The document discusses knowledge transfer activities in Brazil between the Federal University of Minas Gerais and the Minas Gerais State Health Authority. It describes two main activities: 1) an academic detailing pilot project to disseminate treatment protocols for Alzheimer's disease based on clinical evidence and 2) producing technical appraisals to evaluate individual treatment requests and support judicial/administrative decisions. The academic detailing project included training facilitators, visiting physicians to provide information on the Alzheimer's protocol, and found the physicians were receptive. Technical appraisals independently evaluate health technologies and provide evidence-based recommendations to inform decisions.

1. KNOWLOLEDGE TRANSFER IN BRAZIL
Case studies from SUS Collaborating Centre
Prof. Augusto Guerra, PhD
Juliana de Oliveira Costa, MPH
Federal University of Minas Gerais
Brazil
Contact: augustoguerrajr@ufmg.br
contato@ccates.org.br

2. Minas Gerais State Health Authority
recently organized the State
pharmaceutical assistance and is now
facing new demands in a context of
restricted budget.
SUS COLLABORATING CENTRE
INTRODUCTION
• 19 million
people
• growing elderly
population
• crescent new-
drugs scenario
→ Need of procedures for prioritizing
and evaluating what might be
delivered for citizens.
↘ To help address these problems ↙
A partnership between Academia and
Government was established to
enforce the incorporation of clinical
evidence into decision-making
Collaborating Centre
CCATES

3. • To evaluate the compliance of individual requests for treatment with the Brazilian
or the State Protocols;
• To produce Technical Appraisals of judicial requests for medicines and specific
demands about medicines utilization;
• To support judicial and administrative decisions.
SUS COLLABORATING CENTRE
OUR MAIN ACTIVITIES
→ Academic Detailing Pilot Project: Dissemination of SUS Protocols evidence
→ Technical appraisals: To support judicial and administrative decisions
We will presente here

4. Specialized Medicines Component of
Pharmaceutical Assistance
(High cost drug program)
• Comprises high-cost treatment
– e.g.:
• Gaucher’s disease: USD 300,000.00 per patient
year
• Schizophrenia: USD 2,000.00
• Physician must fill in an administrative request explaining
the case and proving that the patient fulfills the inclusion
criteria
• CCATES team evaluate the compliance to the Brazilian or
the State Protocols of all Minas Gerais State requests for
high cost drugs (more than 100,000 per year)

5. Academic detailing for
Alzheimer’s disease
• Dementia disorders are the most common diseases among the
elderly in Brazil, reducing their social and occupational
activities.
– Alzheimer’s disease 60% of dementia cases
• Drug therapy according to Brazilian Protocols
– Cholinesterase inhibitors (donezepil, galantamine and rivastigmine)
• In 2012 - 12% of requests were denied as a result of poor filling
of the request

6. Academic detailing for
Alzheimer’s disease
• Academic detailing:
• Visit of a trained person (health
professional or not) to health professionals
in their own settings (hospital, nursing
home, office) -> one-on-one visits
• The Pilot Program
• Focus on the Clinical Protocol and
Therapeutic Guidelines for Alzheimer’s
disease to improve future prescribing

7. Academic detailing for
Alzheimer’s disease
Results
• 1st step: Seminar about the Pilot Project, the disease and its treatment
• Audience:
– Physicians 64,3%
– Residents 28,6%
– Other health professional 7,1%
Questionnaire answered
by participants of Seminar 1
• 79% of participants found the Pilot Project
relevant and were willing to receive a visit
from a CCATES facilitator
• 30% had more than one difficulty related
to the requests of Alzheimer’s treatment:
–50,0% in fullfilling the requests
–50,0% in the amount of time it requires
–28,6% had doubts about the Protocol
–14,3% other

8. • 2nd step: Study of clinical cases from both accepted and denied requests
– Revision of 165 randomly selected requests from October 2012 to
July 2013
– 80% of compliance to Clinical Protocols on 10 items evaluated
– 38% of cases were sent back to the patient/physician
– Important information lacking to analysis (e.g. educational level)
– From cases sent back, 65% were returned again, since prescribers
did little or no modification
No rejection occurred because it was not an Alzheimer's disease, but by incorrect
reporting of cognitive tests, either by incongruity between them, lack of practical
application or by non-observance of the protocol exclusion criteria.
Academic detailing for
Alzheimer’s disease
Results

9. • 3rd step: Elaboration of the material to be
delivered to physiscians:
– Handouts for patients and caregivers
– Three different bulletins for Physicians,
wich were delivered in a folder with
CCATES and UFMG logos, along with
bussiness cards.
Academic detailing for
Alzheimer’s disease
Results
In addition, we provided other material to support the visit:
‒ Clinical Protocols and Therapeutic Guidelines of the Ministry of Health, volumes 1
and 2.
‒ Book "Multidimensional Assessment of the Elderly“
‒ Pen drive containing all the material needed to request medicines in the
Specialized Component.

