Pharmaceutical representatives in academic medical centers: interaction with faculty and housestaff

Factors that influence prescribing decisions

BACKGROUND

Strategies to control the quality and cost of medication use are largely dependent on the ability to alter selection of medications. Previous models of prescribing behavior have focused on physicians. In the hospital setting, clinical pharmacists and formulary committee members are also key players in drug therapy decision-making. Differences between physicians, formulary committee members, and clinical pharmacists have not been compared. Knowledge of these differences could have importance in predicting the effectiveness of strategies designed to influence drug use in this setting.

OBJECTIVE

To describe and compare the opinions of physicians, clinical pharmacists, and formulary committee members with respect to key factors that influence medication prescribing in community hospitals.

METHODS

Physicians, clinical pharmacists, and formulary committee members were solicited to participate. A trained interviewer administered a standardized questionnaire designed to elicit opinions of participants regarding the importance of factors thought to influence drug prescribing. Responses were described using descriptive statistics, and differences between the groups were determined by post hoc analysis.

RESULTS

A total of 150 individuals participated in the study. Safety, effectiveness, formulary status, and restrictions on prescribing were considered highly influential by all participants. Physicians rated the availability of drug samples and personal experience higher (more influential on prescribing) than clinical pharmacists and formulary committee members. Clinical pharmacists and formulary committee members rated the influence of recommendations by clinical pharmacists, prescribing guidelines, and cost or cost comparisons higher than physicians. Factors that were drug-related or that involved policy-related programs tended to be more influential than indirect factors.

CONCLUSIONS

Those who seek to implement programs to alter medication use should recognize and employ factors that are most influential in the decision-making process. Further, it may be important to consider differences that exist between key participants in the medication use process.

Misperceptions about beta-blockers and diuretics: a national survey of primary care physicians

BACKGROUND

Based on a series of clinical trials showing no difference in the effectiveness or tolerability of most major classes of antihypertensive medications, the Joint National Commission on High Blood Pressure Treatment recommends that physicians prescribe beta-blockers or diuretics as initial hypertensive therapy unless there are compelling indications for another type of medication. Nevertheless, many physicians continue to favor more expensive medications like angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers as first line agents. The persistent use of these agents raises questions as to whether physicians perceive ACE inhibitors and calcium channel blockers to be better than beta-blockers and diuretics.

METHODS

We surveyed 1,200 primary care physicians in 1997, and another 500 primary care physicians in 2000, and asked them to estimate the relative effectiveness and side effects of 4 classes of medication in treating a hypothetical patient with uncomplicated hypertension: ACE inhibitors, beta-blockers, calcium channel blockers, and diuretics. In addition, we asked them to indicate whether they ever provided free samples of hypertension medications to their patients.

RESULTS

Perceptions of the relative effectiveness and side effects of the 4 classes of hypertension medications did not significantly change over the 3 years, nor did prescription recommendations. Physicians perceive that diuretics are less effective at lowering blood pressure than the other 3 classes (P <.001). They also perceive that beta-blockers are less tolerated than the other 3 classes (P <.001). In a multivariate model, perceptions of effectiveness and tolerability displayed significant associations with prescription preference independent of background variables. The only other variable to contribute significantly to the model was provision of free medication samples to patients.

CONCLUSIONS

Despite numerous clinical trials showing no difference in the effectiveness or side-effect profiles of these 4 classes of drugs, most physicians believed that diuretics were less effective and beta-blockers were less tolerated than other medications. Moreover, their prescription practices were associated with their provision of free samples provided by pharmaceutical representatives, even after adjusting for other demographic characteristics. Efforts to increase physicians' prescribing of beta-blockers and diuretics may need to be directed at overcoming misunderstandings about the effectiveness and tolerability of these medicines.

Physician and practice characteristics associated with the early utilization of new prescription drugs

BACKGROUND

Prescription of new drugs contributes to substantial increases in annual drug expenditures. A small proportion of physicians appear to be early users of new prescription drugs and little is known about their characteristics.

OBJECTIVE

To estimate the initial utilization rate of new prescription drugs among physicians, and the physician and practice characteristics associated with early use.

DESIGN

Cumulative prospective assessment over a 5 year period (1989-1994) of new drug utilization rates in a randomly selected cohort of Quebec physicians.

PARTICIPANTS

1661 physicians and 669,867 elderly patients.

