Profession

New reps, new rap: The counter-detailers

States worried about the rising toll of drug spending are sending nurses and pharmacists to talk with doctors about their prescribing habits.

By Kevin B. O’Reilly — Posted Sept. 24, 2007

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Midway through a visit with a physician, drug rep Leigh Bradshaw, RN, noticed the doctor's posture change. He sat up straight and listened intently as she discussed evidence on the relative merits of proton pump inhibitors and other acid-suppressing therapies.

"I was at Grand Rounds last week, and they were saying exactly the same thing," Bradshaw recalls the doctor saying with amazement. "This is really good stuff!"

Accustomed to a seamless mixture of relevant drug information and sales pitch from pharmaceutical sales representatives, it is little wonder that doctors are sometimes taken aback by Bradshaw's approach to detailing. She is one of a new breed of drug reps whose job is not to sell a drug, but to sell the evidence.

Bradshaw, a registered nurse, is one of 11 pharmacists and nurses who work as detailers for a 2-year-old program called the Independent Drug Information Service. IDIS gets $1 million a year from the Pennsylvania Dept. of Aging's Pharmaceutical Assistance Contract for the Elderly program, known as PACE, to pay these so-called counter-detailers.

That money also funds the work of a team of Harvard Medical School pharmacoepidemiologists and physician experts who prepare comprehensive, user-friendly evidence reviews for the detailers to discuss with doctors. The IDIS reps also are trained on how to build relationships with physicians, all aimed at influencing prescribing behavior.

Counter-detailing, or academic detailing, has existed since the 1980s, but only lately has it started gaining traction as a way for states to take a kinder, gentler approach to getting the most out of their drug spending budgets. The idea is to use the pharmaceutical industry's detailing methods to steer physicians toward the older, less-expensive, but still appropriate medication choices.

Canada, New Zealand and England are home to academic detailing efforts. Australia's 9-year-old, government-funded National Prescribing Service boasts of preventing hospitalizations and saving more than $300 million in health care costs. A number of systematic reviews have shown that U.S. counterdetailing programs help physicians adhere more closely to the evidence when prescribing, but their cost effectiveness has yet to be proven conclusively.

While Pennsylvania's program is the most extensive in the U.S., Vermont and West Virginia also pay for academic detailing operations. Earlier this year, Maine enacted a law to establish a program of its own, and Vermont voted to expand its efforts. Officials in Maine, Vermont and New Hampshire are in early talks about a counterdetailing collaboration. And other states are taking note.

The problem, say academic detailing's advocates, is that too often, doctors order medicines that the evidence shows are riskier and costlier and, for many patients, are not demonstrably more efficacious than the venerable standbys.

"It's nearly impossible for any single doctor to keep on top of all the most important information about prescribing that comes out," said Jerome L. Avorn, MD, who heads up Pennsylvania's detailing service and is chief of pharmacoepidemiology and pharmacoeconomics at Brigham and Women's Hospital in Boston.

"The problem with the information that pharmaceutical industry reps provide is that it is all designed to increase product sales," said Dr. Avorn, professor of medicine at Harvard Medical School. Academic detailing is "about making the information and the recommendations salient to the doctor, and having them stick out from a sea of information the doctor is sometimes drowning in."

Traditional continuing medical education is a less-effective method of teaching physicians because it lacks interactivity and there is a time lag between education and application, he said. "We help answer the question, 'What am I going to prescribe tomorrow for the patient who has hypertension or hypercholesterolemia?' "

Drugmakers say academic detailers can serve as a complement to industry reps and illustrate the educational value that drug reps provide physicians. But Clement Cypra, senior director of state policy for the Pharmaceutical Research and Manufacturers of America, said the programs are driven by cost considerations and are superfluous, because already half the prescriptions purchased in the U.S. are for generics.

Cypra said industry reps' information must meet strict Food and Drug Administration standards, while there is "no oversight" of the evidence academic detailers present and "no guarantees that the information they're conveying is accurate."

