Kicking Day 1 off and setting the tone for the entire event, NaRCAD Director Dr. Mike Fischer warmly welcomed our packed room at Harvard Medical School’s Martin Center by encouraging collaboration, connection, and sharing. Our Day 1 Keynote Speaker Dr. Carolyn Clancy, the CMO of the Veteran’s Health Administration, described the VHA’s work to improve pain management in the veteran population while addressing the challenges of medication abuse and overdose. Dr. Clancy shared strategy and data behind the national effort and the critical role of academic detailing in it, connecting attendees to a big-picture view that can be adopted to look at other health epidemics and interventions.

Our first expert panel presented Practice Facilitation in Primary Care. Andy Ellner moderated the session, leading panelists Ann Lefebvre of North Carolina's AHEC Program, Lyndee Knox of LA Net, and Allyson Gottsman of HealthTeamWorks to discuss strategies, contextualize their work in relation to academic detailing and quality improvement, and share their personal approaches to challenges in primary care behavior change.  Allyson Gottsman’s much-appreciated analogy that practice facilitation is not unlike “leading a fisherman to a well-stocked pond” resonated with panelists and participants alike. Many attendees who were actively engaged in practice facilitation in their daily work shared that the panel helped them to think about their work in a new way.

The afternoon’s breakout sessions offered attendees multiple tracks with AD-related topics to explore: deconstructing and analyzing a 1:1 AD visit, exploring the skills needed to manage an effective AD program, and strategizing on ways to identify and harness stakeholder support when initiating a new program or strengthening an existing one.

The afternoon closed with two presentations; the first, by Terryn Naumann of the Canadian Academic Detailing Collaboration (CADC), offered participants a view of the power of synergy and teamwork, the historical context of the CADC’s creation and growth, and the future of the collaboration.

More examples of successful practice change were illustrated by the morning’s Themed Plenary on the Intersection of Public Health and AD. Dr. Phillip Coffin of the San Francisco Department of Public Health shared the success of an intervention focusing on co-prescribing of naloxone to reverse opioid overdose deaths in San Francisco. Another successful AD intervention was presented by Michael Kharfen of the Washington D.C. Department of Health, who highlighted the successful implementation of AD programs to increase HIV and Hepatitis C screening and treatment.

The afternoon featured our second Expert Panel, this time on the role of AD within integrated healthcare systems. Moderated by Dr. Mike Fischer of NaRCAD, panelists Joy Leotsakos of Atrius Health (MA), Sameer Awsare of Kaiser Permanente Medical Group (CA), and Valerie Royal of Greenville Health System (SC) shared their experiences using AD in systems at different stages of development. Attendees had the opportunity to discuss this topic further in the afternoon’s breakout sessions, which also included a session on practice facilitation, as well as third session to continue to explore AD and public health partnerships.

The conference’s closing discussion was led by Mike Fischer, who thanked not only the speakers, panelists, and session leaders, but the participants, whose willingness to share their experiences within an interactive setting was key in creating solutions to bring back to use in their daily work. The creative collaborations, exchange of resources, excitement in combating challenges in the field, and belief in the importance of AD for the future of healthcare transformation were felt by all at the closing of a very full and thought-provoking event.

Our Twitter feed tracks the event’s highlights through #NaRCAD2015, and you can catch our event photo album on our Facebook page. We invite you to explore these topics, learn about our speakers and attendees, and connect with us at the NaRCAD Conference Hub, where you can access on-demand video of all main sessions from the conference. Thank you again to all who attended, and to AHRQ for funding our series. Please stay in touch with us and each other, and continue the conversation and idea sharing below. ​
​We hope to see you in 2016!

by Jerry Avorn, M.D., NaRCAD Co-Director
A number of academic detailing programs began in the 1990s or early 2000s, when the cost of many useful medications in primary care was prohibitive. Some were available then only as expensive brand-name products: clopidogrel (Plavix) as an anti-platelet agent, alendronate (Fosamax) for osteoporosis.  Others could plausibly be replaced in some patients by similar agents in the same class: atorvastatin (Lipitor) for elevated cholesterol, celecoxib (Celebrex) for arthritis and pain, omeprazole and esomeprazole (Prilosec and Nexium) for acid-peptic disease. Then came the game-changing developments around 2011-2012, when the patents on blockbuster drugs like Lipitor and Plavix expired. This was referred to as the “patent cliff” by some; others dubbed it “Pharmageddon.”

Meanwhile, discount drug stores, led by Wal-Mart, had been introducing the $4-a-month generic prescription. Within a short period of time, most common drug categories had one or more key medications available that made it possible to manage many common primary care problems—hypertension, high cholesterol, diabetes—for a modest monthly cost.

While these developments were a boon to patients and payors, they were not good news for the large pharma companies, which had to reassess their business models in the post-blockbuster era. But Pharmageddon also had an impact on another, much smaller group: the tiny international academic detailing community.  Many sponsors of academic detailing programs had been attracted by the prospect that promoting evidence-based practice could also help contain rising drug costs. While that was never the main goal of such work for many of us, it was an attractive feature—at least in part—for many funders in both the public and private sectors.

Stark evidence of this came in a conversation I had with a health insurance executive about the possibility of starting an academic detailing program for primary care providers. “Frankly,” he told me, “we’re not focusing much attention any more on drugs in primary care. Many of them are pretty cheap now. All our energies are going to the expensive specialty drugs.”

I guess if the bottom line is all that matters, any M.B.A. would come to the same conclusion about academic detailing in primary care. However, if the mission of academic detailing is to help health care professionals take better care of their patients, then the goal of quality improvement serves as reason enough in itself. Several state government agencies get this (PA, SC, VT, MA, etc.), as do some Canadian provinces and other nations. But in many private U.S. health care systems, the bottom line still rules.

Luckily, things are changing yet again to make academic detailing potentially attractive even for those whose focus is mostly on finances. Growing impact of the HEDIS measures (Healthcare Effectiveness Data and Information Set) and the Medicare “stars” rating system means that millions of dollars of reimbursement now depend on how a health care system performs on several quality measures. Many of these measures depend upon optimal medication use for conditions such as diabetes, hypertension osteoporosis, and elevated cholesterol; others assess cancer screening and other non-medication-related priorities that can be addressed by academic detailers.

So for those of us who always felt that academic detailing is about optimizing patient care, that goal remains as important as ever. And for those who are concerned with how academic detailing can affect a health care system’s bottom line, even though Pharmageddon temporarily took the edge off some of those concerns in primary care, the renewed focus on outcomes and quality measures, many of which are so drug-dependent, means that this reason to improve prescribing is also now back on the table.

About the Author: Dr. Jerry Avorn is Professor of Medicine at Harvard Medical School and Chief of the Division of Pharmacoepidemiology and Pharmacoeconomics. A general internist and geriatrician, 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. Dr. Avorn has published over 250 papers on these topics over the past three decades.
This article originally appeared in NaRCAD’s Winter 2014/15 Newsletter.