Download The effects of pharmaceutical firm enticements

The effects of pharmaceutical firm enticements on
physician prescribing patterns. There's no such
thing as a free lunch.
J P Orlowski and L Wateska
Chest 1992;102;270-273
DOI 10.1378/chest.102.1.270
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© 1992 American College of Chest Physicians
The Effects of Pharmaceutical
Firm Enticements
Physician Prescribing
Patterns*
There’s
No Such
P Orlowski,
James
Thing
M.D.,
as a Free
F.C.C.?;
and
Lunch
Leon
Wateska,
R.Ph.,
We examined
the impact on physician
prescribing
of pharmaceutical
firms offering all-expenses-paid
patterns
trips to
popular
sunbelt
vacation
sites
to attend
symposia
sponsored
by a pharmaceutical
company.
The impact was assessed
by
tracking
the pharmacy
inventory
usage reports
for two
drugs
before
and after the symposia.
Both drugs
were
available
only as intravenous
preparations
and could be
used
only on hospitalized
patients. The usage patterns were
tracked for 22 months
preceding
each symposium
and for
17 months after each symposium.
Ten physicians
invited to
each symposium
were interviewed
about the likelihood
that
such an enticement
would affect their prescribing
patterns.
A significant
increase
in the prescribing
pattern
of both
A
of
number
paucity
pharmaceutical
physician
authors
prescribing
techniques
have
commented
lack of objective
data
company
marketing
or
practices.
include
‘
advertisements,
contacts
by sales representatives,
other gratuities.
An elaborate
on
consumes
days ofthe
only
trip,
their
impact
drugs,
both
relatively
preparations,
and
Hospital
on
the
new,
printed
an
materials,
samples,
gifts,
recent
enticement
and
has
3 or 4 h on each of the
leaving
the remainder
of
pharmacy
prescribing
patterns
inventory
usage
reports
to track
the prescribing
patterns
before
and after the expense-paid
M
Drug
A was
institution
and
were
a guest
Drug
new
a new
at an island
for
the
meals,
discovered
cm)IIjLItlCtioIl
resort
on the
and
‘We sLIl)sequelitlv
iii
all-expenses-paid
resort
acconimodations,
offered
antibiotic.
intravenous
physician
ill
the
270
Cleveland.
requests:
Avt’nu,i’,
then
used
from
informally
All
other,
The
data
on
a symposium
heen
trip
had
on
drug
Division
l)r. Orlomv.s’ki, Cleveland
Ch’veland
44195
our
years.
This
In addition
to the
Cleveland
Clinic
the
were
centers
expenses.
B at a resort
as
more
these
Services,
Inc.
usage
data
hut
these
1989,
and
one
satisfactory
trend
and B with
the
Mean,
in
were
were
year
the
after
the
controls.
use
ofalternative
which
drugs
median,
and
A and
Test
between
selection
to the
program,
teaching
Data
Ariz).
was
dosage
and
tising
a linear
by constnicting
difference
in
time
1987
the
data
two
the
(designated
1989.
years,
1988
to one
year
served
usage
drugs
before
and
after
model.
the
t test.
the
and
regression
the
Slope
confidence
any change
D,
for descriptive
before
whether
O()fl
A
C and
to replace.
used
drug
underlying
as
of drugs
after
t test and the Wilcoxon
based
to assess
has
Our
therefore
drugs
each
status,
hospital
correlating
compared
two
Services
through
last
and
prior
medical
center.
from
a 95 percent
the slopes
Our
medical
periods
Student’s
assumptions
compared
and for major
for
using
test.
for the
were
were
tested
drug
data
intended
symposia
approximately
of each
B were
in usage
for
use
deviation
Differences
from
three
usage
standard
statistics.
conformed
also
the
to learn
about
Pharmaceutical
symposia
We
trips
afterward.
beds
for only
time
regarding
drugs
Scottsdale,
available
such
these
retrospectively
of the
500
that
of
covering
17 months
from
felt
luxurious
obtained
a residency
affiliation)
attendees
impressions
national
than
symposia
The
they
reports
for
and
these
prescribing
and
control
having
school
Data
was
obtained
usage
The
data
relation
symposia
estimates
was
were
interval
in prescribing
the
rank-
on the
patterns.
RESULTS
of Anesthesiologc
I’bundation,
whether
their
issue
data
also
with
(defined
and a medical
drugs
historical
we
for hospitals
described
previously
Clinic
to attend
ahut
symposia
to the
symposia,
dnigs
two
usage
before
no interviews
ofcolleagues.
influenced
inventory
provided
22 months
sum
airfare,
for incidental
msimilar
the
pharmacy
before
course
expenses
including
questioned
enticement
Usage
hospital
although
invitations
questioning
particular
drugs,
as well as their general
propriety
and ethics of these expensive
ah()ut a new drug.
and
for themselves
drug.
had accepted
by general
elabrate
National
Coast.
