Death of the Pharma Sales Rep?

We’re not feeling a whole load of Christmas cheer among the pharmaceutical industry this festive season.

First came the news that GSK is phasing out all payments to doctors and will no longer be bonusing their reps based on sales.  Now, a new study suggests the end of the road may be nigh for pharma sales reps.

According to a survey of nearly 3,000 physicians undertaken by CapGemini and QuantiaMD, when it comes to receiving clinical and medical info, reps rank last as a resource behind print, digital media and phone links.

• 67% of physicians say digital media is their preferred source of information from drug-makers
• 40%  believe digital media has the most relevant and personalized content
• 52% believe sales reps will eventually become information coordinators
• Only a paltry 20% say reps are their favorite source of information

In parallel, more health care providers are shifting toward larger, organized health systems, which make it more difficult for reps to reach physicians for visits. Sixty four  percent of those surveyed say they restrict rep visits and 31 % of physicians in organized health systems do not allow reps any access, due to corporate policies.

Newer and younger physicians are more likely to rebuff reps – as many as 80%  impose restrictions. 90% of new physicians are joining organized health systems right out of medical school.

“Physicians today are in a time crunch, juggling more commitments than ever before and no longer have the time to dedicate to in-person meetings with pharmaceutical representatives. So the reliance on more digital channels comes as no surprise,” said Dan Malloy, Senior Vice President at Quantia. “This study supports what we’re already seeing from our 200,000 members–that a physician-centric, digital communication model is the most effective way for reaching and engaging doctors.”

On a more positive note, reps slightly edge out other resources when it comes to finding product info and patient education.

Hala Qanadilo, a principal in life sciences at CapGemini says, “While the more traditional face-to-face, in-office visits might decrease, the role of these representatives is projected to be as important as ever. Moving forward, they will need them to be the directors of multiple information sources, customizing their outreach so it is more personalized and physician-centric.”

How are you tackling the changing healthcare environment in these increasingly restrictive times?  We’d love to hear from anyone out there in Pharmaland.

Pharma Under Fire for Fair Balance Failings

Uh oh! Seems like the Pharma industry is in trouble again.

Research published in the Journal of General Internal Medicine suggests that family physicians receive “little or no information” about adverse effects associated with medicines in the majority of drug promotions made by sales representatives.

In the study, 255 family doctors from urban practices in the US [Sacrameto], France [Tolouse] and Canada [Montreal and Vancouver] answered questionnaires following visits from sales representatives.  The primary outcome measure was “minimally adequate safety information” (mention of at least one indication, serious adverse event, common adverse event, and contraindication, and no unqualified safety claims or unapproved indications).

The findings showed that sales representatives did not provide any information about common or serious side effects, or identify the patients who should not be using the drug, in 59% of the promotions. In Canada, no potential side effects were mentioned for 66% of promoted products, according to the results.

The researchers also indicated that although 57% of the promoted drugs carried boxed warnings from the FDA or Health Canada, serious adverse events were only discussed in about 6% of the sales pitches.

Félicitations to the French reps who provided information on harm for 61% of the promotions, compared to only 34% in Canada and 39% in the US.

Despite this lack of “fair balance” overall, the doctors considered the quality of the scientific information to be good or excellent for 54% of the promotions and indicated that they would be willing to prescribe the drugs 64% of the time.

“Laws in all three countries require sales representatives to provide information on harm as well as benefits,” says lead author Barbara Mintzes, Assistant Professor at the University of British Colombia. “But no one is monitoring these visits and there are next to no sanctions for misleading or inaccurate promotion.”

Despite widespread belief by physicians to the contrary, the information provided by pharmaceutical sales representatives has been shown to influence prescribing. Greater exposure to promotion is associated with higher prescribing volume and costs.  And while regulations in all three countries require sales representatives to provide information on the risks as well as the benefits of their drugs, there are differences.  It’s interesting, to correlate the above results with the fact that that France has the strictest information standards, whereas Canada relies on industry self-regulation.

However, across all three countries, the results of this study would appear to question if current approaches are adequate to protect patient health.

