Academic Detailer Training and Resource Material Evaluation

Introduction

Academic detailers usually have a brief (15 - 30 minute) window with primary care prescribers, wherein they are charged with delivering evidence-based key messages. In order to perform this task effectively, these individuals must be both knowledgeable in the detailing topic and armed with the appropriate resource material to assist with the interaction. As such, in creating an academic detailing intervention, consideration must be given to how the academic detailers are trained and what resource material will be available to assist them in the intervention.

Methods

This evaluation will draw upon consultation that occurred with eight academic detailing organizations (five from Canada, two from the United States and one from Australia).

One researcher administered a survey to each organization, conducted the follow-up interviews and preformed the evaluation. A second researcher then reviewed the transcripts and evaluations and provided additional comments. Copies of the transcripts of the surveys and follow-ups are available in Appendices 1 to 8:

• Appendix 1 : CDUP Questionnaire & Follow-Up
• Appendix 2 : ADUP Questionnaire & Follow-Up
• Appendix 3 : RxFiles Questionnaire & Follow-Up
• Appendix 4 : PrISM Questionnaire & Follow-Up
• Appendix 5 : ADP Questionnaire & Follow-Up
• Appendix 6 : iDiS Questionnaire & Follow-Up
• Appendix 7 : DATIS Questionnaire & Follow-Up
• Appendix 8 : NPS Questionnaire & Follow-Up

Through this consultation, it was determined how each organization trained their detailers on a given intervention as well as what resource material was provided for detailing interventions. In order to organize the information we divided the evaluation into two sections. The first section, “Training Process” provides a detailed account of the following:

• Trainer: who within or outside the organization coordinates and administers the training of the detailers on a given intervention?
• Training Description: how does the training occur? What teaching techniques are utilized to provide the training, how long does the training take, etc?

The second section deals with the materials used for training and as resources for academic detailers. For the purposes of the evaluation, these materials have been organized and catalogued into the following sub-sections:

• Presentation Materials: examples of materials from programs that provide didactic presentations as part of their detailer training program.
• Background Literature: description of the background (published) literature provided to academic detailers to facilitate their understanding of the topic and/or for reference purposes during interventions.
• Detail Documents: examples of materials from programs that develop substantial evidence-based reviews on a specific topic. These evidence based reviews are an in depth description and critique of the literature and/or guidelines on each key message within a given topic. It provides a single comprehensive evidence document from which an academic detailing intervention can be developed. This document is utilized to support the development of other academic detailing materials, as a tool for detailer training and as a resource reference once the detailer is in the “field”.
• Supplementary Resource Material: examples of the various other materials produced by programs for the purpose of training and/or resource for their detailers.

Training Description: Draft materials for the detailing intervention are created by key ADS staff. These draft materials along with a package of primary literature are provided to detailers at the beginning of the detailer training. Teleconferences based on the draft materials include the detailers that will eventually take the product into the field. This allows detailers to have input into the document but also for them to gain an understanding of the materials as it evolves towards its final form. The number of teleconferences varies with the topic requirements. Videoconference is also available but its increased expense and reduced convenience (travel to specific venues) makes it unsuitable for most academic training sessions. There are also teleconferences with the Advisory Committee (family physicians). Detailers are involved in these teleconferences as well so they gain first hand knowledge of the regional needs and perspectives of prescribers on particular topics. Finally, the program always holds a face-to-face meeting in Halifax with all of the detailers, which generally involves the content expert. This allows more through discussion and is an important venue to enhance the level of confidence of the detailers.

Throughout the training process, a “script” of how the academic detailing intervention should occur is produced and refined with the input of the detailers. Rehearsal of the final script occurs at the face-to-face meetings in Halifax.

Training and Resource Materials

Lecture Materials: Because ADS provides their detailers with pertinent primary literature and involves them in review of their draft detailing materials, formal lectures on clinical content are not felt to be necessary and are not produced by the program.

Background Literature: The ADS program supplies detailers with copies of any Canadian or other relevant guidelines related to the topic. The relevant primary literature and associated systematic reviews and meta-analyses are shared with detailers. To provide context and highlight areas of controversy, commentaries on the various trials are also shared.

Detail Documents: The ADS detailed document represent the most comprehensive detail document produced by any of the Canadian organizations we surveyed. An example of an ADS detail document associated with their intervention on clopidogrel therapy in acute coronary syndrome is included in Appendix 19 (ACS_Detail_Document.pdf).

