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Schwartz LM, Woloshin S, Lu Z, Ross KM, Tessema FA, Peter D, Kesselheim AS. Randomized Study of Providing Evidence Context to Mitigate Physician Misinterpretation Arising From Off-Label Drug Promotion. Circ Cardiovasc Qual Outcomes 2019; 12:e006073. [DOI: 10.1161/circoutcomes.119.006073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Recent court decisions have thrown into question the Food and Drug Administration’s rules limiting manufacturer promotion of prescription drugs for unapproved uses. We assessed how providing pro forma disclosures or more descriptive evidence context about the data supporting an off-label claim affected physicians’ beliefs about drug efficacy.
Methods and Results:
In online and mailed surveys, we randomized national samples of board-certified, clinically active cardiologists, internists, and endocrinologists to receive 1 of 3 information scenarios about a hypothetical drug derived verbatim from excerpts on the website for Vascepa, a prescription fish oil for which Food and Drug Administration specially permitted off-label promotion after a manufacturer lawsuit. The scenarios presented information about the approved on-label indication (severe hypertriglyceridemia), off-label claim + pro forma disclaimers (suggestive but not conclusive evidence for use as an add-on to a statin for patients reaching low-density lipoprotein goal but with persistent moderate hypertriglyceridemia), and off-label claim + evidence context (eg, reports on 3 trials failing to demonstrate cardiovascular benefit of other triglyceride-lowering drugs for such patients). Among 686 respondents (48% response rate), 29% reported receiving off-label information about Vascepa (ie, use as an add-on to a statin) from the manufacturer, and 16% had prescribed it off-label for this purpose. Off-label prescribing was 5 times higher among physicians who received such off-label information (38% versus 7%,
P
<0.001). For the hypothetical drug, the proportion of physicians endorsing the unproven claim that the drug reduced cardiovascular risk was similar among those randomized to the on-label and off-label claim + pro forma disclaimers scenarios (35% versus 37% [95% CI, −6% to 11%]), but substantially lower among those randomized to the off-label claim + evidence context scenario (21% [95% CI, −24% to 7%]).
Conclusions:
Physicians who received company information about the unapproved use of Vascepa were more likely to report prescribing it off-label. Supplementing off-label claims with evidence context improved the prescribers’ knowledge and reduced enthusiasm for the unproven, off-label indication of reducing cardiovascular risk.
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Affiliation(s)
- Lisa M. Schwartz
- Center for Medicine and the Media, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (L.M.S., S.W.)
| | - Steven Woloshin
- Center for Medicine and the Media, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (L.M.S., S.W.)
- The Lisa Schwartz Program for Truth in Medicine (S.W.)
| | - Zhigang Lu
- Program On Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School in Boston, MA (Z.L., F.A.T., A.S.K.)
| | - Kathryn M. Ross
- American Board of Internal Medicine, Philadelphia, PA (K.M.R.)
| | - Frazer A. Tessema
- Program On Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School in Boston, MA (Z.L., F.A.T., A.S.K.)
| | - Doris Peter
- The Center for Outcomes Research & Evaluation (CORE), Yale-New Haven Hospital, New Haven, CT (D.P.)
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School in Boston, MA (Z.L., F.A.T., A.S.K.)
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2
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Hey SP, Kesselheim AS. Defining "True and Non-Misleading" for Pharmaceutical Promotion. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2018; 46:552-554. [PMID: 30146990 DOI: 10.1177/1073110518782970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Spencer Phillips Hey
- Spencer Phillips Hey, Ph.D., is a Research Scientist in the Program on Regulation, Therapeutics, and Law (PORTAL) in the Division of Pharmacoepidemiology and Pharmacoeconomics at the Brigham and Women's Hospital and a faculty member at the Harvard Center for Bioethics in Boston. Aaron S. Kesselheim, M.D., J.D., M.P.H., is an Associate Professor of Medicine at Harvard Medical School and Director of the Program on Regulation, Therapeutics, and Law (PORTAL) in the Division of Pharmacoepidemiology and Pharmacoeconomics at the Brigham and Women's Hospital and a faculty member at the Harvard Center for Bioethics in Boston. He is also a faculty member at the Harvard Center for Bioethics
| | - Aaron S Kesselheim
- Spencer Phillips Hey, Ph.D., is a Research Scientist in the Program on Regulation, Therapeutics, and Law (PORTAL) in the Division of Pharmacoepidemiology and Pharmacoeconomics at the Brigham and Women's Hospital and a faculty member at the Harvard Center for Bioethics in Boston. Aaron S. Kesselheim, M.D., J.D., M.P.H., is an Associate Professor of Medicine at Harvard Medical School and Director of the Program on Regulation, Therapeutics, and Law (PORTAL) in the Division of Pharmacoepidemiology and Pharmacoeconomics at the Brigham and Women's Hospital and a faculty member at the Harvard Center for Bioethics in Boston. He is also a faculty member at the Harvard Center for Bioethics
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Hey SP, Cohen IG, Adashi EY, Kesselheim AS. Influence, integrity, and the FDA: An ethical framework. Science 2017; 357:876-877. [PMID: 28860375 DOI: 10.1126/science.aao1056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Evaluate external influences on scientific deliberations
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Affiliation(s)
- Spencer Phillips Hey
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA.,Center for Bioethics, Harvard Medical School, Boston, MA 02115, USA
| | - I Glenn Cohen
- Petrie-Flom Center, Harvard Law School, Cambridge, MA 02138, USA
| | - Eli Y Adashi
- Warren Alpert Medical School, Brown University, Providence, RI 02903, USA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA. .,Center for Bioethics, Harvard Medical School, Boston, MA 02115, USA
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Affiliation(s)
- Christopher Robertson
- From the Regulatory Science Program and James E. Rogers College of Law, University of Arizona, Tucson (C.R.); New York University School of Law, New York (C.R.); and the Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (A.S.K.)
| | - Aaron S Kesselheim
- From the Regulatory Science Program and James E. Rogers College of Law, University of Arizona, Tucson (C.R.); New York University School of Law, New York (C.R.); and the Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (A.S.K.)
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