Pharma gift bans for budding doctors have long-term impact
■ Medical school and residency rules on industry-provided meals and other perks appear to influence prescribing once physicians are in practice.
The gift restrictions adopted in medical schools and residency programs are linked to less prescribing of brand-name drugs, said two recently published studies that appear to be the first attempts to gauge the clinical practice impact of efforts within medicine to rein in pharma's influence.
One study, published Jan. 31 in the British medical journal BMJ, examined the effect of bans on gifts from pharmaceutical companies and device-makers at 14 U.S. medical schools by analyzing the drug orders of about 2,500 doctors. Researchers compared the prescribing practices of physicians trained at those schools after they banned gifts in 2004 with those trained at the same schools before the bans, as well as with a matched set of doctors who attended medical schools that allowed gifts such as industry-funded meals.
They then looked at how these doctors — 46% general internists, 23% pediatricians, 10% psychiatrists and the remainder practicing other specialties — responded to three new drugs that were marketed in 2008 and 2009.
The physicians who attended no-gift med schools were 56% less likely than the other doctors to prescribe Shire's Vyvanse (lisdexamfetamine), a stimulant used to treat attention-deficit/hyperactivity disorder. They also were 75% less likely to order Janssen's Invega (paliperidone), an antipsychotic. For a third medicine, Pfizer's antidepressant Pristiq (desvenlafaxine), there was no statistically significant difference in prescribing.
Researchers attributed that to a low level of overall prescribing of the drug that made it difficult to find substantial disparities between doctors who attended no-gift schools and those who did not.
The lead author of the BMJ study, Joseph S. Ross, MD, said the study verifies his personal experience. He completed his first two years at a medical school that allowed gifts from drugmakers. He then transferred, for personal reasons, to another school that had a gift ban.
“I did my last two years at Albert Einstein College of Medicine in the Bronx in 2000 and 2001. They didn't allow drug reps. I think you recognize that in the culture when you're attending a school, when reps are around. It's part of the environment and part of the school and the educational setting. I think we're seeing that effect once these students hit the market as independent prescribers,” said Dr. Ross, assistant professor of medicine at Yale University School of Medicine in Connecticut.
Effect found in residency programs
Another study in the February issue of Medical Care looked at the prescribing habits of nearly 1,700 psychiatrists. About half graduated from residency programs in 2001 before gift bans were in vogue, and the other half completed their training in 2008, after many programs banned gifts from industry as part of following the Assn. of American Medical Colleges' conflict-of-interest guidelines.
The 2008 graduates were less likely than their 2001 counterparts to prescribe heavily promoted, brand-name antidepressants, the study found. The prescribing gap ranged from 3.6 percentage points to 6.2 percentage points, with stricter residency program rules of conflicts being tied to lower prescribing of the brand-name drugs.
“Contact with the pharmaceutical industry may have important informational benefits for physicians,” said Andrew J. Epstein, PhD, lead author of the study and research associate professor of medicine at the Perelman School of Medicine at the University of Pennsylvania. “Nevertheless, while these relationships may be useful in some ways, our study clearly shows that implementation of COI policies have helped shield physicians from the often persuasive aspects of pharmaceutical promotion.”
Proponents of stronger conflict-of-interest rules at medical schools and residency programs welcomed the findings. Since 2008, the American Medical Student Assn. has issued its PharmFree Scorecard, grading medical schools on policies such as whether they allow gifts, let drug reps visit campus without appointments, and scrutinize faculty speaking and consulting agreements with industry. Its March 2012 report found that two-thirds of schools earned an A or B grade, compared with 30% in 2009.
“These studies have shown that strong conflict-of-interest action has an effect on prescribing changes,” said Reshma Ramachandran, a fourth-year medical student at Warren Alpert School of Medicine at Brown University in Rhode Island, who is doing a fellowship on pharmaceutical policy at AMSA. “This is what we'd hoped for — that the AMSA PharmFree Scorecard would have not only an effect on institutions' policies but also a cultural effect on students later on in practice when they are deciding what treatments to give to their patients.”
Further research should be done to evaluate the effectiveness of policies restricting interactions with industry, said Daniel J. Carlat, MD, director of the Pew Prescription Project and a supporter of such policies.
“It's crucial that we begin to move from having strong opinions about conflicts of interest to having good data to support the value of conflict-of-interest policies,” said Dr. Carlat, a psychiatrist.
The findings come as physicians work to digest the final rule implementing the Physician Payments Sunshine Act, adopted as part of the Affordable Care Act in 2010. The Centers for Medicare & Medicaid Services estimates that it will cost physician practices and teaching hospitals staff time worth $59 million to review drugmakers' reports of payments and gifts for accuracy.
Reports of “transfers of value” worth $10 or more to an individual doctor must be tracked, and any doctor who receives $100 or more in a year will see that information publicly reported on a searchable government website starting Sept. 30, 2014. Physicians will have 60 days to review industry reports for accuracy before they are made public.