Clinical Review

Effect of In-Office Samples on Dermatologists’ Prescribing Habits: A Retrospective Review

Author and Disclosure Information

The relationship between physicians and pharmaceutical companies has caused the medical community to question the degree to which pharmaceutical interactions and incentives can influence physicians’ prescribing habits. Our study aimed to analyze whether a change in institutional policy that restricted the availability of in-office samples for patients resulted in any measurable change in the prescribing habits of faculty physicians in the Department of Dermatology & Cutaneous Surgery at the University of South Florida (USF)(Tampa, Florida). Medical records were retrospectively reviewed for common dermatology diagnoses—acne vulgaris, atopic dermatitis, onychomycosis, psoriasis, and rosacea—before and after the pharmaceutical policy changes, and the prescribed medications were recorded. These medications were then categorized as brand name, generic, and over-the-counter (OTC). Statistical analysis using a mixed effects ordinal logistic regression model accounting for baseline patient characteristics was conducted to determine if a difference in prescribing habits occurred.

Practice Points

  • There has been growing concern that pharmaceutical interactions and incentives can influence physicians’ prescribing habits.
  • Many academic centers have adopted policies that attempt to limit the pharmaceutical industry’s influence on faculty and in-training physicians.
  • This study aimed to investigate if there was a change in the prescribing habits of academic dermatologists after the medical school implemented new policies that banned in-office samples.


 

References

Over the years, there has been growing concern about the relationship between physicians and pharmaceutical companies. Many studies have demonstrated that pharmaceutical interactions and incentives can influence physicians’ prescribing habits.1-3 As a result, many academic centers have adopted policies that attempt to limit the pharmaceutical industry’s influence on faculty and in-training physicians. Although these policies can vary greatly, they generally limit access of pharmaceutical representatives to providers and restrict pharmaceutical samples.4,5 This policy shift has even been reported in private practice.6

At the heart of the matter is the question: What really influences physicians to write a prescription for a particular medication? Is it cost, efficacy, or representatives pushing a product? Prior studies illustrate that generic medications are equivalent to their brand-name counterparts. In fact, current regulations require no more than 5% to 7% difference in bioequivalence.7-9 Although most generic medications are bioequivalent, it may not be universal.10

Garrison and Levin11 distributed a survey to US-based prescribers in family practice, psychiatry, and internal medicine and found that prescribers deemed patient response and success as the highest priority when determining which drugs to prescribe. In contrast, drug representatives and free samples only slightly contributed.11 Considering the minimum duration for efficacy of a medication such as an antidepressant vs a topical steroid, this pattern may differ with samples in dermatologic settings. Interestingly, another survey concluded that samples were associated with “sticky” prescribing habits, noting that physicians would prescribe a brand-name medication after using a sample, despite increased cost to the patient.12 Further, it has been suggested that recipients of free samples may experience increased costs in the long run, which contrasts a stated goal of affordability to patients.12,13

Physician interaction with pharmaceutical companies begins as early as medical school,14 with physicians reporting interactions as often as 4 times each month.14-18 Interactions can include meetings with pharmaceutical representatives, sponsored meals, gifts, continuing medical education sponsorship, funding for travel, pharmaceutical representative speakers, research funding, and drug samples.3

A 2014 study reported that prescribing habits are influenced by the free drug samples provided by nongeneric pharmaceutical companies.19 Nationally, the number of brand-name and branded generic medications constitute 79% of prescriptions, yet together they only comprise 17% of medications prescribed at an academic medical clinic that does not provide samples. The number of medications with samples being prescribed by dermatologists increased by 15% over 9 years, which may correlate with the wider availability of medication samples, more specifically an increase in branded generic samples.19 This potential interaction is the reason why institutions question the current influence of pharmaceutical companies. Samples may appear convenient, allowing a patient to test the medication prior to committing; however, with brand-name samples being provided to the physician, he/she may become more inclined to prescribe the branded medication.12,15,19-22 Because brand-name medications are more expensive than generic medications, this practice can increase the cost of health care.13 One study found that over 1 year, the overuse of nongeneric medications led to a loss of potential savings throughout 49 states, equating to $229 million just through Medicaid; interestingly, it was noted that in some states, a maximum reimbursement is set by Medicaid, regardless of whether the generic or branded medication is dispensed. The authors also noted variability in the potential savings by state, which may be a function of the state-by-state maximum reimbursements for certain medications.23 Another study on oral combination medications estimated Medicare spending on branded drugs relative to the cost if generic combinations had been purchased instead. This study examined branded medications for which the active components were available as over-the-counter (OTC), generic, or same-class generic, and the authors estimated that $925 million could have been saved in 2016 by purchasing a generic substitute.24 The overuse of nongeneric medications when generic alternatives are available becomes an issue that not only financially impacts patients but all taxpayers. However, this pattern may differ if limited only to dermatologic medications, which was not the focus of the prior studies.

To limit conflicts of interest in interactions with the pharmaceutical, medical device, and biotechnology industries, the University of South Florida (USF) Morsani College of Medicine (COM)(Tampa, Florida) implemented its own set of regulations that eliminated in-office pharmaceutical samples, in addition to other restrictions. This study aimed to investigate if there was a change in the prescribing habits of academic dermatologists after their medical school implemented these new policies.

We hypothesized that the number of brand-name drugs prescribed by physicians in the Department of Dermatology & Cutaneous Surgery would change following USF Morsani COM pharmaceutical policy changes. We sought to determine how physician prescribing practices within the Department of Dermatology & Cutaneous Surgery changed following USF Morsani COM pharmaceutical policy changes.

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