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David Menkes
Associate Professor in Psychological Medicine, University of Auckland
Pharmaceutical industry payments to doctors are common, often substantial, and can affect clinical decision making.
Seven years after the industry trade association Medicines New Zealand first mooted a disclosure system, pharmaceutical companies operating in New Zealand recently revealed their financial relationships with individual doctors for the first time.
This included disclosure of payments for speaking engagements, consultancies, advisory board memberships, travel costs, attendance at conferences and other sponsored events.
In the absence of relevant legislation, this is a welcome, albeit incomplete, development. It includes only members of Medicines New Zealand, representing less than half the pharmaceutical companies operating in the country. Some member companies did not participate and several payment types (hospitality, conference sponsorship and research funding) were omitted.
Our new research analyses international evidence and concludes that such payments should be subject to mandatory, comprehensive and accessible disclosure.
Why drug company payments are a problem
Accumulating evidence shows pharmaceutical company payments to doctors influence prescribing and other aspects of healthcare, including research and teaching. The deadly opioid epidemic in the US, for example, has been linked to excessive prescribing resulting from industry promotion.
It may sound like a good thing to have medical experts advising industry about the optimal use of medicines. But receiving payments for such advice has been associated with impressive increases in prescribing of the sponsor’s product(s).
Beyond stimulating the prescription of particular drugs, such payments have been associated with the distortion of clinical guidelines by influential doctors. This affects medical practice and can result in overdiagnosis, overtreatment and treatment-related harm.
Since pharmaceutical promotion typically focuses on newer, branded medications, an increase in prescriptions is also linked with rising health costs.
Attempts at regulation
Because of the above concerns, coupled with health professionals’ tendency to favour transparency in principle, disclosure of payments now occurs in most high-income countries.
However, reporting standards for industry payments vary widely, as we discovered when surveying the international evidence.
Court cases in the US have led to billion-dollar fines for illegal pharmaceutical marketing by various companies. The resulting US Sunshine Act 2010 is the most comprehensive legislative requirement to date for reporting payments to health professionals.
Some European countries and South Korea also legislate disclosure requirements. By contrast, other European countries as well as the UK, Australia, New Zealand, Canada and Japan rely on industry to do this.
Accessibility is an important aspect of disclosure. Currently in New Zealand, a patient would need to search company reports separately to discover how much funding their doctor may have received from pharmaceutical firms marketing medicines they are prescribed.
By contrast, the database mandated by the US Sunshine Act includes all companies and details on whether payments to individual doctors are related to one or more of their products.
Apart from providing patients with easily accessible information about payments received by their doctor, this resource has enabled researchers to document the extensive connections between doctors’ payments and prescribing.
Our analysis indicates that industrial gift giving to doctors is also prominent in low and middle-income countries. Provision of drug samples and support to attend educational events are comparable to the Global North, but typically without disclosure requirements.
Studies in Global South countries suggest doctors receive a broader range of gifts not typically seen in wealthier countries. This can include cash, office supplies, cars, personal travel, domestic cattle, and sexual “favours”.
Arguments in favour of the status quo
Some pundits have vigorously defended the benefits of doctors interacting with industry. Others have highlighted the administrative burden and uncertain efficacy of enforcing disclosure requirements.
Retaining industry funding for medical education, especially in the Global South, is seen by some as a priority because of resource limitations. But this rationale needs to be balanced against the typical industry focus on a limited range of topics, the inability of many doctors to perceive bias in industry-funded education, and the potential harm from shifting scarce resources to expensive branded products.
As with other payment reporting schemes led by industry, New Zealand’s system falls short of international best practice, both in terms of completeness and ease of access. Worse, it is less comprehensive than many other schemes, with member companies choosing whether to report and recipient doctors able to opt out of disclosure.
Given its relatively late appearance internationally, we had hoped that Medicines New Zealand would implement a disclosure regime reflecting international best practice. Instead, it has chosen a system which is both limited and cumbersome to use, from the standpoint of both patients and researchers.
Next steps
Implementing best practice is a substantial challenge, considering different political systems and anticipated pushback from industry and others who benefit from weak or absent disclosure policies. But strong evidence that industry payments play a key role in unethical pharmaceutical marketing provides additional impetus for tightening disclosure requirements.
One might expect that transparent reporting of industry payments would discourage doctors from accepting such largesse. This appears not to have happened in the US. Even with its system of mandatory and comprehensive reporting, the volume and impact of payments persist, possibly because most doctors don’t recognise they’ve been influenced.
This suggests transparency requirements may be necessary but not sufficient to address undue industry influence on medical practice.
On a positive note, restricting exposure to pharmaceutical marketing during medical training, coupled with good role modelling by senior doctors, offers a promising means to prioritise evidence-based patient care over company profits.
This article is republished from The Conversation under a Creative Commons license. Read the original article.