Harvard's Dr. Avorn called Cypra's comment "ridiculous, offensive, self-serving and ill-informed." He defended his team's information as being above reproach.

Physicians who have visited with IDIS detailers say the evidence presented is top-notch, and that the visits serve as a useful counterweight to the industry reps they see.

Striking a balance

Mario Sebastianelli, MD, a nephrologist in Scranton, Pa., has met counter-detailer Roberta Collier, RN, about half a dozen times. Dr. Sebastianelli, who sees industry reps as a starting point to learn more about new drugs, said it's his perception that the state program puts "a major emphasis on cost" as a factor in prescribing. He trusts the information Collier presents, he said, because of its Harvard provenance.

"If I see commercial detail people, I should see academic detailing people to get a balance," Dr. Sebastianelli said. "Even if each one is slanted, it's your obligation as a physician to tease apart the excesses on each side."

IDIS consultant Kristin Nocco, a trained pharmacist, has detailed Levittown, Pa., geriatrician Daniel Haimowitz, MD, a number of times. Dr. Haimowitz said he also values pharmaceutical sales reps' visits but believes they arrive with a bias. "I take what [industry reps] say with some skepticism," he said. "When Kristin visits, I can remove that. Talking to a rep is like talking to a car salesman. Maybe it's a good car, but you know they've got an angle. Talking to Kristin is like stepping into a classroom."

As of mid-June, IDIS drug reps -- called consultants -- had visited 716 Pennsylvania physicians a total of nearly 2,000 times to discuss acute and chronic pain treatment, anti-platelets, and therapies to combat excess stomach acid production, high cholesterol and hypertension. The visits last about 20 minutes, and physicians can complete a posttest and earn one Harvard CME credit.

Physicians targeted for detailing visits have 25 or more patients enrolled in the PACE program, which helps seniors who do not qualify for Medicaid pay for their medicines, or prescribe a high volume of drugs for PACE patients. A PACE draft evaluation in July estimated that IDIS is saving the state more than $570,000 a year in reduced prescribing of proton pump inhibitors.

"Physicians are very eager to talk to our people," said PACE Director Tom Snedden. "Many times, they ask for another visit. And I've got to say that it's not because our detailers are the most attractive or because we offer tickets to Broadway shows."

Academic detailers will bring sandwiches if asked, but otherwise only hand out pamphlets, brochures and monographs. So far, the program is covering its $1 million tab by reducing prescribing costs, Snedden said. In October, the service will be expanded to physicians serving patients enrolled in the state health plan for retired state employees.

The Pennsylvania Medical Society has no official position on the program, but the society's patient advocacy project manager, Diane Seibert, LPN, said that while one-on-one medical education is effective, "the ideal program is physicians educating physicians." She also said the medical society should have been invited to work with the Harvard team in establishing the program.

"It's one thing to be in academia, and another to be out there on the front line and dealing with patients on a daily basis," Seibert said.

Dr. Avorn said that it would be too expensive to hire physician detailers, but that IDIS is "exploring how best to involve more Pennsylvania physicians in the program."

A giant question mark is whether these fledgling state detailing efforts can successfully counter the more than $12 billion that drugmakers spend each year to promote their branded drugs.

Academic detailing is "primarily a Band-Aid," said Howard Brody, MD, PhD, director of the University of Texas Medical Branch's Institute for Medical Humanities. "It recognizes and simply accepts at one level that the drug companies are basically in the driver's seat and doctors will get beat up and bombarded by commercial messages."

The "pharmaceutical industry, from day one, did their marketing homework and perfected the art of packaging nuggets of information chosen for pharma's self-interest and delivered it to doctors in a user-friendly way that's digestible," said Dr. Brody, author of Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry. Academic physicians have hitherto failed in this regard, he said, taking a "snooty" attitude toward practicing physicians and expecting them to read "medical journals [that] are about as much fun to read as the phone book."

