Original Research

One practice’s experiment in refusing detail rep visits

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The analysis of participant responses was organized into 6 themes:

  1. patient flow impact
  2. detailing influence on prescribing
  3. appropriate use and availability of therapeutically important medications
  4. relevance of information provided by a pharmaceutical representative
  5. value of detailer visits
  6. patient and public response.

Patient flow impact
Study participants agreed that not seeing pharmaceutical representatives improved patient flow, and they viewed this lack of interruption from detailers positively.

It’s nice not to have all the interruptions. We have enough interruptions without having to get a signature from a doctor here or try and talk them into spending 5 or 10 minutes with this rep.—(Clinic nurse)

Certainly our work flow is easier. I don’t have my office nurse coming to me saying, “You have to go to talk to this drug rep.” I can go through my day without being interrupted that way. There are already plenty of interruptions. That’s not a necessary one.—(Clinic MD)

Influence on prescribing
All interviewees, particularly the physicians, viewed pharmaceutical detailing as a negative influence on clinical prescribing. This was a major reason for the change in policy. Such influences included receiving information of questionable veracity or objectivity; prescribing sampled medications unnecessarily; choosing sampled drugs because of convenience; and possibly making unethical decisions under the sway of representative gifting.

I think we’d all like to think that the presence of the drug reps doesn’t affect the way we prescribe, but they wouldn’t be here if it didn’t.—(Clinic MD)

Not having the sample cabinet…forces me to prescribe more on cost and efficacy than on what is in the sample cabinet.—(Clinic MD)

Appropriate use and availability of therapeutically important medications
Interviewees noted that sample medications offered by drug detailers were often of questionable benefit.

Samples we had were not necessarily the medicines we’d use first line. If you…start [a person with hypertension] on any medicine that’s in your sample cabinet, you’re not practicing good medicine…what you have is…expensive brand- name medicines that shouldn’t be first line, drive up costs, are not more effective, and possibly [have more adverse effects].—(Clinic MD)

For the most part I don’t see [samples as positively] impacting patients’ care at all. …We had a cupboard full of samples but nothing that was real useful in most cases.—(Clinic nurse)

Some respondents indicated that when they looked in the sample cabinet, the medications there were not what they were looking for. This was a source of frustration. It was also noted that often the samples were not being dispensed to patients but were being used by clinic personnel and their families.

The most valuable elements were samples, so our husbands didn’t have to buy Lipitor.—(Clinic nurse)

A lot of our samples were used by our staff and some of our physicians. I know cholesterol medicines in particular, PPIs, some antidepressants.…—(Clinic MD)

Relevance of information provided by pharmaceutical representative
The physicians viewed the information distributed by pharmaceutical representatives as, at best incomplete, and, at worst, misleading.

The straw that broke the camel’s back around here was Vioxx. We were heavily detailed on Vioxx…and you know, the study that was designed to look at GI side effects—do COX-2 inhibitors have less GI risk than other NSAIDS?—found that it caused heart attacks instead. …We’d been talking about this [policy] before Vioxx, but Vioxx brought it full front.—(Clinic MD)

Staff members, though initially less enthusiastic, grew to understand the policy, embrace the philosophy, and take pride in the clinic’s stance on pharmaceutical detailing.

The philosophy of the physicians led to policy. The philosophy is, “Let’s get our information from sources that don’t have anything to gain from their reports. Let’s try to bring down the cost of drugs.” It’s not necessarily to the patient’s advantage to be given samples of the most expensive drug on the market.—(Clinic nurse)

Value of detailer visits
The study subjects did not see the value of pharmaceutical detailing other than the periodic industry-sponsored lunches. The nurses, in particular, enjoyed this perk and viewed it as important social time for clinic employees to interact outside of the clinical environment. Interviewees further noted that the physicians seldom attended these lunches, as they were busy with other tasks.

Staff liked the lunches. It was a nice treat for them. When we started [the policy change], we provided a once-a-month “pharm-free” lunch…still fun, social interaction…paid out of clinic funds.—(Clinic MD)

Now that we’ve adjusted to it, we’re pretty happy with it. Part of it was once per month someone would bring us lunch. …Rather than educational for us, it was a social gathering. So the doctors now provide a once-a-month employee lunch.—(Clinic nurse)

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