Characteristics of recipients of free prescription drug samples: a nationally representative analysis

Oversight of in-office dispensing and samples in dermatology

The provision of samples and in-office dispensing of products and medications to patients are important, yet often controversial, practices in dermatology. Opinions on the practices of sampling and in-office dispensing vary greatly among dermatologists. Ultimately, there are several advantages and disadvantages associated with each practice, and common topics of discussion include ethics, costs, safety, and adherence. Many of the concerns associated with the practices of sampling and dispensing in dermatology may be mitigated by careful consideration and action by prescribers. Providers should be aware of their current practices surrounding these issues and, if used, methods by which these practices can be improved to optimize patient care. With careful consideration, it may be possible to practice sampling and dispensing of products and medications safely, ethically, and to the patients' advantage as an integral part of the dermatology practice.

Pharmaceutical marketing: the example of drug samples

Branded drug samples are one of the most important promotional tools that pharmaceutical manufactures employ. Pharmaceutical sales representatives (“drug reps”) use samples to gain access to physicians and other prescribers. Sample provision is closely intertwined with visits by drug reps; detailing visits convince physicians to try new products, while sampling maintains the flow of prescriptions. Only drugs with the highest profit margins are sampled. Although physicians believe that samples save patients money, patients who receive samples have higher overall out-of-pocket costs. Most studies have found that patients in financial need are least likely to receive samples. Pharmaceutical marketers pitch samples as a low-risk way to deal with diagnostic uncertainty. In fact, there is no evidence that samples aid diagnosis. Sample availability may compromise patient safety by reducing compliance with guidelines and steering patients towards newer drugs, for which adverse effects have not been well-delineated. Although physicians believe that samples improve adherence for low-income patients, branded samples do not improve access or adherence Samples are not a charitable activity, but are instead a highly effective form of drug marketing. Sampling of branded drugs increase drug costs for everyone. Only a cohesive effort by clinicians, legislators and policymakers can end this practice. Evidence supports a ban on sample distribution of branded products.

Characteristics of Copayment Offsets for Prescription Drugs in the United States

IMPORTANCE

Despite ongoing debate regarding the high prices that patients pay for prescription drugs, to our knowledge, little is known regarding the use of coupons, vouchers, and other types of copayment "offsets" that reduce patients' out-of-pocket drug spending. Although offsets reduce patients' immediate cost burden, they may encourage the use of higher-cost products and diminish health insurers' ability to optimize pharmaceutical value.

OBJECTIVE

To examine the drugs most commonly covered by offsets, the percentage of out-of-pocket costs covered by offsets, and the characteristics of patients using offsets for retail pharmacy transactions in the United States in 2017 through 2019.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort analysis was conducted of a 5% nationally random sample of anonymized pharmacy claims from IQVIA's Formulary Impact Analyzer, which captures more than 60% of all US pharmacy transactions. This analysis focused on 631 249 individuals who used at least 1 offset between October 1, 2017, and September 30, 2019.

MAIN OUTCOMES AND MEASURES

Offset source, types of drugs covered by offsets, offset dollar value and percentage of out-of-pocket payment covered, and county characteristics of offset recipients.

RESULTS

The 631 249 individuals in the study (361 855 female participants [57.3%]; mean [SD] age, 45.7 [18.6] years) had approximately 33 million prescription fills, of which 12.8% had an offset used. Of these, 50.2% originated from a pharmaceutical manufacturer, 47.2% originated from a pharmacy or pharmacy benefit manager (PBM), and 2.6% originated from a state assistance program. A total of 80.0% of manufacturer-sponsored offsets were concentrated among 6.2% of unique products, and 79.9% of pharmacy-PBM offsets were concentrated among 4.9% of unique products. Most manufacturer offsets (88.2%) were for branded products, while most pharmacy-PBM offsets were for generic products (90.5%). The median manufacturer offset was $51.00, covering 87.1% of out-of-pocket costs; the median pharmacy-PBM offset was $16.30, covering 39.3% of out-of-pocket costs. There was no meaningful association between offset magnitude and county-level income, health insurance coverage, or race/ethnicity.

CONCLUSIONS AND RELEVANCE

In this analysis of patient-level pharmacy claims from 2017 to 2019, approximately half of all offsets involved pharmacy-PBM contractual arrangements, and half were offered by manufacturers. All offsets were associated with a significant reduction in patients' out-of-pocket costs, were highly concentrated among a few drugs, and were generally not more generous among individuals in counties with lower income or larger Black or uninsured populations.

Use of prescription drug samples in the US and implications for pharmacoepidemiologic research: a systematic search of the literature

INTRODUCTION

Free drug samples are not captured in the pharmacy claims databases used in many pharmacoepidemiologic studies, which could lead to misclassification of drug exposure status and thus bias study results.

AREAS COVERED

We systematically searched the literature in PubMed/MEDLINE, Embase, and Scopus from database inception to August 2020 for studies assessing the magnitude of exposure misclassification in pharmacy claims data associated with uncaptured drug sample utilization. Our review identified five US-based studies with substantially different characteristics, contexts, methods, and results. Taken together, these studies suggest that the risk of sample-related bias may be higher for (1) studies of newly approved, patented brand-only drugs in specific classes and contexts; (2) studies of populations where sample use is common and the unexposed cohort is small; and (3) studies where the outcomes of interest are expected to be early-onset or acute, with non-constant hazards.

