Prescription Drugs: Academic Detailing
Introduction | Evidence of Quality Improvements | Evidence of Savings | Key Considerations | Further Resources | State-by-State Ratings
The Policy
The state/public agency is running an academic detailing program that is reaching health care providers who care for patients who are enrolled in Medicaid.
Introduction
The cost of pharmaceutical treatment in the United States has skyrocketed over the past two decades. In 2009, spending on all prescription drugs increased 5.3 percent and is projected to increase 6.3 percent per year through 2019.
Pharmaceutical companies spend far more on promotion and marketing than they do on the research and development of new medications and this promotion can lead to higher overall prescription drug spending. One of the ways pharmaceutical companies market their products is a strategy known as "detailing," whereby pharmaceutical sales representatives make personal visits to prescribers' offices for the purposes of providing information to prescribers about a company's pharmaceutical products. While estimates vary, in 2005 the pharmaceutical industry spent, at minimum, $7.2 billion solely on detailing to physicians in the United States.
Providers do not always have access to, or the time and resources available to research the most current evidence-based literature regarding medications and treatments. They may rely on the information that they receive from pharmaceutical or medical device representatives, whose responsibility is to market the company's products. This contributes to overall prescription spending and can undermine quality because prescribers are more likely to prescribe the newer treatments they have learned about through detailing. However, these treatments may be more costly, to both the patient and to the insurance company, and may not be as clinically effective as treatments - either pharmaceutical or non-pharmaceutical - that have been in use for a longer period of time.
One way states can improve both drug and non-drug therapies while simultaneously containing rising spending is by funding unbiased educational outreach visits, known as "academic detailing", to recommend the most effective treatment. Academic detailing programs use knowledgeable health care professionals, such as physicians, pharmacists, nurses and physician assistants (rather than the sales representatives used in commercial detailing), to educate providers about treatment options for common medical conditions using unbiased, evidence-based information. The intent of academic detailing is to improve health outcomes and avoid unnecessary health care costs by educating providers about the comparative effectiveness of medications and treatments, without conflicts of interests that can skew the messaging of commercial detailing programs.
Treatment options discussed with the provider may include:
- Improvements in drug therapy based on clinical evidence. These may include brand-name choices within drug classes, or generic equivalents (if available). Generics are required by FDA to be therapeutically equivalent to the brand-name option.
- Non-drug therapy (could mean using other therapies instead of, or in addition to medication; or carefully taking patients off of unnecessary medications).
Academic detailing can be used for a variety of clinical interventions including prescription drugs, prevention and screenings, diagnostic evaluations, and patient education.
Evidence of Quality Improvement
Academic detailing efforts are likely to improve quality of care by increasing the use of evidence-based treatments and diminishing the use of inappropriate treatments. Well-constructed studies of academic detailing have shown that these programs have small to moderate effects on the prescribing behavior of health care providers.
Thus far, studies on the effectiveness of academic detailing have focused more on the change in prescriber behavior and the cost-effectiveness rather than on patient outcomes. However, studies have shown the effectiveness of academic detailing in increasing preventative screenings and improvements in smoking cessation rates.
Academic detailing can help reduce unintended health consequences of treatment choices by emphasizing a more evidence-based approach to prescribing. Effectively educating prescribers and providing evidence-based data can help lower lifetime health care costs for patients, decrease adverse health events, and improve health outcomes.
New drugs and devices, which tend to be the subject of industry-sponsored detailing programs, do not have the track record of the older alternatives and therefore safety and effectiveness may not be well established. Some widely used medications, such as Vioxx and Avandia, which were highly touted and aggressively marketed by the pharmaceutical industry have been removed from the market or restricted due to unintended and significant health consequences.
