Foot Soldiers for EBM

In: Main

1 Apr 2010

We are all familiar with them— the nattily clad, always smil­ing, generally attractive group of men and women who make up the more than 90,000 salespeople in the U.S. and who work as “detailers” for the pharmaceutical industry. Many of our institutions have strict limitations on the access that these detailers can have to key decision-makers. It is likely that almost every P&T committee member signs an appropriate conflict-of-interest statement each year, outlining his or her dual commitments to the institution and possibly also to a large array of biopharmaceutical companies.

I believe that we have made progress in delineating an appropriate relationship between P&T committee members, detailers, and other workers in the pharmaceutical industry. I covered this topic in the February 2004 issue of P&T (“Seeking Middle Ground”). Yet even I was surprised to see an article on the front page of The Wall Street Journal this past spring that described a recent statewide effort devoted to so-called counter-detailing. According to the article, Thomas Snedden, who runs the Pennsylvania Department of Aging’s Drug Assistance Program, called on Dr. Jerry Avorn when he wanted to counterbalance brand name marketing. The department, via a contractor, agreed to pay a foundation, led by Dr. Avorn, $3 million over three years to put an ‘unsales-force’ in the field.
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So there you have it. Pennsylvania’s state government has contracted with one of the leading academics in our field, Dr. Jerry Avorn at Harvard Medical School, to implement an “unsales” force. Simply put, Avorn and colleagues, who have for years contributed to the literature and who have coined the term “academic detailing,” are now being called upon to assist Pennsylvania in a policy-oriented program that would be focused on reducing the cost of prescriptions throughout the Commonwealth.

In the article, Mr. Snedden states: “We’re trying to go directly to the physicians instead of the pharmacists and have a dialogue with them about prescribing practices that we think should be corrected.”

The avowed goal of this unsales force is to get busy doctors to set aside time to hear a presentation, perhaps not unlike the one that may have been delivered by a detail representative; this one, however, would be focused on other available options, including generic products, which may help to lower overall pharmaceutical costs in the state. High pre-scribers are sought out and become the main audience for this kind of presentation.

I cannot do justice to the newspaper article by summarizing all of it here, so I hope that you will read it at your leisure. I was, frankly, amazed at the level of detail shared by a national audience regarding the work of the unsales force and its particular view of primary care doctors, their colleagues in the pharmaceutical industry, academic health services researchers, and even P&T committee members.
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I hope that many of our readers are already familiar with the work of Dr. Avorn, Stephen Soumerai, and others who have contributed much to our understanding about the interaction between physicians, detail representatives, and the drug industry. This is the first instance in my memory that a state has contracted with researchers and others to implement these tools on such a widespread basis.

Honestly, however, I am uncertain about what all of this means. On the one hand, I would surely like to see wasteful prescribing be actively decreased. Of course, I would also like to see the appropriate use of generic products wherever possible. On the other hand, this fascinating social experiment calls for an outside evaluation to make sure that the unsales force is using appropriate evidence-based medicine (EBM) tools in its targeted sales pitches. Given the size and scope of this program and the monies at stake, it will be interesting to see whether these foot soldiers of EBM—these “unsales-persons,” if you will—can have a measurable impact on changing the prescribing behavior of many primary care doctors in Pennsylvania.

Do you know of any comparable statewide, or even regional, programs that are utilizing the tenets of academic detailing to address the issue of prescription writing by primary care doctors? I think it behooves us to create a national dialogue about these programs, and perhaps we can learn from an evaluation of multiple programs about what works and what does not.

Hats off to Avorn, Snedden, and others who have bravely gone where no one has gone before. I hope that we will all be paying close attention as this program and others evolve in the next few years. Good luck to those foot soldiers of EBM as they try to compete head-on with the 90,000-person army deployed by the pharmaceutical industry a long time ago.


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