The Pharma Industry should take note.  Time to clean up your act before the Government and Regulatory Authorities do it for you.

Does Your Doctor ‘Get You’?

Does your doctor understand you? Does he (or she) know what you’re thinking? Does he really feel your pain? In short, does he care?

Seems this is something you should really care about. According to a study just published in Academic Medicine, patients of doctors who are more empathic have better outcomes and fewer complications.

Researchers from Thomas Jefferson University together with a team from Parma, Italy evaluated relationships between physician empathy and clinical outcomes among 20,961 Italian diabetic patients and their 242 physicians.

The study was a follow up to a smaller one undertaken at Thomas Jefferson University that included 891 diabetic patients and 29 physicians, and showed that patients of physicians with high empathy scores had better clinical outcomes than patients of other physicians with lower scores.

“This new, large-scale research study has confirmed that empathic physician-patient relationships is an important factor in positive outcomes,” said Mohammadreza Hojat, Ph.D., Research Professor in the Department of Psychiatry and Human Behavior and the Director of Jefferson Longitudinal Study at the Center.  “It takes our hypothesis one step further. Compared to our initial study, it has a much larger number of patients and physicians, a different, tangible clinical outcome, hospital admission for acute metabolic complications, and a cross-cultural feature that will allow for generalization of the findings in different cultures, and different health care systems.”

The Italian researchers used the Jefferson Scale of Empathy (JSE) –an instrument used to measure empathy in the context of medical education and patient care. The JSE includes 20 items answered on a seven-point scale (strongly agree = 7, strongly disagree = 1) and measures understanding of patient’s concerns, pain, and suffering, and an intention to help.

The primary outcome measure of the study was acute metabolic complications, including hyperosmolar state, diabetic ketoacidosis, and diabetic coma. These were used because they require hospitalization, can develop quickly, and their prevention is more likely to be influenced by the primary care physicians.

A total of 123 patients were hospitalized because of such complications. Physicians with higher empathy levels had 29 : 7,224 patients admitted to the hospital, whereas physicians with lower levels had 42 : 6,434 patients admitted.

There are many factors that add to the strength of the study. Firstly, because of universal health care coverage in Italy, there is no confounding effect of difference in insurance, lack of insurance or financial barriers to access care.

“What’s more, this study was conducted in a health care system in which all residents enroll with a primary care physician resulting in a better defined relationship between the patients and their primary care physicians than what exists in the United States,” said co-author Daniel Z. Louis.

According to the Centers for Disease Control and Prevention, over 25 million people in the U.S. population have been diagnosed with diabetes, with almost 700,000 hospitalizations per year. There are approximately 2 million new cases per year. Worldwide, the number of total cases jumps to 180 million.

“Results of this study confirmed our hypothesis that a validated measure of physician empathy is significantly associated with the incidence of acute metabolic complications in diabetic patients, and provide the much-needed, additional empirical support for the beneficial effects of empathy in patient care” said Dr. Hojat. “These findings also support the recommendations of such professional organizations as the Association of American Medical Colleges and the American Board of Internal Medicine of the importance of assessing and enhancing empathic skills in undergraduate and graduate medical education.”

Does your doctor get you? Let us know.

SATS & CPR

Go Gov. Beverly Perdue!  SRxA’s Word on Health applauds the North Carolina Governor who has just passed a law requiring all high school students in the state to have basic emergency-response training before they can graduate.

Although high schools have been required to teach CPR since 1997, until now this has been unenforced.

But starting with the class of 2015, the bipartisan plan requires that schools teach American Red Cross or American Heart Association curriculum for cardiopulmonary resuscitation and obstructed airway treatment.

The new law comes as great news to Tracey Stell, assistant director of education services at Durham Regional Hospital.  “It melds wonderfully into Durham County’s strategic plan to increase the rate of bystander CPR and it’s really going to help people get more immediate care, which will make a difference in survival,” Stell said. “You shouldn’t have to wait for an ambulance to arrive for CPR to start. Man, that’s a huge win.”

