While physicians may be more wary of marketing relationships with industry, a new national survey of nurse practitioners shows that the group, who outnumber family docs, still has extensive ties with the industry and holds favorable views toward marketing tactics such as drug samples, sponsored lunches and dinners, and industry-backed continuing medical education. Considering nurses’ expanding role as primary prescribers in the U.S. health care system and the way the Sunshine provisions in the health reform law require reporting of only physician payments, these data may presage a turn in the industry’s promotional efforts away from physicians and toward nurses.

In the survey of nurse practitioners, “Under the Radar,” conducted in 2007-2008 by Elissa Ladd et al and published in the latest issue of the American Journal of Managed Care, 96 percent of respondents reported having regular interaction with the pharmaceutical industry, and the same number attended an industry-sponsored CME program over the prior five years. Forty-nine percent of nurse practitioners reported that they regularly attended pharma-backed lunches or dinners in the previous six months, and 48 percent said they’d be more likely to prescribe a drug that was highlighted at such a lunch or dinner event.

While the nurses’ survey does not give us trends, it does suggest an openness to industry marketing that may be waning, if slightly, among physicians. In a widely-cited 2004 survey by Eric Campbell et al in the New England Journal of Medicine, 94 percent of physicians reported having a relationship with the pharmaceutical industry. According to a November 2010 follow-up survey in the Archives of Internal Medicine by the same authors, fewer physicians (about 84 percent) reported relationships with pharmaceutical companies and involvement in all domains—samples, gifts, payments, and reimbursement—had decreased over the previous five years. Still lots of ties, but less of them.

Take samples. The number of physicians accepting samples went from 78 percent in 2004 to 64 percent in 2009; that reduced percentage nearly matches the proportion of nurses—66 percent—who reported taking samples between 2007-2008. So while we can’t see trends in the nursing data, we can surmise that policies around physician-industry relationships, coupled with nursing’s favorable attitudes toward promotional activities and its growing prominence (there are now more prescribing nurses in the U.S. than family physicians) could push both exposure and marketing attention toward the nurses’ corner.

If there is a salt-grain alert, it could be that the nurse survey represented a much smaller pool of respondents (263) than the 2009 AIM physician follow-up (1,891). And as they were independently designed and conducted, the surveys are necessarily snapshots, and not designed for perfect comparison.

Still, a few general lessons are worth noting here. While the spotlight has been trained on physician-industry relations in the last six years, the fact that prescribing nurses still hold a very positive attitude toward and active engagement with pharma marketing is an important signal for the nursing profession and those concerned with the influence of marketing to look more closely at the industry’s interaction with prescribing nurses.

State and federal policymakers moving to curb the influence of marketing on prescribing should keep in mind the implications of a group of prescribers whose numbers and prescribing power in the health care industry is growing, but whose involvement with the industry has largely flown “under the radar,” and make sure that policies don’t make a loophole of the nursing profession, and undercut the regulations that seek to protect the integrity of the patient-prescriber relationship.

–Kate Petersen, PostScript blogger

This week, drug giant Merck is out $671 million in combined settlements in one whopper of a health care fraud case.  Prosecutors for the states and federal government alleged that the maker of Vioxx and Zocor overcharged 49 states and the District of Columbia for four popular drugs, and bribed doctors to prescribe them with kickbacks disguised as consulting fees.

Read AP coverage here.

Row Row Row…Whose boat?

We admit, in the shadow of bribery, fake-rowing seems like a little white lie, but it’s one that may have turned into big bucks for Pfizer, the maker of Lipitor.   A month ago, Dr. Robert Jarvik, the Lipitor frontman that gives millions of primetime viewers the heebie-jeebies during commercial breaks every night, was outed for never having actually practiced medicine.

Now, courtesy of some digging by two Michigan House Democrats, it turns out Jarvik doesn’t row, either, as he’s seen doing in a recent Lipitor commercial (even though his stunt double’s on the team.)

Congress must decide whether the American public was more fooled by Jarvik’s doctorness or his rowing prowess, and why back in 1997 permitting pharma to run TV ads seemed like such a good idea.

