Problem Addressed

• Billions spent on marketing and advertising drugs: The pharmaceutical industry spends more than $30 billion a year on marketing, with $7.2 billion directed toward physicians in an effort to influence prescribing choices.¹
• Little time and/or resources to gather other information: Busy physicians do not have the time to seek out and evaluate independent data on the relative merits of different drugs.
• Leading to suboptimal prescribing, high costs, and potential lack of compliance: Estimates suggest that millions of dollars (including tax dollars) could be saved if physicians were better educated about which drug was the most effective and economic in a given situation.^2,3 In some cases, the unnecessary prescribing of expensive brand name drugs may result in a lack of patient compliance, because many low-income patients, including seniors, fail to fill prescriptions or skip doses to save money. Evidence of this can be seen in an evaluation of nonadherence rates after introduction of the Medicare Part D program; one study found that the incidence of skipping doses, reducing doses, and not obtaining prescriptions due to cost fell from 15.2 percent in 2004 to 11.5 percent in 2006; rates among the sickest Medicare beneficiaries fell from 24.1 percent to 20.1 percent over the same time period, although this change was not statistically significant.⁴ Other studies have found similar results.⁵

Description of the Innovative Activity

• Written materials and handouts for physicians and patients: Physicians on the faculty of Harvard Medical School have developed a variety of modules on common drugs used by and conditions affecting the elderly. (See the Planning and Development section for more information.) For each module, several different types of documents have been created and are distributed to physicians during face-to-face meetings (see next major bullet below), including the following: comprehensive reviews of biomedical literature (known as "evidence documents"); distillations of key information to be used as the basis for the discussion between practitioner and the consultant (known as "summary documents"); patient or caregiver brochures that provide key information geared to the lay public, including resources for additional information and support; and laminated, pocket-sized reference cards with tables for quick reference on treatment recommendations and drug efficacy. In aggregate, these materials detail which patient conditions warrant use of each drug and clarify when more costly, brand name drugs are more effective and when less expensive generic or over-the-counter drugs may be equivalent or better. A summary of each module follows:
  • Acid-suppressing drugs: This module discusses the relative efficacy and safety of proton pump inhibitors (PPIs) versus H-2 blockers for specific clinical syndromes, addresses the duration of therapy for PPIs, and describes the best regimen to eradicate Helicobacter pylori as a risk factor for ulcers. In addition, the module has been recently updated to include the latest guidelines for managing these patients.
  • Antihypertensive therapy: This module addresses the evolving concepts of ideal blood pressure targets; highlights the benefits of adequate blood pressure control and lifestyle changes to lower blood pressure; and offers information about when to treat hypertension with a drug, available drug choices, and use of combination therapy.
  • Antiplatelet medications: This module reviews the growing clinical literature about which patients benefit from clopidogrel and/or aspirin, presents the risks and benefits of antiplatelet therapy, compares the cost of aspirin and clopidogrel, and provides evidence-based recommendations as to which regimen to prescribe after specific cardiovascular events and procedures.
  • Cholesterol-lowering treatments: This module defines evidence-based targets for cholesterol levels, delineates the lifestyle changes needed to lower cardiac risk, and offers the most cost-effective medication choices when pharmacotherapy is needed.
  • Cognitive impairment and associated behavioral problems: This module reviews how to diagnose cognitive impairment and dementia in the elderly, defines an efficient diagnostic workup for finding treatable causes of memory loss, assesses drug treatment for cognitive impairment and its limitations, discusses how to respond to the behavioral problems in patients with dementia, and lists the adverse effects of drugs used in elderly patients with dementia, particularly the antipsychotics.
  • Chronic obstructive pulmonary disease (COPD): This module includes information on how to diagnose and assess the severity of COPD; relates the nonpharmacological and pharmacological management of stable disease, particularly smoking cessation; and reviews the management of COPD exacerbations.
  • Depression in the elderly: This module describes the steps required to diagnose depression, relates the initiation of treatment for mild and moderate to severe depression, reviews how to monitor the response to therapy, and also offers nondrug treatment strategies and guidance on how to manage refractory depression.
