As Little as a Free Meal Influences Prescribing, Data Suggest

Nicola M. Parry, DVM

June 23, 2016

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 De Jong, BA, from the University of California, San Francisco, and colleagues.

Furthermore, "[r]eceipt 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.

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 one 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.

De Jong 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 four 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 four 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 four 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 four 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 one 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 over 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); and desvenlafaxine 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, 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."

DeJong received support for this study from the National Center for Advancing Translational Sciences, National Institutes of Health, and one coauthor received support from the Hawaii Medical Service Association Endowed Chair in Health Services and Quality Research at the University of Hawaii. The other authors and Dr Steinbrook have disclosed no relevant financial relationships.

JAMA Intern Med. Published online June 20, 2016. Article full text, Editor's note full text

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