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The Physician-Pharmaceutical Industry Relationship

The Physician-Pharmaceutical Industry Relationship. Slide presentation by No Free Lunch. The CAGE Questionnaire for Drug Company Dependence. Have you ever prescribed C elebrex TM ? Do you get A nnoyed by people who complain about drug lunches and free gifts?

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The Physician-Pharmaceutical Industry Relationship

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  1. The Physician-Pharmaceutical Industry Relationship Slide presentation by No Free Lunch

  2. The CAGE Questionnaire for Drug Company Dependence • Have you ever prescribed CelebrexTM? • Do you get Annoyed by people who complain about drug lunches and free gifts? • Is there a medication loGo on the pen you're using right now? • Do you drink your morning Eye-opener out of a LipitorTM coffee mug? If you answered yes to 2 or more of the above, you may be drug company dependent.

  3. Case You are on the wards during your medicine clerkship, and today’s noontime conference is on the treatment of community acquired pneumonia. The lecture is being given by one of the infectious disease specialists. Seated in the back of the conference room is a pharmaceutical rep from a company that makes a new broad spectrum antibiotic. The rep has provided lunch as well as brought along free pocket antibiotic guides for the house-staff and students in the audience.

  4. American Medical AssociationCouncil on Ethical & Judicial Affairs • “Any gifts accepted by physicians individually should primarily entail a benefit to patients and should not be of substantial value.” • “Subsidies from industry should not be accepted directly or indirectly to pay for the costs of travel, lodging, or personal expenses of the physicians who are attending the conferences and meetings . . .” • “No gifts should be accepted if there are strings attached.” JAMA 1991;261:501

  5. ACP-ASIM Position Paper: Physician-Industry Relations “Physicians have an obligation to themselves, their profession, and society to evaluate, correct for, and eliminate potential bias in medical information from all sources." Ann Int Med 2002:136:000

  6. ACP-ASIM Position Paper: Physician-Industry Relations “A perception that a physician is dispensing medical advice on the basis of commercial influence is likely to undermine a patient's trust not only in the physician's competence but also in the physician's pledge to put patients' welfare ahead of self-interest.” Ann Int Med 2002:136:000

  7. ACP-ASIM Position Paper: Physician-Industry Relations “Physicians frequently do not recognize that their decisions have been affected by commercial gifts and services and in fact deny industry's influence.” Ann Int Med 2002:136:000

  8. Conflict of interest? “I have never been bought, I cannot be bought. I am an icon, and I have a reputation for honesty and integrity, and let the chips fall where they may.” “It is true that there are people in my situation who could not receive a million-dollar grant and stay objective. But I do.”

  9. Conflict of interest “Set of conditions in which professional judgement concerning a primary interest tends to be unduly influenced by a secondary interest” (Thompson) NEJM 1993;329:573-6

  10. “That stuff doesn’t influence me at all. I don’t even know what drug is on my pen. I just go for the food.”--Fill in your name here?

  11. Attitudes and Practices

  12. Of principles and pens: attitudes and practices of medicine housestaff toward pharmaceutical promotions • Survey of 117 1st and 2nd year residents at a university-based IM training program. • Attitudes towards 9 types of promotion assessed. • 90% response rate (105/117 residents). Am J Med 2001;110:551

  13. Attitudes Toward PromotionsPercent Who Consider Appropriate Am J Med 2001;110:551

  14. Practices Among Residents Who Consider Promotion Appropriate Am J Med 2001;110:551

  15. Practices Among Respondents Who Consider Activity Inappropriate Am J Med 2001;110:551

  16. Perceived influence of pharmaceutical reps on Prescribing Practices p <.0001 Am J Med 2001;110:551

  17. Interactions with the pharmaceutical industry: experiences and attitudes of psychiatry residents, interns, and clerks. • Survey of 105 residents, interns, and clerks rotating through 7 teaching hospitals in Toronto, Canada. • Self-report questionnaire • 70% response rate CMAJ 1995;153:553

  18. Interactions with the pharmaceutical industry: experiences and attitudes of psychiatry residents, interns, and clerks. • Mean value of gifts: $60 (range $0 to $800). • 37% reported attending dinners, 43% reported receiving books. • The number of promotional items received was positively correlated with the belief that discussions with reps have no impact on prescribing behavior. CMAJ 1995;153:553

  19. Interactions with the pharmaceutical industry: experiences and attitudes of psychiatry residents, interns, and clerks. • 34% said discussions with reps do not impact prescribing. • 56% said promotional items do not impact their own prescribing. • 42% disagreed with the statement “I would maintain the same degree of contact with reps if no gifts were distributed.” CMAJ 1995;153:553

  20. Patient Perceptions of Physician Acceptance of Gifts from the Pharmaceutical Industry Telephone survey of adult patients in Kentucky. 649 (55%) responded. 82% were aware that physicians received gifts that were of potential value to patients. 32% were aware that physicians received personal gifts. Arch Fam Med 1995;4:335

  21. Patient Perceptions of Physician Acceptance of Gifts from the Pharmaceutical Industry P=.0001 for all comparisons Arch Fam Med 1995;4:335

  22. Patient Perceptions of Physician Acceptance of Gifts from the Pharmaceutical Industry P=.005 P=.002 Effects on cost of care Effects on quality of care Arch Fam Med 1995;4:335

