Transcript NaCRAD
National
Resource
Center for
Academic
Detailing
Supported by a grant from AHRQ
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NaRCAD
Mission
Team
Background on academic detailing
Elements of a successful program
NaRCAD’s services
Next Steps
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Mission
To promote the use of evidence based medicine
by supporting the establishment and
improvement of academic detailing programs.
NaRCAD provides training, materials, and
consultative support to health care organizations
to establish effective academic detailing
programs.
NaRCAD aims to establish a network of programs
sharing best practices in academic detailing to
further the use of comparative effectiveness data
in medical practice.
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Team
Michael Fischer, MD, MS, Program Director
Jerry Avorn, MD, Co-Program Director
Niteesh Choudhry, MD, PhD, Core Faculty
Steve Farrell, MBA, Program Manager
Lindsay Ritz, MPH, Program Coordinator
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The rationale for academic detailing
• FDA has limited data when treatments or tests
are first approved
– with limited relevance to many patients
• Physician data overload
– hundreds of important clinical papers published each month
• Imbalanced communication
– manufacturers provide much of the information
• Need for non-product-driven overviews
– delivered in a relevant, user-friendly way
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Two different worlds
Academia
Industry
MD comes to us
Goes to MD
Didactic
Interactive
Content ornate, not
clinically relevant
Content is simple,
straightforward, relevant
Visually boring
Excellent graphics
No idea of MD’s
Perspective
MD-specific data informs
discussion
Evaluation: minimal
Outcome evaluated, drives
salary
Goal = ????
Goal = behavior change
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Academic Detailing
Drug/Device
makers:
great
communicators
Government/Medical
School faculty:
Trusted sources of
Clinical information
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The goal of academic detailing
To close the gap between
the best available evidence
actual clinical practice
…so that clinical decisions are based
only on the most current and accurate evidence on:
efficacy
safety
cost-effectiveness
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Academic detailing
Synthesizes up-to-date evidence about comparative
efficacy, safety, and cost-effectiveness of commonly used
therapies
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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The beginning of academic detailing
• Developed in early 1980’s
– “un-ads” for physicians with clinical background and
specific prescribing recommendations
– patient educational materials
• Effective from the start
– 92% MD acceptance rate from ‘cold calls’ to physicians
– Significant 14% reduction in inappropriate prescribing
Avorn & Soumerai, NEJM 1983
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Where Academic detailing is now
(Partial Listing)
USA
Initiatives in various states:
California – Kaiser Permanente
District of Columbia – DOH
Idaho – Medicaid
Maine – DHHS
Massachusetts – DPH and CDC
New York – Medicaid
Oregon – OHSU
Pennsylvania – Aged Care
South Carolina – Medicaid
Vermont – Medicaid
National – new effort funded by AHRQ
World
Australia
Canada
United Kingdom
Sweden
Netherlands
New Zealand
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Current status of the evidence
• Evaluated extensively over the last 25 years
• Large evidence base confirms efficacy
• A large systematic review in 2007 combined 69 studies
and confirmed efficacy of AD
• O’Brien MA, Rogers S, et al. Cochrane, Database of Systematic
Reviews 2007
• However, quality of execution dramatically
impacts effectiveness
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Example: South Carolina - SCORxE
South Carolina College of Pharmacy and South
Carolina DHHS
Main Problem
25% of Medicaid’s prescription medication spending was for mental
health drugs alone
4/5 prescribed drugs from the state’s Medicaid program were for mental
health
Funded in 2007 by a 5-year grant from DHHS
Topics
Schizophrenia
Non-psychotic Major Depressive Disorder
Bipolar Disorder
Smoking Cessation
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Effectiveness – PACE Program
Evaluated acid-suppression module in 2007
Time-series analysis of PPI prescribing
Following their first educational visit, intervention-group
doctors prescribed on average $124 less PPI per
physician per month than external controls (p = 0.09),
and $122 less PPI per physician per month than internal
controls (p = 0.05)
For the first six months after the educational encounter
intervention-group physicians reduced their use of PPIs by
about $286,000 within the PACE program alone
If these changes persisted for a year, the savings would
have amounted to $572,000 for this one drug group
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Differing Scales of Academic Detailing
Programs
Temporary programs: address a specific issue over
a defined time period
Redeployment of current resources
