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Teaching Physicians Geriatric Principles: A Randomized Control Trial on Academic Detailing Plus Printed Materials Versus Printed Materials Only

Division of Geriatric Medicine, University of British Columbia, Vancouver Hospital & Health Sciences Centre, Canada.

Address correspondence to Roger Wong, MD, FRCPC, HP-A7, 855 West 12th Ave., Vancouver, BC, Canada, V5Z 1M9. E-mail: rymwong{at}interchange.ubc.ca

	Abstract

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Background. We compared the effectiveness of academic detailing with printed materials, versus printed materials only, on promoting geriatric knowledge among physicians.

Methods. 31 physicians were randomly assigned to receive academic detailing plus printed materials (group 1 intervention, n = 16), or printed materials alone (group 2 control, n = 15), on 5 geriatric topics identified from a needs assessment survey. Two participants withdrew from group 2, leaving 13 in the control group. Both groups received printed educational materials between baseline and time 1, and at time 2. Only group 1 received an additional 15-minute, one-on-one education session with a geriatrician at time 2. The primary endpoint was knowledge retention, measured by the numeric score of a 5-item questionnaire (range 0 to 5), comprised of items from the Geriatrics Knowledge Test. Knowledge retention was measured at baseline, 1 week (time 1), and on average 29 weeks later (time 2).

Results. Most participants were postgraduate trainees. The mean knowledge score in all participants decreased from 3.6 ± 1.2 at baseline to 3.1 ± 1.2 at time 1 (p =.006). 19 participants (9 in group 1 and 10 in group 2) completed the knowledge questionnaire at time 2. At baseline, group 1 scored lower than group 2 (3.4 ± 1.3 versus 3.8 ± 1.1, p =.39); whereas at time 2, group 1 scored significantly higher than group 2 (4.7 ± 0.7 versus 3.9 ± 0.7, p =.034). Academic detailing plus printed materials produced higher mean score change from baseline (1.1 ± 1.3) than printed materials alone (0.0 ± 1.1, p =.053).

Conclusions. Academic detailing plus printed materials improved knowledge retention among physicians, whereas printed materials only did not.

Commercial detailing is a common marketing strategy used in health care, especially within the pharmaceutical industry. It refers to the process whereby sales staff make person-to-person contact with practicing physicians in promoting the sales of a particular product (2). This serves as a model for academic detailing, which refers to a personal, face-to-face educational outreach experience between a detailer, who has academic training in a particular area, and practicing physicians (3). Some of the more important techniques of academic detailing include understanding baseline motivation of the target physicians, defining clear educational objectives, referencing current and accurate literature, stimulating physician interaction, and repeating the essential messages (3).

Traditionally, academic detailing has been shown to have a positive impact in modifying physician medication prescribing patterns (2–4). Specifically, it has been associated with reducing erroneous prescriptions (5), promoting appropriate use of antihypertensive medications (6), and decreasing use of high-risk medications such as benzodiazepines (7). In the acute care setting, academic detailing can improve the identification and reporting of adverse drug events (8).

The impact of academic detailing in the management of common clinical conditions has been studied, but the results remain inconclusive. Although it has been shown to successfully modify blood product transfusion practice (9) and promote referral and appropriate management for menorrhagia (10), it has not demonstrated improvement in the diagnosis and treatment of major depression among primary care physicians (11).

The effectiveness in teaching concepts to physicians via academic detailing is unclear. In one Australian study, academic detailing significantly improved knowledge scores and self-perceived understanding of evidence-based medicine among general practitioners, but without influencing their attitudes toward it (12). A community-based study also concludes that academic detailing was effective in disseminating smoking cessation interventions among physicians (13). However, in another randomized trial of primary care clinics, academic detailing was not effective in promoting adherence to clinical practice guidelines on hypertension or depression (14).

In this study, we compare the effectiveness of combining academic detailing with printed materials, versus providing printed materials alone, on knowledge retention of important geriatric topics among physicians. This is the first study of its kind that investigates the potential value of academic detailing in teaching geriatric concepts.