Check out the PAL blog’s ideas for Jarvik’s replacement.

Industry-free CME at Sloan-Kettering: a case study

The Carlat Psychiatry Blog found this article in Medical Meetings Magazine on how Sloan-Kettering Memorial Cancer Center in New York cut industry out of its CME curriculum.

Some seemingly simple steps were taken to make up for the 25 percent of industry funding the center turned back:  Conference organizers used more cancer experts already in-house, moved the meetings from hotels to the conference center on campus, cut out catered lunch, and reduced advertising in mailers and medical journals. According to officials at the world-renowned cancer hospital, response has been positive and attendance steady. 

Vanderbilt gets on gift-ban bandwagon

Vanderbilt University Medical Center has banned gifts from pharmaceutical and devicemakers, an announcement that comes in the wake of news that the vice chancellor of health affairs was appointed to the board of Merck.

According to the Fairview Observer, the policy does not affect researchers, only clinicians, and there is no provision for oversight or penalties.

[Yeah, but who wants to anger Commodore Cornelius?]

Between the lines

Gooznews had his reading glasses on for this one:  a sentence in a New York Times story about spine device researchers who invest in the technologies they test.  Count me in, says Goozner, among the “few [who] would argue that doctors should never be allowed to invest in new technologies.”

“Why draw the line at research?” Goozner writes. “Is it okay that the doctor prescribing a particular drug has a huge hunk of his or her retirement portfolio in the stock of the company that makes that drug?”

What Would Nightingale Do?

Without much formal conflict-of-interest training or guidelines, nurses are prime targets and perhaps the next frontier for pharmaceutical detailing, according to this new article in PLoS Medicine.

Portrait Gallery

A nice profile on RxP ally, AMSA PharmFree coordinator, and Tar Heel of the Week Anthony Fleg appeared this week in the Chapel Hill News and Observer.

And the New Jersey Business Journal interviews state Attorney General Anne Milgram.  There are ten questions, but they all fall under the general category : “Why you gotta be so mean to pharma?”

State Round-up

This Charleston Gazette piece looks at the debate around a law recently passed in the West Virginia legislature that would require pharmaceutical companies to disclose all gifts to physicians to a state-wide board.

Pharmalot reports that New York State Senator Tom Morahan has asked the state health commissioner to look into a report that NY Medicaid spent $82.8 million on psych drugs for kids in 2006, many of which were off-label.

The Vermont legislature still stands behind the prescription data confidentiality law it passed last spring, according to a vote on a motion to repeal the embattled law at the state house this week.

Vermont was sued by health information companies who sell the data and awaits a trial in May.  A similar 2006

New Hampshire law was overturned by a district court judge and awaits decision by the  U.S. Court of Appeals.

From the Oops department… Covetous reporters, critics of pharma and all those ever bested by office culture had a good laugh this week after the leak of top secret documents related to Eli Lilly’s high-stakes Zyprexa negotiations to a lucky New York Times reporter was linked back to an error by a Lilly lawyer who used the auto-fill in his email headings one too many times. The docs were supposed to go to Bradford Berenson, Esq., but the unintended recipient was none other than Times pharmaceutical reporter Alex Berenson. Pharmalot has more here.

From the Let the Good Times Roll department…

Comes a good post from the New Orleans-based National Physicians Alliance doc, alias KidShrink, who made a point of speaking up and saying ‘not cool’ to a pharmaceutical Rep-Elf stuffing physician mailboxes with branded trinkets. Queen of England and King cake, all in one post.

A double-issue of the RxP Weekly Reader this week, as PostScript heads down to D.C. for a conference. Happy Reading.  

“Not it” say NIH, universities on tracking researcher COI

A new report from the Office of the Inspector General of Department of Health and Human Services says that the National Institutes of Health are doing not a whole lot to monitor conflicts of interest among grant recipients at universities, despite the fact that such ‘extramural’ researchers receive 80 percent of the agency’s $29 billion budget. 

Conflict of interest reports from researchers will be required come March 1, but neither the NIH nor the AAMC is keen on taking a larger role in such COI oversight.

