Restricting Pharma Reps' Access Cuts Brand-Name Prescribing

Diana Swift

May 02, 2017

Policies that restrict pharmaceutical sales representatives' visits to physicians are associated with modest but significant reductions in prescriptions for detailed drugs, according to a study  published online May 2 in JAMA.

Restrictive policies were also associated with a modest rise in prescribing of less costly generic medications, and hence may help rein in the rising cost of drugs for patients and the US healthcare system.

The reductions were seen at 9 of the 19 studied academic medical centers that had such policies, which was more common than change seen at centers with less restrictive policies, suggesting the policies do have an effect on prescribing. The intervention centers studied were located in five states: California, Illinois, Massachusetts, Pennsylvania, and New York.

Between 2006 and 2012, a number of US academic centers enacted polities to curb drug company detailing, which is the practice of having pharmaceutical company representatives visit physicians.

Overall, regulation was associated with a 1.67–percentage point drop (95% confidence interval, –2.18 to –1.18; P < .001) in the market share of detailed drugs and a 0.84–percentage point increase (95% confidence interval, 0.54 - 1.14; P < .001) in the market share of nondetailed drugs, report Ian Larkin, PhD, an assistant professor of strategy at the University of California, Los Angeles, and colleagues.

The policies included limiting access, prohibiting gifts to physicians, and enforcing restrictions. As previously reported by Medscape Medical News, research has shown that even tokens as small as branded pens, coffee mugs, and inexpensive meals can engender a sense of reciprocity in physicians and tilt them toward prescribing more expensive brand-name drugs.

In the current study, Dr Larkin and colleagues analyzed prescribing patterns for 262 common drugs across eight classes, using a difference-in-differences design to study changes in the prescribing patterns of 2126 physicians at the 19 centers before and after policy implementation. They compared these data with changes in the prescribing behavior of 24,593 matched control physicians. The physicians were about two thirds men, with a mean age of about 45 years. Almost 75% of academic center physicians were specialists vs 54% of controls.

Classes of detailed and nondetailed pharmaceuticals included lipid-lowering agents, gastroesophageal reflux disease drugs, diabetes drugs, antihypertensives, hypnotic drugs for insomnia, attention-deficit/hyperactivity disorder drugs, antidepressants, and antipsychotics. The comparison periods were 10 to 36 months before policy implementation and 12 to 36 months afterward.

Dr Larkin and associates found statistically significant correlations for six of the eight study drug classes and for 9 of the 19 centers with restriction policies. Of the 19 intervention centers, 11 regulated salesperson gifts to physicians, restricted salesperson access to facilities, and had explicit mechanisms for enforcement, and of these, eight showed significant change in prescribing. Only one of eight academic centers that did not have policies in all three areas showed significant change.

Between 2006 and 2012, intervention and control physicians wrote 16,121,483 prescriptions. Before policy enactment, detailed drugs had a mean market share of 19.3% at the "physician-drug-month" level, and nondetailed drugs had a market share of 14.2%.

After the policies were put in place, there was a 1.67 percentage point absolute reduction in market share for detailed drugs and a 0.84 percentage point increase for nondetailed drugs. The relative changes in market share for detailed and nondetailed drugs were −14.2% and 5.6%, respectively.

New York Medical College saw the biggest drop in market share for detailed drugs, at –4.72 percentage points, whereas Boston University School of Medicine showed the largest gain in market share for generic drugs, at 1.92 percentage points.

The detailed drug class most affected by intervention policies was sleep aids, which showed a market share drop of 10.5 percentage points. Market share for generics in this class rose by 4.67 percentage points.

The effect of industry access to physicians is an increasingly important consideration. "This will continue to be a major issue over the next decade, starting with the education of medical students and residents, in part because of the cost of drugs," said Howard C. Bauchner, MD, JAMA's editor-in-chief and a professor of pediatrics at Boston University School of Medicine in Massachusetts, in comments to Medscape Medical News.

According to Dr Larkin and coauthors, changing current prescribing patterns could mean a large reduction in healthcare costs, as 2010 industry revenues for the detailed drugs in the study amounted to more than $60 billion. Noting that generic drugs are 80% to 85% cheaper on average, "[a] 1-percentage point change in market share could represent approximately a 5% relative change in revenue for the average detailed drug, suggesting that the observed changes in prescribing could have important economic implications," the authors write.

These results are in line with other recent research showing correlations between brand-name prescribing and marketing strategies such as payments, meals, and gifts.

The findings strengthen the evidence that implementing detailing restrictions is associated with decreases in more costly brand-name prescribing, and that industry marketing to physicians increases such prescribing, write Collette DeJong, BA, and R. Adams Dudley, MD, MBA, from the Center for Healthcare Value at the Philip R. Lee Institute for Health Policy Studies in the School of Medicine, University of California, San Francisco, in a related editorial.

They caution, however, that any cost savings should be balanced with the downside of limiting interaction between physicians and the pharmaceutical industry.

"In the United States, there is no formal approach to educating physicians about new drugs," they write. "In the absence of such a system, physicians must either find information about new therapies from other sources, such as by reading or attending meetings, or accept information from pharmaceutical representatives." Drug company detailing can serve to accelerate the adoption of effective new therapies, they add.

The commentators suggest strategies for addressing conflicts of interest raised by detailing. These include reinforcing transparency measures to highlight conflicts of interest, such as the federal Open Payments Program and the American Medical Student Association scorecard, which assesses medical schools on their conflict-of-interest policies. "These efforts make it easier for physicians and patients to identify concerns and hold the profession to a high standard," the commentators write.

A second approach would provide alternate nonindustry sources for drug education, including online information. "For example, if the [Centers for Medicare & Medicaid Services] or the US Food and Drug Administration were given the authority to evaluate and grade cost-effectiveness, those agencies could advise physicians about therapeutic equivalence and the highest-value options within each drug class," DeJong and Dr Dudley write.

A third strategy would be to reform the way physicians are remunerated. "Alternative payment models, especially value-based purchasing strategies, encourage physicians to deliver high-quality care at a lower cost," the commentators write.

Feasible alternatives for informing US physicians about new drugs, however, remain largely untested. "It has never been more important for physicians to come together to consider these alternatives, generate evidence about their effectiveness, and move the health care system toward solutions that lower costs for patients and minimize [conflicts of interest]," write DeJong and Dr Dudley.

This study was supported by the National Institute of Mental Health and by data and assistance from CVS Caremark. Two coauthors were supported by the National Science Foundation. Another coauthor reported being an employee of CVS Caremark, and another coauthor reported being an employee of and owing stock in CVS Caremark. The other authors and the editorial commentators have disclosed no relevant financial relationships.

JAMA. Published online May 2, 2017. ArticleEditorial

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