GUIDELINE Academic Detailing - CCATESccates.org.br/content/_pdf/en_PUB_1437678333.pdf ·...

Faculdade de Farmácia - UFMG

Dep. de Farmácia Social

www.ccates.org.br

GUIDELINE

Academic Detailing

Belo Horizonte - MG

April - 2015

METHODOLOGICAL GUIDELINES

Academic Detailing

This work was developed under the cooperation agreement between the Department

of Management and Incorporation of Health Technologies of the Ministry of Health of

Brazil, the Pan American Health Organization and the SUS Collaborating Centre for

Technology Assessment and Excellence in Health.

Elaboration:

Juliana de Oliveira Costa (CCATES/UFMG)

Celline Cardoso Almeida Brasil (CCATES/UFMG)

Augusto Guerra Afonso Júnior - coordination (CCATES/UFMG)

Collaborating:

Ana Alice Pandolfi de Abreu (SES-MG)

Gustavo Simões Santos Leal (PPMAF/UFMG)

Haliton Alves de Oliveira Junior (PPMAF/UFMG)

Isabella Piassi Godói (PPMAF/UFMG)

Lívia Lovato Pires de Lemos (CCATES/UFMG)

Lucas Fonseca Rodrigues (FM/UFMG)

Wallace Breno Barbosa (PPMAF/UFMG)

Specialist review:

Aine Heaney (NPS/ Australia)

Jonathan Dartnell (NPS/ Australia)

Brian Godman (Karolinska Institute, Stockholm, Sweden and Strathclyde Institute of

Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK)

Technical review:

Juliana Álvares (CCATES/UFMG)

Francisco de Assis Acurcio (CCATES/UFMG)


Academic Detailing

LIST OF TABLES

Table 1. Examples of academic detailing purposes…………………………………………………….16

Table 2. Basic structure of the visits……………………………………………………………………………26


Academic Detailing

LIST OF FIGURES

Figure 1. Steps of the process involved to perform an Academic Detailing Program (CCATES/UFMG)...........................................................................................13

Figure 2. Academic Detailing carried out by SUS Collaborating Centre (CCATES) in Belo Horizonte about Alzheimer's disease: materials37.........................................18

Figure 3. Academic Detailing carried out by SUS Collaborating Centre (CCATES) in Belo Horizonte about Alzheimer's disease: standardized form for notes about the visit................................................................................................................ 30


Academic Detailing

LIST OF ABREVIATIONS

CADTH - Canadian Agency for Drugs and Technologies in Health

NARCAD – National Resource Center for Academic Detailing

NICE - National Institute for Clinical Excellence and Health

NIHR - Health Technology Assessment Program

NPS – National Prescribing Service

PCDT - Clinical Protocols and Therapeutic Guidelines

REBRATS - Brazilian Network for Health Technology Assessment

SUS – Brazilian National Health System

http://www.narcad.org/

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Academic Detailing

SUMMARY

PRESENTATION ....................................................................................................................... 6

1. INTRODUTION ............................................................................................................. 8

2. ACADEMIC DETAILING .............................................................................................. 11

5. RECOMMENDATIONS FOR EACH STAGE OF ACADEMIC DETAILING ........................ 14

5.1. Stage 1: Prospection and identification of problems ............................................... 14

5.2. Stage 2: Definition of the purpose of the academic detailing .................................. 14

5.3. Stage 3: Budget estimate, elaboration of schedule and technical team

designation ............................................................................................................... 16

5.4. Stage 4: Elaboration and purchase of the support material .................................... 17

5.4.1. Bulletin contents ....................................................................................................... 18

5.4.2. Format and layout of the bulletin ............................................................................. 20

5.4.3. Use of materials during the visit ............................................................................... 21

5.5. Stage 5: Identification of prescribers and organization of visitation goals .............. 22

5.6. Stage 6: Recruitment of facilitators and workshop training .................................... 23

5.7. Stage 7: Prescribers visiting for academic detailing ................................................. 25

5.7.1. The objective of academic detailing ......................................................................... 25

5.7.2. Structure of a visit ..................................................................................................... 26

5.8. Stage 8: Release the material ................................................................................... 30

5.9. Stage 9: Evaluation of results ................................................................................... 30

5.9.1. Analysis of the effect ................................................................................................ 31

5.9.2. Analysis of feasibility ................................................................................................ 33

5.9.3. Satisfaction analysis .................................................................................................. 33

5.10. Stage 10: Release the results .................................................................................... 34

7. Final considerations .................................................................................................. 35

REFERENCES .......................................................................................................................... 36

APPENDIX 1 ........................................................................................................................... 40

APPENDIX 2 ........................................................................................................................... 44

APPENDIX 3 ........................................................................................................................... 45

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Academic Detailing

PRESENTATION

The Academic Detailing is a strategy used by many countries with the overall aim of

promoting the continuing education of prescribers to enhance the rational use of

medicines (RUM). Academic Detailing consists of face-to-face visits, of a health

professional to a prescriber, in which pertinent topics are addressed including the use

of current medicines, diagnostic techniques, new therapies, and implementing

guidelines.

The concept derives from “detailing”, a marketing technique used by pharmaceutical

companies, in which company representatives make one-to-one visits to individual

prescribers in order to persuade them to prescribe the company’s products. It is

hoped that a personal relationship will develop over a number of visits which will

reinforce the effect of the information presented by the representative. Educational

outreach aims to employ some of the techniques developed in pharmaceutical

marketing to promote prescribing which is rational, evidence-based and adherent to

guidelines. It is typically carried out by health professionals (often pharmacists, also

doctors or nurses) employed by non-profit organizations.

This method combines the level of interactivity employed by the pharmaceutical

industry, illustrated by their representatives, with the evidence based on evidence

information from academia. The objective is to minimize the gap between available

scientific evidence and the clinical practice. As a result, improve the future use of

medicines and hence improve overall efficiency in the context of health systems.

This document was based on an extensive search of the scientific literature, the

Academic Detailing experience of the National Prescribing Service - an independent

nonprofit Australian organization that performs this activity for more than fifteen

years, the National Resource Center for Academic Detailing (United States), of the

Canadian Academic Detailing Collaboration (Canada) and the experience of a pilot

project of the Academic Detailing for Alzheimer's disease in the city of Belo Horizonte

conducted by the SUS Collaborating Centre (CCATES).

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Academic Detailing

The purpose of this document is to present the concepts and the description of the

steps needed to guide the planning and execution of Academic Detailing among

prescribers.

This guideline provides an overview of the academic detailing service. We wish to

assure the quality of academic detailing service and the processes and outcomes that

under pin it. As a result, the main concepts of this technique and examples of materials

and forms necessary for the documentation and evaluation of performance of the

visits are provided.

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Academic Detailing

1. INTRODUTION

According to the World Health Organization, more than 50% of all medicines are

incorrectly prescribed, dispensed and sold; and more than 50% of patients use them

incorrectly. In developing countries, less than 40% of patients in the public sector and

less than 30% in the private sector are treated in accordance with clinical guidelines1.

