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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 Medicine, 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 medicines. 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 pharmaceutical industry 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 physician or pharmacist visits physicians 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 health care 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 pharmacists 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
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