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Are doctors swayed by big pharma largesse?


Oncologists are much more likely to prescribe a company’s drug if that company has provided them with gifts, speaker fees, free meals, travel expenses or research money, a US study has found.

The study, published as a research letter in JAMA Internal Medicine, focused on two cancers: metastatic renal cell cancer (mRCC) and chronic myleoid leukaemia (CML), for which there are multiple drug options.

For mRCC, oncologists who had received money from a pharma company were almost twice as likely to prescribe that company’s drug, compared with doctors who had not received any money from the company. It was a similar story in CML, although the effect was not as great, with a 30% difference in prescribing rates between oncologists who did and did not receive money from the drug company in question.

The drug choices were sorafenib, sunitinib malate or pazopanib hydrochloride for mRCC, and dasatinib, imatinib mesylate or nilotinib for CML. For three of these drugs – sunitinib, nilotinib and dasatinib – prescribing rates were higher for oncologists who received payments from the respective drug companies.

Interestingly, prescribing rates for imatinib went down for physicians who received payments from the manufacturer Novartis. But that same company markets the newer drug nilotinib, and the study authors said their findings reflected the fact that Novartis was trying to get physicians to transition from imatinib, which is soon to go off patent, to nilotinib, which has many more years of patent to run.

The study involved around 3,600 oncologists with a history of prescribing for either of the two conditions.

In the US, big pharma spends around $7 billion wooing clinicians with consultancy fees, expenses and research grants. The figures are much smaller in Australia, but are still considerable. In 2016, Fairfax Media reported that big pharma had splurged around $43 million on health professionals over a period of six months.

That expenditure included a $70,000 trip to Sweden for six oncologists and a $176,000 “educational” trip to Vancouver for nine dermatologists.

Novartis flew 19 health professionals to an Amsterdam conference at its own expense, according to figures from Medicines Australia, and the company also sent five oncologists to a four-day conference in Austria, which included two weeks’ accommodation, at a cost of $32,569.

In 2015, Novartis fell foul of Medicines Australia’s Code of Conduct and was fined $90,000 over a breach of ethical guidelines. It concerned a seven-hour event for only three specialists, with no clear link to educational outcomes. Medicines Australia noted concern that the event was “a form of reward to these individuals who prescribed Novartis’s ophthalmological product”.

Who’s paying for lunch? How drug companies wine and dine doctors


In June 2015, 24 Australian cancer specialists flew to Chicago to attend a five-day conference. Drug giant Amgen funded the trip, including registration, transfers and wining and dining. It cost almost A$270,000.

In December 2013, in a teaching hospital in New South Wales, 11 pharmacists and pharmacy technicians attended a 45-minute presentation by a pharmaceutical representative from a company called Menarini. The presentation was accompanied by a lunch that included sandwiches, wraps, sushi and fruit juice. Lunch cost A$200.

These are just two very different examples of the more than 116,000 events for Australian health professionals that drug companies funded in a recent four-year period, which we analysed in a study just published in BMJ Open.

You can examine the data yourself.

Since 2007, drug companies have been required to publish detailed reports of how they sponsor educational events for health professionals.

They have had to list the number of attendees, the name of the restaurant, resort or clinic, and the costs of food and drink. But so far, they have not had to list the names of the doctors enjoying it.

Until today there has been little analysis of these reports. This is because despite being publicly available, the millions of bits of data were “trapped” in PDF files. Now the information is available for anyone to analyse.

What did we find?

The data shows the routine, yet influential, ways health professionals interact with pharmaceutical companies when it comes to professional education.

Between 2011 and 2015, pharmaceutical companies sponsored more than 116,000 events – on average more than 600 a week. While many of the breakfasts, lunches and dinners were held in hotels and fancy restaurants across the country, most took place inside hospitals or doctors’ offices, suggesting drug companies have a pervasive presence in everyday clinical practice.

Most of the events (82%) included medical doctors, but many included different types of health professionals. For example, 39.6% included nurses, 38.3% trainees and 8.4% pharmacists.

Oncology or cancer – a field where there is increasing concern about the use of high-cost medicines – was the most frequent area of focus of the events, accounting for 19.7% of the functions.

Why does this matter?

Industry sponsored events for health professionals are commonly termed “educational” events. However, they are a key pillar of the pharmaceutical industry’s marketing strategy.

Although health professionals often fail to perceive commercial biases in such events, their educational content can be biased in favour of the sponsor. The prescription rate of the sponsor’s drug has also been shown to increase afterwards.

Even the provision of free meals, which are commonly provided at sponsored events, can influence clinical practice. Evidence of this comes from the United States, where thanks to the Sunshine Act, pharmaceutical companies have to report all payments to individual doctors.

Prescribing drugs based on exposure to industry-sponsored events raises concerns about the unhealthy effects on patient care and increasing health care costs when newer, expensive and aggressively promoted drugs are prescribed.

A recent study conducted in the US found the receipt of even a single sponsored meal worth as little as US$16 was associated with an increase in prescribing of promoted drugs.

Disappearing data

The analysis published today is timely considering two major changes to drug company reporting that have recently been implemented in Australia.

From October 2015, drug companies have no longer had to report on these influential “educational” events. Instead, they are now required to report on payments they make to individual health professionals, and to name those individuals.

This could improve transparency in some ways. For instance, people could check if their own doctor has attended an educational event sponsored by a drug company. But the new rules contain loopholes.

For example, they explicitly exclude the need for drug companies to report how much they spend on food and beverages. As 90% of the events analysed included the provision of food and beverage, a large proportion of potentially influential payments from drug companies to health professionals are now invisible.

The value of transparency and independence

As some authors have pointed out, transparency is not going to solve the problem of unhealthy industry influence as it does not eliminate the conflicts of interest that arise when health professionals interact with pharmaceutical companies.

The most important issue is not just transparency, but if it is appropriate for health professionals to receive meals from and rely on information provided by drug companies in the first place.

Evidence suggests that it is time to forge much greater independence between the companies marketing the drugs, and the doctors prescribing them.

Policies to limit health professionals’ interactions with pharmaceutical companies can be a more effective measure than disclosure to reduce and eliminate unhealthy commercial influence on clinical practice and professional education.

For example, some medical institutions in the US have limited interactions between their students and doctors and the pharmaceutical industry, banning gifts and free food by manufacturers and regulating pharmaceutical representatives visits to physicians. These policies have been associated with changes in prescribing behaviours.

Another example of a policy to provide greater independence comes from the Australian Medical Students Association, which has a strict ban on accepting drug company funding for its conferences – unlike most doctors groups which accept it.

However, notwithstanding the limits of disclosure, there are still enormous opportunities for designing effective and inclusive transparency policies.

Ten years ago, Australia introduced a world-first scheme to disclose every single drug company-funded event for doctors. Since then the US Sunshine Act created a new international benchmark, revealing all payments and naming the doctors who receive them.

The ConversationToday it seems that Australia has dropped the ball, with moves towards individual disclosure overshadowed by abandoning transparency around routine wining and dining, and is slipping backwards into the darkness of secrecy.

Alice Fabbri, PhD student, University of Sydney; Lisa Bero, Chair professor, University of Sydney, and Ray Moynihan, Senior Research Fellow

This article was originally published on The Conversation. Read the original article.