Are Financial Payments From the Pharmaceutical Industry Associated With Physician Prescribing?: A Systematic Review

 In response to the review article “Are financial payments from the pharmaceutical Industry associated with physician prescribing” (March 2021), I would like to share an alternative interpretation of their data. In this review article, it failed to show any clear significant patterns where physicians used medication not FDA approved, that injured patients or were inadequate. What was successfully shown was how effective pharmaceutical companies are in educating and advertising new and often better medications which would obviously lead to an increase in prescriptions. The description of “personal financial payments to physicians “is not common in my medical community nor seen in my 30 years of practice. No cruises, consulting fees, gifts or coffee cups-just diner programs at local restaurants hearing, often nationally renowned experts. These experts, usually university faculty spend the night talking about the disease state and reviewing the scientific studies that the FDA used to approve the medications being discussed. They specifically never talk about a medication that was not FDA approved and never do they compare medications due to the lack of head-to-head studies.

In this review authors made vague implications using concepts like “temporal associations” and “dose-response relationships” showing effectiveness in advertising and insinuating that physician were prescribing inappropriate medications influenced by pharmaceutical presentations.

At the heart of the implications being made is a determination that the quality of one medication is superior over another and audiences are being coerced to select the more expensive newer, less effective agents.  The references used in this article included a 2-page publication by Greenway (a medical school student) and the paper by Lexchin in a Canadian practice. The quality of medications in both pieces are based on a single pharmaceutical bulletin “Prescrire” produced in France. In the article by Brax , he directly states that there were no articles in his review that assessed clinical outcomes. In the article by Spurling because the studies were only observations, he concludes it is therefore not possible to conclude exposure to pharmaceutical information actually changes a physician’s behavior. Simply stated references failed to show choosing one FDA approved medication over another had any results in effecting patient outcomes.

 To share dinners with our colleagues discussing our treatment experiences, to learn new FDA approved interventions is overall beneficial for us and our patients. Finally, most the authors of this review were not physicians or were Oncology subspecialists and therefore hardly represent the General internist.

Dr. Plovsky is incorrect that this study found increases only of “new and often better” medications in response to industry payments. Many of the reviewed studies found increases in prescribing of ineffective, low-value, and/or harmful medications. In particular, studies found increased prescribing of repository corticotropin (which is without supporting evidence and has many, cheaper alternatives),¹ re-branded generic medications,² and nilotinib for CML, which is more expensive, no more effective, and has a greater incidence of major toxicities than generic imatinib. Dr. Plovsky’s assertion that industry payments are in patients’ interests therefore appears to be informed more by prior beliefs than by review of the presented evidence.

We are aware that a substantial portion of industry payments come in the form of sponsored meals to promote on-label indications. Dr. Plovsky’s personal experience may not reflect that of the entire medical profession, wherein consulting, speaker fees, and travel each account for hundreds of millions of dollars in payments to physicians annually. Moreover, it is precisely the “drug dinner” payments that were evaluated in many of the reviewed studies, with the associated detrimental effects on prescribing. The literature on the biased informational content presented at industry-sponsored events is too extensive to review here. Additionally, the social sciences provide a well-developed framework to understand how these interactions influence physicians despite their best intentions.³

We highlight the temporal and dose-response relationships observed in the reviewed studies because these concepts feature prominently in the discipline of causal inference. The implications of these observations are not “vague” but highly specific; as stated in our Discussion, “…these findings strongly suggest that industry payments cause physicians to change their prescribing practices.”

Dr. Plovsky correctly points out that the reviewed studies evaluated physician prescribing as the outcome rather than downstream patient outcomes. Further research in this area is needed. However, given the consistent association between receipt of industry payments and increased prescribing of ineffective, low-value, and sometimes more-toxic drugs, Dr. Plovsky’s assertion that industry payments to physicians are likely to benefit patients seems premature at best. We would also encourage Dr. Plovsky to read recent work by Hadland and colleagues,^4,5 which found associations between industry “advertising” of FDA-approved opioids, increased physician prescribing of opioids, and increased mortality from opioid overdoses.

Criticisms that focus on the educational credentials of the investigators, rather than the content of the study itself, are not productive and do not warrant further response.

1. Hartung DM, Johnston K, Cohen DM, Nguyen T, Deodhar A, Bourdette DN. Industry Payments to Physician Specialists Who Prescribe Repository Corticotropin. JAMA Netw Open. 2018;1(2):e180482. doi:10.1001/jamanetworkopen.2018.0482
2. Sharma M, Vadhariya A, Johnson ML, Marcum ZA, Holmes HM. Association between industry payments and prescribing costly medications: an observational study using open payments and medicare part D data. BMC Health Serv Res. 2018;18(1):236. doi:10.1186/s12913-018-3043-8
3. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003;290(2):252-255. doi:10.1001/jama.290.2.252
4. Hadland SE, Rivera-Aguirre A, Marshall BDL, Cerdá M. Association of Pharmaceutical Industry Marketing of Opioid Products With Mortality From Opioid-Related Overdoses. JAMA Netw Open. 2019;2(1):e186007. doi:10.1001/jamanetworkopen.2018.6007
5. Hadland SE, Cerdá M, Li Y, Krieger MS, Marshall BDL. Association of Pharmaceutical Industry Marketing of Opioid Products to Physicians With Subsequent Opioid Prescribing. JAMA Intern Med. 2018;178(6):861-863. doi:10.1001/jamainternmed.2018.1999