Transcript Academic detailing: an introduction

Academic Detailing:
History, Perspective,
Future
JERRY AVORN, M.D.
Professor of Medicine, Harvard Medical School
Chief, Division of Pharmacoepidemiology
and Pharmacoeconomics
Brigham and Women’s Hospital, Boston
Co-director, NaRCAD
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.
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 evidencebased medicine?
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
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
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
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 unadvertisements”
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
Next target: nursing homes
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# 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
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
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
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
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.
“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.
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.
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