Quality in Primary Care Open Access

Keywords

Academic detailing; Rheumatoid arthritis; Family physicians; Interviews; DMARDS

Introduction

There has been a paradigm shift in the approach to Rheumatoid arthritis (RA) treatment, with current guidelines recommending early, aggressive and consistent use of diseasemodifying anti-rheumatic drugs (DMARDs), with remission as the new target [1-6].

The delivery of care for RA has been shown to be suboptimal [7-14]. In British Columbia (BC), we found low rates of DMARD use and referral to rheumatologists [15]. Similar findings were observed in Quebec, Ontario and United States [8,10,16]. Other researchers have found long delays in receiving care [12,17]. This highlights the importance of addressing the gaps in RA care by informing family physicians (FPs) about recent changes in RA management. Previous studies revealed that many FPs lacked confidence to undertake early diagnoses of RA, and prescription of DMARDs, as well as the need for a shift in approaching RA care [15,18].

Changing physician’s well-established clinical practice patterns can be difficult [19]. Continuing Medical Education (CME) has accounted for one third of clinical practice changes of FPs and consultants [20]. Studies have shown that techniques, such as academic detailing (AD), audit/feedback, and reminders, are more effective than dissemination of guidelines through traditional channels [21-26].

AD is a form of CME where trained health care professionals, such as pharmacists or physicians, visit physicians in their offices to provide unbiased, evidence-based information on a selected topic [27]. AD has been shown to be effective at optimizing clinical practice behaviours [27-32] and has improved care in chronic diseases [33-39]. To date we are aware of only one abstract reporting on a study delivering AD over the phone to inform FPs of the importance of early detection of RA and rheumatologist referral [40].

We report on results from our qualitative descriptive study conducted with FPs who received AD aimed at optimizing the care of RA. The objectives of our study were to understand FPs’ perceptions towards AD, as a way of receiving information about RA management and optimizing RA care. We evaluated FPs’ perceptions of its feasibility, acceptability and utility.

Methods

Study design

We conducted one-on-one semi-structured telephone interviews to explore FP’s perceptions of feasibility, acceptability, and utility of AD for RA management, concurrently with a study evaluating the effectiveness of the AD at changing RA management.

Recruitment

AD was offered to all FPs (n=419) actively practicing family medicine in the intervention health areas, i.e., Burnaby, North Vancouver, Coquitlam and Port Coquitlam, in BC. FPs was identified using the BC College of Physicians’ membership list. Invitation letters were faxed, followed by hand delivery if no response was obtained. FPs was excluded if they were in full-time specialized practices, administrative roles or retired. Ninety-nine FPs received AD. Two weeks after the AD visit, a brief survey was sent to all participating FPs, with 63% response rate. FPs who completed the survey (n=23) were faxed an invitation for interviews. FPs response indicating willingness to participate in the interview was considered informed consent. Interviewed FPs received an honorarium.

AD was used to inform FPs about recent changes in RA treatment and provide support in implementing recommendations [22,35,41]. A pharmacist trained in AD and RA management visited FPs in their offices, delivered a standardized presentation, and offered the opportunity for oneon- one discussion. A resource kit designed to address barriers to care or enhance facilitators, provided practical tools to support FPs' implementation of recommendations [29]. The principles of AD outlined by Soumerai were followed [27].

Data collection

Telephone interviews lasting 25-30 min were scheduled at a time selected by FPs and were conducted by one interviewer (HC). An interview guide (Table 1) was developed. Interviews were audiotaped and transcribed verbatim. Interviews were conducted until data saturation was reached at12 interviews [42].

Table 1: Interview guide for semi-structured interviews.

Analysis

Interview data were analyzed using inductive content analysis [43,44]. Transcripts were read line-by-line and broken down into distinct ideas classified using codes. Codes were compared and contrasted within and between interviews. Codes were clustered into sub-categories and categories. Themes were identified by grouping categories into related concepts.

Interviews were analyzed independently by two researchers (HC and DL) and were compared at each step. Guba and Lincoln’s factors were used to assess criteria of rigor, as suggested by Sandelowski [45]. Ethics approval from University of British Columbia’s Research Ethics Board was obtained [46].

