Academic detailing is an educational outreach service that is effective at promoting evidence-based treatment for a given therapeutic area. This article describes what academic detailing entails, and reviews the findings of studies on the impact of academic detailing on prescribing practices.

As an academic detailer, the first question I often get is “What is academic detailing?” This question was answered during the 2013 CPNP Annual Meeting by Michael Fisher, MD, MS and Melissa Christopher, Pharm.D. Dr. Fisher kicked off this two part programming series with an appropriate quote “What do we want? Evidence-based change! When do we want it? After peer review!” Many clinicians strive to provide the best care for their patients but sometimes find that implementing evidence-based medicine is challenging. Dr. Fisher emphasized that this is in part due to the overwhelming volume of medical research, making it virtually impossible for front-line clinicians to identify the best quality evidence to implement in practice. In addition, many providers practice in an “informational vacuum” where few sources of non-commercially biased information are readily available. Often, sales representatives and industry supported promotional materials are the only ways providers receive drug information about new medications. Industry spends billions of dollars per year on promotional materials and marketing to change behavior…and it works! So the question becomes, how can we use industry methods to help clinicians identify the best treatments for their patients? As Dr. Fisher emphasized, if you take well trained clinicians (Pharm.D., RN, MD) and use the “successful marketing strategies of industry” to promote guidelines and best practices, you can see behavior change.

So what is academic detailing? Dr. Fisher described it as a “service” that provides interactive educational outreach utilizing social marketing to engage the provider and meet his or her specific educational needs. It is based on relationship building and provides specific practice-change recommendations through key message-focused discussions with the clinician. The academic detailer will also use educational materials created based on a careful review of the evidence to provide information about the comparative benefits, risks and cost-effectiveness of treatments for common clinical problems and help guide these educational discussions. Thus academic detailing is non-commercially biased evidence based educational outreach that mimics the pharmaceutical industry's techniques.

In addition to describing what academic detailing is, both Drs. Fisher and Christopher emphasized what academic detailing is not. Academic detailing is not giving lectures to providers. It is not just about formulary compliance and cost reduction. It is also not merely an attempt to undo industry marketing as there are instances where the product promoted by industry may be the most evidence-based agent available. Academic detailing focuses on providing options to clinicians and moves beyond the mentality of “just saying no.” This is important because the “no” mentality is often not enough to promote sustainable change as it does not address the unmet needs of clinicians nor does it promote solutions for issues identified in their practices. Mental health is a prime area for identifying unmet needs and supporting clinicians in both the specialty and primary care arenas. This is especially true in the primary care setting where there is a large opportunity to expand the treatment of mental illness.

Both presentations emphasized that academic detailing interventions have been shown to improve quality of evidence-based healthcare delivery and demonstrate a positive return on investment.1–4 For instance, an academic detailing program targeting nursing homes reduced the excessive use of sedating drugs by 27% compared to 8% in the control group (p=0.02) without negatively affecting the overall behavior and level of functioning of their residents.2 Another randomized trial compared individual academic detailing visits, group detailing visits vs. a control group (mailed guidelines) in a large HMO in the United States. The study authors found that both individual and group detailing improved the prescribing of antihypertensive medication, specifically beta-blockers and diuretics.3 In addition, despite the higher initial cost of individual encounters, the academic detailing intervention resulted in an estimated annual cost reduction of $289 per physician.3 The IMPACT trial found that academic detailing improved adherence to evidence-based stepped care practices for the management of depression in primary care and resulted in improved cost-effective prescribing of antidepressants.4 For example, from June 2005 – June 2006, the intervention saved a total of £48,561 for escitalopram alone ($90,728 converted to 2006 USD).4 Finally, a Cochrane Review of sixty-nine randomized controlled trials found that educational outreach visits resulted in both an increase in clinically appropriate and a decrease in clinically inappropriate prescribing.1 

Academic detailing can cover many topic areas and is an intervention many healthcare systems are investing in to improve patient care. However, little is known about the effectiveness of academic detailing for improving mental health care. This is important because historically, mental health prescribing often does not follow clinical practice guidelines. Dr. Christopher's presentation detailed how the Veterans Health Administration instituted a pilot academic detailing program combined with audit and feedback tools (dashboards) to encourage adherence to evidence-based practice. The program focused on several different mental health disorders and targeted clinicians in both mental health and primary care settings. These topics included PTSD, treatment resistant depression, treatment resistant schizophrenia and metabolic monitoring. Dashboards were developed for the topic areas to provide both population and patient level information and were designed to focus on particular actions or key messages that were emphasized by the academic detailer. Dr. Christopher presented her findings that a model using academic detailing created beneficial changes in prescribing and monitoring practices. Examples included a 25% total cost reduction in off-label antipsychotic utilization by prescribers who were detailed versus those who were not. This resulted in a one year cost reduction of approximately $940,000. In addition to reducing sub-therapeutic and multiple antipsychotic medication regimens, academic detailing was able to increase the appropriate utilization of clozapine by 3.9% (p > 0.001). The PTSD-focused education resulted in a 23% increase in measurement-based care using the PTSD Check List (PCL), a 28% increase in prazosin use for PTSD nightmares and/or sleep disturbances, and a 1% reduction in benzodiazepine and antipsychotic utilization. In addition to the increases in evidence-based care, the providers detailed also reported a high level of satisfaction with the program overall.

Many meeting participants wanted to know how they could use this type of educational outreach to achieve change in their practice environments. As mentioned, academic detailing requires an in-depth knowledge of the subject matter partnered with social marketing skills and oftentimes, many pharmacists have knowledge of the evidence but lack marketing skills. Thus, the first step is to obtain sales training for those subject matter experts. The Veterans Affairs academic detailers trained with the ALOSA foundation, NaRCAD, and Dale Carnegie to develop the communication techniques needed to more effectively deliver key messages and influence change. Once trained on effective communication techniques, academic detailers should develop educational materials to guide their discussions with providers and to serve as a quick reference guide for front-line clinicians. The materials are often subject based (e.g., PTSD, treatment resistant schizophrenia, etc.), easy to read and much of the information is presented graphically. They are designed to support the key message delivered by the academic detailer by showing the evidence behind the key message. Finally, the academic detailer needs to be someone who is sociable and able to adjust to many different personality styles. They also have to be persistent and able to accept rejection as they often have to request an appointment several times before one is granted. It often takes time to develop a relationship with providers and it can be challenging to engage busy providers.

In summary, academic detailing is an educational outreach program that is effective at promoting up-to-date, unbiased, evidence-based treatment for a given therapeutic area. It is based on relationship building and provides a much needed service to front-line clinicians. Academic detailing can improve the quality of care in multiple settings and can be implemented as part of a multifaceted effort to improve health care quality. It is important for the provider to see the detailer as a benefit to their practice and to see the need for the service they provide.

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