Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes

Key Points Question What is the real-world effectiveness of an academic detailing intervention in nursing homes to improve the appropriate prescribing of antipsychotics? Findings In this cluster randomized clinical trial of 40 nursing homes with 5363 residents in Ontario, Canada, academic detailing did not further reduce antipsychotic prescribing beyond a downward secular trend. Meaning The results of this study suggest that academic detailing in nursing homes may not be an effective intervention to reduce antipsychotic prescribing in an environment where standard quality improvement supports are working.


Introduction
Potentially inappropriate use of antipsychotics in nursing homes has been the focus of significant clinical, research, and policy attention. [1][2][3][4] The increased use of antipsychotics during the early 2010s raised concern because of its questionable effectiveness and a well-established risk profile. 5,6 Regulators have issued numerous warnings related to increased harm associated with this drug class, including higher mortality among elderly patients prescribed antipsychotics. [7][8][9][10][11] In 2013, approximately 35% of nursing home residents in Ontario were prescribed antipsychotics, compared with only 4.6% of seniors living in the community. 12 Similar results have been observed in many jurisdictions internationally. [13][14][15] Strategies to reduce inappropriate prescription of antipsychotics have been shown to have considerable variation in their effectiveness. 16,17 Many trials of these interventions have short-term follow-up (ie, <6 months) and are often small in scale. The objective of this study was to evaluate the real-world effectiveness of an academic detailing intervention in nursing homes across Ontario targeting appropriate prescribing of antipsychotics and the management of behavioral and psychological symptoms of dementia.

Trial Design
Details of the trial design and rationale have been reported previously, 18 and the study protocol is available in Supplement 1. Briefly, we conducted a pragmatic cluster randomized clinical trial in nursing homes that shared physicians as the unit of randomization. 19,20 An independent statistician randomly allocated the homes using computer-generated random numbers. Randomization occurred once at the start of the study. Nursing homes were allocated to the full, active intervention (ie, academic detailing) or standard quality improvement supports (ie, usual care). Due to the nature of the intervention, masking of group allocation was not possible. An embedded process evaluation was conducted to explore why the intervention did or did not work and is described elsewhere. 21,22 The evaluation was led by an team of academics, who developed the methods in collaboration with the partners responsible for sponsoring and implementing the interventions, namely the Ontario Ministry of Health and Long-term Care, the Ontario Medical Association, the Centre for Effective Practice, and Health Quality Ontario. For logistic reasons, the academic detailing intervention was administered in 2 waves (October 2015 and February 2016), each for 6 months. The results presented in this article describe homes included in the first wave because the second wave was not randomized to have controls. The second wave was completed based on remaining funding for the program that allowed an extension of the service to additional homes.
The study received ethics approval from the Women's College Hospital and the University of Toronto Research Ethics Boards. The entire nursing home was considered a research participant, so written informed consent was obtained from the medical director and administrative leads from each home. This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline for cluster randomized trials. 23

Participants
Homes were eligible if they were a reasonable travel distance (ie, <100 km) from the central intervention team in the greater Toronto area. Identification of potential homes was completed in collaboration with stakeholders, including the Ontario Long-term Care Association and AdvantageAge Ontario. To be eligible for participation, the medical and administrative leads of the homes were required to express support. Exclusion criteria were homes without any prescribers caring for at least 10 residents at baseline or homes with fewer than 30 residents. A recruitment email was distributed by the Ontario Ministry of Health and Long-term Care to administrative leads and medical directors of nursing homes. Approval for trial participation was obtained from the medical director and administrative leads from each home. Individual clinicians and staff members in the home were free to independently decide whether and how to participate in the intervention.

Intervention Academic Detailing
Academic detailing is a method of educational outreach that leverages 1-on-1 interactions to communicate evidence-based information to clinicians. 24 The intervention was 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 home staff, including administrators, clinicians, and staff from the time of launch to program completion. Detailers provided tailored information to help to support nursing home clinical staff to address challenges and opportunities for improving prescribing of antipsychotics, providing additional materials and resources as needed. They also responded to questions via email or telephone. Given the diverse target audiences that would likely be engaged in the homes, the academic detailer worked to understand the context, barriers, capacity, and needs of each home to ensure the service being provided was relevant.

Usual Care
Usual quality improvement supports included confidential physician-level online report cards that described their prescribing practices for antipsychotics compared with regional and provincial rates, along with clinical and demographic features of the physician's roster. Physicians voluntarily signed up and confirmed their identity to receive updated quarterly reports, which have been available province-wide since October 2015. The reports are produced by Health Quality Ontario using data from ICES, a nonprofit research institute that holds Ontario's health-related data. In addition to the reports, virtual communities of practice were launched to allow sharing of best practices across the province.

Data Sources
Outcomes were assessed using the following population-level administrative claims databases, considerably. Furthermore, each resident also receives a shorter, quarterly assessment. The CCRS database contains information on diagnoses (eg, dementia), dispensing of antipsychotics, and incidence of falls, among other data. Additionally, a number of validated outcome scores are available from the CCRS, including those related to activities of daily living, aggressive behaviors, pain, and mood. 25-28

Outcomes
The primary outcome was antipsychotic medication dispensed, defined at the level of the resident.
This was operationalized as the number of days the resident was provided an antipsychotic in the previous week based on the most up-to-date RAI assessment, as reported in the CCRS, and it was dichotomized prior to analysis as continuous prescription for 7 days or not. Dichotomization was completed because it was found that 99% of reporting was either 0 or 7 days. Nursing home staff complete RAI assessments within 14 days of admission, and assessments are updated annually or with a change in status; a quarterly RAI assessment is required every 92 days. Secondary residentlevel prescribing outcomes included mean daily antipsychotic dose (during the previous month) and any antipsychotic, benzodiazepine, antidepressant, mood stabilizer, and acetaminophen prescribing (defined as any prescription during the previous month), determined from dispensing information.
Daily antipsychotic doses were calculated by converting all active antipsychotic prescriptions into chlorpromazine daily dose equivalents. Primary and secondary prescribing outcomes were assessed at baseline and 3, 6, and 12 months after randomization. Baseline was defined as the week or month immediately before randomization, while postintervention measurements were defined as the third, sixth, and twelfth months after randomization. At each point, outcomes were assessed only for residents alive at the time of the assessment and present in the home for the full duration of the prior month. This analysis included all residents of the home, even if they were not residents at baseline.

