Pharmaceutical Representatives Research Articles

The relationship between the physician and pharmaceutical industry: background ethics and regulation proposals.

Pharmaceutical funding plays an important role in medical progress. Thus, clinical and academic research has been significantly commercialized (1). There are data to suggest that economic interest from industry may have a negative influence on the objectivity of science, research publication, and even patient management (2,3). For example, a manufacturing company has been engaged “… in misleading practices to promote the prescription and usage of rofecoxib, including ‘fake’ journals and guidelines to ‘drug reps’ that minimised the adverse cardiovascular risks” (4). Industry-sponsored reports are up to four times as likely to favor a pharmaceutical company’s product compared to independently published data (5).

An Empirical Model of Drug Detailing: Dynamic Competition and Policy Implications

The practice of detailing in the marketing of prescription drugs is undergoing significant changes. For instance, in September 2013, the Physician Payment Sunshine Act went into full effect. The accompanying transparency requirements have prompted physician practices and hospitals to severely restrict pharmaceutical sales representatives’ direct access to their physicians. Despite all the attention in the popular press, scant scholarly research has investigated how these restrictions on physician access impact physician prescription behavior and competitive detailing to physicians. To analyze the impact of these restrictions, we develop a structural model of how pharmaceutical firms compete dynamically to schedule detailing to physicians. Detailing activities are known to have significant carryover effects that are captured in a first-stage model of physicians’ demand for prescription drugs. We also specify detailing policy functions that describe each firm’s observed detailing actions. In a second stage, we estimate a model that describes costs of detailing, assuming that the observed detailing levels are consistent with a Markov perfect Nash equilibrium. The estimated structural model is used to examine the implications of restrictions on the amount of detailing via counterfactual simulations. We find that restriction policies would increase the market share of a nondrug-treatment-only option but impact firms asymmetrically; firms that are strong in detailing and/or rely more on detailing would be hurt more. Unexpectedly, a policy that imposes a ceiling on detailing frequency could significantly reduce detailing of all firms in the market, including those firms with average detailing levels below the ceiling, and effectively would soften competition between firms and enhance their profits. This paper was accepted by J. Miguel Villas-Boas, marketing.

Conflicts about Conflict of Interest.

Pharmaceutical representatives use detailing, gift giving, and the donation of free samples as a means to gain access to and influence over physicians. In biomedical ethics, there has been an ongoing debate as to whether these practices constitute an unethical conflict of interest (COI) on the part of the physician. Underlying this debate are the following antecedent questions: (1) what counts as a conflict of interest, (2) when are such conflicts unethical, and (3) how should the ethical physician respond to conflicts? This article distinguishes between two perspectives that have been developed on these issues: a reliable performance model (PM) and a trustworthiness model (TM). PM advocates argue that a conflict of interest can only be established by demonstrating that a particular influence is undermining the reliability of the physician's judgment, and this requires empirical evidence of negative patient outcomes. TM advocates, on the other hand, argue that because of the fiduciary nature of the patient-physician relationship, physicians have an obligation to develop and be worthy of patient trust. A COI, on this view, is a condition that undermines the warrant for patients to judge a physician as trustworthy. Although there is much that is right in the PM, it is argued that the TM does a better job of responsibly addressing the unique vulnerabilities of the patient. The TM is then applied to the practices of detailing, gift giving, and sample donation. It is concluded that these practices constitute an unethical conflict of interest.