The new law signed on Thursday joins another aimed at saving lives: a law requiring at least one defibrillator kit in every state building in North Carolina and training for state employees to use them.

North Carolina joins four other states that have signed CPR graduation requirements into law this year: Iowa, Alabama, Tennessee and Minnesota.

By making CPR as important as ABC’s, we hope the next generation of students will be better equipped to start college life and save the lives of others.

Could “No See” docs be doing a disservice to patients?

One of the biggest challenges facing any Pharma rep is the increasing number of  doctors who won’t see them. Every week, more and more physicians are restricting, and some even eliminating, their face time with sales reps.

In fact, the number of doctors willing to see reps has declined by about 20% since 2008.  And while some clinicians chose to do this, others have had it thrust upon them by their institutions or employers who are concerned that medical practice may be unduly influenced by pharmaceutical industry representatives.

Although  “no see” advocates argue that removing commercial influence is better for patients, a new study suggests the practice has downsides too.

This should be good news for the Pharma, who has always maintained that the clampdown on reps amounts to overkill and that more than selling, reps  provide information that can benefit patients.

The study, published in the Journal of Clinical Hypertension, divided medical practices into four categories. Based on the degree of sales representative access to clinicians, they were classified as either very low, low, medium, or high.

The clinical decisions, and prescribing behavior of over 72,000 physicians were then statistically analyzed, with regards to the drugs listed below:

• Januvia® (sitagliptin tablets) – an innovative drug for type 2 diabetes
• Avandia® (rosiglitazone) – an older diabetes drug with a new FDA–required black box warning for cardiovascular safety
• Vytorin® (simvastatin + ezetimbe) – a combination lipid-lowering therapy that had  negative outcomes in a clinical trial

The authors found that after the FDA approved Januvia, docs who had little interaction with reps took longer to write prescriptions than docs whose access to reps was not as restricted. Meanwhile, physicians who rarely, if ever, saw reps were slowest to change their prescribing habits after negative news emerged about Avandia and Vytorin .

Specifically, the study found that docs with very low access to reps had the lowest adoption rates for Januvia. They took between 1.6 and 4.6 times longer to start writing prescriptions after the pill was launched than docs who had low, medium or high access to reps. Docs who had very low access to reps were also 4 times slower than those of their counterparts to reduce their use of Avandia, after the Black Box warning was issued in 2007.  There was also “significantly less” change in the prescribing habits of those who had less access to reps in response to controversial and disappointing trial results released in 2008 for Vytorin, than those with fewer restrictions on rep interactions.

The study authors commented, “These findings emphasize that limiting access to pharmaceutical representatives can have the unintended effect of reducing appropriate responses to negative information about drugs just as much as responses to positive information about innovative drugs.”

George Chressanthis, professor of healthcare management and marketing, and acting director for the Center for Healthcare Research and Management at Temple University Fox School of Business, agrees.

“The study affirms simple intuition that when physicians have to make decisions involving complex issues with less than complete information available to them, and where the consequence of a wrong decision is significant… unintended consequences are likely to appear. Policies that promote physician ignorance of new medical information resulting from access limits, run counter to protecting patient health.”

Could increasing, rather than decreasing  sales representative access to physicians lead to better clinical decision making and better patient health? Let us know what you think.

Reckless Research Race, Results in Rising Retractions. Reform Required?

As our regular readers know, SRxA’s Word on Health loves nothing more than a good alliteration to start the day!  Although the blog post title may rank as one of our more classic tongue twisters, there is nothing amusing about the content.  As involved as we are in medical communications and peer-reviewed, scientific publishing, we are saddened to report on the rise of a recent trend of falsified research. An unsettling pattern is emerging. The rate at which articles are retracted (meaning the study was published, only to later be dubbed unfit for print — typically due to either deliberate misconduct or an honest scientific mistake) is increasing. To our knowledge, at least three scientific journals have published articles over the past two years warning of the rise in retractions and misconduct by researchers who have fudged results.

