THE INFLUENCES OF DRUG COMPANIES ADVERTISING PROGRAMS ON PHYSICIANS

Transcription

1 The Pharmaceutical Industry THE INFLUENCES OF DRUG COMPANIES ADVERTISING PROGRAMS ON PHYSICIANS Dilek Güldal and Semih emin This study investigates the influences of drug companies advertising programs on physicians. Of the 446 physicians interviewed, 53.9 percent were visited by pharmaceutical company representatives at least once a day, and 43.5 percent spent 15 minutes or more per day on these visits. With respect to the information delivered by the pharmaceutical company representatives, 67.7 percent of physicians thought it was not reliable, and 62.8 percent reported that it had no effect on their prescription writing. The promotional gifts had little effect on prescriptions for 43.9 percent of physicians, and 80.3 percent reported that these gifts were distributed unequally among doctors according to the drugs they prescribed. Only 23.5 percent of physicians supported the prohibition of promotion programs; 90.6 percent of physicians agreed that drugs are too expensive, and 82.9 percent agreed on the presence of overprescription. The authors evaluate these results and provide some suggestions for improving the sources of information for drug prescribing. In Turkey, as in much of the world, there are notable problems in the health care system related to the pharmaceutical industry, such as the influences of drug promotion programs and drug overprescribing. Drug consumption constitutes approximately 30 percent of Turkey s total health expenditure (1) and 0.88 percent of total national income, the latter being higher than that in the United States and all European countries except Portugal (2, p. 14). Between 1983 and 1989, drug consumption in Turkey increased 127 percent in dollar terms, whereas population growth was only 16 percent (3, p. 11). About 3,800 different drug products are on the market in Turkey, many of which contain identical materials produced by different drug companies (2, p. 19). Also, rapid developmental changes are occurring in the pharmaceutical industry. These factors make it difficult for physicians to keep up with all the information on new and existing drugs, and this can keep them from using the available drugs in the International Journal of Health Services, Volume 30, Number 3, Pages , , Baywood Publishing Co., Inc. 585

2 586 / G ldal and emin most appropriate and effective way for their patients needs. It is therefore important to investigate what information is used when choosing a drug for treatment and which factors affect physicians drug preferences. Drug companies promotion programs are important among the factors affecting drug selection, and we thought it important to investigate them. Promotion programs around the world began soon after tetracyclines entered the market, and according to recent estimates they constitute at least 10 to 15 percent of drug costs (4). Worldwide resource allocation for promotion programs totals approximately $20 billion. This has been estimated as up to twice the amount allocated for research and development of new drugs (5). Thus it is apparent that promotion programs receive heavy emphasis throughout the world, and the results of this study, which investigates the effects of drug companies promotion programs on physicians in Turkey, may be valid for other countries as well. METHOD We planned a descriptive study to be performed in Izmir, the third largest city in Turkey, located on the Aegean Sea coast. Of the 2,970 government-employed physicians in Izmir, we excluded from the study 998 who work in laboratory branches (pathology, biochemistry, radiology) where there is limited contact with drug companies. Of the remaining 1,972 physicians, we used the stratified random sampling method to choose 492 (25 percent) to contact for our study. Of these, 446 (91 percent) agreed to participate in the study. We obtained the list of physicians from the Ministry of Health (6) and from the 1992 Izmir telephone directory. The physicians were represented in proportion to the organizations they work for (Ministry of Health and universities) and their academic positions (resident, specialist, or general practitioner). Because all the specialists and general practitioners (GPs) in Turkey have the option of working in private offices in addition to their government posts, and because the number of physicians who work only privately is less than 10 percent, no doctors who work only privately were used in this study (7, p. 96). Furthermore, pharmaceutical company representatives (PCRs) often prefer to visit physicians at the hospitals rather than at private offices because they can find more doctors there and because physicians may not be willing to spare time at their private offices because of appointments with patients. Although GPs make up about 40 percent of all physicians in Turkey, this percentage is only 20 percent in Izmir (7, p. 112). A major reason for this difference is the high number of teaching hospitals in Izmir. Also, Izmir has only recently begun to participate in Turkey s socialization program. In this program, the government pays for health care services, the patient must be referred by a doctor to advance to the next level of health care, and health care workers are paid a monthly salary with additional earnings based on services rendered. The program employs a higher percentage of GPs to achieve its emphasis on preventive care and the strengthening of first-level health care services. Because