Empathy, nonverbal immediacy, and salesperson performance: the mediating role of adaptive selling behavior

Purpose Previous studies that examined the role of empathy and nonverbal immediacy on business-to-business (B2B) salesperson performance is limited in scope and yielded inconclusive evidence. Grounded in Plank and Greene’s (1996) framework of salesperson effectiveness, this paper aims to empirically investigate the mediating role of adaptive selling behavior through which empathy and nonverbal immediacy influence sales force performance and the form of empathy (cognitive or affective) that has the most beneficial role in improving relationship (versus outcome) salesperson performance. Design/methodology/approach Using cross-sectional data that were collected from 422 pharmaceutical sales representatives, this study used structural equation modeling to test the hypothesized relationships. Findings Adaptive selling behavior mediates the effect of perspective taking empathy and empathic concern on relationship performance. However, the impact of empathy on outcome performance is not significant through adaptive selling behavior, but perspective taking empathy has a direct influence on outcome performance. Contrary to expectations, nonverbal immediacy is not mediated by adaptive selling behavior but has a direct and positive impact on relationship performance. Research limitations/implications The results of this study have several implications for recruitment, training and assessment of salespeople in a B2B context. Based on the empirical evidence, it is highlighted that firms may use different forms of empathy and nonverbal cues to promote adaptive selling behavior that impact sales force performance (i.e. outcome or relationship). Originality/value To the authors’ knowledge, this is the first study which simultaneously examines the mediating role of adaptive selling behavior in the relationship between three antecedent variables that relate to sales force empathy and nonverbal communication (i.e. perspective taking empathy, empathic concern and nonverbal immediacy) and two aspects of B2B sales performance (relationship and outcome).

Pharmaceutical Representatives' Opinion about Pharmacists' Drug Dispensing Practices in Romania and Factors that Influence them

The objective of the research is to identify pharmaceutical representatives’ opinions on some practices of drug dispensing amongst community pharmacists in Romania. Material and methods: 70 pharmaceutical representatives working with different pharmaceutical companies in Romania answered questions regarding practices of drug dispensing. Different variables were taken into account: age, gender, type of education, and length of employment time. Collected data were analyzed with SPSS 17.0. Results: over 70% of the pharmaceutical representatives consider that pharmacists counsel the patient regarding other drug brand names and take into consideration patient financial contribution when dispensing a certain drug. Regarding the relationship of the pharmacist with doctor and rep, 65% of pharmaceutical representatives consider the relationship with the doctor, and 40% the relationship with the rep, important when dispensing a drug. No important differences were identified in relation to the gender or type of education. Conclusion: the study provides information regarding pharmaceutical representatives’ opinions on practices of drug dispensing. More than 2/3 of the reps consider that pharmacists are counseling the patient regarding a drug to a high level.

The use of social media among business-to-business sales professionals in China

Purpose– The purpose of this study is to explore the role of social media usage among business-to-business sales professionals in China. Specifically, the authors seek to define and explore the unique ways in which Chinese salespeople use social media, with a special emphasis on the role ofguanxi.Guanxiis a complex cultural construct that revolves around the exchange of favors to build trust and connection for business purposes.Design/methodology/approach– Three in-depth interviews of sales managers from two industries along with survey data from 42 pharmaceutical sales representatives were collected to gain an understanding of the general usage and attitudes toward social media in the sales process in China.Findings– Results indicated that virtually all the salespeople in the sample were highly familiar with social media and integrated it into the sales process. Furthermore, all participants indicated that their companies were highly supportive of the use of social media with their customers. More importantly, salespeople in China view social media as a critical tool in buildingguanxiwith their customers. Findings from this exploratory study are used to create a conceptual framework for understanding the important role of social media in buildingguanxiin China.Research limitations/implications– While the sample is limited to three managerial interviews and 42 survey responses, the data indicated a near universal acceptance and use of social media among Chinese salespeople. Most importantly, social media appears to be the modern gateway to the ancient and culturally unique construct ofguanxithat is absolutely indispensable to successful business-to-business sales performance in China.Practical implications– The structural challenges within China make trust and emotional connection essential to any potential business relationship. Trust is at the core ofguanxi. Any firm hoping to succeed in China must understandguanxiand the use of Chinese social media to help build it. This study adds to the knowledge and understanding ofguanxiand begins to elucidate the uses of social media as a tool to build and maintain it.Social implications– Social media appears to be the modern gateway to the ancient and culturally unique construct ofguanxithat is absolutely indispensable to successful business-to-business sales performance in China. This study deepens our understanding of not onlyguanxibut also how the modern phenomenon of social media is affecting it.Originality/value– This is one of very few studies to investigate the use of social media among salesforces in China. More importantly, the authors know of no other study linking social media withguanxi.