Supplementary Resource Materials: The types of resource material that may be provided to ADS detailers depending on the topic can include:

• A “back-pocket” information for their detailers. This information is developed in anticipation of potential questions or areas of controversy that may arise during the detailing sessions (similar to a frequently asked questions document).
• An “Academic detailing script” is produced for most interventions. It focuses on the three issues (key points) that are being delivered to physicians. This five to six page script is developed in conjunction with the detailers and helps to ensure that the main messages of the sessions are delivered in a similar manner using similar terminology. An example of a script created for the intervention on clopidogrel therapy in acute coronary syndrome is included in Appendix 19 (ACS_script.doc).
• The newsletter, prescribing aids or patient information materials associated with the intervention (these materials will be catalogued and discussed in detail in the Academic Detailing Materials section of the Academic Detailing Toolkit project).

Organization: Drug & Therapeutic Information Service (DATIS)

Base of Operation: Lexington , Kentucky , United States  

Contact Person: Frank May, Service Director

Training Process

Trainers: The DATIS material developers and DATIS managers are responsible for detailer training.

Training Description: The training takes place over a four to six week period and is done at a high intensity. The entire process of preparing an individual to conduct academic detailing visits is known as “upskilling”. The term upskilling is used by DATIS to better reflect what the detailer is trying to accomplish. They are not simply attending a presentation about a topic, they are developing the skills that will be require to confidently visit physicians and provide one-on-one education. The level of knowledge and understanding required to do this task goes far beyond what can be classically achieved through didactic training. The first step in upskilling is provision of background information. The topic developers share key papers with detailers. This material is thoroughly read by detailers and individual key papers are “journal clubbed” with review authors and DATIS managers. The training culminates with a series of role-played visits with DATIS staff and the review's authors. Since, all detailers have already participated in a 24-hour contact time, three day workshop dealing specifically with the communication skills of academic detailing, the training discussed here deals with clinical upskilling and only indirectly seeks to polish the communication skills. Classroom learning is deliberately avoided with the focus on the interactive workshop to engage and involve the detailers in their training. Detailers are also given opportunities to discuss key issues with medical and other specialists working in the topic field.

Training and Resource Materials

Lecture Materials: The DATIS training program involves a high degree of discussion-based and interaction-based learning, no formal lecture materials are developed by the program.

Background Literature: Detailers are encouraged to perform an extensive review of the background literature, which includes approximately 50-75 key papers. The detail document may have been produced from a broader scan of the literature involving up to 1500 papers. In keeping with the active approach of DATIS training, ongoing discussion and journal club review of key papers is part of the training process.

Detail Documents: The research for the DATIS detail documents is extremely comprehensive. This document is used as background material for production of other detailing materials and is shared with detailers during the training process. An example of a detail document on the management of type II diabetes in primary care is included in Appendix 20 (T2D_DetailDocument.pdf).

Supplementary Resource Materials: The types of resource material that may be provided to DATIS detailers depending on the topic can include:

• Each detailer is encouraged to develop a script that puts into text an imagined conversation with a hypothetical physician. Coming at the end of the training process, this script incorporates the knowledge and anticipated barriers with physicians. Detailer may even trial their approach and script with a friendly physician. Scripts are used as a tool in early visits on a topic. The information then becomes embedded and, as detailers become more comfortable with the topic, they require scripts to a lesser degree.
• A “Key Message” sheet that distills the specific messages with a brief description into one location is produced. An example of the Key Message sheet for the management of type II diabetes is included in Appendix 20 (T2D_Key_Messages.pdf).
• A “Frequently-asked-Questions” document that provides brief explanations to questions that have come up during visits with prescribers is developed by DATIS. This document is brought to subsequent detailing visits as a reference resource. An example of a “Frequently-asked-Questions” document on the management of type II diabetes is included in Appendix 20 (T2D_FAQs.pdf).
• The newsletter, prescribing aids or patient information materials associated with the intervention (these materials will be catalogued and discussed in detail in the Academic Detailing Materials section of the Academic Detailing Toolkit project).

Organization: Independent Drug Information Service (iDiS)

Base of Operation: Boston , Massachusetts , United States  

Contact Person: Michelle Spetman, Project Manager

Training Process

Trainers: Boston-based academic physicians involved in the production of the detailing materials and the iDiS project managers perform the detailer training.

Training Description: The detailers from Pennsylvania are flown to Boston for the two to three day training session. These sessions allow the detailers access to the Boston-based academic physicians that developed the detailing materials. These sessions allow for team building among detailers who are relatively isolated in the field. The initial training session provides more focus on communication, with subsequent sessions more focused on the clinical topic. The initial training session covers the history and rationale of academic detailing and the healthcare environment in the target state. Detailers are shown the “un-sales” training methods and are made aware of the expectations of the program. Physician behaviour, decision making and change psychology are also discussed.

