William Shrank M.D. MSHSDivision of Pharmacoepidemiology &

Pharmacoeconomics Brigham & Women’s Hospital, Harvard

Medical School

The problemLimited data when drugs first approved

with limited relevance to many patients

Physician data overload

hundreds of important drug-related papers published each month

Imbalanced information

Need for non-product-driven overviews

delivered in a clinically relevant, user-friendly way

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Clinical trialsUsually doesn’t provide head-to-head comparative data

about relevant Rx choices

A drug that achieved a surrogate outcome may not produce expected clinical benefit

e.g., Avandia (rosiglitazone) and M.I.

Unanticipated adverse effects are likely

e.g., Vioxx (rofecoxib)

Use differs in trials vs. actual practice

Efficacy vs. effectiveness

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Information overloadDozens of biomedical journalsPhysician time constraintsSystematic overviews

cover selected fields, but…are lengthy, abstruse hard to wade throughmay not be recently updated

Some important findings not in journalsFDA alerts, ‘Dear Doctor’ lettersimportant trial data presented at clinical

meetingsunpublished results

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Information imbalance

Trial design, promotion, CME favor use of new, costly drugs

Needed head-to-head comparative studies often not performed

Most drug information comes from industry$30 billion per year on promotion2/3rds of continuing medical education is

industry-funded

Industry-generated information

A dominant source of drug information often only available source for new products

Main purpose is to increase sales, so promotes positives not negatives

Industry sales representativesmost have little scientific trainingmost are paid on commissionmessages may be skewed to favor product

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Does promotion work?

Yes!

Clear evidence that sales reps and samples change prescribing

Social science literature shows the persuasive effects of relationships, gifts symbolic power of even small giftsreciprocal obligation

Marketing promotes costliest products

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…delivered in a relevant, convenient, user-friendly way

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The goal of academic detailing

to close the gap between the best available evidence

and actual prescribing practice, so that each prescription is based

only on the most current and accurateevidence about efficacy, safety,

and cost-effectiveness.

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• Academia:– MD comes to us– Didactic – Content ornate, not

clinically relevant– Visually boring– No idea of MD’s

perspective– Evaluation: minimal– Goal: ????

• Drug industry:– Go to MD– Interactive– Content is simple, straightforward,

relevant – Excellent graphics– MD-specific data

informs discussion– Outcome evaluated,

drives salary – Goal: behavior change

Two different worlds

Academic detailingSynthesizes up-to-date evidence about comparative

efficacy, safety, and cost-effectiveness of commonly used drugs

Content independently created by medical school faculty and practitioners

MDs, pharmacists and nurses provide information interactively, in physicians’ own offices

A time-efficient way to keep up with new findings

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• Well trained clinicians (pharm, RN, MD) visit prescribers in their offices and offer a service that provides independent, unbiased, non-commercial, non-product-driven, evidence-based information about the comparative benefit, safety, and cost-effectiveness of drugs used for common clinical problems.

The content of academic detailing

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• Information is provided interactively– generally in the doctor’s own office

• This enables the educator to– understand where the MD is coming from in

terms of knowledge, attitudes, behavior– modify the presentation appropriately– keep the prescriber engaged

• The visit ends with specific practice-change recommendations.

• Over time, the relationship becomes more trusted and useful.

The method of academic detailing

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Where Academic detailing is now

USA Programs initiated by

Government/insurer payors Pennsylvania – Aged Care South Carolina – Medicaid Vermont – Medicaid California – Kaiser

Permanente Programs with legislated

backing Maine District of Columbia New York State Massachusetts New Hampshire

National – Legislation from the US Senate Special Committee on Aging

Australia A nation-wide program using

academic detailing as a spearhead for multiple practice improvement strategies

Canada British Columbia Saskatchewan Nova Scotia Manitoba Alberta

United Kingdom Sweden New Zealand

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• A mass of AD literature has developed in last 25 years

• A large systematic review in in 2007 confirmed efficacy of AD

• Effectiveness varies with quality of execution – like brain surgery

Status of the evidence

Academic detailing- Does it work? O’Brien MA, Rogers S, et al. Educational outreach visits:

effects on professional practice and health care outcomes. Cochrane, Database of Systematic Reviews 2007, Issue 4

69 high quality studies of ‘educational outreach visits’ prior to March 2007

“Educational outreach visits with or without the addition of other interventions can be effective in improving practice in the majority of circumstances, but the effect is variable.”

Dichotomous outcomes: Median adjusted effect overall: 5.6%: (n=34, interquartile range 3% to

9%) Median adjusted effects for non-prescribing outcomes : 6.0%: (n=17,

interquartile range 4% to 16%) Continuous outcomes

Median adjusted effects: 21% (n=18, interquartile range 11% to 41%)

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Is it cost-effective?Economic analysis of the original 1983 research which

coined the term ‘academic detailing’ found that for each $1 spent on their academic detailing program $2 was saved in Medicaid drug expenditures.1

When evaluating global primary care clinical practice changes in a large British study of academic detailing, cost effectiveness was still demonstrated even where only modest overall effect sizes were observed.2

Independent economic study of an Australian DATIS service-oriented academic detailing program showed that between $5 and $6.50 of direct health expenditure was saved for each $1 spent delivering the program.3

1. Soumerai SB, Avorn J. Economic and policy analysis of university-based drug "detailing". Med Care 1986;24(4):313-31.2. Mason J, Freemantle N, Nazareth I, Eccles M, Haines A, Drummond M. When is it cost-effective to change the behavior of health professionals? JAMA 2001;286(23):2988-92.3. Coopers & Lybrand Consultants. Drug and Therapeutics Information Service - Update of the economic evaluation of the NSAID project. In: May FW, Rowett D, eds. DATIS progress report to the Department of Health and Family Services October to March 1995-96. Canberra: Australian Commonwealth Department of Health and Family Services 1996. .

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• Cox-2s/NSAIDs

• G.I. acid Sx (PPIs, H2 blockers)

• anti-platelet drugs (clopidogrel, aspirin)

• hypertension

• cholesterol

• diabetes

• depression

• falls and mobility

• dementia (efficacy and safety of drugs for cognition and behavior)

Clinical topics

Survey item Mean ± SD

1=Strongly disagree 2=Disagree 3=Neutral 4=Agree 5=Strongly Agree

The program provides me with useful information about commonly used medications 4.6 ± .5

The content represents unbiased and balanced information about drugs 4.6 ± .5

The program provides a perspective on prescribing that is different form what I get from other sources 4.4 ± .6

My Drug Information Consultant is a well-informed source of evidence-based information about drugs I prescribe

4.6 ± .5

I find the patient materials useful in my practice 4.3 ± .8

Being able to get Continuing Medical Education credits from Harvard is a valuable component of the service

4.0 ± 1.2

It makes sense for the Commonwealth of Pennsylvania to devote resources to this activity 4.5 ± .6

I would like to see this program continue 4.6 ± .6

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ConclusionsFragmented health care system makes it hard to

identify payors who will support academic detailingStaff model HMOs do this well – Kaiser, VA startingHealth reform – redesigning care – Accountable Care

Organizations – change the playing fieldImprove quality and reduce costsIncentives are now aligned to support academic detailing

programs

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