	METHODS

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Needs Assessment
The study protocol is summarized in Figure 1. Postgraduate trainees (residents and fellows) in the Department of Medicine at the University of British Columbia, as well as staff physicians in the Departments of Medicine and Family Practice, were contacted with an introductory and recruitment letter about the study. A convenient sample was collected, and participant recruitment took place over 6 consecutive calendar months. Forty-five participants consented and completed a needs assessment questionnaire in which they selected 5 geriatric topics that they were most interested in learning more about from an inventory of the 11 topics covered in the validated Geriatrics Knowledge Test (15). We limited the number of topics at five so that the educational printed materials would not be too voluminous to read, and each educational outreach session in the intervention group could be completed within a reasonably short time. The five most frequently chosen topics were: cognitive impairment, competency, urinary incontinence, malnutrition, and stroke. These topics became the core educational focus of subsequent interventions. The remaining topics included: depression, falls, hearing impairment, infections, preventive health, and skin breakdown.

View larger version (33K): [in this window] [in a new window]   Figure 1. Study flow chart

Interventions
Printed educational materials were provided to both study groups at baseline and again at final follow-up. Group 1 received academic detailing (intervention) in addition to the printed materials, whereas group 2 was the print-only group (control). We compiled the printed educational materials to cover each of the 5 geriatric topics identified in the needs assessment. Each printed package contained a 2–3-page summary of the pertinent basic science and clinical information on each topic. The educational content was evidence based, and citations to key original references were included. The information required to correctly answer the subsequent multiple-choice knowledge assessment questions was present in the printed materials for each topic. The format of the printed materials followed that of standard handouts used in academic institutions: black font on white bond paper with the use of point form and summary tables. There was no graphic presentation. The version date was listed at the end of each package.

Each participant in group 1 who completed the study also received a face-to-face educational outreach session (academic detailing) with one of the investigators, who was a specialist in geriatric medicine (detailer), some time between 1-week postrandomization and the final point of measurement. Each detailing session lasted 15 minutes and took place in a quiet room at a university-affiliated hospital (the participant's own clinical base) where both the participant and the detailer would sit comfortably around an office desk to facilitate an informal discussion of the five geriatric topics. All five topics were reviewed within one 15-minute session. The duration of 15 minutes was selected because it approximated the usual duration of commercial detailing by pharmaceutical representatives in a busy clinic practice. While the educational content of the detailing session was identical to that in the printed materials in terms of learning objectives and knowledge details, the detailer would highlight one or two key take-home messages from each topic and provided relevant clinical examples to illustrate. The detailer did not specifically discuss questions from the knowledge test. The detailer also observed established behavioral principles of academic detailing, such as limiting the discussion to the five defined geriatric topics, maintaining credibility, stimulating participant involvement and interaction (by inviting and answering questions), offering practical examples, and repeating a few major points (3).

Outcome Measurement
Outcome measures were collected at baseline (time 0), 1 week after randomization (time 1) and final follow-up (time 2). The average time elapsed between baseline and final follow-up was 29 weeks (median 35 weeks, range 10–48 weeks) later. Although there is no standard duration of time used to assess knowledge retention in the literature, we chose a sufficient duration of time when we could be confident that knowledge retention would be tested. The detailing session occurred for participants in group 1 just prior to retesting at time 2. To quantify knowledge retention in the five selected geriatric topics, five single-option, multiple-choice items were extracted from the 23-item Geriatrics Knowledge Test, which has good validity and reliability data (15). The detailer was not blinded to the items, which was preferable. These extracted items covered the same topics as identified in the needs assessment. Each item had a possible score of 1 (correct response) or 0 (incorrect response). In order to compare overall knowledge retention between groups 1 and 2 with respect to their responses to all five items simultaneously, we aggregated the knowledge scores across the five items for each participant and then compared the mean overall knowledge scores between group 1 and group 2. The same items on competency, urinary incontinence, and malnutrition were used at baseline, time 1, and time 2 because there was only one representative question on each topic in the Geriatrics Knowledge Test. The items on cognitive impairment and stroke used at baseline were different from those used at time 1 and time 2 because there were two questions in the Geriatrics Knowledge Test on each of these two topics. Therefore, one of the two questions on cognitive impairment was used at baseline, whereas the remaining question was used at time 1 and time 2. The same applied for the questions on stroke. We would prefer to perform multivariate comparisons instead, but our sample size was too small. The maximum possible aggregate score was 5, and the minimum score was 0.