Training sessions on a specific clinical topic (which may or may not directly follow initial training) start with the provision of pre-reading material that discuss the disease state, symptoms, and pharmacology. The current (based on PACE database information) and ideal medication use patterns are discussed. Finally the physicians and patient materials prepared for the intervention are reviewed and used in video-taped role playing sessions that simulate the physician encounter. These topic-based discussions briefly review the communication concepts of “un-sales”. Performance measures and program evaluation from past interventions are discussed. Clinical content, evidence summaries, key messages, recommendations and patient scenarios all once again culminate in role playing of physician encounters.

All detailers are provided with a binder of training materials that lay out all lectures, primary references and additional information pertinent to training.

Training and Resource Materials

Lecture Materials: The academic detailer training involves lectures from the Boston-based authors of the detailing material. PowerPoint presentations are used to describe relevant data and evidence. An example of the presentations used in the detailer training on anti-platelet therapy is included in Appendix 21 (note: hard copy of training binder provided by iDiS, no electronic copies of training material are available).

Background Literature: The background literature, consisting of the key reference articles circulated for pre-reading, are included in the training binder. An example of the background literature included for the training on anti-platelet therapy is included in Appendix 21 (note: hard copy of training binder provided by iDiS, no electronic copies of training material are available). Detailers are encouraged to thoroughly review this material and forward any questions or gaps in their knowledge regarding the particular disease state, therapeutic class or other clinical information. The Boston team will then attempt to include the needed background information in the training package and presentations.

Detail Documents: A detail document, produced by the Boston team, contains a complete accounting of the evidence used to guide the production of the other materials. This document is provided as a reference for detailers and may also be provided to interested physicians as a reference document. An example of the detail document on anti-platelet therapy is provided in Appendix 21 (Antiplatelet_Detailed_IDIS.doc).

Supplementary Resource Materials: The types of resource materials that may be provided to iDiS detailers depending on the topic can include:

• The training sessions are videotaped and available to detailers as an additional resource after the Boston meetings. Copies of the training DVD's for the iDiS inaugural training program are provided in hard copy in Appendix 21.
• Patient scenarios are developed as teaching tools and reference documents for detailers. These scenarios are utilized during detailer training and often utilized by detailers in their physician visits. Example patient scenarios are included in Appendix 21 (note: hard copy of patient scenarios provided by iDiS, no electronic copies of material are available)
• The newsletter, prescribing aids or patient information materials associated with the intervention (these materials will be catalogued and discussed in detail in the Academic Detailing Materials section of the Academic Detailing Toolkit project).

Organization: National Prescribing Service (NPS)

Base of Operation: Surry Hills , New South Wales , Australia

Contact Person: Judith Mackson, Manager, Education and Quality Assurance Program

Training Process

Trainers: NPS staff representatives along with a medical specialist from each region conduct the training of academic detailers.

Training Description: As NPS is a national program with detailers located throughout much of the populated country, their training processes are more refined than the other programs that we surveyed. Training on a topic is initiated with the provision of a required reading package to each detailer. They are expected to have reviewed this material in advance of a 1-day tutorial program. Usually eight of these 1-day tutorials are held at major centers throughout Australia to make it more convenient for detailers to attend. Nationally, a total of 90-120 detailers are trained on each topic through these sessions. A medical specialist is contracted from each of the major centers that the training occurs in to assist in conducting the training. Having medical specialists from each region serves two purposes, it provides the detailers with a contact to a “local” expert that they can refer to during their detailing, and it facilitates the “buy-in” process from the specialist community throughout the country.

During the 1-day training session, clinical lectures are provided by the medical specialists and review of all the detailing materials associated with the topic are provided by the NPS staff representatives.

Training and Resource Materials

Lecture Materials: The medical specialist from each major centre is responsible for the development of their own lecture material on topic. NPS does not develop centralized lecture materials. The NPS staff do not utilize formal lectures during the 1-day session, preferring to provide “hands-on” training with the topic materials.

Background Literature: The required reading package provided at the initiation of a detailing intervention includes key primary literature on the topic as well as the most current clinical practice guidelines.

Along with the required reading package is a self-assessment questionnaire that provides the detailers with an indication of the breadth of information that they must obtain from the readings. An example of this self-assessment questionnaire (and answers) from their detailing intervention on the management of depression is included in Appendix 22 (saq_antidepressants.pdf).

Detail Documents: NPS creates a detailed document to support their academic detailers and provides the thorough evidence-basis for their written materials. This document is provided in the required reading package. We were not provided with any electronic copies of a detail document, although it was noted that they are very similar to the DATIS detail documents (see Appendix 20 for an example of the DATIS detail document).

