Influence of industry payments on physicians’ behaviour is well established, and commonly known, but findings of recent research suggest this influence has the potential to negatively affect the patient care.
Patients with cancer whose oncologist received payments from industry appeared more likely to receive non-recommended and low value treatments, and while this study focused on a narrow group of patients and interventions, the authors said further research was needed to better characterise whether, and to what degree, the observed association between payments and poorer care quality extends to other settings.
Given the potential concerns for care quality raised by this study, however, they suggested it might be appropriate to re-examine the current status of personal payments from the drug industry to physicians.
Common practice
Financial relationships between physicians and the pharmaceutical industry are common. iIn the US, for example, apart from industry research funding, physicians overall receive more than $2bn in direct, personal payments from drug and device manufacturers annually.
These payments comprise both cash and in-kind gifts, and most commonly, represent free meals, travel and lodging, and speaker and consulting fees.
But payments from industry have long raised concerns about medical professionalism and the independence of physician decision-making. More recently, such concerns have been supported by empirical findings.
In this study, which was published in The BMJ, the research has found a consistent association between industry payments and prescribing; physicians who receive payments are more likely to prescribe the drugs manufactured by the paying company. Several studies have assessed this association using causal inference methods, strongly suggesting a causal effect of industry payments on prescribing.
Whether industry payments to physicians have positive or negative consequences for patient care has not been evaluated empirically.
The existing research examining the association between payment and prescribing has largely focused on substitution of therapeutically equivalent drugs, such as different agents within the same class.
Evidence of substitution among therapeutically equivalent drugs has been found for various classes, including anticoagulants, anti-hypertensives, statins, antidepressants, proton pump inhibitors, vascular endothelial growth factor inhibitors, gabapentinoids, and cancer drugs.
In many cases, industry payments have been associated with substitution towards higher cost drugs (such as a branded drug over a same class generic), which has the potential to increase costs to the health system and to patients but does not raise immediate concerns about quality of care and patient safety.
In the absence of data that raise concerns about quality, physicians’ opinions on physician-industry relationships have remained largely positive.
Interview and survey studies have consistently found that physicians believe physician-industry interactions – including receipt of payments and gifts – are beneficial for patient care.
In particular, physicians view industry-sponsored education and its potential to speed dissemination of new technologies into clinical practice as a rationale for physician-industry relationships to continue.
The question of whether industry payments to physicians may be associated with lower value or non-recommended care is particularly relevant to oncology. The prevalence of industry payments is higher among oncologists than among other specialties, implying a greater opportunity to influence cancer care.
Oncologists are among the top three medical specialties for dollars accepted from industry per capita, and the gap between oncologists and general internists has increased in recent years.
Additionally, the high prices of cancer drugs mean that low value use is particularly costly, and the greater treatment toxicity that is commonly accepted among cancer drugs creates the potential for non-recommended treatments to be more directly harmful.
This study assessed the association between industry payments and the delivery of non-recommended and low value interventions.
Evidence found
We found evidence of a patient level association between industry payments to physicians and receipt of some non-recommended and low value medical interventions.
These findings are in line with previous evidence that industry payments influence physicians’ selection of therapeutically equivalent treatments, and that there appears to be a physician level association between receipt of payments and the likelihood of using certain high cost, low value treatments.
The finding that industry payments have the potential to be decremental, rather than neutral, may increase concern about this common practice.
Study details
Pharmaceutical industry payments and delivery of non-recommended and low value cancer drugs: population based cohort study
Aaron Mitchell, Stacie Dusetzina, Akriti Mishra Meza, Niti Trivedi, Peter Bach, Aaron Winn.
Published in The BMJ on 25 October 2023
Abstract
Objective
To estimate the association between oncologists’ receipt of payments from the pharmaceutical industry and delivery of non-recommended or low value interventions among their patients.
Design
Cohort study.
Setting
Fee-for-service Medicare claims.
Participants
Medicare beneficiaries with a diagnosis of incident cancer (new occurrence of a cancer diagnosis code in proximity to claims for cancer treatment, and no such diagnosis codes during a ≥1 year washout period) during 2014-19, who met additional requirements identifying them as at risk for one of four non-recommended or low value interventions: denosumab for castration sensitive prostate cancer, granulocyte colony stimulating factors (GCSF) for patients at low risk for neutropenic fever, nab-paclitaxel for cancers with no evidence of superiority over paclitaxel, and a branded drug in settings where a generic or biosimilar version was available.
Main outcome measures
Receipt of the non-recommended or low value drug for which the patient was at risk. The primary association of interest was the assigned oncologist’s receipt of any general payments from the manufacturer of the corresponding non-recommended or low value drug (measured in Open Payments) within 365 days before the patient’s index cancer date. The two modelling approaches used were general linear model controlling for patients’ characteristics and calendar year, and general linear model with physician level indicator variables.
Results
Oncologists were in receipt of industry payments for 2962 of 9799 patients (30.2%) at risk for non-recommended denosumab (median $63), 76 747 of 271 485 patients (28.3%) at risk for GCSF (median $60); 18 491 of 86 394 patients (21.4%) at risk for nab-paclitaxel (median $89), and 4170 of 13 386 patients (31.2%) at risk for branded drugs (median $156). The unadjusted proportion of patients who received non-recommended denosumab was 31.4% for those whose oncologist had not received payment and 49.5% for those whose oncologist had (prevalence difference 18.0%); the corresponding values for GCSF were 26.6% v 32.1% (5.5%), for nab-paclitaxel were 7.3% v 15.1% (7.8%), and for branded drugs were 88.3% v 83.5% (−4.8%). Controlling for patients’ characteristics and calendar year, payments from industry were associated with increased use of denosumab (17.5% (95% confidence interval 15.3% to 19.7%)), GCSF (5.8% (5.4% to 6.1%)), and nab-paclitaxel (7.6% (7.1% to 8.1%)), but lower use of branded drugs (−4.6% (−5.8% to −3.3%)). In physician level indicator models, payments from industry were associated with increased use of denosumab (7.4% (2.5% to 12.2%)) and nab-paclitaxel (1.7% (0.9% to 2.5%)), but not with GCSF (0.4% (−0.3% to 1.1%)) or branded drugs (1.2% (−6.0 to 8.5%)).
Conclusions
Within some clinical scenarios, industry payments to physicians are associated with non-recommended and low value drugs. These findings raise quality of care concerns about the financial relationships between physicians and industry.
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