Evidence-based medicine and life-long learning competency requirements in new residency teaching standards

The objective of this study is to compare accreditation standards across medical and surgical specialties in the USA to determine the requirements for evidence-based medicine (EBM) and information management (life-long...

Effects of Physician-directed Pharmaceutical Promotion on Prescription Behaviors: Longitudinal Evidence.

Spending on prescription drugs (Rx) represents one of the fastest growing components of US healthcare spending and has coincided with an expansion of pharmaceutical promotional spending. Most (83%) of Rx promotion is directed at physicians in the form of visits by pharmaceutical representatives (known as detailing) and drug samples provided to physicians' offices. Such promotion has come under increased public scrutiny, with critics contending that physician-directed promotion may play a role in raising healthcare costs and may unduly affect physicians' prescribing habits towards more expensive, and possibly less cost-effective, drugs. In this study, we bring longitudinal evidence to bear upon the question of how detailing impacts physicians' prescribing behaviors. Specifically, we examine prescriptions and promotion for a particular drug class based on a nationally representative sample of 150,000 physicians spanning 24months. The use of longitudinal physician-level data allows us to tackle some of the empirical concerns in the extant literature, virtually all of which have relied on aggregate national data. We estimate fixed-effects specifications that bypass stable unobserved physician-specific heterogeneity and address potential targeting bias. In addition, we also assess differential effects at both the extensive and intensive margins of prescribing behaviors and differential effects across physician-level and market-level characteristics, questions that have not been explored in prior work. The estimates suggest that detailing has a significant and positive effect on the number of new scripts written for the detailed drug, with an elasticity magnitude of 0.06. This effect is substantially smaller than those in the literature based on aggregate information, suggesting that most of the observed relationship between physician-directed promotion and drug sales is driven by selection bias. We find that detailing impacts selective brand-specific demand but does not have any substantial effects on class-level demand. The increase in brand-specific demand appears to crowd out demand for the substitute branded drug although not for the generic alternative. Results also indicate that most of the detailing response may operate at the extensive margin; detailing affects the probability of prescribing the drug more than it affects the number of prescriptions conditional on any prescribing. We draw some implications from these estimates with respect to effects on healthcare costs and public health. Copyright © 2016 John Wiley & Sons, Ltd.

Knowledge, beliefs and attitudes of physicians in low and middle-income countries regarding interacting with pharmaceutical companies: a systematic review.

BackgroundUnderstanding the perceptions and attitudes of physicians is important. This knowledge assists in the efforts to reduce the impact of their interactions with the pharmaceutical industry on clinical practice. It appears that most studies on such perceptions and attitudes have been conducted in high-income countries. The objective was to systematically review the knowledge, beliefs and attitudes of physicians in low and middle-income countries regarding interactions with pharmaceutical companies.MethodsEligible studies addressed any type of interaction between physicians and pharmaceutical companies. The outcomes of interest included knowledge, beliefs and attitudes of practicing physicians. The search strategy covered MEDLINE and EMBASE databases. Two reviewers completed in duplicate and independently study selection, data abstraction, and assessment of methodological features. The data synthesis consisted of a narrative summary of the findings stratified by knowledge, beliefs and attitudes.ResultsWe included ten reports from nine eligible studies, each of which had a number of methodological limitations. Four studies found that the top perceived benefits of this interaction were receiving information and rewards. In five out of eight studies assessing the perception regarding the impact of the interaction on the behavior of physician prescription, the majority of participants believed it to be minor. In one of these studies, participants perceived that impact to be lesser when asked about their own behavior. The attitudes of physicians towards information and rewards provided by pharmaceutical company representatives (PCRs) (assessed in 5 and 2 studies respectively) varied across studies. In the only study assessing their attitudes towards pharmaceutical-sponsored Continuing Medical Education, physicians considered local conferences to have higher impact. Their attitudes towards developing policies restricting physicians’ interactions with PCRs were positive in two studies. In one study, the majority of participants did not mind the public knowing that physicians were receiving gifts and awards from drug companies.ConclusionsThis review identified few studies conducted in low and middle-income countries. While physicians generally perceived the impact of interactions on their behavior to be minor, their attitudes toward receiving information and rewards varied across studies.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1299-4) contains supplementary material, which is available to authorized users.