Caribbean.
*Fn)1,, the Department
of Pediatrics,
and Department
of hospital
Pharmac;
tioii,
Re)riflt
I’.ucltd
trip
\Vest
a significant
that
were
in our analysis,
to it.
beds and is considered
a major
collection
stretched
over three
years,
drtigs
Physicians
cardiovascular
amid au allowance
with
two
who
identified
respectively)
au
to
to a luxurious
of the
trips.
Physicians
were
its dates
in relation
1 ,006
ETHODS
intravem)us
invited
B was
was held
paid
ii
were
we included
conducted
(hospital
of two
only as intravenous
in hospitalized
patients.
only
occurred
increased
symposium
A
were
available
used
following
the symposia.
The usage of drug
from a mean of 81 ±44
units before
the
to a mean of 272 ± 117 after
the symposium
(p<O.00l).
The usage of drug B changed
from
34 ± 30 units
before
the symposium
to 87 ± 24 units (p<O.OOl)
after
the
symposium.
These changed
prescribing
patterns
were also
significantly
different
from
the national usage patterns
of
the two drugs by hospitals
with more than 500 beds and
major medical centers over the same period
of time. These
alterations
in prescribing
patterns
occurred
even though
the majority
of physicians
who attended
the symposia
believed
that such enticements
would not alter their prescribing
patterns.
(Chest 1992; 102:270-73)
drugs
Florida;
the
the time available
for social and recreational
activities.
Two such symposia
offered
us the opportunity
to
assess
M.S.
on the impact
of
techniques
on
These
marketing
been to offer an all-expenses-paid
trip to an attractive
resort
for the physician
and a significant
other
to
attend
a symposium
on OflC of the company’s
drugs.7
The actual
scientific
or educational
component
of the
trip typically
three or four
on
Founda-
954%)
The
majority
elaborate
trip
ofphysicians
enticements,
to a luxury
resort
interviewed
such
as an
to learn
Pharmaceut,cal
insisted
that
all-expenses-paid
about
a new
drug,
Arm Enticement
(Or!owski,
Wateska)
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© 1992 American College of Chest Physicians
Table
1-Responses
OfEntiCements
ofPhysicians
on Their Drug
about
the Likely
EJJ#{233}CtS
Prescribing
IbUerns
Drug
Would
Not
to
Unlikely
Influence
Could
Influence
B
Possibly
Influence
A course
Drug
(n=10)
Drug
B course
No.
9
1
0
8
1
1
U)
I-
z
2
(n=10)
:D
45
would
in no way
influence
their
prescribing
(Table 1). They appeared
to sincerely
decision
to prescribe
a drug is based
decisions
believe
that any
on scientific
data,
clinical
experience,
and patient
needs,
rather than on
promotion
by pharmaceutical
companies.
A few physicians
were
not
quite
so absolute
in their
denial,
would
drug
Drugs
hospital
prescribe
company
the
medication
FIGURE
Arrows
formulary
mately
22 months
and 17 months
drugs
showed
few months
the course
course
of usage
influence
.
the
We also noted
an invitation
a vely
symposia
to compare.
Both
in usage
within
a
prescribing
showed
additions
to our
we had approxi-
before
of data afterwards
a significant
change
occurred.
A usage
Drug
new
data
of each course
invitations,
since
might
posium
as thanks
trip.
A and B were relatively
formulary.
Nevertheless,
the time of
to the sym-
even
before
significant
the
per
month
for the
22 months
I
123
before
I
6
9
12
3
6
9
12
36
2. The number
ofdispensed
units ofdrug
B over 39 months.
indicate
the date when
the dnig was added
to the hospital
and the dates of the two promotional
courses.
course.
Its
averaged
monthly
272±117
units
(p<O.OO1).
The
highest
usage of drug A before
the course
invitations
use
for
the
17 months
had been
150 units.
After
single
month
when
the use
had never
fallen
below
was 476 units.
Two
symposia
physicians
at
on
our
the
was
the
per
B
month;
were
institution.
of
the
use
ofdrug
B for the
first
the
second
course
had
the
to
the
symposium
advance.
A
20 months
formulary.
after
the
(p<O.OO1)
use ofdrug
averaged
peak
after
the drug
and its presen-
17 months
course
was significantly
greater
use before
the course
(Fig 2). The
for a
its use
offered
The
occurred
approximately
nine months
was added
to our hospital
formulary,
The
course
course,
except
only 39 units,
130 units
drug
after
tation
was unknown
to the authors
in
second
course
was offered
approximately
after drug B had been added
to or
hospital
change
following
the course
invitations
and the symposium
(Fig 1). The usage
of drug A had been an average
81 ± 44 units
9
MONTHS
drug had uses or benefits
for their patients
which
they
had not previously
considered.
