What tricks and techniques can be used to influence prescribing?
| Part of medicines management is
influencing GPs and other health care professionals to change their
prescribing habits. Can some tricks be learnt from the pharmaceutical
industry to improve pharmacists' influencing skills? Christopher
Cutts and Adam LaCaze explore the possibilities |
Dr Christopher Cutts is Head of Medicines Management, St Helens Primary
Care Trust
Adam LaCaze is Associate Lecturer, University of Queensland School of
Pharmacy
|
“Academic detailing” was first described by Avorn and Soumerai
about 20 years ago. It is jargon for a method of education that uses
the principles of “social marketing” to engage a doctor in
a one-to-one discussion about a specific therapeutic topic.
What marketing techniques can be used to influence prescribing |
A growing evidence base exists supporting the impact of academic detailing
on behavioural change, particularly prescribing behaviour.
It is well established that pharmaceutical companies use the principles
that underpin academic detailing, through their sales representatives,
to achieve the behavioural change they want, ie, the prescribing and
purchasing of their own products.
What is “academic detailing”?
We are going to describe the principles of social marketing and the process
of academic detailing, and also consider the potential application of
these techniques by primary care organisations in GP prescribing or medicines
management education programmes.
The fundamental question is, can the marketing techniques used to encourage
people to buy products such as fizzy drinks or trainers be used to encourage
people to adopt behav-iours that will enhance their own and fellow citizens’ lives? Can it help solve health problems
Can we use the techniques of successful selling to solve health and social
problems? It needs to be recognised that social marketing is different,
and in certain aspects more difficult, than standard marketing. Social
marketing tends to be more complex, consumer (doctor) demand is varied,
target groups are more challenging to reach, consumer involvement is
more intense and competition is varied and subtle.
But it is still relevant to pharmacy practice because the core activity
of pharmacy practice, indeed the profession’s role within contemporary
health care, is that of producing behavioural change. This is true whether
one is considering the traditional role of pharmacists in relation to
patients or the role of pharmacists within the hospital setting or a
primary care organisation. Despite this, there is little discussion in
the pharmacy practice literature on what models for producing behavioural
change actually work.
Current techniques in use
A number of techniques are currently used to modify the behaviour of
practising doctors. Continuing medical education, practice guidelines
and care pathways represent the major thrust of these efforts. Traditionally,
these strategies have focused on simple dissemination, lectures and
distribution of printed materials.
Although they may be useful when used as part of a multifaceted programme,
these strategies have a limited influence on behavioural change. On the
other hand, academic detailing has been subjected to considerable investigation
for about 20 years. A Cochrane review summarised the data and concluded
that academic detailing appears to be a promising approach to modify
professional behaviour.
Academic detailing involves a personal visit by a trained person (detailer)
to a health care professional wherever he or she works. The detailer
is highly trained and briefed. The detailer should be an “expert” on
the clinical topic before starting the programme and be trained in behaviour
change principles. (As it happens, many detailers in trials are pharmacists.)
Academic detailing is based on three main concepts. The intervention
should be focused on achieving a behaviour change; focused on building
a professional relationship between the “visitor” and the
recipient; and focused on meeting the needs of the recipient. Such a
focus is achieved by adherence to the principles of academic detailing
as described by Avorn and Soumerai (Panel 1).
Panel 1 Principles of academic detailing
1. Interviews to investigate baseline knowledge
and motivations for current prescribing patterns.
2. Focusing programmes on specific categories of doctors as well
as on their opinion leaders.
3. Defining clear educational and behavioural objectives.
4. Establishing credibility through a respected organisational
identity, referencing authoritative and unbiased sources of information,
and
presenting both sides of controversial issues.
5. Stimulating active doctor participation in educational interactions.
6. Using concise graphic educational materials.
7. Highlighting and repeating the essential messages.
8. Providing positive reinforcement of improved practices in
follow-up visits. |
Why academic detailing works
Everyone has his (or her) personal reasons for current behaviour. Academic
detailing is successful as a prescribing intervention where others
fail because it aims to elicit and understand the key factors, which
underlie an individual’s prescribing habits and tailor the educational
message to these perceptions.
The intervention should provide practical alternatives to current behaviour.
This highlights the importance of communication skills for the detailer, the
need for two-way communication and a focus on building a relationship with
the health care professional. It also suggests why interventions based on one-to-one
visits tend to be more successful.
Message must be clear
To achieve behaviour change it is necessary for the intervention to focus
on a small number of key messages. Repetition and reinforcement, alongside
clear and precise written materials, are used to ensure these messages
are communicated clearly. Key messages must be achievable and relevant
to the targeted group of doctors. The detailer will “sell” the
key messages by presenting their features and benefits.
Panel 2 Benefits of academic
detailing
1. Academic detailing visits are more effective
than no intervention.
2. Academic detailing visits with other complementary interventions
including reminders, audit and feedback, use of local opinion
leaders, marketing strategies or patient-mediated interventions
are more effective
than academic detailing visits alone.
4. Academic detailing visits are more effective than audit and
feedback.
5. Academic detailing visits using patient-related content are
more effective than using performance summaries for content.
6. Academic detailing visits using an influential source are
more effective than academic detailing visits using any other
sources.
7. Using more than one academic detailing visit is more effective
than using one academic detailing visit.
8. The effect of academic detailing decreases over time after
the visits are stopped. |
Use credible sources
An essential component of academic detailing is the reliance on credible
resources. The detailer can use respected resources such as texts (eg,
BNF), local specialists, journals (eg, BMJ) and respected organisations
(eg, SIGN) to build trust.
However, it is clear that the wrong choice, such as controversial NICE
guidance or Department of Health policy will damage attitudes. Over time,
the detailer will develop their credibility through repeated visits and
the reliance on external sources will reduce.
Further, in relation to the credibility of the intervention, it is vital
that the inherent uncer-tainty of clinical practice is acknow-ledged.
Discussions and educational material should communicate concisely both
sides of any debate, as well as outline areas of limited knowledge.
Training and recruitment critical
As would be clear from the above discussion, to conduct a prescribing
intervention based around academic detailing, training and recruiting
suitable staff is paramount. The detailer needs to posses extensive
communication skills and have undergone specific training. The detailer
also requires a comprehensive knowledge of the topic at hand, at such
a depth that the visitor could debate the pros and cons of the message
while being able to provide a detailed justification of the prescribing
intervention key messages.
How can it be used in practice?
Most PCOs will now have an established prescribing (medicines management)
education programme, made up of local meetings, practice-based meetings,
newsletters, reminders and audit. The impact of these programmes needs
to be considered.
The development of an academic detailing programme may appear time consuming,
use a lot of resources and be impracticable. However, a look at the principles
of social marketing show there is a lot to be gained.
The important aspects of trust, credibility, eliciting customer needs
and defining clear aims are crucial when developing education sessions.
Some suggestions on incorporating social marketing in prescribing education
programmes are offered in Panel 3.
Panel 3 How to put theory into
practice
1. Discuss with a small group of GPs what are the
real problems with
prescribing. What do they want to know and learn about?
2. Investigate what sources considered with highly regarded
by the local GPs. Use to add credibility to prescribing education
messages.
3. Observe how pharmaceutical industry representatives deal with
you and colleagues. Imitate the actions that you think work.
4. Brainstorm acronyms and slogans that could summarise key prescribing
messages.
5. Place your messages as part of an overall campaign involving
more than just GPs, include nurses, patient groups, hospital
staff, etc.
6. Develop eye-catching graphic materials to present messages.
Consider a corporate approach to style and layout. |
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