Kathmandu University Medical Journal (2010), Vol. 8, No. 1, Issue 29, 126-134 Review Article Academic detailing Shankar PR1, Jha N1, Piryani RM2, Bajracharya O3, Shrestha R3, Thapa HS4 1Department of Clinical Pharmacology, 2Department of Internal , 3Department of Clinical Pharmacy, 4Department of Hospital Pharmacy, KIST Medical College, Gwarko, Nepal

Abstract There are a number of sources available to prescribers to stay up to date about . Prescribers in rural areas in developing countries however, may not able to access some of them. Interventions to improve prescribing can be educational, managerial, and regulatory or use a mix of strategies. Detailing by the is widespread. Academic detailing (AD) has been classically seen as a form of continuing medical education in which a trained health professional such as a or visits in their offi ces to provide evidence-based information. Face-to-face sessions, preferably on an individual basis, clear educational and behavioural objectives, establishing credibility with respect to objectivity, stimulating physician interaction, use of concise graphic educational materials, highlighting key messages, and when possible, providing positive reinforcement of improved practices in follow-up visits can increase success of AD initiatives. AD is common in developed countries and certain examples have been cited in this review. In developing countries the authors have come across reports of AD in Pakistan, Sudan, Argentina and Uruguay, Bihar state in India, Zambia, Cuba, Indonesia and Mexico. AD had a consistent, small but potentially signifi cant impact on prescribing practices. AD has much less resources at its command compared to the efforts by the industry. Steps have to be taken to formally start AD in Nepal and there may be specifi c hindering factors similar to those in other developing nations.

Key words: Academic detailing, pharmaceutical industry, evidence-based information

ational use of medicines (RUM) has been defi ned readily available through all channels of communication: Ras patients receiving medications appropriate verbal, written and computerised. Industry promotion to their clinical needs, in doses that meet their own budgets are large and the information produced is requirements, for an adequate period of time, and at the invariably attractive and easy to digest. However, lowest cost to them and their community1. Irrational use commercial sources of information often emphasise of medicines has been and continues to be a problem only the positive aspects of products and overlook or the world over, both in developed and developing give little coverage to the negative aspects. Industry nations2. In Australia there has been rising concern information may be unsystematic and biased8 and about the costs of the Pharmaceutical Benefi ts Scheme be a factor responsible for the often observed excess (PBS) and inappropriate prescribing3. Prescribing of variation in physicians’ prescriptions9. medicines by doctors and their use by patients has been characterized by a substantial amount of variability in In the United States, pharmaceutical companies employ both rationality and effectiveness4. Antibiotics among about 90,000 detailers and spend over $7 billion annually the most commonly used therapeutic agents account for to market their products to physicians, spending around 12% of ambulatory care prescriptions5. Antibiotics are $15,000 per year per physician10. Interactions between being over prescribed in primary care, especially for doctors and drug detailers (medical representatives) bias respiratory tract infections6. medical decision making, undermine public confi dence and increase costs11,12 . Obtaining information about medicines There are numerous sources of drug information, ranging from international data bases, journals and Correspondence Dr. P. Ravi Shankar reference books, to national or regional drug information Department of Clinical Pharmacology centres, and locally produced formularies and bulletins7. KIST Medical College Information from the pharmaceutical industry is usually Kathmandu, Nepal E-mail: [email protected]

Received Date: 10 Sep, 2008126 Accepted Date: 14 Mar, 2010 Table 1: Characteristics of selected Academic detailing initiatives discussed in the review Detailing Method Target Country Year Reference Subject covered Outcomes provided adopted participants by No negative impact Peer conducted Medical France 1998-2003 31 Use of antibiotics on invasive infections Doctors visits practitioners in children Dalhousie Signifi cant decrease University Nova Scotia, Face to face Prescribing of General 32 in utilization of Continuing Canada intervention COX-2 inhibitors practitioners COX-2 NSAIDS Medical Education Number of Individual AD Utilization of Hospital appropriate Doctors & United States 2006 33 session antibiotics practitioners prescriptions increased Fewer antibiotic Use of antibiotics General prescriptions & United Individual face Trained 34 in acute dental dental fewer inappropriate Kingdom to face sessions pharmacist pain practitioners antibiotics in guideline group. University Pharmacotherapy Drug therapy General of Utrecht, 35 Group sessions of myocardial and adherence to Doctors practitioners Netherlands infarction guidelines improved. Both group Harvard Use of and individual Medical Individual & 36 antihypertensives Clinicians detailing improved Physicians School, group in primary care antihypertensive United States prescribing AD appeared to be no more effective in Prescribing of Pediatricians reducing antibiotic Physician United States 2000 -2002 37 Individual antibiotics in practicing in use than the practice- leaders young children community specifi c report cards alone AD