Results

Characteristics of the interview participants are described in Table 2. Demographic characteristics and survey responses to questions about AD did not differ between FPs who did or did not; participate in interviews (data not shown). Four themes were generated (Table 3).

Features of AD valued by FPs

FPs identified features of AD which they valued.

Convenience of AD: Aspects of AD found convenient by participating FPs included: the flexibility of AD, the ability to incorporate CME into their working hours and plan visits according to their clinic schedules; not having to take time off or cancel their clinics (Quote#1); not having to travel for CME (Quote#2) and the short duration of AD visits compared to other CME events (Quotes#3, 4).

One-on-one interaction of AD visit: The one-on-one approach was appreciated by many FPs because of the opportunities to ask questions (Quote#5) and to discuss challenging cases (Quote#6) with a knowledgeable person. FPs valued controlling the discussions and focusing on their interests (Quote#7).

Table 2: Characteristics of interview participants.

A few FPs indicated that they missed the opportunities offered by group learning. However, they also recognized that it could be less time efficient when discussions were not relevant to their needs. Other FPs preferred online CME because they could skip familiar information.

Utility of content

Most FPs discussed the utility of the presentation by the detailer and the resource kit provided.

New or reinforcing information: FPs described the content of the AD visit as useful if it was new information to them, reinforced important concepts, or confirmed that their practice was consistent with recommendations (Quotes# 8, 9, 10). They indicated that the visit increased their confidence in managing RA. The FPs described the written material left behind and toolkit as useful because it reinforced their learning or could serve as future reference (Quotes#11, 12).

Topics described useful by FPs included information about the importance of early diagnosis and referral to a rheumatologist, rapidly accessing rheumatologists and a rheumatologist referral tool, recommended blood tests, follow-up assessment checklist, joint involvement diagram, disease activity rating scale, list of community resources and patient education hand-outs. Although many FPs were not planning to prescribe DMARDs themselves, they appreciated receiving this information while co-managing RA patients with rheumatologists.

Practical information: FPs valued practical, as opposed to theoretical, information. The recent changes in RA guidelines were presented as practical “how to” information (Quote#13). Some FPs regarded the resource kit as facilitating information sharing with patients and increasing their involvement in care (Quote#14). A number of FPs found the resource kit useful because it contained everything relevant to RA management, making it practical to use during clinic (Quote#15).

Evidence-based, summarised and synthesised information: Most FPs appreciated the evidence-based information presented during the AD visit. They found the synthesis of literature by subject experts useful, and time efficient (Quotes#16, 17, 18). Some FPs commented on the usefulness of the balanced and targeted information, in contrast to other CMEs where they felt over-loaded with information (Quotes#17, 19).

Relevance of content: FPs discussed the importance of ensuring that the content of the AD visit was relevant to their needs and clinical practice. Most FPs felt the topic was relevant because they had some RA patients, and relatively little knowledge of recent treatment guidelines and hence felt the need for updates (Quotes#20, 21).

Some FPs appreciated the ability of the academic detailer to tailor the AD visit according to their knowledge, needs and interests, improving its relevance and saving their time.

Underlying needs and expectations of the AD visits: Some FPs sought to update their knowledge (Quote#22) while others wanted to confirm that their practice was up to date (Quote#23). Some expressed no a priori expectations while others were expecting to get clinical information regarding RA management (Quotes#24, 25).

Table 3: Examples of participants’ quotations supporting the themes.

Pharmacist as the academic detailer: The utility of the information was evaluated based on the presenter. FPs described the pharmacist delivering the AD visits as well prepared, knowledgeable and trustworthy. FPs mentioned generally trusting pharmacists to deliver evidenced-based and unbiased information, especially about medications (Quotes#26, 27). Some FPs remarked that physician input in choosing the take home messages helped ensure the relevance of the content (Quote#16).

When specifically asked about health professional preference, FPs described some limitations. They mentioned that pharmacists lacked a physician’s perspective and this limited questions/discussion they could ask/have around diagnoses or clinical management (Quote#28).