OUTCOME

Prescribing rate of 20 new drugs, in 6 therapeutic categories, to elderly patients in the first 6 months after inclusion in the Quebec formulary.

RESULTS

The 20 new drugs were prescribed by 1.3-22.3% of physicians, and there was an 8 to 17-fold difference in new drug utilization rates among prescribers. Characteristics associated with higher rates of utilization differed for general practitioners and specialists. Male general practitioners, and physicians graduating from the most recently established medical school in the province, had higher rates of new drug utilization, whereas recent graduation was only associated with higher utilization rates among specialists. Practice volume was associated with higher rates of utilization among GPs. For both GPs and specialists, having a high proportion of elderly in one's practice and a rural or remote practice location was associated with lower utilization rates.

CONCLUSIONS

Physician sex, specialty, medical school, years since graduation, practice location, volume, and relative proportion of elderly in the physician's practice influence the utilization of new drugs.

Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care

CONTEXT

Broad-spectrum antibiotics are commonly prescribed, but little is known about the physicians who prescribe and the patients who take these agents.

OBJECTIVE

To identify factors associated with prescribing of broad-spectrum antibiotics by physicians caring for patients with nonpneumonic acute respiratory tract infections (ARTIs).

DESIGN, SETTING, AND PATIENTS

Cross-sectional study using data from the National Ambulatory Medical Care Survey between 1997 and 1999. Information was collected on a national sample of 1981 adults seen by physicians for the common cold and nonspecific upper respiratory tract infections (URTIs) (24%), acute sinusitis (24%), acute bronchitis (23%), otitis media (5%), pharyngitis, laryngitis, and tracheitis (11%), or more than 1 of the above diagnoses (13%).

MAIN OUTCOME MEASURE

Prescription of broad-spectrum antibiotics, defined for this study as quinolones, amoxicillin/clavulanate, second- and third-generation cephalosporins, and azithromycin and clarithromycin.

RESULTS

Antibiotics were prescribed to 63% of patients with an ARTI, ranging from 46% of patients with the common cold or nonspecific URTIs to 69% of patients with acute sinusitis. Broad-spectrum agents were chosen in 54% of patients prescribed an antibiotic, including 51% of patients with the common cold and nonspecific URTIs, 53% with acute sinusitis, 62% with acute bronchitis, and 65% with otitis media. Multivariable analysis identified several clinical and nonclinical factors associated with choice of a broad-spectrum agent. After adjusting for diagnosis and chronic comorbid illnesses, the strongest independent predictors of broad-spectrum antibiotic prescribing were physician specialty (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.5 for internal medicine physicians compared with general and family physicians) and geographic region (OR, 2.6; 95% CI, 1.4-4.8 for Northeast and OR, 2.4; 95% CI, 1.4-4.2 for South [both compared with West]). Other independent predictors of choosing a broad-spectrum agent included black race, lack of health insurance, and health maintenance organization membership, each of which was associated with lower rates of broad-spectrum prescribing. Patient age, sex, and urban vs rural location were not significantly associated with prescribing choice.

CONCLUSIONS

Broad-spectrum antibiotics are commonly prescribed for the treatment of ARTIs, especially by internists and physicians in the Northeast and South. These high rates of prescribing, wide variations in practice patterns, and the strong association of nonclinical factors with antibiotic choice suggest opportunities to improve prescribing patterns.

Student understanding of the relationship between the health professions and the pharmaceutical industry

BACKGROUND

Pharmaceutical sales representatives and direct-to-consumer advertising may influence physician practices, particularly prescribing. Identifying the relevant knowledge and attitudes students possess about the pharmaceutical industry may help professional curricula address these influences.

PURPOSES

To assess knowledge and attitudes toward pharmaceutical industry marketing, ethical principles guiding drug company interactions, pharmaceutical sales representatives as a source of drug information, and confidence level in addressing consumers seeking a prescription from a direct-to-consumer advertisement among senior-level medical, PharmD, and nurse practitioner students.

METHODS

A cross-sectional survey design was used to assess student knowledge and attitudes of four domains associated with the pharmaceutical industry.

RESULTS

Significant deficiencies were noted in student knowledge of pharmaceutical marketing expenditures, professional ethics regarding interactions with drug companies, and accuracy of drug information from sales representatives.

CONCLUSIONS

Health professional students' knowledge and attitudes toward the pharmaceutical industry are formed prior to graduation. Professional curricula must address the influences of sales representatives before postgraduate training.

