Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review

Cross-sectional survey of sources of information accompanying veterinary product advertisements in two professional print publications

BACKGROUND

Veterinarians should be able to easily access scientific evidence about medical products and devices to incorporate into their clinical decision making. While the characteristics and quality of supporting information accompanying device and pharmaceutical advertisements have been studied in human medicine, little is known about this topic in veterinary medicine. The aim of this study was to characterise the supporting information provided by manufacturers of prescribed products, tests or devices in promotional material found in two commonly read UK-based veterinary publications.

METHODS

Advertisements contained in issues of two veterinary periodicals published between July 2017 and July 2018 were analysed for advertisement and product characteristics and for items of accompanying information. Literature searches were conducted to assess the availability of peer-reviewed sources of information on advertised products.

RESULTS

A minority (16%) of the 451 analysed advertisements were accompanied by references to peer-reviewed literature, despite the availability of scientific literature for many of the products advertised.

LIMITATION

This study sampled two professional publications over a narrow time period.

CONCLUSIONS

There may be insufficient evidence being provided to veterinary professionals via marketing features; this may limit the accessibility of scientific information for clinical decision making around advertised products.

Physician interpretation of information about prescription drugs in scientific publications vs. promotional pieces

BACKGROUND

Physicians gain knowledge about medical product uses from a variety of information vehicles including FDA-approved labeling, peer-reviewed journal articles, compendia, continuing medical education (CME), and physician-directed promotion. The source of this information, the quality of the information, and environmental pressures such as lack of time may impact perceptions.

OBJECTIVE

The authors tested the effect of three types of information sources (journal abstract, sales aid without graphics, sales aid with graphics), the presence or absence of time pressure to read the information, and two levels of methodological rigor (high, low) on perceptions of study quality, perceptions of product effectiveness and riskiness, and prescribing likelihood.

METHODS

Primary care physicians (n = 630) were randomly assigned to view one version of a study abstract and then answered questions.

RESULTS

Participants who viewed a high-methodological rigor study reported more perceived credibility and importance of the data (ps < .05), and less need for interpreting the study data with caution and less bias than those who viewed a low-rigor study. Those who were not under time pressure to read the stimuli rated the fictitious study description as more credible, rigorous, important, and had more confidence in study data than those who were under time pressure. Participants who had less time to review high-rigor journal abstracts and sales aids with graphics were less likely to agree the study data should be interpreted with caution than doctors who had more time with the stimuli. No effects of source type were observed.

CONCLUSIONS

The results suggest that prominently disclosing methodological rigor helps the audience form an accurate perception of the presented information. This also further highlights the importance that any promotional communications should be truthful and non-misleading.

Japanese physicians' perceptions of conflicts of interest with pharmaceutical companies: Estimating two different questioning approaches

Despite being one of the world's largest pharmaceutical markets, interactions between Japanese physicians and pharmaceutical companies often remain opaque. Importantly, potential conflicts of interest associated with these interactions can compromise patient care and increase costs. We conducted an online survey of Japanese physicians to elucidate perspectives on pharmaceutical company promotional activities and how these influence physician prescribing patterns. Anticipating that physicians might downplay their reliance on, or the value of, pharmaceutical company-provided information, the survey incorporated a direct questioning method and an unmatched count technique (UCT) to identify hidden perceptions on factors likely to influence prescribing. Overall, 1080 eligible physicians participated. Of these, 105 (9.7%) self-identified as hospital directors or managers. Surprisingly, nearly twice as many participants responding to direct questioning (18.9%) versus those responding to the UCT (10.1%) asserted that information provided by pharmaceutical companies was important when prescribing medicine. Hospital directors or managers (adjusted odds ratio [adjOR] 2.56, 95% confidence interval [95% CI]: 1.00-6.54, reference = physician without title) and frequent interactions with pharmaceutical sales representatives (adjOR 5.96, 95% CI: 1.88-18.9, reference = rare interaction) significantly valued the information from sales representatives and sponsored lectures when considering prescribing decisions. Additionally, 77.1% of respondents believed that sales representatives provide fair, neutral, or relatively honest and unbiased information about their products. Few Japanese physicians acknowledged the influence of industry-provided information on prescribing patterns. Our study uniquely applies two distinct question formats, providing a novel approach to understanding the depth of physician-industry relationships and the effectiveness of various survey methodologies.

Conflict of interest policies at Australian medical schools

BACKGROUND

Pharmaceutical industry exposure is widespread during medical training and may affect education and clinical decision-making. Medical faculties' conflict of interest (COI) policies help to limit this exposure and protect students against commercial influence.

AIMS

Our aim was to investigate the prevalence, content and strength of COI policies at Australian medical schools and changes since a previous assessment conducted in 2009.

METHODS

We identified policies by searching medical school and host university websites in January 2021, and contacted deans to identify any missed policies. We applied a modified version of a scorecard developed in previous studies to examine the content of COI policies. All data were coded in duplicate. COI policies were rated on a scale from 0 (no policy) to 2 (strong policy) across 11 items per medical school. Oversight mechanisms and sanctions were also assessed, and current policies were compared with the 2009 study.

RESULTS

Of 155 potentially relevant policies, 153 were university-wide and two were specific to medical schools. No policies covered sales representatives, on-site sponsored education or free samples. Oversight of consultancies had improved substantially, with 76% of schools requiring preapproval. Disclosure policies, while usually present, were weak, with no public disclosure required.

CONCLUSION

We found little indication that Australian medical students are protected from commercial influence on medical education, and there has been limited COI policy development within the past decade. More attention is needed to ensure the independence of medical education in Australia.

GPs' Perspective on a Multimodal Intervention to Enhance Guideline-Adherence in Uncomplicated Urinary Tract Infections: A Qualitative Process Evaluation of the Multicentric RedAres Cluster-Randomised Controlled Trial

Urinary tract infections (UTIs) are among the most common reasons patients seeking health care and antibiotics to be prescribed in primary care. However, general practitioners' (GPs) guideline adherence is low. The RedAres randomised controlled trial aims to increase guideline adherence by implementing a multimodal intervention consisting of four elements: information on current UTI guidelines (1) and regional resistance data (2); feedback regarding prescribing behaviour (3); and benchmarking compared to peers (4). The RedAres process evaluation assesses GPs' perception of the multimodal intervention and the potential for implementation into routine care. We carried out 19 semi-structured interviews with GPs (intervention arm). All interviews were carried out online and audio recorded. For transcription and analysis, Mayring's qualitative content analysis was used. Overall, GPs considered the interventions helpful for knowledge gain and confirmation when prescribing. Information material and resistance were used for patient communication and teaching purposes. Feedback was considered to enhance reflection by breaking routines of clinical workup. Implementation into routine practice could be enhanced by integrating feedback loops into patient management systems and conveying targeted information via trusted channels or institutions. The process evaluation of RedAres intervention was considered beneficial by GPs. It confirms the convenience of multimodal interventions to enhance guideline adherence.

Can peer effects explain prescribing appropriateness? a social network analysis

BACKGROUND

Optimizing prescribing practices is important due to the substantial clinical and financial costs of polypharmacy and an increasingly aging population. Prior research shows the importance of social relationships in driving prescribing behaviour. Using social network analysis, we examine the relationship between a physician practices' connectedness to peers and their prescribing performance in two German regions.

METHODS

We first mapped physician practice networks using links established between two practices that share 8 or more patients; we calculated network-level (density, average path length) and node-level measures (degree, betweenness, eigenvector). We defined prescribing performance as the total number of inappropriate medications prescribed or appropriate medications not prescribed (PIMs) to senior patients (over the age of 65) during the calendar year 2016. We used FORTA (Fit fOR The Aged) algorithm to classify medication appropriateness. Negative binomial regression models estimate the association between node-level measures and prescribing performance of physician practices controlling for patient comorbidity, provider specialization, percentage of seniors in practice, and region. We conducted two sensitivity analyses to test the robustness of our findings - i) limiting the network mapping to patients younger than 65; ii) limiting the network ties to practices that share more than 25 patients.

RESULTS

We mapped two patient-sharing networks including 436 and 270 physician practices involving 28,508 and 20,935 patients and consisting of 217,126 and 154,274 claims in the two regions respectively. Regression analyses showed a practice's network connectedness as represented by degree, betweenness, and eigenvector centrality, is significantly negatively associated with prescribing performance (degree-bottom vs. top quartile aRR = 0.04, 95%CI: 0.035,0.045; betweenness-bottom vs. top quartile aRR = 0.063 95%CI: 0.052,0.077; eigenvector-bottom vs. top quartile aRR = 0.039, 95%CI: 0.034,0.044).

CONCLUSIONS

Our study provides evidence that physician practice prescribing performance is associated with their peer connections and position within their network. We conclude that practices occupying strategic positions at the edge of networks with advantageous access to novel information are associated with better prescribing outcomes, whereas highly connected practices embedded in insulated information environments are associated with poor prescribing performance.

Pharmaceutical industry payments and delivery of non-recommended and low value cancer drugs: population based cohort study

OBJECTIVE

To estimate the association between oncologists' receipt of payments from the pharmaceutical industry and delivery of non-recommended or low value interventions among their patients.

DESIGN

Cohort study.

