Veterans Health Administration Pharmacy Benefits Management Academic Detailing Service
Between 2001 and 2007, opioid prescribing increased 184% for methadone, 60% for synthetic/semi-synthetic opioids, and 35% for non-synthetic opioids in Veterans. Further, in 2005, the mortality rate for accidental opioid mortality was two-times higher in Veterans than in the general US population. The Veterans Health Administration (VHA) responded by implementing the Opioid Overdose Education and Naloxone Distribution (OEND) and Opioid Safety Initiative (OSI) campaigns, which were catalyzed by the VHA Pharmacy Benefits Management Academic Detailing Service.
Academic detailing (AD) is an educational service for clinicians-by-clinicians that provides individualized, face-to-face outreach to encourage evidence-based decision-making and improve Veteran healthcare. Academic detailers (specially trained clinical pharmacists) provide guidance using “key message”-focused discussions that engage providers, identify barriers/resolutions, and build relationships. After a three-year pilot, the Interim Under Secretary of Health mandated that all VHA regional networks implement AD by 2015 to address the opioid crisis. Subsequently, the Academic Detailing Service prioritized increasing Veterans’ access to OEND and improving evidence-based pain management.
Academic detailers’ work productivity measured as the number of OEND/OSI-specific educational outreach visits increased rapidly after implementation. In OEND, the number of new providers exposed to AD increased from none in Quarter (Q) 2 Fiscal Year (FY) 2014 to 1,168 in Q2FY2017. In OSI, the number of new providers exposed to AD increased from none in Q3FY2013 to 1,670 in Q2FY2017. As AD implementation spread, the number of naloxone prescriptions increased and opioid use decreased indicating that AD was a major contributor. Formal assessments were made to evaluate these hypotheses.
We performed two retrospective, repeated measures cohort studies that examined the impact of AD on naloxone prescribing for patients at-risk of opioid overdose (Study 1) and opioid utilization in Veterans on high-dose opioids (Study 2). In Study 1, at 1 year, the incidence rate ratio (IRR) was 3.2 times higher in the AD-exposed group compared to the AD-unexposed group (95%CI: 2.0-5.3). Similarly, at 2 years, the IRR was 7.4 times higher in the AD-exposed group compared to the AD-unexposed group (95%CI: 3.0-17.9). Overall, the AD-exposed providers had a greater rate of naloxone prescriptions prescribed compared to AD-unexposed providers over two years (7% greater rate; 95%CI: 2%-13%). In Study 2, AD-exposed providers had a greater reduction of patients with high-dose opioids (58% versus 34%, respectively; p=0.013) and average MEDD (59% versus 31%, respectively; p<0.001) compared to AD-unexposed providers over 36 months.
The Academic Detailing Service contributed to the VHA’s national priority on the opioid epidemic by enhancing the OEND and OSI campaigns using an innovative approach to align providers with evidence-based practice, leveraging clinical dashboards to monitor and benchmark progress, and using Salesforce.com to document and record academic detailers’ activities. In addition, AD offers a unique opportunity for clinical pharmacist specialists to perform population management by directly interfacing with key providers who have an influence on a large group of Veterans. Through partnerships and collaborations, the Academic Detailing Service was successful in acquiring stakeholder buy-in and support while performing several program evaluations validating its effectiveness.