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. 2025 Jan 7:6:26334895241307638.
doi: 10.1177/26334895241307638. eCollection 2025 Jan-Dec.

Changing or validating physician opioid prescribing behaviors through audit and feedback and academic detailing interventions in primary care

Celia Laur  1   2 , Natasha Kithulegoda  1   2 , Nicola McCleary  3   4 , Emily Nicholas Angl  5 , Michael Strange  6 , Barbara Sklar  6 , Thivja Sribaskaran  1 , Gail Dobell  7 , Sharon Gushue  7 , Jonathan M C Lam  7 , Lindsay Bevan  8 , Victoria Burton  8 , Lena Salach  8 , Justin Presseau  3   4   9 , Laura Desveaux  2   10 , Noah Ivers  1   2   11
Affiliations

Changing or validating physician opioid prescribing behaviors through audit and feedback and academic detailing interventions in primary care

Celia Laur et al. Implement Res Pract. .

Abstract

Background: In Ontario, Canada, province-wide initiatives supporting safer opioid prescribing in primary care include voluntary audit and feedback reports and academic detailing. In this process evaluation, we aimed to determine the fidelity of delivery and receipt of the interventions, the observed change strategies used by physicians, potential mechanisms of action, and how complementary the initiatives can be to each other.

Method: Semi-structured interviews were conducted with academic detailers and with physicians who received both interventions. Academic detailer interviews were coded using the Behavior Change Technique Taxonomy; physician interviews were coded to the Theoretical Domain Framework. Change strategies were summarized based on academic detailer intentions and physician-reported practice changes. Potential mechanisms of action were identified using the Theories and Techniques Tool and the literature. Patient partners informed the interpretation of results through ongoing group discussions of preliminary findings.

Results: Interviews were conducted with eight academic detailers and 12 physicians. Change strategies described by academic detailers to support physicians' opioid prescribing included problem solving, instructions on how to perform the behavior, adding objects to the environment, credible source, shaping knowledge, and social support. Physicians mentioned that academic detailing validated current opioid practices or increased their belief about capabilities and their intentions, mediated by increased skills and the impact of environmental context and resources. Potential mechanisms of action included behavioral regulation, behavioral cueing, and general attitudes/beliefs. On its own, receiving the audit and feedback report did not lead to changes in beliefs about prescribing practices; however, for some physicians, it provided validation and reassurance. Physicians saw unrealized potential for complementarity.

Conclusions: New interventions are often implemented in a complex ecosystem with other competing interventions. In this study, we show how examining the fidelity of the intervention from initial design through to delivery can identify opportunities for potential optimization.

Keywords: academic detailing; audit and feedback; behavior change; educational outreach; opioids; prescribing; primary care; process evaluation.

Plain language summary

Two large-scale programs that support safer opioid prescribing in primary care include an audit and feedback report and academic detailing (educational outreach). Although these two programs are effective in general, we aimed to help improve ongoing delivery. Interviews with academic detailers (pharmacists trained to support physicians to implement evidence-based best practices regarding opioid prescribing) and family physicians who received both programs were conducted to understand how these programs impact opioid prescribing. Physicians said that academic detailing either changed the way they prescribed by increasing their confidence and intentions to safely prescribe opioids more generally or validated their current prescribing practices. Physicians reported that academic detailing improved how they communicated with their patients about opioids. Although physicians did not say they changed their behavior after receiving the audit and feedback report, the report did provide physicians reassurance about how they were prescribing opioids. When asked about how these two programs worked together, academic detailers saw challenges, while physicians saw potential. This difference in opinion highlights the importance of considering how a new program fits within the system from the perspective of the developers, the recipients, and those impacted by the program. By examining both programs in detail, we identified if/how each program led to physician behavior change and suggestions for improvement. When designing new programs, and informing ongoing delivery, knowing how the program changed from initial design to final delivery can help identify opportunities for improvements.

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Conflict of interest statement

Nicola McCleary is currently affiliated with Child Health Evaluative Sciences Program, The Hospital for Sick Children – Research Institute, Toronto, ON, Canada; and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: GD, SG, and JL were employed by the organization administering the audit and feedback report at the time of the study. LB, VB, and LS were employed by the organization conducting the academic detailing at the time of the study. No other authors have a conflict of interest.

Figures

Figure 1
Figure 1
Summary of the full process evaluation, which began with document analysis and interviews with intervention developers. The results from the darkest colored boxes are presented separately (McCleary et al., 2023)
Figure 2
Figure 2
Physicians who increased their beliefs about capabilities and their intentions to improve their opioid prescribing practices following visits from academic detailers were all mediated by system factors within environmental context and resources. For some physicians, the use of the tools and patient handouts improved their skills, which then increased their beliefs about capabilities and intentions. These practice changes were all leading to physician self-reported improvements in opioid prescribing
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