SETTING

Fee-for-service Medicare claims.

PARTICIPANTS

Medicare beneficiaries with a diagnosis of incident cancer (new occurrence of a cancer diagnosis code in proximity to claims for cancer treatment, and no such diagnosis codes during a ≥1 year washout period) during 2014-19, who met additional requirements identifying them as at risk for one of four non-recommended or low value interventions: denosumab for castration sensitive prostate cancer, granulocyte colony stimulating factors (GCSF) for patients at low risk for neutropenic fever, nab-paclitaxel for cancers with no evidence of superiority over paclitaxel, and a branded drug in settings where a generic or biosimilar version was available.

MAIN OUTCOME MEASURES

Receipt of the non-recommended or low value drug for which the patient was at risk. The primary association of interest was the assigned oncologist's receipt of any general payments from the manufacturer of the corresponding non-recommended or low value drug (measured in Open Payments) within 365 days before the patient's index cancer date. The two modeling approaches used were general linear model controlling for patients' characteristics and calendar year, and general linear model with physician level indicator variables.

RESULTS

Oncologists were in receipt of industry payments for 2962 of 9799 patients (30.2%) at risk for non-recommended denosumab (median $63), 76 747 of 271 485 patients (28.3%) at risk for GCSF (median $60); 18 491 of 86 394 patients (21.4%) at risk for nab-paclitaxel (median $89), and 4170 of 13 386 patients (31.2%) at risk for branded drugs (median $156). The unadjusted proportion of patients who received non-recommended denosumab was 31.4% for those whose oncologist had not received payment and 49.5% for those whose oncologist had (prevalence difference 18.0%); the corresponding values for GCSF were 26.6% v 32.1% (5.5%), for nab-paclitaxel were 7.3% v 15.1% (7.8%), and for branded drugs were 88.3% v 83.5% (-4.8%). Controlling for patients' characteristics and calendar year, payments from industry were associated with increased use of denosumab (17.5% (95% confidence interval 15.3% to 19.7%)), GCSF (5.8% (5.4% to 6.1%)), and nab-paclitaxel (7.6% (7.1% to 8.1%)), but lower use of branded drugs (-4.6% (-5.8% to -3.3%)). In physician level indicator models, payments from industry were associated with increased use of denosumab (7.4% (2.5% to 12.2%)) and nab-paclitaxel (1.7% (0.9% to 2.5%)), but not with GCSF (0.4% (-0.3% to 1.1%)) or branded drugs (1.2% (-6.0 to 8.5%)).

CONCLUSIONS

Within some clinical scenarios, industry payments to physicians are associated with non-recommended and low value drugs. These findings raise quality of care concerns about the financial relationships between physicians and industry.

Complaints about Violations of Voluntary and Pharmaceutical Industry-Run Medicine Promotion Codes in Canada

Although regulation of pharmaceutical promotion in Canada is covered under the Food & Drugs Act and Regulations, in practice it is regulated by two codes, one a code administered by the Pharmaceutical Advertising Advisory Board and a second one controlled by Innovative Medicines Canada, the lobby organization for the large majority of the Canadian and foreign-owned pharmaceutical companies operating in Canada. This study examines complaints about code violations between 2012 and 2021 and puts those complaints and their outcomes into the context of the stringency of the codes, their governance, monitoring, penalties for violations, and compliance by companies. It combines the findings from this analysis with international experience with industry-run codes and concludes that overall, the Canadian codes are ineffective in controlling promotion. Finally, it offers recommendations for how regulation can be improved and how doctors' reliance on information from pharmaceutical companies can be reduced.

Industry payments to family medicine residents in Portugal: a descriptive analysis of the national transparency database

OBJECTIVE

To analyse payments made to family medicine residents by the pharmaceutical industry during their residency in Portugal, using mandatory disclosure data.

DESIGN AND PARTICIPANTS

Cohort study of residents starting their family medicine training in 2015, using data collected from the public national transparency database (Plataforma de Comunicações Transparência e Publicidade). Payments were categorised into six groups, including scientific meetings, educational activities, travel allowances, fees, gifts and undetermined.

MAIN OUTCOME MEASURES

Number of payments and the total value received by family medicine residents during their training period; number of payments according to their nature (six categories); number of payments and total value by paying entity.

RESULTS

We analysed data of 457 family medicine residents. A total of 2790 payments were made to 424 (92.8%) residents, amounting to €826 271.14. Thirty-three residents did not receive any payment. The median number of payments per resident was 5 and the median amount received per resident was €1309.51. Residents who ranked in the top 25%, according to value received, were subsidised more than €2500.90 over the course of their residency. This subset of residents received 59.1% of the total amount disbursed in payments. Payments were primarily for attending scientific meetings (80.9%) and educational activities (17.1%). The top 10 paying entities accounted for 69.2% of the total amount paid.

CONCLUSION

Pharmaceutical industry funding for family medicine residents was highly prevalent, raising concerns over industry influence on medical education, while payment distribution was heterogeneous.

Marketing of medicines in primary care: An analysis of direct marketing mailings and advertisements

INTRODUCTION

Marketing materials from pharmaceutical companies attempt to create a positive image of marketed, often new, medicines. To gain more insight in strategies pharmaceutical companies use to influence primary care practitioners' attitudes towards marketed medicines, we investigated the use of persuasion strategies in direct marketing mailings and advertisements from pharmaceutical companies sent to general practitioners.

METHODS

General practitioners in the Netherlands were recruited to collect all direct marketing mailings, meaning all leaflets, letters and other information sent by pharmaceutical industries to the practice during one month (June 2022). Direct marketing mailings and advertisements in collected medical journals concerning medicines or diseases (together called marketing materials) were analysed according to presence of one of the seven common persuasion strategies, i.e. reciprocity, consistency/commitment, social proof, liking, authority, scarcity and unity; as well as marketed medicine and year of introduction.

RESULTS

Twenty general practices collected 68 unique marketing materials concerning 37 different medicines. Direct factor Xa inhibitors (n = 12), glucagon-like peptide-1 analogues (n = 5) and sodium-glucose co-transporter 2 inhibitors (n = 4) were the most frequently marketed medicines. The median year of introduction of all marketed medicines was 2012. All seven persuasion strategies were identified, with liking (64.7% of all materials) and authority (29.4%) as most prominent strategies, followed by social proof (17.6%), unity (14.7%), scarcity (13.2%), reciprocity (11.8%) and consistency/commitment (2.9%). In addition to those strategies, we identified emotional pressure (30.9%) as one commonly used new strategy.

CONCLUSION

Marketing materials sent to general practices use a wide range of persuasion strategies in an attempt to influence prescription behaviour. Primary care practitioners should be aware of these mechanisms through which pharmaceutical companies try to influence their attitudes towards new medicines.

Assessment of Financial Relationships Between Otorhinolaryngologists and Pharmaceutical Companies in Japan Between 2016 and 2019

INTRODUCTION

There are prevalent financial relationships between physicians and the pharmaceutical industry in medical specialties, including otorhinolaryngology. Although these relationships might cause conflicts of interest, no studies have assessed the size and contents of the financial relationships between otorhinolaryngologists and pharmaceutical companies in Japan. This study aims to evaluate the magnitude, prevalence, and trend of the financial relationship between Japanese otolaryngologists and pharmaceutical companies.

METHODS

 Using payment data publicly disclosed by 92 pharmaceutical companies, we examined the size, prevalence, and trend in personal payments made to the otorhinolaryngologist board certified by the Japanese Society of Otorhinolaryngology-Head and Neck Surgery (JSO-HNS) between 2016 and 2019 in Japan. Furthermore, differences in payments were evaluated by whether otolaryngologists were clinical practice guideline authors, society board members, and academic journal editors or not. Trends in payments were evaluated by generalized estimating equations.

RESULTS

 Of 8,190 otorhinolaryngologists, 3,667 (44.8%) were paid a total of $13,873,562, in payments for lecturing, consulting, and writing by 72 pharmaceutical companies between 2016 and 2019. The median four-year combined payment per physician was $1,022 (interquartile range: $473-$2,526). Top 1%, 5%, and 10% of otorhinolaryngologists received 42.3% (95% confidence interval (95% CI): 37.2%-47.4%), 69.3% (95% CI: 65.9%-72.8%), and 80.6% (95% CI: 78.3%-82.9%) of overall payments, respectively. The median payments per physician were significantly higher among otorhinolaryngologists authoring clinical practice guidelines ($11,522), society board members ($22,261), and journal editors ($35,143) than those without. The payments and number of otorhinolaryngologists receiving payments remained stable between 2016 and 2019.

CONCLUSION

 This study demonstrates that a minority but a large number of otorhinolaryngologists received personal payments from pharmaceutical companies for the reimbursement of lecturing, consulting, and writing in Japan. Large amounts of these personal payments were significantly concentrated on a small number of leading otorhinolaryngologists.

'You feel like you've been duped': is the current system for health professionals declaring potential conflicts of interest in the UK fit for purpose? A mixed methods study

OBJECTIVE

To understand: if professionals, citizens and patients can locate UK healthcare professionals' statements of declarations of interests, and what citizens understand by these.

