US Pharm. 2014;39(10):16-19.
Comprehensive primary healthcare for adults focuses on the prevention and treatment of general medical problems and the management of chronic disease. Since more than 50% of older adults have three or more chronic diseases, it would be advantageous for senior adults to seek healthcare coordinated by a primary care practitioner. One of the greatest challenges for these clinicians, however, is the provision of optimal care for older adults with multiple chronic conditions, or multimorbidity.1-4
According to the Agency for Healthcare Research and Quality, the primary care system in the United States can be strengthened in fundamental ways to improve healthcare quality, safety, patient experience, and costs.5 But the dilemma of how to deliver healthcare efficiently has surfaced, largely owing to healthcare reform and the continued shortage of primary care physicians and other providers. In this regard, many primary care practices have embraced the patient-centered medical home (PCMH) model, providing patients with a team-based approach to the prevention and treatment of disease.6 The medical home model can reduce emergency department use and hospital admissions through improved care coordination, patient engagement, and application of evidence-based care protocols, while providing additional revenue opportunities as well. In order to achieve these goals, academic detailing—a noncommercial adaptation of the pharmaceutical industry’s detailing process—is being used at a growing pace. Educating clinicians through academic detailing is an effective way of enhancing clinical decision making to optimize treatment and medication-related therapeutic outcomes. Academic detailing provides clinicians with evidence-based information, and, in addition, encourages a culture of critical thinking by informing clinicians of uncertainties and controversies in the interpretation of evidence. Overall, the goal of academic detailing is to provide an accurate, up-to-date synthesis of relevant clinical information in a balanced and engaging format.7
Academic Detailing
Primary care practice providers (e.g., internal medicine and family practice physicians, nurse practitioners, physician assistants) need to keep abreast of the most advanced medical treatments and medications in an ever-expanding healthcare arena. These clinicians need a reliable and continuous source of current data regarding the comparative effectiveness, safety, and cost of therapies that is accessible in a time-efficient and convenient format. Academic detailing not only addresses these needs, but also aligns with the interests of physicians, payers, and patients.
The success of pharmaceutical manufacturers in influencing prescribing practices through detailing is based on a number of theories and principles of communication and behavior change.8 With behavioral science as the base, and with several field trials, it is possible to define the theory and practice of methods to improve physicians’ clinical decision making to enhance the quality and cost-effectiveness of care.8
Academic detailing engages healthcare providers through one-on-one, in-person educational outreach visits. It brings together the interactive communication approach of pharmaceutical industry detailers with the noncommercial, evidence-based information of academia.7 Developed to help physicians make appropriate clinical decisions based on the best available safety, efficacy, and cost-effectiveness data, academic detailing is described as a quality-driven endeavor that is effective and efficient in process.7
Academic detailing has also been referred to as university-based educational detailing and public interest detailing.9 Originally implemented to improve the use of prescription medication, academic detailing is also being applied to outreach for a variety of other topic areas including diagnostic evaluations, prevention and screening, and patient education, among others.7 Further, due to the escalating costs of new drugs and therapies that often come without increased clinical benefit, public and private healthcare budgets are under ever-increasing pressure.7 Through the dialogue that academic detailing creates, the interests of physicians, payers, and patients are aligned to potentially improve patient care and health outcomes while helping to control costs.7 Examples of the techniques of academic detailing used by the nonprofit sector and shown to reduce inappropriate prescribing as well as unnecessary healthcare expenditures can be found in TABLE 1. The role of the clinician (e.g., professional with a degree in pharmacy, nursing, or medicine) in academic detailing may encompass that of 1) academic detailer/clinical educator; 2) evidence reviewer for topics and topic selection; 3) developer of the evaluation framework; or 4) trainer of other academic detailers.5
Academic Detailing Project
The Academic Detailing Project (see Reference 10), which ended in September 2013, involved visits by trained clinician consultants to physicians, pharmacists, nurses, other clinicians, and healthcare system decision makers nationwide to share unbiased, noncommercial information about medications and other therapeutic options with the goal of improving patient care.10,11 The Academic Detailing Project is one of four dissemination and implementation projects funded under the American Recovery and Reinvestment Act. These projects enhance the capacity of the Effective Health Care Program (see Reference 11) to promote the use of evidence-based health information and improve healthcare outcomes.12 Target audiences include consumers, patients, and caregivers; individual clinicians and their professional organizations; hospitals and integrated health systems; businesses and business organizations; academicians and researchers; quality-improvement organizations; policy makers; and advocates for better patient care.12 Special emphasis is placed on reaching priority populations, including seniors, minorities, low-income individuals, and people with limited access to healthcare.12
In the U.S. and Abroad
In 2005, the Pennsylvania Department of Aging’s Pharmaceutical Assistance Contract for the Elderly (PACE) Program launched the first large-scale state academic-detailing program in the United States, with approximately a dozen detailers covering the state.7 Currently, a number of other states are involved in academic detailing using various funding mechanisms. Of note, academic detailing has been used in many other countries to assist prescribers in making optimal treatment decisions as well, including Australia, Canada, the United Kingdom, and the Netherlands.7 In Canada, the Canadian Academic Detailing Collaboration has been instrumental in coordinating training for academic detailers across the country.
