Does information provided by drugmakers to doctors result in higher prescribing frequency, higher costs and lower prescribing quality? This is not a new issue, of course, but a new study that attempted to quantify patterns says the answer is yes. And the researchers came to this conclusion by scouring 58 studies in several countires that examined a variety of company contact.
This included visits by sales reps, journal advertisements, attendance at pharmaceutical sponsored meetings, information that was mailed to docs, prescribing software, and participation in sponsored clinical trials. The outcomes measured were quality, quantity, and cost of physician prescribing, according to the new study published in PLoS Medicine.
The bottom line: the researchers found that docs who accepted meetings, briefings or other info from drugmakers were more likely to prescribe those products. In all, 38 studies showed that exposure to drug company info resulted in more frequent prescriptions, while there was no association in 13 other studies, more than half of which were originally conducted in the US. None of the studies, by the way, found that a drug was prescribed less often due to promotional materials or some other info.
“We found no benefit for doctors from pharmaceutical promotion. So doctors need to recognize these tactics and should instead use information sources that are independent of pharmaceutical companies,” lead author Geoffrey Spurling says in a statement. "If companies want to contribute to medical education then they should put their money into a common pool that would be administered by an independent organization.”
As examples, he cited one study in which docs with low prescribing costs were more likely to have rarely or never read promo mail or journal ads than docs with high prescribing costs. Another study of docs in the UK of more than 1,000 general practitioners found that docs who reps more often prescribed costlier drugs, although that did not mean patients received the most appropriate meds.
But he did acknowledge a caveat: Most of the studies included in the review were observational studies - the docs in the studies were not randomly selected to receive or not receive company info - so it is not possible to conclude that exposure actually causes a change in physician behavior. Some of the authors, by the way, are members of Healthy Skepticism, a non-profit that seeks to improve health by "reducing harm from inappropriate, misleading or unethical marketing of health products or services, especially misleading pharmaceutical promotion," investigate and communicate about marketing practices, and promote healthy skepticism about marketing practices, among other things.
21 Comments
This should be published in the journal, "Duh". It would be even scarier if managment of pharma had been pouring millions of dollars into initiatives that did not lead to prescribers. I am glad that pharma managment is smarter than that. Now, if only researchers had more productive work to do than study hypotheses that are completely obvious. My guess is that it was paid with public funds.
Hi David,
Thanks for the note and I agree that this reaches a conclusion that has been picked over quite a bit. I chose to run with it because the authors attempted to do a more comprehensive look and the issue remains front and center these days.
As to funding, the paper notes there was no private or public backing for the work. If you click on the link where the word 'study' is highlighted in the second paragraph, you can read the disclosure.
Regards ed
I agree with David. It reminds me of the wasteful spending by the Federal government over the years. This was highlighted by the late Sen. William Proxmire, who monthly gave the Golden Fleece Awards for most wasteful spending. Examples include:
1) grant to HUD to study why people move out of high crime neighborhoods;
2) NIDA funded project by psychologist Harris Rubin for $121,000, on developing "some objective evidence concerning marijuana's effect on sexual arousal by exposing groups of male pot-smokers to pornographic films and measuring their responses by means of sensors attached to their penises, in 1976;
3) Office of Education, for spending $219,592 in a “curriculum package” to teach college students how to watch television;
4) US Army, for a 1981 study on how to buy Worcestershire sauce;
5) $84,000 study to determine why people fall in love;
6) A study to determine why prisoners want to get out of jail.
Agreed with David. As I always ask when I see these sorts of studies, what IS the appropriate way for doctors to learn about new drugs?? The article seems to imply that "visits by sales reps, journal advertisements, attendance at pharmaceutical sponsored meetings, information that was mailed to docs, prescribing software, and participation in sponsored clinical trials" are all NOT appropriate ways. So what *IS* appropriate? Anyone?
I was a rep for 10 yrs and came away w a few major themes.
The one I'll mention here is the fact the doc's that saw reps were more informed than the doc's that didn't. Examples:
"I use a blood pressure drug approved in the 50's. It's more effective than what you guys sell." I only talked with this guy once in my ten years of trying. It's been 17 years since that conversation, but I remember that when I looked up the drug it had a black box warning and drug interactions. Small town doc in the one big clinic... sooo protected from reality.
"What? It's BID?!" ...the drug I was selling was a twide a day version of a 4 times a day drug... that we launched three years earlier! What else doesn't this guy know?! ...another large clinic, slightly larger city than examples #1.
