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Editorials |

Prescriber Profiling: Time to Call It Quits

David Grande, MD, MPA
[+] Article and Author Information

From Robert Wood Johnson Health & Society Scholars Program and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104.


Acknowledgment: The author thanks the Robert Wood Johnson Foundation's Health & Society Scholars Program for financial support.

Potential Financial Conflicts of Interest: Dr. Grande is a voluntary member of the Board of Directors of the National Physicians Alliance.

Requests for Single Reprints: David Grande, MD, MPA, 3641 Locust Walk, Colonial Penn Center 308, Philadelphia, PA 19104; e-mail, dgrande@wharton.upenn.edu.


Ann Intern Med. 2007;146(10):751-752. doi:10.7326/0003-4819-146-10-200705150-00010
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Pharmaceutical marketing to physicians recently surpassed $23 billion per year, and the pharmaceutical industry currently employs 1 sales representative for every 5 office-based physicians (12). In this setting, policymakers and patients are understandably concerned about commercial influences on physicians' prescribing decisions.

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Opt-out, Opt-in, or Active Decision-making?
Posted on May 15, 2007
Alexander C. Tsai
University of Washington School of Medicine
Conflict of Interest: None Declared
Given that fewer than 1% of American Medical Association (AMA) members have participated in the Prescribing Data Restriction Program (PDRP), that only 25% of surveyed members are aware of the program's existence, and that 66% disapprove of the sale of physician-specific prescribing data to drug companies, David Grande ("Prescriber Profiling: Time to Call It Quits", May 15, 2007) notes that this "raises concern that the AMA opt-out program is not an effective way to address the concerns of physicians and their patients". That is a tactful understatement.

A thorough literature review at the PDRP's inception would have revealed that opt-out programs are designed to maximize participation while preserving a patina of choice. Implementation of opt-out mechanisms in various contexts has resulted in increased participation in prenatal HIV testing (1), medical journal reviewing (2), clinical research studies (3), and 401(k) plan saving (4). Clearly, default options have an enormous effect on decisions. Implicit in the planner's decision to implement an opt-out policy is a value judgment that the default choice option is socially preferable (4).

Although the PDRP was initially promoted as a "balance" between private financial benefits (to drug company marketers) and public health benefits (5), Jeremy Greene's analysis ("Pharmaceutical Marketing Research and the Prescribing Physician", May 15, 2007) properly eviscerates exaggerations of the latter. With the public health benefits revealed as "more of a potential space", AMA policymakers may wish to reconsider whether an opt-out policy is the optimal way to serve its membership.

If AMA policymakers are unwilling to publicly support the value judgment inherent in an opt-in policy, a benign compromise would be to switch to a regime of active decisions. James J. Choi et al. (4) recently studied the 401(k) savings decisions of employees at a Fortune 500 company in which new employees were required to affirmatively participate in the 401(k) plan or affirmatively decline to participate in the plan; a default option was not available. Such a policy could be useful to the AMA should it decide to rethink whether the PDRP is beneficial to either its members or to the public health. In this context, an active decisions policy would favor neither participation nor non-participation and would force AMA members to actively affirm willingness to permit their prescribing histories to be made available to drug company marketers or actively decline.

References

  1. Introduction of routine HIV testing in prenatal care--Botswana, 2004. MMWR Morb Mortal Wkly Rep. 2004 Nov 26;53(46):1083-6.
  2. Pitkin RM, Burmeister LF. Identifying manuscript reviewers: randomized comparison of asking first or just sending. JAMA. 2002 Jun 5;287(21):2795-6.
  3. Junghans C, Feder G, Hemingway H, Timmis A, Jones M. Recruiting patients to medical research: double blind randomised trial of "opt-in" versus "opt-out" strategies. BMJ. 2005 Oct 22;331(7522):940.
  4. Choi JJ, Laibson D, Madrian B, Metrick A. Optimal Defaults and Active Decisions. National Bureau of Economic Research Working Paper No. 11074, January 2005. Available at: http://www.nber.org/papers/w11074. Last accessed May 15, 2007.
  5. O'Reilly K. AMA opt-out program will keep prescribing data from drug reps. American Medical News, May 22/29, 2006. Available at: http://www.ama-assn.org/amednews/2006/05/22/prl10522.htm. Last accessed May 15, 2007.

