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358 nwww.ajc.con DECEmbEr 2010

n trends from the field n

Managed Care &Healthcare Communications, LLC

Pesciptive decision aking is a coplex pocess inuenced

y othe actos in addition to scientifc knowledge. Studies 1-3

docuent that physicians pesciing decisions ae aected

y actos such as patients equests o edications and phaaceuti-

cal copany pootions (ie, gits, eals, and continuing education

pogas), diect-to-consue advetising, and oulay estictions.

Fewe investigations have addessed the inuence o phaaceutical

pootions on nuse pactitione (NP) pesciing. Studies1,4-6 that

have done so indicate that NPs have positive attitudes towad pha-

aceutical aketing eots, do not elieve that inteactions with

epesentatives o industy aect thei pesciing decisions, and

deonstate high pesciing ates o heavily pooted and-nae

antiiotics.

These esults ae consistent with the liteatue on physicians pesciing

pactices, which docuent that physicians do not elieve that pootional

eots aect thei pesonal pesciing and that oe contact with indus-

ty epesentatives inceases thei likelihood o (1) pesciing and-nae

dugs ove lowe-cost geneics, (2) equesting that a copanys dug e

added to the hospital oulay, and (3) dispensing oe dug saples.3,7,8

Copaale data on NP pesciptive ehavios ae lacking. This death

o data is stiking consideing that thee ae oe than 150,000 NPs, sig-

nifcantly oe than the estiated 100,000 aily physicians in the Unit-

ed States.9,10 Nuse pactitiones ae authoized to pescie in all 50 states

and the Distict o Coluia. by 2015, thee will e oe than 190,000

advanced pactice nuse pescies (cetifed nuse idwives, psychiatic/

ental health clinical nuse specialists, and NPs).11 Alost 97% o NPs

pescie edications, and each pescie wites, on aveage, etween19 and 25 pesciptions a day, o appoxiately 6200 pesciptions pe

NP pescie pe yea.12 In the aggegate, this tanslates into illions o

pesciptions pe yea, epesenting a sustantial potion o the edica-

tions dispensed in the United States. Consequently, these data highlight

the need o a new ocus on NP pescies. The ojectives o this study

wee to suvey a nationally epesentative saple o NP pe-

scies, to assess thei peceptions o

phaaceutical industy pootional

activities, and to identiy thei elies

aout aketing inuences on thei

pesciing ehavios.

In this issue

Take-Away Points / e359 Web Exclusive

www.ajmc.com

Unde the rada: Nuse Pactitione Pescies andPhaaceutical Industy Pootions

Elssa C. Ladd, PD, RN, FNP-BC; Dane Feeney Maney, PD, APRN, BC, FGSA, FAAN;

and Srnvas Eman, PD

Objectives: To assess nurse practitioners interac-

tions with pharmaceutical industry promotional

activities and their perception o inormation reli-

ability and sel-reported prescribing behaviors.

Study Design: Sel-administered online survey.

Methods: A nationally randomized sample o

nurse practitioner prescribers was surveyed. Eligi-

bility criteria included current clinical practice and

licensure to prescribe medications in their state

o practice.

Results: A total o 263 responses were analyzed.

Almost all respondents (96%) reported regular

contact with pharmaceutical sales representa-

tives, and most (71%) reported receiving inorma-

tion on new drugs directly rom pharmaceutical

sales representatives some or most o the time.

A large portion (66%) dispensed drug samples

regularly to their patients, and 73% believed that

samples were somewhat or very helpul in learn-

ing about new drugs. Eighty-one percent o re-

spondents thought that it was ethically acceptable

to give out samples to anyone, and 90% believedthat it was acceptable to attend lunch and dinner

events sponsored by the pharmaceutical industry.

Almost hal (48%) stated that they were more

likely to prescribe a drug that was highlighted

during a lunch or dinner event. Most respondents

stated that it was ethically acceptable or speakers

to be paid by industry.

Conclusions: Nurse practitioner prescribers had

extensive contact with pharmaceutical industry

promotional activities such as pharmaceutical

representative contact, receipt o drug samples,

and regular attendance at industry-sponsored

meal events and continuing education programs.

They reported that industry interace with nurse

practitioner prescribers in the orm o sponsored

meals, education events, and paid speakers was

ethically acceptable.

(Am J Manag Care. 2010;16(12):e358-e362)

For author information and disclosures,see end of text.


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VOL. 16, NO. 12 nTHE AmErICAN JOUrNAL OF mANAGED CArEn 359

nu Pac Pcb a Paacuca iuy P

MEthoDS

Study Population

The suvey was conducted o

Novee 2007 to mach 2008 and

was appoved y the institutional e-

view oad o Spaulding rehailita-

tion Hospital, boston, massachusetts.