DESIGN

The study sample included two groups of participants in three phases. First, healthcare professionals working in the public domain (health professional participants, HPP) were invited to participate. Their conflicts and declarations of interest were searched for in publicly available data, which the HPP checked and confirmed as the 'gold standard'. In the second phase, laypeople, other healthcare professionals and healthcare students were invited to complete three online tasks. The first task was a questionnaire about their own demographics. The second task was questions about doctors' conflicts of interest in clinical vignette scenarios. The third task was a request for each participant to locate and describe the declarations of interest of one of the named healthcare professionals identified in the first phase, randomly assigned. At the end of this task, all lay participants were asked to indicate willingness to be interviewed at a later date. In the third phase, each lay respondent who was willing to be contacted was invited to a qualitative interview to obtain their views on the conflicts and declaration of interest they found and their meaning.

SETTING

Online, based in the UK.

PARTICIPANTS

13 public-facing health professionals, 379 participants (healthcare professionals, students and laypeople), 21 lay interviewees.

OUTCOME MEASURES

(1) Participants' level of trust in professionals with variable conflicts of interest, as expressed in vignettes, (2) participants' ability to locate the declarations of interest of a given well-known healthcare professional and (3) laypeoples' understanding of healthcare professionals declarations and conflicts of interest.

RESULTS

In the first phase, 13 health professionals (HPP) participated and agreed on a 'gold standard' of their declarations. In the second phase, 379 citizens, patients, other healthcare professionals and students participated. Not all completed all aspects of the research. 85% of participants thought that knowing about professional declarations was definitely or probably important, but 76.8% were not confident they had found all relevant information after searching. As conflicts of interest increased in the vignettes, participants trusted doctors less. Least trust was associated with doctors who had not disclosed their conflicts of interest. 297 participants agreed to search for the HPP 'gold standard' declaration of interest, and 169 reported some data. Of those reporting any findings, 61 (36%) located a relevant link to some information deemed fit for purpose, and 5 (3%) participants found all the information contained in the 'gold standard'. In the third phase, qualitative interviews with 21 participants highlighted the importance of transparency but raised serious concerns about how useful declarations were in their current format, and whether they could improve patient care. Unintended consequences, such as the burden for patients and professionals to use declarations were identified, with participants additionally expressing concerns about professional bias and a lack of insight over conflicts. Suggestions for improvements included better regulation and organisation, but also second opinions and independent advice where conflicts of interest were suspected.

CONCLUSION

Declarations of interest are important and conflicts of interest concern patients and professionals, particularly in regard to trust in decision-making. If declarations, as currently made, are intended to improve transparency, they do not achieve this, due to difficulties in locating and interpreting them. Unintended consequences may arise if transparency alone is assumed to provide management of conflicts. Increased trust resulting from transparency may be misplaced, given the evidence on the hazards associated with conflicts of interest. Clarity about the purposes of transparency is required. Future policies may be more successful if focused on reducing the potential for negative impacts of conflicts of interest, rather than relying on individuals to locate declarations and interpret them.

TRIAL REGISTRATION NUMBER

The protocol was pre-registered at https://osf.io/e7gtq.

Pharmaceutical company responses to Canadian opioid advertising restrictions: A framing analysis

The pharmaceutical industry's promotion of opioids in North America has been well-documented. Yet despite the clear consequences of improperly classifying pharmaceutical company messaging and frequently permissive approaches that allow the pharmaceutical industry to self-regulate its own advertising, there has been scarce investigation to date of how pharmaceutical industry stakeholders interpret definitions of "advertising." This study explores how variations of "marketing" and "advertising" are strategically framed by the different actors involved in the manufacturing and distribution of pharmaceutical opioids. We employed a framing analysis of industry responses to Health Canada's letter to Canadian manufacturers and distributors of opioids requesting their commitment to voluntarily cease all marketing and advertising of opioids to health care professionals. Our findings highlight companies' continuing efforts to frame their messaging as "information" and "education" rather than "advertising" in ways that serve their interests. This study also calls attention to the industry's continual efforts to promote self-regulation and internal codes of conduct within a highly permissive federal regulatory framework with little concern for violations or serious consequences. While this framing often occurring out of public sight, this study highlights the subtle means through which the industry attempts to frame their promotion strategies away from "marketing". These framing strategies have significant consequences for the pharmaceutical industry's capacity to influence healthcare professionals, patients, and the general public.

"We don't need no education" - a qualitative study of barriers to continuous medical education among Danish general practitioners

BACKGROUND

Continuous medical education is essential for the individual patient care, the society, and the wellbeing of the general practitioner. There has been research into the reasons for participation in continuous medical education, but little is known about the barriers to participation. To tailor continuous medical education targeting general practitioners who are currently deselecting education, systematic knowledge of the barriers is needed. Continuous medical education can in addition to professional growth stimulate job satisfaction, diminish burnout, and reinforce feelings of competence. Continuous medical education may have positive implications for patients and for healthcare expenditures. Despite renumeration and a comprehensive continuous education model some Danish general practitioners do not participate in continuous medical education.

METHODS

From a total of 3440 Danish general practitioners 243 did not apply for reimbursement for accredited continuous medical education in a two-year period. Ten general practitioners were selected for an interview regarding maximum variation in practice form, number of listed patients, seniority as a general practitioner, geography, gender, and age. All ten selected general practitioners accepted to be interviewed. The interviews were analysed using Systematic Text Condensation.

RESULTS

Each of the ten interviewed general practitioners mentioned several barriers for participating in continuous education. The barriers fell into three main categories: barriers related to the individual general practitioner barriers related to the clinic barriers related to the accredited continuous medical education offered CONCLUSIONS: Approximately 7% of the Danish general practitioners did not participate in accredited remunerated continuous medical education. A knowledge of the barriers for participating in accredited continuous medical education can be used to better target continuous medical education to the general practitioners.

Pharmaceutical policies: effects of policies regulating drug marketing

BACKGROUND

The costs of developing new treatments and bringing them to the market are substantial. The pharmaceutical industry uses drug promotion to gain a competitive market share, and drive sale volumes and industry profitability. This involves disseminating information about new treatments to relevant targets. However, conflicts of interest can arise when profits are prioritised over patient care and its benefits. Drug promotion regulations are complex interventions that aim to prevent potential harm associated with these activities.

OBJECTIVES

To assess the effects of policies that regulate drug promotion on drug utilisation, coverage or access, healthcare utilisation, patient outcomes, adverse events and costs.

SEARCH METHODS

We searched Epistemonikos for related reviews and their included studies. To find primary studies we searched MEDLINE, CENTRAL, Embase, EconLit, Global Index Medicus, Virtual Health Library, INRUD Bibliography, two trial registries and two sources of grey literature. All databases and sources were searched in January 2023.

SELECTION CRITERIA

We planned to include studies that assessed policies regulating drug promotion to consumers, healthcare professionals or regulators and third-party payers, or any combination of these groups.In this review we defined policies as laws, rules, guidelines, codes of practice, and financial or administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug utilisation, coverage or access, healthcare utilisation, patient health outcomes, any adverse effects (unintended consequences), and costs. The study had to be a randomised or non-randomised trial, an interrupted time series analysis (ITS), a repeated measures (RM) study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies. When consensus was not reached, any disagreements were discussed with a third review author.  We planned to use the criteria suggested by Cochrane Effective Practice and Organisation of Care (EPOC) to assess the risk of bias of included studies. For randomised trials, non-randomised trials, and CBA studies, we planned to estimate relative effects, with 95% confidence intervals (CI). For dichotomous outcomes, we planned to report the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For ITS and RM, we planned to compute changes along two dimensions: change in level and change in slope. We planned to undertake a structured synthesis following EPOC guidance.  MAIN RESULTS: The search yielded 4593 citations, and 13 studies were selected for full-text review. No study met the inclusion criteria.

AUTHORS' CONCLUSIONS

We sought to assess the effects of policies that regulate drug promotion on drug use, coverage or access, use of health services, patient outcomes, adverse events, and costs, however we did not find studies that met the review's inclusion criteria. As pharmaceutical policies that regulate drug promotion have untested effects, their impact, as well as their positive and negative influences, is currently only a matter of opinion, debate, informal or descriptive reporting. There is an urgent need to assess the effects of pharmaceutical policies that regulate drug promotion using well-conducted studies with high methodological rigour.

Investigation into financial conflicts of interest and screening for atrial fibrillation in the UK: a cross-sectional study

OBJECTIVE

To understand the relationship between financial conflicts of interest and recommendations for atrial fibrillation (AF) screening in the UK, via examining (1) if the UK media recommend for or against screening for AF, and (2) the financial conflicts of interests of AF screening commentators.

DESIGN

Cross-sectional study.

SETTING/PARTICIPANTS

References in UK mainstream media, Twitter, the UK's National Health Service (NHS), patient information websites and major UK heart-related charities regarding screening for AF between1 January 2018 and 31 July 2021.

OUTCOME MEASURES

Proportion of references advocating for, against and presenting balanced/neutral views on screening. Proportion of references citing commentators with financial conflicts of interest.