Read more at the New York Times, Inside Higher Ed, GoozNews, and the response from the AAMC at Medical News Today.

Spring cleaning in January

A private health system in northern Minnesota and Wisconsin did some spring cleaning a little early, chucking more than 18,000 pharma freebies from its 4 hospitals and 17 clinics.  The move by SMDC health systems represents one of the biggest clean sweeps of pharma influence among private health providers since Kaiser Permanente instituted tougher conflict-of-interest policies in 2005.   

“We’re part of a leading trend that’s trying to get away from the pharmaceutical companies essentially controlling what’s prescribed in this country,” Dr. Kenneth Irons, chief of community clinics for SMDC told the Minneapolis Star-Tribune. “This shows people we’re not in the pharmaceutical companies’ back pockets.”

RxP assistant director Marcia Hams talks to the AP about what this means in the big picture of clinics and medical centers that are starting to put some space between themselves and the drug reps.

and farther east…

The Lewiston Sun-Journal looks at one such hospital, Franklin Memorial, and the changes that have come with the new policy.  Here, the Sun-Journal compares Franklin with other Maine hospitals. 

Left coast Rx legislation considered

And The Olympian reports on a set of bills being supported by the Washington Coalition for Prescribing Integrity, a group of doctors, lawmakers and advocates. The six bills, which have been heard bicamerally in the health care committees, would create a statewide academic detailing program, require public disclosure of all gifts to health care practitioners from pharmaceutical vendors, and restrict prescriber data-mining.

and on the Eastern Seaboard…

A group of advocates for lower prescription drug costs announced the new Massachusetts Prescription Reform Coalition at the State House. The coalition, spearheaded by Health Care for All, will work to support policy change that will limit undue industry marketing by banning gifts to physicians, prohibiting prescription data-mining, and provide doctors with academic detailing resources. State Senators Jim Marzilli and Mark Montigny, key players in the state’s health reform efforts, spoke in favor of the coalition’s goals.

The group includes the Prescription Project, AARP of Massachusetts, Massachusetts Senior Action Group, National Physicians Alliance, Neighborhood Health Plan and others. 

 For more information, read coverage in the Boston Globe, Patriot-Ledger, and the MPRC news release here.

Here’s another article on data-mining – this time from the ‘PhillyBurbs.com.’ [Which, we admit, is faster to type than the Bucks County Courier Times.]

Rep repellent education, courtesy of Pfizer

Businessweek takes a look at Adriane Fugh-Berman’s PharmedOut and Elissa Ladd’s nurse practitioner education program, efforts both aimed to increase awareness of the temptations of pharma reps among future medical practitioners.

Fugh-Berman and Ladd were both recipients of Consumer and Prescriber Grants awarded in a 2004 settlement with Warner-Lambert of Pfizer over off-label marketing of Neurontin.  

FDA issues public health advisory – no cough and cold meds for under-2s 

The FDA issued a formal public health advisory last week: don’t give your infants or toddlers pediatric cough-and-cold medications, because they are risky and have the potential for dangerous overdoses.  The statement follows advisory committee meetings last October, when committee members voted that the drugs were not effective for children under age 6.  Baltimore Health Commissioner Dr. Joshua Sharfstein told the AP that the next step is to get the FDA to assess safety and efficacy of these drugs for children under 12. 

Medicate…Medigate? The pharma tapes  The Philadelphia Inquirer frames the new taping on physician-patient conversations for commercial use as an entrepreneurial lightbulb.  But the scheme dreamed up by two former pharma reps who now run Verilogue, makes prescriber data-mining look like old-fashioned phone-shoe espionage. Doctors are being asked – and permitting – their conversations with patients to be taped for sale.   “To attract physicians,” the Inquirer reports, “the company sent e-mails and faxes, targeting specialty doctors, such as oncologists and psychiatrists who are paid for their time. The company said the fee is similar to stipends paid to medical investigators in other clinical research.” 

The taped talks, then scrubbed of identifiable information by Verilogue, are sold to pharmaceutical companies so they can learn more about the patient-doctor conversation, a dialogue which seems to grow less confidential and more valuable by the day. 