Paticipants wee ecuited o a na-

tional eeship list o the Aei-

can Acadey o Nuse Pactitiones,

the lagest poessional oganization o

NPs in the United States, with oe

than 28,000 ees. The Aeican Acadey o Nuse

Pactitiones used an autoated ando-nue poga to

geneate a andoized saple o 3000 ees. These e-

es eceived a lette y ail inviting the to paticipate y

logging on to the study site. They wee sceened o eligiility,

cuent NP licensue, state authoization to pescie, and ac-

tive NP pactice. On copletion o the suvey, paticipants

eceived a $50 git cetifcate. O 309 espondents who ageed

to paticipate, 12 wee ineligile, and 34 did not coplete

the suvey, esulting in a fnal saple size o 263 NPs and a

paticipation ate o 9%.

Survey Design

The suvey was coposed o 50 ites copising a Lik-

et-type scale, yes o no questions, and scoed esponses. The

online plato allowed a paticipant to deteine the tie

ae o copleting the suvey.

Suvey questions investigated the ollowing 3 piay do-

ains o inteest: (1) pesciing pactices and ehavios and

inteace with industy, (2) peceived eliaility o inoa-

tion povided y the phaaceutical industy, and (3) ethical

acceptaility o pootional gits and eals. Study vaiales

included pootional gits and eals, the acceptance o in-

dusty-supplied ee saples, and equency o attendance at

industy-sponsoed continuing education events. Desciptive

analyses wee peoed to addess the study ojectives us-ing coecially availale statistical sotwae (SPSS vesion

15.0; SPSS Institute, Chicago, Illinois).

RESuLtS

Sample Characteristics

The study population was pedoinantly eale (88%) and

o white ace/ethnicity (94%), and 51% wee 45 yeas o olde.

most espondents (59%) had een in pactice longe than 3

yeas; 28% wee new gaduates o thei pogas (


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pesciptive authoity acoss the nation, they (like thei

physician colleagues) have ecoe ojects o phaaceuti-

cal pootions ecause o thei consideale potential to in-

cease dug sales. Ou fndings indicate that the acceptance o

gits o industy (ee eals ost equently) was coon

aong this NP saple. The paticipants geneally egaded

sponsoed eal events that coincided with lectues aout

dugs as a good way to eceive inoation aout new edi-

cines on the aket. This fnding aises a concen ecause the

espondents also noted that they wee oe likely to pescie

a highlighted dug ate attending an industy-sponsoed eal

event. These data uthe suppot evidence o the edical

and social science liteatue that giting o any kind, even o

sall ites such as pens, snacks, o eals, inuences pesci-

ing ehavios.13

Nuse pactitiones indicated consideale use o dug

saples o patient cae, which in othe investigations has

een shown to inuence pesciing decisions and to add u-

densoe costs to the healthcae syste.14 Nuse pactitiones

noted the need to dispense saples as a way to oset the high

cost o and-nae dugs, especially o thei uninsued and

undeinsued patients. Howeve, this stands in contast to a

ecent study15 deonstating that wealthie insued patients

ae oe likely to eceive dug saples than disadvantaged

patients.

Industy sponsoship o continuing edical education is

poleatic ecause o the inheent potential o popietay

ias.16 In concet with pio eseach on physician pesciing,

ou study deonstated that NP pescies ae inclined to

attend industy-sponsoed continuing education pogas on

a egula asis and, in so doing, ae consistently exposed to

potential aket iases. moeove, ost espondents elieved

that the inoation they eceived at industy-sponsoed con-

tinuing education events was eliale. These fndings ae o

paticula concen ecause industy sponsoship o continuing

education has een ound to avo poducts o the sponso-

ing copany, theey contiuting to inceased pesciptions

o the highlighted dug at the expense o othe nonphaa-

cologic theapies.

17

O note, industy unding o continuingedical education has inceased y oe than 300% etween

1998 and 2007, at a cost o oe than $1 illion, leading to

inceasing scutiny y poessional and legislative oganiza-

tions.18 Accoding to the Institute o medicines Redesigning

Continuing Education in the Health Professions,19 this unding

echanis aises seious questions aout conicts o inte-

est when continuing education pogas ae used to inuence

health poessionals and to incease aket shae.

The ecent passage o the Patient Potection and Aod-

ale Cae Act (healthcae eo), which includes so-called

sunshine povisions, ay have a signifcant eect on the in-

dusty-sponsoed eal events was a good-to-excellent way to

otain inoation aout new dugs, and 61% o espondents

epoted that the inoation was soewhat eliale. Ino-

ation eceived at eal events that also oeed continuing

education cedits was consideed at least soewhat (61%) o

vey (30%) eliale y ost NPs.

Ethical Acceptability of Promotional Giftsand Meals (Domain 3)

most espondents (81%) thought that it was acceptale

to give out dug saples to anyone (fgu 2). Even oe

espondents (90%) elieved that it was acceptale to attend

lunch and dinne events sponsoed y phaaceutical co-

panies, and 75% epoted that it was acceptale o a speake

to e paid y a phaaceutical copany. moeove, ost e-

spondents (61%) noted that the povision o sall gits and

eals to clinical ofces y phaaceutical copanies was an

acceptale pactice.

