william shrank

Document Sample
william shrank Powered By Docstoc
					         William Shrank M.D. MSHS
     Division of Pharmacoepidemiology &
Brigham & Women’s Hospital, Harvard Medical
                       The problem
Limited data when drugs first approved
   with limited relevance to many patients

Physician data overload
   hundreds of important drug-related papers published each
Imbalanced information
Need for non-product-driven overviews
   delivered in a clinically relevant, user-friendly way

                           Clinical trials
Usually doesn’t provide head-to-head comparative data about
 relevant Rx choices
A drug that achieved a surrogate outcome may not produce
  expected clinical benefit
    e.g., Avandia (rosiglitazone) and M.I.

Unanticipated adverse effects are likely
    e.g., Vioxx (rofecoxib)

Use differs in trials vs. actual practice
    Efficacy vs. effectiveness

                 Information overload
 Dozens of biomedical journals
 Physician time constraints
 Systematic overviews
   cover selected fields, but…
   are lengthy, abstruse hard to wade through
   may not be recently updated
 Some important findings not in journals
   FDA alerts, ‘Dear Doctor’ letters
   important trial data presented at clinical meetings
   unpublished results

                Information imbalance

 Trial design, promotion, CME favor use of new, costly drugs

 Needed head-to-head comparative studies often not

 Most drug information comes from industry
   $30 billion per year on promotion
   2/3rds of continuing medical education is industry-funded

              Industry-generated information

 A dominant source of drug information
    often only available source for new products

 Main purpose is to increase sales, so promotes positives not

 Industry sales representatives
    most have little scientific training
    most are paid on commission
    messages may be skewed to favor product

                 Does promotion work?
 Yes!

 Clear evidence that sales reps and samples change

 Social science literature shows the persuasive effects of
  relationships, gifts
    symbolic power of even small gifts
    reciprocal obligation

 Marketing promotes costliest products

…delivered in a relevant, convenient, user-
                              friendly way
  The goal of academic detailing

           to close the gap
 between the best available evidence
   and actual prescribing practice,
  so that each prescription is based
only on the most current and accurate
   evidence about efficacy, safety,
        and cost-effectiveness.

                Two different worlds
• Academia:                • Drug industry:
   – MD comes to us          – Go to MD
   – Didactic                – Interactive
   – Content ornate, not     – Content is simple,
     clinically relevant       straightforward, relevant
   – Visually boring         – Excellent graphics
                             – MD-specific data informs
   – No idea of MD’s           discussion
                             – Outcome evaluated, drives
   – Evaluation: minimal       salary
   – Goal: ????              – Goal: behavior change

                      Academic detailing
 Synthesizes up-to-date evidence about comparative efficacy,
  safety, and cost-effectiveness of commonly used drugs

 Content independently created by medical school faculty and

 MDs, pharmacists and nurses provide information
  interactively, in physicians’ own offices

 A time-efficient way to keep up with new findings

     The content of academic detailing

• Well trained clinicians (pharm, RN, MD) visit
  prescribers in their offices and offer a service
  that provides independent, unbiased, non-
  commercial, non-product-driven,
  evidence-based information about the
  comparative benefit, safety, and cost-
  effectiveness of drugs used for common
  clinical problems.

        The method of academic detailing
• Information is provided interactively
  – generally in the doctor’s own office
• This enables the educator to
  – understand where the MD is coming from in terms of
    knowledge, attitudes, behavior
  – modify the presentation appropriately
  – keep the prescriber engaged
• The visit ends with specific practice-change
• Over time, the relationship becomes more trusted
  and useful.

