(2003; 158 pages)
Chapter 13: Experiences with professional education
1. Why do we need to influence demand?
Health care systems, regardless of how they are funded, are cost constrained. Therefore, to maintain equity it is important that physicians extract the maximum health gain possible for their responsible population from the resources available to them. It can be argued that this is as much an ethical responsibility as a means of obeying Hippocrates’ injunction cost effectiveness for drugs is that physicians should understand and act upon the published evidence base for the medicines they prescribe. The first stage of Continuing Medical Education (CME) is critical appraisal of the literature to establish the evidence base for the teaching which is to be offered, after which the relevant information will have to be made available, regardless of how it is delivered (see Chapter 3). It is possible to obtain relevant evidence, even in countries with limited capacity, since initiatives such as the Cochrane Collaboration conduct systematic reviews to establish the evidence base around specific medical issues: their findings are available internationally. In this chapter different approaches are described to implementing in practice the principles emerging from such evidence.
2. Implementing proven principles
Having established the evidence, the role of CME is to persuade prescribers to change their practice; although change is always happening, its deliberate inducement is usually slow and labourious . Doctors are like any other group of people when responding to new ideas [11,24]; the idea is initially taken up by a few innovators and then spreads slowly to include early adopters who are respected by their peers. The rate of uptake then increases as the majority take up the idea, only to slow again as the process reaches the final group, the laggards, who are slow to change and cling to traditional values . Several approaches have been tried, as described in general in Chapter 3. In this chapter the key features, strengths and weaknesses of the various initiatives are discussed.
3. Postgraduate lectures and conferences
Lectures provided through post graduate centres or universities are voluntary; they therefore attract only those who are motivated and interested: if we look again at the model proposed by Horder , these doctors would tend to be the “innovators” or “early adopters” who form the minority of primary care doctors. As primary care doctors work in geographically distant locations, the opportunities for the innovators and early adopters to network and share ideas are limited, and any diffusion of new practice is limited. It is not surprising then, that lectures or short conferences generally produce no change; in the six studies reviewed by Davis, all the teaching provided was found to have inconclusive or even negative effects .
4. Educational outreach and academic detailing
Since doctors do not all regularly attend postgraduate training centres to keep up to date with advances in medicine, it makes sense to take the education out to them in their own practices. Mailings of written information have been shown to be ineffective , so direct communication is the only alternative. This is the principle underlying educational outreach - put simply, it uses the same techniques that the pharmaceutical industry has used for so many years in employing medical representatives to visit doctors and persuade them to use their company’s products. control trial of educational outreach by using clinical pharmacists to undertake “academic detailing” of Medicaid physicians across four states in America . The pharmacists were trained in communication and influencing skills as well as being given the necessary clinical knowledge, and then made two brief visits to the physicians to discuss inappropriate prescribing of cerebral vasodilators, cephalexin and propoxyphene. They supplemented their discussions with specifically designed support materials summarising the key points in an eye catching and memorable style, with key references provided to underline the messages regarding prescribing change. The visits reduced inappropriate prescribing by 14% and were a significant improvement on merely mailing the support materials to physicians without making a visit. A formal economic analysis of the results indicated that an operational scale programme would produce savings two to three times greater than the costs of mounting such a programme, and this excluded the extra benefit of reduced health care costs from improvements in the quality of care .
A follow up study showed that physician characteristics such as age and speciality did not affect their response to the educational intervention; a second reinforcement visit substantially increased compliance with prescribing recommendations . The most important techniques and principles for academic detailing were described in a later review . These are summarised in Table 1.
As the majority of prescribing is in the community, educational outreach programmes tend to be in primary care, although academic detailing has been successfully used in a teaching hospital setting to reduce the incorrect use of antibiotics , and in nursing homes to reduce the use of psychoactive drugs . Since the original American trial, academic detailing has been piloted in many countries with widely varying health care systems; in some countries it has been institutionalised and become part of the routine health service, though in others some of the basic principles have been lost in the process.
Key principles of academic detailing
- Conduct interviews to investigate baseline knowledge and motivations for current prescribing patterns
- Focus programmes on specific categories of physicians as well as on their opinion leaders
- Define clear educational and behavioural objectives
- Establish credibility by having a respected independent organisational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues
- Stimulate active physician participation in educational interactions
- Use concise graphic educational materials highlighting and repeating the essential messages
- Provide positive reinforcement of improved practices in follow-up visits
The fist UK trial employed a single academic detailer to make a single visit in order to advise general practitioners on the choice of non-steroidal anti-inflammatory drugs . Like the Avorn trial, the “detailer” was a clinical pharmacist who received training in special communication skills, and who used specifically designed support materials to support the message: in order to give the project an independent identity, it was identified by the acronym “PRIDE”. The message and the evaluation were very much cost focussed.
