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

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.

Health professional's exposure, attitude, and acceptance of drug promotion by industry representatives: A cross-sectional study in Ethiopia

Interactions between pharmaceutical companies and health care providers have long been an area of interest from ethical as well as scientific grounds. The information provided by those companies must be scientifically accurate and fair. The current study aimed to investigate the exposure, attitude, and training background of medical doctors and pharmacy professionals regarding drug promotional activities, and assess their acceptance of promotional gifts provided by pharmaceutical sales representatives. A cross-sectional study was conducted on medical doctors and pharmacy professionals working at Bahir Dar and Gondar cities, Amhara regional state, Ethiopia. Data were collected using a self-administered structured questionnaire and Statistical Package for Social Science (SPSS) version 26 was used for analysis. A Chi-square test was computed to investigate the presence of an association between the dependent and independent variables. A p-value of less than 0.05 was considered to declare significance at a 95% Confidence Interval (CI). A total of 105 health professionals, 81 pharmacy professionals, and 24 medical doctors have participated in the study. Above two-thirds of the respondents (69.5%) agreed that most talks sponsored by drug companies were helpful and educational. On the other hand, 39% of the respondents agreed and 47.6% disagreed that receiving gifts from pharmaceutical representatives will increase the chance that they will eventually sell or recommend the drug company's products. The majority of the study participants (81%) preferred drug samples and stationery as appropriate gifts by pharmaceutical sales representatives. Significant gaps were found regarding the training of health professionals about the ethics of drug marketing and how to deal with pharmaceutical representatives. Policies aiming at restricting health care provider's contacts with pharmaceutical companies during residency training along with incorporating gift restriction policies could bring significant improvements.

Antecedents of Symmetry in Physicians’ Prescription Behavior: Evidence from SEM-based Multivariate Approach

The aim of this paper is to examine the direct impact of marketing and medical tools on the symmetry of physicians’ prescription behavior in the context of the Pakistani healthcare sector. This research also investigates the moderating influence of corporate image and customer relationship in an association of marketing & medical tools, and the symmetry of physicians’ prescription behavior. The survey involved a research sample of 740 physicians, comprising 410 general practitioners and 330 specialists. A series of multivariate approaches such as exploratory factor analysis, confirmatory factor analyses, and conditional process analysis are employed. The findings of the study showed that marketing & medical tools have a direct, positive, and significant influence on physicians’ symmetrical prescription behavior. Corporate image and customer relationship have also a significant impact as moderating variables between marketing & medical tools, and the symmetry of prescription behavior of physicians. The outcomes of this research are beneficial to marketers and medical managers in the pharmaceutical industry.

Conflict of interest: "Be rigorous in judging ourselves and gracious in judging others"

The recent New York Times article with the banner headline Top Cancer Researcher Fails to Disclose Corporate Financial Ties in Major Research Journals and the subsequent discussion about Dr. Jose Baselga [...]

Influence of pharmaceutical marketing on Medicare prescriptions in the District of Columbia

Importance

Gifts from pharmaceutical companies are believed to influence prescribing behavior, but few studies have addressed the association between industry gifts to physicians and drug costs, prescription volume, or preference for generic drugs. Even less research addresses the effect of gifts on the prescribing behavior of nurse practitioners (NPs), physician assistants (PAs), and podiatrists.

Objective

To analyze the association between gifts provided by pharmaceutical companies to individual prescribers in Washington DC and the number of prescriptions, cost of prescriptions, and proportion of branded prescriptions for each prescriber.

Design

Gifts data from the District of Columbia’s (DC) AccessRx program and the federal Center for Medicare and Medicaid Services (CMS) Open Payments program were analyzed with claims data from the CMS 2013 Medicare Provider Utilization and Payment Data.

Setting

Washington DC, 2013

Participants

Physicians, nurse practitioners, physician assistants, podiatrists, and other licensed Medicare Part D prescribers who participated in Medicare Part D (a Federal prescription drug program that covers patients over age 65 or who are disabled).

Exposure(s)

Gifts to healthcare prescribers (including cash, meals, and ownership interests) from pharmaceutical companies.

Main outcomes and measures

Average number of Medicare Part D claims per prescriber, number of claims per patient, cost per claim, and proportion of branded claims.

Results

In 2013, 1,122 (39.1%) of 2,873 Medicare Part D prescribers received gifts from pharmaceutical companies totaling $3.9 million in 2013. Compared to non-gift recipients, gift recipients prescribed 2.3 more claims per patient, prescribed medications costing $50 more per claim, and prescribed 7.8% more branded drugs. In six specialties (General Internal Medicine, Family Medicine, Obstetrics/Gynecology, Urology, Ophthalmology, and Dermatology), gifts were associated with a significantly increased average cost of claims. For Internal Medicine, Family Medicine, and Ophthalmology, gifts were associated with more branded claims. Gift acceptance was associated with increased average cost per claim for PAs and NPs. Gift acceptance was also associated with higher proportion of branded claims for PAs but not NPs. Physicians who received small gifts (less than $500 annually) had more expensive claims ($114 vs. $85) and more branded claims (30.3% vs. 25.7%) than physicians who received no gifts. Those receiving large gifts (greater than $500 annually) had the highest average costs per claim ($189) and branded claims (39.9%) than other groups. All differences were statistically significant (p<0.05).

Conclusions and relevance

Gifts from pharmaceutical companies are associated with more prescriptions per patient, more costly prescriptions, and a higher proportion of branded prescriptions with variation across specialties. Gifts of any size had an effect and larger gifts elicited a larger impact on prescribing behaviors. Our study confirms and expands on previous work showing that industry gifts are associated with more expensive prescriptions and more branded prescriptions. Industry gifts influence prescribing behavior, may have adverse public health implications, and should be banned.

