October 20, 2010
Information provided to physicians from the US and around the world
directly by pharmaceutical companies can be associated with higher
prescribing frequency, higher costs, and lower prescribing quality.
Furthermore, exposure to pharmaceutical company information does not
improve physician prescribing behavior. These are the findings of a
systematic review by Geoffrey Spurling from The University of
Queensland, Brisbane, Australia, and colleagues and
this week's PLoS Medicine.
After doing an extensive literature search, the authors analyze and
describe the findings of 58 studies examining the relationship
between exposure of licensed physicians to promotional and other
information from pharmaceutical companies and subsequent prescribing
behavior. All but one of these studies suggested that exposure to
pharmaceutical company information was associated with lower
prescribing quality or no association was detected.
In the 51
studies that examined the relationship between exposure to
pharmaceutical company information and prescribing frequency,
exposure to information was associated with more frequent
prescribing or no association was detected.
In the eight studies that examined the relationship between exposure
to pharmaceutical company information and prescribing costs, with
one exception, these studies indicated that exposure to information
was associated with a higher cost of prescribing or no association
For example, one study found that physicians with low
prescribing costs were more likely to have rarely or never read
promotional mail or journal advertisements from pharmaceutical
companies than physicians with high prescribing costs.
because most of the studies included in the review were
observational studies - the physicians in the studies were not
randomly selected to receive or not receive drug company information
- it is not possible to conclude that exposure to pharmaceutical
information actually causes any changes in physician behavior.
The authors state:
"We did not find evidence of net improvements in
prescribing, but the available literature does not exclude the
possibility that prescribing may sometimes be improved."
"Still, we recommend that practitioners follow the
precautionary principle and thus avoid exposure to information from
An earlier study in the Annals of Internal Medicine
extensive detail about how drug companies push their products in far
more subtle ways.
Some drug makers pay key leaders in a field of medicine, such as
chairs of departments in medical schools, tens of thousands of
dollars if they are saying the right things about their product.
They manipulate medical education sessions, lectures, articles in
medical journals, research studies, even personal conversations
between physicians to get their product message across.
"It is very disturbing," says lead author Dr. Michael Steinman of
the University of California, San Francisco and the San Francisco VA
Hospital. "It really does a disservice to patient care."
Reliable estimates put the drug
industry's expenditure on promotion
to doctors at $18.5 billion that's about $30,000 a year for every
physician in the U.S. Companies conceal the specifics of those
efforts with a jealousy worthy of a state secret.
In 1996, Dr. David Franklin, an employee of the drug company
Parke-Davis, filed the lawsuit under federal whistleblower statutes
alleging that the company was illegally promoting an epilepsy drug
Neurontin for so called off-label uses. Under federal law,
once the FDA approves a drug, a doctor can prescribe it for
But the law specifically prohibits the drug company from
promoting the drug for any unapproved uses.
In 2004, the company, by then a division of Pfizer admitted guilt
and agreed to pay $430 million in criminal and civil liability
related to promoting the drug for off-label use.
What is most interesting is not the illegal actions they reveal, but
the details of activities that are perfectly legal. And according to
people familiar with the industry, the methods detailed in these
company memos are routine.
One tactic identifies certain doctors as thought leaders, key
influencers and movers and shakers those whose opinions influence
the prescribing pattern of other doctors. Those whose views converge
with the company goals are then showered with honoraria, research
and educational grants. In the Parke-Davis case 14 such big shots
got between $10,250 and $158,250 between 1993 and 1997.
Medical education drives this market, wrote the author of one
Parke-Davis business plan in the files. Many state licensing boards
require physicians to attend sessions in what is called continuing
medical education (CME) to keep current in their field.
At one time, medical schools ran most CME courses.
Now, an industry
of medical education and communications committees (MECCs) run most
of the courses. These companies with innocuous sounding names like
Medical Education Systems set up courses, sometimes in conjunction
with medical meetings, at other times often in fancy restaurants and
The drug companies foot the bill, with the program usually
noting it was financed by an unrestricted educational grant from the