RESULTS

217 media stories were identified, containing 284 comments about screening for AF. 185/217 (85.3%) of articles were in favour, 9 (4.1%) were against and 23 (10.6%) were balanced. Quotations within were located from 194 commentators; 44 were quoted more than once. 41/44 (93.2%) were in favour of screening. Of these 41, 37 (90.2%) had a direct or indirect financial conflict of interest, including that due to a work role. Two were balanced and one was negative. 2553 tweets using 3 hashtags promoting screening were analysed. 2119 (83%) of the most impactful tweets promoting AF screening were by industry or organisations with industry funding. Of 23 NHS organisations holding information about funding and promoting AF screening online, 22 (96%) had industry funding. 9 (90%) of the top 10 patient information websites promoting AF screening had industry funding. Four main UK patient charities in this sector promoting screening received industry funding.

CONCLUSIONS

The vast majority of UK media promotes screening for AF, in contrast to the position of the independent UK National Screening Committee, which recommends against screening. Most commentators, internal NHS organisations and UK charities promoting screening had a direct or indirect financial conflict of interest. Independent information was rare. The reasons for this are unknown. Readers should consider the potential for the impact of financial conflicts on recommendations to screen.

Adherence to WHO Criteria on Drug Promotion Literature: An Exploratory Study From a Tertiary Healthcare Facility in South-West Nigeria

Introduction: In many low and middle-income countries (LMIC), drug promotional literature (DPL) remains one of the main sources of drug information for physicians. Studies conducted in many LMICs showed poor compliance to the WHO guidelines for ethical drug promotion especially in the area of information about excipients, adverse drug reactions, drug-drug interactions and contra-indications. These inadequacies in the information provided may mislead the prescriber with potential adverse consequences among patients using the medicines. Nigeria has a big pharmaceutical sector which is poorly regulated and we hypothesize that such unethical drug promotional practices may exist. This study therefore set out to assess compliance to the WHO ethical drug promotion (using DPL) at the Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti, South-West Nigeria. Methodology: This was a descriptive cross-sectional study conducted in several specialist clinics of EKSUTH, Ado-Ekiti. Printed DPLs (brochures and leaflets) were collected from these clinics, collated using a pre-designed data collection form and analyzed using the WHO ethical criteria for medicinal drug promotion. Results:Two hundred seventy-five DPLs were screened A total of out of which 234 DPLs were selected after screening to after removal of duplications. Only 5 (2.1%) DPLs met all the WHO criteria. DPLs promoting antibiotics, cardiovascular drugs, and vitamins/nutritional supplements were in the majority (22.2%, 17.1%, and 11.5% respectively. Most of the DPLs had the generic (223; 95.3%) and brand (234; 100%) names, active ingredients (209; 89.3%), excipients (149; 63.7%), and indications (232; 99.1%). Information about adverse drug reactions (76; 32.5%), contra-indications (73; 31.2%), and drug interactions (46; 19.7%) was less represented. Only 59 (25.2%) DPLs had references. Fixed-dose combination drugs made up 34.6% of drugs being promoted. Conclusion:The DPLs assessed in this study had low adherence to WHO ethical drug promotion criteria especially those related to adverse drug reaction, drug interactions, and contra-indications.

Understanding of Final Year Medical, Pharmacy and Nursing Students in Pakistan towards Antibiotic Use, Antimicrobial Resistance and Stewardship: Findings and Implications

Antimicrobial resistance (AMR) is a leading public health threat, which is exacerbated by the high and inappropriate use of antibiotics. Consequently, there is a need to evaluate knowledge regarding antibiotic use, AMR and the readiness to implement antimicrobial stewardship programs (ASPs) among final year medical, pharmacy and nursing students in Pakistan. This reflects the high and increasing rates of AMR in the country, and students as future healthcare professionals (HCPs). A cross-sectional study was conducted among 1251 final year students from 23 public and private educational institutions in Punjab. The majority of the surveyed participants possessed good knowledge of antibiotic use, AMR and the potential causes of AMR. The most common sources of the information on antibiotics were smartphones (69.9%), peers (35.9%) and medical textbooks (30.6%). However, most surveyed participants were not fully prepared to participate in ASPs. They knew, though, how to reduce AMR by educating HCPs about appropriate prescribing, implementing ASPs and improving laboratory facilities. There was a significant association between antibiotic knowledge and causes of AMR with sex, family income and student type (p < 0.05). Being a student at a public sector university (OR = 4.809; CI = 3.261−7.094; p < 0.001) and age (OR = 0.524, CI = 0.327−0.842; p < 0.008) were among the key factors impacting students’ training on ASPs. Educational curricula must be improved to include more information about appropriate antibiotic use and ASPs, along with sufficient training, workshops and clinical rotations in the final year, to fully equip students by graduation.

An appraisal of the contextual drivers of successful antimicrobial stewardship implementation in Nigerian health care facilities

OBJECTIVES

Antimicrobial resistance (AMR) is a consequence of inappropriate actions, including irrational antimicrobial prescribing and use. Antimicrobial resistance remains an emergent and significant public health threat, particularly in low and middle-income countries (LMICs), including Nigeria. Optimizing antimicrobial (AM) use through functional hospital antimicrobial stewardship (AMS) programs is one of the strategies to control the spread of AMR. Literature is replete with evidence, but few studies examined the contextual factors limiting AMS functionality at the facility levels. This study explored the intrinsic contextual factors shaping AMS practice at the three-tiered levels of care.

METHODS

This was a qualitative case study with a purposeful sample size of 30 participants drawn from two primary, two secondary, and two tertiary health facilities in Nigeria. Data were coded and categorized for thematic analysis.

RESULTS

Emergent themes include lack of AMS programs, inadequate guidelines, lack of modern equipment and incorrect diagnosis, absence of continuous medical education, imbalance of power among professionals, and pervasive external influence of pharmaceutical marketing companies. These findings demonstrate that the AMS program is lacking or poorly implemented at the three-tiered level of care.

CONCLUSION

We recommended that health facilities establish AMS programs in line with the World Health Organization's stepwise approach. These challenges, if addressed, will promote the successful performance of the AMS program, contributing to rational AM use at all levels of care. Since primary health centres constitute 85.4% of all health facilities, customizing the AMS core elements at this level will contribute to achieving the goals of universal health coverage.

The Trend in Industry Payments During the COVID-19 Pandemic Among Gastroenterologists and Hepatologists in the United States

Background Although the sudden coronavirus disease 2019 (COVID-19) pandemic would have significantly influenced financial relationships between the healthcare industry and gastroenterologists and hepatologists, little is known about the trend in financial relations in the United States. This study, thus, aimed to examine the trends in industry payments made to gastroenterologists and hepatologists during the COVID-19 pandemic. Materials and methods Using the Open Payments Database between 2013 and 2021, we evaluated trends in financial relationships between the healthcare industry and gastroenterologists and hepatologists in the United States. Trends in general payments during the COVID-19 pandemic were evaluated by interrupted time series analysis with monthly and yearly payments at the physician level. Results A total of 16,808 or 89.4% of all active gastroenterologists received general payments totaling $393,823,094 from the pharmaceutical and medical device companies between 2013 and 2021. The payment per gastroenterologist and the number of gastroenterologists receiving payments decreased by 70.9% (95% CI: -73.4% - -68.1%, p<0.001) and by 51.5% (95%CI: -52.2% - -50.7%, p<0.001) due to the onset of the COVID-19 pandemic, respectively. However, both payments and the number of physicians with payments have recovered monthly since the COVID-19 pandemic, with relative monthly change rates of 4.1% (95% CI: 3.5% ‒ 4.7%, p<0.001) and 3.2% (95%CI: 3.1% ‒ 3.2%, p<0.001). Additionally, the general payments per gastroenterologist significantly decreased by 2.5% (95%CI: -3.9% - -1.1%, p<0.001) each year before the COVID-19 pandemic, while there was a very small change in the number of gastroenterologists with payments. Conclusions The industry payments to gastroenterologists and hepatologists significantly decreased due to the COVID-19 pandemic, but the payments have recovered right after the pandemic in the United States.

How are declarations of interest working? A cross-sectional study in declarations of interest in healthcare practice in Scotland and England in 2020/2021

OBJECTIVE

To understand arrangements for healthcare organisations' declarations of staff interest in Scotland and England in the context of current recommendations.

DESIGN

Cross-sectional study of a random selection of National Health Service (NHS) hospital registers of interest by two independent observers in England, all NHS Boards in Scotland and a random selection of Clinical Commissioning Groups (CCGs) in England.

SETTING

NHS Trusts in England (NHSE), NHS Boards in Scotland, CCGs in England, and private healthcare organisations.

PARTICIPANTS

Registers of declarations of interest published in a random sample of 67 of 217 NHS Trusts, a random sample of 15 CCGs of in England, registers held by all 14 NHS Scotland Boards and a purposeful selection of private hospitals/clinics in the UK.

MAIN OUTCOME MEASURES

Adherence to NHSE guidelines on declarations of interests, and comparison in Scotland.

RESULTS

76% of registers published by Trusts did not routinely include all declaration of interest categories recommended by NHS England. In NHS Scotland only 14% of Boards published staff registers of interest. Of these employee registers (most obtained under Freedom of Information), 27% contained substantial retractions. In England, 96% of CCGs published a Gifts and Hospitality register, with 67% of CCG staff declaration templates and 53% of governor registers containing full standard NHS England declaration categories. Single organisations often held multiple registers lacking enough information to interpret them. Only 35% of NHS Trust registers were organised to enable searching. None of the private sector organisations studied published a comparable declarations of interest register.

