academic detailing from vision to visit · •cpd, cpe •advisory board •clinical consultants...

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Academic Detailing From Vision to Visit

Isobel Fleming

Dr. Edith Baxter

Pam McLean-Veysey

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Dalhousie Academic Detailing Service and the Drug Evaluation Unit are funded by the Nova Scotia Department of Health and Wellness.

Content is controlled solely by the Office of Continuing Professional Development

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Isobel Fleming has no actual or potential conflict of interest in relation to this topic or presentation

Dr. Edith Baxter has no actual or potential conflict of interest with this topic or presentation

Pam McLean-Veysey has no actual or potential conflict of interest with this topic or presentation

Disclosure

OBJECTIVES

•Describe the process of the Dalhousie Academic Detailing Service

•Provide examples of material produced

•Demonstrate a recent Academic Detailing session

CADTH 2018 AD FROM VISION TO VISIT 4


Unrestricted funding

DRUG EVALUATION ALLIANCE OF NOVA SCOTIA

https://novascotia.ca/dhw/pharmacare/drug-evaluation-alliance-of-

nova-scotia.asp

Academic Detailing

• Outreach education

• Trained health care professional

• Primary health care providers

• Evidence informed discussion

• One-on-one or small group

• History of the Service


Goal

…to promote a culture of critical thinking

among Nova Scotia health care professionals

and to provide them with evidence-based

education to improve practice

CADTH 2018 AD FROM VISION TO VISIT

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Academic DetailingCollaboration with

•Drug Evaluation Pharmacists

•Detailers

•CPD, CPE

•Advisory Board

•Clinical consultants

•Other Academic Detailing Programs in Canada

•CADC

•Provincial Programs

•e.g., DEANS, DCPNS


Role of Dalhousie CPD

•Family physician member of team

•Formal link with Faculty of Medicine

•Formal link with Doctors NS

•Communication with other CPD initiatives•Webinars•Conferences


CPD Family Physician

•Topic selection

•Communicate with content reviewer

•Communicate with Advisory Panel

•Ensure relevance to family practice

•Assist in upskilling of detailers

•Educational materials


Drug Evaluation Unit (DEU) Evidence Informed Policy Support

Atlantic Common Drug Review (ACDR)

DEU

• Evidence based reports to support benefit status of medications on Atlantic Provincial Formularies

• Drugs not reviewed by CADTH

• Alignment of benefit status / criteria reviews

• Class reviews

• Co-ordination functions

• Unrestricted grant from DEANS


3.4 FTE

Pharmacists

DEU Collaborations

• Atlantic Provincial Departments of Health and Wellness, Pharmaceutical services

• Insurance Providers (e.g., Medavie Blue Cross)

• Expert consultants (Prescribers, Pharmacists, other Health professionals)

• CADTH

• CNODES

• Provincial Programs


Drug Evaluation UnitEducational Initiatives

• Academic Detailing

• Educational presentations at conferences/ webinars

• Pharmacists, Physicians, Nurses,

• Professional Organizations

• DEANS initiatives

• Nebulization

• Katie Program

• https://www.dal.ca/faculty/health/cpe/services/katie-program.html

• Coming soon - Pain, Opioid Use Disorder

• Publications • Ex. Severely Frail Elderly Do Not Need Lipid Lowering Drugs

https://www.mdedge.com/ccjm/article/130050/geriatrics/severely-frail-elderly-patients-do-not-need-lipid-lowering-

drugs/page/0/1

• Hypertension in elderly patients, Recommended systolic targets are not evidence based

http://www.cfp.ca/content/cfp/59/1/19.full.pdf


https://www.mdedge.com/ccjm/article/130050/geriatrics/severely-frail-elderly-patients-do-not-need-lipid-lowering-drugs/page/0/1

http://www.cfp.ca/content/cfp/59/1/19.full.pdf

Academic DetailingPutting the Pieces together

DEU involved in

• Topic selection

• Discussions with advisory panel

• Key clinical questions

• Literature Search and Review• Critical appraisal of evidence

• Existing tools (CADTH, CADC)

• Writing of background document, workbook

• Consultation with experts

• Clinical application tools (“laminates”)


Can prescribers applyevidence to their practice?

• Is the patient the same as mine?

• And does it matter?

• Population in clinical trials

• Severity of disease

• Age of participants

• Comorbidities

• Critique

• Similar groups at baseline?

• Number enrolled


Application of Evidence to Practice

• Outcomes that matter to my patients?

• Critique

• Validated, clinically meaningful, surrogates or hard outcomes?

• MCID?

• Adverse events/ drop outs/ serious adverse events

• Should results change my practice?

• Statistical vs clinical significance

• Absolute risks vs relative risk (NNT, NNH)

• Baseline risks

• Grade of evidence in guidelines

• What has not been studied?


