Los médicos y la industria farmacéutica: impacto sobre actitudes y hábitos de prescripción / Physicians and the pharmaceutical industry: impact on prescription attitudes and habits

Resumen Introducción: La relación médico-industria farmacéutica (IF) se ha identificado como un problema ético por favorecer conflictos de interés derivados de los beneficios que reciben los médicos y que pueden afectar su juicio clínico. Objetivo: Identificar la frecuencia de participación de médicos en actividades financiadas por la IF, las actitudes de estos profesionales hacia los representantes de la IF, su conducta prescriptiva y la asociación de sus características y del trabajo con la participación en actividades financiadas por la IF. Método: Encuesta transversal a médicos internistas y cardiólogos. El cuestionario incluyó características de los médicos y centro de trabajo, participación en actividades financiadas por la IF, actitudes hacia los representantes y conducta de prescripción. Resultados: Se analizaron 455 cuestionarios, 78.5 % de los encuestados tuvo conocimiento de la relación médico-IF, la mayoría respondió reunirse con representantes de la IF, 30 % indicó haber recibido subsidios financieros y 10 % consideró que los obsequios afectan su prescripción. Tener conocimiento previo de la relación médico-IF se asoció con menor participación en actividades educativas financiadas por por la IF. Conclusión: Las prácticas y preferencias hacia la IF muestran la necesidad de diseñar estrategias para evitar la prescripción inapropiada.

Abstract Introduction: The physician-pharmaceutical industry relationship has been identified as an ethical problem, due to conflicts of interest motivated by the benefits that doctors receive and that can affect their clinical judgment. Objective: To identify the frequency of physicians participation in activities financed by the pharmaceutical industry (PI), their attitudes towards PI representatives (PIRs), their prescriptive behavior and the association between their characteristics and their workplace with their participation in activities financed by the PI. Method: Cross-sectional survey to internists and cardiologists. The questionnaire included characteristics of the doctors and their workplace, participation in activities financed by the PI, attitudes towards PIRs, and prescription behavior. Results: 455 questionnaires were analyzed; 78.5 % of surveyed subjects were aware of the physician-PI relationship, the majority acknowledged meeting with PIRs, 30 % indicated having received financial subsidies and 10 % considered that gifts affect their prescription. Having prior knowledge of the physician-PI relationship was associated with less participation in PI-financed educational activities. Conclusion: Practices and preferences towards the PI show the need to design strategies to avoid inappropriate prescription.

Current clinician perspective on non-vitamin K antagonist oral anticoagulant use in challenging clinical cases.

OBJECTIVE: The evolution of non-vitamin K antagonist anticoagulants (NOACs) has changed the horizon of stroke prevention in atrial fibrillation (SPAF). All 4 NOACs have been tested against dose-adjusted warfarin in well-designed, pivotal, phase III, randomized, controlled trials (RCTs) and were approved by regulatory authorities for an SPAF indication. However, as traditional RCTs, these trials have important weaknesses, largely related to their complex structure and patient participation, which was limited by strict inclusion and extensive exclusion criteria. In the real world, however, clinicians are often faced with complex, multimorbid patients who are underrepresented in these RCTs. This article is based on a meeting report authored by 12 scientists studying atrial fibrillation (AF) in diverse ways who discussed the management of challenging AF cases that are underrepresented in pivotal NOAC trials. METHODS: An advisory board panel was convened to confer on management strategies for challenging AF cases. The article is derived from a summary of case presentations and the collaborative discussions at the meeting. CONCLUSION: This expert consensus of cardiologists aimed to define management strategies for challenging cases with patients who underrepresented in pivotal trials using case examples from their routine practice. Although strong evidence is lacking, exploratory subgroup analysis of phase III pivotal trials partially informs the management of these patients. Clinical trials with higher external validity are needed to clarify areas of uncertainty. The lack of clear evidence about complex AF cases has pushed clinicians to manage patients based on clinical experience, including rare situations of off-label prescriptions.

Physicians and the pharmaceutical industry: impact on prescription attitudes and habits.