Conflict of Interest:

I am a member of the National Physicians Alliance (www.npalliance.org), an organization that supports a legislative ban on the sale of physician prescribing data for commercial and marketing purposes.

Addendum
Posted on May 18, 2007
David Grande
Robert Wood Johnson Health & Society Scholars Program,Leonard Davis Institute of Health Economics, U
Conflict of Interest: None Declared

Since going to press with the May 15, 2007 editorial, "Prescriber Profiling: Time to Call it Quits," the U.S. District Court of New Hampshire overturned the prescription privacy law arguing that it violated commercial free speech protections [1,2]. The court decision responded to a constitutional challenge by Health Information Organizations currently engaged in data mining. The challenge itself reflects the contentiousness of the debate and the strong financial interests that underlie it.

Although the District Court ruling might at first appear to preclude later legislative remedies, the Court provided guidance on how a modified law could withstand a similar attack, in New Hampshire, or elsewhere [3]. This guidance provides a sense of optimism that legislative solutions remain to limit prescriber profiling. The legislative and judicial battle over this area is far from over.

While the legal battles are fought, professional organizations can increase their resolve to protect the use of prescribing data. The AMA should end the sale of the physician Masterfile for the purpose of prescriber profiling or at a minimum changing to an "opt in" system from the current "opt out" program. Professional organizations could also encourage their members not to participate in market research intended to support the development of prescribing profiles.

Pharmaceutical marketing practices and prescriber profiling threatens medical professionalism and the primacy of patient welfare. Despite current challenges, physicians should continue to engage in efforts to end prescriber profiling through professional leadership and ongoing legislative advocacy.

1. Grande, D. Prescriber profiling: time to call it quits. Ann Intern Med. 2007; 146: 751-752.

2. Saul, S. Court strikes law barring sale of drug data. New York Times. May 1, 2007.

3. Flynn, S. Statement in response to decision in IMS Health vs. Ayotte - NH District Court, No. CV-06-280-PB (April 30, 2007). Program on Information Justice and Intellectual Property "“ American University. May 1, 2007. Accessed at http://www.wcl.american.edu/pijip/documents/ims_statement.pdf on May 2, 2007.

Conflict of Interest:

Dr. Grande is a voluntary member of the Board of Directors of the National Physicians Alliance.

Pharmaceutical Profiling: How Do Doctors Abet It?
Posted on May 22, 2007
Edward J. Volpintesta
none
Conflict of Interest: None Declared

Regardless of how subtle or brilliant a pharmaceutical representative's marketing technique may be, the physician has the final say in whether or not to use a new drug. Physicians use critical judgment all day long in diagnosing and treating patients. That same judgment should carry over into their conversations with pharmaceutical reps.

So? Yes, let the drug companies be allowed to tout their new medicines.

Furthermore, doctors aren't forced into pharmaceutical trials and other drug-company-sponsored meetings that use doctors' experience and insights to market new drugs. They are paid for their time to attend these sessions. I get them all the time over my fax. The point is that doctors' willingness to accept payment for attending these sessions makes them at least partially responsible for pharmaceutical profiling.

Conflict of Interest:

None declared

Masterfile
Posted on June 3, 2007
Stephen M Kirk
No Affiliation
Conflict of Interest: None Declared

As a physician in private practice, I have noted one ramification of the attention directed to physician-pharmaceutical company relations-an awareness of the potential misuse of the AMA Masterfile on physicians.

I had,like most physicians, no idea of the existence of such a data collecting system until recent years. The AMA makes no mention of the sale of this information to pharmaceutical companies on its webpage addressing the Masterfile. Only a comment regarding "...data are shared with other organizations and agencies who credential physicians and are used to identify individuals who attempt to fraudulently assume the credentials of deceased physicians," is provided. I was also surprised that the Masterfile includes non AMA member physicians.

That such data is commercially mined by an organization that is representing physician interests is troubling. That so little information is provided to physicians regarding the Masterfile is wrong. The AMA needs to specifically address physicians regarding why it collects this data, on what basis it releases this data, and how physicians can control access to this information.

Conflict of Interest:

None declared

No Title
Posted on June 5, 2007
Stephen E. Pratt
No Affiliation
Conflict of Interest: None Declared

TO THE EDITOR:

I am writing regarding the editorial by David Grande, MD, MPA of May 15, 2007. I must say that I agree with the sentiment, but I find the line of reasoning to be something of a non-sequitur.

