An evaluation of educational outreach to improve evidence-based prescribing in Medicaid: a cautionary tale

• Published in: Journal of evaluation in clinical practice 2008-10, Vol.14 (5), p.854-860
• Main Authors: Zillich, Alan J., Ackermann, Ronald T., Stump, Timothy E., Ambuehl, Roberta J., Downs, Steven M., Holmes, Ann M., Katz, Barry, Inui, Thomas S.
• Format: Article
• Language: English
• Subjects: academic detailing; Cardiovascular Diseases - prevention & control; Chi-Square Distribution; Diffusion of Innovation; Drug Prescriptions - statistics & numerical data; Education, Medical, Continuing - organization & administration; educational outreach; Evidence-Based Medicine - education; Female; Guideline Adherence; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors - therapeutic use; Indiana; Logistic Models; Male; Medicaid - organization & administration; medication use; Middle Aged; Multivariate Analysis; Practice Guidelines as Topic; Practice Patterns, Physicians' - organization & administration; prescribing; Primary Health Care - organization & administration; Program Evaluation; Telephone; United States
• ISSN: 1356-1294; 1365-2753
• DOI: 10.1111/j.1365-2753.2008.01035.x

Rationale, aims and objectives  Evidence suggests that educational outreach (‘academic detailing’) improves evidence‐based prescribing. We evaluated the impact of an academic detailing programme intended to increase new statin prescriptions. Methods  In a 2 × 2 factorial design we evaluated the effect of an academic detailing programme with/without telephonic care management for patients. Eligible patients were continuously enrolled Medicaid members at high risk for cardiovascular disease utilization who were not receiving statin medication in the 18 months prior to the intervention. All primary care prescribers assigned to these patients were randomized by clinic to academic detailing. Two trained nurses provided the detailing to prescribers, including specific discussion about the use of statins in this high‐risk patient population. Nurses left the prescribers with a summary of clinical practice guidelines, a one‐page detailing sheet and a list of patients under the care of the prescriber who were candidates for statins. The primary outcome was the incidence of a new statin prescription claim during the 6‐month intervention period and the subsequent 6 months. Logistic regression models were used to estimate main effects of the interventions and to adjust for potential confounding variables in the study. Results  Forty‐eight clinics were randomized, effectively randomizing a total of 284 patients and 128 prescribers. Among the 284 patients, 46 (16%) received a new statin claim during the evaluation period. Controlling for significant bivariate associations, the academic detailing intervention had no significant effect on new statin prescriptions compared with the control group (odds ratio = 0.8, 95% confidence interval: 0.4–1.6, P = 0.5). Conclusion  Among this Medicaid population at high risk for cardiovascular events, an academic detailing programme to increase statin prescriptions was not effective. To assist others to learn from our failed effort, we identify and discuss critical elements in the design and implementation of the programme that could account for these results.