Transcript document

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
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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 prescribers
about 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, “unadvertisements,” 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
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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
Survey item [5 = strongly agree; 1 = strongly disagree]
Mean + SD
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
4.3+.8
find the patient materials useful in my practice.
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
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