INTRODUCTION: The physician-pharmaceutical industry relationship has been identified as an ethical problem, due to conflicts of interest motivated by the benefits that doctors receive and that can affect their clinical judgment. OBJECTIVE: To identify the frequency of physicians participation in activities financed by the pharmaceutical industry (PI), their attitudes towards PI representatives (PIRs), their prescriptive behavior and the association between their characteristics and their workplace with their participation in activities financed by the PI. METHOD: Cross-sectional survey to internists and cardiologists. The questionnaire included characteristics of the doctors and their workplace, participation in activities financed by the PI, attitudes towards PIRs, and prescription behavior. RESULTS: 455 questionnaires were analyzed; 78.5 % of surveyed subjects were aware of the physician-PI relationship, the majority acknowledged meeting with PIRs, 30 % indicated having received financial subsidies and 10 % considered that gifts affect their prescription. Having prior knowledge of the physician-PI relationship was associated with less participation in PI-financed educational activities. CONCLUSION: Practices and preferences towards the PI show the need to design strategies to avoid inappropriate prescription. INTRODUCCIÓN: La relación médico-industria farmacéutica (IF) se ha identificado como un problema ético por favorecer conflictos de interés derivados de los beneficios que reciben los médicos y que pueden afectar su juicio clínico. OBJETIVO: Identificar la frecuencia de participación de médicos en actividades financiadas por la IF, las actitudes de estos profesionales hacia los representantes de la IF, su conducta prescriptiva y la asociación de sus características y del trabajo con la participación en actividades financiadas por la IF. MÉTODO: Encuesta transversal a médicos internistas y cardiólogos. El cuestionario incluyó características de los médicos y centro de trabajo, participación en actividades financiadas por la IF, actitudes hacia los representantes y conducta de prescripción. RESULTADOS: Se analizaron 455 cuestionarios, 78.5 % de los encuestados tuvo conocimiento de la relación médico-IF, la mayoría respondió reunirse con representantes de la IF, 30 % indicó haber recibido subsidios financieros y 10 % consideró que los obsequios afectan su prescripción. Tener conocimiento previo de la relación médico-IF se asoció con menor participación en actividades educativas financiadas por por la IF. CONCLUSIÓN: Las prácticas y preferencias hacia la IF muestran la necesidad de diseñar estrategias para evitar la prescripción inapropiada.

Deprescribing: a challenge for clinical cardiologists.

Deprescribing is a holistic process to identify medications that can be ceased, substituted or reduced. This process can improve the health of older patients and also enhance their compliance to the prescribed medications which are actually beneficial. Recommendations and guidelines have been elaborated for extensively prescribed drugs. In clinical cardiology the process of deprescribing is a challenge for doctors because of withdrawal-related adverse effects, but it may be applied in certain clinical conditions such as the discontinuation of statin prescription in patients with advanced senile dementia and those with limited life expectancy. Deprescribing is also focussed on the scarcely known effects of prolonged therapy after the acute phase of a disease is over, especially when continuation may signify potential life-long treatment. There needs to be collaboration between the consultant cardiologist who first prescribes medications and family doctors who are responsible for the long-term care of the patient and reviewing prescribed medications may be necessary.

Variations in Criteria and Practices for Heart Transplantation Listing Among Pediatric Transplant Cardiologists.

Ethical issues in pediatric heart transplantation (Htx) include resource allocation, benefit, and burden assessment in high-risk recipients, and informed consent. Practice patterns and decision-making was investigated using an internet survey with 47-multiple choice items and vignette-based questions. Of 43 pediatric Htx cardiologists contacted, 28 (65%) responded. Respondents reported that an overall median 1-month survival of 73% (range 50-100%), 1-year survival of 70% (range 50-85%), 5-year survival of 50% (range 40-85%), and 10-year survival of 50% (range 25-85%) was adequate to offer Htx. Based on vignettes presented, 100% of those surveyed would offer Htx to a straightforward 12-year old with end-stage dilated cardiomyopathy and a 7-year old with hypoplastic left heart syndrome with protein losing enteropathy. Thirty percent of physicians would offer Htx to a patient status post a Fontan procedure with mutliple co-morbidities. Seventy-five percent of physicians would offer Htx despite proven non-adherence. Considerable variability exists in the practice patterns of pediatric heart transplant cardiologists with regards to decision-making while evaluating patients for listing. Disagreements among pediatric Htx cardiologists exist when there are concerns for non-adherence and associated multiple co-morbidities. Further work is needed to understand these variations and develop consensus for pediatric Htx organ allocation.