effective in Prescribing of Junior Australia 2000 38 Individual reducing erroneous addictive drugs doctors prescriptions Sustained changes in Individual GPs & Australia 1992 39 Use of NSAIDs NSAID use; reduced outreach visits specialists GI adverse events Prescribers Mulitfaceted Individual & in primary Sudan 41 Use of antibiotics interventions more Pharmacists group methods health effective centers Practices Argentina & Hospital 42 Multifaceted associated with Physicians Uruguay doctors childbirth Improvement in Community Rural Bihar, Treatment of Private 43 Multifaceted various aspects of health India childhood illness practitioners practitioner behavior workers Mixed team Practice of – doctors, Karachi, Management of Private practitioners more 48 Multicomponent community Pakistan childhood illness practitioners consistent with IMCI members, guidelines others

127 Improving access to comprehensible, evidence-based representatives are usually very effective in promoting information about medicines is an important challenge a product. Studies had shown that over 90% of doctors for health authorities. In recent years the Italian Ministry see medical representatives (MRs) and depend heavily of Health has made efforts in expanding physicians' on them as a source of information about medicines and access to independent and evidence-based information, therapeutics7. like freely distributing the Italian translation of Clinical Evidence and enhancing the quality of the already The Guide to Good Prescribing describes how to freely distributed NHS Drug Information Bulletin13. At optimize the time spent with MRs. Prescribers the Manipal Teaching Hospital, Pokhara, Nepal a Drug should obtain a copy of the offi cially registered drug Information Centre (DIC) was established in November information (data sheet) about the drug and during the 2003. The DIC provides objective unbiased information presentation compare the information provided by the on drugs and therapeutics to healthcare professionals in MR with that on the sheet. A recent study in the US the teaching hospital and outside14. had shown that certain of the claims made by drug company representatives were inconsistent with those Interventions to pro3mote rational prescribing on the drug data sheet21. Most physicians fi rmly believe Rational use of medicines requires correct prescribing, that they are able to resist being infl uenced by drug dispensing and patient concordance with treatment. companies’ promotion activities according to a recent Promoting RUM requires that the behaviour of all review published from Portugal22. This is however, persons involved in prescribing, dispensing and patient opposite to what has been consistently reported in the use is addressed15. Strategies or interventions to promote literature. Portuguese physicians interact with MRs at the more rational use of medicines can be educational, a higher frequency compared to their colleagues in the managerial and regulatory. Educational strategies aim US and Canada. The study concludes that this may put to inform and persuade users. In service education Portuguese physicians at higher risk of being infl uenced programs, workshops, seminars, drug information by the industry22. centres, drug newsletters and bulletins, a hospital formulary and standard treatment guidelines are some A study had shown signifi cant difference in perceptions of the educational strategies15. in the value of services provided between physicians and pharmaceutical sales representatives. New product Managerial strategies include developing and detailing, old product detailing, providing product implementing standard treatment guidelines, audit studies and research fi ndings were perceived to be less and feedback, clinical pharmacy programs, medicine important by physicians23. However, there were no restrictions, and avoiding perverse fi nancial incentives. perceived differences in value as regards free samples Regulatory strategies include supporting national and promotional lunches and dinners. A study in Canada regulations, framing and enforcing a hospital policy on had looked at the self-perceived role and educational pharmaceutical promotion, among others15. Successes needs of pharmaceutical representatives24. Around 98% and failures in promoting RUM in a teaching hospital in of the surveyed representatives agreed that they had a Western Nepal have been described in a recent article16. role in educating doctors while 52% disagreed about The hospital had mainly used a mix of educational and their main role being marketing. They also felt they managerial strategies to promote rational prescribing. A had been adequately trained to detail their products but recent paper has systematically reviewed interventions a University–accredited program would improve the designed to improve the quality and effi ciency of quality of their detailing24. medication use in managed care between the years 2001 to 200717. The study found that dissemination An American study explored the dynamics of of educational materials alone was commonly used the relationship between physicians and drug 25 as a behaviour change strategy but was found to be representatives . The physicians’ were aware of ineffective17. This has also been shown previously18. the negative effects of detailing but approved the Audit and feedback interventions compare physicians’ relationship at a personal level. The physicians past or current prescribing habits to those of currently emphasised the benefi ts of meeting with detailers and accepted standards. It has been shown to achieve small ignored or downplayed the harms. to moderate improvements in physicians’ prescribing The Guide to Good Prescribing recommends doctors to 19 practice . Collaboration of pharmacologists/pharmacists particularly look for side effects and contraindications in the health care process has emerged as a promising in the written text. They should also ask for copies of 20 approach to improve the quality of care . published references on effi cacy and safety7. Seeing Pharmaceutical industry detailing MRs is useful to learn what is new but it is important to verify and compare the information with more objective The primary goal of detailing by the pharmaceutical sources. industry is to promote the sale of their products.7 Medical

