Prescribing Benefit, Risk to Drug Sales Reps

Fewer pharmaceutical sales representatives try to knock on cardiologists’ doors than in the past, and those who do find access to physicians may be more restricted. Some researchers argue that limiting drug reps’ access potentially deprives physicians of important medical information. Others say that physicians may be more susceptible to marketing manipulation than they realize.

A succession of blockbuster drugs such as Lipitor (atorvastatin) going off patent has prompted big pharma to trim its sales forces substantially, according to ZS Associates. A consulting firm that focuses on sales and marketing, ZS Associates estimates that the number of pharma sales representatives in the U.S. has decreased by 45 percent over the past five years, from roughly 107,000 to 65,000.

The downsizing corresponds with another industry trend: Reps are more likely to get a frosty reception from harried physicians and from medical institutions, many of which have cracked down on physician-industry interactions. “Over the years, there has been a trend of fewer products to talk about from a branded perspective. Also, the physicians have pushed back as their workload increased,” says Pratap Khedkar, PhD, a managing principal at ZS Associates who handles the company’s global pharmaceuticals practice.  

Cardiology is one of the most restricted specialties, according to ZS Associates, which found that 47 percent of cardiologists are restricted or severely restricted to drug reps’ access in its spring AccessMonitor report. The only specialty that posted higher hurdles was oncology, at 61 percent. Among physicians overall, restricted and severely restricted access totaled 35 percent. The call data were collected from drug reps’ records of doctor visits, which pharmaceutical companies are mandated to track.

In 2008, cardiologist accessibility hovered near 85 percent but dipped to 53 percent by 2012. “Typically, when restricted accessibility trends up, there is some kind of ban on reps in an integrated network that owns the practice,” Khedkar says.

Value proposition

But is that bad? George A. Chressanthis, PhD, of the department of risk, insurance and healthcare management at Temple University in Philadelphia, answers “yes.” A former senior director of commercial strategic analysis for AstraZeneca Pharmaceuticals, he says pharma personnel provide physicians with pertinent and timely information about the drugs they sell. And he backs that with research.

“Our hypothesis was that when you restrict the market for medical information—and especially when you restrict a relevant channel for information, as sales representatives are for many physicians—unintended consequences will occur,” he says. “The effects should work more on those physicians who are less knowledgeable about what is going on.”

Chressanthis, Khedkar and colleagues designed a study to evaluate drug reps’ influence on physician prescription decision making in three different scenarios: the launch of sitagliptin (Januvia, Merck), a then-new drug for treating type 2 diabetes; rosiglitazone (Avandia, GlaxoSmith Kline) an older diabetes drug with an FDA black-box warning for cardiovascular safety; and a simvastatin/ezetimbe (Vytorin, Merck) combination for lowering low-density lipoprotein cholesterol that had a negative outcome in the ENHANCE trial (J Clin Hypertens, online May 2012). Using AccessMonitor data on visits of drug representatives to physicians and prescription data from IMS Health, they measured physicians’ clinical responses to the positive and negative medical information.

They found that physicians with low access to sales reps were the slowest to adopt the newest drug, sitagliptin, taking 1.4 and 4.6 times longer than physicians with low and medium access restrictions. They also were slower to change prescriptions on rosiglitazone, a drug with a black-box warning. But access limits had a lesser effect with cardiologists. In both these scenarios, cardiologists were quicker to incorporate sitagliptin into patient care and discontinue rosiglitazone than were primary care physicians (PCPs).

“Access limits had an asymmetric effect,” Chressanthis says. Given the spectrum of conditions in the patients whom PCPs see, it may be difficult for them to remain current on all aspects of care. Cardiologists, on the other hand, may use resources such as specialty journals.  

Docs are human, too

“Drug representatives are in the business to sell and promote, but the messages are FDA approved,” Chressanthis points out. Harlan M. Krumholz, MD, director of Yale-New Haven Hospital’s Center for Outcomes Research and Evaluation in New Haven, Conn., concurs that while communication is overseen by the FDA, “within those restrictions there is a lot of wiggle room in how the evidence is presented.”

People tend to evaluate information selectively, depending on how it affects them, psychologists have observed. Based on research by George F. Loewenstein, PhD, physicians are not exempt from these biases.

Loewenstein, of the department of social and decision sciences at Carnegie Mellon University in Pittsburgh, and colleagues evaluated how biased physicians might be when confronted with two almost identical conflict of interest policies (J Law Med Ethics, online July 2012). One set of physicians was randomized to take a survey about a conflict of interest policy on relationships between physicians and the pharmaceutical industry. Another set was randomized to the same survey, except “financial planner” was substituted for “physician” and “financial companies” for “pharmaceutical companies.”

They recruited and randomized financial planners in a similar fashion, and used a sample of New York Times blog readers as a control. Physicians given the physician conflict of interest policy evaluated it negatively and physicians who read the financial planners’ policy supported the policy. The control group was positive about both policies.

“It is a classic case of motivated bias,” Loewenstein says.

His previous work has shown that physicians, when reminded about the hardships they endured as medical students, rationalized that a gift from a pharmaceutical company is acceptable. (JAMA 2010;304[(11]:1204-1211). In one study that presented gynecologists and obstetricians with results from a hypothetical clinical trial, physicians reported that they should discount information from conflicted sources, but the findings showed that they did not (J Med Ethics 2010;36:265-270). Those who reported relying on pharma reps “often” or “almost always” when making decisions about drug prescriptions were less likely to consider conflicts of interest.

“Pharmaceutical representatives are not an unbiased source of information,” Loewenstein says. “They tend to selectively convey information that is favorable to the drugs made by their employers.”

The future for pharmaceutical sales reps is in flux, according to Khedkar. Chressanthis speculates that physicians may favor getting drug information online as access to digital sources becomes easier. Khedkar observes that the pharma industry itself has undergone a sea change once it realized that past practices such as sending multiple reps to visit the same physician were inefficient and annoying. Many companies now assign only one or two sales representatives per product to a physician. Krumholz observes that pharma increasingly is targeting larger purchasers rather than individual physicians.

Khedkar adds that it is not always physicians who stiff-arm drug reps. Institutional policies also come into play. “Some of this access restriction may continue to grow, but at a slower pace than in the past,” he projects. “It may stabilize.”