Pharmaceutical representatives do influence physician behaviour

Abstract

It is a not a truth universally acknowledged that pharmaceutical representatives influence physician behaviour. However, the pharmaceutical industry clearly believes they do. In fact so sure are they of this that in 2000, $4.8 billion dollars were spent in the USA on ‘detailing’, the one-on-one promotion of drugs by a representative of the company. There is a wealth of anecdotal evidence of changes in behaviour following such marketing. This includes my own experience as a prescribing adviser for a Primary Care Trust (a UK commissioning organization with responsibility for the prescribing budget), where those primary care physicians known to be most receptive to new drugs promoted by pharmaceutical representatives are referred to as ‘the lunch bunch’. However, the detailed scientific evidence in the literature is not extensive. The study by Sondergaard et al. is a clear addition. They assess the impact of pharmaceutical representatives on prescribing behaviour for a new fixed dose combination inhaled corticosteroid and long-acting b2-agonist (LABA) in Denmark. The study found that there was a greater increase in the market share of the promoted fixed dose combination in those practices that received a visit in comparison to those that did not receive a visit. It did not show an increase in the proportion of patients with asthma receiving inhaled steroids. The two outcomes were chosen to examine two different suggested aspects of the promotional process. One of these is that it is principally about increasing market share. The other is that it increases disease awareness and appropriate prescribing; in this case, the supposition is that increased steroid prescriptions would represent such an effect. However, it is worth examining the therapeutic context within which this promotion took place. Asthma guidelines had long stressed the need to start inhaled steroids early in treatment with both the US and UK guidelines of 1997 making this a key treatment point. However, these two guidelines reflected the then continuing controversy over the exact place of LABAs in treatment. The US guidelines mention them as one of a series of options including oral b2-agonists and theophyllines after low-dose inhaled steroids, while the UK guidelines placed them as a possible alternative to increasing steroid dosage following use of low-dose steroids. The US guidelines were revised in 2002 to make LABAs the preferred next step after low dose inhaled steroids and the UK guidelines followed suit in 2003. Thus, this study takes place in the context that steroids have been a long-established treatment and the LABA component is the newly prominent treatment. It is therefore not surprising that steroid use is not increased. However, it would be interesting to know whether the overall use of LABAs increased faster in visited practices during this period than in those that had not been visited. If this had occurred, it would show a faster adoption of new prescribing patterns that would represent a probable patient benefit. With regard to the market share, an increase is associated with the initial visits by representatives. However, the detail is once again worth considering. There was at that time only one other combined product available, ‘Seretide’ a mix of fluticasone and salmeterol, which had been launched earlier than the studied medicine. In Denmark, fluticasone is prescribed significantly less than the budesonide of this study’s inhaler and both are prescribed significantly more than beclometasone. The studied inhaler therefore might have been expected to obtain a large market share. However, this study shows that market share seems to be tailing off at 30%. The question is why a more widely used steroid that continues to be more widely used after this study period is being outsold 2:1 by a competitor when formulated as a combination. One possible answer is marketing by the other company. This might suggest that one way to maintain your market share is to continue to target prescribers. It would also suggest that