The opposite of this situation is the rational use of medicines (RUM) including the

quality use of medicines, which the World Health Organization refers to as "the need

for the patient to receive the appropriate medication in the right dose, for an

adequate period of time, at low cost to him and to the community"2,3. It is well known

that overuse and inappropriate use of medicines can lead to higher rates of adverse

drug reactions and events3. A systematic review found that the median percentage of

preventable drug-related admissions to hospital was 3.7%, with approximately a third

being due to inappropriate prescribing3. Average treatment costs for a single adverse

drug reaction in Germany have been estimated at approximately €2250, equating to

€434million per year, and it is estimated that more than 2 million people are

hospitalised annually in the US due to serious adverse events with the cost of drug-

related morbidity and mortality exceeded US$177.4bn in the US in 20004.

To improve the quality of their prescribing, the prescribers need updated and reliable

sources of information about the comparative effectiveness, safety and cost of

available treatments5. Obtaining this information from the literature can be a long

process and not applicable to the work context of the vast majority of the prescribers

with their limited time available with patients. Due to limitations including time

constraints, difficulties with language and other time-consuming demands, lack of

continuous medical education programs, prescribers often use other sources of

information, including information from representatives of pharmaceutical industries6.

This is augmented by pharmaceutical companies spending up to one third of their

income on promotional expenses, which translated into pharmaceutical companies

spending for instance US$57.5 billion on promotional expenses alone in the US in

20047,8,9.

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Academic Detailing

Representatives of pharmaceutical companies are internationally known as "drug

detailers" because they provide detailed information about their products, visit

prescribers in their offices and deliver marketing materials focused on the products

they promote6. This approach is known be effective with sales of patented products,

including new products, driving increasing pharmaceutical expenditure10, with the

information disseminated typically in the interest of the pertinent company. As a

result, many prescribers are unaware of the existence of more effective, safer or

cheaper therapeutic options. A recent meta-analysis of studies of physicians exposed

to information from pharmaceutical companies found with rare exceptions that

exposure was associated with for instance higher prescribing frequency, higher costs,

or lower prescribing quality. The authors could not find evidence of net improvements

in prescribing. Consequently, they suggested practitioners should avoid exposure to

information from pharmaceutical companies7.

Such concerns have already resulted in a number of countries introducing measures to

limit pharmaceutical company activities which can be accompanied with fines and

other measures for abuse 11,12,13. In addition, introducing academic detailing and other

activities to counter-act their influence. Intensive measures in e.g. Sweden and the UK

to encourage the prescribing of multiple sourced and considerably cheaper proton

pump inhibitors and statins versus patented products resulted in appreciable

increases in prescribing efficiency compared with countries with few demand side

measures, e.g. expenditure on PPIs and statins in Sweden in 2007 was one tenth of

that seen in Ireland when adjusted for population size with no suggestion in patient

care with the products in each class therapeutically similar at appropriate

doses14,15,16,17. There have also been concerns with the bias of current guidelines

unless there are rigorous approaches regarding conflicts of interest which academic

detailing addresses 18,19,20.

From the behavioral science and several trials in the field, methods to contribute to

better decision-making of prescribers for quality and cost-effectiveness of care have

been detected 3-21. In general, educational campaigns are interventions that potentially

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Academic Detailing

alter the practice of health professionals, especially prescribers regarding

prescription22.

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Academic Detailing

2. ACADEMIC DETAILING

Academic detailing is a one on one educational visiting service involving a peer to peer

interaction between two professionals. It uses behavior change methodologies to

provide education and information in an objective, service based approach (rather

than a sales focus), that can be directly related to a health professional's clinical

situation.

The academic detailing is carried out by universities or non-profit institutions, in which

the visitor and his team have no financial relationship with the pharmaceutical

industry, and aims to minimize the gap between the best available science and the

prescription in actual practice6. This method refers to a face-to-face visit with the

objective of improving the care of the health system user, selecting the best evidence

and clinical guidelines on what should be done for a given clinical situation and

presented in usable language by a professional health trained for this purpose6.

The practice of academic detailing to prescribers as a means of improving the quality

of their drug therapy decisions and reducing unnecessary expenditure was pioneered

some thirty years ago by Dr. Jerry Avorn and Dr. Stephen Soumerai of Harvard Medical

School in the USA. According to Soumerai and Avorn 21, 23, some of the most important

features include:

Conducting interviews to investigate baseline knowledge and motivations for

current prescribing patterns;

focusing programs on specific categories of physicians as well as on their

opinion leaders;

defining clear educational and behavioural objectives;

establishing credibility through a respected organisational identity, referencing

authoritative and unbiased sources of information and presenting both sides of

controversial issues;

stimulating active physician participation in educational interactions;

using concise graphic educational materials, highlighting and repeating the

essential messages; and

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Academic Detailing

providing positive reinforcement of improved practices in follow-up visits.

Academic detailing programs are carried out in several countries, such as Australia -

National Prescribing Servicea, United States - National Resource Center for Academic

Detailingb and Canada-The Canadian Academic Detailing Collaboration24.

Published studies have demonstrated the effectiveness and cost-effectiveness of

academic detailing. A systematic review with meta-analysis22 that included 69 studies

involving more than 15,000 health professionals concluded that educational visits

isolated or combined with other interventions have consistent effects on improving

subsequent prescribing behavior to benefit patients and healthcare services. In

relation to cost-effectiveness, an American randomized study25 that evaluated the

economic effects of face-to-face visit to reduce inappropriate prescribing of medicines

involving 435 prescribers, showed that educational sessions reduced the cost of

prescription drugs inappropriately in 13% and the effect was stable over three

quarters.

a National Prescribing Service: http://www.nps.org.au/

b National Resource Center for Academic Detailing: http://www.narcad.org/

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Academic Detailing

3. STAGES OF ACADEMIC DETAILING

The Academic Detailing is an activity that must be performed by a qualified and trained

health professional (referred in this document as "facilitator"), properly identified by

the promoting institution and with supporting material for the execution of the visits.

Features of the academic detailing technique have been described 23,26 and include:

that the visitor is well presented and well briefed; the timing is at the doctor’s

convenience; the doctor does not need to interrupt the normal routine of the working

day; the doctor is on his/her own ground rather than at a disadvantage; and the

message is concise and clearly relevant to patient care. The authors of this paper

commented from their own experience that to present an educational message in such

a format requires considerable preparation, with high quality written and pictorial

material and a standardised presentation.

The steps involved in the process, from planning to the dissemination of results are

illustrated in the figure below and discussed in the following sections of this document.

Figure 1. Steps of the process involved to perform an Academic Detailing Program (CCATES/UFMG)

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Academic Detailing

4. RECOMMENDATIONS FOR EACH STAGE OF ACADEMIC DETAILING

4.1. Stage 1: Prospection and identification of problems

The problems that generate the demand for the Academic Detailing in general are

related to a gap between what the scientific evidence or clinical guidelines recommend

and what treatment approaches are actually undertaken in clinical practice through

other influences including the influence of pharmaceutical companies. The health

system and the health professionals should know the health situation of the

population (i.e. prevalence of diseases and epidemiological transition, and the type of

care that is currently being provided to check if there are alternatives with improved

efficiency, i.e. improved effectiveness for similar expenditure or lower costs for the

same expenditure than could be offered. In this context, the problems may be related

to the need for a guideline, to update existing guidelines, to the over- or under-

utilization of medical technologies, or the use of more expensive treatments when less

expensive but equally effective treatments are available, among others. These

problems can be identified through consultation with specialists; telephone interviews;

database analysis; drug utilization studies; reports and alerts of health surveillance;

literature review; or detection of similar problems observed in other countries.

