Association Between Academic Medical Center Pharmaceutical Detailing Policies and Physician Prescribing

"Caught in Each Other's Traps": Factors Perpetuating Incentive-Linked Prescribing Deals Between Physicians and the Pharmaceutical Industry

BACKGROUND

Despite known adverse impacts on patients and health systems, "incentive-linked prescribing," which describes the prescribing of medicines that result in personal benefits for the prescriber, remains a widespread and hidden impediment to quality of healthcare. We investigated factors perpetuating incentive-linked prescribing among primary care physicians in for-profit practices (referred to as private doctors - PDs), using Pakistan as a case study.

METHODS

Our mixed-methods study synthesised insights from a survey of 419 systematically sampled PDs and 68 semi-structured interviews with PDs (n=28), pharmaceutical sales representatives (SRs) (n=12), and provincial and national policy actors (n=28). For the survey, we built a verified database of all registered PDs within Karachi, Pakistan's most populous city, administered an electronic questionnaire in-person and descriptively analysed the data. Semi-structured interviews incorporated a vignette-based exercise and data was analysed using an interpretive approach.

RESULTS

Our survey showed that 90% of PDs met pharmaceutical SRs weekly. Three interlinked factors perpetuating incentive-linked prescribing we identified were: gaps in understanding of conflicts of interest and loss of values among doctors; financial pressures on doctors operating in a (largely) privately financed health-system, exacerbated by competition with unqualified healthcare providers; and aggressive incentivisation by pharmaceutical companies, linked to low political will to regulate an over-saturated pharmaceutical market.

CONCLUSION

Regular interactions between pharmaceutical companies and PDs are normalised in our study setting. Progress on regulating these is hindered by the substantial role of incentive-linked prescribing in the financial success of physicians and pharmaceutical industry employees. A first step towards addressing the entrenchment of incentive-linked prescribing may be to reduce opposition to restrictions on incentivisation of physicians from stakeholders within the pharmaceutical industry, physicians themselves, and policy-makers concerned about curtailing growth of the pharmaceutical industry.

Policies on doctors' declaration of interests in medical organisations: a thematic analysis

OBJECTIVES

There has been growing concern about doctors' conflicts of interests (COIs) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study mapped existing policies across a variety of organisations and settings to better understand the degree of variation and identify opportunities for improvement.

DESIGN

Thematic analysis.

SETTING

We studied the COI policies of 31 UK and international organisations which set or influence professional standards or engage doctors in healthcare commissioning and provision settings.

PARTICIPANTS

31 UK and international organisations.

MAIN OUTCOME MEASURES

Organisational policy similarities and differences.

RESULTS

Most policies (29/31) referred to the need for individuals to apply judgement when deciding whether an interest is a conflict, with just over half (18/31) advocating a low threshold. Policies differed on the perception of frequency of COI, the timings of declarations, the type of interests that needed to be declared, and how COI and policy breaches should be managed. Just 14/31 policies stated a duty to report concerns in relation to COI. Only 18/31 policies advised COI would be published, while three stated that any disclosures would remain confidential.

CONCLUSIONS

The analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors while addressing the needs of doctors, organisations and the public.

Marketing of medicines in primary care: An analysis of direct marketing mailings and advertisements

INTRODUCTION

Marketing materials from pharmaceutical companies attempt to create a positive image of marketed, often new, medicines. To gain more insight in strategies pharmaceutical companies use to influence primary care practitioners' attitudes towards marketed medicines, we investigated the use of persuasion strategies in direct marketing mailings and advertisements from pharmaceutical companies sent to general practitioners.

METHODS

General practitioners in the Netherlands were recruited to collect all direct marketing mailings, meaning all leaflets, letters and other information sent by pharmaceutical industries to the practice during one month (June 2022). Direct marketing mailings and advertisements in collected medical journals concerning medicines or diseases (together called marketing materials) were analysed according to presence of one of the seven common persuasion strategies, i.e. reciprocity, consistency/commitment, social proof, liking, authority, scarcity and unity; as well as marketed medicine and year of introduction.

RESULTS

Twenty general practices collected 68 unique marketing materials concerning 37 different medicines. Direct factor Xa inhibitors (n = 12), glucagon-like peptide-1 analogues (n = 5) and sodium-glucose co-transporter 2 inhibitors (n = 4) were the most frequently marketed medicines. The median year of introduction of all marketed medicines was 2012. All seven persuasion strategies were identified, with liking (64.7% of all materials) and authority (29.4%) as most prominent strategies, followed by social proof (17.6%), unity (14.7%), scarcity (13.2%), reciprocity (11.8%) and consistency/commitment (2.9%). In addition to those strategies, we identified emotional pressure (30.9%) as one commonly used new strategy.

CONCLUSION

Marketing materials sent to general practices use a wide range of persuasion strategies in an attempt to influence prescription behaviour. Primary care practitioners should be aware of these mechanisms through which pharmaceutical companies try to influence their attitudes towards new medicines.

Characterizing industry payments to US teaching hospitals and affiliated physicians: a cross-sectional analysis of the Open Payments datasets from 2016 to 2022

Industry payments to US teaching hospitals are common; however, little is known about whether these financial relationships influence affiliated physicians to engage in similar financial relationships with industry. Using national hospital, physician, and industry payment data we investigated trends in industry payments made to US teaching hospitals and affiliated physicians to characterize the magnitude and nature of payments. In addition, we assessed if physicians may be influenced to accept higher value industry payments depending on the value of promotional payments accepted by the teaching hospital they affiliate with. We found that physicians with a US teaching hospital affiliation are associated with accepting higher value industry payments as the total value of industry payments of the teaching hospital increases. Our findings varied by specialty, with surgeons accepting the highest value payments. These results highlight the need for greater public disclosure and awareness of payments to better manage and mitigate industry-biased clinical decision making.