Recent Studies
Several studies have examined various ways of presenting academic detailing. One study conducted a pilot project to assess the feasibility and effectiveness of, and satisfaction with, academic detailing delivered face-to-face as compared to a modified approach using distance-learning technology.13 The recipients were four family medicine clinics within the Oregon Rural Practice-based Research Network (ORPRN). Topics included treatment-resistant depression, management of atypical antipsychotics, drugs for insomnia, and benzodiazepine tapering; each clinic received four outreach visits over an 8-month period.13
Overall, 90% of participating clinicians were satisfied with the program. Respondents who received in-person detailing reported a higher likelihood of changing their behavior compared to respondents in the distance detailing group for five of seven content areas. While 90% to 100% of respondents indicated they would continue to participate if the program were continued, the likelihood of participation declined if only distance approaches were offered.13 Hartung et al found strong support and satisfaction for the program among participating clin-icians, and the participants favored in-person approaches to distance interactions. The researchers indicated that in the future, quan-titative methods will be necessary for evaluating the economic and clinical effectiveness of detailing in rural family practice settings.13
Malone et al evaluated the effect of an educational outreach program delivered by clinical pharmacists on reducing the rate of prescribing potential drug-drug interactions (DDIs).14 The effect of the educational outreach was evaluated using a retrospective pre-post study design with a control group; multivariate regression models were used to assess the impact of the educational program on the rate of prescribing potential DDIs. The researchers reported that the study was not able to demonstrate a significant beneficial effect of the educational outreach program on reducing the rate of prescribing potential DDIs.
One British Columbian study looked at the feasibility of using information technologies to facilitate communication between academic detailers and physicians through a comparison to traditional face-to-face academic detailing.15 The results suggest that Technology-Enabled Academic Detailing, or TEAD, is an acceptable alternative to academic detailing for providing physicians with advice about prescribing.15 The researchers found that TEAD is more time-efficient, facilitates effective knowledge exchange and interprofessional collaboration, and can reach those physicians virtually where face-to-face academic detailing is not possible or practical, such as in rural and remote locations.
Academic Detailing and Practice Facilitation
While the goals of academic detailing have traditionally been to improve clinical practice in a targeted area, usually one involving patient care, the peer-to-peer format of these encounters has now been adapted for use in improving care quality, as well as for making change a priority among clinicians and leadership.5
To improve primary healthcare processes and outcomes, including the delivery of wellness and preventive services, the creation of an ongoing, trusting relationship between an external facilitator and a primary care practice is an effective strategy called practice facilitation.5 Practice facilitation activities may focus particularly on assisting primary care practices in becoming PCMHs; in addition, they can also aid practices in more general quality improvement and redesign efforts.6 Thus, practice facilitation programs (see Reference 6) support primary care transformation.
In order to develop leadership’s buy-in to a proposed practice change, there is a place for academic detailing as a peer-to-peer educational outreach that can help members understand the role of practice facilitators—what they can and cannot do—and how they can help practices implement such change.5 This effort shows the practice that it can be done and that barriers can be overcome.
Conclusion
Pharmacists with good communication skills may be well-positioned to be trained as clinical consultants to educate clinicians through the outreach process known as academic detailing. It is an effective way of enhancing clinical decision-making with evidence-based information and discussions about the uncertainties and controversies in the interpretation of evidence, to ultimately optimize medication-related outcomes.
REFERENCES
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2. Mercer SW, Smith SM, Wyke S, et al. Multimorbidity in primary care: developing the research agenda. Fam Pract. 2009;26:79-80.
3. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294:716-724.
4. American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society. J Am Geriatr Soc. 2012;60:1957-1968.
5. Agency for Healthcare Research and Quality. Module 10. Academic detailing as a quality improvement tool. May 2013. www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod10.html. Accessed September 24, 2014.
6. Knox L, Taylor EF, Geonnotti K, et al. Developing and running a primary care practice facilitation program: a how–to guide. December 2011. Agency for Healthcare Research and Quality. http://pcmh.ahrq.gov/sites/default/files/attachments/Developing_and_Running_a_Primary_Care_Practice_Facilitation_Program.pdf#page43. Accessed September 4, 2014.
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10. Agency for Healthcare Research and Quality. Academic detailing project. http://effectivehealthcare.ahrq.gov/index.cfm/who-is-involved-in-the-effective-health-care-program1/about-the-academic-detailing-project/. Accessed September 24, 2014.
11. Agency for Healthcare Research and Quality. Who is involved in the effective health care program. http://effectivehealthcare.ahrq.gov/index.cfm/who-is-involved-in-the-effective-health-care-program1/. Accessed September 15, 2015.
12. Agency for Healthcare Research and Quality. National Initiative for Promoting Evidence-Based Health Information. About the national initiative for promoting evidence-based health information. http://effectivehealthcare.ahrq.gov/index.cfm/who-is-involved-in-the-effective-health-care-program1/about-the-national-initiative-for-promoting-evidence-based-health-information/. Accessed September 15, 2014.
13. Hartung DM, Hamer A, Middleton L, et al. A pilot study evaluating alternative approaches of academic detailing in rural family practice clinics. BMC Fam Pract. 2012;13:129.
14. Malone DC, Liberman JN, Sun D. Effect of an educational outreach program on prescribing potential drug-drug interactions. J Manag Care Pharm. 2013;19(7):549-557.
15. Ho K, Nguyen A, Jarvis-Selinger S, et al. Technology-enabled academic detailing: computer-mediated education between pharmacists and physicians for evidence-based prescribing. Int J Med Inform. 2013;82(9):762-771.
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