CONCLUSION

Despite efforts, the current system of declarations frequently lacks ability to meaningfully obtain complete healthcare professionals' declaration of interests.

Explore of the reasons of irrational prescribing in Iran: A qualitative study

Background

Irrational prescribing is highly prevalent in Iran, and it is under the impact of different factors.

Objective

This research aims to recognize the reasons for Irrational prescribing in Iran.

Methods

A qualitative approach and a conventional content analysis were employed to perform this research. The research community includes some experts and key specialists in medication prescribing. Semi-structured interviews were used for data collection. The intentional sampling method was applied, and theoretical saturation was reached by conducting 40 interviews with experts. The data analysis process was done following the steps suggested by Graneheim and Lundman.

Results

Four main categories and 12 subcategories appeared after analyzing the data. The main categories are organizational and management factors, legal factors, cultural factors, and economic factors.

Conclusion

Irrational prescribing can be prevented by reforming the referral system, overseeing pharmacies and physicians, raising public awareness and correcting their misconceptions about the medications, and creating an appropriate mechanism for pricing and selling medicines.

Professional Relationships With Industry: ACOG Committee Statement No. 2

Developers and manufacturers of pharmaceutical agents and medical devices assist physicians in the pursuit of their educational goals and objectives through financial support of various medical, research, and educational programs. In general, industry seeks to optimize profit by providing useful goods and services. However, industry priorities may not always align with the ethical responsibilities of clinicians to promote the best interests of their patients, of educators to provide evidence-based instruction, and of researchers to ensure the scientific integrity of their investigations. To minimize both actual and perceived conflicts of interest, physicians and institutions should set guidelines for themselves and their employees regarding acceptable interaction with industry representatives. In this Committee Statement, the American College of Obstetricians and Gynecologists' Committee on Ethics provides recommendations for the management of professional relationships with industry, with an updated literature review and discussion of prevalence, regulations, and the effects of industry involvement in clinical care, education, and research.

Physician Payments from Pharmaceutical Companies Related to Cancer Drugs

BACKGROUND

Drug manufacturers claim that the purpose of financial payments to physicians is to facilitate education about new drugs. This claim suggests 2 testable hypotheses: payments should not be associated with drug revenue and payments for each drug should decline over time as physicians become educated.

MATERIALS AND METHODS

We used open payments data on industry payments. We included payments for cancer drugs without generic/biosimilar competitors and used federal data sources to measure Medicare spending (a proxy for overall drug revenue) and a number of prescribers. We used generalized estimating equations (GEE) to model the drug-level association between industry payments and Medicare spending. Separately, we used GEE to estimate the change in payments with respect to the duration of time since initial FDA approval.

RESULTS

The sample included 89 drugs and 361 drug-year observations. The total value of industry payments for oncology drugs increased, from $53 333 854 in 2014 to $90 343 731 in 2018. There was no association between log-transformed mean, per-physician industry payments, and per-physician Medicare spending (estimate -0.001, 95%CI, -0.005 to 0.004). Payments for individual drugs decreased over time; estimated payments in the subsequent year for a drug with mean, per-physician payments of $1000 in the index year was: $681* for drugs 0-4 years since approval, $825 for 5-9 years, and $679* for ≥10 years (*P < .05).

CONCLUSIONS

Although industry-sponsored education may also serve marketing purposes, the absence of association between industry payments and Medicare spending and the decline in payments subsequent to approval are consistent with claims that industry payments function to facilitate physician education.

Association Between Open Payments-Reported Industry Transfers of Value and Prostaglandin Analog Prescribing in the US

Importance

Reported transfers of value (TOV) from pharmaceutical companies have been associated with greater use of branded anti-vascular endothelial growth factor agents by ophthalmologists, but payment under the Medicare Part B buy-and-bill model includes a financial incentive to choose costlier agents, potentially confounding analyses of pharmaceutical TOV and prescribing patterns. How these reported TOV are associated with prescribing patterns for prescription eye drops, not subject to the incentives created by Part B payments, should be considered.

Objective

To assess the association between prostaglandin analog (PGA) eye drop prescribing and reported nonresearch TOV by makers of branded PGAs to US vision care professionals.

Design, Setting, and Participants

This retrospective cohort analysis used a 20% nationally representative sample of 2018 Medicare Part D claims and industry TOV reported to the Open Payments program. Optometrists and ophthalmologists who had more than 10 claims for PGA drops in the 20% sample were analyzed. Analysis took place from June 2021 to February 2022.

Main Outcomes and Measures

Multivariable logistic regression assessing the association between membership in strata of reported TOV and branded PGA prescribing rate, controlling for prescriber demographic factors, local area practices, total PGA prescribing volume, and plan formularies involved.

Results

A total of 20 612 ophthalmologists and 5426 optometrists (7449 [29%] female and 18 589 [71%] male) prescribed PGA eye drops. Of these, 9685 (37%) were reported to have received TOV from manufacturers of branded PGAs in 2018, totaling $5 060 346. The median (IQR) reported TOV was $65 ($24-$147). Multivariable logistic regression showed that the predicted probability of primarily prescribing branded PGAs among prescribers who reported receiving no TOV was 12.9% (95% CI, 12.4%-13.4%). This figure increased to 19.6% (95% CI, 18.8%-20.4%) among prescribers receiving TOV, a 50% increase. There was a dose-response association, such that the top 10% of TOV recipients had a 29.2% probability (95% CI, 26.4%-31.9%) of preferential branded use.

Conclusions and Relevance

While the median reported TOV to a PGA prescriber was relatively low in this study, there was a positive association between amount of reported nonresearch TOV received from PGA makers and the frequency of branded PGA use. This shows that small reported TOV were associated with differences in prescribing. High rates of branded PGA prescribing may pose a cost burden to patients that affects adherence. Clinicians and policy makers should be aware of these associations.

Medical students' exposure to and attitudes towards product promotion and incentives from the pharmaceutical industry in 2019: a national cross-sectional study in France

OBJECTIVES

To measure medical students' exposure to pharmaceutical product promotion and incentives nationwide, and to evaluate students' attitudes towards the pharmaceutical industry, access to education on promotional strategies and knowledge of institutional policies about drug company-student relationships.

DESIGN

Cross-sectional survey based on a 48-item anonymous questionnaire.

SETTING

All 37 French medical schools, from March to April 2019.

PARTICIPANTS

French medical students in their 4th year of study and beyond, having studied exclusively in France.

MAIN OUTCOME MEASURE

Cumulative frequency of students' exposure to pharmaceutical product promotion and incentives.

SECONDARY OUTCOME MEASURES

Exposure within the last 6 months, attitudes regarding interactions with the industry, access to education on pharmaceutical product promotion and incentives and knowledge of institutional policies.

RESULTS

6280 responses were analysed (10.4% out of a total of 60 550 eligible students). 5992 students (96.3% poststratification, 99% CI (96.1% to 96.5%)) had already been exposed to pharmaceutical product promotion and incentives and 4650 (78.1%, 99% CI (77.7% to 78.6%)) within the last 6 months. 5140 students (85.4%, 99% CI (84.8% to 85.8%)) had met a pharmaceutical representative. Regarding attitudes, 2195 students (36.8%, 99% CI (36.0% to 37.5%)) thought receiving a gift could influence their own prescriptions while 3252 (53.6%, 99% CI (53.1% to 54.2%)) thought it could influence their colleagues' prescriptions. 4533 students (76.0%, 99% CI (75.6% to 76.5%)) reported never having attended any lecture on promotional strategies. Exposure seemed to depend on the year of study and specialty. 5122 (88.1%, 99% CI (87.7% to 88.4%)) did not know whether their faculty had a policy regarding drug company-student interactions.

CONCLUSION

In France in 2019, medical students' exposure to pharmaceutical product promotion and incentives remains considerable and starts early during medical training. Education on promotional strategies and institutional policies should be improved to ensure responsible and ethical behaviour in prescribing medications.

Determinants of drug expenditure in the Swiss healthcare market in 2006

Background

Several measures are in force in Switzerland to control the cost of drugs, but are not effective enough. There are many determinants influencing these expenditures, related to treatments, markets, physicians, patients and regions, but their impact on costs is not clear.

Methods

We applied a Bayesian multilevel model with five levels to adjust for patients, drugs’ market, and physicians ‘characteristics, treatment type, and district (i.e. Swiss canton). We used data of the Swiss drugs’ market in 2006, offering real choices for doctors and patients (multiple products for similar active substances), with a neutral position of pharmacists (no financial incentives).

Results

Variance partitioning of yearly drugs’ cost per insured showed that market level (delivered substance) contributed to 76% of the variance, treatment level (delivered product) to 20%, whereas patients’ and physicians’ levels accounted for only 2% each, without significant differences between Swiss cantons. After adjusting for covariables at each level, the model explained about 51% of the variation at the market and 20% at the treatment levels. We found that older but substitutable drugs, generics, larger size of the market and physician’s specialty were associated with lower expenditure, whereas drugs requiring a physician’s prescription, the number of prescribers per patient, patient’ age, male gender, and comorbidities increased expenditure. Our results show that for a specific medication the yearly cost of recently released drugs was 36 CHF higher than for similar and substitutable drugs introduced 15 years earlier, corresponding to one third of the average annual treatment cost observed in our dataset. Competition did not seem to be effective to reduce expenditure on the drug market.