The Role of Physician Networks and Receipt of Opioid-Related Payments

BACKGROUND

Opioid-related promotional payments are associated with increased prescribing of the promoted drug, but little is known about whether physicians receiving payments influence peers to accept similar payments.

OBJECTIVE

We examine the association of physician network-level position among peers and the acceptance of opioid-related promotional payments using national publicly available datasets from 2015. Design National cross-sectional data from the Centers for Medicare and Medicaid Services (CMS) National Downloadable File and Open Payment data.

SUBJECTS

Physicians who shared Medicare patients with at least two other physicians in 2015.

MAIN MEASURES

Modified Poisson's regressions are used to estimate the adjusted incidence rate ratio (aIRR) for social network position (i.e., degree, betweenness, and transitivity) and number of peers with payments as a function of individual receipt of opioid-related promotional payment and among those with payments, those who have five or more payments, and those who have $100 or more in payments.

KEY RESULTS

Physicians with opioid-related payments were significantly more likely to have at least one peer with an opioid-related payment (IRR: 2.5, 95% CI: 2.3-2.8), but had fewer shared patients (i.e., top quartile compared to the first quartile for degree centrality: 0.4, 95% CI: 0.3-0.4) and belonged to less cohesive networks (i.e., top quartile compared to the first quartile for betweenness centrality: 0.9, 95% CI: 0.8-0.9).

CONCLUSIONS

Our study demonstrates that physicians receiving opioid-related payments are more likely to cluster within physician networks.

Interaction between physicians and the pharmaceutical industry: A scoping review for developing a policy brief

Background

Payments to physicians by the pharmaceutical industry are common, but recent evidence shows that these payments influence physician prescribing behavior in the form of increased prescription of brand-name drugs, expensive and low-cost drugs, increased prescription of payer company drugs, etc. Considering that these payments increase drug costs for patients and health systems, there is a public interest in controlling them. Therefore, this study aimed to identify and propose policy options for managing physician-pharmaceutical industry interactions in the context of Iran's health system.

Methods

In the first phase, a systematic search was conducted to identify relevant policies and interventions in Web of Science, PubMed, and ProQuest databases from 2000 to 2022. Then, the opinions of the research team and an expert group (physicians, health policy and transparency experts, and industry representatives) were used to categorize the interventions and propose policy options along with their advantages, disadvantages, and implementation considerations.

Results

In the search, 579 articles were retrieved, and 44 articles were found suitable for the final analysis. Twenty-nine interventions and strategies were identified, and based on these; Five policy options were identified: prohibition, restriction, physician self-regulation, voluntary industry disclosure, and mandatory industry disclosure.

Conclusion

The proposed policies in our study include advantages, challenges, and implementation considerations based on up-to-date evidence that can help policymakers use them to manage COI in physician-pharmaceutical industry interactions in Iran's health system. A combination of measures seems to help manage COI: firstly, using self-regulating physicians and industry to institutionalize transparency, and in the next step, implementing mandatory industry disclosure policies and establishing restrictions on some financial interactions.

State-Level Estimates of the Prevalence of Parent-Reported ADHD Diagnosis and Treatment Among U.S. Children and Adolescents, 2016 to 2019

OBJECTIVE

To provide state-level estimates of diagnosed ADHD and associated treatment among children in the United States in 2016 to 2019.

METHOD

This study used the National Survey of Children's Health to produce national and state-level estimates of lifetime diagnosis and current ADHD among all children aged 3 to 17 years (n=114,476), and national and state-level estimates of medication and behavioral treatment use among children with current ADHD.

RESULTS

The state-level estimates of diagnosed ADHD ranged from 6.1% to 16.3%. Among children with current ADHD, state-level estimates of ADHD medication usage ranged from 37.8% to 81.4%, and state-level estimates of behavioral treatment ranged from 38.8% to 61.8%.

CONCLUSION

There was substantial state-level variation for indicators of ADHD diagnosis and associated treatment. These state-level results can be used by policymakers, public health practitioners, health care providers, and other stakeholders to help address the service needs of children with ADHD in their states.

Impact of the Affordable Care Act's Physician Payments Sunshine Act on branded statin prescribing

OBJECTIVE

To evaluate the impact of the Affordable Care Act's Physician Payments Sunshine Act (PPSA), which mandates disclosure of industry payments to physicians, on physician prescribing of branded statins.

DATA SOURCES

Administrative claims data from 2011 to 2015 from three large national commercial insurers were provided by the Health Care Cost Institute.

STUDY DESIGN

We adopted a difference-in-differences and event study design, leveraging the control group of physicians in two states, MA and VT, which implemented state laws on disclosure of industry payments prior to the national PPSA. To further address potential confounding caused by differences in prescribing patterns across states, our analytical sample includes physicians practicing in border counties between the treatment (NH, NY, and RI) and control (MA and VT) states.

DATA COLLECTION

We restricted our sample to physicians who had at least 50 new-fill prescription claims for statins during the five-year study period, with at least one new-fill prescription claim each year.

