One of the largest problems facing the U.S. health care system is the shortage of primary care physicians. Recent estimates from the American Association of Medical Colleges (AAMC) have explained that “unless more primary-care physicians are recruited, a shortage of 30,000 doctors can be expected by 2015, and in 10 years, this shortage could go up to 150,000.”
This shortage is extremely disturbing because in 2014, the U.S. health care system will have 31 million more Americans. Where will all the doctors come from to treat these patients? To address this issue, health care stakeholders are calling for expanded roles of physician’s assistants, nurses, and nurse practitioners.
Nurse Practitioners
There are more than 150,000 nurse practitioners (NPs), significantly more than the estimated 100,000 family physicians in the United States. Nurse practitioners are authorized to prescribe in all 50 states and the District of Columbia. By 2015, there will be more than 190,000 advanced practice nurse prescribers (certified nurse midwives, psychiatric/mental health clinical nurse specialists, and NPs).
Almost 97% of NPs can prescribe medications. Each prescriber writes, on average, between 19 and 25 prescriptions a day, or approximately 6200 prescriptions per NP prescriber per year. This translates into millions of prescriptions per year, representing a substantial portion of the medications dispensed in the U.S.
While many see the positive role that NPs can play in helping address and close the gap in physician shortages, others are concerned about the potential influences NPs can have in their decision to prescribe medication. Because NPs are writing so many prescriptions, a recent article from the American Journal of Managed Care entitled, “Under the radar: Nurse Practitioner Prescribers and Pharmaceutical Industry Promotions,” says their needs to be a new focus on NP prescribers.
Background
The authors conducted an online survey from November 2007 to March 2008 of a nationally representative sample of NP prescribers, to assess their perceptions of pharmaceutical industry promotional activities, and to identify their beliefs about marketing influences on their prescribing behaviors. The Attorney General Consumer and Prescriber Grant Program funded the study. On completion of the survey, participants received a $50 gift certificate. A total of 263 responses were analyzed.
Survey questions investigated the 3 primary domains of interest: (1) prescribing practices and behaviors and interface with industry, (2) perceived reliability of information provided by the pharmaceutical industry, and (3) ethical acceptability of promotional gifts and meals. Study variables included promotional gifts and meals, the acceptance of industry-supplied free samples, and frequency of attendance at industry-sponsored continuing education events.
Findings
After analyzing the results from the survey, the authors made the following findings:
– 96% reported regular contact with pharmaceutical sales representatives
– 83% reported that information they received from drug reps was reliable
– 93% of respondents reported that free gifts distributed by sales representatives had no effect on their likelihood to prescribe a highlighted drug
– 49% reported regular attendance (1-5 times) at sponsored lunch events in the past 6 months
– 64% reported regular attendance at dinner events during the same period.
– 78% reported that meal events were a good-to-excellent way to receive information about new drugs.
– 61% of respondents reported that the information was somewhat reliable.
With respect to findings about prescribing behaviors of NPs, the study found that:
– 66% of respondents dispensed medication samples for treatment
– 73% stated that samples are somewhat/very helpful in learning about new drugs
– 62% said samples encourage prescription of new highly marketed medications
– 81% thought that it was acceptable to give out drug samples to anyone
Pertaining to continuing education:
– 96% had attended industry sponsored CE programs over the past 5 years
– 91% thought the information at these events was somewhat /very reliable
– 83% believed that sponsored continuing education was a good-to-excellent way of maintaining affordable continuing education.
– 90% believed that it was acceptable to attend lunch and dinner events sponsored by pharmaceutical companies, and
– 75% said it was acceptable for a speaker to be paid by a pharma company
Discussion
For some, the numbers above clearly demonstrate that the use of industry to provide free samples to patients, fund continuing education, and to provide valuable information to NPs is a critical resource. However, for the authors, these numbers are concerning.