Lastly: A large Rheumatology office that didn't see reps had been Rx'ing an old osteoporosis medicine for about 25% of their scripts while the MS in my territory was under 5%. ...older doc's tend to be less interested in changing their habits. "It's always worked for me!" Gee.. hard to argue there.
Dear inside; most doctors prefer to work with drugs they feel comfortable and in the process save their patients huge amounts of money. Best example is my own father, a physician who certainly knows his meds. He has psoriasis and could be eligible for a $15,000/year course of one of the TNF drugs. Instead, his "old fashioned" dermatologist gives him a once weekly injection of dirt cheap methotrexate, which works just fine. And since it is given intermittently it avoids the side effects of methotrexate buildup.
In my experience the only worthwhile drugs approved in the last decade have been the anticlotting drugs. What you detail as the "latest and the greatest" is often just the most expensive.
industry insider, your comments are so ridiculous that they must a parody. Go ask parents of kids with devastating juvenile RA and ask them if MTX works well for their kids. You are a joke! TNF may be the immune conductor, but TNF-alpha plays first fiddle and those drugs are a godsend.
Despite all the hate, pharma does do good things and all new drugs are not bad. The only thing bad are reps, especially the female ones. Fire them all!
Nathan, I don't see reps.
Whle I do hate to brag on myself, you won't find many MDs with a broader and deeper understanding pharmacotherapy (even beyond my area of clinical expertise). All of the pharm/tox specialists in my state (at least) would vouch for this. So I'll share how I learn about new therapies.
First there is a need to have good reference texts (or recall) of biochemistry, pharmacotherapy and physiology. For pharmacotherapy, I'm a tradionalist, so I like Goodman and Gilman. An appropriate clinical textbook for pediatrics or internal medicine (or both) is also essential for a survey of specific pathophysiology, but you can get by with current review articles.
Another important consideration is familiarity with the national (and international) treatment guidelines for specific conditions (there are lots of websites for these). It is important to understand the "institutional bias" that sometimes appears in these. For example almost anything from the AAN is going to say something alluding to their institutional believe about brands versus generics - could that belief be fostered by the staggering levels of support they have(historically) received from PhRMA?
The best starting point for information about any drug is the prescribing information. Always interesting to read, because it reflects the continuing tension between the manufacturer and the FDA. For some companies or drugs, the manufacturer side also reflects a struggle between the scientists who developed the reseearch on the drug and the marketing department. You have to read it from time-to-time because manufacturers don't always highlight when a change occurs - If I say reps, I'm sure I would always know when something that EXPANDS uses is added, but would rarely hear about changes which would limit use (or increase caution). Certainly I wouldn't hear from a rep anything about the PI without spin - and it really is a document which speaks for itself.
Believe it or not other physcians do talk to one another about medications. This happens most commonly in the clinic (with others in the same practice and specialty). It also happens at local, state and national meetings. Docs do have a requirement for continuing medical education, and we do get together socially and professionally from time to time. Since I'm in primary care, I can find out from my patient's medication lists which allergists (for example) are more likely to be using new medications if I want an update on the "latest new treatment."
I have a preference for actually reading the studies relating to medications I need to know about. One can tell a lot about a claim by looking at the study design and the actual reported results - even with the understanding that only the positive studies get published, and the results are generally written in the most favorable light.
I seek out comparative clincal trials, and read those whenever I can find them. If an MD really wants to get really into intense data aggregation and analysis, there are Cochrane Database resources as well as the DERP program from Oregon's Evidence Based Practice Center.
I also pay close attention to news from the FDA as well as the UK NICE, European medicine agency and the various national health systems (Australia, New Zeland, etc). These purpose of these groups is to struggle with the questions of what are the best treatments available.
Of course summaries are available for the busy phsysician who hasn't got my curiosity or patience. "The Pharmacist's Letter" (only just barely ok), and "Prescrire" (highly recommended by colleagues of mine for it's abscence of bias, frankness and irreverence)and even "UpToDate" (as a starting point) can be helpful. (Full Disclosure: I have written for "UpToDate" on a topic not involving medication treatment - I am no longer an author for them since I do not have an academic affiliation - a peculiar bias or theirs.) Sometimes, there's just no substitute for "Facts and Comparisons" (fortunately, I'm very close to the medical library, but most hospital pharmacies - and maybe a few retail pharmacies - should have this reference.) There are other compendia sources available.
