May 23, 2012 After years of reducing their contact with pharmaceutical sales representatives, physicians now risk an unintended consequence: Doctors who rarely meet with pharmaceutical sales representatives -- or who do not meet with them -- are much slower to drop medicines with the Food and Drug Administration's "black box" warnings and to adopt first-in-class therapies.
According to a study published May 21 in The Journal of Clinical Hypertension, doctors whose access to pharmaceutical sales representatives is limited can take more than four times longer to change prescriptions based on new information than their peers who have more frequent contact. This longer response time holds true whether the physicians are responding to "positive news" related to an innovative therapy or "negative news" related to a newly discovered medicine risk.
George Chressanthis, professor of healthcare management and marketing and acting director for the Center for Healthcare Research and Management at Temple University's Fox School of Business, led the study in collaboration with ZS Associates, a global sales and marketing consulting firm with a very deep presence in the health care industry.
"This study analyzed for the first time -- and on a large scale -- what happens to physicians' prescription decisions when you decrease the access that pharmaceutical sales reps have to doctors," Chressanthis said. "We saw that increasing access restrictions affect physician decision-making in ways not anticipated by those at health care systems or large group practices who created these policies."
Chressanthis, his research team and ZS consultants began to measure the behavior of primary care physicians and specialists in 2008 when Chressanthis was at AstraZeneca Pharmaceuticals LP. They drew from ZS' annual AccessMonitor™ report, which since 2006 has tracked how frequently 300,000 physicians and other prescribers meet with pharmaceutical sales reps. According to AccessMonitor™, the number of doctors willing to see reps has declined about 20 percent since 2008. In 2010, about 11 percent of American physicians had "severe" or "no-see" restrictions on rep access, while 34 percent had "some" restrictions.
The study measured prescription activity and behavior by primary care physicians and specialists from 2006-2008 as it related to the following three major product events:
1) The October 2006 launch of a first-in-class drug to treat Type 2 diabetes (sitagliptin) (physician sample size: 65,088);
2) the August 2007 issue of a black box warning (i.e., the FDA's most serious medication warning) for a drug (rosiglitazone) used to treat Type 2 diabetes (physician sample size: 58,647); and,
3) the January 2008 release of a negative outcome associated with a therapy that combined a cholesterol-lowering drug (simvastatin) and another medicine (ezetimbe) to treat dyslipidemia (physician sample size: 72,114).
In the case of sitagliptin, physicians with a "very low" level of sales rep access took up to 4.6 times longer to introduce the new drug to patients than physicians who employed a "medium" level of access. For the black box warning, physicians with "very low" access were up to four times slower to reduce their use of this treatment than physicians with "low" access. In the clinical trial involving the negative outcomes of a lipid therapy prescription, physicians who limited sales rep access showed "significantly less" response in changing their patients' prescriptions than did physicians in less restrictive offices.
ZS managing principal Pratap Khedkar, co-author of the study, said the research demonstrated that most physicians should seek to balance their information sources.
"Though health care professionals work hard to minimize distractions and maximize the time they spend with patients, it's clear that sales rep access restrictions imposed by well-meaning physicians and group practice leaders can result in serious information gaps," Khedkar said. "Even though pharmaceutical sales representatives are not the only source of information, they do help physicians stay current on therapy developments. These findings should be carefully considered by those who set policy -- whether it's at the physician group practice level or on the national stage."
The study also showed primary care physicians rely more heavily on sales reps for drug information than do specialists. "When primary care physicians reduce or eliminate contact with these reps, it impairs their ability to stay current and affects their prescription behavior," Khedkar said. "Because specialists concentrate in a narrow field, they can stay current by other means, including conferences, online forums, podcasts and academic journals. Thus, the updates they receive from reps have less impact on their prescribing abilities."
Chressanthis provides these final notes about the importance of this study. "Our study affirms simple intuition that when physicians have to make decisions involving complex issues with less than complete information available to them, and where the consequence of a wrong decision is significant as seen often in healthcare, unintended consequences are likely to appear," he said. "Policies that promote physician ignorance of new medical information resulting from access limits runs counter to protecting patient health."
Beside Chressanthis and Khedkar, the report authors also include Nitin Jain, ZS principal; Prashant Poddar, ZS consultant; and Michael Seiders, formerly Director of Strategic Public Policy Planning at AstraZeneca. Lead author Chressanthis was employed at AstraZeneca from 2000-2009. He still retains stock grants in AstraZeneca. The research was funded by AstraZeneca Pharmaceuticals LP.
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- George A. Chressanthis, Pratap Khedkar, Nitin Jain, Prashant Poddar, Michael G. Seiders. Can Access Limits on Sales Representatives to Physicians Affect Clinical Prescription Decisions? A Study of Recent Events With Diabetes and Lipid Drugs. The Journal of Clinical Hypertension, 2012; DOI: 10.1111/j.1751-7176.2012.00651.x
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