Educational needs and application of guidelines in the management of patients with mitral regurgitation. A European mixed-methods study.

Aims: To assess the knowledge and application of European Society of Cardiology (ESC) Guidelines in the management of mitral regurgitation (MR). Methods and results: A mixed-methods educational needs assessment was performed. Following a qualitative phase (interviews), an online survey was undertaken using three case scenarios (asymptomatic severe primary MR, symptomatic severe primary MR in the elderly, and severe secondary MR) in 115 primary care physicians (PCPs), and 439 cardiologists or cardiac surgeons from seven European countries. Systematic cardiac auscultation was performed by only 54% of clinicians in asymptomatic patients. Cardiologists appropriately interpreted echocardiographic assessment of mechanism and quantification of primary MR (≥75%), but only 44% recognized secondary MR as severe. In asymptomatic severe primary MR with an indication for surgery, 27% of PCPs did not refer the patient to a cardiologist and medical therapy was overused by 19% of cardiologists. In the elderly patient with severe symptomatic primary MR, 72% of cardiologists considered mitral intervention (transcatheter edge-to-edge valve repair in 72%). In severe symptomatic secondary MR, optimization of medical therapy was advised by only 51% of PCPs and 33% of cardiologists, and surgery considered in 30% of cases (transcatheter edge-to-edge repair in 64%). Conclusion: Systematic auscultation is underused by PCPs for the early detection of MR. Medical therapy is overused in primary MR and underused in secondary MR. Indications for interventions are appropriate in most patients with primary MR, but are unexpectedly frequent for secondary MR. These gaps identify important targets for future educational programs.

Percutaneous coronary intervention patients' and cardiologists' experiences of the informed consent process in Northern England: a qualitative study.

OBJECTIVE: Informed consent is central to ethical medical practice, but little is known about how the process takes place in clinical practice. Percutaneous coronary intervention (PCI) is a common revascularisation procedure. Studies report that patients overestimate benefits, forget the risks and are unaware of alternative treatments. The aim of this study was to describe PCI patients' and cardiologists' experiences of the informed consent process in acute care settings. DESIGN/SETTING/PARTICIPANTS: A qualitative study with a maximum variation sample of elective and acute PCI patients and cardiologists taking their consent, recruited from a district general hospital and tertiary centre. In-depth interviews were conducted, and consent discussions were audio recorded. Data collection, coding and theorising occurred simultaneously. FINDINGS: Forty-one (26 male) patients scheduled for elective (20) or urgent (21) PCI and 19 cardiologists (5 female) participated. Despite diversity in patients' experiences of informed consent, elective and acute patients experienced a common four-stage process of consent. Most patients made the decision to have treatment at PCI referral and took a passive role in the discussions we recorded. They recognised cardiologists as experts, trusted the medical system to 'fix' their health problem and were unaware of their role in the informed consent process. Informed consent discussions functioned as a formal 'event',enabling cardiologists to check patients' understanding and enabling patients to access treatment. CONCLUSIONS: The configuration of services and patients' perceptions of their role in informed consent underpin a mismatch between legal and ethical principles of informed consent and current practice. The variation in patients' experiences of the current place of informed consent in service delivery represents a missed opportunity for cardiologists to work in decision-making partnerships with patients. In light of recent changes in the law, a new approach to informed consent is required.

Survey on Ethical Conduct Thresholds in Cardiologal Medical Practice in Argentina.

The purpose of this study was to analyze the attitude of a group of cardiologists on the ethical conducts they would accept or adopt when encountered with different hypothetical situations of medical practice. Between August and September of 2011, 700 Argentine cardiologists were surveyed in situations which posed ethical dilemmas in the patient-physician relationship, among colleagues or involving financial agreements with employers or the pharmaceutical industry. Ethical conflicts were evidenced in a series of inappropriate conducts such as differential fees, trips and meals sponsored by laboratories, splitting fees, overbilling, self-referral, charging for patient referral, financial compensation for ordering medical procedures, and various situations derived from the relationship with employers. In general, financial compensation from the pharmaceutical industry was more accepted than the conflictive situations which directly involved patients, colleagues or employers. The rejection of these conducts, the physicians' deontological education and the improvement of financial and organizational conditions in medical practice will help to encourage better medical professionalism and avoid unseemly behaviors.