Medicamentos Madrid Mansfield1 Effective Activities
1. Drug bulletins and other
activities for improving clinical
practice
Dr Peter R Mansfield OAM BMBS
peter.mansfield@adelaide.edu.au
2. The place of bulletins
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Important considerations
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Methods for improving clinical practice
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We can learn from drug promotion
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3. 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
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8. 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.
9. 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.
10. 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.
11. 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 and
implementation 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.
12. Methods for improving clinical
practice
• EPOC (Cochrane-Effective Practice and
Organisation of Care) Classification of
Professional Interventions
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 and
implementation strategies 1966-1998. J Gen Intern Med. 2006 Feb;21
Suppl 2:S14-20.
13. 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.
14. Educational meetings
• = health care providers who have participated
in conferences, lectures, workshops, or
traineeships.
• Can be effective when interactive or
enjoyable.
15. Promotional meetings
Orlowski 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.
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16. 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.
17. 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.
18. Cristin Duren, Drug Rep
Saul S. Gimme an Rx! Cheerleaders Pep Up Drug Sales. New York Times.
November 28, 2005 18
19. Local opinion leaders
• = use of providers nominated by their
colleagues as ‘‘educationally influential.’’
• Can be effective but influence networks are
unstable.
21. 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.
22. 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.
23. 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.
24. 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
26. 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.
28. 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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32. Being human has many advantages
Compassion
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Intuition
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Humor
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Imagination
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33. 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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34. Motivations
Burnt out Dodo
Caring Bunny
Conservative Sheep
Entrepreneurial Wolf
Branthwaite A, Downing T.
Marketing to doctors – the
human factor. Scrip Magazine
1995 March;32-5
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37. 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
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38. Common shortcuts
Expert endorsement
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Popular with peers
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Newer
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More expensive
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