‘House Calls’ to Educate Doctors Can Affect How They Practice

By Star Lawrence, Contributing Writer
Health Behavior News Service

Educational outreach visits — to scrutinize firsthand how doctors perform procedures, prescribe drugs, assess patients for health risks and give advice — could improve the way that some physicians practice medicine.

In a systematic review comparing 69 studies using trained individuals to go out to doctors’ offices or hospitals, researchers found that of the 15,000 health professionals on the receiving end, about 4 percent did change their behavior following the visits.

Spread over thousands of physicians and patients, this approach could be useful in improving patient outcomes, according to lead investigator Mary Ann O’Brien, a research fellow at the Support Cancer Care Research Unit, Juravinski Cancer Center and McMaster University in Ontario, Canada.

Also referred to as “educational detailing,� doctors or nurses usually make educational outreach visits (EOVs), unlike the detailing visits by drug company representatives (although a drug company employee did make an educational visit to a physician in one of the review studies).

The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The current look was an expansion of a previous examination of education outreach visits published by The Cochrane Collection. The review includes studies conducted in the United States, Canada, the United Kingdom, Europe, Australia, Indonesia and Thailand.

One study intervention included talking to a physician about the benefits of evaluating cardiovascular risk in patients. As done with other visits, the educational outreach visitor called ahead to request an appointment.

This visit might have come about to discover why the doctor was not assessing risk in more patients, O’Brien said. Maybe, she said, the doctor did not know how to assess risk or was accustomed to prescribing certain drugs and not others.

In a hospital setting, groups of professionals might undergo the educational session.

Other studies delved into such practices as giving anticholinergic antidepressants to people over age 60, NSAIDs (such as aspirin or Tylenol) to those with osteoarthritis and alcohol cessation advice to patients who needed it. Some studies targeted doctors who did not comply with best practices; others did not.

O’Brien said that in every study, the doctors and practices visited agreed to this onsite scrutiny. This advance receptivity led researchers to believe that the visits, or in many cases, the single visit, would result in more health professionals changing their behavior.

O’Brien said she was surprised that the rate of changes in practice was not higher. “These are doctors who agreed to participate,� she said. “Would rates be lower in those who were not part of a trial?�

More than one visit might be necessary to have an affect, O’Brien suggested, and in some studies the visitors did return and offer the doctor feedback or an audit of his or her practice or. In one trial, visitors put cardiovascular risk software on the doctor’s computer. In another case, a phone call about the session followed the EOV on alcohol cessation, which resulted in greater likelihood that the doctor would raise the subject with patients.

Because the change in behavior after the educational outreach visit was consistent across studies, O’Brien concluded: “Overall, our results show that EOVs are effective, although the effect may be small.�

The data did not indicate whether any particular method of doing an educational outreach visits was superior. O’Brien said. “We need to look into that. EOVs may need to be accompanied by other interventions.�

The review noted that sending health professionals to make visits was expensive in some cases, and the increment of improvement in patient outcomes would have to justify the expense. However, the review studies seldom assessed patient outcomes or if the changes in physician behavior were lasting.

According to this review, other research suggests that “social marketing,� such as using visitors who are “opinion leaders,� developing detailed objectives of change desired, establishing credibility with physicians, using concise educational materials and repeating simple messages might facilitate more change as a result of EOVs.

“Tying to improve practice should be ongoing and routine,� O’Brien said. “Obviously, these visits are not magic bullets.�
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