3 Drug Companies Influences on Physicians / 587 many other cities in Turkey have been in this program for many years and Izmir was only recently (1985) accepted, the percentage of GPs in Izmir is rising but is still below the national average. We prepared a questionnaire to ask doctors about their reactions to and evaluations of drug advertising and their information sources on medications. The questions were prepared under five main headings: questions on (a) personal data; (b) relations with PCRs; (c) drug companies product information; (d) reactions to and effectiveness of drug promotions ( promotion as used in this study refers to gifts of various values given by PCRs); and (e) certain drug problems such as high prices and overprescription. A total of 32 questions were prepared with between two and five possible responses to choose from. A pretest was conducted with 25 subjects. RESULTS Personal Data Of the 446 participants, 33.6 percent were women and 66.4 percent men; 23.8 percent of the physicians were GPs, 41.7 percent were specialists, and 34.5 percent were residents. Of the specialists and residents, 52.9 percent were in internal medicine and 47.1 percent were in surgical branches. Of the specialists, 33.3 percent had an academic career. Of all the physicians, 46.5 percent were working for the Ministry of Health, 16.4 percent for the Social Insurance Organization, and 30.1 percent for various university hospitals; overall, 81.2 percent worked in hospitals and 18.8 percent in outpatient clinics; 26.2 percent had private offices in addition to their official posts. With respect to years in medical practice, 21.1 percent had been practicing for three years or less, 44.4 percent for four to nine years, 25.3 percent for 10 to 19 years, 7.8 percent for 20 to 29 years, and 1.4 percent for more than 30 years. Relations with PCRs Table 1 shows the frequency of PCR visits; 53.9 percent of the physicians were visited at least once a day. Table 2 shows the number of PCRs visiting individual physicians; 80.3 percent of the physicians received regular visits. Within this finding there was a statistically important difference between GPs and other physicians, with the GPs receiving more regular visits than the others (P < 0.001). The time spent on PCR visits is shown in Table 3: 44 percent of the physicians were spending at least 15 minutes a day with PCRs. There was a statistically significant difference between GPs and the other physicians, with a higher number of GPs spending at least 15 minutes a day on PCR visits (P < 0.05). PCRs and Product Information Eight percent of the physicians were not reading the written material given out by PCRs, 62.1 percent were reading some of it, 20.2 percent were reading all of it

4 588 / G ldal and emin Table 1 Frequency of PCRs visits to physicians No. of visits No. of physicians (%) Less than once a day Once a day Once in three days Once a week Other 175 (39.3) 65 (14.6) 89 (19.9) 72 (16.1) 45 (10.1) Table 2 Number of PCRs who make regular visits to physicians No. of PCRs No. of physicians (%) >10 Irregular Other 224 (50.2) 98 (22.0) 36 (8.1) 79 (17.7) 9 (2.0) Table 3 Distribution of physicans time spent for PCR visits Duration Number of physicians (%) 30 min to 1 hr/day 15 min to 30 min/day 30 min to 1 hr/week <30 min/week Other 136 (30.5) 60 (13.5) 119 (26.7) 103 (23.1) 28 (6.2)

5 but not keeping it, 4.9 percent were reading and keeping all of it, and 4.8 percent had other comments. Physicians opinions about the validity of the information delivered by PCRs are summarized in Table 4: 67.7 percent thought the information was unreliable. Also, 93.9 percent pointed out the necessity for a reliable source of information about drugs other than the drug companies. Table 5 shows the influence of information from PCRs on physicians prescriptions. No influence was reported by 62.8 percent of physicians. Specialists were less influenced than other physicians (P < 0.001). It is notable that the physicians who found the information delivered by PCRs reliable also reported a higher degree of influence (P < 0.001). Also, 53.8 percent of physicians supported the prohibition of PCR visits to physicians. Physicians had various drug information sources. Drug company advertising publications were one source for 72.2 percent of the physicians. The other sources were books and periodicals (81.2 percent), colleagues (39.0 percent), drug prospectuses (35.7 percent), and other doctors prescriptions (13.5 percent). Drug Promotions Drug Companies Influences on Physicians / 589 The physicians assessments of the impact of promotion program expenditures on drug prices are summarized in Table 6: 38.5 percent assessed the impact on Table 4 Physicians opinions about the reliability of information delivered by PCRs Reliability No. of physicians (%) High Modest None 23 (5.2) 121 (27.1) 302 (67.7) Table 5 Effect of information delivered by PCRs on physicians prescriptions Effect No. of physicians (%) High Modest None 55 (12.3) 111 (24.9) 280 (62.8)