Last year Nature reported a tenfold increase in retractions over the past decade even though the number of published papers only increased by 44%. Before that, the Journal of Medical Ethics published a study in 2010 that said a rise in recent retractions was the fault of misconduct and “honest scientific mistakes.” It calculated that the number of retractions had more than tripled from 50 in 2005 to 180 in 2009.

The latest publication to highlight this issue is Infection and Immunity. In the fall of 2010, Dr. Ferric C. Fang, editor in chief of the journal made an unsettling discovery – one of his authors had doctored several papers. The journal wound up retracting six of the papers from the author, Naoki Mori of the University of the Ryukyus. It soon became clear that Infection and Immunity was hardly the only victim of Dr. Mori’s misconduct. Since then, according to the blog Retraction Watch, other scientific journals, including the International Journal of Cancer  have retracted another 24 of his papers. This was a new experience for Fang. Prior to this incident Infection and Immunity had only retracted nine articles over a 40-year period. “Nobody had noticed the whole thing was rotten,” said Fang, a professor at the University of Washington School of Medicine. Dr. Fang became curious how far the rot extended. To find out, he teamed up with a fellow editor at the journal, and before long they reached a troubling conclusion: not only that retractions were rising at an alarming rate, but that retractions were just a manifestation of a much more profound problem.

Dr. Fang’s colleague, Dr. Arturo Casadevall, said he feared that science had turned into a winner-take-all game with perverse incentives that led scientists to cut corners and, in some cases, commit acts of misconduct. Last month, in a pair of editorials in Infection and Immunity, the two editors issued a plea for fundamental reforms. While no one claims that science was ever free of misconduct or bad research, the new raft of retractions appears to be a mix of misconduct and honest scientific mistakes. Several factors are at play here, scientists say. One may be that because journals are now online, bad papers are simply reaching a wider audience, making it more likely that errors will be spotted. But other forces are more pernicious. To survive professionally, scientists feel the need to publish as many papers as possible, and to get them into high-profile journals. And sometimes they cut corners or even commit misconduct to get there. To measure this claim, Drs. Fang and Casadevall looked at the rate of retractions in 17 journals from 2001 to 2010 and compared it with the journals’ “impact factor,”  – a score based on how often their papers are cited by scientists. The higher a journal’s impact factor, the higher its retraction rate. The highest “retraction index” in the study went to one of the world’s leading medical journals, The New England Journal of Medicine.

The scramble to publish in high-impact journals may be leading to more and more errors. Each year, every laboratory produces a new crop of Ph.D.s, who must compete for a small number of jobs, and the competition is getting fiercer. In 1973, more than half of biologists had a tenure-track job within six years of getting a Ph.D. By 2006 the figure was down to 15 percent. In such an environment, a high-profile paper can mean the difference between a career in science or leaving the field. The scramble isn’t over once young scientists get a job. “What people do is they count papers, and they look at the prestige of the journal in which the research is published, and they see how many grant dollars scientists have, and if they don’t have funding, they don’t get promoted,” Dr. Fang said. “It’s not about the quality of the research.”

With all this pressure on scientists, they may lack the extra time to check their own research. Instead, they have to be concerned about publishing papers before someone else publishes the same results. Adding to the pressure, thousands of new Ph.D. scientists are coming out of China and India, countries that offer cash rewards to scientists who get papers into high-profile journals. Dr. Fang worries that the situation could be become much worse if nothing happens soon. To change the system, Fang and Casadevall say graduate students need a better understanding of science’s ground rules. They would also move away from the winner-take-all system, in which grants are concentrated among a small fraction of scientists by putting a cap on the grants any one lab can receive. A little bit of old fashioned honesty wouldn’t hurt either!

Doctors don’t care if patients take their medicine

When SRxA’s Word on Health read the above title from fellow healthcare blogger Lucy Pyne, we were intrigued.

Could this be true?   Citing a 2008 study entitled “Just What the Doctor Ordered,” she argues that physicians don’t consider adherence to be their primary responsibility and seriously underestimate the incidence of non-adherence, often thinking that they are unable to address the issue themselves. Instead, they believe that patients are responsible for their own adherence.