128 Many academic medical centres are prohibiting visits by based information32. Academic detailing was associated MRs to prescribers working their hospitals. However, with a signifi cant decrease in the utilization of COX-2 the author of a recent article has argued that prohibiting inhibitors in the 3-month period immediately following visits by drug detailers to academic medical centres the intervention. and interacting with doctors may be wrong. Small gifts from detailers are unlikely to create confl icts of In the United States (US), a pilot hospitalist delivered interest for prescribers26. Calls for a ban are premised academic detailing intervention was carried out. The on empirical evidence for harm that is inconclusive at detailing session reviewed inappropriate prescribing best, and emerging literature in economics suggests that practices and also covered current practice guidelines33. detailing may well be socially benefi cial. A study had The academic detailing which included a practice- found that pharmaceutical companies did not respond based component improved antibiotic prescribing satisfactorily to requests for more information about of hospitalists in the medical centre. In the United medicines by doctors in Pakistan27. They responded Kingdom (UK), general dental practitioners were more often to specialists and opinion leaders and the divided into three groups, the control, the guidelines and information provided was rarely appropriate. the intervention group34. The control group received no intervention, the guideline group received educational Academic detailing materials by post while the intervention group received Academic detailing or educational outreach is a form of educational material and academic detailing by a trained continuing medical education (CME) in which a trained pharmacist. Patients in the intervention group received health professional such as a physician or pharmacist signifi cantly fewer antibiotics and fewer inappropriate visits physicians in their offi ces to provide evidence- antibiotics compared to the control34. These sessions based information28. The aim of academic detailing were based on face-to-face or individual academic is to visit doctors and/or disseminate evidence-based detailing sessions. information about specifi c drugs or drug classes after conducting impartial, independent reviews of their In the University of Utrecht in the Netherlands, group effi cacy29. AD sessions was conducted. The intervention consisted of scoring current cardiovascular treatment on separate Academic detailing (AD) was fi rst described in 1983 as forms for each patient, presenting an overview of, and a method of continuing medical education designed to discussing evidence-based treatment after myocardial change physicians’ pharmaceutical prescribing habits30. infarction, defi ning the target population, formulating Proponents of this method had studied the various a binding consensus, and identifying patients who were approaches used by pharmaceutical representatives and eligible for improvement of pharmacotherapy35. The their effectiveness and tried to use the same techniques group detailing sessions were found to be effective in to infl uence physicians’ prescribing behaviour. Face- improving therapy. At the Harvard Medical School in to-face sessions, preferably on an individual basis, the US, a study was conducted to compare the effi cacy of defi ning clear educational and behavioural objectives, individual versus group academic detailing to improve establishing credibility with respect to objectivity, the use of antihypertensive medicines in primary care36. stimulating physician interaction, use of concise graphic Individual detailing entailed a physician-educator educational materials, highlighting key messages, and meeting individually with clinicians to address barriers when possible, providing positive reinforcement of to prescribing guideline-recommended medications. improved practices in follow-up visits are important The group detailing intervention incorporated the same principles of AD30. social marketing principles in small groups of clinicians. Both were successful in improving prescribing. Academic detailing in developed countries Academic detailing is common in developed nations In the US, a study was carried out to examine the like the United States, United Kingdom, Europe, effects of AD and parental education programs on the Australia, New Zealand, France and Canada. In the prescription of antibiotics in young children37. Physician Alpes-Maritimes district of France “an antibiotics only leaders in study practices prepared educational modules when necessary” campaign was carried out to reduce the and presented the modules to their practices. The prescribing of antibiotics in children31. Peer conducted control groups received only practice-specifi c report academic detailing visits were carried out in 2000 and cards. Overall, academic detailing appeared to be 2003. Cross sectional studies showed a 9% reduction no more effective in reducing antibiotic use than the in the proportion of children who received antibiotics. practice-specifi c report cards alone. In Australia, it was In Nova Scotia, Canada, academic detailing was hypothesised that AD could reduce simple errors while provided by Dalhousie University Continuing Medical prescribing potentially addictive drugs. Prescription Education as a face to face intervention using evidence- error rates were documented before and after an