Another source of information some physicians access is their local hospital/clinical pharmacist (who usually has done exhaustive research on what a drug does or fails to do in consideration of inclusion on a formulary). Likewise, most Colleges of Pharamcy have Drug Information Call Centers. They love to get questions. These folks are the reference librarians of pharmacy, God Bless 'Em!
As for awareness of new medication options, most Docs also receive (at least) their specialty journal (and sometimes many other throw away journals too). These always have advertising in them. New medications are never a surprise to the MD (or DO, NP, PA) who is half-paying attention.
Of course, there is now much advertising to consumers, so one can watch the nightly news for an update on any new treatments that are coming out (or changing strategy). I noted the other night that Uloric is now positioning themselves as a primary treatment for Gout - a move that took longer than I expected, but then gout really isn't that common.
Nathan, you may recall that I have about a decade of PhRMA experience prior to becoming an MD. Some of my search strategies come from my time assessing market opportunities and forecasting potential for new drugs.
Nevertheless, during my industry time, I also learned a very important strategy to avoid harming patients. It is stunningly simple. Don't rush to use a new drug on any patient who has other treatment alternatives that have been around longer, even if you are not as familiar with them.
Most new medications have significant problems which no one could (or wanted to) see in their clincal trials. The very bad ones will reveal themselves in less than 3 years (think Baychol or Ketek). The more subtle ones will start to show after about 5 year (think Vioxx). The most subtle, or most rarely used medicines, will show problems after 7 years (think Trasylol).
Only rarely is there a new medication which is a genuine game-changing treatment. There have be a handful that I can recall - like lung surfactant for premies - that have proven to be wildly successful at doing what they do with few if any ill effects. While I can agree that for kids with ACUTE auto-immune disease flairs, Anti-TNF meds can, in-fact, be life-saving. I'm not sure that I or many pediatric rheumatologists share his enthusiasm for them in regular, prolonged use. This is a particular challenge, since typically auto-immune disease presentation at a younger age is a more severe condition than when diagnosed in adulthood.
I also disagree with him that ALL PhRMA reps are bad. To me they are irrelevant, but I've known a few who were quite good at what they did. And who would honestly tell a doc when NOT to use the meds they were promoting.
Has it occurred to anyone that maybe all of the recent turmoil about pharmaceutical reps is designed to justify the mass shedding of jobs?
In the defense of drug reps, who I really do not want involved in my care, it is understandable for them to defend their positions. Seems to me that the image is the result of their employers setting up such a competative environment that their ability to inform doctors of new products has taken a back seat to sales. I could be wrong but it really doesn't feel like all of this is the fault of people who are doing their jobs as they are directed to do them.
Just sayin' I wish them all the best.
When we will ever learn? Pharma companies ALWAYS present their data/drugs in the most positive light possible. They depend on reps with shallow knowledge to convey their marketing messages. After 35 years in this business, it amazes me that anyone would think that pharma companies even want to be fair balanced. If it were not required by the FDA, it would never happen.
Any provider that depends on company reps for "learning" about new therapies, should not be your family's healthcare.
Pharmavet, since MTX works for 80% of kids with JRA, I'll spare them the risk of lymphoma-inducing anti-tnf drugs until I have to use them. If ou're going to use a carcinogenic drug, save them for adult RA, where patients have at least lived a more complete life.
Here's the evidence.
http://jama.ama-assn.org/cgi/content/full/295/19/2275
As the mom of a child with JRA, I could not agree with more M. Helm, MD and Industry Insider. When Enbrel was first recommended for my daughter, my husband's GP told him emphatically, "I would not give a drug like Enbrel to my daughter unless she couldn't walk."
Is my daughter his patient? No. Has he ever even seen my daughter? No. But he provides excellent care to my husband and is not any type of 'renegade' in his practice. His words have stayed with me. No physician would make such a strong statement, if Enbrel was such the 'miracle' it is presented to be to parents.
Adults on biologics tell us not to give them to her, as well.
She may need them someday. I hope not, but she might. If she has trouble at school, or has to stop dance class, or needs pain medication, we will have to make that decision.
Here is the FDA presentation on ped malignancies and TNFs:
http://www.rheumatology.org/practice/clinical/pediatricmalignancies.pdf
Here are two more recent studies where they try to separate Enbrel from the pack: http://www.ped-rheum.com/content/8/1/18
http://www.ped-rheum.com/content/8/1/23
I see a lot of generalizations here in these discussions. The discussion is about a study of studies. The findings are based on how we tease out the data. What they found is not "be all and end all". In addition to the scientific information we all have our own beliefs and the way we do things...whether it is a physician, pharmacist or a rep. I have seen doctors making up their own combinations of drugs to treat diseases whether there is published evidence or not; because ultimately our goal is to help the patient, balancing the benefit for that patient with that approach with what could potentially happen due to that in the near future. Too much money and brain cells are wasted in these studies and their discussions.