Conclusion

The main finding of this study is that recentness of drugs was associated with an increase in drug expenditure in 2006, even after adjustment for all non-controllable determinants. Further research is recommended to confirm those results with updated data.

Sponsorship of Australian and New Zealand medical societies by healthcare companies: an observational study

Objectives

To examine sponsorship of Australian and New Zealand medical societies by healthcare companies and whether societies have policies to deal with conflicts of interest.

Design

Cross-sectional study conducted in March 2022.

Setting

Australia and New Zealand

Participants

Medical societies in both countries.

Main outcome measures

The percent of medical societies that list sponsorship from healthcare companies on either their home webpages or the webpages of their annual meetings and/or that issue prospectuses to potential sponsors. The percent of societies with sponsorship that also have policies about their interactions with their sponsors. Whether societies feature their sponsors’ logos on their webpages and have hyperlinks to sponsors’ webpages and what percent of societies' annual revenue comes from sponsorships.

Results

Ninety-two medical societies were identified. Sixty-two had healthcare company sponsorship and 10 of the societies with sponsorship had policies to deal with interactions with their sponsors. Fifty-four societies displayed the logos of their sponsors on their home webpages and/or the webpages of their annual meetings. Only 6 societies provided enough information to calculate what percent of their revenue comes from sponsorships. For 5 of the 6 the percent was well below 50%.

Conclusions

The acceptance of sponsorships from healthcare companies by Australian and New Zealand societies is common and few societies have policies to deal with these relationships. In general, societies appear to get only a small percent of their annual revenue from sponsorships.

Polish Medical Doctors’ Opinions on Available Resources and Information Campaigns concerning Antibiotics and Antibiotic Resistance, a Cross-Sectional Study

Background: Antibiotic resistance (ABR) is at the top of global health threats. This paper aims to assess Polish physicians’ readiness to impact ABR through prescribing routines. Methods: Surveying Polish physicians participating in specialization courses at the Center for Postgraduate Medical Education in Warsaw, Poland from October 2019 to March 2020. Results: Information was obtained from 504 physicians aged 25–59, mean 32.8 ± 5.9 years, mainly women (65%). Most doctors (78%) prescribed antibiotics at least once a week. Physicians indicated clinical practice guidelines as resources most often consulted in the management of infections (90%). However, clinical experience was also declared a powerful resource. In total, 54% of respondents recalled receiving information about the prudent use of antibiotics within 12 months, which partially translated into changing views (56%) and practice (42%). Physicians disagreed that national campaigns provide good promotion of prudent antibiotics use (75%) or that they are effective (61%). Only 40% of doctors were aware of the national campaign promoting responsible antibiotics use, 24% had heard about the European Antibiotic Awareness Day and 20% knew about the World Antimicrobial Awareness Week. Conclusions: Prescribers most often rely on clinical practice guidelines and their own experience as resources for antibiotics use. Doctors’ awareness of available resources and information campaigns concerning antibiotics and antibiotic resistance should be improved.

Analysis of Risk Factors for Inappropriate Prescribing of Psychotropic Drugs in Primary Health Care in Elderly Patients

Backround: Older people are at risk of inappropriate drug prescribing because pharmacodynamics and pharmacokinetics, and consequently the efficacy and safety of drugs, change after patient’s age.

Objective: The aim of study is to identify major significant risk factors for Potentially Inappropriate Medicines (PIM) of psychotropic drugs and Potential Prescription Omissions (PPO) of psychotropic drugs in population of patients over 65 years of age with associated pathological conditions according to Screening Tool of Older Person’s potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment (STOPP/START) criteria.

Material and method: The study was designed as a cross-sectional study involving 492 patients and 9 selected general practitioners. It was conducted in period from May 2020 to December 2021, after receiving decision from Ethics Committee of HC Kragujevac.

Results: 492 patients, mean age 71.77 ± 5.95, with 62.2% women, participated in the study. 164 PIMs were identified in 139 patients (28.2%). The most common were: use of benzodiazepines over 4 weeks (43.9%) with simultaneous use of different groups of antidepressants (20.3%). Patients with more than two psychotropic drugs have a higher risk for PIM [adjusted OR 2.83, 95% CI (1.98 - 4.140], p <0.001. 439 PPOs were also identified in 270 patients (54.8%). Risk factors for PPO are: age, number of illnesses, total number of medications, number patients, depression presence, patient’s place of residence, cigarettes usage and monthly income level.

Conclusion: STOPP/START criteria can have a major impact in recognizing inadequate prescribing of psychotropic drugs at patients over 65 years of age. Patients who use benzodiazepines more than four weeks and / or antidepressants may be at increased risk of PIM psychotropic drugs. The total number of drugs and presence of symptoms of depression bring higher risk of PPO psychotropic drugs.

Industry influence in healthcare harms patients: myth or maxim?

Healthcare is a major global industry accounting for a significant proportion of government spending. Drug and medical device manufacturers are publicly traded companies with a responsibility to their shareholders to maximise profits by increasing sales. In order to achieve this, industry exerts influence over every part of healthcare including academic research, medical education, clinical guideline development, physician prescribing and through direct interactions with patients. In contrast, healthcare services seek to provide effective, safe and evidence-based treatments. This article examines interactions with industry across these domains and seeks to identify mutually beneficial relationships and potential conflict leading to patient harms. Case studies are used to illustrate these interactions. There is no single solution for improving healthcare's relationship with industry, although increased transparency has raised awareness of this issue. We briefly discuss some successful interventions that have been tried at national and regulatory level. While industry influence is widespread in healthcare and this has benefits for shareholders, healthcare practitioners have an ethical obligation to prioritise their patients' best interests. Industry interactions with healthcare professionals have a valid role in product development and distribution, but industry sponsorship of healthcare education and practice, guideline development or regulatory decision-making can have harmful consequences for patients. Healthcare practitioners need to carefully consider these issues when deciding whether to collaborate with industry.

Educational aims

To explore the many areas where industry influences healthcare and the subsequent effects on patient care. Case studies are used to illustrate examples of beneficial and harmful effects of this influence.To raise awareness of the effects of industry influence and for readers to consider their own potential conflicts of interest.To suggest potential ways to improve the current system with a focus on solutions which have successfully been trialled already.

Bias amplification in the g-computation algorithm for time-varying treatments: a case study of industry payments and prescription of opioid products

Background

It is often challenging to determine which variables need to be included in the g-computation algorithm under the time-varying setting. Conditioning on instrumental variables (IVs) is known to introduce greater bias when there is unmeasured confounding in the point-treatment settings, and this is also true for near-IVs which are weakly associated with the outcome not through the treatment. However, it is unknown whether adjusting for (near-)IVs amplifies bias in the g-computation algorithm estimators for time-varying treatments compared to the estimators ignoring such variables. We thus aimed to compare the magnitude of bias by adjusting for (near-)IVs across their different relationships with treatments in the time-varying settings.

Methods

After showing a case study of the association between the receipt of industry payments and physicians’ opioid prescribing rate in the US, we demonstrated Monte Carlo simulation to investigate the extent to which the bias due to unmeasured confounders is amplified by adjusting for (near-)IV across several g-computation algorithms.

Results

In our simulation study, adjusting for a perfect IV of time-varying treatments in the g-computation algorithm increased bias due to unmeasured confounding, particularly when the IV had a strong relationship with the treatment. We also found the increase in bias even adjusting for near-IV when such variable had a very weak association with unmeasured confounders between the treatment and the outcome compared to its association with the time-varying treatments. Instead, this bias amplifying feature was not observed (i.e., bias due to unmeasured confounders decreased) by adjusting for near-IV when it had a stronger association with the unmeasured confounders (≥0.1 correlation coefficient in our multivariate normal setting).

Conclusion

It would be recommended to avoid adjusting for perfect IV in the g-computation algorithm to obtain a less biased estimate of the time-varying treatment effect. On the other hand, it may be recommended to include near-IV in the algorithm unless their association with unmeasured confounders is very weak. These findings would help researchers to consider the magnitude of bias when adjusting for (near-)IVs and select variables in the g-computation algorithm for the time-varying setting when they are aware of the presence of unmeasured confounding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01563-3.

Australian Cancer Physicians and the Pharmaceutical Industry: A Survey of Attitudes and Interactions

PURPOSE

Interactions between cancer physicians and the pharmaceutical industry may create conflicts of interest that can adversely affect patient care. We aimed to survey cancer physicians regarding their attitudes toward and interactions with industry.

METHODS

We surveyed Australian cancer physicians between December 2020 and February 2021, questioning how often they interacted with industry and their attitudes toward this. We also assessed factors associated with accepting payments from industry and the amount received, and opinions on policies and industry influence. We used logistic and linear regression to examine links between attitudes and behaviors.