Could this be right? When prescribing new or different medication regimens, physicians spend most of the time explaining the purpose and side effects of the drug and sometimes how to take it. Less, and often no time, is spent on consequences of non-adherence, potential interactions, and refills. And in today’s high-volume pharmacy environment,  busy check-outs, drive-thrus, internet pharmacies and home delivery services in-depth pharmacist-to-patient counseling on the safe use of medication is no longer the norm.

Does it matter anyway? There’s plenty of research out there to show that the average patient forgets about half the information provided 15 minutes after meeting with a doctor. Studies also show that patients remember more about diagnosis than the details of treatment.

Hell, Yeah, it does! As a result patients are not being treated properly and the health industry is losing hundreds of millions in revenue. Adherence does matter, and it needs to matter more. There’s an abundance of reasons why patients don’t adhere to their medication. A fear of it harming rather than helping is particularly common.  No surprise then that the most frequently used health-related Google search term is ‘drug side effects.’ And while much of the information on the Internet is accurate, much of it isn’t, requiring healthcare professionals to rebut false information and deliver accurate instructions.

So, what are the options? According to Pyne, the pharma industry must review its approach to marketing. In order to maximize sales and overcome the dangerous consequences of patient non-adherence, the issue of non-adherence cannot be ignored for much longer.  Something needs to change. The simple truth is, drugs don’t work if patients don’t take them. SRxA can help industry address and solve their adherence problems. We have developed a number of unique programs that not only improve medication usage and prescription refills, but deliver better health and reduced costs. Contact us today to learn more.

iPads replace books at Weill Cornell

A month ago SRxA’s Word on Health reported that most doctors are not impressed with iPad wielding pharma reps.  However, it seems, this may be set to change.

Starting this fall, all first and second-year students at Weill Cornell Medical College will be provided with a new iPad 2 in place of the printed course notes and texts used by most students around the country.

With a  wealth of medical information and educational tools at their fingertips Cornell medical students will now be able to download course materials, see video or hear audio recordings of lectures, submit electronic course evaluations, access their grades, collaborate with other students, and save their notes and coursework.

“I am very proud that Weill Cornell is one of the first medical colleges in the country to embrace this technology,” says Dr. Carol Storey-Johnson, senior associate dean of education at Weill Cornell Medical College. “The iPad will open a world of new learning opportunities for students and dramatically expand the way we train and educate a new generation of physicians.”

According to Jason Korenkiewicz, assistant dean of education administration, the paperless iPad is also a green alternative, that will save approximately 2 million pages and copies without being any more expensive.

Students are giving the device high marks. Although some were apprehensive about how the iPad would fit into their learning model, the response has been extremely positive and quickly won over the students who were resistant to changing their study habits.  Not only do they avoid lugging around heavy printed text books, they have found that the iPad reinforces learning and retention of information through a variety of multimedia.

For example an app called “Unbound Medicine” is a medical database for diseases, medications and diagnoses. Such reference applications give students the ability to have the most up-to-date medical facts and findings with them at all times.

Additionally, students can use interactive apps on their iPads to see animated 3-D molecular models of different proteins and compounds. The device’s advanced graphics allow students to view molecular structures with depth, rather than as a flat illustration on a sheet of paper, helping them to better understand how the structures function in the body.

The devices will also help students prepare to be clinicians in the electronic age. Going forward, there are plans to have students’ iPads synched with electronic medical record systems for training during their internships.

We’re guessing that this new generation of doctors will have fewer problems seeing pharma reps with iPads.  Maybe in the future we’ll all be seeing i-to-i.

Infection control controls costs

Aside from blogging, SRxA duties, and volunteering as an EMT, once a month I teach infection control to Fire and Rescue personnel.  During classes I stress the importance of the basics – training, hand-washing, good hygiene While most students probably forget the more scientific aspects of my lectures, they all remember the advice “if it’s wet, sticky and it’s not yours, don’t touch it!”

I was therefore interested, but not altogether surprised, to read a new study published in the September 2011 issue of Health Affairs, which showed that simple infection control measures could save thousands of lives and billions of dollars.

