Academic detailers’ and general practitioners’ views and experiences of their academic detailing visits to improve the quality of analgesic use: process evaluation alongside a pragmatic cluster randomized controlled trial

Among the GPs who received an AD visit, we purposively sampled 20 GPs to obtain a range of GPs from the different regions in Belgium. GPs were invited to participate in the study by the academic detailer and all were asked to participate until we had sufficient participants. If a GP agreed to participate they were telephoned by a researcher.

All 17 academic detailers who were involved in the visits on this topic were asked to participate in an interview, however only 13 were available at the time of interviewing. Participants were unaware of the trial results at the time of interview. The ethics committee of the University of Antwerp – Antwerp University Hospital granted ethics approval for the study (B300201317018).

We interviewed participants face-to-face in their own practice or at an agreed location after informing them about the study, for example advising them that all interview data would remain confidential and anonymous, and receiving written consent to take part in the study. Interviews followed a semi-structured interview guide, which was developed collaboratively by the team and then translated into French. Interview questions asked how GPs experienced their AD visits, how they integrated the information into their consultations and what was most helpful for them in caring for their patients. The academic detailers were asked how they experienced these visits, how they handled these visits, what worked well and not so well for them and how they could improve these visits. The two experienced interviewers had a meeting prior to the interviews to standardize the interview approach. The interviews were conducted in the respective languages. The interviewers were familiar with the intervention content, although they had not designed the intervention themselves. All interviews were digitally recorded and transcribed verbatim.

We used inductive thematic analysis [17‐19]. During the first stage the researcher (SA) read the dataset recursively to develop a preliminary coding structure. SA identified segments of text related to the research question and labelled these to create initial codes. She renamed and refined codes as further transcripts were coded. In the following stage she examined codes for similarities and differences and grouped codes accordingly to create categories and a thematic framework. She added a description of each theme and sub-theme, along with quotes to support each. In order to ensure the clarity of the themes, the research team, interviewers (SA and O.S) and the project leader of Farmaka discussed, refined and confirmed this coding structure. NVIVO10 was used to facilitate coding.

We had to invite 34 GPs in order to have 20 GPs participating in interviews lasting from 30 min to 65 min. Of these, 12 were male and 8 female with ages ranging from 32 years to 60 years. They had two to three AD visit per year. Apart from one GP, they all also received visitors from the pharmaceutical industry with a frequency ranging from once a week to three to four visitors per working day.

The interviewed GPs are positive towards these visits. They are an efficient and pleasant method of CME in their busy daily working lives. They view the ADs as knowledgeable professionals regardless of their educational background and regard them as equals even though they are not necessarily GPs. Some even see it as a bonus that the academic detailers have different background as this stimulates the discussion. The academic detailers appear credible and have a good overview of the entire topic, always related to primary care. This is in contrast to the many visits the GPs still receive from medical representatives of the pharmaceutical industry who only know the product they want to sell and have limited knowledge on the topic as a whole. These pharmaceutical visits are not seen as a discussion between peers. Yet, the information from the industry is also valuable to them, as it keeps the GPs up to date on the newest medications on the market. Through the AD, the GPs learn to reflect critically on the messages they receive from the pharmaceutical industry and take the evidence presented to them with a pinch of salt.

“I receive an AD now once every three months, and for me that's really a ‘breath of fresh air, so to speak, it's a refreshing and a fun interlude in between my daily activities. They are very up to date with the issues and they present it in its completeness especially tailored to primary care. I think that is a very good thing, because when I am very busy I sometimes see up to two commercial representatives in a morning session, sometimes even more and that is not very nice at all.”(H6)

“I think that the greatest merit is that these visits are giving a ‘global synthesis’, a problem such as osteoarthritis is being presented as a whole, schematically presented, with easy to follow steps, all clarified, it gives you a good plan and a good balanced fact sheet with the pros and cons.” (H13)

The participants find all primary care topics relevant as long as they are well documented and relevant to general practice as well as frequently encountered in their clinical care. They find it invaluable to discuss topics that they know well to make them reflect on their embedded routine behavior.

“Yes it is useful because the topic of osteoarthritis or other topics that they have presented, they are very common problems in our practice and the presentations are basics and it is always useful that we GPs are being reminded of the basics again. By force we work by habit…” (H11)

The GPs feel confident about their management of arthrosis and admit that they do not often reflect on their own prescribing behavior. They do find the structured suggestions in the presentation easy to apply in daily practice, but acknowledge that GPs always need to balance out and discuss with their patient what is achievable or acceptable for them. For the GPs, the presentation includes both new and relevant information and it clarifies some earlier misconceptions, especially about the safety issues of analgesics. Some GPs notice that they have not yet experienced any difficulties yet in their practice. However, they are eager to use that information and find the explanation of the risks of certain medication useful. When contrasting their own prescribing behavior with the EBM recommendations, the mismatches trigger them to reflect on it. However, they acknowledge that actively changing behavior is not that easy and straightforward. Having the information is one thing. In order to adapt to it, GPs need the necessary tools.

