Primary care

Reducing prescribing of highly anticholinergic antidepressants for elderly people: randomised trial of group versus individual academic detailing

Martine E C van Eijk, principal researcher ^a, Jerry Avorn, associate professor ^b, Arijan J Porsius, professor ^c, Anthonius de Boer, associate professor ^c. 

^a OZ zorgverzekeringen, Breda, Netherlands, ^b Division of Pharmaco- epidemiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA, ^c Department of Pharmaco- epidemiology and Pharmacotherapy, Utrecht Institute of Pharmaceutical Sciences, Faculty of Pharmacy, PO Box 80082, 3508 TB Utrecht, Netherlands

Correspondence to: A de Boer A.deBoer{at}pharm.uu.nl

	Abstract

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Objective: To compare the effect of individual educational visits versus group visits using academic detailing to discuss prescribing of highly anticholinergic antidepressants in elderly people.
Design: Randomised controlled trial with three arms (individual visits, group visits, and a control arm).
Setting: Southwest Netherlands.
Participants: 190 general practitioners and 37 pharmacists organised in 21 peer review groups were studied using a database covering all prescriptions to people covered by national health insurance in the area (about 240 000).
Intervention: All general practitioners and pharmacists in both intervention arms were offered two educational visits. For physicians in groups randomised to the individual visit arm, 43 of 70 general practitioners participated; in the group visit intervention arm, five of seven groups (41 of 52 general practitioners) participated.
Main outcome measures: Numbers of elderly people (60 years) with new prescriptions of highly anticholinergic antidepressants and less anticholinergic antidepressants.
Results: An intention to treat analysis found a 26% reduction in the rate of starting highly anticholinergic antidepressants in elderly people (95% confidence interval 4% to 48%) in the individual intervention arm and 45% (8% to 67%) in the group intervention arm. The use of less anticholinergic antidepressants increased by 40% (6% to 83%) in the individual intervention arm and 29% (7% to 79%) in the group intervention arm.
Conclusions: Both the individual and the group visits decreased the use of highly anticholinergic antidepressants and increased the use of less anticholinergic antidepressant in elderly people. These approaches are practical means to improve prescribing by continuing medical education.

	Introduction

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The need to improve rational prescribing is increasing, but many questions remain unanswered about how to achieve this goal.^1-3 Educational visits have been shown to modify professional behaviour. ^{4 5} They should consist of repeated personal visits that include feedback, present clear recommendations that are relevant to practice, and anticipate any implementation problems.^6-9 Not all characteristics of effective visits have been identified. ^{4 10}

Collaboration of doctors and pharmacists in regional groups is increasingly used to improve prescribing in several countries, ^{1 11-13} and it can be a cost effective way to disseminate new knowledge and guidelines. We selected antidepressant drugs for elderly people as the focus for the study because analyses of dispensing data¹⁴ and other studies¹⁵ have shown that a substantial portion of patients aged over 60 are prescribed highly anticholinergic antidepressants despite their greater susceptibility to hazardous side effects such as dry mouth, blurred vision, constipation, urinary dysfunction, hypotension, tachycardia, and cognitive impairment.^16-23 We wanted to increase the awareness of the vulnerability of elderly people to anticholinergic side effects and decrease the prescribing of highly anticholinergic antidepressants (such as tertiary amine tricyclics) in this group while encouraging the use of less anticholinergic antidepressants such as secondary amines or selective serotonin reuptake inhibitors when indicated.

We conducted a randomised controlled trial to compare the effect of individual versus group educational visits on the prescribing of highly anticholinergic antidepressants in people aged 60 or over.

	Participants and methods

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Study design
The trial methods are reported according to the CONSORT statement (on www.consort-statement.org) in the full version of this paper (BMJ 's website). To organise the group visits we used an existing system of peer review groups that fosters collaboration between Dutch pharmacists and general practitioners; similar initiatives exist in other countries.^11-13

View larger version (37K): [in this window] [in a new window]   Fig 1.   Flow chart of study

	Intervention

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The intervention was based on theories and experience usually referred to as social marketing or academic detailing. ^{4 5 6 10}

All doctors and pharmacists from groups assigned to the individual visit intervention arm were individually contacted by telephone. They were told of the aim of the study (to improve antidepressant prescribing in elderly people and measure the effectiveness of an educational programme) and invited to participate in the programme. For those who agreed, an appointment was made for a 20 minute visit with the lead investigator (MvE). This session emphasised the unique therapeutic difficulties of treating older people and the problems of anticholinergic side effects. Participants were given a leaflet containing an evidence based summary of the most important information.

