Can a Free Meal Influence Prescribing Habits?

CLINICAL CONTEXT

Pharmaceutical companies and other businesses with an interest in healthcare spend millions and millions of dollars to influence physicians, and these interactions can fulfill a clearly biased self-interest for the private sector. The relationship between clinicians and industry has received increased scrutiny during the past decade, and a review by Alkhaled and colleagues, which appeared in the July 1, 2014, issue of BMJ Open,[1] focused on evidence-based interventions to limit the influence of industry on physician behavior.

The researchers found more than 11,000 citations in their initial search, but only 1 randomized controlled trial and 3 observational studies met their criteria for inclusion in the review. Despite broad research criteria that could focus on legislative, educational, or policy interventions, all 4 included studies focused specifically on the interaction between physicians and pharmaceutical representatives. The majority of studies found that interventions which restricted meetings with pharmaceutical representatives or the distribution of promotional material or drug samples was associated with less influence on physician prescribing behavior. However, this evidence was judged to be of low quality overall.

One of the principal concerns regarding the relationship between the pharmaceutical industry and prescribing physicians is the potential for an increase in the rate of prescriptions for more expensive brand-name medications in the place of effective and lower-priced generic drugs. However, can a limited activity, such as attendance at a meal sponsored by a pharmaceutical company, actually promote such behavior? The current study by DeJong and colleagues evaluates this possibility.

STUDY SYNOPSIS AND PERSPECTIVE

Physicians’ prescribing behavior may be influenced by their receipt of industry-sponsored meals, new data suggest. Physicians who received an industry-sponsored meal promoting a company’s drug were more likely to prescribe the brand-name drug than a less expensive generic one.

“Physicians who received a single meal promoting the drug of interest had higher rates of prescribing rosuvastatin over other statins,” write Colette DeJong, BA, from the University of California, San Francisco, and colleagues.

Furthermore, “receipt of additional meals and receipt of meals costing more than $20 were associated with higher relative prescribing rates.”

The researchers published the results of their study online June 20 in JAMA Internal Medicine.[2]

In the United States, 4.3 million companies paid $3.4 billion to more than 470,000 physicians and 1000 teaching hospitals in the last 5 months of 2013. Although common, such physician-industry relationships remain complicated, and recent attempts in the United States and Europe to provide transparency into these financial ties have further highlighted the controversy over these interactions and, in particular, how they affect physicians’ prescribing habits.

Studies have suggested that these relationships are associated with greater prescribing of brand-name drugs. For example, in 1 study, physicians’ acceptance of payments from industry was associated with greater Medicare Part D prescribing costs. In another, prescribing of brand-name medications was only significantly increased among physicians who received payments of more than $2000.

However, the effect of smaller payments, such as sponsored meals, which account for nearly 80% of all payments from industry to physicians, on prescribing behavior has been unclear.

DeJong and colleagues therefore conducted a study to determine whether physicians’ receipt of industry-sponsored meals is associated with their prescribing the promoted brand-name drug at higher rates to Medicare beneficiaries.

The researchers linked industry payment data from the federal Open Payments program (from August 1 through December 31, 2013) and physicians’ prescribing data from Medicare Part D (for all of 2013).

They included physicians who wrote more than 20 filled Medicare prescriptions in any of 4 drug categories: statins, cardioselective β-blockers without sympathomimetic activity, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACE inhibitors and ARBs), and selective serotonin and serotonin-norepinephrine reuptake inhibitors (SSRIs and SNRIs). They also identified the most-prescribed brand-name drug in each of the 4 categories in Medicare Part D: rosuvastatin calcium (statin), nebivolol (cardioselective β-blocker), the ARB olmesartan medoxomil (ACE inhibitors and ARBs), and the SNRI desvenlafaxine succinate (SSRIs and SNRIs).

  • Overall, 279,669 physicians received 63,524 payments (total value, $1.4 million) related to the 4 target drugs, and 95% of those payments were meals with an average value of less than $20.
  • Physicians who received meals associated with the target drugs had a greater mean prescribing volume than those who received no free meals (statin prescriptions, 742.2 vs 470.1; β-blocker prescriptions, 410.0 vs 299.8; ACE inhibitor and ARB prescriptions, 562.7 vs 394.8; and SSRI and SNRI prescriptions, 437.6 vs 269.5; all comparisons, P <.001).
  • Physicians who received 4 or more industry-sponsored meals related to the target drugs prescribed rosuvastatin at 1.8 times the rate of those who received no free meals (15.2% vs 8.3%), nebivolol at 5.4 times the rate (16.7% vs 3.1%), olmesartan at 4.5 times the rate (6.3% vs 1.4%), and desvenlafaxine at 3.4 times the rate (1.7% vs 0.5%).
  • Even physicians who received only 1 industry-sponsored meal, with a mean value of less than $20, related to one of the target drugs were more likely to prescribe this drug vs others in the same group: rosuvastatin (adjusted odds ratio [OR], 1.18; 95% confidence interval [CI], 1.17-1.18);nebivolol (OR, 1.70; 95% CI, 1.69-1.72);olmesartan (OR, 1.52; 95% CI, 1.51-1.53); anddesvenlafaxine (OR, 2.18; 95% CI, 2.13-2.23).

