Transcript Drug marketing and doctor prescribing habits

Doctors and Drug Companies
Copyright 2011
The Problem
• Drug companies spend a lot of money to influence
doctors’ prescribing patterns
• It works
• This leads to medical practice that is more based on
publicity and promotions than on scientific evidence
How it works
• At morning report, a senior faculty member is working
through a case with the residents and interns. "First we
saw these symptoms. Now that the lab results are back.
How does that change what we think?"
• There are bagels and juice, provided by a drug
company. A representative of the drug company offers
the residents pens, notebooks, and little stuffed toys, all
with the company logo prominently displayed.
Morreim H. Prescribing under the influence.
How it works
• Doctors say of such marketing: "It doesn’t influence me
at all“
• They underestimate the efficacy of such tactics
• The goal is simply to get the names of products in front
of the physicians
Morreim H. Prescribing under the influence.
Doctors think of themselves, but not
their colleagues, as impervious
• Survey sent to 397 members of ACOG
• Asked about gifts and free samples
• Most doctors thought that they would not be influenced
but that their peers would
Morgan et al. J Med Ethics. 2006.
Is it proper to accept gifts?
Morgan et al. J Med Ethics. 2006.
Would a gift influence you?
Morgan et al. J Med Ethics. 2006
Would a gift influence other doctors?
Morgan et al. J Med Ethics. 2006.
Percent of residents in each year who
thought it appropriate to accept free lunch
Lunch
4
Talk @ Noon
Very appropriate
.004
3
.006
2
1
Very inappropriate
PG1
PG2
PG3
Schneider et al. Acad Med. 2006;81:595-602.
House staff tend to see peers, not
selves, as corruptible
Steinman et al. Am J Med. 2001.
Maintaining irrational views
• MDs had positive views of detailing despite
knowing it presented a conflict of interest
• To reduce cognitive dissonance they:
–
–
–
–
–
avoided thinking about the conflict
said that interactions did not affect MDs
told how they remained impartial
said that meetings were educational
said meetings benefitted patients
Chimonas et al. J Gen Int Med. 2007.
"The evidence suggests that self-interest has a
tendency to bias independent judgment in
unconscious ways."
- David Korn, MD, AAMC
Free samples biggest piece of
marketing budget
Direct-to-Consumer Advertising
Donohue et al. N Engl J Med. 2007.
AMA guidelines allow certain types
of small gifts
• Gifts are permitted if they:
– benefit patients
– are of minimal value
– relate to the physician’s work
– are educational
http://www.ama-assn.org/ama/pub/physician-resources
medical-ethics/code-medical-ethics/opinion8061.shtml
AMA guidelines allow drug
companies to sponsor conferences
• Subsidies for meetings should be given to the
conference's sponsor, not to individual participants
• Physicians should not accept subsidies for travel,
lodging, personal expenses or their time
• Scholarship funds should go to students who are
selected by the academic or training institution
• Gifts should not be accepted if there are "strings
attached"
http://www.ama-assn.org/ama/pub/physician-resources
medical-ethics/code-medical-ethics/opinion8061.shtml
American College of Physicians and
of Internal Medicine more strict
• “The acceptance of individual gifts, hospitality, trips, and
subsidies of all types from industry by an individual
physician is strongly discouraged”
• “Physicians should not accept gifts, hospitality, services,
and subsidies from industry if acceptance might
diminish, or appear to others to diminish, the objectivity
of professional judgment”
Policies seem to be changing
doctors’ behavior
Campbell. Arch Intern Med. 2010.
Does it matter?
Effects of marketing
A review of 29 empirical articles on the effect of
industry interactions led to the following
conclusion:
“Although some positive outcomes were identified
(improved ability to identify the treatment for complicated
illnesses), most studies found negative outcomes
associated with the interaction”
Wazana. JAMA. 2000.
Marketing’s negative effects on
medical care
•
Inability to identify wrong claims about medication
•
Positive attitude toward pharma representatives
•
More prescribing of new drugs, less of generics
•
Increasing overall prescription rate
Wazana. JAMA. 2000.
Do visits by drug company reps
influence prescribing practices?
• 165 Danish general practitioners were visited by drug
representatives 832 times from April, 2001 to July, 2003
• The reps promoted Symbicort Turbohaler
• Over the study period, these doctors treated 54,080
patients with asthma drugs
Sondergaard, Family Medicine. 2009
What percentage of prescriptions
were for the Turbohaler?
• Before first visit by drug rep: 15%
• After third visit by drug rep: 28%
Sondergaard, Family Medicine. 2009
Physicians with access to free samples tend to
prescribe drugs that are more costly and that differ
from their drugs of choice
The effect of free samples
• 29 internal-medicine residents made 390 decisions to
start drug therapy over six months in an urban clinic
• Half of the residents, randomly selected, agreed not to
use available drug samples
• Five drug class pairs were chosen for study
prospectively
• Highly-advertised drugs were matched with drugs
commonly used for the same indication that were
cheaper, generic and/or OTC
Adair, Holmgren, Am J of Med. 2005
Access to free samples led to more
prescriptions of advertised drugs
Adair, Holmgren. Am J of Med. 2005.
