The Massachusetts academic detailing program

Jerry Avorn, M.D.

No conflict of interest

• Neither I nor any participants in the Massachusetts Academic Detailing program accept personal compensation of any kind from any pharmaceutical companies.

• I do not receive payment of any kind for my work related to academic detailing.

• The program is conducted by a non-profit organization.

Drug information problems at many levels

• medical school

• residency training

• continuing medical education

• dearth of comparative data

• It’s no-one’s job to make sure clinicians have current, unbiased information about what we prescribe

There is no requirement that a new drug must be tested

against the standard of care.

• FDA must declare a drug “effective” if it works better than placebo.

• FDA has no budget to conduct its own trials.– It must depend on studies conducted by the

manufacturer• …which are designed accordingly

Further complications

• poor economic awareness of drug costs– by doctors– by patients

• Very heavy marketing of costliest products– to doctors: ~ $30 billion/yr (incl. “detailing”)– to patients: $ 5 billion /yr

• established off-patent treatments aren’t promoted

Drinking from a fire hose

• To keep up with all important drug developments, a PCP would have to regularly scan dozens of journals.

• Published systematic overviews:– are lengthy and hard to wade through– may not be recently updated

• Some important findings are not in journals– FDA alerts, ‘Dear Doctor’ letters– important trial data presented at clinical

meetings

What we need: evidence-based,

non-product-driven, effective

communication to prescribersabout drugs

This is a public good.

The logic of academic detailing

• Med school faculty have a solid grasp of the evidence about drug benefits and risks – but we’re often terrible communicators.

• Drug makers are superb communicators– but do so only to increase product sales.

• Can the content of the former be communicated to prescribers through a ‘delivery system’ based on the latter?

The goal of academic detailing

To close the gap between the best available science and actual prescribing practice,

so that each prescription is based on the most current and accurate evidence about efficacy, safety, and cost-effectiveness…

…and to deliver this information to doctors in an efficient, user-friendly way.

The content of academic detailing• Comprehensive reviews of the medical

literature are conducted by physicians with clinical expertise, special training, and no commercial ties.

• These are turned into readable evidence documents, “un-advertisements,” patient education brochures, and other materials.

• Available at www. RxFacts.org

The delivery of academic detailing

• A service in which “outreach educators” (pharm, RN, MD) visit prescribers in their offices to offer the best available information on drugs used to manage common clinical problems.

• The information is provided interactively.• The visit ends with specific practice-change

recommendations.• Over time, the relationship becomes more

trusted and useful.

Evidence that this works

• 1st study: Randomized trial of 435 MDs in four state Medicaid programs

• Avorn & Soumerai, NEJM 1983

• MA nursing home study – clinical improvement as well

• Avorn et al, NEJM 1992

• Cochrane review• updated 2007

• Effectiveness varies with quality of execution – like brain surgery– it’s not a pill

Proliferation of the approach

• Australia, Canada, Europe• U.S. managed care organizations,

integrated delivery systems• Large state-supported programs in PA,

DC, NY, SC, Canada– smaller programs developing in VT, ME,

NH

• Independent Drug Information Service (iDiS)

Modules already produced

• NSAIDs, cox-2 inhibitors• G.I. acid symptoms (PPIs, H2 blockers)• anti-platelet drugs (Plavix, aspirin)• hypertension• cholesterol• diabetes• depression • falls and mobility problems

Physician reaction

1. The program provides me with useful information about commonly used medications.

4.6+ .5 

2. The content represents unbiased and balanced information about drugs.

4.6+.6

3. The program provides a perspective on prescribing that is different from what I get from other sources.

4.4+.7

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

5. It makes sense for the Commonwealth of Pennsylvania to devote resources to this activity.

4.4+.7

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

4.6+.6

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

4.1+1.2

Table 3. Physician survey

Survey item [5 = strongly agree; 1 = strongly disagree] Mean + SD

8. I would like to see this program continue. 4.6+.6

Cost-effectiveness

• Several studies suggest that the savings realized by payors from improved prescribing can help cover the costs of the program– not including improvements in patient

clinical outcomes

• Drug companies know the math works.

“How can we possibly afford this?!”

• The U.S. already spends more per capita on drugs than any other nation.

• Much of that is wasted.• Government (federal, state, VA) is footing a

big part of the bill.– e.g., Medicaid spent $1 billion a year on Vioxx– similar argument for Avandia, Zyprexa, etc.

• Providing evidence-based drug information probably saves more than it costs.

Status of the Massachusetts Academic Detailing Program

• managed by MA Department of Public Health

• two academic detailers hired, trained, contacting physicians

• alliance with Community Health Centers

• great potential for working with “medical home” movement in the future