EXPERT OPINION

In light of declining overall trends in sample use, future research on sample-related exposure misclassification should focus on delineating bias across those modern contexts where sample use remains high and optimizing bias quantification methods to create a more standardized approach. Additionally, further assessment is warranted for other sources of misclassified exposure status in claims-based pharmacoepidemiology research.

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.

Drug samples in family medicine teaching units: a cross-sectional descriptive study: Part 3: availability and use of drug samples in Quebec

OBJECTIVE

To draw a portrait of drug sample distribution and to assess the concordance between drug samples distributed and the medical problems encountered in the ambulatory primary health care setting.

DESIGN

Descriptive cross-sectional survey. A self-administered questionnaire was distributed to all health care professionals (HCPs) in family medicine teaching units (FMTUs) that kept drug samples between February and December 2013. Dispensers were defined as HCPs reporting the use of drug samples. Concurrently, an inventory log sheet was completed by managers of drug samples to document the contents of sample cabinets. Data from the Canadian Disease and Therapeutic Index were used as the criterion standard to assess the consistency between the drug samples found in the cabinets and the profile of the most frequent health problems encountered in primary care.

SETTING

All 33 FMTUs that kept drug samples in Quebec.

PARTICIPANTS

Health care professionals authorized to hand out drug samples (practising physicians, residents, pharmacists, and nurses), and managers of drug sample cabinets.

MAIN OUTCOME MEASURES

Dispensing practices of HCPs; number of doses of each drug contained in the sample cabinets; total market value of the samples; concordance between the drug sample categories made available and the most common medical problems encountered in primary care; and data on safe handling, ethical issues, effect of the pharmaceutical industry on prescribing behaviour, and inventory of samples.

RESULTS

Among 859 HCPs, 579 (67%) reported dispensing drug samples. A large proportion of dispensers (88%) were unable to find the specific drug they sought and half of them (51%) provided the patients with a drug sample even if it was not their first choice for treatment. The drug sample cabinet inventory revealed products from 292 different companies and identified a total of 382 363 medication doses for a total value of $201 872. We found gaps among types of drugs provided to patients, those the HCPs would consider useful, and those available in the cabinets.

CONCLUSION

Drug samples available in FMTUs do not meet the needs of many patients and HCPs, suggesting that the main driving force for drug sample distribution is not patient care. Policies on drug samples in FMTUs should be uniform across the province, and management should be as strict as in community pharmacies. Otherwise, prohibiting their use should be considered.

Use of Prescription Drug Samples in the USA: A Descriptive Study with Considerations for Pharmacoepidemiology

INTRODUCTION

Free prescription drug samples provided in physician offices can lead to exposure misclassification in pharmacoepidemiologic studies that rely on pharmacy claims data.

METHODS

We quantified drug-specific sample provision rates based on nationally projected data from a survey of over 3200 US office-based physicians for 1993-2013.

RESULTS

Between 2009 and 2013, a total of 44.7 % of newly initiated brand-only sitagliptin but only 3.6 % of generically available metformin therapy was provided as samples. We observed similar discrepancies between newly initiated rosuvastatin and simvastatin, dabigatran and warfarin, atomoxetine and methylphenidate, and between oral antibiotic drugs. During continued therapy, sample use was still present though to a lesser extent (sitagliptin 17.0 %, rosuvastatin 23.9 %), and remained high for some oral contraceptives (norethindrone 55.8 %). Oral contraceptives had the longest average days of sample supply (levonorgestrel, continued use 85.1 days). The average days of supply for all other chronically used study drugs ranged from 13.4 (dabigatran, new use) to 25.3 (exenatide, continued use) per sample provided. From 1993 to 2013, we found pronounced drops in sample provisions over time coinciding with more recent generic approval dates.

CONCLUSIONS

We observed markedly differential exposure to medication samples between branded and generic drugs. This can introduce bias in pharmacoepidemiologic studies, especially when adverse events that occur soon after drug initiation are of interest.

Utilization of free medication samples in the United States in a nationally representative sample: 2009-2013

BACKGROUND

Manufacturers provide free sample medications as a means to increase use of branded medications. Sample use varies year-to-year as branded product patents expire and new products come to market.

OBJECTIVE

This study sought to describe the use of sample medications during 2009-2013 and assess individual characteristics associated with sample use.

METHODS

Data from the 2009-2013 U.S. Medical Expenditure Panel Survey (MEPS) were used. MEPS asks participants whether they received each medication they are taking as a sample. The top 10 medications and medication classes used each year by volume were identified as well as the proportion of people who used at least one sample medication. The proportion of new initiators of medications were also classified as the percent who received a sample for the specific medication. Logistic regression was used to assess individual demographics, insurance, and medication characteristics associated with use.

RESULTS

Prevalence of sample use ranged from 9.3% in 2009 to 6.2% in 2013. The most widely used sample medications included statins during 2009-2011, which changed to inhaled β-agonists in 2012-2013, as atorvastatin became available as a generic. The overall volume of the top 10 free sample medications decreased by one-third over this study period. In 2013, 12.6% of new insulin analog users and 11.0% of new oral contraceptive users receive these medications through samples. Regression analysis showed that U.S. Medicaid- and Medicare-insured persons were less likely to use samples compared to those with private insurance.

CONCLUSIONS

Sample medication use has decreased as generic medications are becoming more used in the U.S.

Qualitative insights into promotion of pharmaceutical products in Bangladesh: how ethical are the practices?