No physician
felt that
he or she
6
and
admitted
that such enticements
might
make
them
think ofthe
drug when they might not have otherwise
or that the symposium
might convince
them that the
for the
#{149}11111
3
second
than
the
B before
34 ± 30
units
per
500
DRUG A
450
30,000
400
Drug
Hosp. >500 Beds
Maj. Med. Centers
--
o-o
A
350
U)
300
z
20,000
U)
250
200
150
10,000
100
50
tf
3
6
9
12
3
6
9
12
3
6
9
12
I
1
3
6
1
FIGURE
ofhospital
1. The
use.
formulary,
took
place.
when
number
Arrows
ofdispensed
units ofdrug
A over 39 months
indicate
when drug was added
to the hospital
course invitations
arrived,
and when
symposium
2
3
4
1
2
3
4
1989
1988
MONTHS
(QUARTERS)
3.
FIGuRE
than
500
symposium
National
beds
and
occurred
usage
data for drug A in hospitals
with
major
medical
centers
over 24 months.
during
the first quarter
of 1989.
CHEST
I 102 I 1 I JULY,
Downloaded from chestjournal.chestpubs.org at Lane Medical Library on March 2, 2011
© 1992 American College of Chest Physicians
1992
more
The
271
2000
DRUG B
with a tenfold
increase
in our institution
(Fig 1) (and
the slopes
of the two lines were signfficantly
different
0-0
1500
[p<O.OO1]).
There
was no sudden,
usage or slope of the line.
Hoep. >500 Beds
Ma Me Centers
Likewise
for
maximum
Cl)
w
1000#{149}
U)
2
drug
medical
level
last
two
quarters
(Fig
In
of
(Fig
2
I
1
I
3
4
1
2
1988
I
I
3
4
1989
(QUARTERS)
than
4. National
50 beds
and
second
symposium
FIGURE
2). The
signfficantly
month,
whereas
87 ± 24 units.
the course
compared
the second
per month
was
average
lowest
50 units
use
after
the
usage
and
data
for major
for
hospitals
medical
with
centers
was
3.5-fold
over
the two years
more
that
C and
drug
that
C. Likewise,
drug D. Drug
of drug
drug
D (Fig
slope
with
two
5), the
overall
was
national
drugs
trend
A had not altered
with
was
level,
the use of drug
A had not significantly
drug B was designed
D also showed
wide
replaced
drug
to substitute
for
monthly
variations
suggesting
that drug B had
on the prescribing
pattern
6).
DIsCuSSIoN
than
Despite
a lack
of published
data
DRUG
use of drug A
Drug
A use
(Fig
in best-fit
ofthese
our
increase,
after the
drugs
that drugs
A and B
Drug
C was the drug A
there
were
wide
monthly
but with no obvious
trend,
not signfficanfly
impacted
(Drug
on
the
impact
of
D
B alternate)
800
3), compared
DRUGC
(Drug
(Fig
in use
suggesting
contrast,
compared
the usage
more
centers,
until the
a 4.5-fold
occurring
difference
different
demonstrated
at most a gradual
upward
trend in the
over
the two years
of data
collection.
increased
course
monthly
use of drug B after
with
a peak
of 133 units,
with a highest
use of only 70 units before
course,
except
for a single peak of 110 units
after the first course.
National
500 beds
the
The
more
The
4).
B showed
in slope
the use of the alternative
were designed
to replace.
alternative,
and although
variations
usage
data for drug B in hospitals
with
in major
medical
centers
over 24 months.
occurred
during the first quarter
of 1989.
1989
ofdrug
change
in
showed
with
in major
relatively
usage data (p<O.O1).
We also compared
I
data
in hospitals
beds and 3.5-fold
pattern
remaining
symposia
I
usage
of 2.5-fold
500
the
also
I
national
change
than
with
institations
use
with a dramatic
500-
B,
increases
dramatic
700
A alternate)
3000
600
500
U)
400
2000
Cl)
w
U)
0
300
a
1000
200
100
0
0
2
4
6
810122
4
197
6
810122
1988
4
6
81012
1989
2
4
6
810122
1987
5. uge
Despite
FIGURE
drug
A
prescribing
272
was
data for drug
wide monthly
introduced,
ofdrug
there
C.
C, which
drug
which
no evidence
variations,
was
810122
1988
MONTHS
replace.
46
4
6
81012
1989
MONTHS
A was designed
to
existed
even before
of a change
in the
FIGURE
replace
change
evidence
6. Usage
data for drug D, which
drug B was designed
to
therapeutically.