PRINCIPAL FINDINGS

We found that the PPSA led to a 7% (p < 0.001) reduction in monthly new prescriptions of brand-name statin over the study period, with little change in generic prescribing. The reduction in branded prescriptions was concentrated among physicians with the highest tercile of drug spending pre-PPSA, with a decrease of 15% (p < 0.001) in new branded statin prescriptions. The decline was most prominent after mandated reporting of industry payments began before the payment data was published.

CONCLUSIONS

The PPSA may have achieved its intended effect of reducing branded prescriptions at least in the short run, particularly among physicians most likely to have engaged in excessive or low-value prescribing of branded drugs.

The i-frame and the s-frame: How focusing on individual-level solutions has led behavioral public policy astray

An influential line of thinking in behavioral science, to which the two authors have long subscribed, is that many of society's most pressing problems can be addressed cheaply and effectively at the level of the individual, without modifying the system in which the individual operates. We now believe this was a mistake, along with, we suspect, many colleagues in both the academic and policy communities. Results from such interventions have been disappointingly modest. But more importantly, they have guided many (though by no means all) behavioral scientists to frame policy problems in individual, not systemic, terms: To adopt what we call the "i-frame," rather than the "s-frame." The difference may be more consequential than i-frame advocates have realized, by deflecting attention and support away from s-frame policies. Indeed, highlighting the i-frame is a long-established objective of corporate opponents of concerted systemic action such as regulation and taxation. We illustrate our argument briefly for six policy problems, and in depth with the examples of climate change, obesity, retirement savings, and pollution from plastic waste. We argue that the most important way in which behavioral scientists can contribute to public policy is by employing their skills to develop and implement value-creating system-level change.

Drug Diffusion Through Peer Networks: The Influence of Industry Payments

Pharmaceutical companies market to physicians through individual detailing accompanied by monetary or in-kind transfers. Large compensation payments to a small number of physicians account for most of this promotional spending. Studying US promotional payments and prescriptions for anticoagulant drugs, we investigate how peer influence broadens the payments' reach. Following a compensation payment, prescriptions for the marketed drug increase by both the paid physician and the paid physician's peers. Payments increase prescriptions to both recommended and contraindicated patients. Over three years, marketed anticoagulant prescriptions rose 23 percent due to payments, with peer spillovers contributing a quarter of the increase.

Health Care Clinicians and Product Promotion by Industry

Medical pharmaceutical and device manufacturers are essential in making products that benefit patients, and collaboration between health care clinicians and the industry is necessary for the design and manufacture of these medical products. However, health care clinicians must recognize that their duties and the interests of the industry may at times diverge. Relationships with the industry, even seemingly minor ones, have the potential to shape the decisions made on behalf of patients. The marketing divisions of pharmaceutical and medical device firms view health care clinicians as targets of their efforts, and some of the interactions that occur between the industry and health care clinicians have the potential to alter decision making in ways that may not necessarily benefit patients. Health care clinicians have an ethical duty to recognize situations and marketing strategies that are designed to influence their choice of diagnostic and therapeutic options for their patients. At a minimum, health care clinicians should be aware of the techniques used to attempt to alter their behavior and guard against them.

Ten years later: a review of the US 2009 institute of medicine report on conflicts of interest and solutions for further reform

Conflicts of interest (COIs) in healthcare are increasingly discussed in the literature, yet these relationships continue to influence healthcare. Research has consistently shown that financial COIs shape prescribing practices, medical education and guideline recommendations. In 2009, the Institute of Medicine (IOM, now the National Academy of Medicine) published Conflicts of Interest in Medical Research, Practice, and Education-one of the most comprehensive reviews of empirical research on COIs in medicine. Ten years after publication of theIOM's report, we review the current state of COIs within medicine. We also provide specific recommendations for enhancing scientific integrity in medical research, practice, education and editorial practices.

The effect of medical cannabis laws on pharmaceutical marketing to physicians

Although cannabis is federally prohibited, a majority of U.S. states have implemented medical cannabis laws (MCLs). As more individuals consider the drug for medical treatment, they potentially substitute away from prescription drugs. Therefore, an MCL signals competitor entry. This paper exploits geographic and temporal variation in MCLs to examine the strategic response in direct-to-physician marketing by pharmaceutical firms as cannabis enters the market. Using office detailing records from 2014-2018 aggregated to the county level, we find weak evidence of a relatively small and delayed response in substitute prescription drug- and opioid-related detailing. While these effects on detailing dollars are more pronounced among smaller pharmaceutical firms, the magnitudes are economically small and likely muted at aggregate levels by the small percent of doctors that actively recommend cannabis for medical treatment.

Addressing Barriers to Reducing Prescribing and Implementing Deprescribing of Sedative-Hypnotics in Primary Care

Objective:

To describe interventions that target patient, provider, and system barriers to sedative-hypnotic (SH) deprescribing in the community and suggest strategies for healthcare teams.

Data Sources:

Ovid MEDLINE ALL and EMBASE Classic + EMBASE (March 10, 2021).

Study Selection and Data Extraction:

English-language studies in primary care settings.

Data Synthesis:

20 studies were themed as patient-related and prescriber inertia, physician skills and awareness, and health system constraints. Patient education strategies reduced SH dose for 10% to 62% of participants, leading to discontinuation in 13% to 80% of participants. Policy interventions reduced targeted medication use by 10% to 50%.