Interactions between physicians and the pharmaceutical industry generally and sales representatives specifically and their association with physicians' attitudes and prescribing habits: a systematic review

OBJECTIVES

The objective of this review is to explore interactions between physicians and the pharmaceutical industry including sales representatives and their impact on physicians' attitude and prescribing habits.

DATA SOURCES

PubMed, Embase, Cochrane Library and Google scholar electronic databases were searched from 1992 to August 2016 using free-text words and medical subject headings relevant to the topic.

STUDY SELECTION

Studies included cross-sectional studies, cohort studies, randomised trials and survey designs. Studies with narrative reviews, case reports, opinion polls and letters to the editor were excluded from data synthesis.

DATA EXTRACTION

Two reviewers independently extracted the data. Data on study design, study year, country, participant characteristics, setting and number of participants were collected.

DATA SYNTHESIS

Pharmaceutical industry and pharmaceutical sales representative (PSR) interactions influence physicians' attitudes and their prescribing behaviour and increase the number of formulary addition requests for the company's drug.

CONCLUSION

Physician-pharmaceutical industry and its sales representative's interactions and acceptance of gifts from the company's PSRs have been found to affect physicians' prescribing behaviour and are likely to contribute to irrational prescribing of the company's drug. Therefore, intervention in the form of policy implementation and education about the implications of these interactions is needed.

The impact of health insurance expansion on physician treatment choice: Medicare Part D and physician prescribing

We test the effect of the introduction of Medicare Part D on physician prescribing behavior by using data on physician visits from the National Ambulatory Medical Care Survey (NAMCS) 2002-2004 and 2006-2009 for patients aged 60-69. We use regression discontinuity designs to estimate the effect of part D around the age of 65 before and after 2006 and then compare the discrete jump in outcomes at age 65 before and after Part D. We find a 32% increase in the number of prescription drugs prescribed or continued per visit and a 46% increase in the number of generic drugs prescribed or continued for the elderly after the introduction of Medicare Part D.

Pharmacist-industry relationships

OBJECTIVES

The purpose of this study was to document, in their own words, beliefs and attitudes that American pharmacists have towards the pharmaceutical industry and pharmacists' interactions with industry.

METHODS

An ethnographic-style qualitative study was conducted utilizing open-ended interviews with four hospital pharmacists, two independent pharmacists, two retail pharmacists and one administrative pharmacist in the Washington, DC, metropolitan area to elicit descriptions of and attitudes towards pharmacists' relationships with industry. Analysis of the qualitative material followed established ethnographic conventions of narrative thematic analysis.

KEY FINDINGS

All pharmacists reported interactions with pharmaceutical company representatives. Most had received free resources or services from industry, including educational courses. Respondents uniformly believed that industry promotional efforts are primarily directed towards physicians. Although respondents felt strongly that drug prices were excessive and that 'me-too' drugs were of limited use, they generally had a neutral-to-positive view of industry-funded adherence/compliance programmes, coupons, vouchers, and copay payment programmes. Interviewees viewed direct-to-consumer advertising negatively, but had a generally positive view of industry-funded drug information.

CONCLUSIONS

Pharmacists may represent a hitherto under-identified cohort of health professionals who are targeted for industry influence; expanding roles for pharmacists may make them even more attractive targets for future industry attention. Pharmacy schools should ensure that students learn to rely on unbiased information sources and should teach students about conflicts of interest and the risks of interacting with industry. Further research should be conducted on the extent to which pharmacists' attitudes towards their duties and towards drug assessment and recommendation are influenced by the pharmaceutical industry.

The Relationship of Industry Payments to Prescribing Behavior: A Study of Degarelix and Denosumab

INTRODUCTION

The influence of financial ties to pharmaceutical companies remains controversial. We aimed to assess a potential relationship between pharmaceutical payments and prescription patterns for degarelix and denosumab.

MATERIALS AND METHODS

Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (Medicare B) data containing 2012 claims compared to OpenPayments (Sunshine Act) data for the second half of 2013. Urologists and medical oncologists who billed Medicare for degarelix or denosumab were cross referenced in both databases and payments were aggregated into a consolidated dataset. Adjusted beneficiary count and total Medicare reimbursement were compared according to receipt of Sunshine payment, and an association between Sunshine payment amount and total Medicare reimbursement was also assessed.

RESULTS

Of the 160 prescribers of degarelix and 1,507 prescribers of denosumab, 91 (57%) and 854 (57%) received Sunshine payment, respectively. Degarelix prescribers who received Sunshine payment had higher median total Medicare reimbursement ($13,257 vs. $9,554, p = 0.01). Denosumab prescribers who received Sunshine payment had both higher median adjusted beneficiary count (55 vs. 50, p < 0.001) and median total Medicare reimbursement ($69,620 vs. $60,732, p < 0.001). On multivariable analysis, both receipt of Sunshine payment (adjusted median difference $5,844, 95% CI $937 - $10,749) and oncology specialty (adjusted median difference $34,380, 95% CI $26,715 - $42,045) were independently associated with total Medicare reimbursement for denosumab.

CONCLUSIONS

In the case of degarelix and denosumab, there is a weak association between pharmaceutical company payments on prescribers' prescription behavior patterns.

Sunshine Act: shedding light on inaccurate disclosures at a gynecologic annual meeting

BACKGROUND

Physicians and hospital systems often have relationships with biomedical manufacturers to develop new ideas, products, and further education. Because this relationship can influence medical research and practice, reporting disclosures are necessary to reveal any potential bias and inform consumers. The Sunshine Act was created to develop a new reporting system of these financial relationships called the Open Payments database. Currently all disclosures submitted with research to scientific meetings are at the discretion of the physician. We hypothesized that financial relationships between authors and the medical industry are underreported.

OBJECTIVES

We aimed to describe concordance between physicians' financial disclosures listed in the abstract book from the 41st annual scientific meeting of the Society of Gynecologic Surgeons to physician payments reported to the Center for Medicaid and Medicare Services Open Payments database for the same year.

