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How Doctor's Prescribing Quality and Frequency Are Influenced By Drug Companies

Information provided to physicians from the US and around the world directly by pharmaceutical companies can be associated with higher prescribing frequency, higher costs, and lower prescribing quality. Furthermore, exposure to pharmaceutical company information does not improve physician prescribing behavior. These are the findings of a systematic review by Geoffrey Spurling from The University of Queensland, Brisbane, Australia, and colleagues and published in this week's PLoS Medicine.

After doing an extensive literature search, the authors analyze and describe the findings of 58 studies examining the relationship between exposure of licensed physicians to promotional and other information from pharmaceutical companies and subsequent prescribing behaviour. All but one of these studies suggested that exposure to pharmaceutical company information was associated with lower prescribing quality or no association was detected. In the 51 studies that examined the relationship between exposure to pharmaceutical company information and prescribing frequency, exposure to information was associated with more frequent prescribing or no association was detected.

In the eight studies that examined the relationship between exposure to pharmaceutical company information and prescribing costs, with one exception, these studies indicated that exposure to information was associated with a higher cost of prescribing or no association was detected. For example, one study found that physicians with low prescribing costs were more likely to have rarely or never read promotional mail or journal advertisements from pharmaceutical companies than physicians with high prescribing costs. However, because most of the studies included in the review were observational studies—the physicians in the studies were not randomly selected to receive or not receive drug company information—it is not possible to conclude that exposure to pharmaceutical information actually causes any changes in physician behavior.

The authors state: "We did not find evidence of net improvements in prescribing, but the available literature does not exclude the possibility that prescribing may sometimes be improved." They conclude, "Still, we recommend that practitioners follow the precautionary principle and thus avoid exposure to information from pharmaceutical companies."

An earlier study in the Annals of Internal Medicine provides extensive detail about how drug companies push their products in far more subtle ways.

Some drug makers pay key leaders in a field of medicine, such as chairs of departments in medical schools, tens of thousands of dollars if they are saying the right things about their product. They manipulate medical education sessions, lectures, articles in medical journals, research studies, even personal conversations between physicians to get their product message across. 

"It is very disturbing," says lead author Dr. Michael Steinman of the University of California, San Francisco and the San Francisco VA Hospital. "It really does a disservice to patient care."

Reliable estimates put the drug industrys expenditure on promotion to doctors at $18.5 billion that's about $30,000 a year for every physician in the U.S. Companies conceal the specifics of those efforts with a jealousy worthy of a state secret.

In 1996, Dr. David Franklin, an employee of the drug company Parke-Davis, filed the lawsuit under federal whistleblower statutes alleging that the company was illegally promoting an epilepsy drug called Neurontin for so called off-label uses. Under federal law, once the FDA approves a drug, a doctor can prescribe it for anything. But the law specifically prohibits the drug company from promoting the drug for any unapproved uses. 

In 2004, the company, by then a division of Pfizer admitted guilt and agreed to pay $430 million in criminal and civil liability related to promoting the drug for off-label use. 

What is most interesting is not the illegal actions they reveal, but the details of activities that are perfectly legal. And according to people familiar with the industry, the methods detailed in these company memos are routine.

One tactic identifies certain doctors as thought leaders, key influencers and movers and shakers those whose opinions influence the prescribing pattern of other doctors. Those whose views converge with the company goals are then showered with honoraria, research and educational grants. In the Parke-Davis case 14 such big shots got between $10,250 and $158,250 between 1993 and 1997.

Medical education drives this market, wrote the author of one Parke-Davis business plan in the files. Many state licensing boards require physicians to attend sessions in what is called continuing medical education (CME) to keep current in their field. 

At one time, medical schools ran most CME courses. Now, an industry of medical education and communications committees (MECCs) run most of the courses. These companies with innocuous sounding names like Medical Education Systems set up courses, sometimes in conjunction with medical meetings, at other times often in fancy restaurants and resorts. The drug companies foot the bill, with the program usually noting it was financed by an unrestricted educational grant from the company. 


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