Evidence of Savings
A number of programs have demonstrated the cost savings potential of academic detailing. In 2005 the Pennsylvania Department of Aging implemented academic detailing to keep rising medication costs under control in their Pharmaceutical Assistance Program for the Elderly (PACE). The total academic detailing program cost is about $1 million per year. A 2007 evaluation of the PACE academic detailing module focused on the treatment of acid reflux, demonstrated a reduction in drug costs of about $120 per doctor per month and $378 per month among the heaviest prescribers. This is a total savings of about $527,000 per year for one class of drugs, and it was noted that there were likely to be additional savings for other classes of drugs addressed by the academic detailers. In addition, the evaluation did not measure the likely savings to other programs, such as Medicaid or Medicare, whose patients many of the PACE providers also see. Academic detailing has also been used extensively in Australia and Canada. The National Prescribing Service (NPS) in Australia generated a net savings of $293 million Australian dollars over a ten year period (1997 - 2006) through their prescriber education programs, of which, academic detailing is their most effective component.
While academic detailing programs require upfront costs for implementation, the savings can outweigh the costs if the effects are lasting.
Although the number of evaluations of academic detailing programs in the U.S. is limited, the evidence from both the U.S. and international programs has demonstrated to the Agency for Healthcare Research and Quality (AHRQ) that academic detailing can improve quality and reduce costs. Subsequently AHRQ has funded the National Resource Center for Academic Detailing (NaRCAD) to train, support and provide evaluation for academic detailing programs.
Key Considerations
Start-up Costs: There are a number of concrete ways to start-up and/or build an academic detailing program:
- Start small by focusing on only one drug class or one diagnosis that can produce significant savings and improvements in care.
- Savings generated by the academic detailing program could be used to further expand the program.
- Some states have passed legislation that imposes a fee on pharmaceutical companies marketing within their state. These fees could be used to fund academic detailing.
- Academic detailing programs in New York, Idaho and Oregon have qualified for Federal Medical Assistance Percentages (FMAP) funds.
- Washington, D.C. charges licensing fees to all commercial detailers. These fees fund the academic detailing program.
- Because providers do not generally limit their practice solely to Medicaid patients, the fiscal benefits of academic detailing will accrue to insurers more broadly. Such benefits may justify a more broad-based funding mechanism - such as an assessment on insurers - for the establishment and support of academic detailing programs.
- NaRCAD , funded by AHRQ and based at Harvard Medical School affiliate Brigham and Women's Hospital, assists organizations with planning programs and training academic detailers, thus overcoming part of the start-up cost hurdles.
Elements of Effective Academic Detailing Program:
- Personal Interaction: Academic detailers must have face-to-face interactions with health care providers. The literature shows that individual meetings are most effective, but some larger physician practices may require group academic detailing visits.
- Partnership with Well-Regarded Source for Evidence-Based Information: Academic detailing programs must provide the most current, evidence-based and unbiased data. Therefore, partnership with a highly regarded academic medical center or programs, such as the Drug Effectiveness Review Project (DERP) or the Independent Drug Information Service (iDiS), is essential to obtaining educational data for academic detailing efforts.
- Continuing Medical Education: If possible, academic detailing programs should offer prescribers the opportunity to receive continuing medical education (CME) credits for academic detailing visits.
- Patient Education: Academic detailing programs often include patient education materials which promote good communication and shared decision making, help combat influences such as TV marketing, and increase the chances that patients follow through with treatment.
- Political Considerations: Experts recommend that academic detailing not focus solely on those who are considered to be high-usage prescribers. It is important that academic detailing programs build trust with the health care providers and not be regarded as an attempt to police prescribers. In fact, an evaluation of the PACE program in Pennsylvania revealed that prescribers strongly agreed that the information they received through the academic detailing program was useful, unbiased and provided a perspective that was different from what they received from other sources. Recent evaluations of the Vermont Academic Detailing Program and the Rural Oregon Academic Detailing Project show similar levels of provider satisfaction with the quality and information provided through academic detailing program. Thus, academic detailing is an opportunity to enhance Medicaid's relationships with providers.
Further Resources
Community Catalyst, Medicaid Report Card Policy: Prescription Drugs: Setting Fair Prices
Prescription Policy Choices, Academic Detailing Toolkit
Prescription Project: Community Catalyst Cost Effectiveness of Academic Detailing
National Resource Center for Academic Detailing (NaRCAD)
State-by-State Ratings
 Made the Grade
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 Room to Improve (?)
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 Miss the Mark
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