STUDY DESIGN

Authors and scientific committee members responsible for the content of the 41st annual scientific meeting of the Society of Gynecologic Surgeons were identified from the published abstract book; each abstract listed disclosures for each author. Abstract disclosures were compared with the transactions recorded on the Center for Medicaid and Medicare Services Open Payments database for concordance. Two authors reviewed each nondisclosed Center for Medicaid and Medicare Services listing to determine the relatedness between the company listed on the Center for Medicaid and Medicare Services and abstract content.

RESULTS

Abstracts and disclosures of 335 physicians meeting inclusion criteria were reviewed. A total of 209 of 335 physicians (62%) had transactions reported in the Center for Medicaid and Medicare Services, which totaled $1.99 million. Twenty-four of 335 physicians (7%) listed companies with their abstracts; 5 of those 24 physicians were concordant with the Center for Medicaid and Medicare Services. The total amount of all nondisclosed transactions was $1.3 million. Transactions reported in the Center for Medicaid and Medicare Services associated with a single physician ranged from $11.72 to $405,903.36. Of the 209 physicians with Center for Medicaid and Medicare Services transactions that were not disclosed, the majority (68%) had at least 1 company listed in the Center for Medicaid and Medicare Services that was determined after review to be related to the subject of their abstract.

CONCLUSION

Voluntary disclosure of financial relationships was poor, and the majority of unlisted disclosures in the abstract book were companies related to the scientific content of the abstract. Better transparency is needed by physicians responsible for the content presented at gynecological scientific meetings.

Conflicts of Interest in Medical Technology Markets: Evidence from Orthopedic Surgery

Financial relationships between physicians and industry are vital to biomedical innovation yet create the potential for conflicts of interest in medical practice. I consider an inducement model of the role of financial relationships in health care markets, where consulting payments induce physicians to use more devices of the firms that sponsor them. To test the model, I exploit a policy shock, whereby government monitoring of payments to joint replacement surgeons resulted in declines of over 60% in both total payments and in the number of physicians receiving payments from 2007 to 2008. Using hospital discharge data from three states, I find that the loss of payments leads physicians to switch 7 percentage points of their device utilization from their sponsoring firms' devices to other firms' devices, an effect which is concentrated among surgeons with low switching costs. These results offer support for the inducement model. I also find evidence of an increase in medical productivity following the policy intervention, which suggests conditions under which regulation of financial relationships would be socially beneficial. Copyright © 2015 John Wiley & Sons, Ltd.

Validity of tools used for surveying physicians about their interactions with pharmaceutical company: a systematic review

BACKGROUND

There is evidence that physicians' prescription behavior is negatively affected by the extent of their interactions with pharmaceutical companies. In order to develop and implement policies and interventions for better management of interactions, we need to understand physicians' perspectives on this issue. Surveys addressing physicians' interactions with pharmaceutical companies need to use validated tools to ensure the validity of their findings.

OBJECTIVE

To assess the validity of tools used in surveys of physicians about the extent and nature of their interactions with pharmaceutical companies, and about their knowledge, beliefs and attitudes towards such interactions; and to identify those tools that have been formally validated.

METHODS

We developed a search strategy with the assistance of a medical librarian. We electronically searched MEDLINE and EMBASE databases in September 2015. Teams of two reviewers conducted data selection and data abstraction. They identified eligible studies in one table and then abstracted the relevant data from the studies with validated tools in another table. Tables were piloted and standardized.

RESULTS

We identified one validated questionnaire out of the 11 assessing the nature and extent of the interaction, and three validated questionnaires out of the 47 assessing knowledge, beliefs and attitudes of physicians toward the interaction. None of these validated questionnaires were used in more than one survey.

CONCLUSION

The available supporting evidence of the issue of physicians' interaction with pharmaceutical company is of low quality. There is a need for research to develop and validate tools to survey physicians about their interactions with pharmaceutical companies.

An intellectual virtue "vaccination" for physician-pharmaceutical industry interactions

The pharmaceutical industry's wide range of interactions with physicians, trainees, and other medical professionals--interactions that include information transfer and financial incentives--has been the source of undue influences, especially on physicians' prescription behavior. Current literature has mainly been focused on the financial element of these influences, and the problems in medical professional-pharmaceutical industry interactions are mainly viewed in terms of conflicts of interest. There is often the assumption that physicians are intellectually competent but biased because of financial incentives.The author rejects that assumption and proposes an alternative explanation for the observed influence of the pharmaceutical industry on physicians' behavior by emphasizing the importance of the information-transfer side of the interactions and maintaining that physicians and other medical professionals need certain intellectual virtues (i.e., competencies) to properly assess the information, which is often unreliable and biased. These virtues are necessary for the practice of modern medicine and include mindfulness, the ability to understand practical implications of newly found evidence, to consider alternative explanations of data, to recognize and correct errors, to decide on the best available evidence, and to tailor that to the needs and values of individual patients. On the basis of this view, the author recommends that the best solution for the observed problems in physician-pharmaceutical industry interactions is to "vaccinate" physicians and other medical professionals by increasing efforts to inculcate the necessary intellectual virtues early in medical education and fostering them throughout those individuals' professional lives.

Contact between doctors and the pharmaceutical industry, their perceptions, and the effects on prescribing habits

Background

The prescribing behaviour of doctors is influenced by the pharmaceutical industry. This study investigated the extent to which contacts with pharmaceutical sales representatives (PSR) and the perception of these contacts influence prescribing habits.

Method

An online questionnaire regarding contact with PSRs and perceptions of this contact was sent to 1,388 doctors, 11.5% (n = 160) of whom completed the survey. Individual prescribing data over a year (number of prescriptions, expenditure, and daily doses) for all on-patent branded, off-patent branded, and generic drugs were obtained from the Bavarian Association of Statutory Health Insurance Physicians.

