Do conflict of interest policies adopted by residency programs actually work? To test this notion, a group of researchers examined prescribing data for several widely promoted antidepressants and found that psychiatrists who encountered restrictive policies were less likely to prescribe the drugs than those who did not have to contend with such policies.
Specifically, the University of Pennsylvania researchers compared psychiatry residents who graduated in 2001, before such policies were instituted, and 2008, when the Association of American Medical Colleges developed consensus principles of conflict of interest policies and one year after the American Medical Student Association began a 'PharmFree' scorecard.
They found that, relative to 2001 graduates in the same residency group, 2008 graduates in programs with 'maximally restrictive' conflict policies prescribed heavily marketed antidepressants significantly less than 2008 graduates in programs with 'minimally restrictive' and 'moderately restrictive' policies, or 4.3 percent and 3.6 percent, respectively.
The results were also consistent for prescribing reformulated and brand-name versions. Again, relative to the 2001 graduates, prescribing rates among the 2008 graduates in programs with maximal restrictions were significantly lower than among 2008 graduates of minimally restrictive programs for both reformulated and brand-name drugs, or 3 percent and 4.5 percent, respectively.
"The study is the first of its kind to show that exposure to COI policies for physicians during residency training – in this case, psychiatrists – is effective in lowering their post-graduation rates of prescriptions for brand medications, including heavily promoted and brand reformulated antidepressants," the researchers say in a statement.
The researchers, whose study appears in Medical Care, analyzed the proportion of prescriptions written by 1,652 psychiatrists, about half of whom graduated in 2001 and the others in 2008. They accounted for 901,805 prescriptions written for antidepressants in 2009 (here is the abstract).
Of the 162 residency programs, 30 percent graduated where there were minimally restrictive conflict policies, 51 percent that had moderately restrictive policies and 19 percent where there were maximally restrictive policies. These were categorized based on conflicts policies that were in place in 2008.
“Contact with the pharmaceutical industry may have important informational benefits for physicians. And, by exposing trainees to industry representatives, we may be helping them prepare to navigate these relationships after graduation,” says Andrew Epstein, research associate professor of medicine at the Perelman School of Medicine at the University of Pennsylvania, and lead author on the study.
“Nevertheless, while these relationships may be useful in some ways, our study clearly shows that implementation of COI policies have helped shield physicians from the often persuasive aspects of pharmaceutical promotion,” he concluded.
Overall, the 2008 graduates prescribed fewer antidepressants, most likely because they were in the first year of practice and saw fewer patients than 2001 graduates, the researchers notes. But they added, that if the conflict policies work as intended, such prescribing rates should be lower where residency programs have stricter policies (read a study summary here).
Last year, the AMSA noted that more medical schools are adopting policies that warrant good grades. In the most recent annual scorecard last March, 102 medical schools out of a total of 152 – or 67 percent – were given a grade of A or B for their policies governing interactions between drugmakers and faculty and students (back story).
10 Comments
We compiled the AMSA and IMAP COI policy data into 10 domains: gifts, on-site meals, detailing, samples, purchasing and formularies, continuing medical education, consulting, speaking, travel, and industry support for trainees.
We categorized residency programs into 3 mutually exclusive and exhaustive groups: those affiliated with institutions that by May 2008 had COI policies in place strong enough to earn an “A” or “B” grade from AMSA as “maximally restrictive” (N = 24), programs with evidence of a restrictive COI policy in at least 1 domain in either the AMSA or IMAP data as “moderately restrictive” (N = 72), and the remainder as “minimally restrictive,” including programs without evidence of COI policies in place (N = 66).
Please see the AMSA and IMAP websites for more details of their methodology and the manuscript for more details about ours.
Re: medical appropriateness, we used physician-drug-level TRx counts from IMS Health to calculate shares, and so cannot speak directly to the appropriateness issue.
My concern with the AMSA's "PharmFree" program is it's emphasis on the pharmaceutical industry as the putative source of all COI in the medical profession. In reality, I believe it is a minor player, at least so long as physicians continue to be paid on a piecemeal rather that a salaried basis in the US.
Psychiatrists are largely paid to manage medication in the US. Ultimately, the decision not to prescribe medication to a patient has a direct and negative impact on revenue. They've turned away a "customer".
Likewise, the back surgeon whom I will see tomorrow, will provide a "consulation" on whether I need surgery. If he recommends surgery, and I follow his recommendations, my insurer will direct several thousands of dollars of revenue his way. If he recommends against surgery, he forgoes this revenue.
By focusing concern on the $25 lunch (which unlike the examples I've cited above, is not even contingent upon the medical decision being made), it seems to me that "PharmFree" simply serves to obfuscate the larger issue of COI, which runs throughout every aspect of our medical care reimbursement system.
At the same time, it seems, from my outsider's perspective, that pharma wouldn't detail if it didn't work--which is directly contrary to the notion that docs as a group of trained professionals are above being influenced by marketing efforts. I'm not saying promotion is all bad, but one of its (main) purposes _is_ persuasion.
I guess in part I"m just offended by the language of the discussion. "PharmaFree"? Respectfully, without the products brought to market by the pharmaceutical industry over the last 50 years, these medical students would quickly find their efforts to address human suffering akin to the efforts of the Ethiopians to fend off Italian tanks with spears and wooden shields during WWII.
The current reimbursement system, in my view, is the 600 lb gorilla of financial conflict of interest for physicians in the US healthcare system. The medical profession bears much responsibility for perpetuating this systems due to the near universal opposition of its members to changing it.
In my more cynical moments, I suspect that much of the hu and cry from the medical profession about the pharmaceutical industry is sometimes a narcisistic if not cynical attempt to distract attention from the profession's own problems. As an example of this, consider the recent NYTimes editorial by two Sloan Kettering oncologists. The new heros of the war against "obscene" drug pricing are likely pulling well over $350K in fees per year out of our healthcare system. I don't recall seeing this issue raised anywhere.
It's hard not to be cynical when everyone's looking out for his/her own. Frankly, I'm impressed that the health care system works as well as it does.
1) A medical bag from Lilly with his name embossed. The same bag was given upon graduation with the initials "MD".
2) A bell and diaphragm stethoscope from Littman.
3) A Welch Allyn shphygmomanometer.
4) A Welch Allyn otoscope with interchangeable ophthalmoscopic head.
I don't know the total value of these itsms but couldn't have been cheap. Being the ethical physician he is, he told me on direct questioning that his prescribing practices were never influenced by these companies and he never accepted monies from any of them,
AMSA needs to get their thumbs out of their butts and get humble-some students are genuinely grateful for the little bit of help they receive during the course of a very expensive medical education.