129 academic detailing visit to junior doctors, including the In rural Bihar state in India, the INFECTOM intervention provision of a bookmark containing the requirements was carried out. INFECTOM consisted of standard for this drugs38. At the hospital where the intervention information sessions for practitioners regarding was carried out there was a signifi cant reduction in error standard case management guidelines for common rate and an increase in the self-confi dence of junior childhood illnesses, Feedback based on the results of doctors. the preliminary survey, contracting practitioners to gain their commitment to specifi c guidelines and ongoing In Australia, an educational outreach service has monitoring of their performance was done43. The been provided at a teaching hospital for community intervention resulted in a signifi cant improvement in medical practitioners. In 1992 two visits focused history taking, examination and counselling aspects of on the better use of non-steroidal anti-infl ammatory common childhood illnesses. In Zambia, an increased drugs (NSAIDs)39. It was concluded that a continuing number of appropriate antibiotic prescriptions occurred education and support service for community medical after a series of educational seminars44; in Cuba, practitioners which uses principally academic detailing prescribing habits improved following refresher courses methods in its contact with doctors has contributed to in the management of acute respiratory infections45; and sustained changes in prescribed NSAID use over a fi ve- in Indonesia educational interactional group discussions year period. In Sweden, independent drug information reduced the use of injections and inappropriate was condensed and interpreted by a team and presented antibiotics46. Improved prescribing behavior was also in both written and oral form to practitioners40. Over observed among primary care physicians in Mexico after a period of 10 years the information/education method multiple educational interventions47. The improvement described here has proven sustainable and feasible in was not sustained however. terms of providing the information and participation of the target group GPs in the oral sessions. In Pakistan, INFECTOM, a multi component behavioral change strategy altered the prescribing practices of Academic detailing in developing countries private practitioners in childhood illness48. The care Academic detailing is not common in developing provided after the intervention improved and was more nations compared to the developed ones. Possible consistent with Integrated Management of Childhood reasons could be lack of access to objective, unbiased Illness (IMCI) algorithm. information, lack of trained detailers, non-acceptance of pharmacists/pharmacologists as sources of medicine Factors promoting and hindering academic information by clinicians etc. We have been able detailing to fi nd studies describing AD in Sudan, Argentina Studies have shown factors which can hinder and and Uruguay, rural Bihar state in India, Zambian, promote AD. Problems of fi nding time, lack of faith Cuba, Mexico, Indonesia and Pakistan. In Sudan, a in non-physicians delivering AD, lack of currency and multifaceted intervention was carried out to improve objectivity of the information provided were possible prescribing practices in health centres of Khartoum hindering factors. Relevance of the topic and quality of state. Twenty health centres were randomly assigned written material provided were the promoting (enabling) to receive: (1) no intervention; (2) audit and feedback; factors. In a Canadian study on perceptions of family (3) audit, feedback and seminar or (4) audit, feedback physicians regarding AD a number of factors were and academic detailing41. The authors concluded that discussed27. Spending offi ce time doing Continuing multifaceted interventions involving audit and feedback Medical Education (CME) was a factor which deterred combined with either academic detailing or seminars most physicians. Having non-physicians deliver the appeared to be more effective in changing prescribing educational material was found to be another signifi cant practices of antibiotics than audit and feedback alone. barrier. The factors which encouraged AD were the An educational intervention to improve the healthcare relevance of the topics detailed, the handout material left provided during labour and delivery was carried out in with physicians, and the appreciation of the evidence- Argentina and Uruguay42. The trial aimed to evaluate based approach to AD by the physicians. In a study in the effect of a multifaceted behavioural intervention Belgium, the barriers mentioned by physicians to AD on the use of two evidence-based birth practices, the were doubts about the objectivity of the information, selective use of episiotomies and active management of the given information was not new and the physicians the third stage of labour (injection of 10 International had other ways to access the information49. Additional Units of oxytocin). The results of the study are awaited. problems noted were the visits were time consuming, In a teaching hospital in Western Nepal, a number of were politically coloured and were patronising. initiatives have been taken to promote the more rational use of medicines16. However, academic detailing is not carried out.