  • Falls and mobility problems: This module reviews the risk factors for and consequences of falls; presents simple algorithms to screen for mobility problems and risk of falls in older, community dwelling patients; describes how to develop a targeted medical history and conduct an examination of persons at increased risk of falls; and reports on the community supports available to supplement physician interventions.
  • Type 2 diabetes: This module describes initial management of high blood glucose levels with lifestyle interventions, communicates the role of specific oral agents and insulin therapy, explains evidence-based treatment algorithms, presents information on adverse treatment effects and the cost-effectiveness of different regimens, and discusses the management of other cardiovascular risk factors. Based on the current understanding of risks associated with certain oral agents, an update on therapy has been developed and distributed to physicians.
  • Incontinence: This module includes practical strategies for screening for and diagnosing urinary incontinence and evaluates the available behavioral, pharmacological, and surgical approaches to its management.
  • Osteoporosis: This module addresses a common illness among elderly patients that can cause fractures that lead to hospitalization, loss of mobility, and increased mortality. Risk factors, which include female gender, age, calcium intake, steroid use, smoking, or vitamin D deficiency, are outlined in the materials and appropriate interventions are reviewed.
  • Insomnia: This module presents behavioral interventions, which offer a nonpharmacologic approach to treating many patients who have difficulty sleeping, reinforces the need to determine the underlying causes of insomnia, and offers comparative effectiveness data for the selection of the appropriate drug treatment.
  • Atrial fibrillation: This module reviews data on rate versus rhythm control, presents evidence based information on the degree of rate control needed, presents CHADS2 findings on the relative risk of stroke in patients untreated and treated with warfarin, and offers insight on a promising new anticoagulant.
  • Chronic Pain Management: This module presents the principles of chronic pain management including use of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates as well as non-pharmacologic interventions and drugs that can help relieve neuropathic pain.
  • Congestive Heart Failure (CHF): This module reviews current evidence based information on management of systolic and diastolic CHF and includes the NY Heart Association classification which helps determine best therapies. Additional information focuses on non-drug interventions to help patients manage fluid intake, weight gain and sodium consumption.
  • Antipsychotics: This module addresses appropriate use of antipsychotic medications in primary care, providing information about the relative risk of antipsychotic medications when used as a second line for depression or treating patients with dementia without agitation and aggressive behavior. Also discussed is use of antipsychotics in patients with psychoses such as schizophrenia and bi-polar disorder.
• Periodic meetings between drug education consultants and physicians: Drug information consultants (known as academic detailers) who have been hired and trained by the Independent Drug Information Service meet with physicians periodically to discuss a range of medical topics, including which drugs are best for specific conditions, drug adherence problems, and strategies to reduce side effects. Key components of these sessions include the following:
• Contacting target physicians: The program identifies physicians who provide care for many patients in the PACE program and write a high volume of prescriptions for them. The physician receives an introductory letter about the program, and a representative contacts the doctor to set up an appointment.
• Conducting periodic educational sessions: The academic detailer meets with providers for roughly 20 minutes about three times a year. During the meetings, the consultant introduces the program and presents educational information about a particular therapeutic topic, including the cost and value of older, generic drugs compared to newer, brand name drugs. At the end of the session, consultants encourage the physicians to visit the program's Web site (http://www.rxfacts.org/) for additional information.
• Obtaining continuing medical education (CME) credit: Physicians can receive one CME credit from Harvard Medical School by successfully taking an examination after participating in a meeting with the consultant and reviewing the associated educational materials.
• Ongoing tracking of program impact: Independent Drug Information Service staff members continuously analyze various process and outcome measures to evaluate the impact of the program. Process measures include number and duration of visits, characteristics of the physician practices visited, and indicators of academic detailer performance. Outcome measures include provider participation, satisfaction survey results, CME evaluation results, and analyses of pharmaceutical and medical care claims data.