Supplementary Resource Materials: The types of resource materials that may be provided to NPS detailers depending on the topic can include:

• A “Frequently-asked-Questions” document that provides brief explanations to questions that have come up during the development and peer-review of the intervention materials. An example of a “Frequently-asked-Questions” sheet on an ACE-Inhibitor intervention is included in Appendix 22 (faq_aceinhibitors.pdf).
• The newsletter, prescribing aids or patient information materials associated with the intervention (these materials will be catalogued and discussed in detail in the Academic Detailing Materials section of the Academic Detailing Toolkit project).

Discussion

Importance

Appropriate training and resource materials are a vital component of an academic detailing toolkit produced by COMPUS. All of the Canadian and International programs are sensitive to the need of the detailers that visit primary care prescribers to have a high-level understanding of the information being discussed. This high-level understanding is sometimes achieved through direct involvement of the detailers in the research and development of material. In other cases, the understanding is developed through a structured training program that often requires the detailer to review extensive amounts of primary literature and associated program materials. Either way, in order for the COMPUS Academic Detailing toolkit to be taken up by existing academic detailing organizations, it is going to have to contain a degree of training materials that will facilitate this high-level of understanding.

The importance of training for non-academic detailing organizations may vary with the intended use. If materials such as newsletters and prescribing aids (discussed in the next section of the COMPUS deliverable) are disseminated passively, then training material will not be necessary. However, if non-academic detailing organizations such as regional health authorities attempt to utilize academic detailing principles in the dissemination of this material, the same requirements for understanding will exist.

Content

The primary goal of resource and training material is to provide detailed information that will allow detailers to interact comfortably with prescribers on the intervention topic. As such, the level of detail within this material is quite high with thorough referencing. The optimal length of this material is dependant on the intervention and the type of resource material provided. The detail documents varied considerably in length between the surveyed organizations. The longest are produced by DATIS which are usually >200 pages in length, the materials produced by PrISM and ADS are in the 25-50 page range, and the iDiS detail documents are generally <20 pages. The difference in page numbers is largely a reflection of the depth of detail that each group delves for the various topics, and to some degree, the audience. The iDiS documents are provided to physicians who are interested in more detailed information then what is provided in the newsletter. As such, they keep their detailed documents to a manageable length. For COMPUS's purposes, their detail documents will be under heavy scrutiny by numerous stakeholders. As well, their material will have to be sufficiently detailed to educate detailers to the point they are comfortable with a topic. As such, the COMPUS detail document will likely require a degree of depth similar to the DATIS documents.

The length of other documents used for resource and training of detailers will depend on what it is being used for. Resource documents such as summaries of key messages or guidelines that are designed to be accessed quickly will be concise, usually less than five pages in length.

Other documents such as scripts and frequently asked questions are quite variable in length, depending again on the level of detail is desired. The lengths and content of the various newsletters, prescribing aids and patient information materials will be dealt with in a subsequent section of this deliverable.

Format

The resource materials developed for detailers are generally not widely distributed to primary care prescribers or other healthcare professionals. As such, the aesthetics of the document are less of a consideration. However, the readability of the documents is still important. As the detail documents are largely prose-based, consideration to appropriate text size, use of dark text on white background and appropriate use of tables and charts should be given.

Process

Uptake of this material by academic detailing organizations in Canada will require COMPUS to develop and provide associated training. The two basic approaches to detailer training are either direct involvement of the detailers in material development or providing the education after the materials are produced. Because of the number of detailers in the country, attempting to involve them on the production end of the intervention is impractical, thus the post-production training model should be adopted.

Conducting this type of training will require coordination between COMPUS and each of the Canadian academic detailing organizations. As the release of COMPUS material may not precisely coordinate with the uptake and dissemination by the detailing groups, there has to be flexibility in how and when this training is provided. Consideration of the timing of academic detailer training is important. The programs will require any background information (ex. reference lists and detail documents) well in advance when detailing starts. Although there was no standard amount of advance time provided by the organizations we interviewed, a minimum 4 weeks would be reasonable. After the provision of background material, if any didactic presentations are to be conducted, they should occur closer to when the detailing is to occur. The most practical method of delivery would involve the integration of COMPUS training into the existing training processes of the Canadian groups. This integration could be facilitated through technological connectivity or use of a “train-the-trainer” model. As all organizations we surveyed involved the authors of their detailing materials in the education of the detailers, it would be ideal to have some representation of COMPUS experts involved in the training.

For uptake by non-academic detailing organizations, the flexibility of COMPUS in conducting the training would be even more crucial. These organizations will potentially partake in ad-hoc detailing processes which would not lend themselves to a structured educational release.