Healthy Skepticism Library item: 19547

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Greene J
Drug Reps Targeting Nonphysicians
American Medical News 2000 Mar 27
http://www.ama-assn.org/amednews/2000/03/27/prl20327.htm

Abstract:

Nurse practitioners and physician assistants with prescribing rights are the new audience when drug company sales representatives visit doctors’ offices.

Full text:

For years, physicians have complained about the impositions of unwanted visits from pharmaceutical sales representatives, saying they would rather spend time in their offices discussing treatment plans with patients than listening to marketing pitches on the latest new drug.

Now those drug reps’ attentions are increasingly shifting to physician assistants and nurse practitioners who have at least limited prescribing authority, and some physicians warn that it is an alarming trend.

Like physicians, nonphysician prescribers insist the drug presentations they receive from sales representatives are just one way they get new pharmaceutical information. Like doctors, nonphysicians read clinical journals, take continuing medical education courses and discuss prescription effectiveness with colleagues.

But a survey by Scott-Levin Associates shows drug sales representatives are increasingly targeting nonphysicians who have prescribing rights. Some 52% of physician assistants polled said they saw drug representatives more often than their supervising physicians did, and 41% of nurse practitioners said drug representatives “detailed” them more often than doctors, said Scott-Levin, a pharmaceutical consulting company in Newtown, Pa.

“If the detailing results in an increase in total prescriptions written, then that is worrisome,” said AMA Trustee Yank Coble, MD. “Medications are not only very expensive, but if [overused], there is an increased risk of problems for the patient.”

Doctors have experienced an increase in questions about prescription use the past two years from patients because drug companies have targeted consumers with direct advertisements, Dr. Coble said.

“The public is coming in to doctors’ offices and asking for the drugs they read or hear about,” said Dr. Coble, a Jacksonville, Fla., endocrinologist. “With the time demands on primary care physicians, it is not surprising they are delegating this responsibility [of meeting with drug sales representatives] to nonphysicians.”
Collaboration or abdication?

Although studies by Scott-Levin and the American Academy of Physician Assistants indicate physician assistants are prescribing from 30% to 50% more medications than five years ago, the prescribing rate per patient has remained the same, officials said. Physician assistants and nurse practitioners write 0.8 prescriptions per patient visit, Scott-Levin said. In a different survey, AAPA said physician assistant prescribing has been stable the past three years at 1.1 per patient visit.

“This is an excellent example of the physician-physician assistant team approach. The team is taking in this information from drug sales representatives and using it to coordinate better patient care,” said Steve Crane, PhD, AAPA’s executive director. “The implication that a PA sees a drug rep and tells a doc what to do is not right. They pass along information to doctors in many ways.”

Dr. Crane said physician assistants are increasing total prescriptions because their numbers are growing. There are approximately 38,000 physician assistants and 60,000 nurse practitioners now in practice. Physician assistants have prescribing rights in 46 states, which is double the number from 10 years ago; nurse practitioners write prescriptions in 50 states, although four states (Georgia, Michigan, Ohio and Pennsylvania) require doctors to co-sign the prescription.

“Doctors are less accessible to drug representatives than they have been in the past,” said Greg Thomas, AAPA’s vice president for clinical affairs. “Drug companies have told us they have a team approach to talking with both doctor and physician assistant. This leads to better decision-making at the practice.”

Bryna Elder, Scott-Levin’s director of strategic studies, said some drug companies such as Bayer, Pfizer and Wyeth-Ayerst have aggressive marketing plans to “detail” nonphysician prescribers. Others, she said, are waiting for “proof of return on investment in these types of accounts.”

In the survey, “Expanding the Prescriber Base: Nurse Practitioners and Physician Assistants,” Scott-Levin found drug representative visits to physician assistants last year averaged 4.4 per week and 5.2 for nurse practitioners. Those numbers are expected to rise this year. Visits to doctors’ offices increased 10% to 36 million in 1999 from 33 million in 1995, and 30% of those visits include discussions with nonphysicians, Scott-Levin said. Some 2,000 physicians surveyed said they saw from four to five drug representatives per week.

“We know from discussions with drug companies that they are placing more emphasis on sales visits,” Thomas said.

The Scott-Levin survey also found a majority of nonphysicians make recommendations to physicians to either expand use rates or try new drugs, Elder said. Some 80% of physician assistants and 69% of nurse practitioners said they make recommendations to physicians, she said.

But some doctors are concerned that nonphysicians practicing independently or without adequate physician supervision could be inappropriately swayed by sales pitches.

“Physician extenders lack the knowledge base to understand pharmacology and the complexities of medicine,” said Hil Rizvi, MD, a Fairmont, W.Va., emergency physician. “They are given samples of advanced antibiotics, invited out to dinner and are being prepped to use these samples.”

Supervising physicians should be extremely careful if they allow nonphysicians to listen to drug company promotional information, Dr. Rizvi said. “Drug companies are simply looking for the weakest link in the practice,” he said. “ The nonphysician is the person most likely to comply with marketing and sales messages. They are easily sold.”
Physicians also subject to influence

In a report that caused a stir in the physician community earlier this year, researcher Ashley Wazana, MD, concluded that free gifts given to physicians by drug representatives can influence a doctor’s prescribing habits. More than half of the $11 billion spent in promotions in 1996 was funneled through company sales representatives, wrote Dr. Wazana in JAMA. Although that is a concern, AMA officials said most physicians adhere to strict ethical guidelines on gifts and accept only those from drug representatives that benefit patients or their practice. Nurse practitioners and physician assistants have similar guidelines.

“We are as concerned as the AMA about appropriate detailing,” Thomas said. “We are making people more aware about what is appropriate and what is not.”

Dr. Coble said the AMA is concerned with the overall increase in nonphysician prescribing.

“There is a lot of misinformation out there,” he said. “Supposedly the sales representative is reciting the facts rather than promoting a drug. But to suddenly expect people with less training than doctors to interpret research for patients is unrealistic. I don’t get my information on new drugs from nurses, and I don’t think many other doctors do either.”