ICES, Toronto, Ontario, Canada.
Women's College Research Institute, Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.
JAMA Netw Open. 2020 May 1;3(5):e205724. doi: 10.1001/jamanetworkopen.2020.5724.
Strategies to reduce the inappropriate prescription of antipsychotics have been the focus of recent attention but have shown considerable variation in their effectiveness.
To evaluate the effectiveness of academic detailing in nursing homes targeting appropriate prescribing of antipsychotics.
DESIGN, SETTING, AND PARTICIPANTS: We conducted a pragmatic, cluster randomized clinical trial comparing the effect of academic detailing vs usual care on prescribing antipsychotics in 40 nursing homes with 5363 residents in Ontario, Canada. Data were collected from October 2015 to March 2016 and analyzed from April to August 2018. Primary analyses were conducted using intention to treat.
Academic detailing delivered by health professionals (eg, nurses or pharmacists) who arranged meetings (with administrators, physicians, pharmacists, nurses, and support workers), presentations, group visits (with 2-6 clinicians), and 1-on-1 visits (traditional academic detailing visits). Academic detailers had direct and ongoing contact with the nursing homes from the time of launch.
The primary outcome, defined at the level of the resident, was whether continuous antipsychotics were dispensed in the past week. Secondary outcomes included prescribing of other psychotropic medications and clinical outcomes and scores. Prescribing outcomes were assessed at baseline and at 3, 6, and 12 months, and clinical outcomes and scores were assessed at baseline and 3 and 6 months.
A total of 40 nursing homes with 5363 residents were randomized, with 18 intervention homes (45.0%; 2303 [42.9%] residents) and 22 control homes (55.0%; 3060 [57.1%] residents). Participants in the intervention and control groups had similar median (interquartile range) age (86 [79-91] years vs 85 [78-90] years) and sex (674 [29.3%] men vs 970 [31.7%] men). At 12 months, there was no statistically significant difference in the frequency of daily antipsychotic use (intervention: 569 patients [25.2%]; control: 769 [25.6%]; odds ratio, 1.06; 95% CI, 0.93-1.20; P = .49). There were no significant differences in the rates of health care utilization, but the intervention group did experience a statistically significant reduction in pain compared with the control group (mean [SD] pain score, 0.30 [0.59] vs 0.38 [0.66]; P < .001) and depression (mean [SD] Depression Rating Scale score, 2.18 [2.37] vs 2.81 [2.65]; P < .001) at 6 months.
The intervention did not further reduce antipsychotic prescribing in nursing homes beyond system-level secular trends occurring alongside usual care. Our findings highlight the need for a more targeted approach to quality improvement strategies, including academic detailing, that account for the timing and topic of interventions.
ClinicalTrials.gov Identifier: NCT02604056.
最近，人们一直关注减少不合理使用抗精神病药物的策略，但这些策略的有效性存在很大差异。
评估针对养老院中抗精神病药物合理处方的学术细节干预的效果。
设计、地点和参与者：我们进行了一项实用的、集群随机临床试验，比较了学术细节干预与常规护理对安大略省 40 家养老院 5363 名居民中抗精神病药物处方的影响。数据于 2015 年 10 月至 2016 年 3 月收集，并于 2018 年 4 月至 8 月进行分析。主要分析采用意向治疗。
由卫生专业人员（如护士或药剂师）提供学术细节干预，包括安排会议（与管理人员、医生、药剂师、护士和支持工作人员）、演示、小组访问（与 2-6 名临床医生）和一对一访问（传统学术细节访问）。学术细节人员自启动以来一直与养老院保持直接和持续的联系。
主要结局是在居民层面定义的，即过去一周是否连续开了抗精神病药物。次要结局包括其他精神药物的处方和临床结局和评分。在基线和 3、6 和 12 个月时评估处方结局，在基线和 3 和 6 个月时评估临床结局和评分。
共有 40 家养老院的 5363 名居民被随机分配，其中 18 家干预组（45.0%；2303 [42.9%] 名居民）和 22 家对照组（55.0%；3060 [57.1%] 名居民）。干预组和对照组参与者的中位（四分位距）年龄（86 [79-91] 岁与 85 [78-90] 岁）和性别（674 [29.3%] 名男性与 970 [31.7%] 名男性）相似。在 12 个月时，抗精神病药物的每日使用率没有统计学上的显著差异（干预组：569 例患者[25.2%]；对照组：769 例[25.6%]；优势比，1.06；95%置信区间，0.93-1.20；P = .49）。两组的医疗保健利用率没有显著差异，但与对照组相比，干预组的疼痛评分（平均[标准差]疼痛评分，0.30 [0.59] 与 0.38 [0.66]；P < .001）和抑郁评分（平均[标准差]抑郁评分量表评分，2.18 [2.37] 与 2.81 [2.65]；P < .001）在 6 个月时显著降低。
干预措施并没有在常规护理之外进一步减少养老院中抗精神病药物的使用，而常规护理则与系统层面的季节性趋势同时发生。我们的研究结果强调了需要采取更有针对性的方法来改进质量策略，包括学术细节，以考虑干预的时间和主题。
ClinicalTrials.gov 标识符：NCT02604056。