References/Related Articles

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Innovator Disclosures

Results

• Reduced costs for targeted drug classes: The program has yielded savings for the PACE program in two targeted drug classes (as described below); analysis of the program's impact in other drug classes is ongoing.
  • Drugs for acid reflux disease: A comparison of monthly prescribing practices for PPI prescriptions—primarily Nexium^®—among three groups of physicians (those receiving academic detailing, those practicing in the same counties who did not receive academic detailing, and those in other counties where the program did not operate) found that the costs of PPI prescriptions for PACE enrollees seeing participating doctors averaged $122 to $124 less per physician per month than for PACE enrollees served by physicians in the two control groups.⁶
  • Pain medication: After the withdrawal of Vioxx^® and Bextra^® from the market, many prescribers continued to write prescriptions for similar medications such as Celebrex^®. Six months after implementation of the drug education initiative, high-volume prescribers participating in the program spent approximately $60 less per physician per month for PACE enrollees on this class of painkillers than did physicians in the other two groups.
• Extrapolated savings to other patients: Because the educational messages are not specific to PACE enrollees, physicians can be expected to change their prescribing practices for all patients. As a result, program leaders estimate that the initiative generates overall cost savings to public and private payers in Pennsylvania that easily exceed the $1 million a year it costs to run the program.
• High levels of physician satisfaction: A survey of 450 providers found high levels of satisfaction with the program. On a scale of 1 to 5 (with 5 being the highest), respondents rated the program a 4.6 with respect to providing useful, unbiased, and balanced information about commonly used medications. Early results from a more recent physician survey (conducted in late 2008) show that the current rating for the same question has reached 4.8.
• Comparable results from similar programs: Evaluations of similar kinds of academic detailing programs show that they can have a significant impact on physician prescribing habits.^3,5

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Developing modules: Independent Drug Information Service researchers, including physicians on the faculty of Harvard Medical School, compiled the drug information by exhaustively evaluating all relevant clinical trial results and reviewing medical journals to assemble clinically relevant information about drugs commonly used by internists and family practitioners. This work is done on a nonprofit basis, and none of the clinicians involved accepts any personal compensation from any pharmaceutical manufacturers. Since the program's inception, the Independent Drug Information Service has issued drug/disease topic modules on nonsteroidal antiinflammatory drugs (2005), acid suppressing therapy (2006, 2012), antiplatelet therapy (2006, 2009), cholesterol-lowering drugs (2006, 2009), antihypertensive therapy (2007, 2010), type 2 diabetes treatment (2007, 2009, 2010), management of depression in the elderly (2008), management of falls and mobility in the elderly (2009), cognitive impairment and associated behavioral problems (2009), COPD (2009), incontinence (2010), osteoporosis (2010), insomnia (2010), atrial fibrillation (2011), chronic pain management (2011) congestive heart failure (2011), and antipsychotics (2012).
• Training consultants: The consultants received training from Independent Drug Information Service project directors on each module, including the clinical aspects of the disease condition, drug class pharmacology, and strategies for communicating and educating clinicians on these topics.
• Identifying and contacting physicians: Independent Drug Information Service staff analyzed PACE drug claims data to identify the top prescribers in 28 densely populated counties with a large number of PACE enrollees. This review identified 866 physicians who cared for at least 25 PACE enrollees or had a high volume of PACE-funded prescriptions. The consultants were assigned to doctors based on geographic location. Physicians received a letter about the program, and the consultants began visiting their assigned physicians in October 2005.

Resources Used and Skills Needed

• Staffing: The PACE program has a team of 9 full- and part-time drug information consultants, equal to about 5.5 full-time equivalent (FTE) positions. Most consultants have degrees in pharmacy or nursing. Each FTE serves between 120 and 180 clinicians.
• Costs: Consultants are paid an average of $55 per hour, on par with average salaries for their profession in the area. Total program costs average roughly $1.5 million per year.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Engage leaders and secure funding: Introduce the concept of academic detailing and share information on its potential benefits for prescribing quality and affordability with appropriate leaders in an effort to win their support and secure funding.
• Create coalition to support program: Involve physicians, community leaders, health plans, government leaders, professional societies, and special interest and patient groups early in the process. Do not underestimate the time needed to knit together support for an initiative of this type.
• Gather unbiased evaluations of classes of drugs for common conditions: Obtain independent, noncommercial educational materials to share with physicians. Make sure the reviews are objective, and make it clear that those who conducted them have no ties to pharmaceutical companies.
• Design a variety of materials for providers: Design a broad array of materials for clinicians, ranging from detailed and highly technical evidence monographs to brief, easy-to-read summaries of key points and patient take-home pieces. Alternatively, contact the Independent Drug Information Service for information about how to get permission to use the materials they have created.
• Review prescription data to identify clinicians to be served: Review prescription claims data to identify high-volume physicians. Program developers recommend targeting those physicians who treat a high volume of patients rather than those with specific prescribing patterns, as this latter approach can lead to the creation of adversarial relationships with physicians.