RESULTS

There were 116 responses (94 complete). Almost half (n = 53 of 115, 46.1%) felt that there was a positive relationship between cancer physicians and industry. Most (n = 79 of 104, 76.0%) interacted with industry at least once a month, and 67.7% (n = 63 of 93) had received nonresearch payments from industry previously, with a median value of 2,000 Australian dollars over 1 year. Most respondents believed that interactions could influence prescribing while simultaneously denying influence on their own prescribing (n = 66 of 94, 70.2%). Those who judged general sales representative interactions (odds ratio [OR] 9.37 [95% CI, 1.05 to 83.41], P = .045) or clinician sponsorship (OR 3.22 [95% CI, 1.01 to 10.30], P = .049) to be more acceptable also met with sales representatives more frequently. Physicians were more likely to accept industry payments when they deemed sponsorship of clinicians for conferences (OR 10.55 [95% CI, 2.33 to 47.89], P = .002) or honoraria for advisory board membership more acceptable (OR 3.91 [95% CI, 1.04 to 14.74], P = .04) or when they had higher belief in industry influence over own prescribing (OR 25.51 [95% CI, 2.70 to 241.45], P = .005).

CONCLUSION

Australian cancer physicians interact with industry frequently, and those who feel positive about these interactions are likely to do so more often. More research is needed to understand the motivations behind these interactions.

Rational use of antibiotics and covariates of clinical outcomes in patients admitted to intensive care units of a tertiary hospital in Kenya

OBJECTIVES

: Rational use of antibiotics implies appropriate choice of an antibiotic administered at correct dose, frequency and duration using the most suitable route of administration. Irrational antibiotics use is associated with antimicrobial resistance, drug failure and high mortality in the critical care units (CCUs). This study sought to establish rational use of antibiotics and determinants of clinical outcomes of patients admitted in the CCUs at the Kenyatta National Hospital (KNH). The findings would guide policy formulation of antibiotics use in hospital CCUs in Kenya and the region.

METHODS

: Retrospective review of 220 admissions to the KNH CCUs over the period February 2018-February 2020 was conducted. Participants' sociodemographics, clinical characteristics, antibiotics therapy, and outcome of admission were extracted from patient files and analyzed using STATA version 23. Determinants of irrational antibiotic use and covariates of clinical outcomes were computed at 95% confidence.

RESULTS

The prevalence of rational use of antibiotics was only 18.5%. Inappropriate choice of antibiotics (51.0%) and incorrect duration (32.3%) were the most common irrational practices. Flucloxacillin (100%), cefuroxime (93.3%), cefazolin (85.7%) and ceftriaxone (83.0%) were the most irrationally used antibiotics. Irrational use of ceftriaxone was significantly associated with clinical diagnosis (p=0.012) while that of amoxiclav was associated with patient risk category (p=0.039). Mortality in the CCUs was 10%, and the odds of dying were almost six times among intubated patients compared to those who were not (AOR 5.5, 95% CI=1.1-28.1, p=0.042).

CONCLUSION

Irrational antibiotics prescribing is high in the KNH CCUs, attributable largely to incorrect choice and wrong duration of antibiotic use. Mortality was significantly associated with intubation. Intensification of management in critical care settings should be directed towards intubated patients while ensuring appropriate choice of antibiotics administered for the correct duration. Future studies should explore factors that could promote rational antibiotics use in critical care settings.

Awareness and Perceptions among Members of a Japanese Cancer Patient Advocacy Group Concerning the Financial Relationships between the Pharmaceutical Industry and Physicians

Objectives: Awareness and perceptions of financial conflicts of interest (FCOI) between pharmaceutical companies (Pharma) and healthcare domains remain unclear in Japanese cancer patient communities. This study aimed to assess awareness (RQ1), the influence of FCOI on physician trustworthiness (RQ2), and their perception (RQ3) among the Japanese cancer patient advocacy group members. Methods: A cross-sectional study using a self-administered survey was conducted with a Japanese cancer patient advocacy group between January and February 2019. The main outcome measures included awareness and perceptions of physician–Pharma interactions, their impact on physician trustworthiness, and attitudes towards FCOI among medical and other professions. Furthermore, we performed thematic analyses on the comments which responders provided in the surveys. Results: Among the 524 contacted members, 96 (18.3%) completed the questionnaire, including 69 (77.5%) cancer patients. In RQ1, most of the respondents were aware of physician–Pharma interactions, although the extent differed based on the nature of the interaction. Furthermore, the respondents mainly considered these interactions influential on clinical practice (RQ2) and agreed to the need for further regulation of physician–Pharma interactions (QR3). In qualitative analyses (n = 56), we identified the 4 following themes: perception towards the FCOI (Theme 1), concerns about the respondent’s treatment (Theme 2), reason of physician–Pharma interactions (Theme 3), and possible solutions from the patient perspective (Theme 4). Conclusions: Most respondents were generally aware of physician–Pharma-associated FCOI and perceived them negatively. Additionally, participants appeared supportive of further FCOI regulation to protect patient-centred care. Abbreviations: FCOI—financial conflicts of interest; United States—US; Pharma—pharmaceutical companies; RQ—research question.

An investigation into the pharmaceutical advertising in Iranian medical journals

Background

Pharmaceutical advertising is not only considered a key factor in the successful launch of pharmaceutical products, but is also an important source of public health information with a significant impact on consumer choice and behavior. Nowadays, advertising has become the broadest dissemination channel for various products, including medicines, which may ultimately lead to the generalization of self-treatment or mistreatment. Improper drug promotion can exacerbate unhealthy outcomes by making false or misleading claims, using inferior references, and failing to meet international standards. This study aimed to examine the requirements for pharmaceutical advertising from regulatory perspective and the compliance of Iranian pharmaceutical advertisements to related standards and guidelines. It is limited to print advertisements in Iranian national medical journals and magazines.

Method

The present study is a descriptive–analytical study using bibliometric methods. As a first step, a comprehensive review of the national and international regulations on drug advertising was conducted and a comparison of different regulations was provided. In the second step, a checklist was created to evaluate the compliance of drug advertising with the extracted regulations.

Result

The results of the present study show that the claims made in Iranian drug advertisements are 29.10% valid, 27.67% exaggerated, 23.10% controversial, 12.62% misleading, and 6.8% invalid. In general, we found that most medical advertisements in Iranian journals and magazines comply with national laws and regulations. However, many international requirements are not met in these advertisements.

Conclusions

Although we found that printed medical advertisements in Iran are roughly compliant with national regulations, there is still a long way to achieve full compliance. Monitoring processes should be improved and clearly defined penalties should be set to avoid misleading claims and their likely health consequences. It is very important in Iran to update the existing rules and regulations for medical advertisements according to international guidelines. More careful monitoring of the content of advertising and the accuracy of claims are also needed.

The characteristics of conflict of interest in the doctor's pharmaceutical representative Relationship

INTRODUCTION

Studies addressed the influence of pharmaceutical representatives in drug prescribing habits, in terms of quality and quantity.

AIM

To describe the representatives' strategies, assess their impact on medical prescribing, and study the various factors influencing doctors' prescribing changes.

METHODS

We conducted a cross-sectional study including 70 participants. All of them had an anonymous questionnaire to determine their socio-demographic data, the pharmaceutical representative visits details, the influence of gifts on the medical prescription, and the predictive factors of this influence. We also analyzed the solutions to alleviate the conflict of interest.

RESULTS

We found that 52.8% of participants thought that gifts were the source of an ethical dilemma and 85.7% of them thought that the priority of the pharmaceutical representative was the promotion of the product rather than the scientific interest. However, 68.5% of them thought that the gifts were useful and therefore we can continue to receive them. Nineteen participants (27.1% of cases) thought that gifts can modify their medical prescription. However, there were significantly more subjects (p=0.049) who thought that other colleagues would be more influenced (72.8%). Factors that favor the prescription changing by gifts, were age (p=0.002, OR=1.2) and the number of visits per month (p=0.015, OR=8.8).

CONCLUSIONS

There is a discrepancy between the growing awareness of this ethical issue and the daily practices of physicians who continue to accept gifts. The absence of training in bioethics explains these results.

Interactions with the pharmaceutical industry and the practice, knowledge and beliefs of medical oncologists and clinical haematologists: a systematic review

BACKGROUND

No previous review has assessed the extent and effect of industry interactions on medical oncologists and haematologists specifically.

METHODS

A systematic review investigated interactions with the pharmaceutical industry and how these might affect the clinical practice, knowledge and beliefs of cancer physicians. MEDLINE, Embase, PsycINFO and Web of Science Core Collection databases were searched from inception to February 2021.

RESULTS

Twenty-nine cross-sectional and two cohort studies met the inclusion criteria. These were classified into three categories of investigation: (1) extent of exposure to industry for cancer physicians as whole (n = 11); (2) financial ties among influential cancer physicians specifically (n = 11) and (3) associations between industry exposure and prescribing (n = 9). Cancer physicians frequently receive payments from or maintain financial ties with industry, at a prevalence of up to 63% in the United States (US) and 70.6% in Japan. Among influential clinicians, 86% of US and 78% of Japanese oncology guidelines authors receive payments. Payments were associated with either a neutral or negative influence on the quality of prescribing practice. Limited evidence suggests oncologists believe education by industry could lead to unconscious bias.

CONCLUSIONS

There is substantial evidence of frequent relationships between cancer physicians and the pharmaceutical industry in a range of high-income countries. More research is needed on clinical implications for patients and better management of these relationships.