Results

84% of the doctors saw PSR at least once a week, and 14% daily. 69% accepted drug samples, 39% accepted stationery and 37% took part in sponsored continuing medical education (CME) frequently. 5 physicians (3%) accepted no benefits at all. 43% of doctors believed that they received adequate and accurate information from PSRs frequently or always and 42% believed that their prescribing habits were influenced by PSR visits occasionally or frequently. Practices that saw PSRs frequently had significantly higher total prescriptions and total daily doses (but not expenditure) than practices that were less frequently visited. Doctors who believed that they received accurate information from PSRs showed higher expenditures on off-patent branded drugs (thus available as generics) and a lower proportion of generics. The eschewal of sponsored CME was associated with a lower proportion of on patent-branded drug prescriptions, lower expenditure on off-patent branded drug prescriptions and a higher proportion of generics. Acceptance of office stationery was associated with higher daily doses.

Conclusions

Avoidance of industry-sponsored CME is associated with more rational prescribing habits. Furthermore, gift acceptance and the belief that one is receiving adequate information from a PSR are associated with changed prescribing habits. Further studies with larger sample sizes are needed.

Does exposure to conflict of interest policies in psychiatry residency affect antidepressant prescribing?

BACKGROUND

Academic medical institutions have instituted conflict of interest (COI) policies in response to concerns about pharmaceutical industry influence.

OBJECTIVE

To determine whether exposure to COI policies during psychiatry residency training affects psychiatrists' antidepressant prescribing patterns after graduation.

RESEARCH DESIGN

We used 2009 physician-level national administrative prescribing data from IMS Health for 1652 psychiatrists from 162 residency programs. We used difference-in-differences estimation to compare antidepressant prescribing based on graduation before (2001) or after (2008) COI policy adoption across residency program groups with maximally, moderately, and minimally restrictive COI policies. The primary outcomes were shares of psychiatrists' prescribing of heavily promoted, brand reformulated, and brand antidepressants.

RESULTS

Rates of prescribing heavily promoted, brand reformulated, and brand antidepressants in 2009 were lower among post-COI graduates than pre-COI graduates at all levels of COI restrictiveness. However, differences between pre-COI and post-COI graduates' prescribing of heavily promoted medications were larger for maximally restrictive programs than both minimally restrictive programs [-4.3 percentage points; 95% confidence interval (CI), -7.0, -1.6] and moderately restrictive programs (-3.6 percentage points; 95% CI, -6.2, -1.1). The difference in prescribing reformulations was larger for maximally restrictive programs than minimally restrictive programs (-3.0 percentage points; 95% CI, -5.3, -0.7). Results were consistent for prescribing of brand drugs.

CONCLUSIONS

This study provides the first empirical evidence of the effects of COI policies. Our results suggest that COI policies can help inoculate physicians against persuasive aspects of pharmaceutical promotion. Further research should assess whether these policies affect other drug classes and physician specialties similarly.

Does participation in clinical trials influence the costs of future management of patients?

BACKGROUND

An earlier study showed that from a societal perspective it was less expensive to encourage patients to self-regulate their medication for GERD (gastro-esophageal reflux disease) by treating patients on-demand.

OBJECTIVE

The objective was to investigate whether physician involvement in a clinical trial financed by the pharmaceutical industry subsequently results in higher health care costs.

STUDY DESIGN

An open, observational, multicenter study compared direct medical costs and total costs for three groups of patients with different exposure to the clinical trial; (1) Dual exposed, where both the patients and the GP participated in the former clinical trial, (2) GP exposed, where only the GP participated in the former clinical trial and (3) nonexposed, where neither the patients nor the GP participated in the former clinical trial.

RESULTS

We did not find any statistically significant differences in neither direct medical nor total costs. However, we did observe a numerical difference in direct medical costs of 24% higher in the dual exposed group compared to the nonexposed group mainly due to a higher consumption of prescribed medication. The higher direct medical cost in the dual exposed group was however counterbalanced by lower observed direct nonmedical and indirect costs.

CONCLUSION

Although we did not find any statistical significant differences in health care costs, we did observe a higher consumption of prescribed medication and lower costs of work hours lost if both patient and GPs participated in a former clinical trial. The results may be limited due to a lower number of patients included than expected.

Drug selection in French university hospitals: analysis of formularies for nine competitive pharmacological classes

AIM

To give a panorama of the selectivity and agreement of French university hospitals' drug formularies (HDF) for nine competitive classes.

METHODS

All university hospitals were asked to send their HDF and selection criteria as of January 2009 for nine competitive pharmacological classes (proton pump inhibitors, serotonin antagonists, low molecular weight heparins, erythropoietins, angiotensin converting enzyme inhibitors, angiotensin II receptor antagonists, statins, α-adrenoreceptor antagonists and selective serotonin re-uptake inhibitors). Selectivity of HDF was estimated by the percentage of drug entities selected by the hospital within the pharmacological class. Agreement between hospitals was assessed with modified kappa coefficients for multi-raters.

RESULTS

Twenty-one out of the 29 hospitals agreed to participate. These hospitals selected between 34% and 63% of the drug entities available for the nine classes, which represented 18 to 35 agents. Regarding the nature of chosen drug entities, the overall level of agreement was 'fair' and varied with pharmacological classes. Selection criteria were sent by only 12 hospitals. The technical component was the most important element in all hospitals. The weight of the economic component varied between 20% and 40% in the tender's grade.

DISCUSSION

Large variations were seen in the number and nature of drugs selected by university hospitals which can be attributable to two successive decision-making processes (evaluation by the Drug and Therapeutics Committee followed by the purchasing process).