The prescribing
pattern
for drug D did not
in response
to the introduction
of drug B, and there was no
that drug B was being
prescribed
in place ofdrug
D.
Pharmaceutical
Firm Enticement
Downloaded from chestjournal.chestpubs.org at Lane Medical Library on March 2, 2011
© 1992 American College of Chest Physicians
(Orlowskl,
P.bteska)
pharmaceutical
prescribing
firm
marketing
practices
techniques
of physicians,
the
that
on
it is unlikely
would
spend
large
sums
of money
on
efforts
if they were not felt to be effective.
demonstrated
that one elaborate
promotional
the expense-paid
seminar
at a resort,
was
companies
marketing
We have
technique,
associated
with
a significant
of the promoted
occurred
drugs
in spite
inducements
at one
of the
would
in the
increase
institution.
physicians’
not
prescribing
This change
affect
belief
their
that
to the physician’s
advocate.
It is possible
scious
authors
perceive
that
predominantly
commercial
ments
and
have
their prescribing
by the scientific
role.7’#{176}What
viously
ments
was the temporal
and prescribing
had
changes
in
prescribing
studied
were
due
drugs
pat-
increase
was no
or more
they
temporal
of
the
effective
filled
a unique
relationship
to ignore
and
the
drugs
than
their
to three-
is impressive.
There
in the prescribing
of
alternative
drugs
which
these
new drugs
were
designed
to replace,
suggesting
that the new drugs
were not replacing
older alternatives,
but instead
that
enticements
perhaps
The
were
excessive
use.
results
of this
about
conflicts
interest
and the
firm
relationships.”4
between
the
in a position
professional
of trust.
a service
in
raise
is a discrepancy
and
that
study
of interest
pharmaceutical
ests
resulting
additional
serious
ethics
the
questions
Patients
have
inter-
a right
to
efforts
to the
expect
based
judgment
sound
professional
seminar
prescribing
and
concerning
of that
substantial
occurred
conscious
rocate
panies
real or
products
approach
to the
promotion
advertisements,
articles.
The
of this
salesman
medical
seminar
marketing
ignores
mix,
the
is
and
impact
our
of these
and
vendor
influence
promotional
behavior,
efforts.
despite
our
of
Such
feelings
5
2 Rosner
F. The
Cancer
3 Chren
MM,
4 Dacso
by
Landefeld
CC,
JW,
man:
Murray
1989;
CB.
1987;
8:34-9
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gifts
at conventions.
TH.
Doctors,
drug
compa-
262:3448-51
A physician/medical
Med
SD.
industrial
ethos.
MA.
J
ethical
and the pharmaceutical
Humanities
Bioethics
guidelines
[letter
for
to the
promotion
editor].
of
J
N Engi
between
to draw
and pharmaceutical
physicians
the
line
[letter
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N Engi
322:557
M,
Hartley
of influence
Med
1982;
the
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an ethical
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10
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detail
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7:295-96
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did not feel that the
to a resort
to attend
a
a drug
would
drug.
Nevertheless,
increase
unbiased
promoemploy
symposia
clearly
8 Avorn
and because
it is the
and most cost-effective,
on
desired
their
firms
1 Thompson
WG. The ethics of physician-pharmaceutical
pany relations.
Can Med Assoc J 1988; 139:835-36
or pre-
scribed
because
it is needed
best,
most efficacious,
safest,
extraneous
factors
or inducements.
The physicians
in this study
largesse
of an expense-paid
trip
on these
pharmaceutical
of a person
is recommended
effect
approaches.
6 Solomon
of physicianA conflict
of
responsibilities
or product
and
personal
be the
including
part
or subconuse of these
symposium.
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two-
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pharmaceutical
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present
journal
unethical
Regardless
ofwhat
caused
the change
in prescribing
patterns
of these
two drugs,
it is clear that physicians
need
to be conscious
and careful
about
the effects
the
the
one
was
change
therapeutic
to the
in prescribed
units
discernible
change
enticethat the
these
not
drugs,
fixation
a
that
was
and
other
pre-
two
to a recognition
their
only
is influenced
but in fact
demonstrated
there
a behavioral
contacts,
such as advertisepersonnel,
play
been
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is
responsibility
of indications
a multifaceted
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patterns.
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seminar
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or that
The
not
largely
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that
sources
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interactions
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major
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Other
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by the pharmaceutical
tional
efforts.
Likewise,
terns.
fold
also
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Such
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Whether
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11
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CHEST
I 102
I 1 I JULY, 1992
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273
The effects of pharmaceutical firm enticements on physician prescribing
patterns. There's no such thing as a free lunch.
J P Orlowski and L Wateska
Chest 1992;102; 270-273
DOI 10.1378/chest.102.1.270
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