Oncologists who receive money from the pharmaceutical industry appear more likely to prescribe nonrecommended and low-value drugs in some clinical scenarios, according to a recent analysis of fee-for-service Medicare claims.
Overall, the investigators found that oncologists receiving industry payments were more likely to provide no- or low-value care in three scenarios explored —use of denosumab for castration-sensitive prostate cancer, granulocyte-colony stimulating factor (GCSF) for patients at low risk for neutropenic fever, and nab-paclitaxel instead of paclitaxel — but were less likely to prescribe brand-name drugs vs generic or biosimilar alternatives.
These findings, published online October 25 in BMJ, largely align with previous studies exploring industry payments to physicians and further highlight the influence these financial relationships can have on oncologists’ prescribing practices — practices that could lead to patient harm, the study authors said.
Aside from money wasted on unnecessary drugs, the possibility of direct harm to patients is an important point to consider, according to first author Aaron Mitchell, MD, a medical oncologist and assistant attending physician at Memorial Sloan Kettering Cancer Center, New York City.
For instance, in the subgroup of patients with prostate cancer, “we observed hundreds of patients who received the drug denosumab unnecessarily because their oncologist had received payments for this drug,” Mitchell said. “We know from prior experience that about 1 out of 100 prostate cancer patients who receive this drug will have a side effect called osteonecrosis of the jaw — death of the jawbone — which can be devastating.”
Research to date has uncovered a “consistent association” between industry payments and prescribing practices, Mitchell and colleagues explained. A systematic review, for instance, found that physicians who receive industry payments are more likely to prescribe drugs manufactured by that company. But whether these financial relationships negatively, or positively, impact patient care remains less clear.
In the current analysis, Mitchell and colleagues tried to begin answering this question. The team identified four no- or low-value oncology scenarios using Medicare claims data: denosumab for castration-sensitive prostate cancer, GCSF for patients at low risk for neutropenic fever, nab-paclitaxel (Abraxane) for cancers that would probably respond just as well to paclitaxel, and a brand-name vs a generic or biosimilar agent.
The authors then looked at industry payments tracked through the Open Payment database to determine whether a relationship exists between industry payments and prescribing patterns in these four scenarios and whether prescribing practices vary by payment amount.
Study participants included Medicare beneficiaries diagnosed with incident cancer between 2014 and 2019 identified as being at risk for one of the nonrecommended or low-value interventions.
Among the 9799 patients with castration-sensitive prostate cancer, 30.2% were prescribed denosumab from an oncologist who had received denosumab-related industry payments. Among the 2962 patients whose oncologists received such payments, almost half of patients got the drug within 180 days vs 31.4% of patients whose oncologist did not receive payments.
After patient characteristics and calendar year were controlled for, industry payments were associated with a 17.5% greater use of denosumab (odds ratio [OR], 2.07).
For GCSF, overall, 28.3% of 271,485 patients were prescribed the drug from an oncologist who had received GCSF-related industry payments. Among patients whose oncologists received payments, 32.1% received GCSF during their first cycle of low-risk chemotherapy vs 26.6% of patients whose oncologist did not receive payments.
After patient characteristics and calendar year were controlled for, industry payments were associated with a 5.8% greater use of GCSF (OR, 1.33).
The team observed a similar pattern with nab-paclitaxel vs paclitaxel prescribing: Among patients whose oncologists received payments, 15.1% received nab-paclitaxel rather than paclitaxel, compared with 7.3% when oncologists did not receive payments. That translated to a 2.21-fold higher likelihood of being prescribed nab-paclitaxel from an oncologist receiving industry payments for the drug.
The authors also found that, in most instances, the chance of receiving a nonrecommended or low-value drug increased with increasing industry payment amounts.
Conversely, among patients whose oncologists received industry payments for certain brand-name drugs, 83.5% of these patients received the brand-name version instead of generic or biosimilar alternatives compared with 88.3% of patients whose oncologists did not receive payments (OR, 0.68).
And, in a model looking at physician-level indicators, industry payments were only associated with a greater use of denosumab and nab-paclitaxel, but not GCSF or brand-name drugs.
The study, however, only focused on “a narrow group of patients and interventions, and further research is needed to better characterize whether, and to what degree, the observed association between payments and poorer care quality extends to other settings,” Mitchell and colleagues wrote.
The physician-level model may also “underestimate the net effect of industry payments on prescribing practices,” the authors said. This model does not reflect the influence of payments made outside a 365-day window, which means a physician who frequently prescribes nab-paclitaxel, for instance, because of older industry payments may not increase their use in response to more recent payments.
Overall, “this study can conclude only an association between industry payments and prescribing and cannot infer causality” but, the authors concluded, the findings suggest that “this influence has the potential to negatively impact the care of individual patients.”
Enacting stricter prescribing standards, developing clear guidelines for appropriate industry interactions, and providing greater scrutiny on the flow of large payment from industry to doctors represent a few changes that could help curb the influence these payments may have, Mitchell suggested.
But whether findings like this will translate to changes remains unclear.
“The central challenge is that among physicians — and particularly among oncologists, my own specialty — these kinds of payments from industry remain overwhelmingly popular,” Mitchell said. “Change, therefore, means trying to impose change upon a group that doesn’t want to, which is inherently more difficult.”
Change would also be “bad for these companies’ bottom lines,” Mitchell added.
Mitchell reported research support from the National Cancer Institute, National Institute for Health Care Management, and Memorial Sloan Kettering Cancer Center.
BMJ. Published online October 25. Full text
Sharon Worcester, MA, is an award-winning medical journalist based in Birmingham, Alabama, writing for Medscape, MDedge, and other affiliate sites. She currently covers oncology, but she has also written on a variety of other medical specialties and healthcare topics. She can be reached at [email protected] or on Twitter: @SW_MedReporter.
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