Statistical Analysis
All analyses were done on the basis of the observed case. To look at the difference in knowledge retention between baseline (immediately after printed materials were distributed to both groups) and time 1 (1 week later), the two-sample paired t test was used to compare the mean knowledge scores of all participants at these time points. The mean knowledge scores between participants who completed the study and those who withdrew were compared at both baseline and time 1 using the two-sample unpaired t test. The mean knowledge scores between group 1 and group 2 at baseline, time 1, and time 2 were compared by analysis of variance. Finally, the changes (that is, from baseline to time 1 and from baseline to time 2) in knowledge scores between the two study groups were compared by analysis of variance. In view of the high dropout rate, we repeated this analysis using the last observation carried forward (LOCF) method, in which the same time 1 knowledge score was assigned as the time 2 score for those who dropped out after the time 1 assessment. All statistical analyses were completed using SPSS for Windows standard version release 10.0.5 (SPSS, Inc., Chicago, IL).

	RESULTS

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Most of our participants were either residents in internal medicine (62%) or fellows in subspecialty medical programs (28%). The remainder were attending physicians in the departments of medicine (7%) and family practice (3%). There was no difference in gender distribution (52% females vs 48% males).

At baseline, the Geriatrics Knowledge Test item with the highest proportion of correct responses was on cognitive impairment (96.6%), whereas the items with the lowest proportions were on urinary incontinence and malnutrition (51.7% in each case). At final follow-up (time 2), the items on competency and urinary incontinence had the highest proportion of correct responses (100% each), whereas the item on stroke had the lowest (47.4%).

The individual knowledge scores across the five items for each participant were aggregated, and the mean overall knowledge scores for both study groups are shown in Figure 2. In both groups, the mean scores at time 1 were lower than baseline. Overall, the mean knowledge scores in all participants decreased from 3.6 ± 1.2 at baseline to 3.1 ± 1.2 at time 1 (p =.006). Among the 19 participants who completed the study at time 2, group 1 scored slightly lower than group 2 at baseline (3.4 ± 1.3 versus 3.8 ± 1.1, p =.39). However, the opposite was observed at time 2: group 1 scored significantly higher than group 2 (4.7 ± 0.7 vs 3.9 ± 0.7, p =.034). At baseline and time 1, there was no significant difference in the mean knowledge scores between participants who subsequently withdrew versus those who completed the study (baseline: 3.2 ± 1.4 vs 3.7 ± 1.1, respectively, p =.45; time 1: 2.7 ± 1.3 vs 3.3 ± 1.1, p =.27).

View larger version (13K): [in this window] [in a new window]   Figure 2. Line plots of mean knowledge scores against time for groups 1 (solid line) and 2 (dashed line). T0 = baseline; T1 = 1-week postrandomization; T2 = final follow-up. Both groups 1 and 2 received print materials between T0 and T1. Only group 1 received academic detailing plus printed materials between T1 and T2, whereas group 2 received printed materials only between T1 and T2. Numeric values beside the data points represent mean knowledge scores, with respective p values for between-group differences

View larger version (17K): [in this window] [in a new window]   Figure 3. Bar charts of mean changes in knowledge scores for groups 1 (solid bars) and 2 (shaded bars). The vertical axis represents mean score changes, and the horizontal axis represents time elapsed. Time1-Baseline = score changes at time 1 compared to baseline; Time2-Baseline = score changes at time 2 compared to baseline. Numeric values under the horizontal axis represent mean changes in knowledge scores. The p values represent between-group differences at Time1-Baseline and Time2-Baseline

	DISCUSSION

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The knowledge scores in both groups decreased from baseline to time 1. The exact reasons remain unclear. Perhaps this reflects poor adherence of either group in actually reading the printed materials given at baseline. Assuming that the participants actually read the materials, the decreased scores may represent the natural decay of knowledge retention over time (1 week), although the half-life of such decay appears very short.

The data analysis involved pooling knowledge scores of medical residents and faculty, which would potentially skew the data because one would expect the faculty to achieve higher baseline scores than the residents and therefore might not show the same degree of improvement pre- and postintervention. We also recognize that the Geriatrics Knowledge Test used was originally validated for residents only. In a post hoc analysis, we reanalyzed the data assuming the removal of the 3 faculty participants (2 in group 1 and 1 in group 2). In this scenario, participants in group 1 would produce significantly higher mean score changes at time 2 from baseline (1.3 ± 1.3) than group 2 (0.0 ± 1.1, p =.037). Therefore, if the faculty were excluded from the study, the between-group difference in knowledge score improvement pre- and postintervention would become more robust. A separate study with faculty alone would be interesting, to see how well they improve their knowledge compared with residents.