Often complimentary to other efforts
Limited scale, longer term programs: cover a
wider range of issues
Redeployment of current resources
Augmentation of resources
Cut across multiple disease areas
Larger scale, longer term programs
Dedicated resources
Multiple topics
Broad range of medical areas
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Flexible Uses of Academic Detailing
Improve knowledge
New guidelines
Health threats
Change in treatment
More effective/cost effective or safer
Decrease overuse
Improve patient education
Use of materials
Communication of vital information
Increase diagnosis/screening
What to look for
What to do when found
Increase utilization of complimentary resources
Public health programs
Referral resources
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Basis for AD Programs
(partial listing)
State
Year
Started
Funding
Annual Budget
Idaho
2009
Grant funding by Pew
Charitable Trust and
Medicaid Match
$50,000
Maine
2009
Manufacturer fees,
funding from
settlements
$150,000
Pennsylvania
(PACE)
2005
Funds from PA state
lottery
$1,000,000
Vermont
1999
General funds and
manufacturer fees
$100,000
Washington, DC
2007
Industry detailer
licensing fees
$450,000
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Possible Future Funding
Medicaid Match
Program eligible for federal funds
Matched at a certain percentage from the government
CDC Block Grants
Leverage NaRCAD’s resources
Other government sources
Mandate for dissemination of PCORI findings
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Elements of a Successful Academic
Detailing Program
Identifying
Program
Needs
Developing
and
Producing
Materials
Hiring and
Management
of Academic
Detailers
Training
of
Detailers
Measuring
Program
Effectiveness
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Identifying Program Needs
Goals
Organizational capabilities and experience
Health needs in target population
Gaps in target population
Current practice
Best practices
Evaluate existing data
Prescription data, other health records
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Developing and Producing Detailing
Materials
Compilation of evidence base (AHRQ Comparative
Effectiveness Reviews)
Analysis and summary by relevant experts
Identifying key messages
Synthesized into communication materials
Relevant, useful information for:
physician
patient
Clearly and effectively communicated
Retained for future reference
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Detailing Material Topics
Based on AHRQ Comparative Effectiveness
Reviews
oral diabetes medications and insulin for adults with
type 2 diabetes
off-label use of atypical anti-psychotics for agitation in
dementia
analgesics for osteoarthritis
Updated for the latest evidence
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Hiring and Management of Detailers
Job description
Successful detailer profiles
Full time hires vs. consultants
Establishing goals
Monitoring performance
Team building
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Training of Detailers – How to Detail
Principles of social marketing
Structuring visit
Communicating messages effectively
Actively listening and engaging clinician in conversation
Message delivery under a variety of circumstances
Gaining commitment to action
NaRCAD will have two training sessions a year through
2013
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Training of Detailers – Clinical Background
Grounding in clinical areas and treatments
Diabetes
Agitation in Dementia
Osteoarthritis
NaRCAD will have two clinical training sessions a
year beginning Fall 2011 through summer 2013
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Measuring Program Effectiveness
Change in patterns of care
Prescribing data, other sources
Cost-effectiveness of detailing effort
Potential impact of modifications to program
Impact on expenses outside of network
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Elements of a Successful Academic
Detailing Program
NaRCAD
performs
Identifying
Program
Needs
NaRCAD
performs
Developing
and
Producing
Materials
NaRCAD
advises
NaRCAD
performs
Hiring and
Management
of Academic
Detailers
Training
of
Detailers
NaRCAD
supports
Measuring
Program
Effectiveness
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NaRCAD Experience
Collectively over 40 years in academic detailing
Established or assisted programs in 6 states
Expertise in:
Evidence based prescribing
Training and materials development
Pharmaco analytics
Public and private partnerships
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NaRCAD Partners
Groups wishing to know more about academic
detailing
Groups seeking to establish new academic detailing
programs
Groups seeking assistance to measure current
program effectiveness
Groups seeking to improve or expand current
programs
Experienced groups seeking to share best practices
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Next Steps
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Contact
Stephen Farrell, MBA, Program
Director, [email protected] or Lindsay Ritz,
[email protected]
www.narcad.org
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