All sessions were based on a priority list for issues to be discussed. Depending on the length of the visit and the responses of the professionals, the following items were discussed (in order): altered pharmacodynamics and kinetics in elderly people, ^{18 19} increased vulnerability of elderly people to side effects, ^{20 21} the need to avoid anticholinergic antidepressants in elderly people,²² and difficulties in diagnosing depression, especially in elderly people.¹⁷ The initial visits included no further comment on personal performance. At the end of each visit another appointment was made for about four months later. During the second visit a graph was provided showing personal performance and the proportion of prescriptions for anticholinergic antidepressant versus less anticholinergic antidepressants in three age categories: under 60, 60-70, and over 70 years old.

For the group intervention arm, all group coordinators were contacted to ask permission to use one full meeting for the educational programme. The content of these presentations was essentially the same as in the individual contacts. In the second meeting, a graph of accumulated prescribing in the group was shown and personal graphs were handed out.

Study outcome
We determined the periods before the educational visits, between the visits, and after the visits for each general practitioner in the region to allocate each incident patient to the right period for each general practitioner. Incidence rates (number of incident users/1000 person years) for use of highly anticholinergic antidepressants and less anticholinergic antidepressants were calculated for each general practitioner per period.

Statistics
The evaluation was done on an intention to treat basis. We used a Poisson regression model to estimate rate ratios of starting highly anticholinergic antidepressants and less anticholinergic antidepressants in elderly people in both intervention arms in relation to the control arm.

	Results

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Overall, 190 general practitioners and 36 pharmacists were working in the research area. We visited 69% of the general practitioners and 100% of the pharmacists in the intervention arms. In the individual visit intervention arm, 86% of the professionals visited were visited twice. Our request for a second appointment after the first visit was always granted, but the second visit did not take place on seven occasions. The average time spent per person was 14.6 minutes in the individual visit intervention arm. In the group intervention arm only one group was visited twice. Most groups first wanted to decide together whether and when they were going to join the programme, and there were large differences between groups in contact time (from 15 minutes once to a 1 hour twice).

Table 1 gives the baseline characteristics of the study population. In both intervention arms, incident use of highly anticholinergic antidepressants for patients aged  60 decreased during the study period, while in the control arm incident use increased (fig 1). Table 2 shows the rate ratios of incident prescriptions of anticholinergic antidepressants after correction for baseline rates and sex. All estimates showed a reduction in the prescribing of highly anticholinergic antidepressants in the intervention arms compared with the control arm. This reduction was more than 30% after two visits in the individual visit arm and more than 40% in the group visit arm. This decrease was significant for the group approach and for the combined effect of both interventions.

View larger version (20K): [in this window] [in a new window]   Fig 2.   Rate of incident prescriptions of highly anticholinergic antidepressants in people aged  60 before, during, and after the educational intervention (intention to treat analysis)

View larger version (19K): [in this window] [in a new window]   Fig 3.   Rate of incident prescriptions of less anticholinergic antidepressants in people aged  60 before, during, and after the educational intervention (intention to treat analysis)

In both intervention arms the incidence of prescribing less anticholinergic antidepressants for patients aged  60 years increased during the study period, while in the control arm the incidence decreased (fig 2). In the individual visit intervention arm, elderly patients were 100% more likely to start antidepressant treatment with a less anticholinergic antidepressant after the intervention (table 2). In the group visit intervention arm this figure was almost 70%.

	Discussion

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We have shown that both individual visits and group visits can improve the clinical appropriateness of prescribing behaviour in an area of suboptimal prescribingthe treatment of depression in elderly people. Both interventions had a similar effect that was not seen in the control arm: elderly people starting antidepressant treatment were more likely to receive drugs that were less anticholinergic.

Reasons for non-participation were diverse. For the group intervention it was mainly a time problem. Most groups eventually agreed to participate, but in some cases the intervention period had already ended. For the individual visits, reasons mentioned included shortage of time, a belief that the study should be initiated by the medical faculty rather than the faculty of pharmacy, and lack of motivation.

Validity of results
The data reported probably represent a low estimate of the potential of this approach. Anticholinergic versus non-anticholinergic antidepressant prescribing was a topical issue during the study.^25-28 Although we focused our intervention on use of anticholinergic antidepressants in elderly people, this controversy might have diluted the effect.²⁹

	Acknowledgments

We thank the general practitioners and pharmacists who participated in the study and OZ zorgverzekeringen and its employees for their continued assistance.

Contributors: MECvE initiated and coordinated the formulation of the primary study hypothesis, designed the protocol and was responsible for data collection, interpretation, analyses, and writing the paper. JA participated in the protocol design, interpretation of the data, and editing the paper. AJP initiated the research project, participated in the design of the study protocol, discussed core ideas and interpretation of the findings, and editing the paper. AdB participated in the design and execution of the study (particularly quality control) and statistical analyses and contributed to the paper. MECvE and AdB are guarantors for this study.

	Footnotes

Funding: This research was funded by the health insurance company OZ zorgverzekeringen.

Competing interests: None declared.

The full version of this paper appears on the BMJ's website. This article is part of the BMJ's trial of open peer review, and documentation relating to this also appears on the website

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(Accepted 1 December 2000)