Effect of financial relationships on the behaviors of health care professionals: a review of the evidence

This paper explores the empirical evidence regarding the impact financial relationships on the behavior of health care providers, specifically, physicians. We identify and synthesize peer-reviewed data addressing whether financial incentives are causally related to patient outcomes and health care costs. We cover three main areas where financial conflicts of interest arise and may have an observable relationship to health care practices: (1) physicians' roles as self-referrers, (2) insurance reimbursement schemes that create incentives for certain clinical choices over others, and (3) financial relationships between physicians and the drug and device industries. We found a well-developed scientific literature consisting of dozens of empirical studies, some that allow stronger causal inferences than others, but which altogether show that such financial conflicts of interests can, and sometimes do, impact physicians' clinical decisions. Further research is warranted to document the causal relationship of such changes on health outcomes and the cost of care, but the current base of evidence is sufficiently robust to motivate policy reform.

Private practice perspective on conflict of interest mandates

This article assesses the current mandates on conflict of interest issues as they affect the practice of community-based vascular surgery and the pharmaceutical and medical technology industries and expresses the views of a private practice vascular surgeon. Scenarios where conflict of interest may occur are presented with assessments on how these scenarios will play out if such mandates are enforced.

[Drug advertisement in a medicine school in the Southern of Brazil]

This is a quali-quantitative study on drug advertisement in a Medicine school in Santa Catarina state. Participants were medicine students, faculty physicians and patients of school ambulatories, totaling 1,231 interviewees. The focal group technique was used to the qualitative research; the quantitative research with a semistructured questionnaire. 53.6% of the faculty physicians considered they were rarely or never influenced by the propaganda, and 53.7% claimed their colleagues are. Among the students, 43.2% believe that, after graduated, they will rarely or never be influenced; while 42.0% believe that graduated are always or frequently influenced. For 41.7%, the information given by the representatives of the pharmaceutical industry is good or excellent. Also, 74.8% reported that the pharmaceutical industry will be able to contribute for their professional practice. This study identified that the distribution of free drug samples are one of the main advertising and propaganda techniques used by the pharmaceutical industry; as there is a certain pressure of the medical preceptor upon the choice of the prescription; although no direct impact of the influence of the pharmaceutical industry on the ambulatories was observed. Drug prescription is usually not rational.

Prescription Drug Use and Seniors

L'augmentation des dépenses de médicaments a placé les aîné(e)s sous les feux de la réforme de santé puisqu'ils en sont les plus grands consommateurs. On pourrait apporter des modifications substantielles à la consommation de médicaments presents, ce qui rehausserait les bienfaits des traitements et en minimiserait les effets négatifs, surtout chez les aîné(e)s. On documente ici un bon nombre de problèmes, notamment la surconsommation et la sous-consommation des médicaments, les erreurs d'ordonnances, la conformité au traitement et les médicaments inutilement coûteux. On a démontré l'efficacité de certaines éléments à l'égard de certains aspects du problème; qu'on cite simplement les politiques reliées au système de soins de santé, les interventions de certains médecins et de pharmaciens d'hôpitaux, les aides à la prise de dècisions et à la conformité aux traitements. Il faut mettre en place l'intégration des principales politiques et des interventions en une solution globale visant une meilleure utilisation des médicaments. Elle pourrait se composer des éléments suivants: (1) la révision des politiques de relations entre l'industrie pharmacologique et le secteur de la santé; (2) l'établissement de règlements d'expérimentation des médicaments chez les aînés avant leur approbation; (3) un institut du consommateur servant de ressource centrale objective aux demandes de renseignements des patients et de système d'appui aux décisions; (4) des systèmes intégrés d'information clinique à l'appui des systèmes de gestion des ordonnances et de la fourniture des médicaments et de la gestion des médicaments et des maladies à l'intention des pharmaciens et des médecins de premier recours; (5) une réforme de la formation médicale et de l'octroi des permis.

Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review

BACKGROUND

Pharmaceutical companies spent $57.5 billion on pharmaceutical promotion in the United States in 2004. The industry claims that promotion provides scientific and educational information to physicians. While some evidence indicates that promotion may adversely influence prescribing, physicians hold a wide range of views about pharmaceutical promotion. The objective of this review is to examine the relationship between exposure to information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing.

METHODS AND FINDINGS

We searched for studies of physicians with prescribing rights who were exposed to information from pharmaceutical companies (promotional or otherwise). Exposures included pharmaceutical sales representative visits, journal advertisements, attendance at pharmaceutical sponsored meetings, mailed information, prescribing software, and participation in sponsored clinical trials. The outcomes measured were quality, quantity, and cost of physicians' prescribing. We searched Medline (1966 to February 2008), International Pharmaceutical Abstracts (1970 to February 2008), Embase (1997 to February 2008), Current Contents (2001 to 2008), and Central (The Cochrane Library Issue 3, 2007) using the search terms developed with an expert librarian. Additionally, we reviewed reference lists and contacted experts and pharmaceutical companies for information. Randomized and observational studies evaluating information from pharmaceutical companies and measures of physicians' prescribing were independently appraised for methodological quality by two authors. Studies were excluded where insufficient study information precluded appraisal. The full text of 255 articles was retrieved from electronic databases (7,185 studies) and other sources (138 studies). Articles were then excluded because they did not fulfil inclusion criteria (179) or quality appraisal criteria (18), leaving 58 included studies with 87 distinct analyses. Data were extracted independently by two authors and a narrative synthesis performed following the MOOSE guidelines. Of the set of studies examining prescribing quality outcomes, five found associations between exposure to pharmaceutical company information and lower quality prescribing, four did not detect an association, and one found associations with lower and higher quality prescribing. 38 included studies found associations between exposure and higher frequency of prescribing and 13 did not detect an association. Five included studies found evidence for association with higher costs, four found no association, and one found an association with lower costs. The narrative synthesis finding of variable results was supported by a meta-analysis of studies of prescribing frequency that found significant heterogeneity. The observational nature of most included studies is the main limitation of this review.

