Director's Letter | Mike Fischer, MD, MS
The entire health care system is grappling with uncertainty. What will happen to the provisions of the Affordable Care Act? Will clinicians and health systems face major changes in how they are expected to provide care and how they are reimbursed? Will state and local public health agencies have support for the many initiatives undertaken in recent years?
As we wait for answers to these questions, the role of academic detailing is more important than ever. AD programs will face new challenges, and will need to understand how AD can be adapted to fit changing constraints and still have a beneficial impact on clinician engagement, the quality of care, and patient outcomes. At NaRCAD, we look at this unpredictable environment and see a mandate to collaborate and innovate, working with our partners to develop and evaluate novel ways to implement AD.
At NaRCAD, we look at this unpredictable environment and see a mandate to collaborate and innovate.
Planning for NaRCAD2017, our annual conference, is well underway, and the call for proposals is open. Submit results of your current work or your ideas for panels and breakout sessions that will let you share your work and inspire colleagues.
To keep AD growing and thriving requires an active pipeline of newly trained detailers, which we have just added to with our recent AD Techniques Training on March 30 & 31, 2017.
This spring’s training class came to Boston to learn the techniques of academic detailing in order to support important interventions, including better use of smoking cessation treatment for patients with serious mental illness, increasing HPV vaccination rates, enhanced safety of opioid prescribing, and improving the care of chronic diseases such as COPD, HIV/AIDS, diabetes, heart failure, and kidney disease.
Our trainees hailed from Canada, Brazil, and around the U.S., including South Carolina, Rhode Island, Idaho, Massachusetts, Oregon, Texas, Kentucky, Connecticut, and Colorado, bringing their unique experiences and backgrounds to 2 days filled with hands-on learning opportunities. Stay tuned for upcoming details about our Fall 2017 training, to be held this September--dates announced soon!
What continues to motivate us during times of uncertainty is working with the NaRCAD community, and we want 2017 to continue to be a year of even deeper engagement. Submit to the 2017 conference, share your ideas, suggestions, and comments on our blog, or reach out to us directly. We’re excited to continue to support your work and to build new collaborations--tell us what you need as part of our community of clinical outreach educators. -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.
by Joy Leotsakos, PharmD
Who We Are. The Academic Detailing Service (ADS) of the Atrius Health Clinical Pharmacy Program provides clinically appropriate, evidence-based, cost-effective medication management in a multidisciplinary team setting. Our Clinical Pharmacy Program includes 15 clinical pharmacists (CPs) serving nineteen Internal Medicine and Family Medicine (IM/FM) ambulatory care practice locations. In the past four years, our program has evolved and transformed through evaluating our impact, absorbing and implementing internal feedback, and collaborating with others in the field, including NaRCAD.
Our Start. As the program manager of our ADS, I’ve seen our service grow and change. When we began our program in 2011, it was as an administrative mandate to meet with all IM/FM prescribers once per fiscal quarter to deliver messages about cost-effective prescribing and clinical quality. We started by formulating a menu of topics to cover in our ADS work each quarter, including individual clinician prescribing reports reflecting performance on prescribing initiatives from the Pharmacy & Therapeutics Committee, specific questions to survey clinicians on a clinical topic, targeted education for low performers on prescribing initiatives, and various other ‘hot topic’ clinical issues. CPs detailed individual clinicians via formal 1:1 scheduled appointments, and also did so less formally (such as by catching them in the hallways) or in larger groups during department meetings.
Is it Working? We documented our ADS activities by checking off the individual clinicians we detailed each quarter. At that time, there was no formal training for our CPs on how to conduct a detailing meeting. Unfortunately, this method of creating content for visits soon resulted in a large menu of topics so varied that each quarter’s detailing became unwieldy and too broadly focused. And our documentation, while it gave us a general sense of the number of clinicians detailed, did not tell us anything about the quality of this detailing.
Room for Improvement. Our group is fortunate in that our ADS activities have always been accepted and even expected by our IM/FM clinicians. We experienced almost no clinician resistance to our educational meetings. But in 2013, when attending one of NaRCAD’s 2-day Academic Detailing Training sessions, I learned that we could make changes to improve our services, as well as my own skills as a detailer. As a result, we altered the format of our ADS program, choosing to detail clinicians in a 1-1 or small group format of less than 4. We also selected a goal of 90% of clinicians receiving detailing at least once every quarter.
Evaluating Impact. We began evaluating the impact of the changes we’d made to our ADS, specifically choosing to look at its impact on a discretely measurable topic: reducing the unnecessary ordering of an ALT test (alanine transaminase) in patients on the ’statin’ cholesterol-lowering medications. We were able to demonstrate that our detailing of all IM/FM clinicians led to significant reductions in ALT ordering and meaningful cost avoidance for our organization.
Asking for Feedback. With NaRCAD’s support, we further refined our program in 2014 based upon feedback from an internal focus group. By soliciting honest feedback from the CPs about their detailing experiences, I discovered considerable variation in how they approached the menu of topics provided each quarter and came to understand that the continuous process of visiting with each clinician at their sites often felt stale and repetitive.
New Approach, New Results. We revised our ADS workflow to tie each round of clinician appointments directly to a specific and single P&T prescribing initiative. Furthermore, we developed a method to tag low performing clinicians for an ‘intense’ ADS visit and higher performers for a ‘touch’ ADS visit. We began this new workflow with an initiative to improve the use of evidence-based beta-blockers in patients with heart failure, a quality measure for the Medicare Pioneer Accountable Care Organization (ACO) project. Using this new approach, clinical pharmacists were able to deliver a fresh and meaningful message to the right prescribers, resulting in a change from 73.6% to 97.8%prescribing of evidence-based beta-blockers in this patient population.
Partnering with NaRCAD for Ongoing Learning. In March 2015, we coordinated with NaRCAD again, and they provided our group of clinical pharmacists with a 2.5 hour workshop to enhance our AD skills. I’d encourage anyone who does this type of educational outreach to make use of this invaluable resource. Of course, our Atrius Health Academic Detailing Service will continue to grow and change as we find additional ways to improve our workflows and messages. I look forward to continued collaboration with NaRCAD and with others in the field, so that we can all keep learning from each other and improve health outcomes through effective academic detailing.
Bio: Joy Leotsakos is a senior clinical pharmacist and the program manager for the Academic Detailing Service (ADS) of the Atrius Health Clinical Pharmacy Program. Joy joined Atrius Health in 2007 and became the program manager for the ADS program in 2012. Prior to joining Atrius Health, Joy worked as an assistant professor at Massachusetts College of Pharmacy and Health Sciences University in Boston, MA and provided ambulatory care pharmacy services to the South End Community Health Center also in Boston. Joy graduated with a Doctor of Pharmacy degree from Virginia Commonwealth University School of Pharmacy and then completed her residency in Ambulatory Care and Community Pharmacy at the University of Florida College of Pharmacy. Joy is the mother of one son, and enjoys salsa dancing, cycling and running in the summer and skiing in the winter. You can reach Joy by email at firstname.lastname@example.org.
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