No pain, no gain

The New York Times reports that there is still a lot of debate over the existence fibromyalgia as a diagnosable disease, but that didn’t hinder the sales pitch of Lyrica, the first FDA-approved drug for the nebulous pain condition.  Pfizer spent $46 million ads for the fibromyalgia drug in the first nine months of 2007.  

The cost of keeping a pharma rep

This Pharmalot post based on a Marketwire report says on the average cost of a primary care pharmaceutical sales rep has trended up in recent years, and is now at $175,000 per rep (which includes samples). Food for thought: the average salary for a primary care internist is around $150,000, and a little less for a family practice doc.   

And in closing, the Macy Foundation released this executive summary of a report to be released later this year. The report calls for a complete separation of corporate interests from CME. If you’ve stayed up late worrying about industry supported-symposia, or ever pondered the fate of CME at the hands of Medical Education and Communication Companies (MECCs) and pharmaceutical company ghostwriters recently, this is a must read.

Elissa Ladd’s career as a nurse practitioner has run parallel to the nursing field’s entry into the prescribing world.  Ladd, who holds nursing degrees from the University of Pennsylvania and Rush University and a doctorate in health policy and nursing from the University of Massachusetts, is now an assistant clinical professor of nursing at the Massachusetts General Hospital Institute of Health Professions.  She recently received a $400,000 grant from the Attorney General Consumer and Prescriber Grant Program to create an education program to teach advanced practice nurses about pharmaceutical companies’ influence on prescribing.  

Ladd talked with PostScript about her time in the classroom and the exam room, and how she’s seen pharma pay increasing attention to nurse prescribers in both. 

PS: How does the pharmaceutical industry interact with the nursing profession? Does it differ from industry interaction with physicians?

EL: Throughout my career, I’ve watched the evolution of prescribing influence on nursing grow.  When I first started practicing as a nurse practitioners, most NPs across the country didn’t have the statutory authority to prescribe yet—we would be practicing, and we’d get scripts from physicians.  About 20 years ago, NPs began to gain prescriptive authority on a state by state basis.

PS: So how wide does nurse prescribing power extend?

EL: Nurse practitioners can now prescribe in all 50 states, as can a group of advanced practice nurses (APNs), which includes psychiatric nurse specialists/clinicians, nurse anesthetists and nurse-midwives.  And that whole group of APNs who prescribe – 150,000—is comparable to the number of family practice physicians practicing in the U.S. today. So we are a sizable force, and Pharma has begun to recognize that.

For the last decade, it’s been interesting to watch the drug company influence grow.  Drug detailers are heavily, heavily targeting NPs now.  It’s the same thing as physicians — annual meetings, continuing education.  And even though there’s been a lot written in the press, I think it’s going to be a developmental process for our profession, because we haven’t had prescribing authority as long as doctors have. Advance practice nurses are now getting  a lot of attention from pharma, and they are enjoying the recognition in a sense, but it’s, you know, perverse. 

PS: In the course of your training and career, when did you become aware of the relationship between the drug industry and the medical profession?  Was industry present in nursing school? 

EL: Well, there wasn’t any pharmaceutical influence during my training at nursing school.  We took pharmacology, but that’s about it.  We didn’t have prescriptive authority, and though it was understood to be just a matter of time and regulation, industry influence was never an issue.  The same is true today: they really haven’t injected themselves into NP training and nursing school, and Im not sure the reason for this – it could be now that pharma influence in medical schools is being scrutinized more closely.

PS: In your view, what is the most worrisome part of the pharmaceutical industry’s relationship with prescribers?

EL: Continuing Education. Absolutely.

PS: Why?

EL: CE is required in order to maintain your nursing license and nurse practitioner certification, just as CME is for physicians, and many times the ones that are free are offered by pharma—and that means pharma provides the speakers.  There’s clearly a conflict of interest operating in this system, and people are really naïve about that.  They can get CE credits and go to these sponsored luncheons.  The problem is that most people think it’s educational, but the programs are really biased.  It’s a veiled process of marketing that people don’t acknowledge or understand, but it’s clearly marketing, nonetheless.  I just think a lot of people aren’t even at the point of acknowledging it.  But both nurses and physicians are very influenced by industry-funded continuing education programs.