BACKGROUND

The pharmaceutical market in Bangladesh is highly concentrated (top ten control around 70 % of the market). Due to high competition aggressive marketing strategies are adopted for greater market share, which sometimes cross limit. There is lack of data on this aspect in Bangladesh. This exploratory study aimed to fill this gap by investigating current promotional practices of the pharmaceutical companies including the role of their medical representatives (MR).

METHODS

This qualitative study was conducted as part of a larger study to explore the status of governance in health sector in 2009. Data were collected from Dhaka, Chittagong and Bogra districts through in-depth interview (healthcare providers and MRs), observation (physician-MR interaction), and round table discussion (chief executives and top management of the pharmaceutical companies).

RESULTS

Findings reveal a highly structured system geared to generate prescriptions and ensure market share instituted by the pharmaceuticals. A comprehensive training curriculum for the MRs prepares the newly recruited science graduates for generating enough prescriptions by catering to the identified needs and demands of the physicians expressed or otherwise, and thus grab higher market-share for the companies they represent. Approaches such as inducements, persuasion, emotional blackmail, serving family members, etc. are used. The type, quantity and quality of inducements offered to the physicians depend upon his/her capacity to produce prescriptions. The popular physicians are cultivated meticulously by the MRs to establish brand loyalty and fulfill individual and company targets. The physicians, willingly or unwillingly, become part of the system with few exceptions. Neither the regulatory authority nor the professional or consumer rights bodies has any role to control or ractify the process.

CONCLUSIONS

The aggressive marketing of the pharmaceutical companies compel their MRs, programmed to maximize market share, to adopt unethical means if and when necessary. When medicines are prescribed and dispensed more for financial interests than for needs of the patients, it reflects system's failed ability to hold individuals and entities accountable for adhering to basic professional ethics, code of conduct, and statutory laws.

Pharmaceutical Cost-Saving Strategies and their Association with Medication Adherence in a Medicare Supplement Population

BACKGROUND

On average, Medicare Supplement insureds take about seven unique prescription medications each year, resulting in substantial out-of-pocket drug copayments, in addition to Medicare Supplement and Part D premiums. To help alleviate this financial burden, many individuals resort to cost-saving strategies that are not trackable by Part D insurance plans, likely resulting in an underestimation of medication adherence rates.

OBJECTIVE

We aimed to estimate utilization rates of cost-saving strategies, measure member characteristics associated with these strategies and estimate if these strategies are associated with medication adherence.

DESIGN

This was a cross-sectional analysis of a 2012-2013 survey of AARP® Medicare Supplement plan insureds with Part D pharmaceutical coverage.

PARTICIPANTS

The study included 5,784 community-dwelling survey respondents ≥ 65 years of age, living in ten states and with self-reported use of prescription medications.

MAIN MEASURES

Self-reported use of cost-saving strategies included: obtaining free samples from physicians, splitting pills so medications lasted longer, purchasing medications from other countries and/or over the internet, or purchasing medications through the Veterans Administration. Propensity weighted multivariate regressions were utilized to determine characteristics associated with the use of such strategies and the association with medication adherence as measured from Medicare Part D claims.

KEY RESULTS

Among those taking medications, 39.6% used cost-saving strategies. Those using these strategies were significantly (p < 0.05) more likely to be male, non-minority, have more comorbid conditions, have more disabilities and use more medications. Few variables were significantly related to pharmaceutical nonadherence, but those who were nonadherent were significantly more likely to use more medications, split pills, obtain free samples from their physicians and be male.

CONCLUSION

Cost-saving strategies are used extensively as a means to augment Medicare Part D coverage. These strategies are associated with measured medication nonadherence and likely result in underreporting of medication adherence rates. Pharmacy management programs should consider these additional medication sources in assisting plan members to problem solve cost-related medication management issues.

Changes in drug coverage generosity and untreated serious mental illness: transitioning from Medicaid to Medicare Part D

IMPORTANCE

More than 1 in 5 disabled people with dual Medicare-Medicaid enrollment have schizophrenia or a bipolar disorder (ie, a serious mental illness). The effect of their transition from Medicaid drug coverage, which varies in generosity across states, to the Medicare Part D drug benefit is unknown. Many thousands make this transition annually.

OBJECTIVES

To determine the effect of transitioning from Medicaid drug benefits to Medicare Part D on medication use by patients with a serious mental illness and to determine the influence of Medicaid drug caps.

DESIGN, SETTING, AND PARTICIPANTS

In time-series analysis of continuously enrolled patient cohorts (2004-2007), we estimated changes in medication use before and after transitioning to Part D, comparing states that capped monthly prescription fills with states with no prescription limits. We used Medicaid and Medicare claims from a 5% national sample of community-dwelling, nonelderly disabled dual enrollees with schizophrenia (n = 5554) or bipolar disorder (n = 3675).

MAIN OUTCOMES AND MEASURES

Psychotropic treatments included antipsychotics for schizophrenia and antipsychotics, anticonvulsants, and lithium for bipolar disorder. We measured monthly rates of untreated illness, intensity of treatment, and overall prescription medication use.

