Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial

Abstract

Importance: Strategies to reduce the inappropriate prescription of antipsychotics have been the focus of recent attention but have shown considerable variation in their effectiveness.

Objective: To evaluate the effectiveness of academic detailing in nursing homes targeting appropriate prescribing of antipsychotics.

Design, setting, and participants: We conducted a pragmatic, cluster randomized clinical trial comparing the effect of academic detailing vs usual care on prescribing antipsychotics in 40 nursing homes with 5363 residents in Ontario, Canada. Data were collected from October 2015 to March 2016 and analyzed from April to August 2018. Primary analyses were conducted using intention to treat.

Intervention: Academic detailing delivered by health professionals (eg, nurses or pharmacists) who arranged meetings (with administrators, physicians, pharmacists, nurses, and support workers), presentations, group visits (with 2-6 clinicians), and 1-on-1 visits (traditional academic detailing visits). Academic detailers had direct and ongoing contact with the nursing homes from the time of launch.

Main outcomes and measures: The primary outcome, defined at the level of the resident, was whether continuous antipsychotics were dispensed in the past week. Secondary outcomes included prescribing of other psychotropic medications and clinical outcomes and scores. Prescribing outcomes were assessed at baseline and at 3, 6, and 12 months, and clinical outcomes and scores were assessed at baseline and 3 and 6 months.

Results: A total of 40 nursing homes with 5363 residents were randomized, with 18 intervention homes (45.0%; 2303 [42.9%] residents) and 22 control homes (55.0%; 3060 [57.1%] residents). Participants in the intervention and control groups had similar median (interquartile range) age (86 [79-91] years vs 85 [78-90] years) and sex (674 [29.3%] men vs 970 [31.7%] men). At 12 months, there was no statistically significant difference in the frequency of daily antipsychotic use (intervention: 569 patients [25.2%]; control: 769 [25.6%]; odds ratio, 1.06; 95% CI, 0.93-1.20; P = .49). There were no significant differences in the rates of health care utilization, but the intervention group did experience a statistically significant reduction in pain compared with the control group (mean [SD] pain score, 0.30 [0.59] vs 0.38 [0.66]; P < .001) and depression (mean [SD] Depression Rating Scale score, 2.18 [2.37] vs 2.81 [2.65]; P < .001) at 6 months.

Conclusions and relevance: The intervention did not further reduce antipsychotic prescribing in nursing homes beyond system-level secular trends occurring alongside usual care. Our findings highlight the need for a more targeted approach to quality improvement strategies, including academic detailing, that account for the timing and topic of interventions.

Trial registration: ClinicalTrials.gov Identifier: NCT02604056.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Tadrous reported receiving personal fees from the Centre For Effective Practice outside the submitted work. Dr Desveaux reported receiving personal fees from the Centre for Effective Practice outside the submitted work. Dr Gomes reported receiving grants from the Ontario Ministry of Health outside the submitted work. Dr Taljaard reporting holding a patent unrelated to the submitted work. Dr Bell reported receiving personal fees from the Ontario Ministry of Health during the conduct of the study and outside the submitted work. Dr Ivers reported receiving grants from Government of Ontario Ministry of Health and Long-term Care and the Canadian Institutes of Health Research during the conduct of the study; receiving personal fees from the Centre for Effective Practice outside the submitted work; receiving grants the Canadian Institutes of Health Research and the UK National Institutes of Health Research to support the conduct and evaluation of interventions featuring audit and feedback; being the Women’s College Hospital Chair in Implementation Science; and receiving a Clinician Scholar award from the Department of Family and Community Medicine at the University of Toronto. No other disclosures were reported.

Figures

Figure 1.. Study Flow Diagram for Cluster Randomized Trial

Figure 2.. Proportion of Residents Receiving Any Antipsychotic Prescription 1 Year Before and After Intervention