Didactic teaching conferences for IM residents: who attends, and is attendance related to medical certifying examination scores?

PURPOSE

Didactic teaching conferences are a cornerstone of residents' training in internal medicine, yet these programs have received little formal evaluation. This study determines the factors associated with residents' attendance at didactic teaching conferences and the relationship of attendance to residents' scores on medical certification examinations.

METHOD

The attendance of 81 residents was recorded at 199 conferences at one university hospital's internal medicine residency program during the 1996-97 academic year. Characteristics of the conferences were recorded, including the date, whether lunch was provided, the daily census on the medicine general wards, daily ambient temperature, and conference type. Residents' scores on the United States Medical Licensing Examination (USMLE) Step 2 and American Board of Internal Medicine (ABIM) certification examination were collected.

RESULTS

Residents' attendance at conferences was 34% overall or 54% excluding excused absences. Adjusting for the conferences' and residents' characteristics, attendance declined by one third as the year progressed. Providing lunch at noon conferences enhanced residents' attendance (odds ratio [OR] 1.26 overall and OR 1.64 for residents on inpatient rotations). Higher attendance was not associated with improvement in standardized medical knowledge test scores.

CONCLUSIONS

Absenteeism and waning attendance through the year have important implications for structuring didactic internal medicine teaching. Providing lunch improves attendance, but this incentive should be weighed against the potential burdens of the pharmaceutical industry's funding of these lunches. The lack of relationship between attendance and residents' adjusted board scores calls for a better understanding of the value of this high-intensity medical education intervention.

Ethical considerations in the relationship between physicians and the pharmaceutical industry

Persuasion, influence, and change are familiar domains in psychiatry. Frequently, therapists attempt to identify and understand the cognitions, affects, and perceptions their patients have developed or acquired and then, by a number of means, trigger therapeutic changes. Whereas they spend much work in the therapeutic setting attempting to delineate the mechanisms that produce such transformations and to influence change, physicians are often in a similar relationship with the pharmaceutical industry. However, in this relationship, they are the recipients of persuasion and influence.

Assessing the quality of drug detailing

This study measured the validity of a new instrument, the Assessment Instrument for Drug Detailing (AIDD), used by doctors to score the quality of drug detailing provided by pharmaceutical representatives in their offices. Five pharmaceutical representatives provided "good, medium, and poor" details to 135 family doctors in their offices, who were blinded to the quality of the details. A "reference standard group" constructed the details and trained the representatives. An "assessment group" trained family physicians to use the AIDD to score the details. Physicians discriminated between different quality details in all but one domain, nomenclature (P </=.001). Physicians scored good quality presentations 2.3 points higher than poor quality details, and reported that they learned more from good than poor quality details. Approximately 71% of the variability in physicians' global ratings (R(2) = 0.71) was explained by assigned detail quality, F(2, 118) = 54.64, P <.0001, presentation time, F(2, 118) = 9.98, P <.0001, pharmaceutical representative, F(4, 118) = 9.58, P <.0001, and physician rating the detail, F(109, 118) = 1.94, P <.0001.

Managing the pharmaceutical industry-health system interface

BACKGROUND

Direct-to-consumer advertising, media, and Internet marketing to physicians and patients, as well as enticing marketing strategies, are used by the pharmaceutical industry to ensure market share growth of new drugs. Our health system adopted a strict vendor policy governing detailing and sampling activities of pharmaceutical representatives, but realized that further analysis of vendor influence in our system was needed.

OBJECTIVE

An assessment of tangible benefits, ethical concerns, and financial liabilities and gains was conducted to reassess the need for further vendor restriction.

CONCLUSIONS

Based on our findings, several recommendations have been made. Medical practices and health systems are encouraged to establish and enforce explicit vendor policies, measure their effectiveness, partner proactively with representatives to deliver a drug-detailing message consistent with system initiatives, monitor and regulate continuing medical education funding, and implement strategies to ensure appropriate drug use.

Of principles and pens: attitudes and practices of medicine housestaff toward pharmaceutical industry promotions

PURPOSE

Little is known about the factors that influence housestaff attitudes toward pharmaceutical industry promotions or, how such attitudes correlate with physician behaviors. We studied these attitudes and practices among internal medicine housestaff.

