Scrutiny of physician relationships with industry has culminated in passage of the US Physician Payments Sunshine Act (part of the Affordable Care Act), intended to bring greater transparency to such relationships. However, according to authors in this week's PLOS Medicine, interactions with industry of non-physician clinicians—Registered Nurses, advanced practice nurses with prescriptive authority, physicians' assistants, pharmacists, dieticians, and physical or occupational therapists—have not undergone the same scrutiny, although they may be involved in the same types of decision making as physicians. Quinn Grundy (Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco) and colleagues conducted the first (to their knowledge) systematic review of the evidence regarding interactions of non-physician clinicians with industry and beliefs regarding such interactions.
In a search of studies published in Medline and Web of Science through June 2013, the researchers identified 15 studies that met their inclusion criteria. Overall, non-physician clinicians reported meeting regularly with sales representatives from the pharmaceutical industry; few had eliminated these meetings from their practice. The majority of sampled nurses, nurse practitioners, and Registered Nurses reported receiving gifts, food and beverages including sponsored lunch and dinner events. Non-physician clinicians reported frequent receipt of samples of pharmaceuticals and other medical products for patient use and they generally held favorable views of such samples. Large majorities of non-physician clinicians reported attending industry-sponsored educational events or receipt of industry-provided educational materials. Most non-physician clinicians across disciplines held favorable views of interactions with sales representatives and industry interactions in general. A minority perceived that industry marketing influenced their own practice, but more felt their colleagues would be influenced. Preparation for industry interactions generally was not a part of professional training. In addition to the pharmaceutical industry, the infant formula industry targeted marketing efforts at non-physician clinicians.
The authors state, "The frequency of industry interactions and, despite clinician recognition of the potential for bias and conflict of interest, the common view of industry as at worst, a 'necessary evil', suggest that clinician-industry interactions are normalized in clinical practice settings." The authors acknowledge several limitations of their study, including that the studies were observational and of varying methodological rigor, thus the findings may not be generalizable, and given the types of studies the prevalence or frequency non-physician clinician-industry interactions could not be quantified.
In a related Perspective, James Yeh and Aaron Kesselheim (Harvard University, Boston, MA) state that while recent policy changes may have been successful in insulating more physicians from promotional interactions, "By contrast, the study from Grundy and colleagues shows that promotion to non-physician health care providers remains vibrant." They suggest that because current programs intended to provide transparency about the prevalence of pharmaceutical industry marketing may not reach the non-physician clinician population, institutional policies should be constructed to apply to all providers of patient care.
Grundy Q, Bero L, Malone R (2013) Interactions between Non-Physician Clinicians and Industry: A Systematic Review. PLoS Med 10(11): e1001561. DOI: 10.1371/journal.pmed.1001561