Effect of Promotional Literature on the Prescribing Habits of Practitioners

Pharmaceutical companies are the manufacturing units of drugs, with established conformity for dispersal into the public. To increase their sales and hence, their shareholder value, these corporations need to make their product have earmarks of a better formulation than those already available and stand out from their adversaries. This is achieved with the help of rigorous promotion of the drug to the prescribers. Medical Representatives (MRs) or Pharmaceutical Sales Representatives (PSRs) advertise to the doctors with the help of eye catching visual presentation, citing various benefits and advantages. These presentations are accompanied by leave-behind brochures, pamphlets, drug guides, drug samples etc. for the doctor to read, and are consistently full of points featuring the promoted drug as an advancement with better effectiveness, supported with various research works, colorful pictures, graphs and diagrams that make a physician take notice of the advertised drug. This raises the question of the ability of a GP to critically appraise the information presented to him/her and segregate the fact from fraud. Too often aid is tied to the trade, and any practicing physician should be aware of the tricks being played on him/her and be able to wring the quality of the information presented from the vast quantity of information and assess it for its accuracy.

Urologists’ experiences with treatment of castration-resistant prostate cancer.

315 Background: Urologists are at the forefront of treating prostate cancer. Since 2010 four non-chemotherapy drugs have been approved for castration-resistant prostate cancer (CRPC). We aimed to ascertain Society of Urologic Oncology (SUO) members’ practices, training, and barriers as they relate to the treatment of CRPC. Methods: An IRB approved nine item REDCap survey was emailed to 697 SUO members (440 US urologists) without a financial incentive. Urologists were asked whether they should and/or have treated men with CRPC, what barriers they experience and how these barriers may be overcome. Results: Eighty-four surveys were completed. 86% definitely or somewhat agreed that it was within the purview of urologists to prescribe therapy for CRPC. Abiraterone, enzalutamide, sipuleucel-T, or Radium-223 were prescribed by 51% and out of those, 44% personally prescribed them to > 50% of their CRPC patients; 52% were aware of other urologists who prescribed these drugs. Education on the use of these drugs was most commonly via self-study (19%), national meetings (19%), pharmaceutical representatives (17%), and informal discussions with colleagues (16%). Although some did not see barriers (27%), side-effects management (23%), the time it takes to counsel patients on these therapies (14%), and their practice’s time and energy costs (14%) were the greatest obstacles to using these medications. 34% felt that more educational sessions at national meetings or greater support by professional organizations would help them increase drug administration. 53% see the recent changes in the management of CRPC as increasing the collaboration between urologists and medical oncologists and 30% believe there are increasing opportunities for urologists to strengthen their relationship with their CRPC patients. Conclusions: The majority of SUO respondents agreed that it is within the scope and practice of urologists to prescribe therapy for CRPC. Half have prescribed these therapies themselves and/or were aware of other urologists who had done the same. Some would be encouraged to increase their use of therapies for CRPC via greater support by professional organizations and education at national meetings.

