Various pills (Photo credit: Wikipedia)  Can cutting off doctors’ access to drug company sales representatives actually make patients more likely to receive a prescription for a dangerous or ineffective drug?  That’s the provocative conclusion from a paper published in the Journal of Clinical Hypertension last month. By itself, the paper doesn’t represent a defense of drug company sales forces, which are frequently blamed for fomenting the overuse of heavily advertised pills. But it does raise questions about how doctors will get information at a time when companies are making fewer sales calls and when 80% of medicines are generic, meaning there is neither a pharmaceutical company promoting the medicine nor one trying to badmouth it to get market share.  Less than a decade ago, there was one pharmaceutical salesperson for every 9 doctors; that’s no longer seen as acceptable to either society or drug company balance sheets. The question is how doctors will get information about drugs in this new world.  Caveats: ZS Associates, which helped conduct the study and collect the prescription data, is a consulting firm which advises drug companies on their sales practices. George Chressanthis at Temple University, the lead author of the study, is a former employee of AstraZeneca, which also funded the trial. The data can’t establish cause and effect.  Chressanthis and the folks at ZS looked at three different news events: the marketing launch of Januvia, a first-in-class diabetes pill, by Merck; the release of a study that showed that Merck’s Vytorin had no more impact on ultrasound measures of heart-attack-causing atherosclerosis than the older generic Zocor; and the news that Avandia, a GlaxoSmithKline diabetes pill, was linked to a higher risk of heart attacks.  An increasing number of doctors don’t see sales reps, either because their hospitals or universities ban sales calls or because they don’t think it’s worth the time. The authors of the study compared the prescribing behavior of high-access doctors, who see a lot of reps, to low-access doctors, who rarely are visited by salespeople. Patients of high access doctors were more likely to get Januvia, but less likely to have their Vytorin and Avandia stopped quickly.  I asked Pratap Khedkar, of ZS, to help me find a way to present the data more clearly. New cuts of the raw data follow; for the adjusted analyses, refer to the paper.  For Januvia, 44,120 doctors with “high access” to sales reps wrote a prescription for the drug 8.2% the time when they were writing for a diabetes drug. Their adoption rate (the speed at which they started writing Januvia scripts) increased 1 percentage point every four months. The 1,667 docs with “very low access” wrote just 3.3% of anti-diabetic prescriptions for Januvia, and their adoption rate was much slower, increasing just 1 percent in 9.3 months. A patient seeing a “very low access” doctor was 60% less likely to get Januvia than one who is seeing a “high access” doctor.  That’s just evidence that salesmanship works. But let’s look at Vytorin, where the new issue was a question of whether the drug was as effective at preventing heart attacks as other, more thoroughly studied products.  The Vytorin example is interesting because there were no new marketing claims being made about the product. The new data weren’t officially in the drug’s FDA-approved packaging, and sales reps for Merck would have had no reason to advertise them – although it’s possible rivals at Pfizer (maker of Lipitor) and AstraZeneca (maker of Crestor) were making the results known.
One study shows that decreasing access to sales representatives can lead to slower reductions in the use of risky of ineffective drugs.