Presentation of Data


Patient education tools: PPIs 2008

http://cme.medicine.dal.ca/ad_resources.htm#ID


http://cme.medicine.dal.ca/ad_resources.htm

Challenges in Applying Evidence to Practice

•External validity of RCTs

•Comparators and doses used in clinical trials

• Ex. IMPROVE IT trial (ezetimibe + simvastatin 40 mg vs. simvastatin 40 mg)

•Select patient populations and generalizability of results

• Limited evidence in elderly, pediatric, ethnic populations, women


“If everyone only knew the details of the evidence!”

Challenges in Applying Evidence to Practice


• Outcome measures – valid and clinically relevant?

• Interpretation beyond statistical significance

• Predicting off label use

• Practice guidelines don’t agree with appraisal interpretation

• Grading of evidence in guidelines vs. recommendations

• Inadequate knowledge transfer to prescribers, consumers

• Continuing Professional Development and Pharmacy education

• Residency programs

• Provincial Programs

• Diabetes Care Program NS

• Cardiovascular Health NS

• Public Health

• Guidelines (Diabetes, Hypertension, ACS)

• National Agencies

• CADTH, NIHB, professional organizations

• Hospital pharmacists (CSHP presentations)

DEU KNOWLEDGE SHARING


Preparation for the Visit

•Upskilling of regional detailers• Day in Halifax

• Phone meetings

•Printing of materials

•Maintaining up-to-date physician emails

•Shipping to regional detailers


Notification of the Visit

•Email letter of invitation to all family physicians in database

•Letter to specialists with links to document

•Case to consider

•Getting visits booked


The Visit

Detailer has to be prepared

Suitable time and place

Meet needs of physician

Discuss the evidence

Leave a “gift”



https://medicine.dal.ca/departments/core-units/cpd/programs/academic-detailing-service.html


Laminates

Follow-up

•Evaluation forms

•Reflective exercise

•CFPC Credits

•Researched questions


From: Academic Detailing Service

Re: Stability of epinephrine in pre-filled syringes

Following our visit…

Question: Is there information about the stability of epinephrine in pre-filled syringes?

Response: According the product monograph, epinephrine solution contains no bacteriostatic or antimicrobial agent and is intended for use as a single-dose injection. When smaller doses are required, the unused portion should be discarded. Concerns exist regarding the stability and sterility of pre-filling syringes with epinephrine because epinephrine degrades with exposure to ultraviolet light, oxygen in ambient air, and excessive heat. Epinephrine readily oxidizes and changes from colorless to pink, as adrenochrome forms, to brown, as melanin forms.

Two studies have evaluated the stability of epinephrine in pre-filled syringes, and one of these studies also evaluated the sterility. The aim of the first study was to evaluate the effects of high ambient temperature, high or low humidity, and light or dark on the stability of epinephrine solutions drawn up from ampules into unsealed, disposable plastic 1-mL syringes. Forty unsealed syringes each containing a dose of 0.3 mg of a 1 mg/mL epinephrine solution were stored at 38○C for 5 months. The epinephrine dose was at the lower end of compendial limits (90% - 115%) by 2 months after storage at 38○C and low humidity and by 3 months after storage at 38○C and high humidity. Light had no significant effect. This study did not evaluate the sterility of the samples. Ann Allergy Asthma Immunol.2009;102:500–503

The second study examined 140 samples of 1 mg of a 1 mg/mL epinephrine solution in unsealed plastic 1 mL syringes, needles were left attached and recapped. All of the syringes were kept in pencil boxes to protect from light and left at controlled room temperature. Samples were evaluated monthly up to 3 months. The epinephrine concentration at 1,2 and 3 months was 101.36%, 99.31% and 101.09%, respective (acceptable range 90%-110%). The pH was in an acceptable range at all time points. There were no aerobic bacterial or fungal growth in any sample and norepinephrine, which is a degradation product of epinephrine, was not detected in any sample. However, brown particles were found in the needle cap in some syringes. These particles were did not have any bacterial or fungal growth. The study investigators concluded the brown particles was caused by degradation of epinephrine via oxidation which turns pink first then brown. By 4 months most of the pre-filled syringes had developed a pink-brown solution. Asian Pacific Journal of Allergy and Immunology (2010) 28: 53-57 There are no published studies available examining the safety and efficacy of self-administered epinephrine in pre-filled syringes for the treatment of anaphylaxis and there are factors that would need to be considered such as how to administer etc. Other potential limitations include unintentional disconnection of the needle from the syringe, accidental needle pricks, or premature release of the medication.

We hope this information is helpful.

Evidence of change

•CADC

•Antibiotics

• Anecdotal

•COPD


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Less of …More of …

Can you use

this in your

practice?

How?

Appropriate, affordable, accessible

… Demonstration


Questions

CADTH 2018 AD FROM VISION TO VISIT

academic detailing from vision to visit · •cpd, cpe •advisory board •clinical consultants...

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