SUBJECTS AND METHODS

Confidential surveys about attitudes and behaviors toward industry gifts were distributed to 1st- and 2nd-year residents at a university-based internal medicine residency program.

RESULTS

Ninety percent of the residents (105 of 117) completed the survey. A majority of respondents considered seven of nine types of promotions appropriate. Residents judged the appropriateness of promotions on the basis of their cost (median percentage of items considered appropriate 100% for inexpensive items vs. 60% for expensive ones) more than on the basis of their educational value (80% for educational items vs.75% for noneducational ones; P < .001 for comparison of appropriateness based on cost vs. educational value). Behaviors were often inconsistent with attitudes; every resident who considered conference lunches (n = 13) and pens (n = 18) inappropriate had accepted these gifts. Most respondents (61%)stated that industry promotions and contacts did not influence their own prescribing, but only 16% believed other physicians were similarly unaffected (P< .0001). Nonetheless, more than two thirds of residents agreed that it is appropriate for a medical institution to have rules on industry interactions with residents and faculty.

CONCLUSIONS

Residents hold generally positive attitudes toward gifts from industry, believe they are not influenced by them, and report behaviors that are often inconsistent with their attitudes. Thoughtful education and policy programs may help residents learn to critically appraise these gifts.

The use of oral contraceptive pharmaceutical sample packs by adolescent health care providers

STUDY OBJECTIVE

The purpose of this study was to understand how health care providers use and distribute oral contraceptive pill (OCP) sample packs to adolescents.

DESIGN

Qualitative study involving face-to-face structured interviews.

SETTING

Interviews lasted approximately 20-30 minutes and were done in the health care provider's office setting.

PARTICIPANTS

A convenience sample of fourteen health care providers (pediatricians, family practitioners, nurse practitioners, and midwives) who have practices that include adolescents were interviewed.

MAIN OUTCOME MEASURES

Interviews were audio-recorded and transcribed. Two independent reviewers read the transcripts for themes. Transcripts were then coded and frequency counts were done.

CONCLUSIONS

OCP sample packs are an important tool for education and compliance. The pharmaceutical OCP sample supply may influence the health care provider's OCP choice for a teen.

Encounters with pharmaceutical sales representatives among practicing internists

BACKGROUND

Although pharmaceutical sales representatives provide physicians with information on new products, these encounters have rarely been studied in practice settings. We examined these interactions among practicing internists and assessed whether prior residency policies limiting pharmaceutical sales representative access affected the subsequent behavior of practitioners.

METHODS

We conducted a mail survey of the internal medicine staffs of a medical school hospital and two affiliated community hospitals. A second request was sent to nonresponders. After the second mailing, a random sample of nonresponders was compared with a similar sample of respondents. Multivariate odds ratios (OR) and 95% confidence intervals (CI) were estimated with logistic regression.

RESULTS

Of the 346 (40%) internists who responded, 22% were women and 60% were trained in university hospitals. There were no differences in gender, subspecialization, or type of training when survey responders and nonresponders were compared. Two hundred eighty-seven (83%) physicians had met with pharmaceutical sales representatives within the previous year, of whom 248 (86%) had received drug samples. Having had a policy that limited access to pharmaceutical sales representatives during residency did not affect the subsequent likelihood of seeing these representatives (P = 0.20) or accepting samples in practice (P = 0.99). Those describing themselves as busy practitioners were significantly less likely to abstain from meeting pharmaceutical sales representatives (OR = 0.2, 95% CI: 0.1 to 0.6, P <0.001). Those with very frequent contacts (>10 times/month) were virtually all busy practitioners.

CONCLUSIONS

Encounters between physicians and pharmaceutical sales representatives are common in internal medicine practice, especially in busy offices. Policies designed to limit pharmaceutical sales representative access during residency do not appear to affect the subsequent likelihood of meeting with pharmaceutical sales representatives or accepting samples.

Pharmaceutical companies and academic departments of psychiatry : a call for ethics education

Pharmaceutical companies contribute over $13,000 per physician for promotion and advertisement of products. Psychiatrists and psychiatric residents are influenced by these interactions. Two recommendations to psychiatric residency training programs are offered: Incorporation of ethics education into teaching forums and the establishment of specific ground rules that would govern the interaction of pharmaceutical companies with psychiatric residents.

A comparison of physicians' and patients' attitudes toward pharmaceutical industry gifts

OBJECTIVE

To compare physicians' and their patients' attitudes toward pharmaceutical gifts.