Relevance to Patient Care and Clinical Practice:

Patient engagement and empowerment successfully convince patients to deprescribe chronic SHs. Quality improvement strategies should also consider interventions directed at prescribers, including education and training, drug utilization reviews, or computer alerts indicating a potentially inappropriate prescription by medication, age, dose, or disease. Educational interventions were effective when they facilitated patient engagement and provided information on the harms and limited evidence supporting chronic use as well as the effectiveness of alternatives. Decision support tools were less effective than prescriber education with patient engagement, although they can be readily incorporated in the workflow through prescribing software.

Conclusions:

Several strategies with demonstrated efficacy in reducing SH use in community practice were identified. Education regarding SH risks, how to taper, and potential alternatives are essential details to provide to clinicians, patients, and families. The strategies presented can guide community healthcare teams toward reducing the community burden of SH use.

Medical Device Firm Payments To Physicians Exceed What Drug Companies Pay Physicians, Target Surgical Specialists

Many physicians receive payments from medical device companies that make products physicians can use or recommend. Such payments are controversial because of concerns that they might influence physicians to treat patients with devices made by the firms that make those payments, even if those devices are not optimal for patients. This issue has been studied extensively in the drug industry. Medical devices entail a greater degree of physician-industry interaction regarding treatment, training, and innovation than pharmaceuticals, and they have been less studied because of data limitations. We summarize and compare device and drug firm payment rates and magnitudes reported in Open Payments data by payment type, physician specialty, and Medicare billing amount. Relative to drug firm payments, device firm payments as a percentage of industry revenue were seven times as large; device firm payments were also more often related to product development and training and were more strongly correlated with physicians' Medicare billing amounts. Using Food and Drug Administration product approval data, we further document that top-paying firms dominate high-revenue device categories. Our results suggest that optimal policy regarding physician-industry relationships for medical devices may be very different from that for pharmaceuticals. Estimating the causal relationships between payments and device use, pricing, and innovation to inform policy makers will be possible only with greater data transparency, such as including device identifiers in medical claims.

The Impact Of Academic Medical Center Policies Restricting Direct-To-Physician Marketing On Opioid Prescribing

Direct-to-physician opioid marketing by pharmaceutical companies is widespread and may contribute to opioid overprescribing, an important driver of the US opioid crisis. Using a difference-in-differences approach and Medicare Part D prescriber data, we examined the effects of academic medical centers' conflict-of-interest policies that restrict direct-to-physician marketing of all drugs on opioid prescribing by physicians at eighty-five centers in the period 2013-16. We examined restrictions on gifts and meals, speaking and consulting engagements, and industry representatives' access to academic medical centers, as well as rules requiring conflict-of-interest disclosures. Bans on sales representatives were associated with a 4.7 percent reduction in the total volume of opioids prescribed and disclosure requirements with a 2.5 percent reduction, while having all four marketing restriction policies was associated with an 8.8 percent reduction. Policies that restrict direct-to-physician pharmaceutical marketing may curb opioid prescribing, but additional patient-level research is needed to understand how such policies affect the delivery of evidence-based treatment for chronic pain.

Improving quality, affordability, and equity of multiple sclerosis care

Objective

The prevailing approaches to selecting multiple sclerosis (MS) disease modifying therapies (DMTs) have contributed to exponential increases in societal expenditures and out‐of‐pocket expenses, without compelling evidence of improved outcomes. Guidance is lacking regarding when and in whom the benefits of preventing MS‐related disability likely outweighs the risks of highly effective DMTs (HET) and when it is appropriate to consider DMT costs. Our objective was to develop a standardized approach to improve the quality, affordability and equity of MS care.

Methods

MS experts partnered with health plan pharmacists to develop an ethical, risk‐stratified, cost‐sensitive treatment algorithm. We developed a risk‐stratification schema to classify patients with relapsing forms of MS as high, intermediate or low risk of disability based on the best available evidence and, when the evidence was poor or lacking, by consensus. DMTs are grouped as highly, modestly or low/uncertain effectiveness and preferentially ranked within groups by safety based on pre‐specified criteria. We reviewed FDA documents and the published literature. When efficacy and safety are equivalent, the lower cost DMT is preferred.

Results

Assignment to the high‐risk group prompts treatment with preferred HETs early in the disease course. For persons in the intermediate‐ or low‐risk groups with cost or health care access barriers, we incorporated induction therapy with an affordable B‐cell depleting agent. Based on more favorable safety profiles, our preferred approach prioritizes use of rituximab and natalizumab among HETs and interferon‐betas or glatiramer acetate among modestly effective agents.

Interpretation

The risk‐stratified treatment approach we recommend provides clear, measurable guidance in whom and when to prescribe HETs, when to prioritize lower cost DMTs and how to accommodate persons with MS with cost or other barriers to DMT use. It can be adapted to other cost structures and updated quickly as new information emerges. We recommend that physician groups partner with health insurance plans to adapt our approach to their settings, particularly in the United States. Future studies are needed to resolve the considerable uncertainty about how much variability in prognosis specific risk factors explain.

Perceptions of the provision of drug information, pharmaceutical detailing and engagement with non-personal promotion at a large physicians network: a mixed-methods study

OBJECTIVE

Non-personal promotion (NPP) such as digital, print-based marketing, direct promotional visits and free drug samples are means of pharmaceutical marketing. This study described practices of drug information, pharmaceutical detailing and engagement with NPP at an integrated network of providers.