  23. “What would my patients think about this arrangement?” (ACP) [Image of flyer]

  24. Pharmaceutical industry promotion pharmaceutical industry profits

  25. Promotional spending on prescription drugs, l996-2000 Source: NIHCM, 2001

  26. Promotional spending on prescription drugs, 2000 Total spending: $l5.7 billion Source: IMS Health

  27. Direct to consumer advertising on prescription drugs,l996-2000 Source: NIHCM, 2001

  28. Spending on DTCA of prescription drugs, 2000 Total spending: $2.5 billion dollars Source: IMS Health

  29. Comparison of median revenue dedicated to R&D, profits, and marketing/administration, Fortune 500 drug companies, 2000 (n=11) Source: Public Citizen, 2001

  30. Pay, Profits, and Spending by Drug Companies • All of the 9 U.S. drug companies that market the top-selling 50 drugs for senior citizens spent more money on promotion and administration than on research and development in FY 2000. • 6 of these 9 companies made more money in net profits than they spent on R&D. • The highest-paid executive in each of the 9 companies earned an average of almost $19,000,000. Families USA, 2001.

  31. Main task of drug company employees, 2000 Source: PhRMA Industry Profile 2000; percentages calculated by Sager and Socolar

  32. Drug company jobs in marketing and research, 1995-2000 # Jobs Source: PhRMA Industry Profile 2000; percentages calculated by Sager and Socolar

  33. Profitability of drug industry, l993-2000 . 2.8% • Source: Public Citizen update of Stephen W. Schondelmeyer calculation, Competition and Pricing Issues in the Pharmaceutical Market, PRIME Institute, University of Minnesota based on data found in Fortune magazine, 1958 to 1999; Fortune magazine, April 2000, Fortune 500 (www.fortune.com).

  34. Fortune 500 drug company profitability compared to all other Fortune 500 companies, 2000 Source: Public Citizen, 2001

  35. Prescription drug expenditures in the U.S, l993-2000 Source: IMS Health

  36. Sources of increased drug expenditures, 1999-2000 22% 42% 36% Total increase: $20.8 billion Source: NIHCM, 2001

  37. Direct to consumer advertising • $2.5 billion dollars were spent on advertising to consumers in 2000; $468 million dollars were spent on journal ads. • Increases in the sales of the 50 drugs most heavily advertised to consumers in 2000 were responsible for almost half (47.8%) of the $20.8 billion increase in spending on drugs that year. • Over 40% of DTC spending was concentrated on ten products, among them Claritin, Prilosec, Viagra, Paxil, and Meridia. Source: NIHCM, 2001

  38. Direct to consumer advertising spending in the U.S., 2000 Source: NIHCM, 2001

  39. ACP-ASIM Position Paper: Physician-Industry Relations “Physicians frequently do not recognize that their decisions have been affected by commercial gifts and services and in fact deny industry's influence.” “Research, however, shows a strong correlation between receiving industry benefits and favoring their products.” Ann Int Med 2002:136:000

  40. Influence

  41. The Effects of Pharmaceutical Firm Enticements on Physician Prescribing Patterns Pharmacy records reviewed 22 months before and 17 months after two pharmaceutical company-sponsored symposia on two medications: Drug A: New intravenous antibiotic Promotion: All-expenses-paid trip to “luxurious resort on West Coast” (n=10 travelling MDs) Drug B: New intravenous Cardiac drug Promotion: All-expense-paid trip to island resort in the Caribbean (n=10 travelling MDs) Chest 1992;102:270

  42. The Effects of Pharmaceutical Firm Enticements on Physician Prescribing Patterns Chest 1992;102:270

  43. Physicians' Behavior and their Interaction with Drug Companies Case-control study at a University Hospital Cases: 40 physicians who had requested formulary additions. Controls: 80 physicians who had made no such requests. Information regarding interaction with drug companies obtained by survey instrument. JAMA 1994;271:684

  44. Physicians' Behavior and their Interaction with Drug Companies • Physicians who had requested formulary changes were more likely to have accepted money from drug companies to attend or speak at symposia. (OR=5.1, 95%CI, 2.0 - 13.2) • Physicians were more likely to have requested additions of drugs made by companies with whose reps they had met (OR=4.9, 95%CI, 3.2 - 7.4). JAMA 1994;271:684

  45. Scientific versus commercial sources of influence • Telephone questionnaire of 85 randomly selected internists in Boston area • Questioned about two classes of drugs: • Propoxyphene analgesics • Cerebral and peripheral vasodilators. Am J Med 1982;273:4

  46. Scientific versus Commercial Sources of Influence Am J Med 1982;273:4

  47. Scientific versus Commercial Sources of Influence Am J Med 1982;273:4

  48. Scientific versus Commercial Sources of Influence on the Prescribing behavior of Physicians Were physicians who believed these drugs to be effective more likely to rely on commercial than academic sources? • Vasodilators: Yes (p=0.006) • Propoxyphene: No Am J Med 1982;273:4

  49. The role of commercial sources in the adoption of a new drug • Interviews with 124 doctors in private practice in 2 distinct geographical areas in Australia. 40% specialists. • Target drug: temazepam • Response rate 60% • Interviews conducted 13 months after release. Soc Sci Med, 1988;26:1183

  50. The role of commercial sources in the adoption of a new drug Soc Sci Med, 1988;26:1183

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