10. • 4th and 5th steps: Training and visiting
Academic detailing for
Alzheimer’s disease
Results
Team: eight
pharmacists with
knowledge of SUS and
evidence-based
medicine concepts.
Two-day training covering
academic detailing
techniques and principles,
Alzheimer’s disease, and
simulation of visits.
Facilitators received a
bussiness card, a badge,
the support materials
and a list of prescribers
to be visited
Physicians: selected
randomly from
CCATES database.
Criteria: requested at least
three times medicines for the
treatment of Alzheimer’s
disease during the year prior to
the study.
37 physicians were visited,
at least twice, including
psychiatrists, neurologists,
geriatricians and general
practitioners

11. Academic detailing for
Alzheimer’s disease
Results
• 6th step: Satisfaction survey by telephone evaluating acceptability, relevance
and the quality of the Academic Detailing received -> soft measures.
– 28 physicians participated
85.7% (24)
67.9% (19)
71.4% (20)
71.4% (20)
92.9% (26)
60.7% (17)
75.0% (21)
53.6% (15)
71.4% (20)

12. Academic detailing for
Alzheimer’s disease
Lessons learned
• The success of Academic Detailing depends on several factors; among the main
ones are programming and carefully training to address a topic considered
relevant to clinical practice.
• The attractiveness of visits and the support material should be targeted and
carefully planned to ensure prescriber confidence in the disseminated content
and to address the barriers identified for changing behavior.
• The physicians do not seem to be a barrier to evidence-based medicine
utilization. The barrier may be the way their practice works, since they allege to
not have time to keep-up with science publications ad the bureaucracy.
• Most of physicians were receptive to visits, which shows that they are receptive
to new information as well.

13. Academic detailing for
Alzheimer’s disease
Lessons learned
• Main evidence to use this technique was for the dissemination of clinical
protocols and compliance with its recommendations, but Academic
Detailing can also be used to track issues, challenges and suggestions of the
prescribers.
– They suggested the Protocol and the request formularies to be simplified
• In this case, the perception of the prescribers would help to update or
develop new protocols, possibly increasing their acceptability and the rate
of implementation of its recommendations.
• The prescribers’ perceptions are an important source for the identification
of problems and formulation of actions.

14. Technical Appraisals
• Used to:
– Evaluate litigated Health Tecnologies
– evaluation of the technology usefulness is needed
• Ministry of Health Guideline for Technical Apraisals
• Sumarize the cientific evidence of:
– Efficacy/Effectiveness
– Safety
– Cost-effectiveness
– Decisions of international agencies such as NICE and
CADTH.
• Quality of the evidence and strength of a
recommendation: GRADE system
– “the extent to which we can be confident that the
desirable effects of an intervention outweigh the
undesirable effects”

15. Technical Appraisals
Executive Summary
Includes the group of
patients that benefits from
the use of the technology
and if there is any alternative
available from SUS
Main part of the Technical
Appraisals
Contains the level of
recomendation of the
technology
• Weak against
• Weak in favor
• Strong against
• Strong in favor

16. Technical Appraisals
Exemples
Efficacy and safety of temozolomide in the
treatment of low grade astrocytomas
Eficacy and safety of ranibizumab and bevacizumab
in the treatment of Age-Related Macular
Degeneration
Amphotericin B formulations for the treatment of
fungal infections in patients with HIV/AIDS
Efficacy and safety of sorefenib in the
treatment of liver cancer
Efficacy and safety of rituximab for the
treatment of systemic lupus erythematosus
Efficacy and safety of zoledronic acid for the
treatment of osteoporosis
Efficacy and safety of sertraline and citalopram for
the treatment of depression
Efficacy and safety of medicines based on Cannabis
sativa extract for the treatment of epilepsy in Rett
Syndrome
Treatment of diabetic neuropathic pain:
Efficacy, safety and cost-effectiveness of pregabalin
and the association of vitamin B12, uridine and
cytidine
From 2012 to 2015: 37 Technical Apraisals were published
Efficacy and safety of drug-eluting stents in
the treatment of coronary artery disease
Ischemia time on renal graft survival:
Efficacy of perfusion machine

17. Technical Appraisals
Key points of a
Knowledge transfer
The team that develops the Technical Appraisals is
independent and free of conflicts of interests
The Technical Appraisal answers a specific question using the
evidence-based medicine principles
Gives a clear recommendation
It is written in a plain language
It is available full text at Ministry of Health and CCATES
websites

18. www.ccates.org.br
rebrats.saude.gov.br/sisrebrats
Technical Appraisals