After identifying the problem, it is necessary to evaluate whether this could be

addressed by the education of the prescribers, that is, if Academic Detailing can be

considered an effective strategy to solve this problem. This technique can be

considered effective when the solution of the identified problem depends on a change

in behavior, and for which other simpler techniques such as computer systems

reminders or dissemination of reports are not sufficient. For the success of the visits, it

is important that the theme selected has local relevance, in order to contribute to the

prescribers and patients’ needs in the context of health care.

4.2. Stage 2: Definition of the purpose of the Academic Detailing

The visits should be carried out in order to solve a specific problem, i.e. have a specific

aim and objective that is measurable. The purposes of academic detailing found in the

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Academic Detailing

literature are varied and can be directed to the development and dissemination of

Clinical Protocols and Therapeutic Guidelines (PCDT, acronym in Portuguese), changes

in drug prescribing patterns, among others. The visits can be directed to health

professionals (individually or in group), to the community, and to patients. The main

purposes are described in Table 1.

Important principles of academic detailing involve:

understanding existing behavior – what are the key motivations and barriers for

current behavior;

understanding where people are currently at – what people feel/think about

the issue - not where you want them to be;

providing information to improve knowledge and patient care rather than

focusing on what not to do;

focusing on how to encourage and achieve ‘voluntary action’ not coercion or

enforcement.

Objectives of academic detailing include:

Knowledge transfer

Affirming current decision making

Altering future decision making

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Academic Detailing

Table 1. Examples of academic detailing purposes Purpose Examples Study/country

Change the pattern of resource utilization

Reduction in the use of images diagnostic for shoulder problems

Increase the screening for breast cancer

Broadhurst NA., 200727

Australia

Gorin SS., 200728

United States

Change the pattern of drug prescription

Reduction in the use of broad-spectrum antibiotics in an academic center

Reduction of inappropriate prescriptions in a hospital in relation to the legal criteria of the country

Solomon DH., 200129

United States

Shaw J., 200330

Australia

Development and implementation of Clinical Protocols and Therapeutic Guidelines

Development of Clinical Protocol about anticoagulants in four hospitals

Development of Clinical Protocol and its dissemination for treatment of respiratory tract infections, media otitis and urinary tract infections with antibiotics

Compliance of the Clinical Protocol for Streptococcus B screening prenatal

Compliance of the Clinical Protocol for colorectal cancer screening

Roberts GW., 200631

Austrália

Ilett KF., 200032

Australia

Silva JM., 201333

Brazil

Curry WJ., 201134

United States

Change the incidence of events

Control and weight reduction in African-american low-income women, in primary care

Control and reduction of tobacco use in health systems

Davis M., 200635

United States

Schauer GL., 201236

United States

4.3. Stage 3: Budget estimate, elaboration of schedule and technical team designation

Once the problem and the purpose of the Academic Detailing are established, a

technical team should be formed. This team should be composed of at least one

specialist on the subject to be addressed, as well as researchers and interns, it is

recommended that at least one person (coordinator) manage the process, orient the

other members of staff, and conduct the training of facilitators.

To increase the chances of success of the visits and identify prescribers to be visited, it

is important to establish partnerships with institutions such as the Medical Societies

and Prescribers Councils.

The technical team should define the number of visits required to resolve/minimize

the problem identified. The materials to be produced and/or eventually purchased will

be defined based on the number of visits.

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Academic Detailing

The estimation of the budget will depend on the scope of the program, i.e. local or

national, the number of prescribers to be visited - which can range from all specialists

registered in the Council, or be restricted to the prescribers of the Brazilian National

Health System; alternatively, a chosen subset of physicians where a specific problem

was observed.

The budget for the implementation of the Academic Detailing should consider the

following costs (i) Staff: experts, researchers and interns (ii) Freelance services: graphic

designer and consultants, among others (iii) Facilitators: health professionals who will

be recruited to carry out the visits, including time taken to upskill and train them (iv)

Graphics services: print newsletters, bulletins, folders, badges and business cards (v)

Materials: tablet, pen drive, suitcase with wheels and notebooks.

4.4. Stage 4: Elaboration and purchase of the support material

The technical team should develop strategies of influence focused on the prescribers,

the multidisciplinary health team and on patients and their families regarding the

disease/treatment in question, through the elaboration of key messages. It is

important that the materials are attractive, objective and simple. They will be used to

support the visit and as a 'leave-behind' information source for the prescriber, who is

often busy and with little time available. The material must be adjusted to the number

of visits required to the individual doctor. At each visit, it is suggested to give different

and complementary material to re-enforce the message. This will help with

relationship building and trust. It helps to build rapport and place the visitor as a

service provider.

In addition, we recommend the development of in house material, through bulletins

with technical language for professionals and others focused on patients and families

(Figure 2).

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Academic Detailing

Figure 2. Academic Detailing carried out by SUS Collaborating Centre (CCATES) in Belo

Horizonte about Alzheimer's disease: materials37

4.4.1. Bulletin contents

The elaboration of the bulletin for academic detailing should include as many of the

following items to ensure their quality38,39,40. Commented bulletins can be found in

Appendix 1 and sources of information for their preparation in Appendix 2.

The bulletins should be structured based on key messages

It is recommended to include only three or four key messages in a bulletin according to

the purpose of the intervention. If multiple information is needed, the ideal is to

prepare bulletins in series. The key messages should be highlighted and easily

retrieved and behavioral goals should be highlighted. Different color boxes with

strategic positioning in the document can be used, for example, at the first page or at

the end of the bulletin, as an abstract.

The bulletin should be based on systematic review of the literature.

This criterion is intended to assure the reader that the literature used to prepare the

bulletin was not selected with a bias to support a particular point of view. When using

Materials delivered in Academic Detailing about the Clinical Protocol and Therapeutic Guidelines for

Alzheimer's disease.

The several materials used for the visits were distributed as follows: Visit 1:

• Clinical Protocols and Therapeutic Guidelines of the Ministry of Health, volumes 1 and 2.

• Bulletin for prescribers volume 1 in folder containing business cards;

• Folder for caregivers and patients.

Visit 2: • Book "Multidimensional

Assessment of the Elderly"

• Bulletins for prescribers volumes 2 and 3;

• Pen drive containing all the material needed to request medicines in the Specialized Component.

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Academic Detailing

this method, it is good to provide this information in the bulletin. It is important to

address aspects of the disease, such as pathophysiology, etiology and epidemiology.

The team should seek information on diagnosis, differential diagnosis, selection of

medicines for prescription, non-pharmacological treatment, among others.

The scientific evidence found must be translated into useful clinical information

to patients and prescribers with appropriate language according to the target

audience.

Supporting information for the therapeutic decision-making should be

included.

When the focus is drug treatment, the bulletin may include dosage recommendations,

alternative therapies, duration of therapy, and/or information on comparative prices.

This information, with their sources, shall be provided in frames, graphs, tables or flow

charts to facilitate their identification in the text.

