Evaluating the Strength of the Association Between Industry Payments and Prescribing Practices in Oncology.

BACKGROUND: Financial relationships between physicians and the pharmaceutical industry are common, but factors that may determine whether such relationships result in physician practice changes are unknown. MATERIALS AND METHODS: We evaluated physician use of orally administered cancer drugs for four cancers: prostate (abiraterone, enzalutamide), renal cell (axitinib, everolimus, pazopanib, sorafenib, sunitinib), lung (afatinib, erlotinib), and chronic myeloid leukemia (CML; dasatinib, imatinib, nilotinib). Separate physician cohorts were defined for each cancer type by prescribing history. The primary exposure was the number of calendar years during 2013-2015 in which a physician received payments from the manufacturer of one of the studied drugs; the outcome was relative prescribing of that drug in 2015, compared with the other drugs for that cancer. We evaluated whether practice setting at a National Cancer Institute (NCI)-designated Comprehensive Cancer Center, receipt of payments for purposes other than education or research (compensation payments), maximum annual dollar value received, and institutional conflict-of-interest policies were associated with the strength of the payment-prescribing association. We used modified Poisson regression to control confounding by other physician characteristics. RESULTS: Physicians who received payments for a drug in all 3 years had increased prescribing of that drug (compared with 0 years), for renal cell (relative risk [RR] 1.81, 95% confidence interval [CI] 1.58-2.07), CML (RR 1.22, 95% CI 1.08-1.39), and lung (RR 1.69, 95% CI 1.58-1.82), but not prostate (RR 0.97, 95% CI 0.93-1.02). Physicians who received compensation payments or >$100 annually had increased prescribing compared with those who did not, but NCI setting and institutional conflict-of-interest policies were not consistently associated with the direction of prescribing change. CONCLUSION: The association between industry payments and cancer drug prescribing was greatest among physicians who received payments consistently (within each calendar year). Receipt of payments for compensation purposes, such as for consulting or travel, and higher dollar value of payments were also associated with increased prescribing. IMPLICATIONS FOR PRACTICE: Financial payments from pharmaceutical companies are common among oncologists. It is known from prior work that oncologists tend to prescribe more of the drugs made by companies that have given them money. By combining records of industry gifts with prescribing records, this study identifies the consistency of payments over time, the dollar value of payments, and payments for compensation as factors that may strengthen the association between receiving payments and increased prescribing of that company's drug.

Atrofia muscular espinal y fracaso respiratorio. ¿Cómo actúan los pediatras de atención primaria en un escenario simulado? / Spinal muscular atrophy and respiratory failure. How do primary care pediatricians act in a simulated scenario?

Introducción: La atrofia muscular espinal tipo 1 (AME-1) suele ser mortal en el primer año de vida sin soporte ventilatorio. La decisión de iniciar dicho soporte o no supone un conflicto ético para los profesionales sanitarios. Material y métodos: Se incluyó un escenario de fracaso respiratorio agudo en un lactante con AME-1 en un programa de formación mediante simulación avanzada para pediatras de atención primaria (PAP). Se analizaron de forma sistemática las actuaciones de 34 grupos de 4 pediatras que participaron en 17 cursos. Se valoraron los aspectos clínicos, éticos y de comunicación con los padres. Resultados: La asistencia técnica inicial (administración de oxígeno y soporte ventilatorio inmediato) fue realizada correctamente por el 94% de los equipos. Sin embargo, los PAP tuvieron problemas al abordar los aspectos éticos del caso. Del 85% de los equipos que plantearon el conflicto ético a los padres, lo hizo por iniciativa propia el 29%, el 23% los excluyó de forma activa y solo el 6% los implicaron y tuvieron en cuenta su opinión en la toma de decisiones. Solo el 11,7% preguntó por la calidad de vida del niño y el 12% por su conocimiento del pronóstico de la enfermedad. Ninguno les explicó las alternativas de tratamiento ni trató de contactar con el pediatra de referencia. Conclusiones: Ante un caso simulado de AME-1, los PAP tienen dificultades para interactuar con la familia e implicarla en la toma de decisiones. La formación práctica de todos los pediatras debería incluir problemas de ética clínica (AU)

Introduction: Spinal muscular atrophy type 1 (SMA-1) tends to be fatal in the first year of life if there is no ventilatory support. The decision whether to start such support is an ethical conflict for healthcare professionals. Material and methods: A scenario of acute respiratory failure in an infant with SMA-1 has been included in a training program using advanced simulation for Primary Care pediatricians (PCP). The performances of 34 groups of 4 pediatricians, who participated in 17 courses, were systematically analyzed. Clinical, ethical and communication aspects with parents were evaluated. Results: The initial technical assistance (Administration of oxygen and immediate ventilatory support) was correctly performed by 94% of the teams. However, the PCP had problems in dealing with the ethical aspects of the case. Of the 85% of the teams that raised the ethical conflict with parents, 29% did so on their own initiative, 23% actively excluded them, and only 6% involved them and took their opinion into account in making decisions. Only 11.7% asked about the quality of life of children and 12% for their knowledge of the prognosis of the disease. None explained treatment alternatives, nor tried to contact the pediatrician responsible for the child. Conclusions: When faced with a simulated SMA-1 infant with respiratory failure, PCP have difficulties in interacting with the family, and to involve it in the decision making process. Practical training of all pediatricians should include case scenarios with an ethical clinical problema (AU)

Dentistry at the crossroads.