Dr. Grande is advocating that physicians discontinue participation in market research of pharmaceuticals and that the sale of physician prescribing data also be ended. This would be in order to "roll back the influences of commercial marketing practices on clinical decisions."

While these actions may be desirable for other reasons, neither would address the primary issue of the influence of commercial promotion on prescriber decision making. We could enact these changes tomorrow, and drug manufacturers would continue to advertise their medications, send out field representatives, and sponsor promotional "educational" activities. Drug producers would continue to target physicians with attempts to influence the prescribing of medications, albeit with lower quality background information on their audience.

If physicians really wish to prescribe medications in the best interest of their patients without the influence of manufacturer marketing, the solution is already in our hands. If we do not want to be influenced by advertising, then we should not be an audience to it. To be specific, stop allowing sales reps into our offices, stop attending pseudo -CME lectures, stop stocking samples (which, let us not fool ourselves, are themselves marketing materials) and stop reading advertisements. A sales rep can have all the data on our prescribing patterns in the world, but if they can not have access to us, they can not influence us.

For this reason, I have established a policy that my office will be free of all pharmaceutical marketing materials: no sales rep visits, no pens, no sticky pads and no samples. And on the contrary, I do my best to obtain information on new drugs from unbiased sources, such as peer- reviewed general medical journals.

In the end, I need the pharmaceutical manufacturers to fulfill their purpose in producing high quality, effective medications in order for me to fulfill my purpose as a physician. But I do not need their advertising materials in order to know how best to prescribe medications. And in the end, what they do or do not know about me does not change my responsibility to provide unbiased recommendations to my patients.

Conflict of Interest:

None declared

In Response
Posted on June 13, 2007
Charles Guida
Southampton Hospital
Conflict of Interest: None Declared

To the Editor:

It would be a very sad indeed to think that highly educated and trained professionals such as physicians find it necessary to hide behind a cloak of legislative protection from the pharmaceutical industry. (1) Is it not contrary to our free enterprise spirit to outlaw marketing strategies? Can we not as a collective body of socially responsible physicians just close our doors and simply say, "No thank you" to sales representatives and their so seductive gifts of cheap pens and free lunches? Must we be embarrassed in major newspapers e.g. The New York Times etc. and be helpless pawns in the game of shrewd marketing? But what should embarrass us the most is the audacious and unauthorized policy of our AMA to sell our database to the HIO's to the tune of $43 million dollars.

Woe to our lot the day we ask lawyers to protect us from what amounts to our own poor judgment and benign neglect.

The time has indeed come for physicians to roll back the influence of commercial marketing on our clinical decisions by calling the AMA to task and demand the immediate cessation of the sale of our personal data and above all for us to have the fortitude to just say "No" to the marketers and instead return to the business of healing.

Sincerely,

Charles V. Guida, MD, FACP Chairman, Department of Medicine Southampton Hospital Southampton, NY 11968

Reference: Grande, D., MD, MPA Proscribing Profiling: Time to Call It Quits, Ann Inter Med. 2007;146:751-752.

Conflict of Interest:

None declared

Response
Posted on August 7, 2007
Adriane Fugh-Berman
Georgetown
Conflict of Interest: None Declared

The AMA's Prescription Data Restriction Plan (PDRP) only restricts drug reps and their immediate supervisors from accessing brand-specific prescribing information for individual physicians (1). Any pharmaceutical company employees above that level have full access to details of physicians' prescribing habits. The restrictions also do not apply to "deciles at the market or therapeutic class level", which means that drug reps still have access to the information that, for example, Dr. X prescribes more antidepressants than 90% of his peers and more antipsychotics than 70% of his peers. Also, when a physician signs up for the PDRP, what few restrictions apply may not go into effect for three months, and the restrictions expire three years after sign-up (2).

References

1. Musacchio, R J. Hunkler RA. More Than a Game of Keep Away. Pharmaceutical Executive 2006 (May 1) Available at: http://www.ama-assn.org/ama1/pub/upload/mm/432/pdrppharexecmay06.pdf. Accessed May 25, 2007.

2. American Medical Association. PDRP. Available at: http://www.ama-assn.org/ama/pub/category/12054.html

Conflict of Interest:

None declared

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