Ed, the title of your article is quite misleading. It is premised on the fact that "higher prescribing frequency, higher costs and lower prescribing quality" are bad things that need to be avoided. The only one of those things that are necessarily bad is the "quality" statement. Higher prescribing frequency and higher cost might actually result in better patient outcomes. They might not be bad at all. If you look at the article you cited carefully, you'll see that "quality" really has nothing at all to do with patient outcomes. Rather, it has to do with "quality scoring of prescribing decisions, guideline adherence, prescribing appropriateness of an individual drug class, and prescribing range."
Here's a couple examples in particular quoted directly from the article. "Residents attending a sponsored meeting were more likely than nonattending residents at the same hospital to prescribe the sponsoring company's medication, both when it was appropriate according to the authors and when it was not." (my comment: Is this bad? Is higher "inappropriate" treatment really worse that higher non-treatment?) Other example: "Primary care providers who saw more pharmaceutical sales representatives and those who used the pharmaceutical industry in general as a source of information prescribed a wider range of drugs." (my comment: Is this really a bad thing? I would rather have a physician with a large toolbox of available drugs)
Also, thank you for pointing out the conflict-of-interest for the authors. We see the pharma COI's all the time. It's nice to see it work both ways.
To pharmavet - I hope you were joking re: your statement "esp. the female ones." If not, let me make it official - you're a jackass. Was anyone gonna call this guy out?
Love Dr. Helm's response. If all MDs took their responsibility as seriously, we'd all be better off.
Fembot, as a physician and researcher I would be the first to say that you should not rely on these boards for medical advice, even though I think that Dr. Helm and I base our suggestions on evidence-based medicine. Not that MD's are know-it-alls, but you and Suzanne seem capable of separating the wheat from the chaff.
PharmaVet-
On the off chance that you have a relative with JRA, I suggest you find some RA Kids boards to monitor for a year or so. Form a 'reality' opinion, not a emotional one based on Pharma propaganda designed to maximize their profits. Figure out which kids maintain some quality of life and which ones are circling the drain.
JMHO
While I found the report on the study quite interesting (and note that few conclusions should be drawn from a report of a study without the chance to read the study itself), I was disappointed by what appears to be a biased conclusion without consideration of what else the results might tell us (at least as described in the report).
Is it not possible that physicians who receive information directly from reps prescribe those drugs more because they now actually know something about them? There are numerous drugs approved every year and most physicians received at most a semester of training on pharmaceuticals in med school, however long ago that might have been.
With the increasing pace of physician practices, I would question whether they have the time to devote to educating themselves on new drugs and updates to existing drugs.This is also considering where we think a physicians limited time for continued education is best spent - on new advances and understanding about disease, or on the medicines used to treat them?
As the report above stated (and a point apparently overlooked by the majority of commentators), "it is not possible to conclude that exposure actually causes a change in physician behavior."
Yes, it would indeed be a better option, as suggested by Spurling, were all of pharma to contribute to an educational pool to be administered by an independent third party. But how likely is it that the third party would really be considered independent if financed by the industry - certainly a sufficient quantity of allegations are thrown at the FDA for not being sufficiently independent because they are funded by the industry (a legal mandate) to suggest that an educational organization would encounter the same issues.
Finally, let us not forget that we, the consuming public, are complicit in any type of "over prescribing behavior" of which we complain. When was the last time you went to your doctor and were content to be told "you have x disease, I'm sorry, I have nothing to give you to treat that."
Hi Mollie,
Thanks for the note, but the study can be read here. If you look in the second paragraph, the word 'study' is highlighted and so if you click on this word, you will get right to the PLoS study. Sorry for any confusion. I thought highlighting the word 'study' would have been obvious, but I guess not.
Hope this helps, Ed
Look, I am a drug rep with over 10 years experience in the hospital market, sub-specialty market, primary care, and oncology. Let me just say with 100% confidence: There is no need for drug reps in the practice of medicine. Period. We are a waste and a drain on shareholder value. It is comical to think otherwise, and any rep that does is practicing an incredible level of self-delusion.