The dental practice pattern is shifting from small dental office to large corporate dental groups. This article analyzes the powers behind this change, and discusses the choices dental practitioners are facing and the reasons why many may choose to work in a corporate practice setting. Dental associations and specialty groups need to reaffirm their mission to provide quality oral health care. Dental treatment should not be viewed as a commodity used to measure corporate profitability.

[What is Internal Medicine?]. / Qué es Medicina Interna?

Internal Medicine can be defined as a medical specialty devoted to the comprehensive care of adult patients, focused in the diagnosis and non surgical treatment of diseases affecting internal organs and systems (excluding gyneco-obstetrical problems) and the prevention of those diseases. This position paper reviews the history of Internal Medicine, the birth of its subspecialties and the difficulties faced by young physicians when they decide whether to practice as internist or in a subspecialty. In Chile as in most occidental countries formal training in a subspecialty of internal medicine requires previous certification in internal medicine but the proportion of young physicians who remain in practice as general internists appears to be considerably lower than those who choose a subspecialty. The main reasons for this unbalance can be related to financial advantages (by the practice of specialized technologies) and the patients' tendency to request direct assistance by a professional thought to be better qualified to take care of their specific problems. Training programs in internal medicine should consider a greater emphasis in comprehensive outpatient care instead of the traditional emphasis for training in hospital wards.

¿Qué es Medicina Interna? / What is Internal Medicine?

Internal Medicine can be defined as a medical specialty devoted to the comprehensive care of adult patients, focused in the diagnosis and non surgical treatment of diseases affecting internal organs and systems (excluding gyneco-obstetrical problems) and the prevention of those diseases. This position paper reviews the history of Internal Medicine, the birth of its subspecialties and the difficulties faced by young physicians when they decide whether to practice as internist or in a subspecialty. In Chile as in most occidental countries formal training in a subspecialty of internal medicine requires previous certification in internal medicine but the proportion of young physicians who remain in practice as general internists appears to be considerably lower than those who choose a subspecialty. The main reasons for this unbalance can be related to financial advantages (by the practice of specialized technologies) and the patients' tendency to request direct assistance by a professional thought to be better qualified to take care of their specific problems. Training programs in internal medicine should consider a greater emphasis in comprehensive outpatient care instead of the traditional emphasis for training in hospital wards.

Apart from Medicare, what other work do GPs do?

BACKGROUND: Although Australian general practitioners are increasingly being encouraged to perform more non-Medicare funded work, little is known about the its extent or nature. METHOD: A cross sectional survey was sent to all 2107 potential GPs in Western Australia. RESULTS: The response rate was 480/1807 (27%). Nearly all GPs (95%) performed paid or unpaid non-Medicare work; 83% cared with non-Medicare payment for patients, averaging 6.5 hours per week. Paid nonpatient work (an average 4.3 hours per week, undertaken by 41% of GPs) was for divisions, teaching and research. Unpaid work was approximately 3.7 hours per week for patients, (mostly informal consultations and voluntary work) and 1.9 hours per week for nonpatient related activities (principally research, meetings and teaching). Overall GPs were satisfied with their job but were dissatisfied with government intrusion. The type and amount of non-Medicare funded work performed was not related to job satisfaction. CONCLUSION: General practitioners are involved in non-Medicare funded work to the extent of an average of 9.5 hours per week, including teaching, research and divisional activities.

[Alternative medicine between adaptation and demise: exemplified by homeopathy]. / Alternativmedizin zwischen Anpassung und Ausstieg: das Beispiel Homöopathie.

For the past several years, conventional health care systems--often called "conventional medicine"--have been criticized widely. Reasons mentioned are increasing costs and its ill equipment to handle multifaceted chronic illnesses. Such a decline of legitimacy is paralleled by an increase of alternative and complementary medicine. As the example of homeopathy shall demonstrate, successful strategies of professionalization in orthodox medicine can not simply be applied to its "holistic challengers". Important reasons to be outlined encompass the economic impacts of health care which have reached both orthodox and alternative medicine as well.

The persistence of Chinese medicine: adjustment and diversity.

Chinese medicine persists in many parts of East and Southeast Asia. This persistence has meant the re-organisation of traditional Chinese medical practice. Institutional developments and adjustments observed among the traditional Chinese medical practitioners, the chung-i, have created diversity. Such diversity among the chung-i is evident by comparing not only the practices which are based in shops and those which are clinic-based but also the newer and older practices.