DiSCuSSioN

Like any o thei physician colleagues, NPs in this study

elieved that, despite equent inteactions with dug co-

pany epesentatives, they eained ojective in thei pe-

sciing pactices. most espondents thought that gits o

phaaceutical sales epesentatives had no eect on thei

likelihood to pescie a highlighted dug. Study fndings

also indicate that any espondents have egula contact

with phaaceutical sales epesentatives in pactice settings,

as well as at national eetings, sponsoed eal events, and

continuing education pogas. Indeed, as NPs have gained

100

90

80

70

60

50

40

30

20

10

0

% Of NPs

Regular

contact with

PRs

Received

information

on new drugs

from PRs

Samples

helpful in

learning about

new drugs

Attended

industry-

sponsored CE

in past 5 y

96 71 73 96

%

n Figure 1. Prescribing Practices and Behaviors and

Interace With Industry (Domain 1) Among 263

Respondents

CE ndcaes cnnng edcan; NPs, nrse pracners; PRs, parma-

cecal sales represenaves.


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VOL. 16, NO. 12 nTHE AmErICAN JOUrNAL OF mANAGED CArEn 361

nu Pac Pcb a Paacuca iuy P

teace o industy pootions and NP pesciing. Stating

in 2013, these povisions will equie phaaceutical and

edical device anuactues to epot all payents ade to

physician pescies o sevices and gits such as consulting

ees, honoaia, entetainent, ood, tavel, education, and

eseach.20 Howeve, the povisions apply only to physicians

o teaching hospitals. Theeoe, industy ay ediect poo-

tional activities towad NP and othe nonphysician pesci-

es ecause o the asence o epoting and othe constaints

o this population o pescies.

Ou analysis has soe liitations. The study had a low

esponse ate, aecting genealizaility o ou fndings. How-

eve, online suveys have een noted to have low esponse

ates, especially aong healthcae poessionals.21 Also, ou

esults deonstated convegent validity with othe copa-

ale NP eseach peoed duing the sae peiod elative

to esponse ate, educational level, clinical specialty, pactice

setting, and espondent sex.22

In conclusion, NPs have heetooe een opeating unde the

ada egading eseach and policy on the inuences o phaa-

ceutical aketing. Although the scope and extent o thei pe-

sciing activities have een less than ovious to consues and

to othe healthcae poessionals, the phaaceutical industy has

clealy taken notice. Accoding to the phaaceutical eseach

copany Veispan23 (now SDI, Plyouth meeting, Pennsylva-

nia), a 20% incease in aketing etween 2004 and 2006 was

diected to NPs and othe nonphysician pescies.This is stik-

ing consideing the sustantial nue o NPs and thei gowing

ole in the delivey o piay healthcae in the United States.

Theeoe, it is ipotant that all pescies, including NPs, have

access to uniased inoation that is not undewitten y in-

dusty. Futue eseach should assess inuences o evidence-ased

acadeically sponsoed continuing education pogas on NP

pescies elies and pactices.

Acknowledgments

We thank melissa maloney, mS, rN, and maion rideout, mS, rN, othei suppot with initial liteatue eview and data evaluation. We also thankD Anthony Guaino o his input on statistical content.

Author Afliations: Fo mGH Institute o Health Poessions, School

o Nusing (ECL, DFm), boston, mA; Depatent o Geneal medicine (SE),bigha & Woens Hospital, boston, mA; and Depatent o medicine(SE), Havad medical School, boston, mA.

Funding Source:This study was unded y the Attoney Geneal Con-sue and Pescie Gant Poga.

Author Disclosures: The authos (ECL, DFm, SE) epot no elationshipo fnancial inteest with any entity that would pose a conict o inteest withthe suject atte o this aticle.

Authorship Inormation:Concept and design (ECL, DFm); acquisitiono data (ECL); analysis and intepetation o data (ECL, DFm, SE); datingo the anuscipt (ECL, DFm, SE); citical evision o the anuscipt o i-potant intellectual content (ECL, DFm, SE); statistical analysis (DFm, SE);otaining unding (ECL); adinistative, technical, o logistic suppot (ECL);and supevision (ECL).

Address correspondence to: Elissa C. Ladd, PhD, rN, FNP-bC, mGH

Institute o Health Poessions School o Nusing, 36 Fist Ave, boston, mA02129. E-ail: [email protected].

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n Figure 2. Ethical Acceptability o Promotional Gits

and Meals (Domain 3) Among 263 Respondents

100

90

80

70

6050

40

30

20

10

0

% Of NPs

Acceptable

to give out

sample

medication

to anyone

Acceptable

to attend

sponsored

lunch or

dinner events

Acceptable

for speaker

to be paid by

industry

Acceptable

to receive

small gifts or

meals in

practice

81 90 75 61

%

CE ndcaes cnnng edcan; NPs, nrse pracners; PRs, parma-cecal sales represenaves.


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13. Katz D, Caplan AL, Mertz JF. All gits large and small: toward anunderstanding o the ethics o pharmaceutical industry git-giving. AmJ Bioeth. 2003;3(3):39-46.

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