First, the authors believe that NPs positive attitudes toward pharmaceutical marketing efforts will affect their personal prescribing and that more contact with industry representatives will increase their likelihood of (1) prescribing brand-name drugs over lower-cost generics, (2) requesting that a company’s drug be added to the hospital formulary, and (3) dispensing more drug samples.
Part of their concern stems from their belief that “industry may redirect promotional activities toward NP and other non-physician prescribers because,” the Sunshine Physician Payment Act—requiring pharmaceutical and medical device manufacturers to report all payments made to physician prescribers for services and gifts—contained in the Affordable Care Act, only applies to physicians or teaching hospitals, not NPs. Critics also believe that NPs have become objects of pharmaceutical promotions because of their considerable potential to increase drug sales.
These assertions however are highly unlikely and completely unfounded. As the study showed, 83% of respondents reported that information they received from drug reps was reliable and 93% reported that gifts distributed by sales representatives had no effect on their likelihood to prescribe a highlighted drug. Industry critics dispute these numbers by pointing to “social science” studies. However, these studies are insignificant because they did not cover the affect of gifts on patient care.
The issue about industry influence, as it always should be, is whether such “potential influence” will harm patients, and the authors of this study present no findings or measures whatsoever on this critical issue.
Second, with respect to continuing education, the authors fail to recognize that with 96% of respondents attending industry sponsored CE this resource is clearly valuable. Especially considering 91% believed the information at these events was somewhat or very reliable. Moreover, the vast majority believed that sponsored CE was a good-to-excellent way of maintaining affordable continuing education. Although the authors believe that industry sponsored CE exposes NPs to potential market biases, they completely ignore three studies which showed almost no bias in industry funded CE (Cleveland Clinic; Medscape, and UCSF).
Third, the authors underscore the value NPs find in attending industry events. With 49% of respondents regularly attending lunch events and over two-thirds attending dinner, it is clear that NPs believe these programs are crucial. No one forces NPs to go. They are voluntary, and if over three-quarters of respondents believe meal events were a good-to-excellent way to receive information about new drugs, then why criticize them? Almost two-thirds of participants at these events reported that the information was somewhat reliable and therefore, NPs clearly benefit from attending such events.
Fourth, the overwhelming use of samples should be encouraged and continued because almost three-fourths of respondents state that samples are somewhat/very helpful in learning about new drugs. Don’t we want our NPs to learn about new drugs that can help us and other patients? While the authors claim that drug samples add burdensome costs to the healthcare system, samples are overwhelmingly used to offset the high cost of brand-name drugs, especially for uninsured and underinsured patients.
Besides using such a small sample, the study failed to address a significant limitation, which should render almost all of the findings meaningless. This survey was conducted between 2007 and early 2008. Significant changes have occurred since then in PhRMA and AdvaMed Codes of Ethics, as well as guidance documents from OIG, HHS, and FDA. Additional changes have been implemented by ACCME and similar accrediting organizations.
What this all means is that today, and in the three years since the survey was completed, gifts are practically non-existent, CE is objective and free from industry control or bias, meals are limited, and drug reps have new rules to follow. Furthermore, while the authors use numbers for industry funded CME between 1998-2007 increasing 300%, they failed to realize that it has decreased almost 30% since 2007.
Conclusion
Many factors come into play when NPs or physicians make a prescription, including patients’ requests for medication, drug reps, direct-to-consumer advertising, and formulary restrictions.
While the authors believe that NPs have been operating “under the radar” regarding research and policy on the influences of pharmaceutical marketing, the reality is NPs have been trying to account for the severe shortage in primary care physicians. NPs have been doing this by working with industry through CE and other educational programs to stay up to date on new advances and clinical information. Do we really want to stop the valuable continuing education that NPs are getting at a time when they will need it the most?
It is always crucial for health care practitioners to have access to unbiased information. The recent changes in the continuing education field have created appropriate safeguards that ensure objective information free from bias. Had the authors conducted a more recent survey, the results would likely have reflected these changes, showing that industry influence is being actively managed.