RESULTS

Prior to Part D, the prevalence of untreated illness among patients with a bipolar disorder was 30.0% in strict-cap states and 23.8% in no-cap states. In strict-cap states, the proportion of untreated patients decreased by 17.2% (relatively) 1 year after Part D, whereas there was no change in the proportion of untreated patients in no-cap states. For patients with schizophrenia, the untreated rate (20.6%) did not change in strict-cap states, yet it increased by 23.3% (from 11.6%) in no-cap states. Overall medication use increased substantially after Part D in strict-cap states: prescription fills were 35.5% higher among patients with a bipolar disorder and 17.7% higher than predicted among schizophrenic patients; overall use in no-cap states was unchanged in both cohorts.

CONCLUSIONS AND RELEVANCE

The effects of transitioning from Medicaid to Medicare Part D on essential treatment of serious mental illness vary by state. Transition to Part D in states with strict drug benefit limits may reduce rates of untreated illness among patients with bipolar disorders, who have high levels of overall medication use. Access to antipsychotic treatment may decrease after Part D for patients with a serious mental illness living in states with relatively generous uncapped Medicaid coverage.

The Physician Payments Sunshine Act: data evaluation regarding payments to ophthalmologists

PURPOSE

To review data for ophthalmologists published online from the Physician Payments Sunshine Act.

DESIGN

Retrospective data review using data acquired from a publicly available electronic database.

METHODS

A database was downloaded from the Centers for Medicare and Medicaid Services website under Identified General Payments to Physicians and a primary specialty of ophthalmology. Basic statistical analysis was performed including mean, median, and range of payments for both single payments and per provider.

MAIN OUTCOME MEASURES

Data summary by category of payment and geographic region and comparison with other surgical subspecialties.

RESULTS

From August 1, 2013, through December 31, 2013, a total of 55 996 individual payments were reported to 9855 ophthalmologists for a total of $10 926 447. The mean amount received in a single payment was $195.13 (range, $0.04-$193 073). The mean amount received per physician identifier (ID) was $1108 (range, $1-$397 849), and the median amount was $112.01. Consulting fees made up the largest percentage of fees. There was not a large difference in payments received by region. The mean payments for the subspecialties of dermatology, neurosurgery, orthopedic surgery, and urology ranged from $954 to $6980, and median payments in each field by physician ID ranged from $88 to $173.

CONCLUSIONS

A large amount of data were released by the Centers for Medicare and Medicaid Services for the Physician Payment Sunshine Act. In ophthalmology, mean and median payments per physician did not vary greatly from other surgical subspecialties. Most single payments were less than $100, and most physicians received less than $500 in total payments. Payments for consulting made up the largest category of spending. How this affects patient perception, patient care, and medical costs warrants further study.

Evidence of sample use among new users of statins: implications for pharmacoepidemiology

BACKGROUND

Epidemiologic studies of prescription medications increasingly rely on large administrative health care databases. These data do not capture patients' use of medication samples. This could potentially bias studies of short-term effects where date of initiation may be inaccurate.

OBJECTIVES

To assess the extent of sample use among patients initiating statin therapy.

RESEARCH DESIGN

Retrospective cohort of patients who filled a first prescription for a statin after at least 6 months of statin-free period in 2007-2010. Low-density lipoprotein (LDL) values obtained within the 15 days preceding the first prescription were analyzed using a 2-component Gaussian mixture model to look for evidence of prior treatment.

SUBJECTS

A total of 26,033 statin initiators with at least 1 LDL laboratory result within the 15 days preceding the prescription fill.

MEASURES

Estimators for the proportion of patients filling a new prescription already on treatment.

RESULTS

Among 9256 patients filling a branded statin, LDL distribution was bimodal, consisting of 2 Gaussian distributions: one, which made up 13.4% of the total population, had much lower LDL values (mean=71.8 mg/dL) compared with the second (mean=148.0 mg/dL), suggesting drug use before first dispensed prescription. Among 16,777 patients filling a generic statin, LDL levels were substantially higher with no evidence of bimodality that would suggest prior sample use.

CONCLUSIONS

These results provide indirect evidence that the initial period of branded medication use may often be missed when using pharmacy claims data to define drug initiation. Further research is needed to examine approaches to better identify incident medication use when assessing short-term effects.

Characterizing the relationship between free drug samples and prescription patterns for acne vulgaris and rosacea

IMPORTANCE

Describing the relationship between the availability of free prescription drug samples and dermatologists' prescribing patterns on a national scale can help inform policy guidelines on the use of free samples in a physician's office.

OBJECTIVES

To investigate the relationships between free drug samples and dermatologists' local and national prescribing patterns and between the availability of free drug samples and prescription costs.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study investigating prescribing practices for acne, a common dermatologic condition for which free samples are often available. The settings were, first, the offices of nationally representative dermatologists from the National Disease and Therapeutic Index (an IMS Health Incorporated database) and, second, an academic medical center clinic without samples. Participants were ambulatory patients who received a prescription from a dermatologist for a primary initial diagnosis of acne vulgaris or rosacea in 2010.

MAIN OUTCOMES AND MEASURES

National trends in dermatologist prescribing patterns, the degree of correlation between the availability of free samples and the prescribing of brand-name medications, and the mean cost of acne medications prescribed per office visit nationally and at an academic medical center without samples.

RESULTS

On a national level, the provision of samples with a prescription by dermatologists has been increasing over time, and this increase is correlated (r = 0.92) with the use of the branded generic drugs promoted by these samples. Branded and branded generic drugs comprised most of the prescriptions written nationally (79%), while they represented only 17% at an academic medical center clinic without samples. Because of the increased use of branded and branded generic drugs, the national mean total retail cost of prescriptions at an office visit for acne was conservatively estimated to be 2 times higher (approximately $465 nationally vs $200 at an academic medical center without samples).