DESIGN

This was a sequential explanatory mixed-methods study. A survey was followed by semistructured interviews. The questionnaire elicited preferred sources of drug information, management of drug information and perceptions on drug samples, coupons and pharmaceutical representative visits. Interviews were audio-recorded and transcribed. Data were analysed using descriptive statistics (quantitative) and content analysis (qualitative).

SETTING

Face-to-face or telephonic interviews were conducted at a large physicians network in Northern Kentucky.

PARTICIPANTS

Eighty-two medical assistants, primary care, specialty providers and other office staff who completed the survey and 16 interviewees.

RESULTS

Most respondents were women (79.3%), office managers (26.8%) and individuals employed for 15 years or longer within the organisation (30.5%). Most participants (85.3%) indicated that pharmaceutical representative visits are the most common source of drug information. Paper-based material was the most frequent form in which information was received in physician offices (62.2%). Medical assistants were usually responsible for handling drug information (46.3%) on arrival in the office, compared with 15.3% of physicians. Drug representative detailing and lunches (62.2%) were the desired method of drug information communication followed by electronic mail or e-journals (11%). Interviewees generated three themes that described pharmaceutical representative visits and interactions with prescriber and non-prescriber personnel in the offices.

CONCLUSIONS

We found significant involvement of non-prescriber personnel in drug information management at primary and specialty care offices. Participants perceived that pharmaceutical representatives have an important role in keeping the offices informed and supplied with relevant drug information, coupons and samples. Findings highlight the importance of engaging prescriber and non-prescriber personnel to guarantee relevant information reaches providers.

Association between Opioid Prescribing in Medicare and Pharmaceutical Company Gifts by Physician Specialty

BACKGROUND

The association between pharmaceutical industry promotion and physician opioid prescribing is poorly understood. Whether the influence of industry gifts on prescribing varies by specialty is unknown.

OBJECTIVE

To examine the relationship between opioid-related gifts to physicians and opioid prescribing in the subsequent year across 7 physician specialties.

DESIGN

Panel study using data from 2014 to 2016.

PARTICIPANTS

236,103 unique Medicare Part D physicians (389,622 physician-years) who received any gifts from pharmaceutical companies measured using Open Payments and prescribed opioids in the subsequent year.

MAIN MEASURES

Amounts paid by pharmaceutical companies for opioid-related gifts including meals and lodging; quartile of opioid prescribing as a percent of total prescribing compared with other same-specialty physicians.

KEY RESULTS

In 2014-2015, 14.1% of physician received opioid-related gifts from the industry with 2.6% receiving > $100. Gifts varied by specialty and were concentrated among two pharmaceutical companies responsible for 60% of the value of opioid-related gifts. Receiving opioid-related gifts was associated with greater prescribing of opioids compared with same-specialty physicians in the next year. Primary care physicians are nearly 3.5 times as likely to be in the highest quartile of prescribing versus the lower quartiles if they were paid ≥ $100. Psychiatrists and neurologists were 7 to 13 times as likely to be in a higher quartile of opioid prescribing compared with colleagues who were paid $0 in the preceding year.

CONCLUSIONS

The value of opioid-related gifts given to physicians varies substantially by provider specialty, as does the relationship between payment amounts and prescriber behavior in the following year.

Evolving Communication with Healthcare Professionals in the Pharmaceutical Space: Current Trends and Future Perspectives

The pharmaceutical industry is subject to complex regulations relating to the safety and efficacy of medicinal products, as well as pricing and reimbursement, added value, communication, and advertising. In addition, multiple stakeholders have evolved and now not only include physicians, but also payers, regulatory authorities, patients, and patient advocacy groups in the move toward an added value-based healthcare system. The advent of digitalization has also had a significant influence on how healthcare professionals and decision makers are identified and the most effective and preferred methods of communicating with them. This review will investigate how communication between pharmaceutical companies and healthcare professionals as well as other stakeholders is changing. It will then examine how pharmaceutical companies can employ the latest technologies to identify, target, and inform relevant parties about the medicinal product and its value at the time of launch and post-approval activities. This has been achieved by a review of the available literature and supported by a survey of industry representatives. The results indicate that an optimal communication strategy is likely to involve a combination of face-to-face interactions and an increased use of digital platforms with an emphasis on clinical data and scientific information.

Who cares about a label? The effect of pediatric labeling changes on prescription drug utilization

Off-label drug use is common, particularly in pediatric populations. In response, legislation requires and/or provides financial incentives for drug manufacturers to perform pediatric clinical trials. Using New Hampshire's all-payer claims database, we examine the impact of subsequent changes to drug labeling on pediatric drug utilization. To separate changes in utilization induced by labeling changes from other temporal factors, we estimate difference-in-differences models that compare utilization trends for pediatric patients to those of adults. We estimate that establishing safety and efficacy increases a drug's market share by (a statistically significant) 2.8 percentage points, whereas failure to do so decreases a drug's market share by (a statistically insignificant) 0.9 percentage points. We then interpret these estimates within the context of public and market incentives to conduct pediatric clinical trials.