6 590 / G ldal and emin Table 6 Physicians assessment of the impact of promotion program spending on drug prices Impact No. of physicians (%) Low (<5%) Modest (5% 10%) High (10% 15%) No comment 49 (11.0) 65 (14.6) 172 (38.5) 160 (35.9) prices as high (10 to 15 percent); specialists constituted the minority in this group (P < ). Also, 40.6 percent of physicians approved of the promotion programs and 40.6 percent did not; the rest had other comments. Almost half (45.8 percent) of the physicians who were against promotion programs were aware of the role of these programs in high drug prices (P < 0.001). From an ethical perspective, 32.9 percent of the physicians interpreted promotion programs as not ethical, 35.9 percent not ethical in some aspects, and 20.4 percent ethical ; 10.8 percent had no opinion on this issue. According to 17.5 percent of physicians, advertising gifts had a high effect on prescriptions, 11.5 percent reported a medium effect, 43.9 percent a low effect, and 27.1 percent no effect. The number of GPs who assessed this effect as high was greater than the other physician groups (P < 0.001). With respect to distribution of advertising gifts among doctors, 80.3 percent of physicians stated that it was unequal, 8.3 percent reported a moderate amount of unequal distribution, and 2.7 percent said distribution was equal; 8.7 percent had no comment about the issue. Among the doctors who thought distribution was unequal, the reasons were listed as being in a position to influence other physicians to prescribe certain products (77.6 percent), prescribing products of certain companies regularly (41.1 percent), and unjust use of friendly relations between doctors and PCRs (3.7 percent). The physicians expectations about promotion programs from drug companies were as follows: reliable educational publications (81.8 percent); medical equipment for private or common use (56.5 percent); distribution of free drug samples (53.6 percent); financial support for training courses for physicians (42.8 percent); educational information from related companies about their products (35.6 percent); social events such as dinners, trips, and so forth (34.3 percent); and gifts of up to $50 for private use (26.7 percent). According to 53.6 percent of the physicians, doctors who receive expensive advertising gifts tend to prescribe that company s products; 46.4 percent denied

7 this. On this topic there was no statistically significant difference among the various groups of physicians (P > 0.05). In the opinion of 76.5 percent of the physicians, the number of participants would significantly decrease if meetings of drug companies were not followed by social activities; 19.5 percent were opposed to this interpretation, and 4.0 percent had other comments. Public knowledge that physicians were receiving gifts and awards from drug companies did not matter for 63.9 percent; 25.4 percent stated they would mind and would try to hide it. The remaining 10.7 percent had other comments. Other Drug-Related Issues Drug Companies Influences on Physicians / 591 The proportion of physicians opposed to drug sales without prescriptions was 96.9 percent, and the remaining 3.1 percent supported the existing system in which all drugs except narcotics are available without a prescription. In the opinion of 82.9 percent of physicians, drugs were overprescribed; 10.1 percent assessed existing overprescription as little, and 7.0 percent had other comments. The reasons for overprescription were given as insufficiency of diagnostic facilities and therapy methods other than drugs (65.2 percent), insufficiency of time available per patient (62.6 percent), drug demands of patients (59.4 percent), and low training level of physicians and a lack of continuing education programs (56.9 percent). Almost all (95.8 percent) of the physicians agreed on the insufficient informational and educational level of the public; the remainder (4.9 percent) had other comments. Drug prices were extremely high according to 48.0 percent of physicians, high for 42.6 percent, normal for 6.9 percent, and low for 0.2 percent; the remaining 2.3 percent had no comment. The use of generic drugs was supported by 60.8 percent of physicians and not supported by 26.0 percent; 10.3 percent had no information about the issue, and 2.9 percent had other comments. Among the physicians who supported use of generic drugs, specialists were a majority (P < 0.01). DISCUSSION The findings of this study suggest that the number of pharmaceutical company representative visits to doctors and the time spent on these visits are fairly high in Turkey compared with developed countries. A study in the United States revealed that residents in internal medicine were visited two to four times a month by PCRs. The results of a U.K. study were similar, showing five visits a month (8, p. 676). In our study, visits to specialists were fewer, shorter, and less regular than visits to GPs and residents. This may be the result of the high prescription rate of the latter two groups, who mostly work in outpatient clinics. The relation between