Public Relations as Part of Integrated Communication of an Enterprise-Consumer Oriented On

Pharmaceutical Representatives and Prescription Decisions by Physicians in Saudi Arabia Ishak Abubakar Y. Ibrahim, Charles H. Bélanger Abstract Purpose: This research aims to identify key factors that influence physicians’ drug selection decisions as well as the main sources of information for physicians about new drugs and the most effective “reminder methods” used by pharmaceutical sales representatives. This study fills a gap within the existing literature by identifying the most important factors that affect physicians’ drug selection decisions in Saudi Arabia Design/methodology/approach: A survey was conducted in the Western region of Saudi Arabia using a convenience sample. A total of 106 physicians who met with pharmaceutical sales representatives filled out a questionnaire identifying the factors that influenced their prescribing decisions, as well as determining their main sources of information about new drugs, and the most effective “reminder methods” used by pharmaceutical representatives. Data were analyzed using SPSS. Findings: The results indicate that pharmaceutical sales representatives are the most commonly mentioned main source of new drugs information. Moreover, the factors identified as most impacting physicians’ drug selection decisions include in order, the patient’s financial situation and prevailing hospital policies, followed by media advertising and frequent visits from pharmaceutical sales representatives. Finally, leaflets were identified as the most effective ‘reminder method’ used by pharmaceutical sales representatives. Originality/value: The study findings are relevant because they can help pharmaceutical sales representatives to focus their efforts on the most effective marketing methods to boost their sales revenue, increase their market share, reduce marketing expenses, and potentially pass on the savings to patients. Full Text: PDF DOI: 10.15640/jmm.v3n2a7

Management of pharmaceutical sales representatives: A literature review

This paper reports literature review in the field of pharmaceutical marketing emphasizing problems faced by medical representatives. India after globalization and being the second highest populated country has emerged as major pharmaceutical market in the world. Pharmaceutical marketing in India is highly relied on personal relationship between medical representatives and doctors. In the last decade, many foreign companies have entered in Indian market. This has posed highly competitive and challenging work environment for medical representatives. Therefore, it is indispensable to study the challenges faced by medical representatives in this dynamic environment. Keywords: Job satisfaction, Medical representatives, Pharmaceutical marketing, Pharmaceutical sales representatives, Sales management, Turnover intention CLC number: R952 Document code: A Article ID: 1003-1057(2016)1-73-06

Understanding the degree of awareness among medical professionals regarding the ethics of pharmaceutical marketing activities in context of revised medical council of India code of ethics

Background: Pharmaceutical marketing activities are regarded as ethically challenging by most medical professionals. This study was planned to understand the extent of the interaction of pharmaceutical companies with healthcare providers & to determine the level of awareness about the ‘Medical Council of India (MCI) Code of Ethics’. Methods: A questionnaire based survey was conducted among 100 consultants and residents. The questionnaire mainly dealt with ethical issues about accepting free gifts, medicines and other sponsorships from pharmaceutical representatives, interactions and expectations from representatives of pharmaceutical companies by doctors and ascertaining among them the level of awareness about the MCI’s code of ethics. Results: 59.4% residents and 58.8% consultants do not consider small gifts (stationery/books/drug samples) as ethically problematic. 88% residents and 85% consultants felt that offers should be limited. 72% of consultants were aware of the revised MCI code of ethics as compared to 28% of residents. Conclusions: Most physicians do maintain a code of ethics with regards to accepting gifts and they felt that inexpensive gifts do not influence clinical judgment. Consultants were of the view that amended MCI code of ethics would not affect their clinical practice significantly.

