NEWS Academic drug detailing: an evidence-based alternative t’s a little known service to physi- cians offered in 5 provinces. One, I though, recently axed its program, while another may soon follow suit. It could be called a distant and poor cousin of pharmaceutical detailing be- cause it too hopes to influence physi- cian prescribing patterns. But there’s no commercial interest in academic de- tailing. Its aim is to visit doctors or oth- erwise disseminate evidence-based in- formation about specific drugs, or classes of drugs, after conducting im- partial, independent reviews of their ef- ficacy. The long-term goal is simply to Comstock promote optimal prescribing. Publicly funded efforts to promote optimal prescribing, such as academic detailing programs, Is there a need for such a creature? have modest budgets and staffing compared with pharmaceutical industry efforts. As one of just a handful of academic detailers in the country providing inde- pendent, analytic advice about pharma- est. According to an August 2006 study gies in Health, was created in 2004 to ceuticals to doctors, Dr. Michael Allen of academic detailing conducted by the promote optimal prescribing. Modelled wryly notes it’s axiomatic for Canadian University of Victoria’s Drug Policy Fu- on the Australian National Prescribing physicians to believe they aren’t in any tures team and entitled Show me the Ev- Service, it received $19.5 million over 5 way influenced by the subtle pitches of idence, Canada’s 5 provincial programs years to conduct 3 to 4 drug studies per pharmaceutical detailers. “But they had a combined work force of 10.2 posi- year for use by policy-makers, provincial think that their colleagues are,” the di- tions. The study concluded such pro- drug plans, prescribers and patients. Its rector of the Dalhousie Academic De- grams are invaluable, even though their first major study, on proton pump in- tailing Service adds. budgets range between $75 000 and hibitors, is slated for release this spring. The scale of those divergent forms $500 000 per year. The best funded, in Ontario’s Institute for Clinical Eval- of detailing, however, are hardly com- Alberta, was recently discontinued, uative Sciences has occasionally re- parable. The pharmaceutical industry while the most modestly funded, in viewed classes of drugs, but spokesper- spends an estimated $500 million an- Manitoba, awaits word on renewal. son Julie Dowdie says the non-profit nually meeting with doctors and clini- Modest fund also typifies other pub- organization’s mission isn’t to directly cal pharmacists to promote the use of licly funded initiatives aimed at provid- promote better prescribing so much as their medications and boost sales. In- ing evidence-based drug information, to research effectiveness and efficiency dustry watchers say such outlays for pro- such as University of British Columbia’s within the broader health care system. motion, and the number of detailers Therapeutics Initiative and Health In short, the magnitude of publicly working doctor’s offices, continues to Canada’s Canadian Optimal Medication funded initiatives to promote evidence- rise. According to the Hay Group, a Prescribing and Utilization Service based drug choices, compared with the global human resource consultancy, (COMPUS). pharmaceutical industry’s effort to influ- there are 5500 to 6000 pharmaceutical The Therapeutics Initiative, which ence sales, is nothing short of what Allen sales representatives in the country. The conducts comprehensive systematic re- calls “a case of David and Goliath.” IMS Health Group says there are views of drugs or classes of drugs and Academic detailing’s goal is to famil- roughly 5700 people employed as repre- mails the information out to the iarize physicians with such concepts as sentatives or managers of those repre- province’s doctors and pharmacists, re- relative risk reduction and uncertainties sentatives — about 1 pharmaceutical ceives $1.5 million per year from the BC surrounding data about specific drugs, sales rep for every 11 doctors. and federal governments. Allen says. Essentially, it promotes “crit- By contrast, public efforts to promote COMPUS, an off-shoot of the Cana- ical thinking. Because of the evidence- optimal prescribing are altogether mod- dian Agency for Drugs and Technolo- based approach we use and the informa- CMAJ • February 13, 2007 • 176(4) | 429 © 2007 Canadian Medical Association or its licensors News tion we present, they are now more criti- through a provincial survey of doctors. Program Director Loren Regier says the cal of the information they get from Dalhousie disseminates its findings 10-year-old, $315 000 per year initiative other sources and that includes pharma- through office visits with physicians but also conducts sessions at medical confer- ceutical reps.” its 4 counterparts in other provinces ences, issues newsletters and email up- The Dalhousie program, which be- employ a range of methods. dates through the Saskatchewan