8 592 / G ldal and emin PCR visits and prescription rates has also been reported in other studies. For example, Lexchin found that for physicians who prescribed medicine once to ten times a week the number of visits was two per week, while for those who prescribed 150 times a week it was eight per week (8, p. 677). None of the physicians in our sample refused to receive PCRs, which may indicate a general acceptance of PCR visits among the physicians. Another study found that physicians who refused visits were criticized by 95 percent of their colleagues. Furthermore, these visits had the general approval of most of the doctors working under high pressure as relaxing times (8, p. 673). The data in our study imply that physicians do not benefit from PCR visits with respect to their professional improvement. In other studies in the United States and Canada, 64 percent and 66 percent of the physicians, respectively, found the information delivered by PCRs unreliable (8, pp ). Furthermore, many authoritative authors have found that many articles by drug companies that claimed to have scientific value were not scientific at all (9). We were surprised to find that 72.2 percent of physicians were considering these documents among their information sources. Likewise, 51 percent of U.K. GPs, 56 percent of Canada s family physicians, and 70 percent of New Zealand s GPs considered the information delivered by PCRs useful (8, p. 665). The explanation of this contradiction may be the lack of independent sources providing reliable information on drugs. This is supported by another study in which 93.9 percent of the physicians found it necessary to have an independent information source other than drug companies. Frequently published periodicals and alternative educational programs would decrease the dependency of physicians on drug companies. Unfortunately, drug companies are the only sources of continuous, systematic information in Turkey, even though their main purpose is commercial. Another indication of the necessity for reliable information sources is the effect of information on prescriptions. In our study, 91.7 percent of the physicians admitted some impact of the information given by PCRs on their prescribing. Lexchin found that at the end of PCR visits, 20 percent of specialists and 32 percent of residents made some changes to their prescriptions; 17 percent of internal medicine specialists made some changes in the regular drug demands of their clinics after PCR visits (8, p. 667). He also determined that PCRs have more influence on the prescribing of low-risk drugs and drugs with low side effects; physicians prefer to use other sources of information for high-risk drugs. Evaluation of this study from the aspect of wide-range promotion programs points to some important results. We found that 72.9 percent of the physicians agreed on the impact of advertising gifts on prescriptions. McKinney and colleagues (10) found that 77 percent of specialists and 72 percent of residents accepted the effect of promotional gifts on their practice. Also, 80 percent of the physicians stated that gifts worth more than $100 would compromise doctor s objectivity. Drug companies may well understand this and use advertising gifts as their main promotional method precisely because it is an effective way to

9 Drug Companies Influences on Physicians / 593 influence physicians to prescribe their products. Drug companies annual expenditure per physician for promotion is $5,000 in the United States and ^2,500 in the United Kingdom (11, p. 22). In Turkey, annual drug expenditure is $1.2 billion, with 10 percent allocated for promotion programs (3, p. 13). Given the number of doctors and pharmacists in Turkey, expenditure on promotion programs per physician/pharmacist is about $2,000 a very high figure given that the yearly salary of a physician is only about $4,500. The majority of physicians (80.3 percent) in our study stated that promotional items are not equally distributed among doctors. Most (77.6 percent) thought the reason for this was the physician s position, which has an effect on drug prescribing. Also, 76.5 percent of the physicians agreed that the absence of social activities following training sessions would decrease the number of participants; the proportion was 91.9 percent in a U.S. study of internal medicine residents (12). The majority of physicians were aware of the purpose of promotional gifts, and most of them denied the effect of programs on their own practice but claimed they had an effect on their colleagues. On the other hand, physicians demands play an important role in this relationship. Only 26.7 percent of physicians were satisfied with small gifts worth less than $50. The remaining 78.4 percent had higher expectations such as trips, dinners, and congress fees. Similar results have been obtained by other investigators. In one study it was determined that 37.5 percent of internal medicine residents took part in tours and trips arranged by drug companies; 66.9 percent agreed on the benefits of these programs (12). Nevertheless, in our study there was no agreement from an ethical perspective on the benefits of these programs; 40.6 percent of physicians were in favor of such programs and 40.6 percent were against. Likewise, 79.6 percent of physicians found promotion programs unethical, but only 53.8 percent supported prohibition of such activities. The percentage of physicians who supported prohibiting these programs was almost the same in a U.S. study in which 66 percent of specialists and 52 percent of residents were in support of prohibition (10). These findings reveal physicians reservations about the prohibition of promotion programs. This may be the result of unawareness of the impact of these programs on their practice and on drug prices or opportunistic attitudes related to their personal benefit. A finding of this study that supports the first argument is the high ratio of physicians who don t mind public awareness of their relationship with drug companies (75.5 percent). Also supporting this argument is the physicians ignorance about the relationship between drug prices and promotion programs. According to some publications, promotion programs increase the cost of drugs by as much as 15 to 16 percent in Turkey (11, p. 19); 65.5 percent of physicians in our study were not aware of this. Frazier and colleagues (13) found that even short periods of training about drugs and prices changed the preferences of physicians for prescriptions. And 70 percent of the drugs currently prescribed were either not on the market or not learned about during the physicians training years.

