Prescribing better way to inform Pa. doctors

Goal is to give them objective advice.

Posted: June 12, 2007

The evidence of Kristin Nocco's competitors was easy to see as she walked into Dr. Melanie Jewell's waiting room in South Philadelphia early one morning this month.

There was information about Alzheimer's disease from Namenda and about the shingles vaccine from Merck, a word search puzzle from Rozerem ("Your dreams miss you") and tissues from Nasonex and Ambien.

These are the kind of token gifts that pharmaceutical sales representatives - known as detailers - leave behind after lauding their employers' latest drugs.

Nocco, a pharmacist and former detailer herself, is an "academic" detailer.

She is paid to sell the truth, or at least Harvard's version of it.

Her unusual job is to give doctors objective information about the cost and benefits of all kinds of treatments, including diet and exercise. Her work is supported by the state of Pennsylvania's PACE program, which helps more than 300,000 poor senior citizens pay for their medications.

The goal is to foster better care and maybe save PACE, which spends $600 million a year on drugs, some money in the process.

"If you just practice smart, you'll be able to give better care and, by the way, save money," said Jerry Avorn, a Harvard University internist and drug expert whose team of doctors is paid by PACE to scour scientific studies and create the reports that detailers like Nocco give doctors.

On this day, Nocco, polished and enthusiastic, arrived armed with breakfast from Dunkin' Donuts for the staff and a stack of information on high blood pressure for Jewell. Before the doctor started seeing patients at 9 a.m., the two raced through thiazide diuretics - "a very cost-effective way to start" - ACE inhibitors, ARBs, beta-blockers, calcium channel blockers, and the widely ignored recommendation to eat right and exercise more.

Jewell said she knew most of it already but appreciated the refresher course and the slick, readable materials Nocco left for her and patients.

Company detailers have been demonized, but Jewell likes them. The drug samples they bring help her patients, she said, and the reps help her keep up to date on the newest drugs. But she limits visits to about 10 a week, by appointment only. And she's well aware that the detailers' job is to sell drugs.

"You always have to wonder how much of their message is marketing and how much is actual science," she said.

She called the PACE detailing program, known as the Independent Drug Information Service, "refreshing."

Avorn dreamed up academic detailing more than 25 years ago while in med school. He realized pharmaceutical companies were outclassing scientists when it came to telling doctors about new drugs and changing behavior. Med school provided continuing-education classes and densely written papers, then expected that doctors would naturally do the right thing. Meanwhile, drug companies sent detailers to talk with doctors one-on-one, offer samples, give them attractive print materials and encourage them to try their newest drug.

Several countries, including Australia and parts of Canada, pay for academic detailing. But, with its fragmented payer system, the United States has been less receptive. Avorn believes Pennsylvania is the only state with such a program now, though Maine, New Hampshire and Vermont are actively considering one. Pennsylvania will soon expand the model to include its state retiree-benefit program.

Kaiser Permanente, the giant California health plan, has had an academic detailing program for 20 years. It employs 60 detailers - pharmacists and physicians - in northern California alone.

"We think the investment has paid off many times," said Sharon Levine, a pediatrician responsible for drug-use management in northern California.

Drug marketing aims at getting doctors to prescribe newer, more expensive drugs. "The major marketing push from industry is to blur the distinction between 'new' and 'improved,' " Levine said. Because of its detailing program, she said, Kaiser did not embrace cox-2-inhibitor pain drugs when the rest of the country was "infatuated." She estimates that alone saved the health plan $50 million.

PACE, which stands for the Pharmaceutical Assistance Contract for the Elderly, has a long history of trying to influence prescribing, Tom Snedden, the program's director, said. Soon after PACE started in 1984, officials realized that some members were getting the wrong medicine or too much of the right medicine.

The program hired a private company to do academic detailing in the mid-1990s but gave up on it because it was "labor-intensive and expensive," Snedden said. He thought it was worth trying again because of today's heavy drug marketing and patient demands for drugs they see advertised on television.

The state is spending $3 million over three years on detailing. Eleven academic detailers, some of whom work part time, are paid $50 an hour to visit doctors with high numbers of PACE patients.

Snedden and Avorn insist that the program's goal is to get patients on the best drugs, not the cheapest. But if, as often happens, older drugs are cheaper and can get the job done, why not try them first?

In hypertension, for example, "a lot of people are on medications that don't do any better a job than the good, old-fashioned thiazide diuretics," Avorn said. Thiazides, he said, cost 50 times less than the most commonly prescribed brand-name drug.

The group also recommends aspirin for preventing blood clots. But, for some patients, a more expensive drug, Plavix, is better from the beginning, it says. "You don't want them to fail aspirin, because their failing aspirin might mean they'll have a heart attack," Avorn said.

Snedden said the program, now in its second year, would have to prove its value or "we're not going to continue it."

A study of the first topic - pain relievers - found that spending on cox-2 inhibitors decreased by $60 a month per physician after a detailer's visit. Those drugs were already getting negative media coverage. A study, now in progress, of the program's impact on prescriptions for acid-reflux drugs is finding much greater cost savings, Avorn said.

When the program started, it was tough to get face time with skeptical doctors, some of whom are so busy the detailers have to make appointments months in advance. At first, there was no budget for food, but doctors' only free time is often before work and during the lunch hour. Nocco said a few hoagies and pizzas saved money in the long run because it was so much easier to get an appointment. Another inducement for the doctors is that they can get continuing-education credits.

After she left South Philadelphia that morning, she drove to Levittown to see geriatricians Daniel Haimowitz and Michelle Scannapieco.

Haimowitz joked about his good intentions - so far unrealized - to read the program's reports for doctors. At 23 pages, the hypertension report is the most daunting. He was glad Nocco could summarize and praised the state for being a "pioneer."

He agreed with the Harvard recommendations and said he already follows them. "It's . . . reassuring to us that what we are doing in practice is consistent with the standard of care and evidence-based," he said. "Even if I didn't learn a thing, it's really valuable because it tells me I'm doing the right thing."

He won't let the state spend tax dollars buying him food but has no problem with letting drug companies do it.

As Nocco was walking to her car, a pharmaceutical company rep arrived carrying two bags from a Famous Dave's barbecue restaurant.


Read what academic detailers have to say about clinical topics, such as pain relievers and cholesterol-lowering medicines, at http://go.philly.com/detailing


Contact staff writer Stacey Burling at 215-854-4944 or sburling@phillynews.com.

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