William Shrank M.D. MSHS Division of Pharmacoepidemiology & Pharmacoeconomics Brigham & Womens Hospital, Harvard Medical School

The problem Limited 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 2

Clinical trials Usually doesnt 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 3

Information overload Dozens of biomedical journals Physician time constraints Systematic overviews cover selected fields, but… are lengthy, abstruse hard to wade through may not be recently updated Some important findings not in journals FDA alerts, Dear Doctor letters important trial data presented at clinical meetings unpublished results 4

5 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 promotion 2/3rds 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 representatives most have little scientific training most are paid on commission messages may be skewed to favor product 6

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 gifts reciprocal obligation Marketing promotes costliest products 7

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

9 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 accurate evidence about efficacy, safety, and cost-effectiveness.

10 Academia: –MD comes to us –Didactic –Content ornate, not clinically relevant –Visually boring –No idea of MDs 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 detailing Synthesizes 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 11

12 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

13 Information is provided interactively –generally in the doctors 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

14 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

15 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? OBrien 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%)

17 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 Soumerai SB, Avorn J. Economic and policy analysis of university-based drug "detailing". Med Care 1986;24(4): 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): 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 Canberra: Australian Commonwealth Department of Health and Family Services

18 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 20

Conclusions Fragmented health care system makes it hard to identify payors who will support academic detailing Staff model HMOs do this well – Kaiser, VA starting Health reform – redesigning care – Accountable Care Organizations – change the playing field Improve quality and reduce costs Incentives are now aligned to support academic detailing programs 21