Four members (Spurling, Montgomery, Doust and Vitry) of the 25-strong group of No Advertising Please organisers were authors on the seminal 2010 systematic review about the effect of pharmaceutical company information on doctors’ prescribing habits. Because this is the best evidence currently in existence, it is worth examining in some detail. For individual references, see the original Spurling et al paper.
Of 7323 relevant studies published since 1966, 58 met inclusion criteria. These studies assessed prescribing quality in four distinct ways: quality scoring of prescribing decisions, guideline adherence, prescribing appropriateness of an individual drug class, and prescribing range.
Of the 29 studies of pharmaceutical sales representative (rep) visits, 17 found associations with increased prescribing of the promoted drug, six found significantly increased prescribing for some but not all measures, and none found less frequent prescribing. Longer rep visits to physicians and residents were more likely to be associated with increased prescribing.
In addition to increasing the promoted drug’s market share, rep visits were associated with a decrease in the market share of competitor products. Rep visits were more likely to be associated with drugs with more side effects.
Rep visits were associated with a greater increase in market share for new entrants into a therapeutic field than was positive scientific information. And one study found that journal advertisements have a more pronounced effect on market share for the advertised drug than does positive scientific information published in medical journals.
Reduced quality: all but one study reported that exposure to information from pharmaceutical companies was associated with either lower prescribing quality or no association was detected.
Increased costs: all but one study reported that exposure to information from pharmaceutical companies was associated with an increase in prescribing costs or no association was detected.
Hence, the best available evidence shows an association between rep visits and an increase in prescription quantity and cost, and either a decrease in quality or no change.
We believe the crucial relationship between a doctor and a patient should not be interfered with by a marketing representative whose job is to persuade the doctor to use one specific treatment at the expense of all other potential options (including non-pharmacological treatments).
Drug company reps are usually more informative about benefits than the harms and costs of medications and often make statements that do not accord with approved product information (Lexchin and Roughhead). A US study found that 11% of statements made by drug company representatives were inaccurate and every one of these statements favoured the drug company representative’s drug. Fourteen per cent of statements concerned the competitor’s drug: all were accurate and none were favourable. A survey of the 27 doctors who participated in the study found that 74% did not recognise that they had heard any false statements. (Zeigler)
The doctor has a professional duty of care to their patient. Because, as the evidence suggests, the information may be biased, some doctors who see reps say they then go straight to the literature to double check most of the positive claims the rep had just made. This is an inefficient use of the doctor’s time. (Brody) We suggest skipping the first step and going straight to the independent literature.
Intelligence offers little protection when it comes to vulnerability to sales techniques. Pharmaceutical advertising material specifically targets its educated, intelligent audience. Reps are trained to deliver tailored approaches to different personalities: the friendly doctor, the no-nonsense doctor and the sceptical doctor. (Fugh-Berman)
Information does not have to be incorrect to be persuasively misleading. Simple promotional techniques include presenting selective evidence from favourable studies, and carefully choosing which statistics to highlight – e.g., (large) relative risk for benefits and (small) absolute risk for harms.
See Where do I find better, independent sources of medicines information? for some useful examples such as NPS Medicinewise and the Australian Medicines Handbook. In this online age, the huge variety of independent journal articles and decision-making tools available for free in a matter of seconds prevents us listing them all here. Every TGA-approved medicine has its product information available at the click of a mouse. The days of doctors seeing drug reps to save the time spent time travelling to the nearest medical library are long gone.
The drug industry has an irreducible conflict of interest. They’re there to make money for their shareholders—quite right and legitimate—and in doing so, they often create good products that we rely on and need. But they don’t have a legitimate role in the education of doctors.
Many medical practices have already made changes to reduce or cease seeing pharmaceutical reps.
In one general practice, the doctors, nurses and administrative staff voted to significantly reduce their exposure to the pharmaceutical industry. The new policy stated that doctors could initiate contact with representatives they wanted to see but it had to be outside consulting hours and could not be at lunchtime without everyone’s consent. The policy recommended against taking promotional material, gifts and samples. Most importantly, drug reps were no longer allowed to make unsolicited appointments with doctors via the reception team which meant there was less interaction in corridors and fewer requests to sign for samples. After nine months, staff were satisfied with the changes, there was a large drop in promotional material in the service, and more generic medications were being prescribed. (Spurling 2007)