Economic analysis of a randomized trial of academic detailing interventions to improve use of antihypertensive medications.

The authors estimated the costs and cost savings of implementing a program of mailed practice guidelines and single-visit individual and group academic detailing interventions in a randomized controlled trial to improve the use of antihypertensive medications. Analyses took the perspective of the payer. The total costs of the mailed guideline, group detailing, and individual detailing interventions were estimated at 1000 dollars, 5500 dollars, and 7200 dollars, respectively, corresponding to changes in the average daily per person drug costs of -0.0558 dollars (95% confidence interval, -0.1365 dollars to 0.0250 dollars) in the individual detailing intervention and -0.0001 dollars (95% confidence interval, -0.0803 dollars to 0.0801 dollars) in the group detailing intervention, compared with the mailed intervention. For all patients with incident hypertension in the individual detailing arm, the annual total drug cost savings were estimated at 21,711 dollars (95% confidence interval, 53,131 dollars savings to 9709 dollars cost increase). Information on costs of academic detailing could assist with health plan decision making in developing interventions to improve prescribing.

Clinical and nonclinical correlates of adherence to prescribing guidelines for hypertension in a large managed care organization.

To examine correlates of guideline adherence in a population with access to health care and prescription drug benefits, the authors conducted a cross-sectional analysis among 5789 patients undergoing hypertension treatment with a single medication in a large New England managed care organization. Logistic regression was used to determine correlates of adherence, defined as use of diuretics or beta blocker as antihypertensive monotherapy during the 1-year study period. Women were more likely than men to receive guideline-adherent therapy (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.45-1.85). Compared with patients covered by health maintenance organization plans, Medicare coverage was positively associated with guideline adherence (OR, 1.38; 95% CI, 1.13-1.69), but fee-for-service coverage was negatively associated (OR, 0.66; 95% CI, 0.48-0.91). Patient age was not a significant correlate of adherence to guidelines (OR, 1.01; 95% CI, 0.94-1.09). Understanding these observations may lead to strategies to improve guideline adherence and reduce health care disparities.

Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: a cluster-randomized controlled trial.

PURPOSE: To compare group versus individual academic detailing to increase diuretic or beta-blocker use in hypertension. METHODS: We conducted a cluster-randomized controlled trial in a large health maintenance organization. Subjects (N=9820) were patients with newly treated hypertension in the year preceding the intervention (N=3692), the 9 months following the intervention (N=3556), and the second year following intervention (N=2572). We randomly allocated 3 practice sites to group detailing (N=227 prescribers), 3 to individual detailing (N=235 prescribers), and 3 to usual care (N=319 prescribers). Individual detailing entailed a physician-educator meeting individually with clinicians to address barriers to prescribing guideline-recommended medications. The group detailing intervention incorporated the same social marketing principles in small groups of clinicians. RESULTS: In the first year following the intervention, the rates of diuretic or beta-blocker use increased by 13.2% in the group detailing practices, 12.5% in the individual detailing practices, and 6.2% in the usual care practices. As compared with usual care practices, diuretic or beta-blocker use was more likely in group detailing practices (adjusted odds ratio (OR), 1.40; 95% confidence interval (CI), 1.11 - 1.76) and individual detailing practices (adjusted OR, 1.30; 95% CI, 0.95 - 1.79). Neither intervention affected blood pressure control. Two years following this single-visit intervention, there was still a trend suggesting a persistent effect of individual (OR, 1.22; 95% CI, 0.92 - 1.62), but not group, detailing (OR, 1.06; 95% CI, 0.80 - 1.39), as compared with usual care. CONCLUSION: Both group and individual academic detailing improved antihypertensive prescribing over and above usual care but may require reinforcement to sustain improvements.

Measurement of prostate-specific antigen by use of a novel blood collection and analytical system.

BACKGROUND: Prostate-specific antigen (PSA) is widely used in the detection and monitoring of prostate cancer. We developed a system for the self-collection and transport of capillary whole blood for PSA analysis, with the goal of reducing phlebotomy visits and, thus, increasing the access and utilization of PSA in prostate cancer screening and monitoring. METHODS: The blood collection device [BIOSAFE Blood Transport System (BTS] collects 70 microL of blood through a heparin-coated material into 200 microL of stabilizing solution. The diluted whole blood is used for measurement of PSA by a modified version of the Hybritech Tandem-MP PSA Assay. Results were compared for matched samples of professionally and self-collected BTS blood and for matched BTS samples sera from blood collected by venipuncture. Imprecision for the whole-blood PSA measurement was estimated from analysis of whole-blood controls in duplicate, twice per day, over 20 days. RESULTS: BTS samples (n = 140) collected by a qualified healthcare professional compared with serum samples yielded the regression equation: y =1.02x + 0.04 (S(yx) = 0.35; r = 0.99). Comparison of the results for samples (n = 128) collected by the patient without professional assistance with serum samples yielded: y = 1.08x + 0.02 (S(yx) = 0.31; r = 0.99). The between-run CVs at 0.069, 0.53, 2.9, and 10.7 microg/L were 21%, 6.0%, 3.5%, and 3.8%, respectively. PSA was stable in BTS samples stored for 21 days at 18-24 degrees C and for 7 days at 37 degrees C. CONCLUSION: The BIOSAFE BTS system allows accurate and convenient measurement of circulating PSA by a precise method for diluted whole blood.