Relación médico-industria y los conflictos de interés: aspectos históricos y normativos, impactos negativos y propuestas

El presente artículo revisa de manera narrativa y general la relación entre los médicos y la industria (RMI); se incluye a la industria farmacéutica, de dispositivos, de suplementos y los conflictos de intereses que surgen de dicha relación. Se aborda el tema mediante algunas definiciones y un breve recuento histórico de cómo la RMI se ha convertido en un problema importante en el ejercicio médico y los sistemas de salud.El artículo expone los diversos roles dentro de los escenarios más comunes en los que ocurre la RMI: en la investigación biomédica, las guías de práctica clínica, la educación médica continua, la visita médica, los líderes de opinión, así como en la interacción directa, la exposición indirecta y la que denominamos exposición temprana. Se mencionan, posteriormente, algunas técnicas que utiliza la industria para modificar los hábitos de prescripción basadas en elementos de psicología social, así como el papel que ejercen los obsequios y otras estrategias de mercadeo.Se revisó la literatura que muestra el impacto y el efecto que estas técnicas tienen en el ejercicio médico. Finalmente, se plantean algunas propuestas que se han desarrollado desde la normatividad y recomendaciones para afrontar el problema que podrían contribuir a mitigar los efectos negativos de una RMI muy estrecha. Estas propuestas son prohibir el contacto de los estudiantes con la industria, la inclusión del tema de conflictos de intereses (CI) en los currículos de medicina, financiación alternativa de la educación continua, declaración de conflictos como norma, campañas de concientización, uso de evidencia sintetizada y analizada transparente e independientemente, entre otras.

Improving the Affordability of Prescription Medications for People with Chronic Respiratory Disease. An Official American Thoracic Society Policy Statement

BACKGROUND

Mounting evidence indicates that out-of-pocket costs for prescription medications, particularly among low- and middle-income patients with chronic diseases, are imposing financial burden, reducing medication adherence, and worsening health outcomes. This problem is exacerbated by a paucity of generic alternatives for prevalent lung diseases, such as asthma and chronic obstructive pulmonary disease, as well as high-cost medicines for rare diseases, such as cystic fibrosis. Affordability and access challenges are especially salient in the United States, as citizens of many other countries pay lower prices for and have greater access to prescription medications.

METHODS

The American Thoracic Society convened a multidisciplinary committee comprising experts in health policy pharmacoeconomics, behavioral sciences, and clinical care, along with individuals providing industry and patient perspectives. The report and its recommendation were iteratively developed over a year of in-person, telephonic, and electronic deliberation.

RESULTS

The committee unanimously recommended the establishment of a publicly funded, politically independent, impartial entity to systematically draft evidence-based pharmaceutical policy recommendations. The goal of this entity would be to generate evidence and action steps to ensure people have equitable and affordable access to prescription medications, to maximize the value of public and private pharmaceutical expenditures on health, to support novel drug development within a market-based economy, and to preserve clinician and patient choice regarding personalized treatment. An immediate priority is to examine the evidence and make recommendations regarding the need to have essential medicines with established clinical benefit from each drug class in all Tier 1 formularies and propose recommendations to reduce barriers to timely generic drug availability.

CONCLUSIONS

By making explicit, evidence-based recommendations, the entity can support the establishment of coherent national policies that expand access to affordable medications, improve the health of patients with chronic disease, and optimize the use of public and private resources.

Open data on industry payments to healthcare providers reveal potential hidden costs to the public

Healthcare industry players make payments to medical providers for non-research expenses. While these payments may pose conflicts of interest, their relationship with overall healthcare costs remains largely unknown. In this study, we linked Open Payments data on providers’ industry payments with Medicare data on healthcare costs. We investigated 374,766 providers’ industry payments and healthcare costs. We demonstrate that providers receiving higher amounts of industry payments tend to bill higher drug and medical costs. Specifically, we find that a 10% increase in industry payments is associated with 1.3% higher medical and 1.8% higher drug costs. For a typical provider, for example, a 10% or $25 increase in annual industry payments would be associated with approximately $1,100 higher medical costs and $100 higher drug costs. Furthermore, the association between payments and healthcare costs varies markedly across states and correlates with political leaning, being stronger in more conservative states.

Industry payments to healthcare providers for non-research costs are common in the US. Linking Medicare and Open Payments data, the authors find that providers receiving more industry payments tend to bill higher drug and medical costs, and this association is stronger in more conservative states.

Characteristics of Industry Payments to Ophthalmologists in the Open Payments Database

Importance

An increased awareness of the interactions between the medical industry and health care professionals may lead to lower health care costs and more effective health care practices.

Objective

To assess the characteristics of industry payments made to ophthalmologists between 2013 and 2017.

Design, Setting, and Participants

This analysis included data reported in the June 29, 2018, update of the Centers for Medicare & Medicaid Services Open Payments Database (OPD). The OPD contains public records of industry payments made to physicians and teaching hospitals from August 1, 2013, to December 31, 2017, as reported by the medical industry. All general or research payments distributed to US ophthalmologists and contained in the OPD were included in this study. Data are summarized by practitioner, manufacturer, payment category, and geographic location.

Main Outcomes and Measures

Main outcomes were the distribution, quantity, and value of payments made to ophthalmologists practicing in the United States or US territories. The financial characteristics of payment category, manufacturer, product, and location were also assessed.

Results

This analysis revealed that the OPD showed industry reporting a total of 20 943 ophthalmologists receiving 736 517 payments worth $543 679 603.53 (1.67% of all industry-reported funds in the OPD). The median payment value was $22.44. Most payments were for food and beverages (581 588 [78.96%]), whereas most funds were allocated toward research ($310 142 151.88 [57.05%]) and consulting fees ($73 565 327.71 [13.51%]). The median payout to each ophthalmologist was $637.75 (interquartile range, $167.33-$2065.54). California was the highest-grossing state, receiving $101 135 980.34 (18.60%) of all payments. Fifteen companies were responsible for 87.68% of all funds distributed ($476 719 470.11) and were mostly involved in the production of pharmaceutical agents (anti-vascular endothelial growth factor agents, glaucoma eyedrops, and ocular lubricants) and surgical devices (cataract and glaucoma).