Off-Label 'Promotion' May Not Be Merely Commercial Speech

Most attorneys (whether in practice or academia) assume that pharmaceutical companies’ discussion and dissemination of information regarding “off-label” uses of prescription drugs (i.e., uses that have not been specifically approved by the Food and Drug Administration (FDA)) are inherently commercial in nature. Two aspects of the speech, however, suggest that it does not cleanly fall into the category of “commercial speech” for purposes of First Amendment analysis. First, most prescribers are not, in fact, purchasing drugs for their patients, and so conversations between pharmaceutical company representatives and prescribers are not directly linked to a commercial transaction the same way they are with an advertisement or sales pitch to an end consumer. Second, prescribers are “learned intermediaries,” charged by profession and law to research and weigh the range of potential risks and benefits of each product they prescribe for their patients, whether it is prescribed for an FDA-approved use or an off-label use. As a result, scientific and medical information is “inextricably linked” to any speech that would be considered merely commercial. Prior attempts to restrict speech that included both financially driven and noncommercial components have received exceptionally rigorous scrutiny when reviewed by the Supreme Court. This Article suggests that the current restrictions on some pharmaceutical company speech may be given what I shall call “enhanced intermediate” (or even strict) scrutiny, rather than the usual intermediate scrutiny given to restrictions of merely commercial speech, because of the unique professional and legal role played by prescribers.

Medical Schools' Industry Interaction Policies Not Associated With Trainees' Self-Reported Behavior as Residents: Results of a National Survey.

Medical students attending schools with policies limiting industry/student interactions report fewer relationships with pharmaceutical representatives. To investigate whether associations between students' medical school policies and their more limited industry interaction behaviors persist into residency. We randomly sampled 1800 third-year residents who graduated from 120 allopathic US-based medical schools, using the American Medical Association Physician Masterfile. We surveyed them in 2011 to determine self-reported behavior and preferences for brand-name prescriptions, and we calculated the strength of their medical schools' industry interaction policies using the 2008 American Medical Student Association and Institute on Medicine as a Profession databases. We used logistic regression to estimate the association between strength of school policies and residents' behaviors with adjustments for class size, postresidency career plan, and concern about medical school debt. We achieved a 44% survey response rate (n = 739). Residents who graduated from schools with restrictive policies were no more or less likely to accept industry gifts or industry-sponsored meals, speak with marketing representative about drug products, attend industry-sponsored lectures, or prefer brand-name medications than residents who graduated from schools with less restrictive policies. Residents who correctly answered evidence-based prescription questions were about 30% less likely to have attended industry-sponsored lectures (OR = 0.72, 95% CI 0.56-0.98). Any effect that medical school industry interaction policies had on insulating students from pharmaceutical marketing did not persist in the behavior of residents in our sample. This suggests that residency training environments are important in influencing behavior.

Gestão de Competências: Um Estudo Sobre a Percepção dos Representantes Farmacêuticos do Rio Grande do Sul

The objective of this article is to verify how representatives of the Brazilian pharmaceutical industry see their competence management, as well as analyzing opinions and needs about the training offered to them by those companies. The theory and methodology utilized in this article refers to both national and international literature covering business administration, and the quantitative and qualitative data was collected from 100 surveys which were applied to pharmaceutical representatives from Rio Grande do Sul, compiled with two softwares: SPSS and Excel. The results indicate that the perception of pharmaceutical representatives about competences is related to factors that contribute directly to their work and are present more frequently, in order of importance: knowledge, pro-activity, compromise, productivity, organization, motivation and optimism. Regarding soft and hard competencies, the representatives favour mainly hard competencies. The training offered by the companies is considered essential to achieve better performance at work despite being mass-implemented nowadays, only 15% of the subjects answered that a good salesman does not need training and 13% believe that training is not capable of turning any person into a high performance salesperson.

Perceptions and Attitudes of Egyptian Health Professionals and Policy-Makers towards Pharmaceutical Sales Representatives and Other Promotional Activities.

