Industry Payments to Gastroenterologists Tied to Biologic Rx

Ricki Lewis, PhD

July 09, 2019

Gastroenterologists who received gifts or funds from drug manufacturers were more likely to prescribe biologics for inflammatory bowel disease (IBD), according to a study published online July 8 in JAMA Internal Medicine.

To determine whether there was an association between industry payments and prescriptions, Rishad Khan, MD, from the Division of Gastroenterology, St Michael's Hospital, University of Toronto, Ontario, Canada, and colleagues compared the Centers for Medicare & Medicaid Services (CMS) Part D Prescriber Database to the CMS Open Payments Database.

They restricted their analysis to those agents that had been prescribed by more than 100 gastroenterologists between 2014 and 2016, which included adalimumab (Humira, AbbVie) for Crohn disease and ulcerative colitis, and certolizumab (Cimzia, Union Chimique Belge) for Crohn disease. The researchers included only those physicians who prescribed at least 11 filled prescriptions for the drugs annually.

As has been seen in other clinical areas, the researchers found a significant association between industry payments and Medicare spending on related prescriptions. Every $1 in payments was linked to a $3.16 increase in spending for adalimumab (95% confidence interval [CI], $2.84 – $3.48; P < .001) and a $4.72 increase for certolizumab (95% CI, $3.65 – $5.80; P < .001).

The association remained significant when the team restricted their analysis to physicians who received less than $5000 over 3 years (adalimumab: n = 3532; certolizumab: n = 607) or when they restricted it to only those gastroenterologists who wrote more than 100 prescriptions (adalimumab: n = 233). Only three physicians prescribed certolizumab more than 100 times, so the analysis was not performed for that drug.

The trend continued when the investigators assessed three types of payments separately — those for education; those for food, travel, and lodging; or those for speaking and consulting.

Every dollar spent for education was associated with a $232.65 increase (95% CI, $88.41 – $376.88; P = .002) in Medicare spending for adalimumab and a $5.83 increase for certolizumab, which was not significant (95% CI, −$19.26 to $30.91; P = .62).

Every dollar spent for food, travel, and lodging was associated with a $6.13 increase (95% CI, $5.40 – $6.86; P < .001) in spending for adalimumab and an increase of $10.48 (95% CI, $7.53 – $13.43; P < .001) for certolizumab.

For consulting and speaking payments, every dollar was associated with a $3.55 increase (95% CI, $2.14 – $4.97; P < .001) in spending for adalimumab and a $6.82 increase (95% CI, $3.36 – $10.28; P < .001) for certolizumab.

"We found an association between payments from the manufacturers of adalimumab and certolizumab to gastroenterologists and Medicare spending on these drugs. These findings persisted with smaller payments, higher-volume prescribers, and different payment types," the researchers write.

Limitations of the study include potential errors in the CMS data and not adjusting for potential confounders, such as practice location and age of physician.

In an editorial, Robert Steinbrook, MD, from the Yale School of Medicine, New Haven, Connecticut, who is editor at large for JAMA Internal Medicine, cites the precedents of associations between pharmaceutical industry marketing and payments and prescription of opioids and targeted cancer therapies for Medicare beneficiaries. "All of these studies have essentially the same finding — that marketing to physicians is associated with increased sales of a company's product and increased Medicare expenditures," he writes.

Steinbrook identifies an "indisputable pattern" in the new study, even though it does not establish cause and effect and did not consider influence of direct-to-consumer advertising. The study also did not probe the degree to which the prescribed biologics were indeed the optimal treatment on a case-by-case basis.

"The many studies establishing the association between industry payments and physicians' prescribing of brand-name medications raise troubling questions about whether it is in patients' interests for physicians to accept these payments at all," he concludes.

Khan has received funding from AbbVie, Ferring Pharmaceuticals, and Pendopharm. Coauthor Samir C. Grover, MD, has received funding from AbbVie, Takeda, Ferring Pharmaceuticals, and Janssen and has equity in Volo Healthcare. The other coauthors and Steinbrook have disclosed no relevant financial relationships.

JAMA Intern Med. Published online July 8, 2019. Abstract, Editorial

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