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

Authors

  • Alan J. Zillich PharmD,

    Corresponding author
    1. Research Scientist, Center for Implementing Evidence Based Practices, Roudebush VA Medical Center and Assistant Professor, School of Pharmacy, Purdue University, Indianapolis, IN, USA
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  • Ronald T. Ackermann MD MPH,

    1. Assistant Professor, Department of Internal Medicine, School of Medicine, Indiana University, Indianapolis, IN, USA
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  • Timothy E. Stump MA,

    1. Biostatistician,
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  • Roberta J. Ambuehl BA,

    1. Data Analyst, Regenstrief Institute, Inc, Indianapolis, IN, USA
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  • Steven M. Downs MD MS,

    1. Professor, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, USA
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  • Ann M. Holmes PhD,

    1. Associate Professor, School of Public and Environmental Affairs, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
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  • Barry Katz PhD,

    1. Professor, Division of Biostatistics, Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN, USA
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  • Thomas S. Inui ScM MD

    1. President and CEO, Regenstrief Institute, Inc, Professor, Department of Medicine, Indiana University School of Medicine and Affiliated Research Scientist, Centre for Implementing Evidence Based Practices, Roudebush VA Medical Center, Indianapolis, IN, USA
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Alan J. Zillich
Center for Implementing Evidence Based Practices
Roudebush VA Medical Center and School of Pharmacy
Purdue University
W7555 1001 W 10th Street
Indianapolis
IN 46202
USA
E-mail: azillich@purdue.edu

Abstract

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.

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