Impact of Academic Detailing on Benzodiazepine use among Veterans with Posttraumatic Stress Disorder

Abstract

Background: Benzodiazepine use in the US Veterans Administration (VA) has been decreasing; however, a small number of veterans with posttraumatic stress disorder (PTSD) continue to receive benzodiazepine. Academic detailing, a targeted-educational outreach intervention, was implemented at VA to help reduce the disparity between existing and evidence-based practices, including the reduction in benzodiazepine use in veterans with PTSD. Since evidence to support the national implementation of academic detailing in this clinical scenario was scarce, we performed a quality improvement evaluation on academic detailing's impact on benzodiazepine use in veterans with PTSD. Methods: A retrospective cohort design was used to evaluate the impact of academic detailing on benzodiazepine prescribing in veterans with PTSD from January 1, 2016, to December 31, 2016. Providers exposed to academic detailing (AD-exposed) were compared with providers unexposed to academic detailing (AD-unexposed) using generalized estimating equations (GEEs) controlling for baseline covariates. Secondary aims evaluated academic detailing's impact on average lorazepam equivalent daily dose (LEDD), total LEDD, and benzodiazepine day supply. Results: Overall, there was a decrease in the prevalence in benzodiazepine use in veterans with PTSD from 115.5 to 103.3 per 1000 population (P < .001). However, the decrease was greater in AD-exposed providers (18.37%; P < .001) compared with AD-unexposed providers (8.74%; P < .001). In the GEE models, AD-exposed providers had greater reduction in the monthly prevalence of veterans with PTSD and a benzodiazepine prescription compared with AD-unexposed providers, by À1.30 veterans per 1000 population (95% confidence interval [CI]: À2.14, À0.46). Similar findings were reported for the benzodiazepine day supply; however, no significant differences were reported for total and average LEDD. Conclusions: Although benzodiazepine use has been decreasing in veterans with PTSD, opportunities to improve prescribing continue to exist at the VA. In this quality improvement evaluation, AD-exposed providers were associated with a greater reduction in the prevalence of veterans with PTSD and a benzodiazepine prescription compared with AD-unexposed providers.

Tracking implementation strategies in the randomized rollout of a Veterans Affairs national opioid risk management initiative

“…In addition to the specific survey-defined strategies that were actively used during implementation, we found that pre-implementation academic detailing was one of the strongest predictors of case review completion. Academic detailing is, in and of itself, an evidence-based, multi-component implementation strategy that includes needs assessments, education, and focused training and has contributed to successful implementation efforts across a number of domains [24,[28][29][30][31]. In VA, academic detailing is typically conducted by clinical pharmacists, who deliver face-to-face, 1-on-1 training.…”

Secondary Effects of an Opioid-Focused Academic Detailing Program on Non-Opioid Controlled Substance Prescribing in Primary Care

“…BZD-focused AD programs have been associated with reductions in BZD, although demonstrated among prescribers who care for the veteran population. 24 In terms of policy initiatives at the health system level, delivery of focused education on evidence-based guidelines for BZD prescribing, risks of BZD use, and alternative pain management options may be important components to integrate into opioid-focused AD programs to help address inappropriate prescribing of BZD. Additionally, incorporation of clear, actionable guidance into opioid-focused AD programs on how to use the data found in state PMPs may help to facilitate informed clinical decision-making.…”

Tracking Implementation Strategies in the Randomized Rollout of a Veterans Affairs National Opioid Risk Management Initiative

“…Academic detailing is, in and of itself, an evidence-based, multi-component implementation strategy that includes needs assessments, education, and focused training and has contributed to successful implementation efforts across a number of domains. 24,[28][29][30][31] In VA, academic detailing is typically conducted by clinical pharmacists, who deliver face-to-face, 1-on-1 training. Our ndings support the notion that academic detailing is effective as a preimplementation, or "preparation" strategy, as we found that academic detailing measured prior to implementation was associated with the outcome.…”