10 594 / G ldal and emin Physicians in our study found the information delivered by PCRs unreliable but useful, which is quite contradictory but consistent with the following declaration of the International Federation of Pharmaceutical Manufacturers Associations (IFPMA): Most of the underdeveloped countries are not aware of the accepted rules about the indication, contraindication and side effects of drugs and therefore IFPMA offers them assistance (14). In our study, 60.8 percent of physicians supported the use of generic instead of brand-name pharmaceuticals to encourage the consumption of cheaper drugs. This suggests that many physicians find high drug prices more important than the restriction on their prescribing independence that use of generics would impose. Our findings on the prevalence of overprescribing, and the reasons given for it, are important because they indicate that both patients and caregivers need more education about drugs. They also reveal different dimensions of problems related to drugs, such as inadequate facilities and insufficient time with patients. The significant differences between GPs and specialists in our study also deserve comment. General practitioners spent more time with PCRs and were more influenced by both drug company information and promotional gifts. We believe the explanation of these differences is related to GPs position in Turkey. These physicians work at the first line of health organizations, with high prescription rates and without the support of continuing education programs, and thus they may be more open to the influence of drug companies promotion programs. In conclusion, our aim in this study was to reveal physicians opinions on drug companies advertising programs. Because of the sensitivity of physicians about this issue, some results of the study, especially those related to promotional gifts, may be disputable and underestimates. Drug companies spend large amounts of money on promotion programs, which are often tax deductible. The rest of society ends up paying the bill for these programs through increased drug prices and taxes. Radical regulations about drug companies advertising programs must be put on the agenda for all who are concerned with this issue. And providing continuing education through organizations other than drug companies would decrease the dependency of physicians on drug companies educational programs. Overall, the main objective would be to change the attitude of physicians and raise ethical standards. Acknowledgments We thank Dr. Serap Erdogdu (Esin) and Gerard Sobnosky for their valuable assistance in the preparation and writing of this article. REFERENCES 1. emin, S. Toplum sagligi yönünden lacin öteki yüzü. Toplum ve Hekim 56: 42 62, 1993.

11 Drug Companies Influences on Physicians / Pharmaceutical Association of British Pharmaceutical Industry. Pharma Facts and Figures Domaç, M. laç etken maddesi bak m ndan laç sanayiinin ncelenmesi. Havan 8: 8 15, Arman, S. The Internationalisation of Capital and Industrialisation in the Third World: A Case Study of Turkish Pharmaceutical Industry Mandani, M., and Walker, G. Essential drugs in developing world. Health Policy Planning 1(3): , Ministry of Health, Turkey. Statistical of Health, T.C. Government Printing Office, Ankara, Ministry of Health, Turkey. Saglik Hizmetlerinde Mevcut Durum, T.C. Government Printing Office, Ankara, Lexchin, J. Doctors and detailers: Therapeutic education or pharmaceutical promotion? Int. J. Health Serv. 19(4): , Shimn, D. S., and Spece, R. Industry reimbursement for entering into clinical trials: Legal and ethical issues. Ann. Intern. Med. 115: , McKinney, M., et al. Attitudes of internal medicine faculty and residents toward professional interaction with pharmaceutical sales representatives. JAMA 264(13): , Eroglu, L. laçta Reklam Promosyon. Havan 9: 16 24, Lichstein, P., et al. Impact of pharmaceutical company representatives on internal medicine residency programs. Arch. Intern. Med. 152: , Frazier, L. M., et al. Can physicians education lower the cost of prescription drugs? Ann. Intern. Med. 115: , International Federation of Pharmaceutical Manufacturers Associations. Code of Pharmaceutical Marketing Practices Direct reprint requests to: Dr. Dilek Güldal 175 sok No. 3/4 Basin Sitesi Izmir Turkey