There must be a mechanism to facilitate the storage and retrieval of the

bulletin.

Possible strategies include the publication of a series volume/issue, to be delivered in

different visits and stored in a folder or a specific packaging; provision of a website for

recovery of the items; delivery of printed materials and also in pen drives.

Should contain case studies.

It is good if the bulletin contains commented case studies, with real and/or complex

clinical situations. Real stories, personas and case vignettes can be very engaging and

illustrative for readers.

The newsletter shall include references and be peer reviewed.

It is recommended references are included in the bulletin to inspire the reader's

confidence in the content. Documents drawn up and published by the Ministry of

Health and Health Departments are relevant as well as those produced by Brazilian or

non-Brazilian medical societies. It is important to seek information in agencies that

evaluate health technologies such as the Brazilian Network for Health Technology

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Academic Detailing

Assessment (REBRATS, acronym in Portuguese), National Institute for Clinical

Excellence and Health (NICE/England and SMC/Scotland), Health Technology

Assessment Program (NIHR/ United Kingdom) and the Canadian Agency for Drugs and

Technologies in Health (CADTH/Canada).

4.4.2. Format and layout of the bulletin

The development of an Academic Detailing bulletin should incorporate as many of the

formatting items described below 38.

Preferably hire a graphic designer to prepare the layout of the bulletin and its

illustrations, as infographics.

Contain logo or "distributed by" to facilitate the identification of the promoting

institution and partner organizations.

The smallest/minimum number of sections should be appropriate to the topic

being discussed and generally should not exceed five (e.g. introduction,

diagnosis, inclusion criteria, non-pharmacological treatment, pharmacological

treatment).

If more than five sections are required, they must be allocated into broader categories

(e.g. treatment of disease, which includes both pharmacological and non-

pharmacological treatment).

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Academic Detailing

There must be editorial consistency in the bulletin and its various volumes.

Any bulletin must observe the hierarchy of information, by standardizing ordering of

subtitles, which should be a maximum of three; formatting text and tables, such as

font, size, table headings, text justification; insert standard for highlights in the text

and colors.

Textual sections in the bulletin should be formatted in columns with

appropriate widths, avoiding excessively long stretches; the text should be structured

in topics, whenever possible; the font size should be appropriate and aligned and the

use of colors can be used to enhance readability.

4.4.3. Use of materials during the visit

It has been shown in many different circumstances that printed materials alone

(especially if unsolicited) rarely produce significant changes in clinical practice.

However, the use of print materials that are well presented and structured to support

the focus of the face to face visit are useful adjuncts for getting the messages across.

Consistent use of logos and credibility building program associations’ details,

references and reviewer can help to build 'brand recognition' as well as building

confidence in the integrity and reliability of program materials.

Such helpful printed material can provide a gift of value to be left with the prescriber,

as well as providing a structure in a flow for the interaction. In programs where

multiple visits (or visitors) are involved, printed materials can help with consistency of

message delivery.

However because of the systemization of the placement of information in a specific

location on a printed page, it is also possible that print materials can deflect a

facilitator from their core responsibility in each encounter: that of first establishing and

understanding the needs of the individual prescriber with respect to the key messages

which are to be imparted.

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Academic Detailing

Thus care, practice and conscious skill is needed to effectively use printed materials

during a visit. It is important to maintain physical control of the materials during the

visit. Do not allow them to get in the way of the dialogue - maintain eye contact with

prescriber and only occasionally point out areas of interest on the page. Reassure the

clinician that you will be leaving the materials behind at the end of the visit so they do

not become too distracted.

4.5. Stage 5: Identification of prescribers and organization of visitation goals

After the definition of the target population, it should be decided which prescribers

should receive a visit as resources (time and money) may be scarce. Often due to lack

of financial resources and time, it is impossible to cover all prescribers of the target

population. This creates need to select those physicians who will receive a visit. It may

then be appropriate to identify those prescribers that can serve as opinion leaders for

other prescribers. Alternatively, select those physicians with the greatest concern with

their prescribing41. If this is difficult, methods such as random sampling can be

considered.

It is important to emphasize the need to select about 30% more prescribers for the

visitation, since expected losses due to refusals, not identifying the selected prescriber

or loss of follow-up between one visit and another.

The selected prescribers should be grouped according to the clinical care area

(preferably in their office, if they work in hospitals as well), to maximize the number of

daily visits by facilitator. The number of prescribers by facilitator should be calculated

based on the number of visits and the medical specialty, since the number of visits will

be influenced by specialist involved. For example, consultations with geriatricians may

take up to four times longer than with general practitioners. We recommend the goal

of four prescribers per facilitator per day. However, this will vary if a greater density of

experts is required.

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Academic Detailing

4.6. Stage 6: Recruitment of facilitators and workshop training

To ensure a successful visit, the organizers of the academic detailing should follow as

many of the items described below as possible 39,42,43:

Selection of facilitators

A facilitator should ideally have the following characteristics: be a good communicator;

have availability; be friendly; have some understanding of concepts related to Evidence

Based Medicine; know the scope/ workings of the health care system; have practical

experience in the subject; understand and internalize the importance of the work to be

developed in order to carry out the visits with conviction and efficiency; and have his/

her own vehicle (if pertinent for transport between physicians).

The professional background of the facilitator is less important than their

communication skills and the soundness and breadth of their understanding of clinical

therapeutics and barriers to prescribing change. If the facilitator does not have these

characteristics, these should be addressed in the workshop training. If the facilitator

does not have his own vehicle, the potential for taxis should be explored.

Provide identification material for facilitators

To ensure greater credibility to the prescriber, the visitors should be provided with

identification badges and business cards. Facilitators should introduce themselves and

the institution they represent at the beginning. It establishes credibility through a

respected organisational identity. This provides reassurance to the prescriber and can

open a warm and friendly dialogue as they know the conversation will be informed and

independent.

Ensure adequate training

At this stage, the team will hold workshop training to the facilitators, with the

minimum duration of approximately 12 hours. The training should include the

following items:

Study of the theme: The facilitators should receive the materials to read and study

about Academic Detailing and the problem in question. After this study, the

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Academic Detailing

facilitators should be encouraged to develop key messages with their own

language. The dedication of time for this item is variable, and it is estimated to be a

minimum of three hours.

Training on visitation techniques: In training, the facilitators will be exposed to the

methods of different approaches (visitation techniques) during the academic

detailing visit, with the participation of non-Brazilian guests with experience in this

area, as representatives of pharmaceutical industries (drug detailers) or

professionals that have already performed academic detailing visits. The estimated

time for this item is four hours, but can be reduced to further training in other

subjects if the visiting team is maintained.

Training on the content of the visits: At this time, the facilitators will be exposed to

the contents/material to be covered in each of the visits, with the participation of

the specialist in the field. The estimated time for this item is two hours.

Individual test application on visitation techniques and content: At the end of the

individual study and training, a multiple choice test covering the visitation

techniques, the scientific evidence documented in the bulletin and other aspects

that must or may be addressed during the visit likely to be asked by prescribers is

highly recommended.