The authors note that although these findings are cross-sectional and “represent an association, not a cause-and-effect relationship,” they support the importance of ongoing transparency efforts in physician-industry relationships in the United States and Europe.

In an accompanying editor’s note,[3] JAMA Internal Medicine Editor-at-Large Robert Steinbrook, MD, professor adjunct of internal medicine at the Yale School of Medicine, New Haven, Connecticut, writes that the results of this study agree with those from other recent studies and show that industry payments are associated with a prescribing approach that benefits pharmaceutical companies.

He also raises the broader question of whether it is even necessary to prove a causal relationship between industry payments and physicians’ prescribing of brand-name drugs. Other than research support, product development, and bona fide consulting related to specific research, there are few reasons for physicians to have financial ties with industry, he says.

“There are inherent tensions between the profits of health care companies, the independence of physicians and the integrity of our work, and the affordability of medical care,” Dr Steinbrook writes. “If drug and device manufacturers were to stop sending money to physicians for promotional speaking, meals, and other activities without clear medical justifications and invest more in independent bona fide research on safety, effectiveness, and affordability, our patients and the health care system would be better off.”

STUDY HIGHLIGHTS

Researchers evaluated physician prescription data in the Physician Compare and Medicare Part D Prescriber file data. They focused on year-end data from 2013 regarding the number of prescriptions in 4 drug classes: statins, cardioselective β-blockers, ACE inhibitors and ARBs, and SSRIs and SNRIs. Researchers identified the 4 most prescribed brand-name prescriptions in each drug class: rosuvastatin, nebivolol, olmesartan, and desvenlafaxine, respectively.The main study outcome was the prescription rate of these 4 drugs compared with that of other drugs in the same class. The principal variable was data on payments to physicians in the form of industry-sponsored meals from August through December 2013. Data were drawn from the federal government’s Open Payments database. All payment data were for events promoting the use of the 4 target drugs.The study analysis was adjusted to account for demographic data from the prescriber and other prescribing habits, including the physician’s overall propensity to prescribe brand-name drugs.155,849 physicians provided data for analysis for prescriptions in at least one of the target drug classes.Across the database generated by the researchers, rosuvastatin accounted for 8.8% of all statin prescriptions. Nebivolol was associated with 3.3% of all cardioselective β-blocker prescriptions, and olmesartan represented 1.6% of all ACE inhibitor and ARB prescriptions. Finally, desvenlafaxine accounted for 0.6% of all SSRI and SNRI prescriptions.63,524 payments were made for the target drugs, for a total of $1.4 million. An estimated 95% of these costs were for sponsored meals, and the average payment per physician per meal was $12 to $18.Compared with physicians not receiving payments, those who received payments were more likely to be men, solo practitioners, and practice medicine in the South. Physicians receiving payment were less likely to care for low-income populations.The adjusted OR for prescribing each of the 4 target drugs was significantly higher among physicians who received at least 1 sponsored meal. The associated OR for rosuvastatin was 1.18 (95% CI, 1.17-1.18); for nebivolol, it was 1.70 (95% CI, 1.69-1.72). The OR for olmesartan was 1.52 (95% CI, 1.51-1.53), and the OR for desvenlafaxine was 2.18 (95% CI, 2.13-2.23).Accepting more meals and accepting costlier meals were both associated with progressively higher ORs for prescribing one of the target drugs.Other factors associated with a higher rate of prescriptions for the target drugs included an increased propensity to prescribe any brand-name drug and practicing in the South.

CLINICAL IMPLICATIONS

A previous systematic review by Alkhaled and colleagues found evidence that limiting prescribers’ contact with pharmaceutical representatives could reduce industry influence on prescribing habits, but there were no quality data on other interventions.The current study by DeJong and colleagues suggests that receiving a sponsored meal worth less than $20 can result in a significantly higher rate of prescribing the brand-name prescription drugs promoted at the event. Accepting more meals and costlier meals was associated with even higher rates of brand-name prescriptions.Implications for the Healthcare Team: Newer brand-name prescription drugs may or may not be more effective or better tolerated compared with older medications, but they are invariably more expensive. The current study should raise the awareness of the healthcare team, including the patients who should stand in the center of the team, regarding the direct and measurable effect of commercial interests on practice habits.

REFERENCES

  1. Alkhaled L, Kahale L, Nass H, et al. Legislative, educational, policy and other interventions targeting physicians’ interaction with pharmaceutical companies: a systematic review.BMJ Open. 2014;4:e004880. https://www.ncbi.nlm.nih.gov/pubmed/24989618. Accessed June 23, 2016.
  2. DeJong C, Aguilar T, Tseng C-W, Lin GA, Boscardin WJ, Dudley RA. Pharmaceutical industry-sponsored meals and physician prescribing patterns for Medicare beneficiaries. JAMA Intern Med. Published online June 20, 2016. http://archinte.jamanetwork.com/article.aspx?articleid=2528290. Article abstract. Accessed June 23, 2016.
  3. Steinbrook R. Industry payments to physicians and prescribing of brand-name drugs. JAMA Intern Med. Published online June 20, 2016. http://archinte.jamanetwork.com/article.aspx?articleid=2528285. Editor’s Note extract. Accessed June 23, 2016.

 

Source: Medscape Pharmacist

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