Although a rheumatologist would have been preferred by some, it was acknowledged as impractical. FPs suggested that rheumatologist’s input in content development was an acceptable alternative, enhancing the credibility of the material presented by the pharmacist.

Disadvantages of AD

FPs also commented on aspects of AD perceived as disadvantages compared to other CME activities.

Challenges incorporating CME into clinic time: Although most FPs found it convenient to have AD visits during their clinic hours, some found it difficult to find time during working hours (Quote #29). Scheduling CME events during weekends or time booked off from clinic, provided CME time free of interruptions (Quote#30). One FP also mentioned that AD during clinic time could have negative financial implications for their practice (Quote#31).

Although most FPs liked short AD visits, some indicated a preference for longer visits, so they would not spend time covering material provided after the visit. However, they recognized that finding time for longer visits might be difficult (Quote#32).

Delivering a standardised message: Some FPs found that delivering a standardized message was a drawback of AD because it failed to consider individual information needs. Some recommended a prior needs assessment to tailor the message accordingly (Quotes#3, 34).

Providing information already known to some FPs: Some FPs did not find the AD visit useful because the content was not new to them (Quote#35).

Practical issues using material after the AD visit: Although the content of the toolkit was regarded as useful by most FPs, some found information left in paper format impractical to incorporate into electronic medical records (Quote# 36). They expressed concern about finding time to read educational material and figuring out how to integrate practice support tools into regular clinic. Some were uncertain about how duties should be shared between FPs and rheumatologists (Quotes # 37, 38).

Perceived and anticipated impact of AD visit

FPs perceived important outcomes resulting from the AD visits, which they described as valuable due to low prevalence of RA and difficulty staying up to date with current recommendations.

Improved confidence in managing RA: A number of FPs felt more confident after the AD visit (Quote#39). One FP mentioned using information from the toolkit to correctly diagnose a new RA case. FPs indicated increased confidence due to new information about RA management and the AD visit reassuring them that their practice followed current recommendations (Quote#40).

Anticipated practice changes: FPs anticipated practice changes resulting from this AD visit including: planning to diagnose early, referring to rheumatologists early, facilitating rapid referral, initiating DMARDs in a timely fashion, aiming for remission and changes in management of RA comorbidities. Since their practices had relatively easy access to rheumatologists, they described preferring to focus on early referral and letting the rheumatologists prescribe DMARDs as needed (Quote #41). FPs mentioned that knowledge gained would allow them to inform patients about DMARDs prior to their rheumatologist visit.

Other FPs expected only fine tuning of their practice because the AD visit confirmed that their RA management was already appropriate (Quote#42).

Willingness to participate in future AD: Most FPs indicated willingness to participate in future AD, if the topic was of interest to them and it was easy to schedule visits. CME credits were an incentive for some FPs. Other reasons for considering AD included: convenience; opportunity for new knowledge, staying up-to-date and evaluating their practice patterns and knowledge (Quote#43).

Most valuable messages learnt from this visit: FPs endorsed early diagnosis because they linked early and aggressive treatment of RA to preventing joint damage and comorbidities and improving patients’ quality of life. They also appreciated that aggressive treatment and early referral could reduce the cost of RA management to the healthcare system. Some described being unaware of the importance of early and aggressive DMARD therapy (Quotes#44, 45,).

Discussion

To our knowledge, this is the first published qualitative study exploring FPs’ perceptions of the feasibility, acceptability, and utility of AD to deliver information about RA management. We found that participating FPs valued the convenience and flexibility of scheduling AD visits. The content of the AD visit was described as useful by FPs if the information was new to them, reinforced concepts or confirmed that their current practice was consistent with recommended guidelines. They appreciated summarised and synthesised information by subject experts. FPs described AD as an acceptable form of CME they would be willing to repeat. FPs’ descriptions of improved confidence and anticipation of changes in their management of RA suggest that the AD visits met their CME need and improved knowledge gap.

Our findings add to the limited literature on FPs’ perceptions of AD [29,47,48]. Similar to a previous study [44], we found that short AD visits were preferred by most FPs due to easier scheduling. Janssen et al. found that FPs who declined AD visits would consider AD in the future, if the visits were very short. Our study results suggest that convenience of AD in terms of scheduling, in-office location and short duration of the visits contribute to the feasibility and acceptability of delivering AD to FPs.

