3 May 2017

A long, hard look at conflicts of interest

Drugs Pharmaceuticals

Questions have again been raised about the role of pharmaceutical representative visits, after research showed them being linked with greater prescribing of more expensive drugs.

US researchers analysed prescribing data from 2000 physicians at 19 academic medical centres that had introduced policies restricting visits from pharma reps, and compared these with prescribing data from 25,000 matched control across eight drug classes.

The study, published in JAMA, found a 1.67 percentage point drop in the market share of those drugs currently being detailed by the pharma reps among those centres which had introduced the restricted pharma marketing policies. Market share for detailed drugs was calculated as the number of scripts for the specific drug as a percentage of the overall scripts for that drug class written over the course of a month.

In these centres, there was also a 0.87 percentage point increase in the market share of non-detailed drugs.

Specifically looking at drugs treating insomnia, gastroesophageal reflux disease and ADHD, centres that had restricted policies showed a decrease of at least five percentage points in market share for detailed drugs, whereas specifically detailed antidepressants, antihypertensives and lipid-lowering medications decreased by 0.84 to 2.32 percentage points.

These results were all statistically significant.

“It is likely that industry marketing has myriad effects on prescribing patterns, potentially accelerating the uptake of beneficial drugs but also stimulating overuse of expensive, high-risk, or inappropriate drugs,” Dr Colette DeJong and her co-authors added.

Policies in the intervention group differed, but they all limited or banned pharmaceutical representatives providing meals, branded items and educational gifts and went further than the industry’s voluntary code of conduct.

This study improved upon other research that was limited to cross-sectional or before-and-after designs, Dr DeJong wrote.

While industry detailing had been previously tied to doctors learning inaccurate information about the sponsor’s and competitors’ drugs, costlier prescribing, Dr DeJong cautioned against demonising
it altogether.

“Restricting interaction between physicians and the pharmaceutical industry without replacing the education about novel drugs that it offers also has possible risks,” she said. “The work of physicians draws on an expanding base of medical knowledge, and there is always more to learn than time to read.

“Understandably, help is appreciated. It is easier when educational opportunities are convenient and enjoyable, such as when they are combined with meals brought into clinic by pharmaceutical representatives and others.”

Conflicts of interest were in the spotlight in this week’s edition of JAMA, which featured 23 scholarly editorials and two research papers.

A key question was the extent to which conflicts of interest undermined the integrity of the medical profession, whether it was individual physicians receiving money from industry, or researchers, medical educators, speakers and journals.

A second research paper revealed that almost one in two US physicians received industry funding in 2015, which accounted for $US2.4 billion.

Surgeons drew more attention from industry than primary care physicians, receiving an average of $US6879 in payments such as consulting fees and food and beverages compared to GPs’ $US2227.

Fewer than half of primary-care doctors received these “general payments”, whereas 61% of surgeons did.

A separate article in JAMA, by healthcare journalist Charles Ornstein, welcomed this increased transparency, saying it had prompted “uncomfortable, and perhaps overdue, questions about whose interests should come first – physicians’ privacy or patients’ right to know”.

Analysis of payment data by the not-for-profit newsroom, ProPublica, had found there was a dose-response relationship between the amount of money physicians received and higher rates of brand name prescribing, he said.

While substantial changes have been made in the medical industry to increase transparency and counter the risks of conflicts of interest, it is unclear how this has affected the average patient.

Despite research suggesting an overwhelming majority of patients want to know about policies affecting their doctors’ hip pocket, Associate Clinical Professor Abigail Zuger said patients did not appear to feel capable of judging whether a conflict of interest would affect their own health.

“[A] safe assumption may be that no matter how transparent the mechanics of medical practice become, they will never become transparent enough to provide patients with a full understanding of how it all works, and also not transparent enough to deflect suspicion of additional hidden manoeuvres,” Professor Zuger wrote.

“Physicians and patients all know that information is not necessarily wisdom, certainly not when it comes to disclosure.”

JAMA 2017; online 2 May