BackgroundPharmaceutical promotion activities in low and middle-income countries are often neither regulated nor monitored. While Egypt has the highest population and per capita use of medicines in the Arab world, we know very little about pharmaceutical companies promotional activities in the country.AimTo explore and analyze the perceptions of physicians towards promotional and marketing activities of pharmaceutical companies among physicians and pharmacists in Egypt.MethodologyPerspectives of different healthcare system stakeholders were explored through semi-structured, in-depth interviews conducted in 2014 in Cairo, Egypt. Interviewees were chosen via purposive sampling and snowball technique. Each interview was recorded and transcribed. Then qualitative, thematic analysis was conducted with the help of NVIVO software.FindingsThe majority of physicians and pharmacists acknowledged exposure to pharmaceutical promotion. It was commonly believed that interaction with the pharmaceutical industry is necessary and both associated risks and benefits were acknowledged. The interviewed physicians considered themselves competent enough to minimize risks and maximize benefits to their prescribing habits. Views diverged on the extent and magnitude of the risks and benefits of pharmaceutical promotion, especially in regard to the influence on patients’ health.ConclusionsPharmaceutical promotion in Egypt is intensely directed at prescribers and dispensers. Physicians, pharmacists and policymakers expressed little skepticism to the influence of promotion towards their individual prescribing. Raising awareness of the pitfalls of pharmaceutical promotion is necessary, especially among the less experienced physicians.

Dangerous liaisons: doctors-in-training and the pharmaceutical industry.

Interaction between doctors and the pharmaceutical industry is long-standing and ingrained in modern practice. Doctors-in-training are at a vulnerable stage of their careers, both in requiring knowledge and forming lasting relationships. There is evidence that limiting contact between industry and junior doctors has a positive effect on subsequent clinical behaviour. Currently in Australia, there is no limitation on pharmaceutical representatives approaching doctors-in-training, and the majority of education sessions are sponsored by pharmaceutical companies. This purposefully creates a sense of reciprocity, which may have adverse long-term consequences on attitudes, behaviours and patient care. Several guidelines exist that may assist junior doctors in navigating these potential interactions, most notably the Royal Australasian College of Physicians' own Guidelines for Ethical Relationships between Physicians and Industry. Despite this, there is no reflection of its importance or necessity within subspecialty curricula. This should be rectified, to the benefit of both the profession and public.

Risk factors for potentially inappropriate prescribing to older patients in primary care

The aim of this study is to determine modifiable risk factors contributing to potentially inappropriate prescribing in older primary care outpatients (≥65years). Two separate, age- and sex-matched case-control studies were carried out simultaneously at the Primary Health Care Center Kragujevac, Serbia, during the period September 2013-September 2014. The cases were defined as patients with at least one prescription for potentially inappropriate medication (PIM) according to Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) criteria (n = 122), and patients who had at least one potential prescribing omission (PPO) listed in Screening Tool to Alert doctors to the Right Treatment (START) criteria (n = 108), while the control groups consisted of patients without such outcomes (n = 244 and n = 216, respectively). A total of 138 PIM and 161 PPO events were identified using 26 (41.3%) of STOPP criteria and 17 (77.3%) of START indicators, respectively. The unhealthy behaviors including at least two of the following: sedentary lifestyle, improper nutrition, active smoking or heavy alcohol consumption (adjusted OR 2.57, 95% CI 1.28-5.20), use of multiple drugs (five to eight drugs, adjusted OR 3.05, 95% CI 1.59-5.85; ≥9 of drugs adjusted OR 7.17, 95% CI 3.07-16.74) and frequent contacts between patients chosen general practitioners (GPs) and pharmaceutical sales representatives (adjusted OR 2.28, 95% CI 1.10-4.75), were identified as major risk factors for PIM use. Patients who were handled by GPs from smaller practices (adjusted OR 0.51, 95% CI 0.29-0.93), those with more organ systems affected by the extremely severe disorders and those who often visited the outpatient specialist services (adjusted OR 0.88, 95% CI 0.81-0.95), had a significantly reduced risk of PPO. This study suggests that avoidance of major polypharmacy, use of nonpharmacological measures to improve lifestyle habits and decreasing the exposure of physicians to drug promotional material may reduce the risk of PIM use in older primary care outpatients. The only modifiable protective factors for PPOs were working environment of the patients chosen GPs and more frequent ambulatory visits to specialists.