Simulation of the visit: It is recommended to simulate the visits among the

facilitators so that all can act either as prescriber or as facilitators, with the

handling and the "delivery" of the material. These simulations should be recorded

to enable harmonization of the approach. If possible, a final simulation can be

made between the facilitator and a specialist in the field. The estimated time for

this item is three hours.

Release the visit materials for the facilitators

After training the facilitators should receive and organize the materials that will be

distributed during the visits. It is recommended that the coordination of the project

provide, in addition to the materials to be delivered to prescribers and customized

business card, other materials to assist in the visit, e.g. suitcase with wheels for all the

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Academic Detailing

materials to be distributed, a tablet or notebook for notes. Alongside this, the use of

standardized forms to the production of post visit notes and feedback.

4.7. Stage 7: Prescribers visiting for academic detailing

Each facilitator should receive a list of prescribers to be visited, containing their

specialty, address and contact phone number. Before the visit, the facilitator should

call to the prescriber workplace and confirm the address and check the days and times

that that the physician will be available. Scheduling must be done, preferably at a time

that the prescriber has no patients, to avoid prolonged time in the waiting room.

It is important to remember that Academic Detailing aims to encourage the voluntary

change of attitude, not through coercion or other means. The facilitator should

estimate the duration of the visit between 15 and 20 minutes.

4.7.1. The objective of academic detailing

Is to move beyond communication of just information;

involves understanding existing behavior and what key motivators & barriers

are for current behavior;

understanding where people are at - what they think/feel about issues;

focuses on how to encourage and achieve voluntary action - not about coercion

or enforcement.

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Academic Detailing

4.7.2. Structure of a visit

A visit to Academic Detailing should go through all the steps listed in Table 2, ranging

from the introduction of the facilitator and the visit reason as to maintain the

relationship with the prescriber. Then other topics that should be observed are

presented.

Table 2. Basic structure of the visits Stages Actions Introduction

Create a suitable space for the visit

Attend to the immediate needs of the doctor

Practice the art of small talk to establish rapport

Demonstrate attentiveness through your body language

Explain the purpose of your visit

Confirm time/availability is still convenient Build trust and establish your credibility

Mention organisational imprimatur or credentials

Mention to be unbiased and independent

Conduct a clinically based visit

Present credible and related to patient care information

Demonstrate empathy, honesty, commitment, expertise Identify the needs of the prescriber

Use open questions to get the person talking

Use minimal encouragers to keep the conversation flowing

Reflect what you’ve heard to show that you’re listening and to check that you’ve understood correctly

Helps to gain information but also guage opinion, feelings and ideas Present the features and benefits “key messages”

Present the key messages of your visit so that they relate to the beliefs, needs, values and interests of the doctor as you perceive them.

Turn features or 'facts' of your message into benefits/value for the doctor and patient

Target them to overcome barriers to change Overcome any objections and handle any challenging responses

E.g. anger or indifference that stands in the way of the staff “buying” your message.

Be alert (listening, observing non-verbal cues) for barriers to your messages

Close the communication loop

Use ‘reflecting’ skills to make sure your messages have been ‘received’

Offer further support

Gain commitment for subsequent visit

Offer the materials for reciprocal obligation Follow-up and maintain your relationship with the clinic staff

Service philosophy

Commitment to mutual goals

Important for behaviour change

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Academic Detailing

Personal presentation

To conduct the visit, is recommended facilitators value their personal appearance, i.e.

wear social discrete colors costumes, avoid excessive makeup and chewing gum, keep

the nails manicured and in the case of men be clean shaven. The facilitator should

identify himself/herself with discretion (avoid conversations and speak softly) and

greet everyone related to the activity.

Basic guide for the visit

Schedule the visit first, or go in person to the office; arrive in the reception, present

yourself and give your business card (treating the attendant by name); check the

availability of the prescriber to visit; wait in a place in the office that does not disturb

the workings of the surgery and sit only if there is space (the patients and their

companions always have priority); expect the prescriber to invite you to enter; sit only

when there is availability or when you are invited; use the tablet or an agenda to take

notes; have clear the main points of approach to avoid forgetting them during the visit;

be prepared to hear different opinions and for the visit to be refused due to recent

extenuating circumstances.

The wait can be hours. If the attendant warns that there will be a long waiting time,

the facilitator can visit other prescribers in nearby locations.

During the visit the facilitator should:

Be punctual;

turn off the cellphone or put it on silence;

act naturally and be attentive;

compliment the prescriber with warmth and friendliness and identify themselves

with the business card as well as avoid actions that demonstrate intimacy (unless

the gesture comes from the prescriber);

summarize the proposal of the visit;

report on the confidentiality of data;

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Academic Detailing

ask about the experience of the prescribing and their clinical practice experience,

seeking for their participation;

address the issues planned for the visit;

combine talking with the use of the printed material;

be firm, demonstrate knowledge, provide a good service;

be prepared to reduce the time of the visit, if this is needed;

observe signs of interest/disinterest, haste, impatience, misunderstanding and

other signs shown by the prescriber and react to these changes or even end the

visit;

deliver the material always at the end of the visit, avoiding to distract the

prescriber;

at the end of each visit, always ask if something was not understood, if the

prescriber has any questions that you can clarify, and schedule the next visit, if

there is any;

in subsequent visits, try to resume the subject under discussion and answer the

questions raised.

During the visit the facilitator should avoid:

Address the issues of future visits, if there are any.

issues that deviate from their goal and with personal matters;

come into direct confrontation with the prescriber, even if it is a controversial

subject;

expressions or sudden gestures;

use of slang or treat the prescriber by "you" (unless if it is requested by the

prescriber).

Conduct in specific situations:

if the prescriber has limited availability to meet representatives, the facilitator

should explain briefly their work, clarifying that it is not representative of the

pharmaceutical industry and that the activity stems from the need for public

29


Academic Detailing

health. Inform the physician of the estimated time required for the visit, the

frequency and then check if you can count on prescriber collaboration;

if the prescriber still has time and has shown interest, the facilitator should take

advantage of this and fully explore the material and content for the visit;

if the facilitator does not know how to respond any inquiry, they must say that will

get the answer and send it by email or phone message, or reply personally in the

next visit, rather than give false information. It is very important to follow up on

this.

After the visit;

the facilitator should thank the attendant by his/ her name when they leave the

office.

if any material or content is not addressed, try to address this during the next visit,

if there is any. The continuity of the visits is very important, and the notes about

the visit are essential to ensure a good relationship with the prescriber, giving them

the impression that this facilitator paid special attention to the questions raised

and remembered what was discussed during the last visit

the facilitator should write down all the information that he/she found relevant on

the visit, right after the contact with the prescriber. It is recommended to pay

attention to any barriers identified in the visit to improve the academic detailing

program. To do that, the facilitator should carry a notebook or tablet with a

standardized form and a free space for insights and questions of prescribers (Figure

3).

30


Academic Detailing

Figure 3. Academic Detailing carried out by SUS Collaborating Centre (CCATES) in Belo Horizonte about Alzheimer's disease: standardized form for notes about the

visit

4.8. Stage 8: Release the material

All materials developed for the visit, as well as those used for the training of

facilitators, should be made available in digital media by the promoting institution of

the Academic Detailing Program, for free access by other researchers, prescribers and

the public in general.