130 Impact of academic detailing Academic detailing in Nepal AD programs have been curtailed in certain countries In Nepal AD is underdeveloped. The Drug Information citing lack of objective evidence of impact of the Network of Nepal (DINoN) was started with the goal of program among other factors. Providing objective providing unbiased, objective information about drugs evidence of impact of AD may be diffi cult but is essential and therapeutics to various stakeholders. Independent to convince administrators and policy makers. An drug bulletins are being published by the Department evaluation of the impact of Educational Outreach Visits of Drug Administration (DDA), the national drug (EOVs) has been carried out by the Cochrane database regulatory authority, the Tribhuvan University Teaching of systematic reviews. EOVs alone or when combined Hospital, and Nepalgunj Medical College. Bulletins with other interventions had relatively consistent and used to be published by the Manipal Teaching Hospital, small, but potentially important effects on prescribing50. the College of Medical Sciences, Bharatpur. These have Their effects on other types of professional performance unfortunately been discontinued. vary from small to modest improvements. In the US, it was estimated that an AD program to improve the use However, AD has not been formally started. of hypertensive medications resulted in a total annual Pharmacists go for rounds with the medical team in individual cost saving of around 21, 711 US$51. certain institutions and serve as an important source of medicines information. At the KIST Medical College, Many of the AD initiatives mentioned in this review a new medical school in Lalitpur AD sessions for were effective in changing prescribers’ behaviour. prescribers and other staff members in a large group However, a study from Denmark shows the opposite. format (maximum of 30 participants). Informal feedback There was no effect of AD on the prescribing of asthma from the participants of the session has been positive54. medicines in Danish General Practice52. Involving pharmacists and pharmacologists in ward Lessons learnt rounds can serve as a good beginning. The clinicians AD is likely to be successful if the program is well become aware of role of pharmacologists/pharmacists in thought out and discussed before implementation. providing medicines information and of their usefulness AD has a greater chance of success if combined to the healthcare team. Establishment of a DIC will with other educational and managerial interventions. provide up to date, objective and unbiased information Use of a hospital formulary, a hospital drug list and on drugs and therapeutics. Formal academic detailing computer aided decision support system were among sessions can now be considered. The large group format the few mentioned. Individual, face to face detailing might be less expensive in terms of resources but the is generally considered to be more effective than feasibility of one-to-one detailing can be investigated. group detailing but signifi cant changes in prescribing The authors of a recent article identifi ed lack of local behaviour have occurred even with group detailing. health statistics, lack of awareness about evidence-based Provision of written materials has been shown to practice, challenge from pharmaceutical representatives improve the effectiveness of AD. However, publicly and lack of fi nancing capability as specifi c challenges funded AD programs have moderate budgets and staffs to conducting AD in Nepal55. Despite these challenges compared to the efforts of the pharmaceutical industry. an effective AD program can play an important role in Also the detailers do it as a part time effort coupled with promoting rational use of medicines. their other responsibilities. It has been compared to a classic David and Goliath battle29. In Canada, AD was References discontinued in the Canadian province of Alberta and 1. Management Sciences for Health. Managing may face a similar fate in the province of Manitoba. In drug supply. West Hartford, Connecticut, USA: Indonesia, small group intervention and formal seminars Kumarian Press;1997. were compared for improving appropriate drug use53. 2. Hogerzeil, H. V. Promoting rational prescribing: both interventions were equally effective in improving An international perspective. 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