Even small gifts (i.e. pens) influence
prescribing patterns
• 352 third- and fourth-year students
• Two medical schools with different policies toward drug
marketing
• Subjects assigned to treatment were exposed to small
branded promotional items for Lipitor (atorvastatin)
• Implicit Association Test (IAT) used to gauge attitudes
toward Lipitor and Zocor in exposed and control groups
Grande et al. Arch Intern Med. 2009.
Different responses to promotional
items at different schools
Note: Univ. of Penn restricts drug marketing; Univ. of Miami does not
Grande et al. Arch Intern Med. 2009.
Conclusion
“Subtle exposure to small pharmaceutical promotional
items influences implicit attitudes toward marketed
products among medical students. We observed a reversal
of this effect in the setting of restrictive policies and more
negative school-level attitudes toward marketing.”
Grande et al. Arch Intern Med. 2009.
American Medical Student
Association (AMSA) campaigns to
end drug- company gifts
In 2002, the AMSA launched its “Pharmfree”
campaign and adopted the following standards:
“All medical students should learn about the ethics of drug
company interaction with health professionals and make
the rational, informed decision to eschew "free" gifts from
the pharmaceutical industry throughout their training
careers.”
www.pharmfree.org
AMSA grades medical schools based
on conflict of interest policies
• The American Medical Student Association each year
grades U.S. medical schools for their conflict-of-interest
policy – or lack thereof
• Grades are based on policies addressing drug samples,
gifts, payments for consulting or speaking, funding of
education and other factors
www.amsascorecard.org
2009 grades cover the gamut
A – 12 schools
B – 46 schools
C – 20
D – 13 schools
F – 30 schools
I (incomplete) - 28 schools
www.amsascorecard.org
ProPublica, a website, now provides
lists of individual doctors who have
taken money from drug companies
• Type a physician’s name into the database and find out
how much he or she was paid by the seven drug
companies during 18 months in 2008 and 2009
• ProPublica also is producing a series of stories titled
“Dollars for Docs” about drug company influence over
physicians, medical practice and medical education
http://projects.propublica.org/docdollars
Legislative initiatives
In Congress
• The Physician Payment Sunshine Act, part of the
Affordable Care Act, requires drug and medical-device
companies to report all payments to doctors and
teaching hospitals that exceed $100 annually. DHHS will
post the records on a web site.
• Payments related to clinical trials or product
development agreements for new products can remain
confidential for four years or until product approval,
whichever comes first.
In statehouses
• Vermont, Minnesota, W. Virginia, California, Maine,
Massachusetts, and Washington D.C. have laws limiting
gifts from drug companies to doctors, and/or requiring
disclosure of some gifts and expenditures.
Trends are clear
• Professional society guidelines are more and more
restrictive
• Laws and regulations demand disclosure
• Traditional means of promoting drugs are gradually
changing
Lessons for the practitioner
• Drug companies work harder to influence you than you
work to resist their efforts
• Studies show that you are more malleable than you think
you are
• Smaller gifts are as powerful as bigger ones
• Gifts will be made public
Resources
The Pew Prescription Project - This initiative of the Pew Charitable Trusts aims to
promote consumer safety through reforms in the approval, manufacture and marketing of
prescription drugs, as well as through initiatives to encourage evidence-based
prescribing. The Pew Prescription Project conducts rigorous nonpartisan research related
to federal oversight of drug safety to better illuminate problems and potential solutions.
PharmFree - In 2002, the American Medical Student Association launched a campaign to
end gift-giving relationships between physicians and the pharmaceutical industry. The
site has ratings of medical-school conflict-of-interest policies, news articles, information
about state and federal legislation and a guide on getting involved in the issue.
RCT finds medical residents prescribe costlier drugs when free samples are available:
Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A
randomized trial. Am J Med. 2005 Aug;118(8):881-4.
Drug gifts lead docs to seek additions to formulary:
Chren MM, Landefeld CS. Physicians’ Behavior and their Interactions with Drug
Companies: A Controlled Study of Physicians Who Requested Additions to a Hospital
Drug Formulary. JAMA. 1994;271(9):684-689.
The American Medical Association’s guidelines to physicians on accepting gifts from
industry:
Code of Medical Ethics. Opinion 8.061 – Gifts to Physicians from Industry. 1998.
Resources (cont’d)
Essay argues that doctors can’t help but be swayed by favors from drug companies:
Dana J, Loewenstein G. A Social Science Perspective on Gifts to Physicians from
Industry. JAMA. 2003;290(2):252-55.
RCT finds 4th-year medical students tend to be swayed by drug marketing:
Grande D, Frosch DL, Perkins AW, Kahn BE. Effect of exposure to small pharmaceutical
promotional items on treatment preferences. Arch Intern Med. 2009 May 11;169(9):88793.
Study by business-school faculty takes position that drug-rep detailing leads to relatively
few additional prescriptions:
Mizik N, Jacobson R. Are Physicians ‘Easy Marks’?: Quantifying the Effects of Detailing
and Sampling on New Prescriptions. Management Science. 2004;50(12):1704.
O’Reilly KB. Drug industry ties to doctors weaken as disclosure, gift rules spread: More
physicians are saying no to free lunches, drug reps and consulting relationships, new
data show. 2010 Nov 29.
A review of 29 studies concludes that gifts influence practice:
Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA.
2000 Jan 19;283(3):373-80