Sample Size
The a priori sample size target was determined based on logistical constraints. Specifically, the funding specified that a maximum of 40 homes would receive academic detailing in 2 waves. Only the first wave was randomized in our study. For our primary outcome (ie, days with an antipsychotic prescription in the past 7 days), we required 45 independent clusters to achieve an 80% power to detect a minimally important difference of 0.6, assuming 120 residents per home and an intraclass correlation coefficient of 0.01. For secondary prescribing outcomes using a simulation study with 1000 simulation runs, a power of 83.4% to detect an odds ratio (OR) of 0.75 at 6 months was calculated.

Statistical Analysis
Descriptive statistics were calculated for all variables. Continuous variables with a normal distribution were described using means and SDs, categorical variables were summarized using frequencies and proportions. Primary analyses were conducted with an intention-to-treat analysis. We used a resident-level, repeated measures analysis with generalized linear mixed-effects regressions.
Dichotomous outcomes were analyzed using a binomial distribution and logit links; continuous outcomes, using normal distribution and identity link. The model included fixed effects of time (categorical), intervention, and intervention-by-time as the main variables of interest, plus random effects for the home to account for clustering. To account for within-period and between-period correlation within homes, random intercepts and period effects were included, defined at the level

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Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotics in Nursing Homes of the home. An additional random effect was used to account for repeated measures on the same resident over time. Prespecified secondary analyses were conducted to explore prescribing trends in the year before and after the intervention. This secondary analysis was included with our initial plan to allow more time for the intervention to have an effect, based on findings in our process evaluation. 21 All analyses were completed using SAS version 9.4 (SAS Institute) at ICES in Toronto, Ontario. Statistical significance was set at P < .05, and all tests were 2-tailed.

JAMA Network Open | Geriatrics
Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotics in Nursing Homes   P < .001) ( Table 3). The proportion of patients receiving other medications did not appear to change Abbreviation: NA, not applicable. a Intervention effect for daily antipsychotic use in past 7 days (primary outcome) and continuous daily prescriptions in past 28 days (secondary outcome) presented as odds ratio with 95% CI; for mean days on antipsychotic in past 28 days and mean daily antipsychotic dose in past 28 days, mean difference with 95% CI. in either group (eTable 3 in Supplement 2). Additional sensitivity analyses were undertaken, and their results are described in eTable 4 and eTable 5 in Supplement 2.

Discussion
We performed a randomized clinical trial of academic detailing in partnership with health system administrators to reduce antipsychotic prescriptions in nursing homes. Homes receiving academic detailing did not achieve additional reduction in the prescribing of antipsychotics compared with standard quality improvement supports. The relative reductions in the proportion of residents receiving an antipsychotic prescription in the prior 28 days in the intervention and usual care groups were 22.4% and 12.8%, respectively, but this difference was not statistically significant. Of note, a simple before-and-after study design would have come to a completely different conclusion regarding the effectiveness of the intervention.
This study occurred during a

Limitations
This study has limitations. It may be limited by the voluntary nature of enrollment at the home level.
However, when the homes in the study were compared with the provincial average of antipsychotic prescribing, there was no significant difference. Furthermore, voluntary participation of staff and clinicians within homes led to considerable variation in the number of clinicians engaged across participating homes, 21 which resulted in varying levels of exposure at both the home and clinician level. It is plausible that a threshold level of exposure required to achieve an effect was not consistently achieved (ie, inadequate intervention fidelity). Participants in the qualitative process evaluation reported that more comprehensive changes were observed when frontline clinicians,

JAMA Network Open | Geriatrics
Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotics in Nursing Homes including personal support workers and nurses, were engaged in addition to physicians and pharmacists. Another potential limitation is the reliance on data that were not collected specifically for the study. This pragmatic choice provided a picture of real-world effectiveness to inform policy but makes it difficult to answer specific efficacy questions, including whether those who engaged in both the academic detailing and feedback reports achieved greater improvements in prescribing.
This work was part of a larger assessment, presented elsewhere, that explored the feasibility and perceptions of this intervention. 21,22 Furthermore, conclusions regarding the effectiveness of academic detailing based on a small number of initial encounters for a topic chosen by policy makers rather than by health professionals, may be premature, given the existing trend toward deprescribing and the likelihood that the intervention works better over time as relationships are developed.

Conclusions
The findings of this study suggest that academic detailing in nursing homes may not be an effective intervention to reduce antipsychotic utilization in an environment where standard quality improvement supports are already creating desirable changes in prescribing. Our findings highlight the need for policy makers to carefully consider the topic and timing of such interventions. Role of the Funder/Sponsor: Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information. The funding agreement ensured that authors had independence in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer:
The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario Ministry of Health and Long-term Care is intended or should be inferred. The analyses, conclusions, opinions, and statements expressed herein are those of the authors, and not necessarily those of Canadian Institute for Health Information. The views expressed in this publication are the views of the research team and do not necessarily reflect those of the funder.