The counter-detailing movement may be "doing a huge good deed by getting academic medicine to think about repackaging information in a way that's useful to the practitioner," Dr. Brody said.

Bridging the divide between the ivory tower and the front lines is critical, according to Frank W. May, an Australian pharmacist who helped establish that country's prescribing service and is at Harvard, working on the Pennsylvania program.

"The secret of why academic detailing works: ... We embrace the uncertainty that doctors feel and share with them the certainties of any particular medicine at that moment in time," May said. "That's what doctors really, really appreciate and why they are willing to give up their time to actually have this kind of visit."

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ADDITIONAL INFORMATION

Less expensive, more appropriate care

Proton pump inhibitors such as Nexium (esomeprazole) and Prilosec (omeprazole) nearly eradicate stomach acid production and are a boon to patients with peptic ulcer or severe gastroesophageal reflux disease. But studies show that PPIs may not be the right choice for patients whose stomach problems are less serious. Drug reps working for Pennsylvania's Independent Drug Information Service have discussed this evidence with doctors to encourage them to consider -- when appropriate -- less-expensive histamine receptor antagonists such as Zantac (ranitidine) and Pepcid (famotidine). The visits are having an effect, according to a July draft evaluation.

Prescribing category IDIS physicians 6-month PPI savings by IDIS physicians
Very low (fewer than 20 PPI prescriptions in past year) 60 $23,436
Low (20-40 scripts) 68 $53,285
Medium (41-75 scripts) 71 $69,197
High (76+ scripts) 92 $139,983
Total $285,901

Source: Pennsylvania's Independent Drug Information Service

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No trinkets, but plenty of pamphlets

When detailers working for the Independent Drug Information Service in Pennsylvania visit doctors, they leave behind reference cards, brochures and monographs that a team of Harvard Medical School physician experts prepared. The materials aim to give doctors unbiased, evidence-based prescribing advice in an easily digestible, yet carefully documented manner. For example, a four-page brochure on "Life after Vioxx" states, "The overwhelming evidence from clinical trials shows that selective COX-2 inhibitors do not have any stronger analgesic efficacy than conventional [nonsteroidal anti-inflammatory drugs] such as naproxen (e.g., Aleve) or ibuprofen (e.g., Motrin). ... Elaborate media campaigns directed at patients created an aura of superiority that was not backed up by clinical trial data." (Emphasis in original.) Here is how the December 2005 pamphlet summarizes the evidence about the risks of NSAIDs and COX-2 inhibitors:

Vioxx (rofecoxib): Considerable evidence of increased risk of myocardial infarction and other cardiovascular complications seen in randomized controlled trials and epidemiological studies, especially at higher doses. (Withdrawn from market.)

Bextra (valdecoxib): Doubling or tripling of cardiovascular events compared with placebo in two randomized controlled trials of patients undergoing cardiac surgery. Also causes potentially fatal dermatologic side effect of Stevens-Johnson syndrome. (Withdrawn from market.)

Celebrex (celecoxib): At high doses (200 mg to 400 mg, BID), dose-related doubling or tripling of myocardial infarction in one randomized controlled trial compared with placebo, but no increase in risk found in another RCT with a single daily dose of 400 mg per day. Several epidemiological studies have found no elevated risk signal compared with Vioxx and other NSAIDs.

Ibuprofen: Conflicting evidence of risk, much less clear than with previous three drugs. However, little information is available on cardiac risk from randomized placebo-controlled trials.

Naproxen: Evidence of slightly reduced risk of MI in many but not all randomized controlled trials and epidemiological studies.

Aspirin: Clear evidence of reduction in risk of MI, based on large randomized controlled trials in men; less evidence of benefit in women.

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External links

Pennsylvania's Independent Drug Information Service (link)

Australia's National Prescribing Service (link)

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