It is good to develop a list of the most frequently asked questions of the prescribers,

answer them and provide these together with the other materials. Coordinators

should circulate this list among all facilitators to ensure they answer a greater number

of questions and to provide standardized answers for the facilitator to use.

4.9. Stage 9: Evaluation of results

Evaluation and planning should be built in to all stages of development of a program. It

is important that this be part of the thinking from the outset and an evaluation plan

developed during the design of the program. This will then determine the evaluation

methodology – be careful not to over-complicate the evaluation approach – need to be

31


Academic Detailing

clear what is really important to measure, and if it is measurable, can be interpreted,

and will make a difference to future work. The availability of data sets is an important

consideration here.

It is critical to evaluate the results achieved, any identified areas to improve the

strategy adopted, demonstrate the relevance of the Academic Detailing, and ensure

the continuity of the work. The academic detailing program can be evaluated in terms

of analysis of the effect, its feasibility and prescriber’s or patient’s satisfaction38.

4.9.1. Analysis of the effect

The effect obtained after the end of the visits should be evaluated in order to validate

the usefulness and cost-effectiveness of the Academic Detailing as an intervention to

achieve the proposed objective. To do this, one must define what the outcomes are at

the beginning and which study design is more appropriate to identify and measure

these outcomes. In addition, the costs involved.

Definition of the outcomes

The impact of the intervention can be evaluated in terms of outcomes related to the

prescriber or the patient.

The outcomes related to prescribers include, in many cases, knowledge, attitudes and

behavior change and can be identified through self-evaluation of the prescribing of

their knowledge in the area before and after the intervention. Also the changes in the

pattern of drug prescriptions or the compliance of prescribers to Clinical Guidelines

can be measured after the Academic Detailing through drug utilization studies.

If it is not possible to assess the outcomes related to the prescriber, or, if there is

interest to extend these results, it is possible to assess the outcomes related to

patients. It can be evaluated though self-reported symptoms, treatment adherence,

satisfaction with the care provided by the prescriber, the reduction in the incidence of

some events, or the quality of life of patients treated by prescribers who received the

32


Academic Detailing

intervention. However, this can be much more difficult, time consuming and

expensive.

The two different levels of outcome (patients and prescribers) are not exclusive, since

the same study may examine the results in more than one level.

Study design:

Depending on the outcome of interest, the method of evaluation can be a randomized

controlled trial, or quasi-experimental studies.

Randomized controlled trials are used when the randomized group is the same as the

group that will be evaluated (i.e., the level of randomization and the level of analysis

are the same). For example, studies that attempt to assess the change in knowledge of

prescribing before and after the intervention compared with the control group, also of

prescribers. The control group may receive no intervention or just printed educational

material. A limitation of this study design would be the "educational contamination" of

the control group by prescribers who received the intervention and share information

with co-workers. Conduct the randomization in clusters, in other words, randomize

clinics or regions instead of prescribers would be an option to minimize this problem.

In quasi-experimental studies there is no control group and the measurements are

made before and after the intervention. It is a suitable study design for studies that

cover the entire target population of prescribers or studies where the outcome can’t

be measured individually, but only in groups. However, it may be difficult to interpret

the results due to potential changes over time that may have altered the outcome and

that are not related to the intervention.

The assessment can be done in statistical terms, considering the differences in the

percentage or average outcomes, or descriptively. Qualitative studies of prescriber’s,

patient’s and/or facilitator’s perceptions on academic detailing can also be used. For

evaluation of programs of Academic Detailing already established and programs in

progress, ecological studies to analyze changes in certain outcome over time or a

33


Academic Detailing

series of cross-sectional studies can also be used. The Australian organization NPS, for

example, publishes an annual report presenting the results of the activities carried out

and the improvement in some outcomes over the years, such as quality of

prescription, quality use of medicines and improved practice of health professionals44.

4.9.2. Analysis of feasibility

The feasibility analysis is generally descriptive and should consider:

costs associated with the facilitator work (recommended to pay per visit

performed);

costs associated with materials (development and print);

time spent in training;

time spent in visit;

loss of prescribers;

difficulty of scheduling;

perceptions of the facilitator in relation to the visit.

This analysis may be conducted by the organizing team. If this is not the case, the costs

involved with hiring this team should be considered as well as the time to develop the

material in any subsequent evaluation.

4.9.3. Satisfaction analysis

The perception of the professionals visited is critical to assess the acceptability,

relevance and quality of the academic detailing. This inquiry can be carried out by

questionnaire administered by telephone, forms to be filled online using, visual

analogue scales or numerical scales applied after the last visit. A model of

questionnaire for a telephone interview and visual analogue scales are provided in

Appendix 3.

In the case of telephone inquiry, the interviewer should not be the facilitator who

conducted the visit. This method ensures that the respondent does not feel pressured

to positively evaluate the visit by the facilitator presence. Other advantages of this

34


Academic Detailing

approach are: does not depend of equipment and internet availability for submission

of information and is more convenient to the prescriber.

To avoid memory bias, this inquiry should preferably be done within seven calendar

days after the last visit made to each prescriber. The presentation of results should

consider the number of survey respondents and description of the answers of the

questionnaire.

4.10. Stage 10: Release the results

The dissemination of results in the scientific community is essential, especially when

the first intervention provides evidence about the effectiveness and efficiency of

Academic Detailing. The results should also be disseminated to medical societies in

order to strengthen relations for future interventions and to provide feedback to the

prescribers visited. Another equally important role is raising awareness of other

prescribers regarding the Academic Detailing and the information transmitted.

It is recommended to prepare a report containing all the steps of detailing for

dissemination in electronic and physical format, and a scientific article that addresses

the process as a whole, with emphasis on evaluation of the impact of intervention.

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Academic Detailing

5. FINAL CONSIDERATIONS

In this document, we sought to address in a simple and practical way the main steps

for planning and implementing an Academic Detailing Program. This guideline does not

exhaust the subject, so those wishing to carry out visits toward to prescribers should

deepen the content in specific readings.

The focus of this document was the visitation of prescribers, but there are other forms

of Academic Detailing, addressed to patients, community and professional groups.

Published evidence also shows the effectiveness of other teaching strategies and

continued education, such as audits and feedback which can be used complementary

to the Academic Detailing strategy. Although a visit face-to-face is preferable,

telephone or videoconference contact are alternatives, especially when it is the

extension of an existing Academic Detailing Program.

The success of Academic Detailing depends on several factors; among the main ones

are the programming and carefully training to address a topic considered relevant to

clinical practice. The attractiveness of visits and the support material should be

targeted and carefully planned to ensure prescriber confidence in the disseminated

content and to address the barriers identified for changing the behavior of the

prescribers.

Although the principal evidence found addressed the use of this technique for the

dissemination of clinical protocols and compliance with its recommendations,

Academic Detailing can also be used to track issues, challenges and suggestions

reported by the prescribers. In this case, the perception of the prescribers would help

to update or develop new protocols, possibly increasing their acceptability and the

rate of implementation of its recommendations.

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Academic Detailing

REFERENCES

1. W O R L D H E A L T H O R G A N I Z A T I O N . Medicines: rational use of medicines. Fact sheet n° 338. May 2010. Disponível em: <http:// www.who.int/mediacentre/factsheets/fs338/en/ print.html> Access in: March 06, 2013.