CONCLUSIONS

With rare exceptions, studies of exposure to information provided directly by pharmaceutical companies have found associations with higher prescribing frequency, higher costs, or lower prescribing quality or have not found significant associations. We did not find evidence of net improvements in prescribing, but the available literature does not exclude the possibility that prescribing may sometimes be improved. Still, we recommend that practitioners follow the precautionary principle and thus avoid exposure to information from pharmaceutical companies. Please see later in the article for the Editors' Summary.

Effect of drug sample removal on prescribing in a family practice clinic

PURPOSE

Little is known about the impact of recent restrictions on pharmaceutical industry detailing and sampling on prescribing behavior, particularly within smaller, independent practices. The objective of this study was to evaluate the effect of a policy prohibiting prescription drug samples and pharmaceutical industry interaction on prescribing patterns in a rural family practice clinic in central Oregon.

METHODS

Segmented linear regression models were used to evaluate trends in prescribing using locally obtained pharmacy claims. Oregon Medicaid pharmacy claims were used to control for secular prescribing changes. Total and class-specific monthly trends in branded, promoted, and average prescription drug costs were analyzed 18 months before and after policy implementation.

RESULTS

Aggregate trends of brand name drug use did not change significantly after policy implementation. In aggregate, use of promoted agents decreased by 1.43% while nonpromoted branded agents increased by 3.04%. Branded drugs prescribed for respiratory disease declined significantly by 11.34% compared with a control group of prescribers. Relative to the control group, prescriptions of promoted cholesterol-lowering drugs and antidepressants were reduced by approximately 9.98% and 11.34%, respectively. The trend in average cost per prescription for lipid-lowering drugs was significantly reduced by $0.70 per prescription per month. Overall, average prescription drug costs increased by $5.18 immediately after policy implementation.

CONCLUSIONS

Restriction of pharmaceutical industry representatives and samples from a rural family practice clinic produced modest reductions in branded drug use that varied by class. Although aggregate average costs increased, prescriptions for branded and promoted lipid-lowering agents and antidepressants were reduced.

Are rates of pathology test ordering higher in general practices co-located with pathology collection centres?

OBJECTIVE

To determine whether rates of pathology test ordering by general practitioners in general practices co-located with pathology collection centres (PCCs) are higher than those of GPs in practices located apart from PCCs.

DESIGN, SETTING AND PARTICIPANTS

We identified all practices in the Melbourne and Sydney metropolitan areas that were co-located with PCCs (same or immediately adjacent suite) and the date co-location was established. This information was merged with the Bettering the Evaluation and Care of Health database to identify samples of GP-patient encounters in co-located practices (n = 31,700) and practices located apart from the nearest PCC (n = 289,700) over the period 2000-2009. Using Poisson regression analysis and logistic regression analysis, we compared GP test-ordering rates across the two types of practices, controlling for a range of potential confounders.

MAIN OUTCOME MEASURES

Numbers of tests ordered per encounter; likelihood of ordering one or more tests per encounter.

RESULTS

In unadjusted analyses, GPs in co-located practices ordered more pathology tests than GPs in practices located apart from PCCs (40.3 v 37.0 tests per 100 encounters, P = 0.01) and had a higher likelihood of ordering one or more tests (16.8% v 15.5% of encounters, P < 0.01). After adjusting for other predictors of test ordering, however, neither test-ordering rate (rate ratio, 0.98; 95% CI, 0.93-1.05; P = 0.56) nor likelihood of ordering one or more tests per encounter (odds ratio, 1.01; 95% CI, 0.95-1.07; P = 0.79) differed significantly by co-location status. Sub-analyses within specific test groups and types showed few systematic differences.

CONCLUSIONS

Pathology test-ordering rates are not higher in practices co-located with PCCs. To the extent inappropriate commercial influences and relationships exist in the pathology sector, GPs' test-ordering behaviour may be unaffected.

Treating and precepting with RESPECT: a relational model addressing race, ethnicity, and culture in medical training

BACKGROUND

In 2000 a diverse group of clinicians/educators at an inner-city safety-net hospital identified relational skills to reduce disparities at the point of care.

DESCRIPTION

The resulting interviewing and precepting model helps build trust with patients as well as with learners. RESPECT adds attention to the relational dimension, addressing documented disparities in respect, empathy, power-sharing, and trust while incorporating prior cross-cultural models. Specific behavioral descriptions for each component make RESPECT a concrete, practical, integrated model for teaching patient care.

CONCLUSIONS

Precepting with RESPECT fosters a safe climate for residents to partner with faculty, address challenges with patients at risk, and improve outcomes.

Why lunch matters: assessing physicians' perceptions about industry relationships

Many studies have shown that pharmaceutical marketing affects prescribing choices. Studies that have assessed the effects of educational interventions on perceptions of pharmaceutical promotion have found mixed results. This study assesses the short-term effects of an educational intervention about marketing tactics on the attitudes and fund of knowledge of residents, medical students, and attending physicians. A 1-hour slide show that covered detailing, prescription tracking, drug samples, medical meetings, and journals was developed by PharmedOut and presented at a total of 14 grand rounds and seminars at departments of family medicine, internal medicine, pediatrics, psychiatry, cardiology, and neurology. Pre- and posttests included attitudinal and fact questions addressing the influence of drug reps, gifts, pharmaceutical advertising and drug samples on prescribing behavior. The posttest asked whether attendees intended to change their prescribing behavior. The Mann-Whitney U test was used for Likert-scale questions and the Fisher exact test was used to compare the number of pre- and posttest correct answers for the multiple choice and true/false questions. Three hundred seventy-three participants completed pre- and posttests. Significant attitudinal shifts were seen overall, particularly in questions addressing influence of salespeople on physicians in general and on the respondent individually. Some participants commented that they intended to stop seeing drug reps or stop attending industry-funded meals. A new educational presentation can substantially shift attitudes toward perceived susceptibility to pharmaceutical marketing activities. Further research is needed to see if attitude change persists.