CONCLUSIONS AND RELEVANCE

Free drug samples can alter the prescribing habits of physicians away from the use of less expensive generic medications. The benefits of free samples in dermatology must be weighed against potential negative effects on prescribing behavior and prescription costs.

Trust and transparency: patient perceptions of physicians' financial relationships with pharmaceutical companies

Financial ties between physicians and pharmaceutical companies are pervasive and controversial. However, little is known about how patients perceive such ties. This paper describes an experiment examining how a national sample of U.S. adults perceived a variety of financial relationships between physicians and drug companies. Each respondent read a single scenario about a hypothetical physician and his financial ties to the pharmaceutical industry; scenarios varied in terms of payment type of (e.g., payment for meals vs. consulting fees) and amount. Respondents then evaluated the physician on several dimensions (e.g., expertise, trustworthiness, knowledge of new treatments, moral character, focus on patients' interests). Findings revealed that perceptions of the physician were more strongly influenced by payment type than by payment amount. Specifically, respondents were quite critical of doctors who owned drug company stock or received industry payments for meals and lodging, but were more forgiving of physicians who received free drug samples (which were perceived as benefiting patients) or consulting fees (which were seen as signaling physician expertise). Interestingly, physicians who received no payments, while seen as honest, were also viewed by some respondents as inexperienced or uninformed about new treatments. Implications for public policy and future research are discussed.

Infused chemotherapy use in the elderly after patent expiration

PURPOSE

The use of anticancer drugs (chemotherapies) is an important determinant of national spending trends. Recent policies have aimed to accelerate generic entry among chemotherapies to generate cost savings.

METHODS

We examined the effects of generic entry on the choice of chemotherapy for the treatment of metastatic colorectal cancer (MCRC) between 2006 and 2009 using autoregressive-moving average modeling with case control. A nationally representative sample of oncologists and patients with cancer (age ≥ 65 years) was employed to estimate the magnitude and significance of the impact of the generic entry of irinotecan in February 2008 on the number of administrations of irinotecan compared with oxaliplatin.

RESULTS

The generic entry of irinotecan resulted in a 17% to 19% decrease (P < .001) in use among elderly patients with MCRC compared with oxaliplatin. The results were robust to multiple sensitivity checks.

CONCLUSION

This study provides novel and robust estimates of the decline in use of a chemotherapy to treat a common cancer in the elderly after patent expiration. The results suggest estimates from a previous Office of the Inspector General report of the potential savings derived from the generic entry of irinotecan for public payers are an overestimate, likely confounded by oncologists' response to financial incentives, changes in scientific evidence, and promotional activities. As calls for improving the quality and cost efficiency of oncology increase, future empirical work is needed to examine the responsiveness of oncologists' treatment decision making to incentives among patients of all ages and insurance types.

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.

Use of prescription drug samples and patient assistance programs, and the role of doctor-patient communication

BACKGROUND

Cost-related underuse of medications is common among older adults, who seldom discuss medication costs with their physicians. Some older adults may use free drug samples or industry-sponsored patient assistance programs (PAP) in hopes of lowering out-of-pocket costs, although the long-term effect of these programs on drug spending is unclear.

OBJECTIVE

To examine older adults' use of industry-sponsored strategies to reduce out-of-pocket drug costs and the association between doctor-patient communication and use of these programs.

DESIGN

Cross-sectional analysis of a 2006 nationally representative survey of Medicare beneficiaries.

PARTICIPANTS

14,322 community-dwelling Medicare beneficiaries age ≥65.

MAIN MEASURES

We conducted bivariate and multivariate analyses of the association between receipt of free samples and participation in PAPs with sociodemographic characteristics, health status, access to care, drug coverage, medication cost burden, and doctor-patient communication.

KEY RESULTS

51.4% of seniors reported receiving at least one free sample over the last 12 months and 29.2% reported receiving free samples more than once. In contrast, only 1.3% of seniors reported participating in an industry-sponsored PAP. Higher income respondents were more likely to report free sample receipt than low-income respondents (50.8% vs. 43.8%, p < 0.001) and less likely to report participating in a PAP (0.42% vs. 2.2%, p < 0.001). In multivariate analyses, those who reported talking to their doctor about the cost of their medications had more than twice the odds of receiving samples as those who did not (OR 2.17, 95% CI 1.95-2.42).

CONCLUSIONS

In 2006, over half of seniors in Medicare received free samples, but only 1.3% reported receiving any medications from a patient assistance program. Doctor-patient communication is strongly associated with use of these programs, which has important implications for clinical care regardless of whether these programs are viewed as drivers of prescription costs or a remedy for them.

National estimates and predictors of prescription medication sample use in the United States, 1999-2005

OBJECTIVES

To determine the prevalence of free medication sample use in the United States and analyze the effects of socioeconomic status and drug safety actions.

DESIGN

Cross-sectional study.

SETTING

United States from 1999 to 2005.

PARTICIPANTS

Survey respondents representative of the civilian noninstitutionalized population.

INTERVENTION

Analysis of data from the Medical Expenditure Panel Survey, a nationally representative longitudinal household survey.

MAIN OUTCOME MEASURES

Identification of a medication as being provided as a sample at least once during a study year.

