Drug bulletins and other activities for improving clinical practice

Dr Peter R Mansfield OAM BMBSpeter.mansfield@adelaide.edu.au

• The place of bulletins

• Important considerations

• Methods for improving clinical practice

• We can learn from drug promotion

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Thank you

• Major sponsors: – IQWiG [German Institute for Quality and

Efficiency in Health Care] – SSMI [Swiss Society of Internal Medicine]

• Juan Gervas and “nogracias”• Audience

The place of bulletins

The house

• Roof (Implementation eg educational visiting)

• Walls (Evidence in context eg bulletins, guidelines)

• Foundations (Evidence eg RCTs, systematic reviews, qualitative studies)

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Important considerations

Education or promotion?

• Education = giving knowledge and/or skills to enable people to decide for themselves what to do.

• Promotion = persuading people to do something you want them to do.

• Both can be unethical.

Reactance

Reactance is an emotional reaction against threats to freedom or pressure to change. Reactance can cause people to adopt or strengthen views contrary to what was intended.

Limited time and resources

• If you ask doctors to do more of x, either they don’t or they do less of something else. You may do more harm than good.

• If asking doctors to less of y, they may replace it with something worse.

• Best to ask them to do more of x and less of y.

Are the methods effective?

• Results are mixed so too early for conclusions.

• Will not be effective if not done properly eg poorly written educational materials.

• Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, Vale L. Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination andimplementation strategies 1966-1998. J Gen Intern Med. 2006 Feb;21 Suppl 2:S14-20.

• Lu CY, Ross-Degnan D, Soumerai SB, Pearson SA. Interventions designed to improve the quality and efficiency of medication use in managed care: a critical review of the literature - 2001-2007. BMC Health Serv Res. 2008 Apr 7;8:75.

Methods for improving clinical practice

• EPOC (Cochrane-Effective Practice and Organisation of Care) Classification of Professional InterventionsGrimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, Vale L. Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination andimplementation strategies 1966-1998. J Gen Intern Med. 2006 Feb;21 Suppl 2:S14-20.

Educational materials

• = distribution of published or printed recommendations for clinical care, including clinical practice guidelines, audio-visual materials, and electronic publications.

• Often not effective, but cheap and …

• Can be effective when well written, + doctors believe they have a problem + the materials quickly provide an easy solution.

Educational meetings

• = health care providers who have participated in conferences, lectures, workshops, or traineeships.

• Can be effective when interactive or enjoyable.

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Promotional meetingsOrlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician prescribing patterns: there’s no such thing as a free lunch. Chest 1992;102:270-3.

Local consensus processes

• = inclusion of participating providers in discussion to ensure that they agreed that the chosen clinical problem was important and the approach to managing the problem was appropriate.

• Message may be improved or worsened so may lead to better or worse practice.

Educational outreach visits

• = use of a trained person who met with providers in their practice settings to give information with the intent of changing the provider’s practice.

• Can be very effective because message can be individualised.

• Expensive but cost effective sometimes.

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Cristin Duren, Drug Rep

Saul S. Gimme an Rx! Cheerleaders Pep Up Drug Sales. New York Times. November 28, 2005

Local opinion leaders

• = use of providers nominated by their colleagues as ‘‘educationally influential.’’

• Can be effective but influence networks are unstable.

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Expert Opinion Leaders (OL)

Patient mediated interventions

• = new clinical information (not previously available) collected directly from patients and given to the provider, e.g., depression scores from an instrument.

• Taps doctor’s desire to please the patient.

• The patient’s request can create the time to do the work.

Audit and feedback

• = any summary of clinical performance of health care over a specified period of time.

• Some times done with comparison with peers.

• Peer comparisons can be a powerful influence but can mislead.

Reminders

• = patient or encounter-specific information, provided verbally, on paper or on a computer screen that is intended to prompt a health professional to recall information

• Can be effective if doctor is already convinced that recommendation is sound and doctor is not overloaded.

Marketing• = use of personal interviewing, group

discussion, or a survey of targeted providers to identify barriers to change and subsequent design of an intervention that addresses identified barriers.

• Can be very effective if done well.

• The barriers that people mention may not be the real barriers. Checkland K, Harrison S, Marshall M. Is the metaphor of ‘barriers to change’ useful in understanding implementation? Evidence from general medical practice. J Health Serv Res Pol 2007;12(2):95–100

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Mass media

• = varied use of communication that reached great numbers of people including television, radio, newspapers, posters, leaflets, and booklets, alone or in conjunction with other interventions; and targeted at the population level.

• Taps doctor’s desire to please the patient.

• The patient’s request can create the time to do the work.

We can learn from drug promotion

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Promotion is a mirror to our souls“Now can you think what the Mirror of Erised shows us all?’…Harry thought. Then he said slowly, ‘It shows us what we want … whatever we want …’‘Yes and no,’ said Dumbledore quietly. It shows us nothing more or less than the deepest, most desperate desire of our hearts.”Mansfield P. Accepting what we can learn from advertising's mirror of desire. BMJ. 2004 Dec 18;329(7480):1487-8.

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Being human has many advantages

• Compassion

• Intuition

• Humor

• Imagination

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Doctors are human“Medical men are subject to the same kinds of stress, the same emotional influences as effect laymen.Physicians have, as part of their self image, a determined feeling that they are rational and logical, particularly in their choice of pharmaceuticals.The advertiser must appeal to this rational image, and at the same time make a deeper appeal to the emotional factors which really influence sales.”Smith MC. Principles of pharmaceutical marketing. Philadelphia: Lea & Febiger 1968

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MotivationsBurnt out Dodo

Caring Bunny

Conservative Sheep

Entrepreneurial WolfBranthwaite A, Downing T. Marketing to doctors – the human factor. Scrip Magazine 1995 March;32-5

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Context:

Information Overload

Pressure for quick decisions

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Decision Shortcuts

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Shortcuts can be:• A quick easy

path to the right conclusion

• A quick easy path to the wrong conclusion

• Difficult to avoid because of lack of time

Common shortcuts

• Expert endorsement

• Popular with peers

• Newer

• More expensive

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Healthy Skepticism

Improving health by reducing harm from misleading drug promotion

www.healthyskepticism.org