New study explores prevalence of drug promotions in primary care practices

According to a new Dartmouth study published in JAMA Internal Medicine, pharmaceutical companies' promotional access to outpatient practices that deliver primary care in the U.S. is substantial, especially in smaller practices, those outside of healthcare systems, and those without academic affiliation, possibly impacting prescribing quality and cost.

While direct-to-consumer advertising has been the fastest growing segment of pharmaceutical marketing in the U.S. in recent years, drug companies actually spend more (a total of $18.5 billion in 2016) on promoting their products directly to physicians—through clinician office visits known as "detailing" and free drug samples known as "sample closets."

Detailing and free samples have been shown to affect prescribing quality and costs, often by promoting new and expensive brand name drugs over equally effective, older, and less expensive options.

To help determine the widespread prevalence of detailing and sample closets, the researchers surveyed a national sample of U.S. outpatient practices delivering primary care services and with at least three physicians between June 2017 and August 2108. They compared visit frequency and the presence of sample closets overall (across 2,190 practices), and by ownership, practice size, geographic location, and academic affiliation.

Ownership characteristics were organized into the following categories: independent multi-physician practices (with at least three primary care physicians), medical groups (with at least one multi-physician practice), simple systems (those with at least one multi-physician practice and at least one hospital), and complex systems (those with multiple simple systems).

The researchers found that weekly detailing was more common in independent multi-physician practices than in those who were part of complex systems (60 percent versus 39 percent), smaller practices with less than 10 doctors vs. those with more than 20 physicians (55 vs. 27 percent), non-academic-affiliated practices vs. those with academic affiliations (56 percent vs. 32 percent), and in those practices located in the Southern region of the country. A very similar pattern was seen for the presence of free sample closets.

"These findings are consistent with a study of broader physician populations from 2007 and likely reflect limited infrastructure in these practices to impose access restrictions or to provide independent drug information," explains lead author Steven Woloshin, MD, MS, a general internist and a professor of medicine and community and family medicine at Dartmouth's Geisel School of Medicine, and of The Dartmouth Institute for Health Policy and Clinical Practice.

"Although our findings are insufficient to fully explain the higher level of promotional access in the South, it's noteworthy that healthcare spending is also higher in the South than in other regions of the U.S.," he says.

While factors such as industry consolidation and stricter policies among hospitals and medical centers have limited some of the promotional access previously afforded to pharmaceutical companies, these activities still have a substantial effect on prescribing quality and expenditures.

"If reducing industry influence on prescribing is a priority, our findings indicate that further measures are needed, at least in practices delivering primary care, and particularly in smaller practices and those outside of health systems or academic settings," says Woloshin.