Conclusions and Relevance

Although there is no way to know the veracity of these reports, the findings suggest the financial ophthalmologist-industry relationship is substantial. These relationships may be adding to health care costs and affecting the quality of care, although those associations were not evaluated in this study.

The Bionic Radiologist: avoiding blurry pictures and providing greater insights

Radiology images and reports have long been digitalized. However, the potential of the more than 3.6 billion radiology examinations performed annually worldwide has largely gone unused in the effort to digitally transform health care. The Bionic Radiologist is a concept that combines humanity and digitalization for better health care integration of radiology. At a practical level, this concept will achieve critical goals: (1) testing decisions being made scientifically on the basis of disease probabilities and patient preferences; (2) image analysis done consistently at any time and at any site; and (3) treatment suggestions that are closely linked to imaging results and are seamlessly integrated with other information. The Bionic Radiologist will thus help avoiding missed care opportunities, will provide continuous learning in the work process, and will also allow more time for radiologists' primary roles: interacting with patients and referring physicians. To achieve that potential, one has to cope with many implementation barriers at both the individual and institutional levels. These include: reluctance to delegate decision making, a possible decrease in image interpretation knowledge and the perception that patient safety and trust are at stake. To facilitate implementation of the Bionic Radiologist the following will be helpful: uncertainty quantifications for suggestions, shared decision making, changes in organizational culture and leadership style, maintained expertise through continuous learning systems for training, and role development of the involved experts. With the support of the Bionic Radiologist, disparities are reduced and the delivery of care is provided in a humane and personalized fashion.

Opioids: The Painful Public Health Reality

The analgesic, sedative, antidepressant, euphoriant, intoxicating, and addictive properties of opium and its synthetic derivatives are well known and have been known for centuries. Hence, the current major public health problems due to excessive availability should be no surprise. What is unprecedented in the United States, and emerging elsewhere, is the extent of the profound consequences and complexity of addressing this public health crisis.

An Implementation Guide to Promote Sleep and Reduce Sedative-Hypnotic Initiation for Noncritically Ill Inpatients

Sedative-hypnotic medications are frequently prescribed for hospitalized patients with insomnia, but they can result in preventable harm such as delirium, falls, hip fractures, and increased morbidity. Furthermore, sedative-hypnotic initiation while in the hospital carries a risk of chronic use after discharge. Disrupted sleep is a major contributor to sedative-hypnotic use among patients in the hospital and other institutional settings. Numerous multicomponent studies on improving sleep quality in these settings have been described, some demonstrating an associated reduction of sedative-hypnotic prescriptions. This selected review summarizes effective interventions aimed at promoting sleep and reducing inappropriate sedative-hypnotic initiation and proposes an implementation strategy to guide quality improvement teams.

Association of Mandatory Disclosure Policies and Laws With Physician-Industry Financial Relationships

Importance

Beside the goal of increasing transparency to the public, disclosure policies and laws have been established with a goal to also reduce ethically questionable financial relationships between physicians and the medical industry. Data on these relationships should be reviewed to understand the association between these policies and laws and the attainment of reduced relationships.

Objective

To assess whether disclosure policies and laws have been associated with a decrease in financial disclosure reporting by physicians.

Design, Setting, and Participants

This cross-sectional study uses yearly data from 2008 through 2015 from the participants in the American Academy of Ophthalmology's Annual Meeting. Trends in financial disclosures over time were investigated for the association of disclosure policies and laws with potentially beneficial, as well as ethically questionable physician-industry ties. Linear regression models were used to estimate the annual change in financial disclosures and are reported with 95% CIs.

Exposures

Disclosure policies and laws.

Main Outcomes and Measures

The annual aggregate financial disclosures by type (ie, consultant, lecturer, employee, grant support, equity owner, patent holder).

Results

Financial disclosures increased from 3966 in 2008 to 5266 in 2015 (P < .001). The number of disclosures reported in the categories consultant, equity owner, patents, and grant support all increased from 2008 to 2015 (consultant disclosures, 121 [95% CI, 88-155] per year; P < .001; equity owner disclosures, 32 [95% CI, 22-42] per year; P < .001; patent disclosures, 19 [95% CI, 13-26] per year; P < .001; grant support disclosures, 78 [95% CI, 48-107] per year; P < .001), while the employee and lecturer categories did not change significantly. The percentage of financial disclosures in the lecturer category decreased relative to the total (estimate, -1.1% [95% CI, -1.3% to -0.8%] per year; P < .001), owing to the number of financial disclosures for this category remaining stable while most other types increased.

Conclusions and Relevance

Disclosure was not associated with a chilling effect (decrease in financial disclosures associated with potentially beneficial physician-industry ties). Disclosure was associated with a possible disinfecting effect, whereby the percentage of ethically questionable disclosures (ie, lecturers) decreased, although the frequency remained stable. A permissive effect (physicians becoming more inclined to having industry relationships) was also observed. Thus, disclosure rules should be enhanced or alternative approaches to disclosure reconsidered to promote a decrease in ethically questionable relationships.