RESULTS

An annual average of 5.1% (range 4.4% in 2005 to 5.8% in 2002) of all prescription medications were provided as a sample at least once during a year, with 18.3% of all Americans who received at least one prescription drug receiving at least one drug as a sample. On multivariate analysis, sample use was greater among young (18-30 years) non-Hispanic whites and the uninsured but had minimal independent association with income. The proportion of sample use among users of hormone replacement therapy and cyclooxygenase-2 inhibitors remained relatively constant even as total use of these drugs declined after Food and Drug Administration regulatory action.

CONCLUSION

Use of medication samples is common in the U.S. population. After adjusting for health insurance, sample use was not associated with income and samples were less frequently provided to racial/ethnic minorities and to the elderly. The putative economic benefits of free samples do not appear to go to patients with the greatest financial need. Drug regulatory actions did not have a disproportionate effect on provision of drugs as samples.

Managing conflicts of interest in clinical care: a national survey of policies at U.S. medical schools

PURPOSE

Policy recommendations specify how academic medical centers should manage clinical conflicts of interest (CCOIs), including gifts and payments to physicians from pharmaceutical companies. However, no reliable data exist on the extent to which schools have policies to manage CCOIs. The authors sought to determine the extent and strength of medical schools' CCOI policies.

METHOD

A survey asked compliance officers at 125 MD-granting medical schools in the United States to indicate whether their institutions had policies covering 11 areas of CCOI and to provide copies of relevant policies. Policies were scored as 0 (no policy), 1 (permissive), 2 (moderate), or 3 (stringent), based on published recommendations. Each school's scores were averaged to create a measure of overall policy strength. The authors also collected information on schools' public/private status, hospital ownership/affiliation, and NIH funding to determine whether these characteristics were associated with differences in policy strength.

RESULTS

A representative sample of 77 of 125 (62%) medical schools responded between October 2007 and December 2008. Absence of policy was the most frequent finding in 7 of 11 CCOI areas. The mean score for overall policy strength was 1.2. Greater NIH funding was associated with stronger policies in 9 areas.

CONCLUSIONS

This analysis provides a comprehensive overview of medical schools' CCOI policies. Wider adoption of CCOI policies is crucial to eliminate undue industry influence in clinical care and to preserve public trust in the medical profession. The authors close with a consideration of why so few medical schools have implemented strong policies.

The effect of medication samples on self-reported prescribing practices: a statewide, cross-sectional survey

BACKGROUND

The pharmaceutical industry spends billions of dollars annually to encourage clinicians to prescribe their medications. Small studies have demonstrated that one of the marketing strategies, the distribution of free sample medications, is associated with increased use of brand name medication over generic medication.

OBJECTIVES

To determine the relationship between the presence of drug samples in primary care clinics and prescription of preferred drug treatments.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Primary care prescribers in the state of Vermont.

MAIN MEASUREMENT

Prescribers were presented with two clinical vignettes and asked to provide the name of the medication they would prescribe in each case. We compared the responses of prescribers with and without samples in their clinics.

KEY RESULTS

Two hundred six prescribers out of the total population of 631 returned the survey and met the eligibility criteria. Seventy-two percent of prescribers had sample closets in their clinics. Seventy percent of clinicians with samples would prescribe a thiazide diuretic for hypertension compared to 91% in those without samples (P<0.01). For managing depression 91% of prescribers with samples would have provided a generic medication in a patient with no health insurance, compared to 100% of those without samples in their clinic (P=0.02).

CONCLUSIONS

Clinicians with samples in their clinics were less likely to prescribe preferred medications for hypertension and depression.

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.

Psychiatrists' relationships with industry: the principal-agent problem

Psychiatrists' relationships with the pharmaceutical and device industries have been a growing focus of attention, with questions raised about the impact of those relationships on prescribing practices, diagnostic criteria, practice guidelines, continuing education, conduct and reporting of research, and patients' and public trust. Indeed, these concerns exist for the medical profession as a whole, with various remedial measures proposed. We suggest that such relationships can be understood as giving rise to a "principal-agent problem," which occurs when an agent (here, a physician) is engaged to advance the interests of another party, the principal (typically a patient), but also faces incentives to promote other interests. Studies suggest that at least some relationships--which include attending industry-sponsored presentations, meeting with marketing representatives, and accepting samples--can alter psychiatrists' and other physicians' behavior in ways that can compromise patients' interests, and that industry-funded research may create bias in the medical literature. These effects are difficult to detect in specific cases, however, because of asymmetries of information and may not be apparent even to physicians themselves. Principal-agent analysis suggests that the possible responses to such problems, including appeals to ethical principles, monitoring behavior, and managing risk-inducing situations, should include consideration of aligning agents' incentives with principals' interests. This type of analysis underscores the similarity of the issues raised by physicians' relationships with industry to problems that arise more generally in society, thus reducing physicians' potential affective responses to these issues and efforts to address them. Finally, such analysis directs attention to the benefits and costs of each alternative, thereby encouraging reliance on evidence as a basis for policy.

Drug samples in dermatology: special considerations and recommendations for the future

BACKGROUND

The use of drug samples is a controversial issue in medicine.

OBJECTIVE

We sought to determine the pros and cons of drug sampling, and how drug sampling in general medicine differs from dermatology.

METHODS

Literature searches were conducted on PubMed, Google, and Yahoo!. Articles were found pertaining to drug sampling in general, and for dermatology specifically.

