect Sizes for the Academic-Detailing Characteristics and Structural Variables Constituting the Focus of Analysis Cornerstones | Volume One | Number One 19



Tout cela n’a pas échappé aux colons blancs. Eux aussi se servent de l’échinacée, contre lasyphilis notamment, selon un texte datant dumilieu du XIXe siècle. Une trentaine d’années L ’ é c h i n a c é e plus tard, aux alentours de 1880, un immigréallemand établi dans l’Ohio, H.C.F. Meyer, entire un médicament qu’il préconise contre lesmaux de tête, les névralgies,

C l i n i c a l C a r e / E d u c a t i o n / N u t r i t i o n / P s y c h o s o c i a l R e s e a r c h O R I G I N A L Relationships Between Daily Acute Glucose Fluctuations and Cognitive Performance Among Aged Type 2 Diabetic Patients ARIA ROSARIA RIZZO, MD, PHD FRANCESCO VESTINI, MD AFFAELE MARFELLA, MD, PHD BIAGIO LETTIERI, MD tions is still difficult. Considering that t

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