Medical gan in 2001, has annually received be- Saskatchewan’s RxFiles Academic De- Association, and electronically compiles tween $200 000 and $300 000 to conduct tailing Program visits roughly two-thirds a compendium of its drug comparison 1 or 2 reviews per year on topics chosen of the province’s physicians annually, but charts, which it publishes periodically as a book that is distributed to every doctor in the province. The next edition, slated for release “This is the kind of information we need” this month, will cover over 55 thera- peutic areas. “We’re getting to be pretty here’s no doubt in the mind of clinical pharmacist Dr. Aaron Tejani, comprehensive on the core areas.” the co-ordinator of clinical research and drug information for The discontinued 7-year-old Alberta T British Columbia’s Fraser Health Authority (FHA), that academic Drug Utilization Program (ADUP), by detailing has a indispensable role to play in the daily decisions that physi- contrast, relied primarily on written re- cians and pharmacists make. ports to disseminate findings. Two Tejani, whose duties include serving as pointman for the FHA’s 12 acute years ago it began meeting with physi- care hospitals in meetings with pharmaceutical reps, says that becomes ap- cians face-to-face, says Program Ad- parent many days that he meets pharmaceutical detailers. Last summer, for ministrator Don Phillipon, a professor example, Tejani met with a Pfizer Inc. representative who pitched the use of of strategic management and health acetylcholinesterase inhibitor donepezil (sold as Aricept for the treatment of policy at the University of Alberta. The Alzheimer’s disease) to treat mild cognitive impairment (MCI), an off-label in- $500 000 per year program provided dication. visits to physicians in 2 (Calgary and Tejani promptly hauled out a Therapeutic Letter , an academic detailing David Thompson) of Alberta’s 9 health publication produced by the University of British Columbia’s Department of regions, reaching about 100 physicians. Pharmacology and Therapeutics (April-August 2005;56). It indicated: that When it was axed, Calgary authorities an unpublished clinical trial of the drug involving patients with MCI demon- were so disappointed they found a way strated no benefit in terms of preventing or delaying progression toward to resuscitate it within city boundaries. Alzheimer’s disease; that several trials had suggested just 16% of people with Phillipon can’t comprehend why MCI go on to develop Alzheimer’s; and that there wasn’t a known correlation ADUP was scuttled. “It’s hilarious…. I between the 2 disease states. teach a course comparing health sys- “A 16% conversion rate is relatively small, so treating all people with MCI tems, and pharmacy is one of the areas would be, in my mind, dangerous, especially when you have trials showing we comment on because this is the area some of these drugs cause harm,” Tejani says. of the Canadian health system that’s Pfizer spokesperson Christine Antoniou says the promotion of off-label use most disorganized when you compare of drugs “is not standard practice and our representatives receive a lot of train- it to other countries with universal ing and regular reminders that off-label promotion is not at all something that health systems. And here was an initia- we want to do. We hope it’s an isolated incident and we’re looking into it.” tive that was really looking at utiliza- Tejani says off-label promotion is common and described a number of tion issues and it was discontinued.” similar pitches, including ones for off-label use of Recombinant Factor 7 for Alberta Health and Wellness Com- stroke patients, and moxifloxacin eyedrops for people undergoing cataract munications Director Michael Shields surgery. Pharmacy representatives have even urged FHA staff to lobby regula- says ADUP’s limited scale proved its tors to approve a drug for off-label indications, Tejani adds. undoing. “The program, while provid- In 2005, the FHA invited drug company representatives to a forum, where ing evidence of effectiveness in chang- expectations regarding the accuracy and quality of clinical evidence presented ing prescriber behaviour, was not by drug detailers were spelled out. “We told them: ‘This is what we feel is ap- viewed as cost-effective if scaled to the propriate, and this is where we think you will be crossing the line.’” entire prescriber community. There are Tejani says such incidents demonstrate the value of optimal prescribing ini- over 7100 prescribers registered in Al- tiatives like therapeutics letters or academic detailing visits. “It [does away] berta, ADUP reached only 250 physi- with clinical opinion and bias. Instead, it simply states what we know and what cians in 2 areas in the province.” we don’t know about the evidence… [and] this is the kind of fact-based infor- Prescription Information Services in mation clinicians and patients need to make informed decisions.” — Wayne Manitoba faces a similar fate.