Dr. Wells is program manager in Benecia, California; Dr. Popish is program manager in Sarasota, Florida; Dr. Kay is clinical data manager in St. Louis, Missouri; all for the Pharmacy Benefits Management (PBM) Academic Detailing Service. Dr. Torrise is deputy chief consultant for the PBM Professional Practice Office in Washington, DC. Dr. Christopher is the national director of the PBM Academic Detailing Service in San Diego, California.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
National and international studies have shown that academic detailing (AD) interventions improve the quality of evidence-based health care and provide a positive return on investment.1-5 Many health care systems are investing in AD to improve patient care. Existing systems typically tasked with containing drug costs address neither underprescribing and overselection of high-risk agents, which could result in adverse outcomes, nor nondrug alternatives to treatment.
Academic detailing uses marketing strategies (similar to those of the pharmaceutical industry) to deliver evidence-based information to health care providers (HCPs) but without sales goals. The information is disseminated primarily through one-on-one and small-group educational outreach sessions. The goal of AD is to influence clinician decision making and care delivery behavior and promote evidence-based treatment and monitoring. The academic detailer focuses on delivering targeted messages, embedded within provider handouts, and uses audit and feedback tools to help the clinician identify patients for whom treatment plan change may be warranted. Clinicians also are given patient education tools to use in their discussions with veterans. These tools are used to help veterans take charge of their health. Academic detailing has an advantage over didactic lectures because it provides customized content and barrier resolution strategies to meet clinicians’ individual needs and local constraints.
Although the ability of AD to effectively improve the quality of medical care has been thoroughly studied, much less is known about the cost-effectiveness of AD. Historically, capturing the short- and long-term benefits and costs of AD interventions has been difficult. Eliminating AD’s confounding variables also has proven difficult.
Principal areas that impact the effectiveness of AD programs include geographic concentration of the medical issue across the prescriber population, differences in costs/outcomes between current practice and optimal practice, number of detailing sessions required to effect change, and the short- and long-term impact on outcomes. These considerations should influence the design of AD programs to gain maximum program efficiency and effectiveness.
The more geographically concentrated the priority prescribers are, the greater the potential impact of AD. Geographic concentration can reduce travel and administrative costs. Prescribers also may have a high concentration of the targeted patient population; therefore, an intervention specifically targeting high-volume or geographically concentrated populations can be more efficient and effective.
Academic detailing is most effective when a large gap between desired practice and actual practice has been identified. An AD intervention may be highly cost-effective without immediately reducing overall health care costs. For example, if the gap in practice is due to undertreatment of a disease, then an AD intervention may increase short-term treatment costs but eventually achieve better long-term outcomes in the target population. However, establishing cause-and-effect relationships when dealing with long-term outcomes and confounding variables can be difficult.
Interventions in which the evidence is compelling and current practices are not well established may require only 1 AD visit to induce change. In addition, accelerated integration of the evidence into practice can be seen when operational changes, such as formulary restrictions or policies, are mandated. Multiple sessions often are required to effect change when the change is complicated to initiate, when a formidable learning curve exists, or where current practice is heavily ingrained. Subsequently, intensive discussions and an investment in designing practice delivery of the recommendation are needed to consistently achieve the care delivery goal.
For some interventions, specific and readily measurable changes occur almost immediately. For example, switching a high-cost medication to a low-cost alternative provides an immediate cost benefit. In other interventions, such as reduction of future complications, the benefits might be long-term. In such cases, a longer period and a more complex analysis are necessary to measure the impact.
In 2010, a VA AD Service pilot program began as an intervention to improve evidence-based treatment of mental illness. The pilot was funded through the VA T21 Healthcare Transformational Initiatives, which are designed to support new programs that enhance veteran-centric health care. The VISN 21 and 22 pilot locations included 11 medical centers and 73 clinics in Nevada, California, the Pacific Islands, and the Philippines.
An oversight steering committee was formed. It included leaders from Patient Care Services, Mental Health Services (MHS), and Pharmacy Benefits Management Services (PBM). Clinical pharmacy specialists (CPSs) were chosen to function as academic detailers because they are considered medication experts by prescribers and health care teams. The pilot employed 6.0 full-time employment equivalents (FTEEs) CPSs who were residency trained, held doctorate degrees in pharmacy, and had VA practice experience. The VA AD Service used several strategies to promote evidence-based treatment of common mental health disorders.
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