2. CONFERENCIA DE EXPERTOS, 1985, Nairobi. Uso Racional de Medicamentos. Informe de La Conferencia de Expertos, Nairobi, 25-29 de noviembre de 1985. Ginebra: Organización Mundial de La Salud, 1986. 304 p.

3. HOLLOWAY KA. Combating inappropriate use of medicines. Expert review of clinical pharmacology. 2011;4(3):335-48.

4. GODMAN B, FINLAYSON AE, CHEEMA PK, ZEBEDIN-BRANDL E, GUTIERREZ-IBARLUZEA I, JONES J, et al. Personalizing health care: feasibility and future implications. BMC medicine. 2013;11:179

5. TABA P, ROSENTHAL M, HABICHT J, TARIEN H, MATHIESEN M, HILL S, et al. Barriers and facilitators to the implementation of clinical practice guidelines: a cross-sectional survey among physicians in Estonia. BMC health services research. 2012;12:455

6. NATIONAL RESOURCE CENTER FOR ACADEMIC DETAILING (NaRCAD). About Academic Detailing. Disponível em http://www.narcad.org/about/aboutad/ Access in: March 06, 2015.

7. SPURLING GK, MANSFIELD PR, MONTGOMERY BD, LEXCHIN J, DOUST J, OTHMAN N, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review. PLoS medicine. 2010;7(10):e1000352.

8. CIVANER M. Sale strategies of pharmaceutical companies in a "pharmerging" country: the problems will not improve if the gaps remain. Health policy (Amsterdam, Netherlands). 2012;106(3):225-32.

9. GODMAN B, GUSTAFSSON LL. A new reimbursement system for innovative pharmaceuticals combining value-based and free market pricing. Applied health economics and health policy. 2013;11(1):79-82

10. MOUSNAD MA, SHAFIE AA, IBRAHIM MI. Systematic review of factors affecting pharmaceutical expenditures. Health policy (Amsterdam, Netherlands). 2014;116(2-3):137-46

11. YU SY, YANG BM, KIM JH. New anti-rebate legislation in South Korea. Applied health economics and health policy. 2013;11(4):311-8

12. BRKICIC LS, GODMAN B, VONCINA L, SOVIC S, RELJA M. Initiatives to improve prescribing efficiency for drugs to treat Parkinson's disease in Croatia: influence and future directions. Expert review of pharmacoeconomics & outcomes research. 2012;12(3):373-84

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13. ROEHR B. Drug companies will have to report all payments to US doctors from March 2014. BMJ (Clinical research ed). 2013;346:f826

14. GODMAN B, SHRANK W, ANDERSEN M, BERG C, BISHOP I, BURKHARDT T, et al. Comparing policies to enhance prescribing efficiency in Europe through increasing generic utilization: changes seen and global implications. Expert review of pharmacoeconomics & outcomes research. 2010;10(6):707-22

15. WENG TC, YANG YH, LIN SJ, TAI SH. A systematic review and meta-analysis on the therapeutic equivalence of statins. Journal of clinical pharmacy and therapeutics. 2010;35(2):139-51

16. USHER-SMITH J, RAMSBOTTOM T, PEARMAIN H, KIRBY M. Evaluation of the clinical outcomes of switching patients from atorvastatin to simvastatin and losartan to candesartan in a primary care setting: 2 years on. International journal of clinical practice. 2008;62(3):480-4.

17. NORMAN C, ZARRINKOUB R, HASSELSTROM J, GODMAN B, GRANATH F, WETTERMARK B. Potential savings without compromising the quality of care. International journal of clinical practice. 2009;63(9):1320-6.

18. BJORKHEM-BERGMAN L, ANDERSEN-KARLSSON E, LAING R, DIOGENE E, MELIEN O, JIRLOW M, et al. Interface management of pharmacotherapy. Joint hospital and primary care drug recommendations. European journal of clinical pharmacology. 2013;69 Suppl 1:73-8

19. NEUMAN J, KORENSTEIN D, ROSS JS, KEYHANI S. Prevalence of financial conflicts of interest among panel members producing clinical practice guidelines in Canada and United States: cross sectional study. BMJ (Clinical research ed). 2011;343:d5621.

20. DE SOUZA AL, ACURCIO FD, GUERRA JUNIOR AA, DO NASCIMENTO RC, GODMAN B, DINIZ LM. Authors' Reply to Dr. Malerbi: "Insulin Glargine in a Brazilian State: Should the Government Disinvest?". Applied health economics and health policy. 2014

21. SOUMERAI SB, AVORN J. Principles of educational outreach ('academic detailing') to improve clinical decision making. JAMA. 1990 Jan 26;263(4):549-56. PubMed PMID: 2104640.

22. O’BRIEN, MA et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, 2007; Issue 4. Art. No.: CD000409.

23. AVORN J, SOUMERAI S. Improving drug therapy decisions through educational outreach: A randomised controlled trial of academically based ‘detailing’. New Engl J Med 1983;308:1457-63

24. JIN M, NAUMANN T, REGIER L, et al. A brief overview of academic detailing in Canada: Another role for pharmacists. Canadian Pharmacists Journal: CPJ2012;145(3):142-146.e2. doi:10.3821/145.3.cpj142

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25. SOUMERAI SB, AVORN J. Economic and policy analysis of university-based drug "detailing". Med Care. 1986 Apr;24(4):313-31. PubMed PMID: 3083161.

26. POND CD, MANT A, KEHOE L, HEWITT H, BRODATY H. General practitioner diagnosis of depression and dementia in the elderly: Can academic detailing make a difference? Family Practice 1994;11 (2) 141-147.

27. BROADHURST, NORM A., et al. "A before and after study of the impact of academic detailing on the use of diagnostic imaging for shoulder complaints in general practice." BMC family practice 8.1 (2007): 12.

28. GORIN SS, ASHFORD AR, LANTIGUA R, DESAI M, TROXEL A, GEMSON D. Implementing academic detailing for breast cancer screening in underserved communities. Implementation science : IS 2007;2:43. doi:10.1186/1748-5908-2-43.

29. SOLOMON DH, VAN HOUTEN L, GLYNN RJ, BADEN L, CURTIS K, SCHRAGER H, AVORN J. Academic detailing to improve use of broad-spectrum antibiotics at an academic medical center. Arch Intern Med. 2001 Aug 13-27;161(15):1897-902.

30. SHAW J, HARRIS P, KEOGH G, GRAUDINS L, PERKS E, THOMAS PS. Error reduction: academic detailing as a method to reduce incorrect prescriptions. Eur J Clin Pharmacol. 2003 Nov;59(8-9):697-9. Epub 2003 Oct 18. PubMed PMID: 14566443.

31. ROBERTS GW, ADAMS R. Impact of Introducing Anticoagulation-Related Prescribing Guidelines in a Hospital Setting using Academic Detailing. Therapeutics and Clinical Risk Management 2006;2(3):309-316.

32. ILETT KF, JOHNSON S, GREENHILL G, et al. Modification of general practitioner prescribing of antibiotics by use of a therapeutics adviser (academic detailer).British Journal of Clinical Pharmacology 2000;49(2):168-173. doi:10.1046/j.1365-2125.2000.00123.x.

