1. Academic Detailing: History, Perspective, Future J ERRY A VORN, M.D. Professor of Medicine, Harvard Medical School Chief, Division of Pharmacoepidemiology and Pharmacoeconomics Brigham and Women’s Hospital, Boston Co-director, NaRCAD

2. Sources of Support The division’s research is funded primarily by NIH, AHRQ, FDA, and PCORI. Neither I nor any faculty in DoPE accept personal compensation of any kind from any pharmaceutical companies. The Division accepts occasional unrestricted research grants from drug companies to study specific drug safety and utilization questions. The iDiS academic detailing work is done on a non-profit basis and receives governmental support from PA, DC, and the VA. I accept no payment for any of my work on these projects.

3. How I Got Into This… Seeing a huge gap between the science we were learning in the classroom, vs. actual prescribing practices in the outside world Striking difference between the effective, behavior-changing approach of the drug industry, vs. the boring, pedantic, passive approach of academics Could the “delivery system” of industry be used to serve the mission of evidence- based medicine?

4. Yeats said it well… “The center cannot hold; The best lack all conviction, while the worst are full of passionate intensity.” – The Second Coming, 1920

5. An informational vacuum In medical school – We do a poor job preparing students to systematically evaluate risk-benefit-cost data on drugs, or anything. The house officer years – free lunches / infomercials – ‘product placements’ in teaching hospitals After training – few sources of non-commercial information – industry funds much of CME / blurring of boundaries – no requirements for continuing pharmacologic competency Little comparative data is available to weigh alternative clinical decisions

6. The first academic detailing research New health policy interventions need to be tested rigorously, just like new drugs are. Four-state randomized controlled trial, published in New England Journal of Medicine Avorn & Soumerai, NEJM, 1983 The reverse side of each “un-ad” contained concise clinical background and specific prescribing recommendations – with references

10. Patient education materials In focus groups, many physicians said it would be easier to change their prescribing if they could better explain to patients why the change was necessary. So we created what might be the first “direct-to-consumer un- advertisements”

13. Initial results of the first study 92% MD acceptance rate from ‘cold calls’ to physicians Significant 14% reduction in inappropriate prescribing – Avorn & Soumerai, NEJM 1983 Benefit-cost analysis based on actual expenditures: saved $2 for every dollar spent – Soumerai & Avorn, Medical Care 1987

14. Next target: nursing homes # of patients greater than in acute hospitals sickest pts, most meds, low MD/RN staffing a different social & clinical context heavy use of psychoactive drugs no data on baseline patterns of med use! – so we studied it Beers et al, JAMA 1988 helped lead to better federal regulations

17. Outcomes of nursing home study significant reduction in use of targeted drugs – with no change in use of more acceptable meds significant improvement in memory in pts who were prescribed antipsychotic drugs no increase in staff distress – Avorn et al, New Engl J Med 1992 – all ‘un-ads’ are at www.PowerfulMedicines.org

18. Where we are now Academic detailing programs operating in Canada, Europe, Australia, developing world – public payment for drugs = a spur to public action – funded by government, but controlled by profession Managed care organizations have taken lead best example: Kaiser Permanente Government-funded programs in PA, NY, SC, DC, New England, other states, Veterans Affairs. Funding sources: APM settlements, opioid ‘epidemic’, funding from licenses, lotteries

19. Status of the evidence A cottage industry of literature has developed in last 25 years Cochrane Collaborative exhaustive review in 2007 – 69 randomized trials – confirmed efficacy Effectiveness varies with quality of execution – like brain surgery – it’s not a pill

20. The essence of any academic detailing program It’s a service to practitioners. The goal is to help clinicians provide their patients with optimal management of a specific clinical problem. The educational outreach encounter must be – concise – user-friendly – interactive – based on learning about the practitioner’s perspective and needs.

21. “How can we afford this?” The U.S. already spends more per capita on drugs (and other health care interventions) than any other nation. Much of that is wasted (maybe a third?) Government (federal, state, VA) is footing a big part of the bill. – for all health care decisions, including meds Providing evidence-based clinical information will save more than it costs.

22. Where do we go from here? Until now, little economic or organizational motivation to maximize quality and contain costs. That’s changing with the evolution of health care. Increasingly, funding is being tied to quality of care and clinical outcomes. Medicare stars, HEDIS measures, global payments Once an organization has the motivation to move in this direction, it will have to enlist clinicians in making these changes. Accountable Care Organizations are likely to foster this.  growing impetus for academic detailing programs in many clinical areas.

23. For more information: www. NaRCAD.org www. DrugEpi.org www. AlosaFoundation.org Avorn, “Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs” www. PowerfulMedicines.org