PS: Are there alternatives?

EL: Yes, you can find industry-free CE programs, but you have to go looking.  The thing that concerns me is that a lot of the industry-free content  is for CME, not CE, which is what nurses need to get recertified.  I know there are some NIH ones.  But I’d say overall it’s probably less available for nurses than physicians. 

PS: You’ve written that there is a dearth of literature about pharmaceutical influence on your profession—have we missed an opportunity by not paying enough attention to industry relations with nurses?

EL: As I said, nurses are still a bit naïve about this whole thing, since prescribing is a relatively new aspect of the profession.  Physicians are naïve, too, but also in denial.  Oh, it doesn’t influence me, you hear them say.  But of course, pharmaceutical companies aren’t stupid, and they wouldn’t be spending billions unless it influenced practices.  So they know, but they don’t want to know. 

PS: From your vantage as a professor and clinician, do you see this relationship between industry and medicine changing?

EL: I do think there is a tremendous momentum around this.  I think that there’s not only an individual awareness, but policy-wide awareness is growing, too.  Academic Medical Centers are leaders in terms of practice issues, and I think changes there will really trickle down into smaller practices and hospitals, and filter into the NP community as well.  Whether people like it or not, I think the culture is changing. 

PS: A recent survey by the Center for Congressional and Presidential Studies at American University reported that 82 percent of Americans trust the FDA to oversee medication approval, 67 percent trust drugmakers, and 53 percent trust Congress.

In your opinion, how much unrealized public outrage is out there to be harnessed?  And is public outrage—grassroots anger—necessary to move this issue?  Whom must we convince?

EL: There have been some interesting studies that have asked patients: “Do you know your doc takes gifts from pharmaceutical reps?”  It’s funny because most of the patients didn’t know that, and they are angry once they find out.  I see a shift happening at the physician and medical center level.  But once consumers become more aware, I think there will be even a larger shift.

The Attorney General Consumer and Prescriber Grant Program [of which Ladd is a recipient] will be awarding a grant to a consumer education project on these issues in the coming months, which I think will help patients  become more involved in this issue, too, the way they did with antibiotics.

PS: A shift in antibiotics?

EL: Once the public learned that about bacterial resistance – from their doctors and the CDC guidelines issued in 2001 about antibiotic overuse – we saw a lot of awareness, a big decrease in prescribing, especially among pediatricians.  It was a significant shift.  That’s an example where the docs, especially pediatricians, have done a very good job of changing their own culture. 

PS: What has been your most memorable experience with pharmaceutical reps or marketing? How did it change the way you practice or prescribe?

EL: It was a couple of years ago and I was working at a family practice, with two docs.  I had never seen so much drug paraphernalia—it was plastered all over the place, down to the paper on the exam table.  It was like the Nexium ad or something.  He couldn’t even buy his own exam paper?  I mean, that’s pretty in-your-face.  I’ve actually seen it on toilet paper, too.

And this practice was getting free lunches every day.  Every day!  And you listen to a talk while you eat.  You don’t really think about it initially.  But one day, I did start thinking: Wait a second, they’re doing this every day, and I just didn’t feel right about it. So I decided I wasn’t going to go to the next lunch.  One of the docs passed me on his way there. 

“Don’t you want to get some lunch?”  I said no, I was just going to stay and work on my charts.  Then there was this silence, probably ten seconds.  “It doesn’t affect what I prescribe,” he said.  “I just go in there and eat their food.”

But ultimately, it’s the patients that pay for those meals, in the form of higher cost drugs.  It was a cascading clarity that I got about this issue.  It’s all unconscious, that name recognition.  It works for drugs, for cars, for washing machines.  It works for refrigerators.  It just works.

The amazing thing to me is that we know this happens.  We know.  They wouldn’t be spending what they spend if they weren’t getting some return.