33. SILVA JM, STEIN AT, SCHÜNEMANN HJ, BORDIN R, KUCHENBECKER R, DE LOURDES DRACHLER M. Academic detailing and adherence to guidelines for Group B streptococci prenatal screening: a randomized controlled trial. BMC Pregnancy Childbirth. 2013 Mar 19;13:68. doi: 10.1186/1471-2393-13-68.

34. CURRY WJ, LENGERICH EJ, KLUHSMAN BC, et al. Academic detailing to increase colorectal cancer screening by primary care practices in Appalachian Pennsylvania. BMC Health Services Research 2011;11:112. doi:10.1186/1472-6963-11-112.

35. DAVIS MARTIN P, RHODE PC, DUTTON GR, REDMANN SM, RYAN DH, BRANTLEY PJ. A primary care weight management intervention for low-income African-American women. Obesity (Silver Spring). 2006 Aug;14(8):1412-20.

36. SCHAUER GL, THOMPSON JR, ZBIKOWSKI SM. Results from an outreach program for health systems change in tobacco cessation. Health Promot Pract. 2012 Sep;13(5):657-65. doi: 10.1177/1524839911432931. Epub 2012 Apr 11.

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37. GODMAN B, ACURCIO F, GUERRA JUNIOR AA, ALVAREZ-MADRAZO S, FARIDAH ARYANI MY et al Initiatives among authorities to improve the quality and efficiency of prescribing and the implications. J Pharma Care Health Sys 2014;1(3):1-15

38. CANADIAN AGENCY FOR DRUGS AND TECHNOLOGIES IN HEALTH (CADTH). Academic Detailing Templates. 2015. Available in: < http://www.cadth.ca/en/resources/academic-detail-toolkit>

39. MACLURE M, ALLEN M, BACOVSKY R, et al. Show me the evidence: best practices for using educational visits to promote evidence-based prescribing. Victoria (BC): Drug Policy Futures; 2006. 2015. Available in: http://web.law.columbia.edu/sites/default/files/microsites/attorneys-general/files/Show_me_the_evidence_report.pdf

40. WORLD HEALTH ORGANISATION. Promoting the Rational Use of Medicines. In: Drug and Therapeutics Committees - A Practical Guide. 2015. Available in http://apps.who.int/medicinedocs/pdf/s4882e/s4882e.pdf.

41. PICHETTI S, SERMET C, GODMAN B, CAMPBELL SM, GUSTAFSSON LL. Multilevel analysis of the influence of patients' and general practitioners' characteristics on patented versus multiple-sourced statin prescribing in France. Applied health economics and health policy. 2013;11(3):205-18

42. AGENCY FOR HEALTHCARE RESEARCH AND QUALITY. The Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers. Module 10. Academic Detailing as a Quality Improvement Tool. May 2013., Rockville, MD. Available in: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod10.html

43. NATIONAL RESOURCE CENTER FOR ACADEMIC DETAILING (NaRCAD). About Academic Detailing. Available in: http://www.narcad.org/services/training/academic-detailing-training/ Access in: March 06, 2015.

44. NATIONAL PRESCRIBING SERVICE (NPS). NPS MedicineWise Annual Evaluation Report 2012/13. Available in: http://www.nps.org.au/about-us/what-we-do/our-research/publications/reports/annual-evaluation-report. Access in: January 27, 2015.

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Academic Detailing

APPENDIX 1

Examples of bulletins

Example 1 – Bulletin for prescribers developed by the Prescription Information Services of Manitoba (PrISM – Canada)

Publication in volumes

Supporting information for the therapeutic decision-making

Key messages

References Identification of the promoter institution and partnerships

Source: CANADIAN AGENCY FOR DRUGS AND TECHNOLOGIES IN HEALTH (CADTH). Newsletter Evaluation: NL-02. Available in: http://www.cadth.ca/media/compus/cac_review/Jan_2007/Appendix%2026%20-%20Newsletters_Evaluation_Catalogue.pdf

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Academic Detailing

Example 2 – Bulletin for prescribers, containing cases study, developed by Prescription Information Services of Manitoba (PrISM – Canada)

Narrative of the case

Question to the prescriber

Correct answer and comment

Source: CANADIAN AGENCY FOR DRUGS AND TECHNOLOGIES IN HEALTH (CADTH). Prescribing Aid Evaluation: PA-07. Available in: http://www.cadth.ca/media/compus/cac_review/Jan_2007/Appendix%2029%20-%20Prescribing%20Aid%20Evaluation%20Catalogue.pdf

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Academic Detailing

Example 3 – Folder for patients and caregivers developed by SUS Collaborating Centre (CCATES – Brazil)

Key messages

Identification of the promoter institution and partnerships

Language appropriate to patients / caregivers

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Academic Detailing

Example 4 – Folder for patients and caregivers developed by National Prescribing Service (NPS - Australia) ]

Aspects of the disease, etiology, epidemiology and treatment

Non-pharmacological care

Language appropriate to patients/ caregivers

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Academic Detailing

APPENDIX 2

Frame 1 – Information sources for Academic Detailing Program

Information sources Address

Health technology assessment agencies

Brazilian Network of Health-Technology Assessment - REBRATS

http://200.214.130.94/rebrats/

Cadadian Agency for Drugs and Technologies in Health – CADTH (Canada)

http://www.cadth.ca/

National Institute for Clinical Excellence and Health – NICE (United Kingdom)

http://www.nice.org.uk/

Agencias y Unidades de Evaluación de Tecnologías Sanitarias – AUbETS (Spain)

http://aunets.isciii.es/web/guest/home

Helth Technology Assessment Program – NIHR (United Kingdom)

http://www.hta.ac.uk/

NHS Evidence https://www.evidence.nhs.uk

Effective Health Care –AHRQ (United States)

http://www.effectivehealthcare.ahrq.gov/

Clinical protocols and therapeutic guidelines

Ministry of Health http://portalsaude.saude.gov.br/index.php/component/content/article?id=9315

National Guideline Clearinghouse http://www.guideline.gov/

Best Practice (BMJ) http://portalsaude.saude.gov.br/ Access through the Portal Saúde Baseada em Evidências

Dynamed http://portalsaude.saude.gov.br/ Access through the Portal Saúde Baseada em Evidências

Support materials for the visit

Alosa Foundation (United States) http://www.alosafoundation.org/clinical-materials/

Cadadian Agency for Drugs and Technologies in Health – CADTH (Canada)

http://www.cadth.ca/en/resources/academic-detail-toolkit/supporting-information-appendices

RxFiles Academic Detailing Program (Canada)

http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx Free access to the Newsletter

New York State Prescriber Education Program(United States)

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Academic Detailing

APPENDIX 3

Evaluation models of satisfaction of prescribers

Example 1 - Questionnaire prepared for telephone survey

Example 2 – Visual analog scale for satisfaction research applied in the end of the visit

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Academic Detailing

Source: Jackson SL, Peterson GM, Vial JH. A community-based educational intervention to improve antithrombotic drug use in atrial fibrillation. Ann Pharmacother. 2004 Nov;38(11):1794-9. Epub 2004 Sep 28.

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