RESUMO
Incentive-linked prescribing (ILP) is considered a controversial practice universally. If incentivised, physicians may prioritise meeting pharmaceutical sales targets through prescriptions, rather than considering patients' health and wellbeing. Despite the potential harms of ILP to patients and important stakeholders in the healthcare system, healthcare consumers (HCCs) which include patients and the general public often have far less awareness about the practice of pharmaceutical incentivisation of physicians. We conducted a scoping review to explore what existing research says about HCCs' perceptions of the financial relationship between physicians and pharmaceutical companies. To conduct this scoping review, we followed Arksey and O'Malley's five-stage framework: identifying research questions, identifying relevant studies, selecting eligible studies, data charting, and collating, summarising, and reporting results. We also used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses' extension for scoping reviews (PRISMA-ScR), as a guide to organise the information in this review. Quantitative and qualitative studies with patients and the general public, published in the English language were identified through searches of Scopus, Medline (OVID), EMBASE (OVID), and Google Scholar. Three themes emerged through the analysis of the 13 eligible studies: understanding of incentivisation, perceptions of hazards linked to ILP, and HCCs' suggestions to address it. We found documentation that HCCs exhibited a range of knowledge from good to insufficient about the pharmaceutical incentivisation of physicians. HCCs perceived several hazards linked to ILP such as a lack of trust in physicians and the healthcare system, the prescribing of unnecessary medications, and the negative effect on physicians' reputations in society. In addition to strong regulatory controls, it is critical that physicians self-regulate their behaviour, and publicly disclose if they have any financial ties with pharmaceutical companies. Doing so can contribute to trust between patients and physicians, an important part of patient-focused care and a contributor to user confidence in the wider health system.
RESUMO
BACKGROUND: Despite known adverse impacts on patients and health systems, "incentive-linked prescribing," which describes the prescribing of medicines that result in personal benefits for the prescriber, remains a widespread and hidden impediment to quality of healthcare. We investigated factors perpetuating incentive-linked prescribing among primary care physicians in for-profit practices (referred to as private doctors - PDs), using Pakistan as a case study. METHODS: Our mixed-methods study synthesised insights from a survey of 419 systematically sampled PDs and 68 semi-structured interviews with PDs (n=28), pharmaceutical sales representatives (SRs) (n=12), and provincial and national policy actors (n=28). For the survey, we built a verified database of all registered PDs within Karachi, Pakistan's most populous city, administered an electronic questionnaire in-person and descriptively analysed the data. Semi-structured interviews incorporated a vignette-based exercise and data was analysed using an interpretive approach. RESULTS: Our survey showed that 90% of PDs met pharmaceutical SRs weekly. Three interlinked factors perpetuating incentive-linked prescribing we identified were: gaps in understanding of conflicts of interest and loss of values among doctors; financial pressures on doctors operating in a (largely) privately financed health-system, exacerbated by competition with unqualified healthcare providers; and aggressive incentivisation by pharmaceutical companies, linked to low political will to regulate an over-saturated pharmaceutical market. CONCLUSION: Regular interactions between pharmaceutical companies and PDs are normalised in our study setting. Progress on regulating these is hindered by the substantial role of incentive-linked prescribing in the financial success of physicians and pharmaceutical industry employees. A first step towards addressing the entrenchment of incentive-linked prescribing may be to reduce opposition to restrictions on incentivisation of physicians from stakeholders within the pharmaceutical industry, physicians themselves, and policy-makers concerned about curtailing growth of the pharmaceutical industry.