REGISTRATION

PROSPERO identification number CRD42020143353.

Increasing Financial Payments From Industry to Medical Oncologists in the United States, 2014-2017

BACKGROUND

Personal payments from the pharmaceutical industry to US physicians are common and are associated with changes in physicians' clinical practice and interpretation of clinical trial results. We assessed temporal trends in industry payments to oncologists, with particular emphasis on payments to authors of oncology clinical practice guideline and on payments related to immunotherapy drugs.

METHODS

We included US physicians with active National Plan and Provider Enumeration System records and demographic data available in the Centers for Medicare & Medicaid Services Physician Compare system who had a specialty type of medical oncology or general internal medicine. Medical oncologists serving on NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Panels were identified manually. Industry payments, and the subset associated with PD-1/PD-L1 drugs, were identified in Open Payments, the federal repository of all transactions of financial value from industry to physicians and teaching hospitals, from 2014 to 2017.

RESULTS

There were 13,087 medical oncologists and 85,640 internists who received payments. The mean, annual, per-physician value of payments to oncologists increased from $3,811 in 2014 to $5,854 in 2017, and from $444 to $450 for internists; the median payment increased from $152 to $199 for oncologists and remained at $0 for internists. Oncologists who served on NCCN Guidelines Panels received a greater value in payments and experienced a greater relative increase: mean payments increased from $10,820 in 2014 to $18,977 in 2017, and median payments increased from $500 to $1,366. Among companies marketing PD-1/PD-L1 drugs, mean annual per-oncologist payments associated with PD-1/PD-L1 drugs increased from $28 to $773. Total per-oncologist payments from companies marketing PD-1/PD-L1 drugs experienced a 165% increase from 2014 to 2017, compared with a 31% increase among similar companies not marketing PD-1/PD-L1 drugs.

CONCLUSIONS

Pharmaceutical industry payments increased for US oncologists from 2014 to 2017 more than for general internists. The increase was greater among oncologists contributing to clinical practice guidelines and among pharmaceutical companies marketing PD-1/PD-L1 drugs. The increasing flow of money from industry to US oncologists supports ongoing concern regarding commercial interests in guideline development and clinical decision-making.

Impact on In- and Outpatient Hospital Drug Prescriptions of Including a More Expensive Me-Too Antidepressant in a Hospital Drug Formulary: a Controlled Longitudinal Study

BACKGROUND

The effect of the inclusion of a more expensive me-too medicine in a hospital drug formulary (HDF) on both in- and out-of-hospital utilization, and the contextual factors which influence this type of induction is rarely studied. Accordingly, this work aimed to quantify the effect of the decision of a hospital of including a more expensive me-too antidepressant in its HDF.

METHODS

A controlled longitudinal study was carried out in a Regional Health Service of Spain. We performed a segmented regression analysis with control group. We used the following dependent variables: defined daily doses (DDD) per 1000 inhabitants per day, DDD per 100 bed days, and cost per DDD.

RESULTS

At a hospital level, the modification in the formulary led to utilization changes: (1) an increase in immediate consumption of the newly included me-too drug; and, (2) an annual 25.96% [95%CI: 2.96%-48.95%] decrease in the adjusted trend of the already existing parent antidepressant. The adjusted trend of the cost per DDD of the sum of all medications in the therapeutic group increased by 20.03% annually [95%CI:3.24%-36.82%]. In the out-of-hospital setting utilization changes were: (1) the adjusted trend of the newly included me-too drug rose by 12.14% annually [95%CI:4.97%-19.30%]; and, (2) that of the parent drug underwent a negative change in trend of 4.18% annually [95%CI: 0.00%-8.36%].

CONCLUSIONS

The inclusion of a more expensive me-too drug in the HDF led to increased consumption of this more expensive me-too drug both in- and out-of-hospital. This article is protected by copyright. All rights reserved.

Drugs Becoming Generics-The Impact of Genericization on the Market Performance of Antihypertensive Active Pharmaceutical Ingredients

To explore long-term changes in intra and inter-class choices between generic compounds, this paper investigates the market trends of two antihypertensive drug classes that have closely related pharmacological mechanisms—angiotensin convertase enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). We analysed the development of ACEI and ARB markets between 2001 and 2016 in nine European countries, covering the genericization transition periods of both therapeutic groups. The analysis was undertaken on the level of the active pharmaceutical ingredients (API) and focused on international and country-specific diffusion patterns. Comparison of ARB and ACEI therapies shows that although ARBs became off-patent during the observed period, and have a clinical advantage in terms of the adverse event profile over ACEIs, the increasing dominance of ARBs cannot be identified. One explanation is that ACEI therapies became generics earlier, relocating competition to the level of brands, while competition among ARBs remained at the level of the APIs. As for intra-class drug preferences, it was observed that the long-term trends show that ramipril outperformed its ACEI competitors, even though the kinetics and the rank order of preferred active compounds were inconsistent among markets. The diffusion of clinically preferable therapies seems to be ultimately supported by generic entries. In Eastern European countries, the emergence of generic markets has not only improved access to ACE inhibitors and ARBs, but has been a prerequisite for changing preferences. In contrast, genericization resulted in the relative anchoring of prior, branded era-based preferences in some Western European countries, which may be attributed to the role of the cessation of promotion and the fixity of prescription behaviour.

Pharmaceutical promotional activity and patient’s quality of life

Purpose

The purpose of this paper is to explore the impact of these unethical promotional activities on patient’s quality of life.

Design/methodology/approach

In-depth interviews were conducted, and then quantitative method was also used on a large number of health care professionals.

Findings

Findings of the study demonstrated that unethical activities influence biased prescriptions and then it helps to misuse of medicines. The drug resistance is also affected by misuse of medicines. Misuse of medicine further affects on financial burden on patient. Drug resistance has impact on health compromise. Furthermore, finding of the study describes that drug resistance, health compromise and financial lead to the imbalance of patient’s quality of life. Overall, findings revealed that pharmaceutical unethical promotional activity to achieve sales target is also a major cause of elements that disturbs patient’s quality of life.

Originality/value

This is a research paper and not published before.

How Does Regulation Impact Strategic Repositioning by Firms Across Submarkets? Evidence from the Indian Pharmaceutical Industry

We study coercive institutional pressures as an impetus for firms to reposition across intraindustry boundaries. Integrating the literatures on strategic repositioning and submarkets, we predict that firms respond to regulations limiting the profitability of a submarket by repositioning and shifting demand to proximate, unregulated submarkets within the industry. We expect repositioning to be more pronounced for firms with greater ability to shift demand across submarkets. Evidence from pharmaceutical firms’ responses to partial price regulation in India supports our hypotheses. Repositioning firms increase prices and sales in the unregulated submarket, consistent with a Dorfman–Steiner-type model of endogenous and costly demand shifting toward the unregulated submarket. We contribute to the literature on strategic repositioning and highlight challenges of regulating industries with internal boundaries and insulated niches.

The effect of medical cannabis laws on pharmaceutical marketing to physicians

Although cannabis is federally prohibited, a majority of U.S. states have implemented medical cannabis laws (MCLs). As more individuals consider the drug for medical treatment, they potentially substitute away from prescription drugs. Therefore, an MCL signals competitor entry. This paper exploits geographic and temporal variation in MCLs to examine the strategic response in direct-to-physician marketing by pharmaceutical firms as cannabis enters the market. Using office detailing records from 2014-2018 aggregated to the county level, we find weak evidence of a relatively small and delayed response in substitute prescription drug- and opioid-related detailing. While these effects on detailing dollars are more pronounced among smaller pharmaceutical firms, the magnitudes are economically small and likely muted at aggregate levels by the small percent of doctors that actively recommend cannabis for medical treatment.

Assessing variation among the national essential medicines lists of 21 high-income countries: a cross-sectional study

OBJECTIVE

Essential medicines lists have been created and used globally in countries that range from low-income to high-income status. The aim of this paper is to compare the essential medicines list of high-income countries with each other, the WHO's Model List of Essential Medicines and the lists of countries of other income statuses.

DESIGN

High-income countries were defined by World Bank classification. High-income essential medicines lists were assessed for medicine inclusion and were compared with the subset of high-income countries, the WHO's Model List and 137 national essential medicines lists. Medicine lists were obtained from the Global Essential Medicines database. Countries were subdivided by income status, and the groups' most common medicines were compared. Select medicines and medicine classes were assessed for inclusion among high-income country lists.

RESULTS

The 21 high-income countries identified were most like each other when compared with other lists. They were more like upper middle-income countries and least like low-income countries. There was significant variability in the number of medicines on each list. Less than half (48%) of high-income countries included a newer diabetes medicines in their list. Most countries (71%) included naloxone while every country including at least one opioid medicine. More than half of the lists (52%) included a medicine that has been globally withdrawn or banned.

CONCLUSION

Essential medicines lists of high-income countries are similar to each other, but significant variations in essential medicine list composition and specifically the number of medications included were noted. Effective medicines were left off several countries' lists, and globally recalled medicines were included on over half the lists. Comparing the essential medicines lists of countries within the same income status category can provide a useful subset of lists for policymakers and essential medicine list creators to use when creating or maintaining their lists.