DESIGN

Survey of physicians and their patients.

SETTING

Two tertiary-care medical centers, one military and one civilian.

PARTICIPANTS

Two hundred sixty-eight of 392 consecutively surveyed physicians, 100 of 103 randomly selected patients at the military center, and 96 patients in a convenience sample at the civilian center completed the survey.

MEASUREMENTS

Participants rated 10 pharmaceutical gifts on whether they were appropriate for physicians to accept and whether they were likely to influence prescribing. Patients found gifts less appropriate and more influential than did their physicians. About half of the patients were aware of such gifts; of those unaware, 24% responded that this knowledge altered their perception of the medical profession. Asked whether they thought their own physician accepted gifts, 27% said yes, 20% no, and 53% were unsure. For patients, feeling that gifts were inappropriate was best predicted by a belief that gifts might influence prescribing, while for physicians, the best predictor was knowledge of guidelines.

CONCLUSIONS

Patients feel pharmaceutical gifts are more influential and less appropriate than do their physicians. Physicians may want to consider this in deciding whether to accept particular gifts. Broader dissemination of guidelines may be one means of changing physician behavior. At the same time, future guidelines should further consider the potentially different viewpoints of patients and physicians.

Effects of an educational intervention on residents' knowledge and attitudes toward interactions with pharmaceutical representatives

To assess primary care resident and faculty knowledge and attitudes concerning interactions between physicians and pharmaceutical representatives (PRs) and to measure changes in residents' knowledge and attitudes after an educational intervention, we conducted preintervention and postintervention surveys with a causal-comparative group in a university-based primary care residency program. All primary care internal medicine and internal medicine-pediatrics residents and faculty were given the voluntary survey. In general, residents and faculty demonstrated similar responses for the preintervention survey. Differences between faculty and resident opinions were seen in two areas. Faculty were more likely than residents to believe that PRs sometimes use unethical marketing practices (p < .05) and that the amount of contact with PRs in the outpatient clinic is excessive (p < .01). The postintervention survey of residents demonstrated significant differences between the control and intervention groups for three attitude scales. After the intervention, residents showed an increased belief that PRs may use unethical marketing practices (p < .01), that marketing gifts with no patient benefit may be inappropriate (p = .05), and that other physicians' prescribing patterns could be negatively influenced through the acceptance of gifts (p < .05). A brief educational intervention can change resident attitudes concerning physician interactions with PRs.

Boundary violations and departments of psychiatry

OBJECTIVE

To explore a number of issues related to boundary violations in psychiatry, including the relationship between the individual physician and his or her patient and broader issues related to various dilemmas arising in academic departments of psychiatry.

METHOD

Several potentially troublesome scenarios are presented and discussed in the contexts of 1) the doctor-patient relationship, 2) sexual boundary violations, and 3) nonsexual forms of exploitation, such as finances, confidentiality, dual relationships, and relationships with industry.

CONCLUSIONS

A number of examples of boundary problems involving psychiatrists have been explored, and although some of these behaviours are clearly forbidden and harmful, others are less clear and require careful consideration if the profession is to arrive at a thoughtful consensus.

The effect on resident attitudes of regulatory policies regarding pharmaceutical representative activities

OBJECTIVE

To determine the effect on resident attitudes of policies regarding pharmaceutical representative interactions with residents.

DESIGN

Cross-sectional survey.

SETTING

National sample of U.S. family medicine residencies.

PARTICIPANTS

Three hundred seventy-eight residents from 14 randomly selected programs. Seven programs had written policies and restrictions (restricted programs), and seven had no such restriction or guideline (free programs).

MEASUREMENTS AND MAIN RESULTS

The authors assessed resident attitudes regarding the perception of benefit from pharmaceutical representative activities, the usefulness of various sources of drug information, and the appropriateness of accepting gifts from a pharmaceutical representative. There were 265/378 respondents (70% response rate). Residents from restricted programs reported fewer benefits from pharmaceutical representative interactions and were less likely to feel that acceptance of gifts was appropriate. The amount of exposure to pharmaceutical representatives was positively correlated with perceived benefit and negatively correlated with ratings of appropriateness of gift acceptance.

CONCLUSION

Regulatory policies can influence resident attitudes and perceptions. Training programs should develop written policies to help guide resident-pharmaceutical representative interactions.