The appeal of one-on-one interaction during AD visits documented in our study has not previously been reported. Although a few FPs in our study discussed the advantages of group learning they indicated that group learning could also be less time-efficient. These factors should be taken into consideration while deciding between group and individual visits.

Allen et al.’s finding that content and topic relevance to FPs’ practice was one of the major reasons for agreeing to receive AD was consistent with our findings [29]. Our finding that pharmacists were well accepted as academic detailers by participating FPs contrasted with two previous studies reporting higher participation when academic detailers were physicians and non-physician academic detailers as a barrier to participation [29,49].

Disadvantages of AD discussed by some FPs in our study were mostly related to personal preferences. While most FPs found that having the AD scheduled during work hours was convenient; others found this challenging. Other studies described similar results wherein spending office time for CME was perceived as a barrier to participation [29,48,49]. Because that barrier was described by non-users but not previous users of AD [29] it suggests attention must be paid to overcoming that constraint, possibly through testimonials from previous AD users.

Some FPs’ suggestion that needs assessment would have increased the relevance of the messages to their needs has not previously been described. This is however inconsistent with principles of AD which recommend the delivery of a standardized message [27]. Our finding highlights the need to have some individualized discussion time for FPs, after delivering a standard message.

FPs’ views about the resource kit were mixed. While many FPs appreciated having practical resources organized into an easily accessible kit for clinic use, others found the kit timeconsuming. Allen et al. found that providing material for patient education was an enabling factor for FPs’ participation in AD [29]. While some FPs indicated the resource kit could engage patients more in their care other FPs raised questions about whether learning to use these tools was time efficient when the rheumatologists could do this more effectively. Our findings reflect the need for clarifying respective roles of FPs and rheumatologists in a shared care model for RA. Similar to previous studies, our FP participant’s also expressed willingness to participate in AD again. Overall findings suggest that AD is an acceptable CME method for some FPs [29,47].

Our results have implications for planning or implementing AD programs. To enhance utility and credibility, the material should focus on practical information which is evidencebased, and summarised and synthesised by subject experts. Supporting material should be in both paper and electronic format. Tailoring the visit according to individual needs of FPs, after the delivery of a standardised message, would respect the principles of AD while providing FPs with personalized CME. The type of health professional performing the academic detailing should be chosen according to the topic. In our study, FPs was very accepting of a pharmacist as the academic detailer, given the focus on pharmacological management of RA. This has important implications for AD programs, which often rely on pharmacists, and is consistent with the diverse roles of pharmacists within health care [39,50,51].

Limitations

The perceptions described represent those of FPs who agreed to participate in AD and to be interviewed; they are not generalizable to all FPs. FPs accepting AD visits are more likely to have a favourable opinion of AD; may be more interested in CME and more willing to implement practice changes. Our sample has a high proportion of FPs with prior AD experience and university affiliation. In our study, the academic detailer was regarded as knowledgeable, competent and well prepared, which might have influenced FP’s perceptions. Many FPs mentioned that they were already incorporating recent RA guidelines in their practice. These results contrast previous findings from our group that RA patients in BC, at the population-level, were not receiving the recommended care [7]. This discrepancy points to the possibility of social desirability bias influencing the responses of interview participants. However, a number of other factors, unrelated to FPs, could also explain why patients are not receiving recommended treatment.

Conclusion

AD was perceived by participating FPs as a convenient and useful way of receiving information about RA management. The effectiveness of AD intervention at changing actual practice would require evaluation in an effectiveness study. Our results provide evidence that AD is a promising technique for improving the management of chronic diseases such as RA.

Funding

Harpreet Chhina was supported by a stipend from the Canadian Arthritis Network. The research was funded by a peer reviewed grant from the Canadian Arthritis Network (08-SRID-IJD-02). Dr. Lacaille holds the Mary Pack Chair in rheumatology research from the Arthritis Society of Canada and the University of British Columbia.

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