“I think I still use a lot of anti-inflammatories and that I put too little emphasis on regular analgesia, physiotherapists, good mobilization, weight, avoid overload, and so on. These are matters which I partially knew, but the information on anti-inflammatories were of course an 'eye-opener' to me, of course, they usually lead to patient satisfaction, mostly anyway, but I will still try to go easier on them .... You will recall certain things which it is good and you will see confirmation of things that you already thought you knew or things that you didn’t know. The topic of osteoarthritis was actually good.” (H6)

“Sometimes I do think, strange I have never really encountered this in my practice, or the presentation seems different from my management, and then I do not find it easy to change my behavior. Because I do not always experience these disadvantages, and that is a difficult one, because on the one hand, I really want to do well, but on the other hand, it is going well the way I am doing it now, why would I change my behavior. It is always difficult to balance that out (…)But I do think, one thing that has stuck and I will change this immediately with new patients, is that I will be a lot more restrained with prescribing NSAIDs, that I have definitely picked that up from the presentation.” (H3)

Overall, GPs are very positive and keen towards the visits. If possible they would prefer more visits as these are an easy and pleasant way to keep up to date with good practice. The GPs support the views of the academic detailers that the relationship between the academic detailer and the GP is built on trust and the frequency of the AD visits, and that a good relationship as well as group discussions enhances the interaction between GPs and academic detailers, therefore creating more in-depth discussions. Interactions with colleagues can enhance the peer learning as well as the reflection process. Stimulating questions or reflections from peers on how they handle or encounter these issues in day to day practice can enhance the discussion with the AD. The leaflet can act as and this is appreciated by the GPs as it is concise and up to date. However, they admit that they rarely look at it again and that it is often buried under the usual piles of paper. Yet, they have no suggestions for improvement as they like the format. GPs find it very practical that at the end of the session, a future appointment is scheduled in their diaries.

“Each time the presentations become more interactive, because luckily enough it is always the same lady, we are starting to get to know each other a bit better, and then automatically the session becomes more interactive. In the beginning my colleague and I were just good listeners; we were both just sitting quietly. She then asked whether we had any questions, but we didn’t really dare to ask any questions. That has completely changed now, if she explains something, and I am not sure whether i have understood it well, or i have a different idea about it I will ask for more explanation. She has always presented it in an interactive way, but I think you need to have that trusting relationship first before you can have a good interaction. I very much appreciate it that it is always the same person.” (H2)

“It would be good not to have just individual sessions, but also group sessions, because in my experience, you generate more questions from group discussions, you create a certain dynamic, now i sometimes feel I am a bit stuck on my chair by myself, I would prefer and I also think it is an essential element to have that group dynamic.” (H4)

To date the AD visits have been delivered as a stand-alone intervention. However, it has been shown that a multifaceted strategy may increase the likelihood that efforts to improve in GP practice will be successful [2]. It was interesting to find that both GPs and academic detailers preferred (more) interaction, since there is evidence from systematic reviews that CME activities are effective for improving GPs performance and patient outcomes if they are highly interactive and involve multiple exposures [7]. In a recent systematic review, the authors state that the most effective interventions call for coherence but also emphasize collective action and reflexive monitoring. These interventions provide mechanisms for participants to relate their performance to external reference group expectations, and create opportunities for reinforcing internal peer group norms [20]. Therefore, feedback about their prescribing behavior in relation to their peers might optimize the intervention and also stimulate the discussion [19, 20].

Habraken et al. found that Belgian physicians highly rated AD visits. Approximately 90% of those who used the ADS wished to use it again [11], which is in accordance with our findings. GPs were eager to schedule new appointments and would rather have more visits than a decline in the number of visits. Habraken et al. also identified the following barriers to participation: the information was not new or could be obtained in other ways, the information was politically colored and designed to cut expenses, and the educational visits were time-consuming [11, 15]. Also in the study by Allen M, GPs did not see AD as efficient and convenient [21]. Our findings suggested that AD visits are perceived as an efficient and convenient way of participating in CME. The educational background of the AD seems appropriate and is valued. Yet, in addition to the content expertise they have, the process expertise – knowing how to effect behavior changes and knowing how to communicate information in ways that promote evidence-based care – seems to be lacking [22, 23] and is reflected in the RCT results [16]. Special training might be critical to improve the expected outcomes.

This study provides a valuable insight into GPs’ and academic detailers’ perceptions of their AD visits. It is a strength of the study that the views of the GPs and ADs can be compared.

All academic detailers were interviewed. The sampling of GPs was restricted by the resources of this study and sampling in the intervention arms was prioritized. As a result GPs who were not willing to receive an AD visit, were not interviewed.

Academic detailers contacted the GPs themselves to ask for their agreement to take part in the study. These GPs are probably more favorable towards AD than the general population of GPs. Our findings should be interpreted in the light of this possible bias. However, we were encouraged to find that all participants in this study freely reported their negative views on aspect of the visits, indicating that they were comfortable critiquing or giving feedback about their AD visit and Farmaka’s ADS.

Overall these findings suggest that the visits of the academic detailers on the topic of NSAIDs are a well-accepted intervention. It is an appreciated way of independent CME and a counterbalance to the frequent visits of the pharmaceutical industry. Individual contacts are valuable, but peer interaction in a small group could enhance discussion and increase reflection on their prescribing behavior. At the time of the interviews, the ADs were not actively working towards changing behavior and were using the visits to inform the clinicians. In addition to content expertise, they should be trained in knowing how to effect behavior change, i.e. communicate information in ways that is more than just informative. They should receive training on communication and interpersonal skills to overcome anticipated GP barriers to behavior change. Audit and feedback information could enhance reflection of GPs prescribing behavior and could be a basis of interaction and discussion. Repetition of information is necessary to achieve change in behavior, different organizations need to give similar messages, multiple exposures are necessary in order to achieve change. A low intensity approach is not likely to produce change.