Extent of physician-pharmaceutical industry interactions in low- and middle-income countries: a systematic review

Background

Pharmaceutical companies spend large amounts of money promoting their products to physicians. There is evidence that physicians' interactions with pharmaceutical companies negatively affect their prescribing patterns. The objective of this study was to systematically review the extent of the relationship between physicians and pharmaceutical companies in low- and middle-income countries (LMICs).

Methods

Studies assessing the extent of any type of interaction between practicing physicians and pharmaceutical companies were eligible. We searched MEDLINE and EMBASE databases in July 2016. Reviewers worked in duplicate and independently to complete study selection, data abstraction and assessment of methodological features. We summarized the findings narratively.

Results

We included 11 eligible studies (7 quantitative and 4 qualitative). Quantitative studies found that pharmaceutical company representatives visited at least 90% of physicians. Printed material, stationery items and drug samples were the most frequently received gifts. Two of the studies assessing direct payment found percentages of 16 and 5%, respectively. Findings of qualitative studies were consistent with those of quantitative studies. In addition, they revealed an increasing tendency for pharmaceutical companies to provide expensive personal gifts, sponsor social events and offer cash as inducements to physicians based on their demands. They also identified building personal relationships, creating a sense of indebtedness and emotional blackmailing as commonly used techniques to influence physicians.

Conclusion

A relatively high percentage of physicians in LMICs interact with pharmaceutical companies. Findings have implications for policy and practice, given the current extent of interaction is likely affecting the prescribing habits and professional behaviour of physicians.

Association of Pharmaceutical Industry Marketing of Opioid Products With Mortality From Opioid-Related Overdoses

IMPORTANCE

Prescription opioids are involved in 40% of all deaths from opioid overdose in the United States and are commonly the first opioids encountered by individuals with opioid use disorder. It is unclear whether the pharmaceutical industry marketing of opioids to physicians is associated with mortality from overdoses.

OBJECTIVE

To identify the association between direct-to-physician marketing of opioid products by pharmaceutical companies and mortality from prescription opioid overdoses across US counties.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, county-level analysis of industry marketing information used data from the Centers for Medicare & Medicaid Services Open Payments database linked with data from the Centers for Disease Control and Prevention on opioid prescribing and mortality from overdoses. All US counties were included, with data on overdoses from August 1, 2014, to December 31, 2016, linked to marketing data from August 1, 2013, to December 31, 2015, using a 1-year lag. Statistical analyses were conducted between February 1 and June 1, 2018.

MAIN OUTCOMES AND MEASURES

County-level mortality from prescription opioid overdoses, total cost of marketing of opioid products to physicians, number of marketing interactions, opioid prescribing rates, and sociodemographic factors.

RESULTS

Between August 1, 2013, and December 31, 2015, there were 434 754 payments totaling $39.7 million in nonresearch-based opioid marketing distributed to 67 507 physicians across 2208 US counties. After adjustment for county-level sociodemographic factors, mortality from opioid overdoses increased with each 1-SD increase in marketing value in dollars per capita (adjusted relative risk, 1.09; 95% CI, 1.05-1.12), number of payments to physicians per capita (adjusted relative risk, 1.18; 95% CI, 1.14-1.21, and number of physicians receiving marketing per capita (adjusted relative risk, 1.12; 95% CI, 1.08-1.16). Opioid prescribing rates also increased with marketing and partially mediated the association between marketing and mortality.

CONCLUSIONS AND RELEVANCE

In this study, across US counties, marketing of opioid products to physicians was associated with increased opioid prescribing and, subsequently, with elevated mortality from overdoses. Amid a national opioid overdose crisis, reexamining the influence of the pharmaceutical industry may be warranted.

Conflicts of interest in infection prevention and control research: no smoke without fire. A narrative review

Conflicts of interest (COIs) do occur in healthcare research, yet their impact on research in the field of infection prevention and control (IPC) is unknown. We conducted a narrative review aiming to identify examples of COIs in IPC research. In addition to well-known instances, we conducted PubMed and Google searches to identify and report case studies of COIs in IPC and antimicrobial resistance (AMR), which were chosen arbitrarily following consensus meetings, to illustrate different types of COIs. We also searched the Retraction Watch database and blog to systematically identify retracted IPC and/or infectious disease-related papers. Our review highlights COIs in academic research linked to ties between industry and physicians, journal editors, peer-reviewed journals' choice for publication, and guideline committees participants and authors. It explores how COIs can affect research and could be managed. We also present several selected case studies that involve (1) the chlorhexidine industry and how it has used marketing trials and key opinion leaders to promote off-label use of its products; (2) the copper industry and how reporting of its trials in IPC have furthered their agenda; (3) the influence of a company developing "closed infusion systems" for catheters and how this affects networks in low- and middle-income countries and guideline development; (4) potential perverse incentives hospitals may have in reporting healthcare-associated infection or AMR rates and how government intervention may restrict AMR research for fear of bad publicity and subsequent negative economic consequences. Finally, the analysis of reasons for the retraction of previously published papers highlights the fact that misconduct in research may have other motivations than financial gain, the most visible form of COIs. COIs occur in the field of research in general, and IPC and AMR are no exceptions. Their effects pervade all aspects of the research and publication processes. We believe that, in addition to improvements in management strategies of COIs, increased public funding should be available to decrease researchers' dependency on industry ties. Further research is needed on COIs and their management.