Jul 11, 2010

Academic Detailers: No Really, We're Not Biased

As the debate heats up over whether physicians should be able to interact with commercial entities such as industry sales representatives and scientists (HERE), the Globe has thrown their weight behind funding the group they hope will move in to fill the educational vacuum: State-sponsored, non-profit sales reps called "academic detailers."

Although every attempt is made in the editorial below to distinguish the lofty motives of academic detailers from their sinister for-profit counterparts, their job descriptions seem strikingly similar: Show up at physician's offices with clinical information and attempt to influencing prescribing decisions.

Of course, there are differences. The for-profit reps have to abide by FDA guidelines and labeling; the non-profit side doesn't need to be limited by these constraints. The commercial side makes no delusions about their biases; they hope their product will be the right choice for some patients and in that case it will be selected. The non-profit side, however, seems reticent to admit that they could have any bias. To the contrary, they would have us believe that since they are paid by the State, and aren't beholden to stockholders, they are unbiased.

That argument may fly in some circles, but the rest of us may be a little skeptical. Academic sales reps are paid by the State to save the State money, yet we are to believe that they do not have a predisposition for the cheapest treatment available?

Side Note: Here is a great quote from the Godfather of academic detailing, Jerry Avorn, a staunch supporter of limiting interactions between all commercial entities and physicians, during an interview with NPR (HERE) on whether academic sales reps should be able to provide lunch while providing their education:

"Well, we actually had a soul searching about the lunch. We originally started out by saying, we’re not going to do any bribes, we’re not going to give any freebies. And then some of the doctors said, I’d really love to talk to you but the only time I have is during my lunch hour, can you bring me a sandwich. So we crossed the line and said yes, we’ll spring for a pizza or a sub sandwich but not for a meal at Anthony’s Pier 4." - Jerry Avorn, MD

Doctors need unbiased info, not a soft sell by drug reps

TO UNDERSTAND why doctors need an objective way to learn about pharmaceuticals, look at how information usually gets to them.

Meet Dr. Jeffrey Geller, a charismatic family doctor at Greater Lawrence Family Health Center. He stopped attending lunches sponsored by drug companies in recent years. But he still accepts free samples from drug company representatives who drop by his office, because they allow him to offer the latest asthma inhaler or a dose of Viagra — neither of which would be covered by his patients’ health insurance — to the poor and underserved that come to this community clinic. Even during brief exchanges, where he signs off for a sample and basic information about a drug, he is on guard, he said. The drug company representatives are often attractive, sharply-dressed, and charming. Talking to them and looking through their snazzy brochures about the drugs they promote, he says, can make a doctor feel obligated or subconsciously swayed to prescribe their drugs. Like most doctors who are surveyed about the subject, Dr. Geller says he’s wise to the subversive influence these drug representatives can have, but he still worries about their effect on what doctors prescribe.

As Massachusetts seeks to get its health care spending under control, the state has taken a small step toward reducing the influence of paid marketers, at least on the overworked doctors at community health centers. Two years ago, the state started sending out its own representatives to provide unbiased information on diseases, clinical trials, and treatment options — all prepared by doctors and drug researchers at Harvard Medical School. When delivered by trained circuit-riders, this information can balance the one-sided pitches that doctors receive from paid marketers. Yet the limited scale of the initiative underscores the need for objective information not just in community health centers, but across the medical profession.

As of last year, Massachusetts has had stricter rules about drug company interactions with doctors than most other states. The Commonwealth bans gifts from the companies to doctors, and requires companies to report payments to doctors for services that are greater than $50. But at community health centers that serve mainly the poor, drug representatives wield influence. They drop by for chats with doctors about their drugs, and sponsor lunches to talk to nurses.

Pharmaceutical company representatives save doctors’ time by giving them slick and easy-to-digest promotional materials about their drugs. They give them flexibility, by providing free samples they can share with their patients. The problem is that drug company representatives do not provide a balanced view of how to treat an illness. They don’t tell doctors that medicines other than their own — or alternatives to medication — could be safer or more effective, even when the evidence points in that direction. And drug company representatives don’t tell doctors and nurses that their new, brand-name medicines might not be the best option for patients with poor prescription coverage and little money to spare. Even their free samples may interrupt a patient’s routine care.

In contrast, the representatives sent by the state tell doctors about the risks, costs, and effectiveness of various drugs. The method, called academic detailing, has been shown in other states and in Australia and the Netherlands to save insurers and the health care system money, on balance, by decreasing prescriptions of brand-name drugs and improving health outcomes. One of two academic detailers in the Commonwealth, Barbara Russell, has been making visits to the Lawrence center this year. But the state-funded program may not be able to secure funding to scale up or continue past the coming year.

At $250,000, the pilot program pales in comparison to the academic detailing program in Pennsylvania, where 11 detailers and more than $1.5 million in state funding are devoted to providing doctors with unbiased information about drugs and disease. Both to save money and better promote public health, Massachusetts should ramp up its effort on this front.

Doctors need the ability to treat their patients based on good science rather than good marketing.

Editorial Link HERE.