RESULTS

Numerous pros and cons for drug sampling were found in the literature search. We divided these by cost-related issues, such as the industry-wide cost of sampling and the use of sampling to assist the underinsured and poor, and quality of care issues, such as adherence, patient education, and safety considerations. Articles also suggested that dermatology may differ from general medicine as topical treatments have fewer side effects, are more complicated to use, and come in different vehicles.

LIMITATIONS

We identified few studies specifically focused on issues relevant to sampling in dermatology.

CONCLUSION

There are strong arguments for and against drug sampling involving both cost and quality of care issues. Dermatology-specific medications clearly differ from oral medications in several regards. We ultimately conclude that the benefits of drug sampling outweigh the risks, but give recommendations on how drug sampling can be done ethically and effectively, including limiting personal use, not selling samples, properly documenting sample release, teaching patients about proper use, teaching students and residents ethical use of samples, working with pharmaceutical representatives in an ethical manner, prescribing the drug that is best for the patient, and securing samples appropriately to prevent theft and misuse.

Medication assistance programs: do all in need benefit equally?

OBJECTIVE

To determine if medication assistance programs (MAPs) provided by pharmaceutical companies were used differently by African Americans and Whites.

RESEARCH DESIGN

A cross-sectional survey was conducted among patients of primary care practices from 2005 to 2007 within the Alabama Nonsteroidal Anti-Inflammatory Drug (NSAID) Patient Safety Study.

SETTING

Telephone survey.

PARTICIPANTS

Respondents were 568 African American and White patients reporting annual household incomes < $50,000.

MAIN OUTCOME MEASURE

Use of MAPs.

RESULTS

Of all patients, 12.8% used MAPs, 39.5% were African American, 75.2% were female, 69.1% were aged > 65 years, 79.8% had annual household incomes < $25,000, and 35.5% indicated that their income was inadequate to meet their basic needs. MAPs were used by 11.2% African-Americans and 14.0% Whites. After multivariable adjustment, MAP use was higher among respondents with incomes not adequate to meet basic needs (odds ratio [OR]: 2.19, 95% confidence interval [CI]: 1.17-4.08) but lower among African Americans than Whites (OR: 0.49, 95% CI: 0.25-0.95). Physician characteristics did not independently predict MAP use.

CONCLUSIONS

Overall MAP use was low even among the most vulnerable, and especially among African Americans. As currently used, MAPs may contribute to disparities in medication access.

Factors associated with physicians' reliance on pharmaceutical sales representatives

PURPOSE

To examine relationships between pharmaceutical representatives and obstetrician-gynecologists and identify factors associated with self-reported reliance on representatives when making prescribing decisions.

METHOD

In 2006-2007, questionnaires were mailed to 515 randomly selected physicians in the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network. Participants were asked about the information sources used when deciding to prescribe a new drug, interactions with sales representatives, views of representatives' value, and guidelines they had read on appropriate industry interactions.

RESULTS

Two hundred fifty-one completed questionnaires (49%) were returned. Seventy-six percent of participants see sales representatives' information as at least somewhat valuable. Twenty-nine percent use representatives often or almost always when deciding whether to prescribe a new drug; 44% use them sometimes. Physicians in private practice are more likely than those in university hospitals to interact with, value, and rely on representatives; community hospital physicians tend to fall in the middle. Gender and age are not associated with industry interaction. Dispensing samples is associated with increased reliance on representatives when making prescribing decisions, beyond what is predicted by a physician's own beliefs about the value of representatives' information. Reading guidelines on physician-industry interaction is not associated with less reliance on representatives after controlling for practice setting.

CONCLUSIONS

Physicians' interactions with industry and their familiarity with guidelines vary by practice setting, perhaps because of more restrictive policies in university settings, professional isolation of private practice, or differences in social norms. Prescribing samples may be associated with physicians' use of information from sales representatives more than is merited by the physicians' own beliefs about the value of pharmaceutical representatives.

Prescribers and pharmaceutical representatives: why are we still meeting?

CONTEXT

Research suggests that pharmaceutical marketing influences prescribing and may cause cognitive dissonance for prescribers. This work has primarily been with physicians and physician-trainees. Questions remain regarding why prescribers continue to meet with pharmaceutical representatives (PRs).

OBJECTIVE

To describe the reasons that prescribers from various health professions continue to interact with PRs despite growing evidence of the influence of these interactions.

DESIGN, SETTING, AND PARTICIPANTS

Multi-disciplinary focus groups with 61 participants held in practice settings and at society meetings.

RESULTS

Most prescribers participating in our focus groups believe that overall PR interactions are beneficial to patient care and practice health. They either trust the information from PRs or feel that they are equipped to evaluate it independently. Despite acknowledgement of study findings to the contrary, prescribers state that they are able to effectively manage PR interactions such that their own prescribing is not adversely impacted. Prescribers describe few specific strategies or policies for these interactions, and report that policies are not consistently implemented with all members of a clinic or institution. Some prescribers perceive an inherent contradiction between academic centers and national societies receiving money from pharmaceutical companies, and then recommending restriction at the level of the individual prescriber. Prescribers with different training backgrounds present a few novel reasons for these meetings.

CONCLUSIONS

Despite evidence that PR detailing influences prescribing, providers from several health professions continue to believe that PR interactions improve patient care, and that they can adequately evaluate and filter information presented to them by PRs. Focus group comments suggest that cultural change is necessary to break the norms that exist in many settings. Applying policies consistently, considering non-physician members of the healthcare team, working with trainees, restructuring the current primary care model and offering convenient, individualized, non-biased educational options may aid success.

