Impact of Academic Detailing on Opioid Overdose Risk in the U.S. Veterans Health Administration
Opioid prescribing and overdose mortality have increased in Veterans in recent years, Strategies to address opioid overdose mortality included implementation of the Opioid Overdose Education and Naloxone Distribution (OEND) Program and the Opioid Safety Initiative (OSI). However, providers’ lack of knowledge, system barriers, and stigma prevented them from properly addressing the opioid epidemic within the Veterans Health Administration (VHA). The OSI and OEND Program collaborated with the VHA Pharmacy Benefits Management Academic Detailing Service to target providers for educational outreach with the goal of aligning their prescribing behavior with evidence-based practice to reduce and prevent opioid overdose mortality.
Academic detailing is an innovative, multifaceted, educational outreach intervention that educates prescribers through interactions with specially trained clinical pharmacists (academic detailers) using evidence-based research, educational brochures, and benchmarking tools with the goal of aligning prescribing behavior with best practices. Previous studies have reported that academic detailing increased naloxone and reduced opioid prescribing; however, there is no evidence to support that these changes resulted in a reduction in opioid overdose risk.
The VHA developed an opioid overdose risk prediction tool, “Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose (RIOSORD),” which provides an opioid overdose risk prediction for each patient using risk factors such as opioid dependence, use, and medical history. Academic detailers identified prescribers whose panels included high-risk patients (e.g., those with high RIOSORD scores, benzodiazepine-opioid combinations, and diagnosis of opioid use disorder), then arranged one or more visits with providers, and shared provider-specific naloxone- and opioid-prescribing data, along with population management tools (e.g., online clinical dashboards).
We investigated the impact of academic detailing on the average RIOSORD score for providers’ patient panels. We hypothesized that providers who received one or more academic detailing interactions (“exposed”) would better adhere to pain management guidelines, thereby decreasing the risk for opioid overdose in high-risk Veterans.
A repeated, measures retrospective cohort study was conducted to evaluate the monthly change in RIOSORD score between providers exposed and unexposed to academic detailing. Using VA Corporate Data Warehouse to collect data on pharmacy claims, provider characteristics, and patient risk scores between November 2014 and June 2017, we used a generalized estimating equations approach with a difference-in-differences analysis controlling for providers’ baseline characteristics (age, gender, tenure, provider type, practice site, and exposure duration). The outcome was monthly average RIOSORD score per provider’s patient-panel.
Altogether, 1,287 (16.8%) out of 7,653 providers received academic detailing for an average duration of 15 months per provider. On average, the providers’ patient-panel RIOSORD scores decreased from 15.2 to 13.4 points across the entire study period (P<0.001). The average reduction in RIOSORD score was significantly greater in providers exposed to academic detailing compared to providers unexposed to academic detailing (difference-in-differences) at -0.6 RIOSORD points over 15 months (95% CI: -0.9, -0.3; P<0.001).
Our findings suggest that academic detailing modified provider behavior to reduce opioid overdose risk and may be an important element in the overall strategy to prevent opioid overdose mortality. Future research will need to determine whether these findings are clinically significant.