Friday, May 25, 2012

Docs Who Shun Drug Reps Are Misguided

Prescribing After years of reducing their contact with pharmaceutical sales representatives, healthcare providers and their patients now face unintended consequences. According to a new study, practitioners who rarely meet with pharma reps — or who do not meet with them at all — are much slower to stop prescribing medicines with “black box” warnings and to adopt first-in-class therapies that may benefit patients. Concerns about undue pharmaceutical industry influence may be driving clinical practice in the wrong direction.

According to the study, published May 21, 2012, in The Journal of Clinical Hypertension, clinicians whose access to pharmaceutical sales representatives is limited can take more than 4 times longer to change prescribing practices based on new information than their peers who have more frequent contact [Chressanthis et al. 2012]. And, this longer response time holds true whether the physicians are responding to “positive news” related to an innovative therapy or “negative news” related to a newly discovered medicine risk.

According to lead author, George Chressanthis, PhD, of Temple University, in a news release [here], “This study analyzed for the first time — and on a large scale — what happens to physicians’ prescription decisions when you decrease the access that pharmaceutical sales reps have to doctors. We saw that increasing access restrictions affect physician decision-making in ways not anticipated by those at health care systems or large group practices who created these policies.

Chressanthis and his team were able to access data on the prescribing practices of 300,000 primary care and specialist physicians collected since 2006. They found that, since 2008, the number of clinicians willing to see reps has declined about 20%; in 2010, approximately 11% of American physicians had “severe” or “no-see” restrictions on rep access, while 34% had “some” restrictions — in all, nearly half (45%) were curtailing their exposure to information and education provided by pharmaceutical reps.

To exemplify effects of this trend, the researchers report on prescribing activity and behavior by primary care physicians and specialists from 2006 to 2008 relating to 3 major product events:

  1. The October 2006 launch of a first-in-class drug to treat Type 2 diabetes (sitagliptin) — physician sample size 65,088;

  2. the August 2007 issue of a “black box” warning (ie, the FDA’s most serious medication warning) for a drug (rosiglitazone) used to treat Type 2 diabetes — physician sample size 58,647;

  3. the January 2008 release of negative outcomes associated with a therapy that combined a cholesterol-lowering drug (simvastatin) and another medicine (ezetimibe) to treat dyslipidemia — physician sample size 72,114.

In the case of sitagliptin, physicians with a low level of sales rep access took nearly 5 times longer to introduce the new drug to patients than prescribers who employed a medium level of access. For the black box warning, physicians with very low access were up to 4 times slower to reduce their use of rosiglitazone than physicians with more lenient access. In the clinical trial involving negative outcomes of the lipid therapy (simvastatin+ezetimibe), physicians who limited sales rep access showed “significantly less” response in changing their patients’ prescriptions than did those with less restrictive practices.

One of the study’s coauthors, Pratap Khedkar, PhD, noted in the news release…

“Though health care professionals work hard to minimize distractions and maximize the time they spend with patients, it’s clear that sales rep access restrictions imposed by well-meaning physicians and group practice leaders can result in serious information gaps. Even though pharmaceutical sales representatives are not the only source of information, they do help physicians stay current on therapy developments. These findings should be carefully considered by those who set policy — whether it’s at the physician group practice level or on the national stage.”

In summarizing the importance of this study, Chressanthis observed that when physicians have to make decisions involving complex issues based on incomplete information, and where the consequences of wrong decisions can be significant as is often seen in healthcare, unintended consequences are likely to appear. Policies or practices that limit access to new medical information run counter to protecting patient health, he asserted.

COMMENTARY: This was a large-scale and well-conducted study; albeit, it was funded by AstraZeneca Pharmaceuticals LP, which might have vested interests in the outcomes. Pain specialists, as a category, were not included in this study; although, neurologists, gastroenterologists, psychiatrists, and a large group of primary care practitioners — all of whom may be involved in pain care — were included. Nearly half or more of these pain-treating clinicians had moderate to severe access limits.

It is important to consider from this evidence that pharmaceutical representatives are conduits of both positive and negative information. Practitioners who limited their exposure to pharma reps were slower to receive information that otherwise might have caused them to alter their prescribing and spare patients added risks. At the same time, patients of these rep-averse clinicians may not always have received the most current or advanced therapies in a timely fashion.

The cause célèbre these days for pundits, academics, and even U.S. congressmen is concerns about relationships between pharmaceutical companies, or “Big Pharma,” and healthcare providers, medical educators, and organizations serving the field. The tone of the lopsided debate has been hostile, emphasizing alleged influence peddling by industry and unreasoned implications of collusion on the parts of well-respected professionals and organizations. And, while there have indeed been some atypical cases of disreputable activity in the past, the far-reaching allegations of today are unsupported by any evidence rising above innuendo.

Conversely, this present study provides some concrete evidence that when the pendulum swings too far in an attempt to avoid any possibility of industry influence there can be negative consequences. Policies or practices that end up restraining the communication of medical information, and ultimately foster information gaps or ignorance in the healthcare field, run counter to protecting the public health and promoting better care for patients.  As always, reader comments are welcome.

REFERENCE: Chressanthis GA, Khedkar P, Jain N, et al. Can Access Limits on Sales Representatives to Physicians Affect Clinical Prescription Decisions? A Study of Recent Events With Diabetes and Lipid Drugs. J Clin Hypertension. 2012; online ahead of print [access here].

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