Implementation of an evidence-based guideline on fluid resuscitation: lessons learnt for future guidelines

INTRODUCTION

There is little experience with the nationwide implementation of an evidence-based pediatric guideline on first-choice fluid for resuscitation in hypovolemia.

METHODS

We investigated fluid prescribing behavior at (1) guideline development, (2) after guideline development, and (3) after active implementation and identified potential barriers and facilitators for guideline implementation. In order to minimize costs and to optimize implementation effect, we continuously developed and adjusted implementation strategies according to identified barriers. Implementation success was evaluated using questionnaires, pharmaceutical data, and data from medical records.

DISCUSSION

The most remarkable change occurred after guideline development and dissemination: Normal saline use by neonatologists increased from 22-89% to 100% and by pediatric intensivists from 43-71% to 88-100%, and synthetic colloid use by pediatric intensivists declined from 29-43% to 0-13% with a reduction in albumin use by neonatologists from 11-44% to 0%. After active guideline implementation, most of specialist's management behavior was according to the guideline.

CONCLUSION

Stakeholders involved in the developmental process are of great importance in disseminating recommendations before active implementation. Therefore, to successfully implement guidelines and reduce costs of active implementation, any guideline development should consider implementation right from the beginning. Implementation strategies should target identified barriers and will therefore always be guideline specific.

Promoção e propaganda de medicamentos em ambientes de ensino: elementos para o debate

A indústria farmacêutica utiliza a propaganda para a promoção de seus produtos. Os de uso controlado só podem ter a propaganda dirigida a profissionais habilitados a prescrevê-los ou dispensá-los. Este artigo faz uma ampla revisão de artigos científicos que discutem questões éticas e legais acerca da promoção e propaganda de medicamentos em ambientes de ensino médico. Conclui-se que não se justifica a auto-regulamentação da propaganda de medicamentos e que existem evidências suficientes de como o poder da indústria farmacêutica é capaz de influenciar as decisões no âmbito da relação médico-paciente, sendo a promoção e a propaganda um de seus instrumentos. Defende-se sua total proibição em ambientes de ensino, bem como a incorporação da temática na formação dos estudantes. Como a legislação vigente permite a propaganda de medicamentos vendidos sob prescrição apenas a médicos e farmacêuticos, destaca-se que tal propaganda é ilegal quando atinge estudantes de medicina e de farmácia.

Characteristics and impact of drug detailing for gabapentin

BACKGROUND

Sales visits by pharmaceutical representatives ("drug detailing") are common, but little is known about the content of these visits or about the impact of visit characteristics on prescribing behavior. In this study, we evaluated the content and impact of detail visits for gabapentin by analyzing market research forms completed by physicians after receiving a detail visit for this drug.

METHODS AND FINDINGS

Market research forms that describe detail visits for gabapentin became available through litigation that alleged that gabapentin was promoted for "off-label" uses. Forms were available for 97 physicians reporting on 116 detail visits between 1995 and 1999. Three-quarters of recorded visits (91/116) occurred in 1996. Two-thirds of visits (72/107) were 5 minutes or less in duration, 65% (73/113) were rated of high informational value, and 39% (42/107) were accompanied by the delivery or promise of samples. During the period of this study, gabapentin was approved by the US Food and Drug Administration only for the adjunctive treatment of partial seizures, but in 38% of visits (44/115) the "main message" of the visit involved at least one off-label use. After receiving the detail visit, 46% (50/108) of physicians reported the intention to increase their prescribing or recommending of gabapentin in the future. In multivariable analysis, intent to increase future use or recommendation of gabapentin was associated with receiving the detail in a small group (versus one-on-one) setting and with low or absent baseline use of the drug, but not with other factors such as visit duration, discussion of "on-label" versus "off-label" content, and the perceived informational value of the presentation.

CONCLUSIONS

Detail visits for gabapentin were of high perceived informational value and often involved messages about unapproved uses. Despite their short duration, detail visits were frequently followed by physician intentions to increase their future recommending or prescribing of the drug.

Conflict of Interest in the Physician Interface with the Biomedical Industry

The physician interface with the pharmaceutical industry stands at the forefront of a debate about the effect this relationship has on the behavior of both researchers and clinicians. The authors explore the basis for this conflict of interest and show how it affects physician judgment and behavior. These effects lead to negative consequences for patients and threaten the professional status that society accords physicians. In view of the potential for ethical compromise, physicians should refrain from contact with pharmaceutical marketing representatives.

Residents' perceptions over time of pharmaceutical industry interactions and gifts and the effect of an educational intervention

PURPOSE

To describe change in residents' attitudes toward gifts from and interactions with industry and to measure the effects of a formal educational workshop on changes in perceptions.

METHOD

At the University of Chicago, 118 internal medicine residents completed an observational survey and took part in a controlled intervention across three years (2001-2004) of residency. Four cohorts of residents completing the program in 2004-2007 participated. The intervention was an interactive educational workshop, including reviews of literature and guidelines, and three videos demonstrating routine resident interactions with pharmaceutical representatives. Residents graduating in 2005 were the intervention group and residents graduating in 2004 the comparison group. Analysis of variance and linear regression models were used to determine the relationship between variables.

RESULTS

Residents perceived "lunch sponsored at noon conference" and "pharmaceutical representative brief talk at noon conference" as increasingly appropriate over their training period (p < .02). Residents perceived "pens, notepads, pocket antibiotic guides" as increasingly appropriate and "tickets to sporting events," "round of golf," and "travel/registration for national conference" as increasingly inappropriate (p < .05). The intervention group was more likely to rate only one item, "lunch at noon conference," as less appropriate (p = .042).