According to the U.S. Department of Health and Human Services at any given time, one of every 20 hospital patients has a hospital-acquired infection. This leads to an estimated 99,000 deaths in the U.S. each year and up to $33 billion in preventable health care costs.

The study, undertaken by researchers at the University of North Carolina at Chapel Hill, tested three interventions aimed at preventing and reducing hospital acquired infections.

The first intervention was strict enforcement of hand hygiene practices. All health care workers were expected to wash their hands with soap and running water or an alcohol-based rub on entering and leaving a patient’s room, before putting on and after removing gloves, and before and after any task that involves touching potentially contaminated surfaces or body fluids.

The second intervention was aimed at preventing ventilator-associated pneumonia and included measures such as elevating the head of the patient’s bed while the patient was on a ventilator, giving the patient daily breaks from sedation to assess whether or not the patient is ready to come off the ventilator, and providing daily oral care (teeth brushing, mouth washes, etc.) with a long-lasting antiseptic.

The final intervention was ensuring compliance with guidelines for the use and maintenance of central-line catheters. Examples included using sponges impregnated with an antiseptic, using catheters impregnated with antibiotics whenever possible, and performing two assessments per day of whether patients with central-line catheters still needed them.

Results showed that patients admitted after these interventions were fully implemented got out of the hospital an average of two days earlier, their hospital stay cost about $12,000 less and the number of patient deaths were reduced by two percentage points.

The costs for implementing these measures were modest – less than $22 / patient/day. However, adoption of the three interventions could potentially save thousands of lives and billions of dollars each year and improve the care of all patients.  Proving once again, it’s sometimes the simple things in life that are the most effective.

Pharma Reps being replaced by iPads and Portals

As previously reported here, industry downsizing has resulted in the loss of over 30,000 sales positions over the past 5 years.   Now, according to a recent article in the Wall Street Journal, big pharma companies have found a way to replace many of the sales reps they’ve been laying off in recent years.  Apparently the void is being filled by digital sales tools such as websites and iPad apps. Doctors can use the tools to ask questions about drugs, order free samples and find out which insurers cover certain treatments. The changes are designed to cut costs and to reach doctors in ways other than the traditional office visit, which many busy physicians say they find intrusive and annoying. In 2009, one of every five doctors in the U.S. was what the industry calls a “no see,” meaning the doctor wouldn’t meet with reps. Just a year later that jumped to one in four.  Currently about three-quarters of industry visits to U.S. doctors’ offices fail to result in a face-to-face meeting. Throughout the 1990s and early 2000s, drug companies dramatically increased their U.S. sales forces, an escalation most companies came to regret as the economy took a downturn.  Many of those same companies are now involved in this digital shift including Sanofi-Aventis, Merck, Pfizer, GlaxoSmithKline, Novartis and Boehringer Ingelheim . Citing data from market-research firms, Eddie Williams, head of Novo Nordisk‘s biopharmaceutical business in the U.S., said 72% of U.S. doctors own a smartphone, and 95% of them use it to download medical applications. Novo Nordisk has several applications available on iTunes, including one that helps doctors calculate blood-sugar levels and another iPad/iPhone application which offers tools to help doctors diagnose bleeding disorders. Other companies such as Eli Lilly  are now considering “on-demand portals” that will allow doctors to access information instantly as they are treating patients. Although some companies have yet to be convinced of the benefits of e-marketing, most agree it is the way forward. Following the launch of Pradaxa in the U.S., Boehringer Ingelheim put together a digital-marketing package to target doctors, but found that sales calls to doctors’ offices were still the most powerful tool for driving new prescriptions, says. “No doubt digital marketing does have an impact…but I don’t believe, however, the shift happens overnight,” said Wa’el Hashad, the company’s VP of marketing. SRxA can help pharmaceutical clients with all of their digital marketing needs. Whether it’s interactive e-learning platforms, webinars, podcasts, e-newsletters, e-surveys or website design and development our fully customized, physician approved offerings will exceed your expectations. Contact us today to learn more.