             Where Academic detailing is now

 USA                                         Australia
    Programs initiated by                       A nation-wide program using
     Government/insurer payors                    academic detailing as a spearhead
           Pennsylvania – Aged Care              for multiple practice improvement
           South Carolina – Medicaid             strategies
           Vermont – Medicaid                Canada
           California – Kaiser Permanente       British Columbia
     Programs with legislated backing           Saskatchewan
         Maine                                  Nova Scotia
         District of Columbia
                                                 Manitoba
         New York State
                                                 Alberta
         Massachusetts
         New Hampshire                       United Kingdom
     National – Legislation from the         Sweden
      US Senate Special Committee on          New Zealand

              Status of the evidence

• A mass of AD literature has developed in
  last 25 years

• A large systematic review in in 2007
  confirmed efficacy of AD

• Effectiveness varies with quality of
  – like brain surgery

Academic detailing- Does it work?
 O’Brien MA, Rogers S, et al. Educational outreach visits: effects on
  professional practice and health care outcomes. Cochrane, Database of
  Systematic Reviews 2007, Issue 4
    69 high quality studies of ‘educational outreach visits’ prior to March 2007
    “Educational outreach visits with or without the addition of other interventions
     can be effective in improving practice in the majority of circumstances, but the
     effect is variable.”
    Dichotomous outcomes:
         Median adjusted effect overall: 5.6%: (n=34, interquartile range 3% to 9%)
         Median adjusted effects for non-prescribing outcomes : 6.0%: (n=17, interquartile range
          4% to 16%)
    Continuous outcomes
         Median adjusted effects: 21% (n=18, interquartile range 11% to 41%)
                         Is it cost-effective?
 Economic analysis of the original 1983 research which coined the
  term ‘academic detailing’ found that for each $1 spent on their
  academic detailing program $2 was saved in Medicaid drug
 When evaluating global primary care clinical practice changes in a
  large British study of academic detailing, cost effectiveness was
  still demonstrated even where only modest overall effect sizes
  were observed.2
 Independent economic study of an Australian DATIS service-
  oriented academic detailing program showed that between $5 and
  $6.50 of direct health expenditure was saved for each $1 spent
  delivering the program.3

    1. Soumerai SB, Avorn J. Economic and policy analysis of university-based drug
    "detailing". Med Care 1986;24(4):313-31.
    2. Mason J, Freemantle N, Nazareth I, Eccles M, Haines A, Drummond M. When is it cost-
    effective to change the behavior of health professionals? JAMA 2001;286(23):2988-92.
    3. Coopers & Lybrand Consultants. Drug and Therapeutics Information Service - Update of the
    economic evaluation of the NSAID project. In: May FW, Rowett D, eds. DATIS progress report to the
    Department of Health and Family Services October to March 1995-96. Canberra: Australian
    Commonwealth Department of Health and Family Services 1996. .

                         Clinical topics
• Cox-2s/NSAIDs
• G.I. acid Sx (PPIs, H2 blockers)
• anti-platelet drugs (clopidogrel, aspirin)
• hypertension
• cholesterol
• diabetes
• depression
• falls and mobility
• dementia (efficacy and safety of drugs for cognition and

                      Survey item                             Mean ± SD

    1=Strongly disagree 2=Disagree 3=Neutral 4=Agree 5=Strongly Agree
The program provides me with useful information about
                                                                4.6 ± .5
commonly used medications
The content represents unbiased and balanced information
                                                                4.6 ± .5
about drugs
The program provides a perspective on prescribing that is
                                                                4.4 ± .6
different form what I get from other sources
My Drug Information Consultant is a well-informed source of
                                                                4.6 ± .5
evidence-based information about drugs I prescribe

I find the patient materials useful in my practice              4.3 ± .8
Being able to get Continuing Medical Education credits from
                                                               4.0 ± 1.2
Harvard is a valuable component of the service
It makes sense for the Commonwealth of Pennsylvania to
                                                                4.5 ± .6
devote resources to this activity
I would like to see this program continue                       4.6 ± .6

 Fragmented health care system makes it hard to identify payors
  who will support academic detailing
 Staff model HMOs do this well – Kaiser, VA starting
 Health reform – redesigning care – Accountable Care
  Organizations – change the playing field
    Improve quality and reduce costs
    Incentives are now aligned to support academic detailing programs


Shared By: