The DETAILS BLOG
Capturing Stories from the Field: Reflections, Challenges, & Best Practices
 The genius of the American health care system is its fragmentation. And by ‘genius,’ I mean evil genius, or demented genius. And sadly, also ‘very stable genius,’ since that awful fragmentation has been stubbornly resistant to change. It’s a great way to maximize revenue and expenditures, but not the best way to provide care to patients – and it leads to much of the poor care and unaffordable costs that we face. In many organizations caring for patients over 65, their medication use is stripped away into Medicare drug benefit plans separate from the way the rest of their clinical care is paid for and organized. Many payors in the private and public sector carve out the use of drugs for specific conditions, removing it from the organization and payment for the care of the illnesses those drugs treat. Outside integrated health care systems, in many settings the content and costs of prescribing decisions live in a pharmacy silo separate from ambulatory care, which itself is often a world apart from inpatient care, with all of these sectors de-coupled from assessment of clinical outcomes and patient satisfaction. But sick people don’t come in silos, and the drugs we prescribe for them drive hospitalization and other clinical outcomes and the enormous human and economic costs of both.  Academic detailing can help pull these domains together in a way that can make medical care more person-based and evidence-based, as well as more cost-effective. The AD interventions that work best start from the global perspective of the practitioner: how to diagnose and care for a given clinical problem, whether it’s Alzheimer’s disease, diabetes, or incontinence, rather than focusing narrowly on simple medication use questions (“Don’t prescribe Drug X; Drug Z isn’t on the formulary”). This holistic approach is what clinicians and patients need and want, and the one most likely to bring about optimal care decisions. Such a “beyond the drug silo” approach also has implications for the content and focus of the printed clinical materials our programs use, as well as the interactive approach employed by the outreach educator in these programs. Focusing on silo-busting can also help the academic detailer be seen as a valued colleague helping the clinician improve overall patient care, rather than as a nag, a busybody, or a scold. And as the US health care system continues its slow transition away from the evils of fragmentation to a more rational approach that focuses more on integration of care and less on widget-based revenue maximization, the comprehensive, clinical outcome based vision of academic detailing will increasingly help to pull all the pieces back together where they belong. Want more? Peruse the archive of Jerry's pieces here on DETAILS. _____________________________________________________________ Biography. Jerry Avorn, MD, Co-Director, NaRCAD Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use. Read more.
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An Interview with Victoria Adewumi, MA, Community Liason, City of Manchester Health Department NaRCAD Training Alumna by Kayland Arrington, MPH, Program Manager at NaRCAD  Victoria @NaRCAD2018's panel on AD for the opioid crisis. NaRCAD: How did you get into AD? How was the Manchester team formed? Victoria: I was very interested in community outreach and improving the health and well-being of families! I had cursory experience with substance use disorder management and had to jump in with both feet. It really helped having other detailers on the team that NaRCAD trained that I could lean on. The other detailers constantly provided support, and one helped open the door for me at her health system to speak with clinicians. She even provided me talking points that previously worked for her so I could walk into my first appointment feeling confident.  NaRCAD: What has your experience been as a detailer who does not have clinical experience but who does have public health expertise? Is someone able to be effective as an academic detailer without as much prior clinical training? Victoria: My experience has been extremely positive! I care about community, and I thought this was a great opportunity to gain new expertise in this field. I’ve always felt that a community perspective is needed for us to be able to leverage our impact in this field. The NaRCAD Academic Detailing techniques training was fantastic in helping me build tools to be able to speak well and motivate clinicians around medication-assisted treatment (MAT). My goal as an individual detailer is always to present myself as being on the same team as clinicians. I really see detailing as having a solution for clinicians, rather than simply trying to sell them an idea.  Manchester is located in Hillsborough County, NH NaRCAD: Was there a time when a clinician presented pushback or obstacles that made it difficult to get your message across? Victoria: Some clinicians seemed to have already decided whether they were going to be on board or not before I even met with them. I had to feel strong and confident in the skills that I have. When I meet with a clinician, I always frame it as “I’m coming in as a representative of the community. There’s a crisis in our community, and you, as a provider, are a key part of the solution. How can we get you involved?” and “What kinds of things can you tell us that we haven’t even thought about before?” We need everyone’s participation if we’re going to change the tide of the city of Manchester, and clinicians are a vital part of that.
NaRCAD: You have mentioned the power of the team of detailers--can you tell us how the Manchester AD came to be so strong and effective? Victoria: I didn’t know any of the other detailers before the project. The NaRCAD training was great as an introduction to the work and to each other. We all had a sense of hope that was immediately apparent. We have the privilege of doing work that helps save lives and because of this attitude, there was a sense of camaraderie right away. We’ve been effective because our AD team is strong, and it was strong because we were intentional about building bonds. During the implementation period, we never went more than a month without checking in with each other, and sharing successes and challenges. I don’t think I would have enjoyed the process as much if I didn’t have this amazing AD team of colleagues. We’ve had incredible success in building a team of detailers who are all committed to and excited about the work of connecting with frontline clinicians to improve patient care around opioid safety.  NaRCAD: How would you recommend other programs go about recruiting those people that are equally committed and excited? Victoria: That’s a great question! I didn’t necessarily have an opioid response background, but I’ve always cared about communities. That desire to help others makes a great detailer. The trainings can teach the clinical content, but that element of wanting to improve people’s lives is the anchor of a strong AD team, and will resonate with the providers you’ll be detailing. I would then advise new sites to do the important work of helping their detailers to build strong relationships and a sense of teamwork right from the beginning. Those relationships will support everything, from good communication with clinicians, to a renewed sense of purpose in doing the work, which shields against burn out moving forward. Consistent opportunities to check in and connect between AD team members can’t be overemphasized—it truly made me feel that I was never in this alone; I was always working as part of something bigger than myself.  Biography
Victoria Adewumi, MA Community Liaison City of Manchester Health Department Victoria Adewumi is a Community Liaison with the Manchester Public Health Department. Victoria primarily helps coordinate and staff programming of the Manchester Community School Project, a model that facilitates better health for Manchester residents through place-based interventions. Victoria serves Manchester residents by linking them to partners in the health, social service, business, non-profit, and faith communities and by engaging community members in resident leadership and equity activities. Victoria also participates in efforts to serve refugees and newcomers in New Hampshire through both direct service and community-building initiatives. Victoria holds Bachelor and Master of Arts Degrees in Political Science from the University of New Hampshire. Opening Up the Conversation: An Interview with the Bell County, Kentucky Academic Detailing Program10/26/2018  Featuring: Robin Tuttle, RN, ER Nurse, Academic Detailer, NaRCAD Training Alumnus Interview by Kabaye Diriba, Senior Program Analyst, NACCHO, in partnership with NaRCAD EDITOR'S NOTE: Bell County, Kentucky, was the first site of four selected for a 2018 pilot program of the CDC (Centers for Disease Control and Prevention), NACCHO (the National Association of City and County Health Officials), and NaRCAD (The National Resource Center for Academic Detailing). This exciting pilot program focused on community-level work with local public health departments to develop customized interventions to reduce opioid overdose and death. Four sites experiencing significant public health problems related to opioids were selected to be trained in academic detailing; those trained health professionals then conducted 1:1 field visits with front line clinicians to impact behavior around prescribing, treatment referrals, and patient care, all within a rural area. As year 1 comes to a close, we’re showcasing successes from the field. Thanks for talking with us about your on this pilot project with NACCHO, the CDC, and NaRCAD, working to support local efforts in your community. Robin: What we’ve been doing has been a breath of fresh air! I'm proud to be a part of it, and happy to help in any way that I can. Tell us how local detailers were selected for this project—what kinds of professional backgrounds make up your diverse team members? Robin: I was asked by a co-worker, another detailer, who thought “I know this really outgoing, outspoken person that might fit the team.” Our team is made up of people that have hands-on knowledge about the opioid epidemic. I’ve been in healthcare since 1988 and I’ve been living here in Bell County for 30 years. I started working as a nurse aid at one of the local hospitals and then went on to college to get my RN. Our detailing team all had a common interest when we got together.  What elements of the training do you apply most often during your visits when delivering your key messages? Robin: What helped me the most was that last day of training when we were practicing academic detailing. Asking open-ended questions is the most important thing. You get so wrapped up in wanting to deliver your messages, but it’s not necessary that you get all of your messages in on that first visit. You may feel rushed to deliver all your messages if you’re afraid you’re not going to make it back in the door, but what I found is the more I met with doctors, and the more I said things like, “What have you seen in your practice?” or “Tell me about a patient…” or “Talk to me about the problems you’re having…”, the more I saw the conversation open up. That’s something I really picked up on the second day of training—learning to turn it back around and asking [needs assessment] questions. Let them get involved, and let me really listen to what they have to say; that way it'll help contribute to the conversation going forward. The opioid epidemic can be a sensitive topic. When you approach clinicians to discuss their behaviors around the opioid epidemic, how are you generally received? What do clinicians in Bell County see as major challenges in your community? Robin: Almost everyone I spoke to was very receptive about everything that we talked about, including all 5 of our campaign’s key messages. Because treatment in this area is slim to none, it all circled back to, “What if I find someone [a patient] that has opioid use disorder? How can you help me?” Doctors here are telling me that even people that have overdosed and come to the hospital are having a hard time [getting access to treatment]. There are places that are not in Bell County, but we would need some sort of transportation system that could get patients to those places.  What challenges do Bell County clinicians face, along with being busy, when trying to support their patients who are prescribed opioids? Robin: Clinicians are often challenged in identifying symptoms of someone with opioid use disorder. Also, sometimes patients are sent to a pain [management] clinic, but those don’t always work. In our community, we can send them to the local Suboxone clinic which is accessible and easy to get to. When it comes to Suboxone, you cannot look at it as an “all-or-nothing” approach. That’s a challenge here in Bell County, trying to get the community to know that abstinence is not always the answer, and sometimes people might have to take some form of medication for life to get the wiring back together that they've already lost because of their disorder. I also understand some of the doctors are adamant about their current patients that have been taking these medications for 25 years for this chronic pain, which they don’t think they can do much about, and they’re concerned about this newer generation [of patients] coming in.  What have been some of the more rewarding exchanges you’ve had with clinicians you’ve met with? Robin: I've had a lot of good visits, but this one sticks out in my mind: there was one clinician where I felt immediately like I was going to get the “brush off”. But I ended up staying for an hour and a half! I sat there with this doctor, who I’ve had a challenging professional relationship with historically, and he ended up talking to me at length about patients he was seeing, and those he had inherited. I was so excited that I’d spoken with him for so long, and that I’d covered all 5 of our campaign’s key messages. I walked away from that visit with questions to follow up on that I wanted to be able to answer for him at a future visit, and I felt like I made a new friend. What do you want to tell new detailers who are just starting to form teams and try this kind of 1:1 outreach education model out with clinicians in their communities? What piece of advice would you have appreciated when you started your first detailing visits? Robin: Try not to get discouraged! After we divided up all the physicians, we started making phone calls. That can be discouraging. I found out we actually had more luck stopping by. We called it the “drug representative look”: you dress up, put your badge on that says academic detailer, have the clipboard and all the paperwork, and you look professional. I really found out that I had more luck by just walking in and saying, “Do you have a minute?” Don’t get discouraged if you're making calls all day long and they keep putting you off, because receptionists are making appointments all day long too and it’s hard to explain what you’re doing over the telephone. We definitely felt discouraged during the first couple of weeks of outreach. We were feeling like we hit a brick wall, and that’s when we coined the term "drive-by” detailing visits. We started driving around and just showing up at offices. So, get out and drive if you can’t get through over the phone. Go with a card and introduce yourself. They [clinicians] all want to talk about opioids. You'll be surprised when you get in the room with them and they start talking. Ideas? Comments? Questions? Sound off on this blog in the comments section below!
 Here’s the good news: academic detailing is becoming so widely accepted that everyone wants to help provide the evidence that is disseminated. That’s also the bad news; worrisome examples range from the grotesque to the sinister. One eminent health policy expert wanted to know how much it would cost to put together a nationwide academic detailing program (my heart leaped) that would be underwritten by the pharmaceutical industry (dammit). Prescription drug management (PBM) companies now offer so-called academic detailing services as part of their contracts with payors to oversee drug choices and spending. Sounds good until one realizes that a large chunk of PBM revenue come from payments by manufacturers to move market share to their products. So much for communicating evidence that is neutral, unbiased, and non-commercial. You’d think we’d have learned our lesson by now. Do universities or insurers or government fail to offer enough continuing education about prescribing? No problem, drugmakers will be more than happy to fill the gap, either for free or at amazingly low cost…. often with really great food. That local clinical expert who shows up at Grand Rounds to provide an overview of all the new treatments for diabetes, at no cost to the hospital? Don’t ask who’s paying him to be there. And those convenient smartphone apps that provide so much handy dosing information for any drug you can think of? All you have to do is read the commercial messages that pop up on your way to the data, as the vendor promises its pharmaceutical sponsors the chance to "embed your brand message at multiple points across the care continuum."  There is a solution to the concern about who’s providing the content for academic detailing programs, and it’s much easier than figuring out whether a particular Facebook ad is brought to you by a Russian bot. Just expect that any purveyor of AD information will reveal clearly all the financial ties it and its authors have with any drug or device maker, in relation to program sponsorship as well as the creation and editing of the clinical content. After years of being misled about hidden data on adverse events or failed studies, we’ve developed a higher set of expectations about disclosing all information about clinical trials, and the need to reveal authors’ financial ties for published studies. Those same higher standards must also be applied to academic detailing programs, so that its audiences will know whether the material is the carefully vetted work of a team of unconflicted reviewers who don’t work for any manufacturers, or is instead yet another terribly sophisticated new way to market particular products. Want more? Peruse the archive of Jerry's pieces here on DETAILS. _____________________________________________________________ Biography.
Jerry Avorn, MD | NaRCAD Co-Director Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist, geriatrician, and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use, particularly in the elderly. Read more.  Guest Blogger: Joseph Leishman Academic Detailer/Masters in Public Health Candidate Center for Clinical Management Research, Ann Arbor VA The University of Michigan School of Public Health NaRCAD Training Alumnus  NaRCAD: How did you get into AD? What were you doing before? Joe: I’m a graduate student at The University of Michigan School of Public Health studying epidemiology. As a student I started working at the Ann Arbor VA Center for Clinical Management Research on a lung cancer-screening project. Our project involves 8 different VA sites across the country. As we shifted into an implementation phase, academic detailing was selected as an implementation method. I transitioned to an academic detailer role because of my background in epidemiology, my understanding of lung cancer screening (LCS), and my ability to communicate these principles. I attended the NaRCAD academic detailing techniques training and things took off from there!  NaRCAD: Why is AD for lung cancer screening so important? Joe: Lung cancer screening can be more complex and complicated compared to other preventative services, and most primary care physicians have very limited time to discuss lung cancer screening with patients. There are a number of potential downsides to screening – false positives, overdiagnosis, invasive procedures, and complications from invasive procedures. The benefits of the screening outweigh the challenges, and we have developed a tool for doctors to quickly evaluate a patient’s lung cancer risk, facilitate shared decision making, and make personalized screening recommendations. NaRCAD: Tell us about the lung cancer screening detailing aid and related tools that you made with NaRCAD’s support. How was the process of developing the detailing aid? Joe: Our detailing aid contains background information on lung cancer screening and some of the key evidence behind our tool. It also outlines some of the reasons and benefits behind using this risk-based approach. We tried to keep the detailing aid simple enough that doctors could quickly understand the concepts with little or no additional explanation. This was our group’s first attempt at making something like this. We worked with NaRCAD during the creation of the detailing aid to improve the clinical content, layout, and language. There was a lot of trial and error to create the detailing aid. We ended up going through 10 versions before it was finalized.  NaRCAD: How did you decide what information was most important to put on your detailing aid? Joe: Initially, we started out with too much information. It was too complicated and wordy to effectively communicate our message. We tested it out with our team to see if our message was clear. It was obvious when sections of detailing aid didn’t work well. We really had to focus on narrowing down the main evidence and messages we wished to convey. We used the primary lung cancer screening evidence from the US Preventative Task Force and the National Lung Screening Trial. Our tool goes a step beyond screening eligibility to look at individual risk, life expectancy, and patient preferences, which help providers get past some of the difficulties and complexities of lung cancer screening.  NaRCAD: How does your website complement the detailing aid when you are 1:1 detailing? Joe: A link to the tool is embedded in the Computerized Patient Record System (CPRS), the EMR system that the VA uses. However, it can be also accessed outside the VA with a URL. What I typically do is I have PCPs pull up the website in their workspace after going through the detailing aid. I have providers role play with a sample patient, and I demonstrate how the tool could be used for that specific patient. Using the actual web tool in a detailing meeting really helps to reinforce our message. We feel like it increases the likelihood that it’ll be adopted in an actual clinical practice. NaRCAD: How have clinicians been responding to your campaign? Joe: So far there has been a decent response from the doctors we have worked with. Some of the doctors in the VA have met with detailers before which makes the initial contact easy. However, the most majority of the doctors I have met were receptive to my visits. We’ve been tracking the use of our tool before and after academic detailing at a site level. We don’t have exact numbers, but there has been an increase between before and after AD. We’d be happy to share more complete data in a future blog post.  NaRCAD: That'd be terrific, we'd love to share that when it's ready! What other reflections do you have from this process that you'd like to share with our community?
Joe: Academic detailing is a new approach for our group. It has been a real learning experience for discovering what does and doesn’t work and how to best address provider needs. For me, going through this process has been a lot of fun. I love talking with doctors about their struggles and being able to offer a tool that can help them better handle lung cancer screening with their patients.  The NaRCAD Team is excited to kick off the latest episode in our C.O.r.E. Podcast Series, this time featuring the insights of Program Director Rebecca Edelberg, MPH, from the Boston-based non-profit academic detailing organization Alosa Health, as she shares her experiences managing field programs in clinical outreach education. This episode's 15-minute interview with Rebecca hones in on the "how-to's" of strong AD program management, including:
 Tune in here, and sound off on Twitter or in the comments section below with insights, questions for Rebecca, or topics you'd like to see featured on our next podcast. Learn more about Rebecca and Alosa Health below!  Biography.
Rebecca Edelberg, MPH, Program Director, Alosa Health Rebecca is responsible for providing technical and operational support to field staff, and for ensuring that field-based clinical education programs are executed to clients' satisfaction. Rebecca previously worked at Boston Medical Center implementing a clinical trial and as a consultant in the electronic medical records (EMR) industry, where she engaged in one-on-one clinician education. She has an undergraduate degree from Tufts University and a Masters in Public Health from Boston University with concentrations in Epidemiology and Health Policy. Learn more about Alosa Health's programs, clinical modules, and expert team on their website.  As the Public Health Education Specialist for the WIC (Women, Infants & Children) program and the Opioid Task Force in Butte County, California, Stacy Piper, CLEC, acts as a regional liaison with the medical community as well as coalition's and various community partners. Learn more about Stacy in the bio at the end of this piece. NaRCAD: Hi, Stacy! Thanks for joining us. Tell us a little bit about your work—we understand you, like many folks in public health, wear multiple hats. As the Butte County Public Health Education Specialist for the WIC (Women, Infants & Children) program and the Opioid Task Force in Butte County, I act as a liaison with the medical community. I collaborate with hospitals, health care providers, public health programs, and community organizations to improve public health and continuity of care.  NaRCAD: Talk to us about detailing for the opioid crisis—you do this 1/4th of your time. How did you get started? After providing educational detailing for the WIC Program funded at 30 hours a week, I was asked to be an Opioid Academic Detailer for Butte County. In preparation, I attended the Academic Detailer Training in San Francisco. The training provided by the CA Health Department, San Francisco Public Health Department's Substance Use Research Unit, and NaRCAD was one of the finest training experiences - even after the countless hours of extremely comprehensive training I received in the Pharmaceutical Industry. Regarding impact on a local level, it is indescribable how every interaction with a healthcare provider is beneficial. Academic Detailing (AD) is an equal exchange of information. I consider it a huge responsibility, and a privilege, to be an educator for doctors and medical professionals. I prefer the word “educator” instead of “detailer” because I have concerns that a “detailer” may be initially viewed as a salesperson. I love and respect that AD is not driven by attempting to influence medical professionals for personal gain. It’s all about helping providers improve health outcomes in patients with the entire focus of the conversation about the real people in their practice that need help.  NaRCAD: Tell us a little about your background in pharma, and how this translates to your detailing work now. I was a Senior Executive Pharmaceutical Sales Representative for 15 years in Northern California, advocating for immunizations and promoting various prescription drugs. This provided first-hand experience of the astonishing evolution in the Medical, Pharmacy, and Insurance industries. Understanding the basic dynamics of medical offices has helped me navigate and gain access at a quicker pace for AD. Also, understanding the business acumen component of running a medical practice has proven to be valuable in my recent interactions.  NaRCAD: You mentioned that you’re committed to providing value for clinicians and patients alike. Talk to us about how you share key messages with the clinicians you visit. In my experience, to truly influence the behavior of a highly-educated and experienced individual, you must come to the table with the goal of learning. With attentive listening, you ‘hear’ the medical professional, and process what you have learned. Your intuition will guide you to ask the appropriate, insightful questions needed to evaluate his/her priorities and challenges. This is a beautiful thing, because trust starts to blossom and the partnership has begun. You can then confidently tailor key messages, valuable resources and solutions that are closely tied to those needs and challenges you uncovered. You should begin to see the individual’s genuine desire to truly change behavior and habits.  NaRCAD: Talking about opioids is a sensitive topic. What’s some of the typical pushback you get from clinicians you detail about opioid safety? The response to academic detailing really depends on the situation and the type of clinician and/or establishment I am working with. Sharing local opioid statistics compared to our state statistics is an eye opener! I try to paint real life pictures by telling true stories. For example, I’m honest about my own family members who were innocently caught up in this crisis, including the true story about the day my sister’s husband accidentally took his prescribed opioid medication twice. My sister lost her husband that day.  NaRCAD: Along with telling true stories, how do you handle pushback and stay positive, encouraging clinicians to pivot? Time, or lack of time, is the biggest culprit in keeping physicians from attempting to personally assist in ending the addiction cycle for patients. I passionately believe clinicians need more time with people on opioids. It takes several visits with an office to start moving in the right direction. Working with the medical assistants, nurses, and/ office managers is a key component. They can often have influence, give advice or insight, and even advocate when you are not there. Also, I review our county’s Safe Prescribing Guidelines. If clinicians cannot institute all items in the guidelines, I ask providers to choose what they can commit to doing and to think about some specific patients they can work with. I also ask them to consider prescribing Naloxone for patients on high doses of opioids (above 50 morphine milligram equivalents).  NaRCAD: What would you share with new detailers who are about to go into the field and use AD to tackle the opioid crisis? I have a few reminders and tips for detailers:
Biography.
Stacy M. Piper, CLEC, Public Health Educational Specialist Butte County California Public Health Department As a Public Health Education Specialist, Stacy was chosen to work with two CA State grant funded programs educating Medical Professionals, Hospitals and Community Organizations for the WIC Program and the Opioid Drug Abuse Prevention Program. She maintains an active involvement with the Butte County Opioid Task Force, as well as the Butte County Drug Addiction Prevention Coalition, ACE’s Coalition (Trauma Informed), Breastfeeding Roundtable Coalition, Butte County Breastfeeding Coalition, Mother Strong Coalition, and Perinatal Coalition. Stacy has had extensive training with the California Department of Public Health's Opioid Stewardship & Chronic Pain Detailing Program, ID Training, UCSD CLE (Certified Lactation Educator), Coalition & Equity Training, Advocacy Training and holds 14 years of ongoing training & certification in the Pharmaceutical Industry. She is a member of the team coordinating and orchestrating the 2018 Northern California Opioid Summit.  Jerry Avorn, MD, Co-Director, NaRCAD Of all the medication use issues facing the U.S., the most pressing is of course that of opioid mis-prescribing. When the anatomy of that mis-use is dissected, it becomes clear that the principles and methods of academic detailing are especially well suited to addressing this crisis, for several reasons.  First is the problem of information deficit: before the mid- to late-1990s, practical issues of the assessment and management of pain were often poorly covered (or not at all) in most medical school or residency training programs – so there’s a lot of good that can be accomplished by simple personalized knowledge transfer, to start with. Second is dealing with the contamination of dis-information: the growing documentation of the fact that sales reps for OxyContin, for example, actually under-stated the drug’s risks and over-stated its potential indications when describing their product to prescribers – distortions for which the company had to pay $600 million in penalties. Third is the fact that for this therapeutic category more than for most others, a prescriber’s attitudes and motivations play an especially important role. These can involve “non-scientific” issues such as:
 There is ample evidence that simple “gotcha” letters accusing a prescriber of opioid over-use have no effect. Similarly, draconian restrictions imposed by governments or health care systems limiting the amount of opioid that can be prescribed to a given patient clearly run the risk of under-treating genuine pain – a grotesque example of health care rules that seem guaranteed to increase patients’ suffering. Evidence-based guidelines, such as those promulgated by the CDC, are fine as far as they go, but most doctors haven’t read them, and even fewer have integrated them into their practices.  But a well-trained, skilled academic detailer can interact with a prescriber to understand just what issues lie behind the apparent misuse of opioids by that physician, and present a set of interactive messages tailored to those particular needs. This will involve constructing a personalized blend of new knowledge transfer, dis-information detoxification, practice facilitation (including help accessing Prescription Drug Monitoring Program data less burdensomely), accessing local resources for help in patients with opioid use disorder, and assistance with patient education.  A similar approach could also be enormously helpful for encouraging naloxone prescribing and improving the care of patients with opioid use disorder, including medication-assisted treatment, where information deficits and attitudinal issues are even more prominent. Together, this kind of individualized outreach education can accomplish far more than mailed guidelines, accusatory nastygrams, or legal restrictions – and in doing so, do more to improve patient care and reduce preventable misery than can be expected from more old-fashioned interventions.  Biography.
Jerry Avorn, MD, Co-Director, NaRCAD Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use. Read more. Guest Blog | Alyson Decker, NP, MPH | San Francisco Department of Public Health  Our AD program is part of a 3-year demonstration project (CDC Project PrIDE), and as part of our grant-funded work our overarching goal is increasing PrEP access and prescribing to MSM (men who have sex with men) of color and transgender persons who are at substantial risk of acquiring HIV. Our goals include improving sexual health in the primary care setting, refining sexual health history-taking, increasing screening and testing for those with risks, promoting best practices around PrEP prescribing, and helping to establish relationships between our health department and our community providers.  The added benefit of public health detailing is that it also increases awareness about the issues that affect our community. I have been inviting clinicians that I meet to join us in our city-wide Getting to Zero consortium, which helps providers feel that they are part of this important movement of preventing HIV transmissions, deaths, and stigma.  In San Francisco, there is a need for urgency around this issue, especially because it’s become evident that as HIV transmissions continue to decrease, the disparities among new HIV positive diagnoses become more apparent. Many of these disparities are among communities who still may not be aware of PrEP, or are facing barriers to access. Our academic detailing program strives to reach the providers who work with these vulnerable communities.  When kicking off an intervention such as this, identifying the clinicians who see this target population is the first step. To do this, we used STD surveillance data to determine which providers and clinics were diagnosing syphilis and rectal gonorrhea and chlamydia, which are associated with an increased risk for HIV. However, since many providers are not performing appropriate screenings, we also reached out to clinics known to serve our priority population and those located in neighborhoods with the highest HIV incidences.  The next step is how to “get in the door” with these clinicians, which means finding a way to secure a 1:1 visit. I’ve found that initial non-responsiveness isn’t the end of the world—persistence pays off, so keep trying to get in the door, or find an entry point through other community contacts. Sometimes, choosing a different access point can really work well to start a relationship. There are many places where 1:1 visits aren’t feasible due to clinic structure or culture. If I’m able to detail to a small group, it can be a way to meet with a few providers and gain insight about how PrEP might be incorporated or enhanced in their setting. Being invited to an all-staff meeting is often an excellent way to kick off an introduction to this important intervention, and can result in follow-up conversations with individual clinicians. One benefit of meeting in small groups is that if a clinician hears a fellow clinician say that he or she is already prescribing PrEP, there may be more openness to discussing the topic; other providers might feel comforted in having a PrEP "ally", resulting in buy-in from the clinic overall. Some clinicians may think that this type of intervention isn’t relevant to their patient population; as I detailer, I often hear responses such as, “I don’t see this population reflected in my practice,” or “My patients don’t have this risk,”, even if it’s been proven that these clinics do, indeed, serve priority populations. In order to talk about PrEP, you first have to talk about risks for HIV, which often means talking about sex. I think there can be discomfort on both the patient and provider side, and sex is often still a stigmatized topic. There are also overarching resource barriers, including the fact that clinicians are extremely busy and have to address competing health needs in the primary care setting.  While a small pool of clinicians have minimal understanding of PrEP, and require a basic overview about elements like identifying potential PrEP candidates, how to take a good sexual history, and how to bring up PrEP in an appointment, I’ve found that many clinicians are aware to some extent about PrEP already, and are interested in next-level details about how to implement it. This might include what kind of testing is recommended, how to increase number of basic screens, and increasing their knowledge about comprehensive health. There are also providers who are very advanced in their knowledge of what options are available to populations with risks for HIV. This is where the academic detailing becomes more intricate; some providers are seeing lots of patients with risk factors, and may have been prescribing PrEP already. In a scenario such as this, my messaging focuses more on how to support clinicians in ensuring consistent follow-up with their patients, or in how to deal with multiple risk factors, such as when high-risk sexual behavior may overlap with instances of substance use or homelessness. For those who are just getting started, it may help to know that even after meeting with 300 providers, I still get nervous each time I prepare to detail, especially if I’m unfamiliar with a practice. Regardless of the nature of my visits, I walk away feeling that I’ve accomplished something if I’ve answered only one question that’s helped the clinician with his or her practice. And I’ve found that in most cases, the people I meet with are very thankful for this service, and are appreciative of the health department. I always thank providers for the work they do and remind them what an important role they have in the community.  Biography. Alyson Decker, NP, MPH
Alyson Decker is a Clinical Prevention Consultant and nurse practitioner with Disease Prevention & Control at the San Francisco Department of Public Health. As the branch’s lead academic detailer, she helped develop San Francisco’s first HIV pre-exposure prophylaxis (PrEP) detailing program. Her role consists of detailing with community providers to increase PrEP prescribing in the primary care setting and promote best prescribing practices. In addition, she provides training assistance to healthcare providers and frontline staff around improving sexual healthcare and STD testing and treatment. She also sees patients at the municipal sexual health clinic, San Francisco City Clinic. Navigating a Disorienting Healthcare Landscape | Jerry Avorn, MD, NaRCAD Co-Director  First, about the grammar. Readers under 65 will be forgiven if they never heard of the daytime television quiz show “Who Do You Trust?” that aired from 1957 to 1963. In it, male contestants were asked if they wanted to answer a question or whether they ‘trusted’ their wife to do so. Concerns by snarky little kids like me that it really should have been “Whom Do You Trust?” did not diminish the show’s popular appeal. Gender issues went totally undiscussed. All grown up now and confronting a changing health care landscape, that still-sometimes-snarky little boy often wonders, as do many of my clinician colleagues, who can be trusted in the world of medical information, especially in relation to prescription drugs. Gone are the simpler times when one had to worry only about whether the drug ads and sales reps were really presenting a balanced picture of all the evidence, which was a hard enough challenge.  We now know that we also have to be concerned about off-label marketing campaigns offering impermissible (and often downright deceptive) statements about efficacy – excesses for which over $16 billion has now been paid to state attorneys general in legal penalties and settlements. As I’ve noted previously, the courts and the FDA are also moving toward much more permissiveness with company claims about efficacy and safety. And in last year’s 21st Century Cures Act, Congress instructed the FDA to be more open to accepting lower standards for drug approval.  Then there are newer sources of information whose trustworthiness is not always clear. More and more, this includes the prescription benefit management (PBM) companies, which seem to be holding on to an ever-larger fraction of the funds flowing through their rich payment pipelines, yet provide little transparency about who gets to keep what rebate dollars, and for what reason. Once billed as cost-savings protectors and comparative effectiveness gurus, the PBMs are under increasing scrutiny, and asked to make their financial data transparent and to clarify just who’s saving what for whom (or is it ‘for who?’).  Nor can we always be sure what angle the payors are playing. Why is Drug A on the formulary, but not its sibling Drug B? It may be an astute purchasing decision, or just the result of a rebate hack. And how much are prior authorization rules and growing co-payments designed to promote evidence-based care, or other less worthy goals? Even clinical guidelines put out by third parties vary from the most rigorous to pretty sketchy.  This leads to one good answer to the ungrammatical question in our title. With these galloping changes in an ever-more marketplace-oriented health care system, every prescriber needs and deserves a smart, superbly informed colleague to rely on to get the best possible syntheses of the clinical evidence – someone who has no other agenda or motivation other than getting the facts right and transmitting them faithfully. Each year, we can take less comfort in counting only on FDA-approved indications, or payor policies, or PBM choices, or advertised claims. The more compromised each of these sources becomes, the more we’ll need ‘honest brokers’ like well-trained and un-conflicted academic detailers, whose only duty is to communicate the fairest evidence summaries as effectively as possible. Like lightweight clothing in an era of global warming, it’s a need that’s only going to increase. Thoughts? Reactions? Sound off below.  Biography.
Jerry Avorn, MD, Co-Director, NaRCAD Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use. Read more. Listen closely, and you’ll hear the other shoe dropping. For several years FDA has been besieged by litigation brought by drug makers and their supporters which argued that the agency’s limiting companies’ promotional claims violated those corporations’ First Amendment-protected rights to ‘commercial free speech.’ Then the 21st Century Cures Act signed by still-President Obama in December of 2016 authorized FDA to consider less demanding standards in approving medications. 2017 began with a new administration vowing to free the pharmaceutical industry from the onerous regulatory burdens of the FDA. Now all these forces are coming together in a worrisome confluence of regulatory derangement.  The House Energy and Commerce committee in mid-July held hearings on how best to implement the Congressionally mandated loosening of drug approval standards set forth in the “Cures” act. At the same time, the new FDA Commissioner has argued that FDA’s “public health mandate” should be met by relieving manufacturers of some of those troublesome requirements to demonstrate clinical benefit, in order to get drugs to the public more easily. At the same time, he noted, as FDA reduces the complexity and duration of the drug approval process, this speeding of new drugs onto the market will help contain their high prices. Nevermind that FDA’s approval process is already the swiftest in the world, clocking in at a mere 6 months for priority decisions. And nevermind that the cost of the regulatory process accounts for only a small portion of medication prices. And just ignore the fact that worrying about cost never has been part of that agency’s mandate. Justifying the reduction of FDA’s regulatory standards to meet its “public health mandate” is a troubling Orwellian development that is likely to have exactly the opposite effect. It is eerily reminiscent of the notorious Vietnam-era claim by the military that a village “had to be destroyed in order to save it.” Invoking FDA’s public health mission to justify approving drugs that have not been adequately shown to help patients is both bizarre and irrational. These developments raise the ante for evidence-based prescribing in general, and for academic detailing in particular. Most clinicians and health care systems are not yet aware that FDA approval may become an eroded imprimatur to guide medication decisions, and most people will continue to believe that pharmaceutical company claims have to pass muster with FDA for their accuracy, even as this becomes less and less true in the coming years.  Even if we cannot stop these disturbing developments, we must at least make sure that they are understood by our colleagues in medicine, so that academic detailing services – by definition rigorously evidence-based and non-commercial – can play an increasingly large role in informing prescribing decisions, as an antidote to these worrisome ongoing developments. Share your thoughts in our discussion forum below.  Biography. Jerry Avorn, MD, Co-Director, NaRCAD
Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use. Read more. Director's Letter: Summer 2017 | Mike Fischer, MD, MS, NaRCAD Director Academic detailing is naturally versatile, growing from the initial studies focused on prescribing decisions to include interventions to improve childhood screening, assessment of cardiovascular risk, smoking cessation treatment, and many other important clinical topics.  Whenever medical care and patient outcomes can be improved by outreach education to frontline clinicians, there’s an opportunity for AD to make a crucial difference. We’ve seen our partner organizations use AD in novel and exciting ways, making adaptations to fit their specific interventions and to combat diverse challenges. Healthcare is in a period of ongoing, rapid change—and continued innovation in clinical outreach education is critical in improving the quality of patient care. But for new ideas to have an impact, they need to be evaluated and communicated to the larger community. Tell us more about what you’re working on—we’ll connect you with others addressing the same clinical topic, or working with a similar geography or population, and we’ll share your experiences and results via our best practices blog, website, newsletter, and social media platform. Along with trainings and networking opportunities, NaRCAD provides targeted consultation and technical assistance to improve your successes in the field. We also participate in collaborations with programs as part of multifactorial interventions and research studies.
If so, drop us an e-mail, give us a call, or write a note in the comments section below--we’ll be in touch to figure out next steps, whether that involves submitting a proposal together, figuring out a customized training, or connecting you with experts that can support your project.  Whether you’re looking to strengthen your team, meet thought leaders in the field, or tell us more about your work in person, we hope you’ll join us at our Fall Training in September, and our annual International Conference on AD this November--registration is open for both, and we look forward to seeing you soon! -Mike Biography. Michael Fischer, MD, MS, NaRCAD Director
Dr. Fischer is a general internist, pharmacoepidemiologist, and health services researcher. He is an Associate Professor of Medicine at Harvard and a clinically active primary care physician and educator at Brigham & Women’s Hospital. With extensive experience in designing and evaluating interventions to improve medication use, he has published numerous studies demonstrating potential gains from improved prescribing. Read more.  Bevin K. Shagoury, NaRCAD Communications Director We're getting ready for our September 2017 training course, and our waiting list is already packed with health professionals who are eager to learn the techniques of academic detailing. So, what's our 2-day training class all about? First, some background on why academic detailing ("AD") is a critical tool in healthcare improvement. AD, or "clinical outreach education", is a unique clinical outreach education strategy where a trained health professional visits a frontline clinician, providing custom-tailored, 1:1, interactive service to that clinician in order to share best evidence and promote specific behavior changes.  In a 1:1 clinician visit, best evidence is shared to promote changes in care across clinical topics and strategies, including anything from shifts in patient prescribing (e.g., to prescribe fewer antibiotics, or switch to a more effective statin) to increases in use of screening and prevention tools (e.g., using a new tool to assess fall risk for seniors, or increase colon cancer screening for a specific demographic.) But knowing the best evidence is only half the battle. Effective academic detailers must learn how to truly connect with a busy clinician, figure out quickly and accurately what that clinician needs to support his or her practice, and deliver information in a dynamic, engaging, and clinician-centric way. "AD" is never a lecture, nor is it simply a delivery of glossy printouts. It's a personalized service used to actively engage busy front line clinicians, and the only way to learn how to deliver that service is to practice doing it. We teach our trainees to prepare for inevitable pushback and artfully deliver critical information that a front line clinician needs in order to provide the best care.
 Over 300 of our trainees have completed our 2-day course ready to visit practices, build trusting relationships with front-line clinicians, skillfully share best evidence, and successfully implement effective health interventions.
If you're thinking about attending but would like to know more, please drop us an e-mail and our team will be happy to discuss this unique training experience. You can also check out testimonials from previous trainees here. Ready to register? Just visit our training series page after July 1st, 2017, and save yourself a spot at our September 2017 session. Jerry Avorn, MD | Co-Director, NaRCAD “There are no facts, only interpretations.” Friedrich Nietzsche “The best lack all conviction, while the worst are full of passionate intensity.” William Butler Yeats “A lie can travel half way around the world while the truth is putting on its shoes.” Mark Twain  The late Senator Patrick Moynihan (D, NY) once famously noted, “Everyone is entitled to his own opinions, but not to his own facts.” Leaving aside the more contemporary position that women are entitled to opinions too, in our strange new sociocultural milieu Moynihan’s adorable truism now suddenly seems, like certain body parts, to be totally up for grabs. Global warming is a hoax; China devalues it currency; Hillary Clinton murders her enemies and runs a pedophile ring out of a Washington pizzeria. A presidential spokesperson re-frames a lie as an “alternative fact”; shouted mistruths seem to get more public attention than established realities. For growing audiences, rogue fake news websites seem to carry the same credibility as the New York Times or The Washington Post. And now this strange new wonderland of unreality is poised to redefine communication about medical facts, particularly about drugs. 
All this will make the provision of rigorously evaluated, evidence-based knowledge about anything, especially the effectiveness and safety of medical interventions, an increasingly needed service. Prescribers will be less and less able to feel comfortable that FDA approval means that a drug has been shown to actually benefit patients. And we always knew that sales reps were adept at putting their products in the best possible light; now they’ll be able to toss out not-quite-true promotional quasi-factoids with more and more impunity. This is the medical world in which academic detailing programs will exist for the foreseeable future. And the more health care is provided in an environment of alt-facts and distortions, the more our sources of unbiased, non-commercial information will be valued and vital. We have our work cut out for us. Biography. Jerry Avorn, MD, Co-Director, NaRCAD
Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use. Read more. The National Academic Detailing Service’s Opioid Overdose Education & Naloxone Distribution (OEND) Program Guest Blog Authors: Melissa Christopher, PharmD, National Director Mark Bounthavong, PharmD, MPH, National Clinical Program Manager  In 2015, the Department of Veterans Affairs (VA) invested in the National Academic Detailing Service to improve the health of our Veterans to address the call to action for the opioid crisis. Through the Opioid Overdose Education and Naloxone Distribution (OEND) Program, our goals were to reduce harm and risk of life-threatening opioid-related overdose and deaths among Veterans.  Key components of the OEND program include raising awareness about the epidemic, 1:1 academic detailing visits with clinicians to provide education and training regarding opioid overdose prevention, opioid overdose rescue response, and issuing naloxone products. We developed direct-to-consumer marketing and other e-resources, including a video, Introduction to Naloxone for People Taking Prescribed Opioids. We also created implementation tools, including population management dashboards to aid staff in evaluating risk factors of their patient population and distributing naloxone accordingly. Academic Detailers demonstrated to VA providers these resources to help raise awareness of opioid overdose risk for their patient panel. Decision-makers believed that funding this program would yield a good return on investment. As part of the National Academic Detailing Service, it’s our responsibility to collect data and supply decision-makers with evidence on the value and success of our program. In other words, we’re accountable for answering the question, “Is academic detailing worth it?”  To answer this question, we performed several program evaluations of the National Academic Detailing Service from 2015 to 2017, one of which we just published in the Journal of American Pharmacists Association (JAPhA) (Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: A preliminary analysis.) The evaluation found that our program improved naloxone distribution rates at a seven times greater increase for Veterans at risk for opioid overdose. These results provided key empirical evidence that VA’s strategy of academic detailing was working. Just as important, these findings also gave decision-makers what they needed—proof that their investment in an area of high risk to Veterans’ health paid off by improving care.  But we learned that another group of stakeholders was just as important as the decision-makers who funded the program—the clinicians that academic detailers visited to provide outreach education as a service. Academic detailers work with clinicians to help them change practice patterns, focusing on improving health outcomes in alignment with balanced, current evidence. As clinicians commit to sustainable behavior change, these providers need to hear the feedback about how the time they’ve invested with their patients ultimately improves outcomes and, in this case, saves lives.  Sharing program results with the clinicians in this intervention also encouraged these providers to share their own results, many of which were stories of patients returning to the clinic to relate their experiences of using naloxone to reverse an overdose. These stories, along with reversal reports from the field that tracked the outcomes of naloxone kit distribution and subsequent use, also created a tangible “return on investment” for everyone involved. We encourage other academic detailing programs to prioritize program evaluation as we have at the VHA—no matter the size of your program, if you’re thinking, “we can’t afford to do program evaluations,“ we stress that you can’t afford not to do them. Measuring program work builds a case not just for the success of one academic detailing intervention, but for the success of future programs—a case for sustainability. Evaluation measures the quality of a program, analyzing results to look at a program’s impact, and allowing for process improvement adjustments to be made to streamline efforts and strengthen that impact. Evaluation cannot be optional, especially when lives are at stake. We also recommend that the results from program evaluations are shared with other stakeholders, such as clinicians, in order to encourage and sustain their behavior changes. Leveraging results from well-designed evaluation is essential for academic detailing interventions to illustrate success, share value, and provide stakeholders and community members with a clear “Yes!” in answer to their overarching question: “Was the investment worth it?” Resources:
 Biography. Melissa Christopher, PharmD National Director, Academic Detailing, US Department of Veterans Affairs Central Office, Pharmacy Benefits Management (PBM) Academic Detailing Service Dr. Christopher is the National Director of VA Academic Detailing Services, overseeing the implementation efforts for academic detailing expansion across all Veteran Integrated Service Networks since 2014. She received her Doctor of Pharmacy from Duquesne University, Pittsburgh Pennsylvania. She completed a Pharmacy Practice Residency and Post Graduate Year 2 in Pharmacoeconomics and Formulary Management at VA San Diego Healthcare System. Dr. Christopher conducted research in health outcomes and pharmacoeconomic analysis for several chronic disease management areas. In recent years, Dr. Christopher has embraced the mission to expand efforts for educational outreach by clinical pharmacists for improvement of evidence based care in Pain Management, Depression, Schizophrenia, and Posttraumatic Stress Disorder as well as other substance use disorders. Most of her program efforts focus on development of educational materials, outcome monitors, provider specific electronic audit and feedback tools to trend practice patterns with implementation efforts for the newly developed as well as fully implemented AD programs.  Mark Bounthavong, PharmD, MPH
National Clinical Program Manager, Academic Detailing Service, Veterans Affairs Dr. Bounthavong graduated from the College of Pharmacy at Western University of Health Sciences. He completed a PGY-1 Pharmacy Practice Residency at the Veterans Affairs Loma Linda Healthcare System followed by a fellowship in Outcomes Research and Pharmacoeconomics at Western University of Health Sciences. He started his career at the Veterans Affairs San Diego Healthcare System as a pharmacoeconomics clinical specialist. During his tenure at the VA, Mark worked on identifying cost-effective strategies and formulary management; directed the PGY-1 Managed Care Pharmacy Residency; and completed a Master of Public Health from Emory University. Mark left the VA in order to pursue a PhD in the Pharmaceutical Outcomes Research and Policy Program at the University of Washington. He recently accepted a position at the VA as one of the National Clinical Pharmacy Data Program Managers in the Academic Detailing Service. Jerry Avorn, MD, Co-director of NaRCAD As I write this in mid-January, it is difficult to know how the health care system will be transformed in the coming weeks, months, and years. But one thing is clear: the new administration and Congress are intent on repealing the Affordable Care Act, and they will have the votes in Washington to do so. Despite their holding this policy position for six years, followed by a long (if issues-light) campaign season, it is not at all clear what will replace it. But one thing is certain: the new administration is committed to reducing federal support for health care for enormous numbers of American citizens. “Better coverage and lower costs” is more bumper-sticker rhetoric than plausible policy, and doesn’t meet the basic criteria of arithmetic. This means that all those who care for patients in the U.S., as well as policymakers, will be forced to live under the yoke of that awful cliché, “doing more with less.” (Our colleagues in Canada and overseas must be reading this message from the richest nation on earth with a mixture of horror and pity.) Appropriate clinical decision making is about to be transformed from a noble goal we should all strive for to a literal matter of life and death. As the ranks of the uninsured and underinsured swell, prescribing a costly drug when a more inexpensive one would work as well will increasingly mean that patients without adequate coverage will simply be unable to afford treatment for their atrial fibrillation, hypertension, or heart failure. The aftermath of the November election will convert a bumpy, imperfect patchwork of coverage into a public administration catastrophe, soon to be followed by a public health debacle.  These changes will transform the active provision of evidence-based, non-commercial information about clinical care from a smart choice for quality improvement to an urgent requirement. Practitioners who care for the millions of patients whose coverage is legislated away will desperately need the very best information about comparative efficacy and cost-effectiveness. Most of us engaged in academic detailing programs have shied away from emphasizing cost-containment as a primary feature or goal of such programs, and for good reason. But just as battlefield medicine often has to dispense with the niceties of office practice to address front-line emergencies, we will need to consider the possibility of “battlefield academic detailing” in the coming year to help deal with the widespread health care financial trauma that patients throughout the U.S. will be confronting, along with their health care professionals. Most of us in American medicine – patients and clinicians alike – will find our hazard ratios going up, and our quality of life going down. Now more than ever, it will be imperative to communicate the best science as effectively as we can.  Biography. Jerry Avorn, MD, Co-Director of NaRCAD
Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist, geriatrician, and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use, particularly in the elderly. Read more. Director’s Letter: Fall 2016 | Mike Fischer, MD, MS, Director of NaRCAD When the leaves start to turn here in Boston, we know it’s almost time for NaRCAD’s International Conference on Academic Detailing. This year’s 4th annual conference features several new and exciting sessions we’re excited to share with our community. #NaRCAD2016 highlights the work of innovators in academic detailing from many locations and organizations, ranging from large national health systems to small independent programs.  Diverse clinical topics will be featured at our interactive sessions, including pediatric developmental screening, smoking cessation in patients with serious mental illness, opioid misuse and overuse, screening for ADHD, and many others. Breakout sessions offer attendees a chance to work closely with leaders in the field, featuring in-depth and hands-on exploration of specific elements of academic detailing. Whether your focus is on training detailers, preparing clinical topic materials, or program evaluation, our dynamic breakout sessions offer a chance to network and acquire new skills.  Our conference is our largest event of the year, but our team has been busy this fall with other activities. At our Boston-based training in September we welcomed trainees from organizations across the country, all of whom concentrated on learning the techniques of academic detailing. We also spent two days this fall in San Francisco, working with the city’s Department of Public Health on an intervention to increase the use of pre-exposure prophylaxis (PrEP) for patients at risk of contracting HIV. We’re excited to continue supporting our partners at the SFDPH as they move forward on this important initiative.  Come join us at #NaRCAD2016! There’s only a month left to register, and space is limited. Check out our conference hub archival page to see what previous events were like, including on-demand video and program highlights. We’re excited that clinical outreach education has been such an effective strategy to address the pressing problems facing patients, clinicians, and health systems. This year, we know that the opportunity to learn, share ideas, and connect with experts will continue to ignite inspiration for our community’s important work in improving quality of care and patient outcomes in 2017 and beyond.  Biography.
Michael Fischer, MD, MS | Director, NaRCAD Dr. Fischer is a general internist, pharmacoepidemiologist, and health services researcher. He is an Associate Professor of Medicine at Harvard and a clinically active primary care physician and educator at Brigham & Women’s Hospital. With extensive experience in designing and evaluating interventions to improve medication use, he has published numerous studies demonstrating potential gains from improved prescribing. Read more. NaRCAD's Interview Series: Public Health Detailing Program at New York City Department of Health and Mental Hygiene (DOHMH) Featuring Michelle Dresser, MPH, Senior Manager, Programming & Strategy  Thanks for taking the time to share the great clinical outreach education work that’s being done by the NYC Department of Health and Mental Hygiene, Michelle! Tell us a bit about yourself and how you got involved in public health, specifically public health detailing. Michelle: Thank you for the opportunity to speak about the Public Health Detailing Program. I have over 20 years of public health experience in both the non-profit and government setting, with the last 12 here at the New York City DOHMH. Throughout my professional career, my specialty has been in healthcare marketing and provider education, emphasizing how providers and consumers can better communicate with each other by tailoring complex messages using health literacy principles.
 An excerpt from DOHMH's obesity pocket guide. It’s essential our reps have excellent selling and communications skills, so when they engage providers and get their buy-in, providers are then equipped to get their patients “on board”. One-on-one provider engagement helps them understand how important it is to have a 2-way communication with patients. How can an outreach representative encourage providers to “get on board” and think about care as a dialogue? Michelle: Let’s use obesity as an example. With obesity, both providers and patients are frustrated, for different reasons. Providers may be frustrated that patients’ comorbid conditions are being exacerbated or don’t have the same kinds of tools to treat obesity as they do other conditions; patients might feel that providers aren’t using great communication techniques, like motivational interviewing (MI), to help them set goals and take small steps towards the goal. If a patient is only told, “You need to lose weight,” which is such a broad and overarching goal, they’ll be frustrated, and frankly, non-adherent. I know I would be.  Example of a coaching script created by DOHMH. Click to learn more. Encouraging providers to have specific dialogues using a customized approach for each patient is important. This kind of dialogue takes into account patients’ literacy beyond the written and spoken word—it looks at scientific, fundamental, health and cultural literacy, too. We work on “coaching scripts”, which take the key recommendations and reframes them in order to custom-tailor the conversation for each patient.
One thing that’s unique about public health detailing is that we detail the whole team through one-on-one interactions. Evidence shows these types of interactions with providers and staff are more effective at changing behavior; however, sometimes due to the makeup of the practice we must conduct group presentations. It’s not ideal, but it still allows us to get the messages and materials out there.
 A coaching guide designed by the NYC DOHMH to aid clinicians in smoking cessation support for patients. So when an outreach representative goes into an office, they detail...everyone? Michelle: If there are 15 people who work in an office, we’re going to detail all 15 of them. It’s a lot! Sometimes, the person who is the champion of a new behavior or workflow isn’t going to be the provider. We see the front desk staff as instrumental; they’re interacting with all of the patients. We work with our teams to ensure even the front desk staff receives the materials and information, rather than seeing them merely as a “gatekeeper” to get to the providers. Sounds like a lot of training goes into preparing for your campaigns, and for thinking about the entire process of effective outreach. Tell us more about your trainings, and about how you prepare outreach representatives on disease content training, as well as in marketing and communications skills.  Click to view more Public Health Action Kits (copyright of NYC's DOHMH) Michelle: On average, our trainings are about 5 days in length and take place the week prior to launching a new campaign. About 40 percent of the training is disease content, so we work with our internal Health Department experts, as well as external experts, where we learn about prevention strategies, treatment strategies, epidemiology and the landscape around the key recommendations chosen based on the evidence of that topic. We need to know the ‘why’ behind the campaign. Once we have that under our belt, we shift to sessions on how to frame the issue, how to promote the materials, figuring out the “features and benefits” as well as the “barriers and objections” and finally “gaining a commitment”, which are phrases that come from pharmaceutical marketing. We’re “selling” and promoting public health interactions, so we work on those skills. We also do a great deal of role playing, including videotaped analysis of each rep. We look at body language, what communication skills are effective, we do knowledge assessments, quizzes—we make sure our team is well-prepared to go out and detail. We take this seriously—they’re representing the New York Department of Health and Mental Hygiene.
 What’s a major barrier your program has faced, and how have you tackled it? Michelle: A big challenge, when starting a detailing program, is access. The landscape of healthcare systems in NYC has drastically changed over the past few years. As an example, several years ago, the majority of our Brooklyn territory was almost entirely made of up of small practices where access wasn’t an issue. What’s changed since then? Michelle: Now, many of these sites have become part of larger institutions, so there’s corporate buy-in that needs to happen for people to come in and talk to the staff. As I mentioned before, although we try and limit group presentations, this has proven to be an effective strategy when entering into a new relationship. Once they get to know us and recognize the value of the program, they’re engaged in having us come back to conduct 1:1 visits on the follow-up and subsequent campaigns. How do you know when a campaign is working and becoming successful? Michelle: Evaluation is always on the top of our priorities, and can be a challenge for any program to evaluate effectiveness. For every campaign we conduct an initial and follow-up visit where we assess provider practice. This allows us to see if there has been a change in practice from the initial to the follow-up visit. Additionally, we rate what providers intend to adopt in terms of the key recommendations and supporting tools and resources. We also collect a large amount of qualitative data because it's also critical to gaining a more complete picture of the campaign’s success, especially when reporting on barriers, access and materials.
You can scale this up or down, depending on your need and organizational priorities. Our program focuses on where there’s the greatest need and potential for greatest impact. Programs should make sure to look at their organization’s agenda and goals. It’s important to look at the data and plan the best course of action within the capacity you have. Biography: Michelle Dresser. Michelle Dresser is the Senior Manager of Programming and Strategy for the Public Health Detailing Program within the Bureau of Chronic Disease Prevention and Tobacco Control at the New York City Department of Health and Mental Hygiene. In this role, she oversees the overall programmatic direction and strategy of the program. This includes, campaign strategy and timing, campaign content, training and economic incentive development, provider selection, identification of targets to ensure the greatest impact on populations most in need, and identification of “new needs” opportunities to expand program reach and achievement of program goals. She also oversees internal and external strategic relationships to enhance programmatic objectives.
The exponential increase in computing power and data storage capacity, coupled with the sharp decrease in data processing costs, have made possible an era of ‘big data’ that is transforming many aspects of life and commerce. In health care, this evolution is enabling access to information that was impossible to imagine in the era when I first began this work when most prescriptions and test orders were still written on little scraps of paper. As applied to academic detailing, this growing capacity opens up a veritable armory of double-edged swords. Knowing what doctors are ordering: This information has always been an important advantage of the pharmaceutical industry, which routinely buys the detailed prescribing records of specific physicians from intermediaries such as IMS, who in turn purchase these records from nearly every pharmacy in the nation. In the hands of an agile pharmaceutical representative, knowing a doctor’s drug preferences can be a powerful tool in shaping a promotional message tailored to that person.
 Many of us in have had mixed views about the use of such data. On the one hand, it can make possible a more precisely focused discussion about optimal ordering of tests and treatments that is based on a given practitioner’s actual behavior. On the other hand, the approach comes with several risks. One is the concern that clinicians may feel “spied upon” – a problem that doesn’t seem to come up much in industry visits. This in turn can divert the conversation to discussion of “Why are you visiting me?” rather than a conversation about optimal patient care. Data feedback to clinicians also degenerates frequently into he said-she said debates that often come down to “My patients are different!” We welcome feedback from academic detailing programs on how this use of data has worked (or hasn’t) in their own settings. What patients are (or aren’t) doing: The computerization of dispensing records opened an era of hitherto-difficult research on patient adherence to their medication regimens, with generally depressing findings of low adherence. The full import of this rampant epidemic of non-compliance is still not well understood by most prescribers. The rapid growth in mobile and wearable technologies that capture physical activity and other lifestyle choices provides another potential source of data on patient behavior, but the best applications of this information are even less well understood. In principle, academic detailing programs embedded in health care organizations can provide feedback to clinicians on how much or how little their patients are taking medications as directed or complying with other medical advice, and – more important – what to do about it. Is this a useful component of the educational encounter? Again, we would welcome hearing how this use of big data to provide feedback on adherence or patient behavior does or doesn’t fit into the work of ongoing academic detailing programs.
In the coming years, we will see even greater access to terabytes of data on who is ordering what, and what patients are doing with their prescriptions and other treatments. Used well, this technological revolution can provide added power to programs designed to improve that clinical decision making. Expert Trainer Insight Series, Part 2:An Interview with Amanda Kennedy, PharmD, BCPS, Director of the Vermont Academic Detailing Program  Dr. Amanda Kennedy & NaRCAD's Dr. Jerry Avorn NaRCAD: Hi, Amanda! We’re looking forward to chatting with you. You’ve been an academic detailer for about 13 or 14 years—tell us about the Vermont program. Amanda: The Vermont Academic Detailing Program was started in 1999, by Amy Jaeger, PharmD. I trained with Dr. Jaeger as a pharmacy resident. When she left Vermont in the early 2000s, she wanted to leave the program to someone who would be passionate about evidence-based prescribing in primary care. So the job was mine! Amy unfortunately passed away unexpectedly in 2005, but her mentoring and passion for patient care has stayed with me, and has forever shaped the way I think about pharmacy and academic detailing. We’ve evolved over time into a more organized program, with a grassroots focus of serving our state’s primary care providers. This commitment to service is how we succeed in building strong relationships with providers over time, and we infuse the spirit of service into all of our sessions.  NaRCAD: What challenges do you face that are specific to being a rural program? Amanda: Our program has been stable, but it's been low budget over time. Despite being a small state, we face many challenges balancing the feasibility of delivering sessions to providers with our rural geography. The evidence-base for academic detailing clearly demonstrates the value of a 1:1 ratio of academic detailer to provider. However, it doesn’t make sense for us to travel 2 hours each way to see one provider only to repeat the process the next day for a second provider within the same practice. So we mostly deliver small group academic detailing sessions, as a way to serve as many providers as possible within our budget. We‘re mindful that “small group” means about 3 prescribers, which matches the types of practices we serve. NaRCAD: Along with being a seasoned academic detailer, you also help us here at NaRCAD to train groups of new detailers at our Boston-based techniques trainings. Can you share some highlights? Amanda: The power of the NaRCAD trainings is in the power of the individuals who attend. Realizing that other people are struggling with the same issues, and trying to address these issues with academic detailing, is so powerful.
 Amanda works 1:1 with a trainee at a 2016 NaRCAD course. NaRCAD: What would you tell someone who’s thinking about coming to a future NaRCAD training? Amanda: I'd tell them to have fun with it! This training is a special opportunity to focus on how to best communicate with people around behavior change. It allows one to put aside specific topics and come together in a group to think about how best to deliver complex information. The model applies across topics, allowing people from all types of programs to work towards a common goal. The training is hard work, but so rewarding, and offers the chance to learn and network with other trainees. The best part is that it’s immediately applicable upon returning to your program. NaRCAD: That’s good advice—we agree that learning opportunities should be both challenging and enjoyable. In other news, we heard you recently presented at a U.S. House of Representatives Congressional Briefing. Tell us about that. Amanda: I was invited to present at the briefing entitled, “Getting the Medications Right”: An essential ingredient in achieving the goals of H.R. 4878 – the Medicare Better Care, Lower Cost Act. The briefing was presented by the American College of Clinical Pharmacy and the College of Psychiatric and Neurologic Pharmacists. The purpose of the briefing was to highlight pharmacists as members of the primary care team. I specifically presented some of my Vermont research that involved partnering pharmacists within patient-centered medical homes. It was the perfect opportunity to showcase the innovative work we are doing here in Vermont. I think there was a great response from those who attended and for me personally, it was an absolute honor to be there.
NaRCAD: Thanks so much for taking the time to connect with us, Amanda. We’re delighted to have you as part of our core team of training facilitators, and we’re excited to share what you’re doing in Vermont with our community. Learn more about Amanda Kennedy, or visit our Team Page to learn more about NaRCAD staff. Join Us: NaRCAD's next training is open for registration.
Ask the Expert: Questions for Amanda? Ideas for us? Thoughts on detailing? Share your response in the comment section below for community discussion! |
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