Examining the Role of Academic Detailing in Improving Immunization Practices

Academic detailing is an educational approach intended to create sustainable practice change and improve decision making.¹ Through academic detailing visits, health care providers share tailored material with each other, with the goal of encouraging the use of evidence-based guidelines. The academic detailing model was developed by faculty from Harvard Medical School in the 1980s. For the model to be successful, there must be a focused problem that can be addressed through educational outreach and a well-defined target audience. Interactive learning is emphasized with repetition and reinforcement of key points.²

For those interested in learning more about academic detailing, the National Resource Center for Academic Detailing (NaRCAD) is a useful guide.³ NaRCAD was founded in 2010 and operates as part of Brigham and Women’s Division of Pharmacoepidemiology and Pharmacoeconomics.⁴ This resource center supports clinical outreach education programs across the United States and internationally,³ offering information about live training programs, an online core toolkit, material created during previous successful academic detailing projects, and a blog written by health care providers actively engaged in providing detailing to address a variety of medical issues.³

UTILIZING ACADEMIC DETAILING TO IMPROVE IMMUNIZATION RATES

Academic detailing has shown promise as a method for improving immunization rates. A national pneumococcal vaccination task force found that barriers to vaccination included provider vaccine knowledge gaps and failure to assume responsibility for patient vaccination.⁵ Academic detailing can be utilized to engage providers on both of these issues. According to the National Foundation for Infectious Diseases, there are 4 key barriers to vaccinating adults with chronic conditions⁶:

• Addressing other competing priorities during patient visits
• Lack of ownership to educate
• Difficulty determining vaccination status
• Complexity of recommendations

Competing priorities during patient visits create difficulty in integrating adult vaccination screening, education, and administration.⁶ To address these issues, providers must become efficient at recognizing the vaccination needs of a patient, which is a task that can be addressed through academic detailing.

The results of a study to identify barriers and facilitators of pneumococcal vaccination in older adults demonstrate that of those patients who were not vaccinated for pneumococcal pneumonia, three-quarters believed their physician either did not think they should be vaccinated or they did not know their provider’s position on the vaccine.⁷ One of the major predictors of vaccination success is having a vaccination recommendation from a health care provider.^8,9 Using academic detailing to enhance awareness of the current immunization guidelines and taking steps to ensure physicians and other patient-care providers will endorse vaccinations are crucial to improving immunization rates.

UTILIZING ACADEMIC DETAILING TO IMPROVE PROVIDER KNOWLEDGE

From November 2013 through June 2015, a pharmacist-led academic detailing team reached out to more than 400 practice sites in Rhode Island.¹⁰ The goal of this statewide education campaign was to increase knowledge and awareness of pneumococcal immunization recommendations. The results were measured using multiple metrics. After participating in the academic detailing, providers were asked to participate in an anonymous 6-question survey. The results showed 92% of providers agreed or strongly agreed to having improved knowledge of identifying patients needing a pneumococcal vaccine, 83% of participating providers intended to apply the knowledge in their clinical practice, and 73% expected to change their vaccination practices as a result of the academic detailing and education materials.¹⁰

In addition to the survey, the research team compared state vaccination rates from 2013-2015. During this time, a statistically significant increase in pneumococcal immunization rates was seen in Rhode Island: The state had a 5.4% jump compared with 4.3% nationally. Additionally, a statistically significant decrease in the number of patients admitted to a hospital for pneumococcal disease was observed from the pre-intervention period to the postintervention period.¹⁰

In a separate study in Washington state beginning in 2016, an interprofessional team comprising 5 faculty members from 2 universities (Washington State University and the University of Washington) and 3 health disciplines (medicine, nursing, pharmacy) collaborated to provide academic detailing. The goal of this project was to improve rural medical staff knowledge about pneumococcal immunization rates.¹¹ The team developed academic detailing material to inform an interdisciplinary provider base about appropriate use of 2 adult pneumococcal vaccines.¹¹ Two members of the project team attended a 2-day academic detailing training program at NaRCAD to gain skills with developing and presenting academic detailing material.⁸ Then the research team met with physicians from 2 local clinics, with the goals of learning about current pneumococcal immunization practices and inquiring about what educational materials would be useful to the clinic personnel. The interprofessional team created academic detailing materials using Avorn’s 3-step approach¹:

• Utilize literature and guidelines
• Create relevant and accessible materials
• Share material through academic detailing visits presented by trained providers

The results showed the detailing materials were well received at both clinic locations. One physician stated in an email, “What I have found is that if I advocate for [immunizations], most of my patients just do them—they say something like ‘Do you think I should?’; [and] I respond with ‘Yep’ and that is almost always the end of the conversation... Who would guess that is all it takes?”

CONCLUSION

Although more studies are needed to confirm the success of academic detailing in improving immunization practices and increasing immunization rates, this novel educational approach shows promise. Existing research demonstrates improvement in immunization rates and provider knowledge and a decrease in the prevalence of vaccine-preventable diseases.

KIMBERLY MCKEIRNAN, PHARMD, BCACP, is a clinical assistant professor in the department of pharmacotherapy at the Washington State University College of Pharmacy and Pharmaceutical Sciences.

REFERENCES

• Avorn J. Academic detailing; “marketing” the best evidence to clinicians. JAMA. 2017;317(4):361-362. doi: 10.1001/jama.2016.16036.
• Soumerai SB, Avorn J. Principles of educational outreach (‘academic detailing’) to improve clinical decision making. JAMA. 1990;263(4):549-556.
• About us. NaRCAD website. narcad.org/about-us.html. April 17, 2019.
• Division of Pharmacoepidemiology and Pharmacoeconomics. Brigham and Women’s Hospital website. drugepi.org. Accessed April 17, 2019.
• Rehm SJ, File TM, Metersky M, Nichol KL, Schaffner W; National Foundation for Infectious Diseases Pneumococcal Disease Advisory Board. Identifying barriers to adult pneumococcal vaccination: an NFID task force meeting. Postgrad Med. 2012;124(3):71-79. doi: 10.3810/pgm.2012.05.2550.
• National Foundation for Infectious Diseases. Call to action: preventing pneumococcal disease in US adults with chronic conditions. NFUD website. adultvaccination.org/professional-resources/pneumo/cta-chronic-conditions.pdf. Published July 2015. Accessed April 17, 2019.
• Zimmerman RK, Santibanez TA, Fine MJ, et al. Barriers and facilitators of pneumococcal vaccination among the elderly. Vaccine. 2003;21(13-14):1510- 1517.
• National Vaccine Advisory Committee. A pathway to leadership for adult immunization: recommendations of the National Vaccine Advisory Committee: approved by the National Vaccine Advisory Committee on June 14, 2011. Public Health Rep. 2012;127(suppl 1):1-42.
• Koch JA. Strategies to overcome barriers to pneumococcal vaccination in older adults: an integrative review. J Gerontol Nurs. 2012;38(2):31-39. doi: 10.3928/00989134-20110831-03.
• Caffrey AR, DeAngelis JM, Ward KE, et al; Rhode Island Pharmacy Pneumococcal Vaccination Education Group. A pharmacist-driven academic detailing program to increase adult pneumococcal vaccination. J Am Pharm Assoc. 2018;58(3):303-310. doi: 10.1016/j.japh.2017.08.010.
• McKeirnan K, Colorafi K, Panther S, Potyk D, McCarthy J. Teaching the healthcare team about pneumococcal vaccination practices for older adults through academic detailing. Sr Care Pharm. In press.