AN EVIDENCE-BASED APPROACH TO IMPROVING PRESCRIBING
States concerned about patient safety and escalating prescription drug costs should
consider authorizing academic detailing for publicly funded health programs.
Pharmaceutical companies spend billions promoting the rapid diffusion of the
newest, most expensive drugs – even if their product is no better than other less
expensive, time-tested options.
Pharmaceutical industry detailers state that their mission is to educate physicians – but
the carefully crafted sales pitches they present to physicians are more akin to promotion
than education. These marketing efforts are backed by billion dollar budgets.
- Annual spending on pharmaceutical marketing reached 11.4 billion in 2005 – with
7.2 billion targeted directly to physicians.
- The industry employs over 90,000 detailers – a workforce that has doubled
within the past decade.
The biggest bang for their buck – and the smallest for the consumer’s
The industry does not market indiscriminately. It invests most heavily in marketing the
newest, most expensive brand names where profit margins are highest. Consumers
pay for these practices in two ways:
- The cost of industry marketing – which represented almost 20% of the $200.7
billion in spending on prescription drugs in 2005 – is passed on to consumers
through the high price of drugs.
- Industry detailing also drives up costs by promoting the inefficient use of health
care dollars when it succeeds in encouraging a physician to prescribe an
expensive brand name drug over a therapeutically equivalent generic.
Sky-rocketing marketing budgets over the past decade have been mirrored by doubledigit
growth rates in prescription drug spending – the highest growth rates of any part of
the health care sector. As health care cost spiral, access to health care declines.
Overcoming caution – the Vioxx story
The potential to compromise patient safety is another, even more troubling aspect of
pharmaceutical marketing. While physicians have traditionally been cautious in
prescribing new drugs, especially in lieu of existing options with proven, real-world
safety records, industry detailers are rewarded for pushing the quick uptake of their
products from the day they reach the market.
While the pain-killer Vioxx began as a success story in pharmaceutical marketing, it
ended as a public health tragedy. Launched in September of 1999, Vioxx had been
prescribed to more than 80 million patients, with sales exceeding 2.5 billion, before its
withdrawal from the market in September 2004 due to safety issues. One FDA official
estimated that Vioxx caused 88,000-139,000 heart attacks, 40% of which were fatal.
Though a company might wish to see wide use of its new product from the moment the
patent clock starts ticking, the example of Vioxx – and other drugs such as Avandia –
suggest that it may be in the interest of public safety to encourage a wait-and-see
Academic detailing helps physicians prescribe what patients and payers want:
the safest, most clinically-effective, and cost-effective drugs.
Academic detailing provides an educational service that doctors want. Rather than
forcing a physician to sort through a sea of competing promotional messages, academic
detailing helps physicians to improve their prescribing based on the best available
scientific evidence. Physicians have reacted quite favorably to this more time-efficient
approach to keeping them abreast of new information on prescription drugs.
Academic detailing is based on individual outreach to physicians within the setting of
their practice, a proven technique for effective continuing education. Academic
detailing provides physicians with unbiased, balanced, evidence-based information
regarding the safety and efficacy of drugs. This promotes appropriate prescribing
habits, including the cost-effective use of drugs which can help increase access to
Academic detailing programs rely on credible, independent drug reviews and are
usually based in medical or pharmacy schools. They employ clinicians such as
physicians, pharmacists, and nurses to give prescribers reliable guidance on potential
benefits and possible harms of specific drugs. In contrast, industry detailers are not
required to have a scientific or medical background, and are recruited based on their
Almost 30 years ago, Jerry Avorn of Harvard Medical School first envisioned turning the
marketing tactic of physician detailing on its head to instead use one-on-one visits to
physicians to promote optimal prescribing. Since then, a sizable body of evidence has
accumulated demonstrating its ability to promote safe and appropriate drug use. A
recent review of a variety of approaches to continuing medical education concluded that
interactive educational approaches like academic detailing are the most effective means
to improve physician practices and patient outcomes. Australia and Canada have long
recognized the potential of academic detailing and put it to use. Reviews of their
experience also demonstrate the positive impact of academic detailing.
Is academic detailing economically feasible?
Though the results of academic detailing are positive, they must be measured against
the level of investment required to realize them. Economic analyses of existing
academic detailing programs have found them to be cost-effective. Particularly in
the American setting, in which prescription drug spending is aggravated by the overuse
of costly brand name drugs in lieu of appropriate generic options, academic detailing
programs can recoup their costs by promoting more rational prescribing. Finally, as the
Canadian experience suggests, as academic detailing programs grow in number, it is
possible to achieve economies of scale by sharing the production and use of
educational materials, training programs and data management systems. There is
great potential for states to come together on this issue. Payers need to recognize that
it is their best interest – and their patients’ - to get involved in high-quality, objective
educational outreach to physicians on prescription drugs.
States are in motion on the issueAn increasing number of states are using or exploring academic detailing as a mechanism for reducing prescription drug costs, improving the quality of care, and increasing the value derived from drug coverage programs. Academic detailing programs currently exist in Maine, Vermont, Massachusetts, New York, Pennsylvania, South Carolina and the District of Columbia. Pilots are underway in Idaho and Oregon. Legislation is pending in California, Minnesota and Wisconsin as well as at the federal level in the form of a bill known as the Independent Drug Education and Outreach Act (H.R. 1859 and S. 767).
(Updated September 2009)
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