This is the first study that demonstrates the effectiveness of academic detailing on teaching geriatric concepts. The generalizability of our findings is, however, limited by several factors. We would prefer to assemble a consecutive sample over a longer period of time instead, but were limited by available resources. The sample size was small and did not allow stratification to compare between subgroups (for instance, trainees versus staff physicians). All participants were recruited from the university setting. It is unclear whether the same benefit of academic detailing extends to community-based physicians.

The dropout rate was rather high (about one third of participants withdrew after randomization), raising the practical question of how to maintain physicians' interest long enough for detailing to satisfactorily occur. This high rate of dropout was present even though participants were offered an honorarium of $100 CDN to participate. This occurred possibly because the study was conducted near the end of the academic year, and there were other competing interests and pressures faced by the participants (mostly medical residents), which distracted them from completing the study. Overall, the small number of participants who enrolled and subsequently completed the study limits our ability to draw definitive conclusions that reach statistical significance. We would prefer to complete the measurement at time 2 at a uniformly fixed time for all participants, but this was not possible because of scheduling challenges with busy clinicians.

We recognize that, although the Geriatrics Knowledge Test has been shown to be valid and reliable in its entirety, there is no validity or reliability data on our extracted items alone. We understand that one question per topic is not sufficient to fully assess knowledge retention in that topic. However, we were limited by the number of representative questions available in the Geriatrics Knowledge Test (one question for three of the five topics and two questions each for the remaining two topics). We are also sensitive not to impose excessive burden on the participants by keeping the questionnaires simple and brief.

While we would like to separate out the individual effect of academic detailing from that of printed materials in group 1, our sample size was too small and would not allow multivariate analysis. It would be interesting if we had asked participants in both groups whether or not they actually read the printed materials. However, we believe that the absence of this information does not detract from the point of the study.

Finally, we recognize the potential confounding effect of using the investigators as detailers because of their involvement in item selection of the outcome measurement tool.

A recent systematic review of randomized studies on academic detailing concluded that academic detailing could successfully modify health professional behavior, mostly in medication prescribing (16). While the current study produces positive results in terms of knowledge retention, it remains uncertain whether academic detailing can modify geriatric practices. The dichotomy between clinical knowledge and professional practice is not a new concept. For instance, an Australian randomized trial showed that, although intensive academic detailing improved knowledge marginally, it did not improve an opportunistic approach to cervical screening among general practitioners (17). In contrast, individual and group academic detailing were shown to be effective in reducing prescriptions for highly anticholinergic antidepressants and increasing prescriptions for less anticholinergic antidepressants in elderly patients (18). Even if practice is changed, the impact on patient outcomes may not follow suit. A Canadian trial on hypertension concluded that, although academic detailing and other educational interventions improved the follow-up of hypertension, they were ineffective in changing blood pressure levels in patients (19). Therefore, to further study the impact of academic detailing on geriatric practices, actual or simulated clinical audits will be necessary, with documentation of patient outcomes.

Apart from knowledge, attitude is another key determinant of professional behavior. Unfortunately, academic detailing has not been shown to be effective in changing attitude (12). Future studies are needed to investigate the effect of educational outreach on physicians' attitude towards geriatric care.

This study provides foundational data for future efforts to implement academic detailing in geriatrics. There is growing interest among medical educators to use academic detailing on a widespread basis to improve professional practice (20). While this is a promising idea, there are still many unanswered questions including which components of academic detailing are the most effective, what is the optimal duration per session, what are the cost implications, and so forth. These will need to be addressed by future studies.

Summary
Academic detailing (educational outreach) plus printed materials tended to be superior to printed materials alone in teaching physicians geriatric principles.

	Acknowledgments

 
We wish to thank Dr. Iain Mackie (Department of Medicine) and Dr. Reinhold Bernat (Department of Family Practice) at the University of British Columbia for their assistance in participant recruitment.

Part of the funding support is obtained through a grant from the University of British Columbia Division of Geriatric Medicine Practice Plan.

Part of this manuscript was presented in abstract form at the Canadian Geriatrics Society annual meeting in Ottawa, Ontario, in May 2003.

Received March 1, 2004

Accepted April 13, 2004

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