Sustaining This Innovation

• Monitor program impact over time: Sponsors of academic detailing should have data processing systems in place to analyze and interpret drug claims data, including how frequently targeted clinicians adhere to evidence-based recommendations related to prescribing both before and after program implementation.
• Be patient with respect to program impact: It may take time for patients to switch to more effective and/or lower-cost medications, as they may continue to refill prescriptions written before the delivery of the educational module to the prescriber. The effectiveness of the program is likely to increase as the clinician–consultant relationship deepens and as messages are reinforced during subsequent one-on-one encounters.
• Train consultants in two-way communication: Program success depends on two-way communication and the development of mutually respectful relationships between consultant and clinician.

Additional Considerations and Lessons

• Link providers to experts to handle pressing questions: Convey clinician questions about research findings to experts, and get answers back to the provider as soon as possible.
• Acquaint physicians with generic drug alternatives: Physicians may underuse older, effective generic drugs, and physicians who have recently joined a practice may not have a balanced perspective on certain classes of drugs. To address these issues, provide information on the relative efficacy, safety, and cost-effectiveness of drugs during educational visits.
• Provide information to all staff: Be sure to share clinical information with nurses, onsite pharmacists (if present), and allied health professionals within a practice or health plan.
• If possible, make visits to any physician who requests one: Whenever possible, Independent Drug Information Service consultants honor requests for a visit from physicians who do not see a large number of PACE enrollees.
• Develop a Practitioner Advisory Board of physicians participating in the program: Periodic discussions between practitioners receiving the academic detailing service and the clinical team of the sponsoring program can be helpful in: identifying particular areas of concern to the practicing physician on a clinical topic under development; exploring future topics of interest; obtaining suggestions for promulgating the program.

Use By Other Organizations

• University of Vermont Medical School's Academic Detailing Program: This statewide program, operated by the University of Vermont's Office of Primary Care, educates primary care providers about one condition each year (e.g., depression, cholesterol treatment). The current annual budget of $200,000 supports 100 visits per year. More information is available at http://www.vtad.org.
• South Carolina's Prescribing Excellence program: This collaboration between the South Carolina Department of Health and Human Services and the South Carolina College of Pharmacy focuses on face-to-face interactions between impartial clinical educators and Medicaid providers. The current emphasis is on pediatric-focused topics and visits with pediatric practices. More information is available at http://www.sccp.sc.edu/SCORxE.
• Maine Independent Clinical Information Service: In 2007, Maine passed legislation mandating that the Maine Department of Health and Human Services establish this program, which was launched in 2009 with two part-time academic detailers. This free, voluntary service for Maine prescribers, targeted at primary care providers, is administered by the Maine Medical Association in partnership with the Department of Health and Human Services under the direction of a physician-led advisory committee. As of June 2012, the program has delivered over 1500 modules on type 2 diabetes, antiplatelet therapy, hypertension, atrial fibrillation, chronic pain management and atypical antipsychotics. The program makes use of materials and training by the Independent Drug Information Service. The annual budget of $140,000 is raised from fees assessed on pharmaceutical manufacturers and labelers that market their products in Maine (small, one-product companies are exempt from the fee). More information is available at http://www.mainemed.com/academic/index.php.
• Kaiser Permanente: Kaiser Permanente has incorporated academic detailing into its communications with network doctors.
• Massachusetts Department of Public Health: The Massachusetts state legislature passed legislation establishing the Prescription Drug Outreach and Education Program within the Department of Public Health in 2008. The following year, the department contracted with the Independent Drug Information Service to develop, implement, and operate this academic detailing program, which targets primary care practitioners who participate in MassHealth, the state Medicaid program. The program has focused on type 2 diabetes, antiplatelet therapy, cholesterol-lowering therapies, hypertension, and atrial fibrillation. In mid-2011, the program was discontinued because of loss of funding.
• District of Columbia Department of Health: The District of Columbia established its academic detailing program on passage of the SafeRx Amendment in 2008. In 2009, the Department of Health contracted with the Independent Drug Information Service to implement and operate the program, which focuses on primary care practitioners, particularly those caring for Medicaid patients. The focus of the program has been on type 2 diabetes, antiplatelet therapy, cholesterol-lowering therapies, hypertension, atrial fibrillation, HIV/AIDS, and antipsychotics.