Provider Education

Many systematic reviews have shown that passive dissemination of information, or passive education, is generally ineffective in changing physician practice (20,30). A more important measure, of course, would be to evaluate the impact of physician education on patient health outcomes, but these data are scarce. When education is tailored to change specific behaviors, and tailored to specific providers or situations, this type

Table 3

Important Techniques Used in Academic Detailing

1. Interviewing prescribers to determine baseline knowledge and rationale for current prescribing patterns

2. Targeting specific categories of physicians and their opinion leaders

3. Defining clear educational and behavioral objectives

4. Establishing credibility as an educator by representing a respected organization, referencing quality and unbiased sources of information, and presenting all aspects of a controversial clinical issue

5. Engaging prescriber participation in educational outreach visits

6. Using graphical materials to enhance the educational message

7. Reinforcing the essential educational methods through repetition

8. Using positive reinforcement of improvement in practice patterns on follow-up visits

of intervention is more effective. Interactive educational meetings, where providers participate in workshops that include discussion or demonstration of skills, have been consistently effective (20). In addition, educational outreach visits or academic detailing has been effective, particularly when the visit is conducted by a peer or local opinion leader. To ensure success, academic detailing activities must include several techniques (see Table 3), including assessment of baseline knowledge of each provider, identification of local opinion leaders, and using positive reinforcement of improvements in clinical practice (25).

In an early study, investigators evaluated the effect of three educational methods on antibiotic prescribing in office practices in Tennessee (27). The three educational methods included a mailed brochure, a 15-min visit by a pharmacist (drug educator), and a 15-min visit by a physician counselor. Topics of educational activities were three antibiotics contraindicated for office practice (chloramphenicol, clindamycin, and tetracycline for children < 8 yr old) as a measure of the quality of care, and the use of oral cephalosporins as a measure of the cost of care. Based on their use of the mentioned antibiotics, 372 physicians were selected for the interventions. The mailed brochure had no measurable effect on prescribing, and the pharmacist visit had only a modest effect. The physician visit corresponded with a subsequent 44% reduction in patients receiving contraindicated drugs, and a 21% reduction patients receiving and prescriptions for oral cephalosporins. Therefore, the intervention was effecting in improving the quality of care and reducing the cost of care, particularly when the message was delivered by a peer. Further studies of academic detailing activities have demonstrated a benefit of physician visits and small group education over simple mailing of educational materials (24,38,39).

The advantages of academic detailing programs and education outreach visits include the ability to tailor the discussion to the learners level of understanding and scope of practice. However, programs are very dependent on the peer educator's abilities, as well as the physician's active participation in the discussion. Because most improvement initiatives involve some sort of educational program, the positive aspects of academic detailing programs should be highlighted when possible. More practically speaking, however, the effectiveness of an educational intervention is greatly limited by the size of the population in which the change is desired. When implementing a change in a small group of physicians, the cost and time involved in academic detailing may be worth the investment. However, it is impractical to think that an academic detailing program could be implemented in a large provider group, such as a health maintenance organization or a state health care plan. The cost to send a drug educator (either peer physician or pharmacist) to meet with each provider in the system would be exorbitant, and even if effective, would only affect prescribing of the target clinical question, such as antibiotic prescribing for common infections. Considering the number of target clinical questions that could be subject for improvement, this method becomes even more impractical outside the research environment.

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