Not long after the PRIDE trial was completed, the UK health service set up a network of prescribing advisers; initially the majority were doctors, but within a couple of years pharmacists had become the dominant prescribing advisers. There is usually at least one full time prescribing adviser per health economy, covering on average 20 primary care general practices. Resource constraints have mitigated against these advisers fully exploiting the principles of academic detailing; few of the advisers have for example received formal training in communication and influencing skills; clinical updates are provided by the National Prescribing Centre, but the key messages are not standardised and there are no specially designed materials to support advisers during their visits. Given the number of practices they have to visit, as well as other tasks within the health authority, advisers rarely visit doctors more than once a year, and often less frequently. Since previous studies have shown that repeat visits are most effective to produce a change, advisers need further support if they are to fulfil their objectives of encouraging appropriate cost effective prescribing by the general practitioners in the area they cover.
Several different models have been tried. That which is most rooted in the principles of academic detailing is the IMPACT project . The model is based on the one proposed by Avorn and Soumerai, but is modified to make it more easily replicated. Teams of community pharmacists are employed on a sessional basis, covering about twenty practices each rather than using a full time clinical pharmacist to cover all practices. This has several advantages; the community pharmacists are familiar with general practitioner prescribing patterns and see the same community of patients and so are more empathetic with family doctors attitudes to prescribing. As they are paid per visit made, they are focussed on the task and there is less possibility of the “job drift” that can happen with full time advisers. Data is used to generate “target matrices and prioritise visits, and the pharmacists are supported by a mentoring system and regular update programmes to hone both clinical and influencing skills.
The pharmacists receive an initial three-day training programme focussed on influencing skills and using role-plays to reinforce the clinical messages. Once trained, they receive a two-day update course when a new programme starts - on average every four months. Support materials to help structure the interview and reinforce the messages support each programme. A page from a typical brochure is shown in Fig. 1. All materials also have the key references attributed.
5. Practice based audit and feedback
If access to patient records is possible, and there is a sufficient pool of suitably trained auditors, practice based audit and feedback can produce a lasting change [29,31,32]. The success and effectiveness of audit and feedback are variable, and initiatives may falter when it comes to implementing the change suggested by the audit . Like academic detailing, the first stage is to establish the potential for change from baseline prescribing habits; again, it is important to place the emphasis on the quality of prescribing and allow cost reductions to follow. Considerable changes and substantive savings can be realized from revising and refining practice repeat prescribing systems - it has been estimated that 80% of drug costs are from repeat prescriptions. Doctors initially had reservations about community pharmacists being involved with repeat prescribing but over time they have come to agree with the concept.
Fig. 1. An example of an Impact detail aid.
Medication reviews can be conducted by either community or clinical pharmacists or clinical pharmacologist depending on local circumstances, but both need further training. Community pharmacists need their clinical knowledge updating and must learn how to read case notes, whereas clinical pharmacists and pharmacologists need to become familiar with the structure and processes of primary care general practice.
Having identified patients with the potential for change, the pharmacist produces an action list for the prescriber. At this point either the doctor follows up the patients concerned and writes to them inviting them for a medication review, or the pharmacist facilitates this on behalf of the prescriber. Occasionally, such a pharmacist has also held advisory clinics to explain the medication change to the patient. One model used a clinical pharmacologist to support the pharmacist, but this was not possible to replicate in the UK due to the high costs and the limited number of clinical pharmacologists available to undertake this work. In The Netherlands, small groups of GPs discuss their individual prescription profiles together with the local community pharmacist and agree on first-choice treatment options. Once patients have had the medication change explained to them, the majority prove to be comfortable with the change, trusting the doctor’s opinion. Thus changes can be which both the prescribers and their patients are comfortable. Practice based work is resource intensive, so it is best targeted at those practices with greatest potential for change; it can achieve remarkable synergy if used in conjunction with educational outreach.
In summary, while traditional methods of continuing medical education do not produce change in prescriber behaviour, well designed methods specifically designed to influence prescribing in a favourable manner have been proven to do so. Such a form of continuing education is critical if prescribing practices are to be kept up to date and evidence based The first stage of implementing change is to evaluate all evidence. Thereafter one should make use of practice based pharmacist facilitators; given specialised training they can be effective agents for change. Subsequent training of medical and pharmacy undergraduates should include critical appraisal skills. The most successful change strategies use several approaches to achieve their aim.
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