No more free drug samples?

Susan Chimonas and Jerome Kassirer argue that giving out "free" drug samples is not effective in improving drug access for the indigent, does not promote rational drug use, and raises the cost of care.

Pharmaceutical industry marketing: understanding its impact on women's health

The delivery of modern health care entails significant involvement from the pharmaceutical industry, including developing and manufacturing drugs. However, the industry also has tremendous influence on the practice of medicine through its considerable marketing efforts, both to patients through direct to consumer advertising, and to physicians through detailing, providing samples, continuing medical education, and other efforts. This article will review the role that pharmaceutical marketing plays in health care, and the substantial evidence surrounding its influence on patient and physician behaviors, with additional discussion of the medical device industry, all with particular attention to women's health. Understanding the effects of pharmaceutical marketing on women's health, through discussion of relevant examples-including oral contraceptive pills, drugs for premenstrual dysphoric disorder, Pap smear cytology techniques, and neonatal herpes prophylaxis-will help ensure that women receive unbiased, evidenced-based care. We will conclude with a discussion of guidelines that have been proposed by professional organizations, policy makers, and universities, to assist physicians in managing exposure to pharmaceutical marketing.

Free drug samples in the United States: characteristics of pediatric recipients and safety concerns

OBJECTIVES

Free drug samples frequently are given to children. We sought to describe characteristics of free sample recipients, to determine whether samples are given primarily to poor and uninsured children, and to examine potential safety issues.

METHODS

We analyzed data on 10295 US residents <18 years of age from the 2004 Medical Expenditure Panel Survey, a nationally representative survey that includes questions on receipt of free drug samples. We performed bivariate and multivariate analyses to evaluate characteristics associated with receipt of >or=1 free drug sample in 2004. We identified the most frequently reported sample medications and reviewed potential safety issues.

RESULTS

Ten percent of children who received prescription medications and 4.9% of all children received >or=1 free drug sample in 2004. In bivariate analyses, poor children (family incomes of <200% of the federal poverty level) were no more likely to receive free samples than were those with incomes of >or=400% of the poverty level (3.8% vs 5.9%). Children who were uninsured for part or all of the year were no more likely to receive free samples than were those who were insured all year (4.5% vs 5.1%); 84.3% of all sample recipients were insured. In multivariate analyses, routine access to health care (>or=3 provider visits in 2004) was associated with free sample receipt. The 15 most frequently distributed pediatric free samples in 2004 included 2 schedule II controlled medication, Adderall (amphetamine/dextroamphetamine) [corrected] and 4 medications that received new or revised black box warnings between 2004 and 2007, Elidel (pimecrolimus), Advair (fluticasone/salmeterol), Strattera (atomoxetine), and Adderall (amphetamine/dextroamphetamine).

CONCLUSIONS

Poor and uninsured children are not the main recipients of free drug samples. Free samples do not target the neediest children selectively, and they have significant safety considerations.

Medicare beneficiaries and free prescription drug samples: a national survey

BACKGROUND

New policies regulating physician/pharmaceutical company relationships propose to eliminate access to free prescription drug samples. Little is known about the prevalence of patient activity in requesting or receiving free prescription drug samples, or the characteristics of patients who access drug samples.

OBJECTIVE

To determine the prevalence of free sample access and to examine demographic, clinical, and insurance characteristics of Medicare beneficiaries who access free samples.

DESIGN

Cross-sectional study.

PARTICIPANTS

A national sample of 13,847 Medicare beneficiaries participating in the fall 2004 Medicare Current Beneficiary Survey.

MEASUREMENTS AND MAIN RESULTS

Prevalence of free prescription drug sample access (self-reported request for or receipt of free drug samples) and the demographic, clinical, and insurance characteristics of Medicare beneficiaries who accessed drug samples. Overall, 48.3% (95% confidence of interval [CI]: 46.6%, 49.9%) of Medicare beneficiaries reported accessing free drug samples. Access was higher among beneficiaries reporting cost-related medication nonadherence compared to those without (77.7% (95% CI: 74.5%, 80.6%) vs 43.0% (95% CI: 41.4%, 44.7%)). Multivariable analysis revealed cost-related medication nonadherence (CRN) to have the strongest relationship with accessing drug samples (adjusted odds ratio [AOR] 4.43 [95% CI: 3.64, 5.39]). Compared to beneficiaries with generous drug benefits from Medicaid, beneficiaries who lacked prescription drug benefits were more likely to access drug samples (AOR 2.42 [95% CI: 2.06, 2.85]). Beneficiaries with drug coverage from employer-sponsored plans or partial coverage (Medicare HMO, self-purchased Medicare supplement, or state-sponsored low-income plans) were also more likely to access drug samples (AOR 2.02, 1.74, respectively). Having 2-3 or > or = 4 comorbidities (vs 0-1 comorbidities) also increased the likelihood of accessing drug samples (AOR 1.60 (95% CI: 1.44, 1.79) and 2.00 (95% CI: 1.74, 2.29).

CONCLUSIONS

Accessing free prescription drug samples is prevalent among many categories of beneficiaries, especially among individuals with cost-related medication nonadherence and poor health status. Policies restricting or prohibiting drug sample distribution may adversely impact access to medications among patients in high-risk groups.