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Friday Jul 22, 2016

Singing the Praises of a Pharma-free Practice

Do you remember a time when your practice was filled with pharmaceutical-branded pens, notepads, clipboards, clocks and other swag?

I don't. I attended a pharmaceutical-free residency program, and after graduation, I started working at a primary care office that was so new the carpets had been installed just a few weeks before I arrived. In those early days, our patient population grew slowly as people discovered our existence.

However, one group of people knew about us even before the paint had dried and the wall art had been hung. They started knocking on our doors well before we opened them to patients. Every day. They were pharmaceutical reps with shiny pamphlets and offers of free lunch.

The Influence
Pharmaceutical companies spend $3 billion each year marketing to patients while they shell out $24 billion annually marketing to health care professionals(www.pewtrusts.org). Why? Because it works.

It's distressing to think that years of medical education could crumble against a free meal, but pharmaceutical influence is well-documented. A recent study in JAMA Internal Medicine(archinte.jamanetwork.com) found physicians who were treated to a free lunch accompanied by a drug company presentation on a specific medication were 70 percent more likely to prescribe, for example, the brand-name drug Bystolic and 52 percent more likely to prescribe the brand-name drug Benicar than generic blood pressure medications. They also were 18 percent more likely to prescribe Crestor than generic statins. Generic blood pressure medications and statins are available that are  less expensive and as effective as these brand-name products.

Although soaring health care costs are a by-product of pharmaceutical influence, they are not the only problem. More disturbing is the fact that physicians prescribe medications that are inappropriate -- with only lackluster evidence for their off-label use -- but that are still marketed for these unapproved uses by some pharmaceutical companies.

The reason? A lot of research, even in peer-reviewed medical journals, is funded by industry or includes experts who acknowledge they have ties to industry. In fact, the drug and device industry funds six times more clinical research than the federal government(www.baltimoresun.com). As a result, it can sometimes be difficult for physicians to distinguish legitimate, evidence-based conclusions from potentially murkier data.

Complicating the issue further is the vast gray area of medicine. Medications from the same class often have similar effectiveness. As a result, physicians (appropriately) prescribe based on other factors, including side effect profiles, safety, ease of use, cost or patient history.

For example, selecting the right antidepressant for a patient is notoriously complex(effectivehealthcare.ahrq.gov). Slightly more people tend to have diarrhea with sertraline than fluoxetine, but fluoxetine has a higher incidence of dry mouth. Their costs are similar, as is their effectiveness. Several other meds also fall into this category, with only minor distinctions.

Yet the physicians in the JAMA Internal Medicine study were more than twice as likely to prescribe brand-name Pristiq instead of other antidepressants.

Drug manufacturers will argue that their direct education to physicians demonstrates how XYZ medication benefits specific patient populations. But the downside is the education isn't objective. Per the above scenario, I suspect physicians conflated the extensive data on antidepressants -- both objective and subjective -- and decided their patients would benefit from Pristiq.

Making the Change
Knowing all this, our organization decided to join the growing number of practices that eschew pharmaceutical influence. Family medicine is already making progress in this area. In 2013, about half of family medicine residencies were pharma-free(www.stfm.org).

Our practice declines visits from pharmaceutical reps, drug samples, free lunches and other gifts (no Jublia clocks or Nexium pens). As with any change, we worried at the beginning about how this would be received. One concern was the struggle to keep current on medical literature and emerging medications. Some colleagues relied on drug reps to introduce new products, and then they would follow up by reviewing evidence-based research on their own.

To prioritize lifelong learning and combat this concern, our office holds weekly "rounds," where we discuss best practices and recent journal articles and invite guest speakers. We also have an internal system of expert advice, where our clinicians can ask questions of primary care colleagues who excel in different fields across our organizations (i.e., cardiology, dermatology, HIV medicine, etc.).

Another concern was the loss of free samples. Patients still ask me for Viagra samples, but I direct them to prescription assistance programs instead. It's a short-term sacrifice for long-term benefits. Studies show samples most likely raise the cost of drugs(www.ncbi.nlm.nih.gov) and contribute to health care overspending(www.propublica.org).

We've seen positive effects from the changes we've made in our practice. We no longer spend time fielding inquiries from pharmaceutical representatives during our busy days or organizing lunches. And our office isn't cluttered with extra pens or notepads.

Most importantly, we are able to fulfill the growing expectation of transparency among our patients at a time when the complicated relationship between the drug industry and physicians is under increasing scrutiny.

As part of the Patient Protection and Affordable Care Act, patients can look up their own doctors through the CMS Open Payments data website(www.cms.gov), which contains information about payments from manufacturers of drugs, devices and biologics to doctors. ProPublica hosts a similar Dollars for Docs search tool(projects.propublica.org).

I anticipate an additional important benefit to this conversation about relationships between drug companies and physicians: a recognition among patients that the latest medication does not mean it's the greatest medication. When patients themselves start understanding high-value care, then the real health care revolution begins.

Natasha Bhuyan, MD, is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan(twitter.com).

Posted at 04:06PM Jul 22, 2016 by Natasha Bhuyan, M.D.

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