CONCLUSIONS

Residents' perceptions toward industry gifts and interactions changed modestly during their training to reflect institutional policy. "Appropriate" gifts of minimal value were generally perceived as increasingly appropriate, whereas "inappropriate" gifts were perceived as increasingly inappropriate over time. An educational workshop alone may not significantly alter residents' perceptions toward industry without the implementation of broad and consistent institutional policy.

Interactions between pharmaceutical representatives and doctors in training. A thematic review

OBJECTIVE

Medical school and residency are formative years in establishing patterns of prescribing. We aimed to review the literature regarding the extent of pharmaceutical industry contact with trainees, attitudes about these interactions, and effects on trainee prescribing behavior, with an emphasis on points of potential intervention and policy formation.

DESIGN

We searched MEDLINE from 1966 until May 2004 for English language articles. All original articles were included if the abstract reported content relevant to medical training and the pharmaceutical industry. Editorials, guidelines, and policy recommendations were excluded.

MEASUREMENTS AND MAIN RESULTS

Contact with pharmaceutical representatives was common among residents. The majority of trainees felt that the interactions were appropriate. A minority felt that their own prescribing could be influenced by contact or gifts, but were more likely to believe that others' prescribing could be influenced. Resident prescribing was associated with pharmaceutical representative visits and the availability of samples. A variety of policy and educational interventions appear to influence resident attitudes toward interactions with industry, although data on the long-term effects of these interventions are limited. Overall, residents reported insufficient training in this area.

CONCLUSIONS

The pharmaceutical industry has a significant presence during residency training, has gained the overall acceptance of trainees, and appears to influence prescribing behavior. Training programs can benefit from policies and curricula that teach residents about industry influence and ways in which to critically evaluate information that they are given. Recommendations for local and national approaches are discussed.

Medical students' exposure to pharmaceutical industry marketing: a survey at one U.S. medical school

PURPOSE

While much is known about the interactions between the pharmaceutical industry and physicians, very little is known about pharmaceutical marketing directed toward medical students. This study sought to characterize the extent and forms of medical students' exposure to pharmaceutical industry marketing.

METHOD

In 2001-02, an anonymous, 17-item questionnaire was distributed to 165 preclinical and 116 clinical students at the University of Minnesota Medical School-Twin Cities. The main outcome measures were the number and forms of exposures to pharmaceutical industry marketing reported by medical students and whether students had discussed these exposures with teachers or advisors. Preclinical and clinical students were compared using chi(2) analysis (p < .05).

RESULTS

One hundred fourteen (69.1%) preclinical students and 107 (92.2%) clinical students responded. Nearly all students reported at least one exposure to pharmaceutical industry marketing. Seventy-six (71.7%) clinical students compared to 38 (33.3%) preclinical students recalled over 20 exposures (p < .005). Clinical students were more likely to have received a free meal (p < .01), textbook (p < .005), pocket text (p < .005), or trinket (p < .005) than were their preclinical colleagues. Most students (68.2%) had not discussed pharmaceutical marketing with an instructor or advisor; 59 (55.7%) clinical students as compared to 87 (80.6%) preclinical students recalled no such discussion (p < .005).

CONCLUSION

Medical students have extensive exposure to pharmaceutical industry marketing during their early years of training. Given existing evidence that such exposure influences physicians' practice and prescribing patterns, the authors propose that medical school curricula include formal instruction to prepare students to critically assess these contacts.

A prospective before-and-after trial of an educational intervention about pharmaceutical marketing

PURPOSE

There is increasing evidence that physicians may be compromised by their interactions with the pharmaceutical industry. The authors aimed to develop and determine the effect of an educational intervention to inform family medicine residents about pharmaceutical marketing.

METHOD

Confidential, self-administered questionnaires were administered to family medicine residents at McMaster University, Hamilton, Canada, immediately before and after a two-part, 2.5-hour educational intervention. The curriculum consisted of (1) a faculty-led debate and discussion of a systematic review of physician-pharmaceutical industry interactions, and (2) an interactive workshop that included a presentation highlighting key empirical findings, a video illustrating techniques to optimize pharmaceutical sales representatives' visits, and small- and large-group problem-based discussions. Residents were asked about their attitudes toward five marketing strategies: drug samples, industry-sponsored continuing medical education, one-on-one interactions with sales representatives, free meals, and gifts worth less than CAN $10.

RESULTS

A total of 37 residents responded to both questionnaires. After the intervention residents had more cautious attitudes, rating marketing strategies on a five-point Likert scale as less ethically appropriate (-0.41, p < .05) and less valuable to patients or useful to the resident (-0.39, p < .05), and reporting less intention to use them in the future (-0.44, p < .01).

CONCLUSION

This intervention appears to have promoted more cautious attitudes toward pharmaceuticals marketing. Its long-term sustainability and effect on behavior remain unknown.

[Analysis of the relationship between primary care doctors and the pharmaceutical industry]

OBJECTIVES

To describe the type of relationship between primary care family doctors (PCDs) and the pharmaceutical industry (PI) and its representatives in Aragon, to describe doctors' attitudes to this relationship and to find out how doctors behave towards offers from the industry.

DESIGN

Descriptive cross-sectional study, through a self-filled questionnaire with closed replies, of a representative sample of the population under study.

SETTING AND PARTICIPANTS

Family doctors working in primary care teams throughout Aragon.

RESULTS

The reply rate of 28.17% maintained the study's representativity. Differences in the kind of relationship between PCDs and PI were found in gender (greater relationship of male doctors) and setting (it was greater in urban areas). Doctors working in centres with teaching credentials and woman doctors had a more critical attitude. The tendency to collaborate with the industry's offers was greater in the rural areas and among men. The group of doctors that interacted most with the industry tended to collaborate more with the proposals of the PI. No relationship was found between attitude and conduct of PCDs.

CONCLUSIONS

Results confirm both the starting hypotheses: a) the nature of relationships between PCDs and the PI and its representatives affects prescribing behaviour, and b) there are differences between what doctors think they should do and what they really do in their dealings with the PI.