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April 30, 2014
Free Samples Increase Expensive Drug Prescribing in Dermatology

Stanford, CA—Physicians may say otherwise, but the availability of free drug samples affects prescription decision-making.

That’s according to a new Stanford University School of Medicine study finding that dermatologists with access to free drug samples are more likely to write prescriptions for more expensive drugs.

In fact, the study, published recently in JAMA Dermatology, found that the average retail cost of the prescriptions written by dermatologists with access to samples is about twice as much as those written by dermatologists at an academic medical center where such samples are prohibited.

“Physicians may not be aware of the cost difference between brand-name and generic drugs,” said senior author Alfred Lane, MD, emeritus professor of dermatology and pediatrics at Stanford, “and patients may not realize that, by accepting samples, they could be unintentionally channeled into subsequently receiving a prescription for a more expensive medication.”

Branded drugs and branded generics—categories which often have similar retail prices –made up 79% of prescriptions written by dermatologists nationwide, but only 17% of those written by physicians at the academic medical center where drug samples are banned, according to the study.

Interestingly, using dermatologists as the study group could have exaggerated the effect; the report notes that the percentage of prescriptions written with a sample by dermatologists increased from 2001 to 2010 from 12% to 18%, while the proportion for all other specialties decreased during the same time period from 7% to 4%.

In 2006, Stanford Medicine began prohibiting its physicians from accepting samples or other industry gifts. After that, Lane noted a discrepancy between the medications he tended to prescribe and those prescribed by other physicians in the community, so he conducted a study to determine why.

“I realized that patients were referred to Stanford with prescriptions for newly introduced, branded generics that were unfamiliar to me,” Lane said. “Sometimes I had to look up what they actually were. It wasn't clear to me that there was much benefit to these drugs, and they were definitely very expensive.”

Pharmaceutical companies have said they provide samples because physicians and patients appreciate the opportunity to try out a medication before having to buy it. Furthermore, clinicians have suggested that samples are a cost-effective way to help patients without insurance or to prescribe a preferred medication to which a patient is more like to adhere, according to the study.

Focusing on medications prescribed to treat adult acne, the researchers examined the prescribing patterns of dermatologists in the National Disease and Therapeutic Index, which represents the results of a survey of primarily office-based physicians. The database includes self-reporting information on aspects of clinical encounters such as prescriptions and usage of samples.

Study authors note that the top five medications prescribed for adult acne changed when comparing the years 2001, 2005 and 2010. That may have reflected differences in available drugs and preferences in treatment approaches, the authors suggest, but they point out a significant overlap among the most commonly prescribed medications and the availability of free samples for those medications.

For example, in 2005, the top four most commonly prescribed medications for adult acne were also the top four medications prescribed with a sample, according to the authors.

Comparing the database results to the prescribing patterns at Stanford, the authors reported that the average cost of prescriptions for a patient treated by a doctor who received samples was around $465, compared to about $200 for patients treated by a doctor without access to samples.

In addition, only one of the top 10 medications prescribed at the academic medical center in 2010 was also in the top 10 nationwide. Overall, nine of the 10 most-commonly prescribed medications nationwide for adult acne were branded or branded generics, and only 21% of prescriptions written by doctors in the national database were for generic drugs. At the academic medical center, however, 83% of prescriptions were for generic drugs.

The article also emphasizes that, between 33% and 62% of the time, nine of the top 10 nationally prescribed medications were prescribed with samples, although much cheaper generic versions existed for eight of these nine.

“The negative consequences of free drug samples affect clinical practice on a national level, and policies should be in place to properly mitigate their inappropriate influence on prescribing patterns,” according to the study.

Neither patient satisfaction nor medication adherence rates were measured in the study, even though, for example, patients might be more likely to comply with one pill a day of an extended-release branded generic than two pills a day of a generic version of the drug.

“At one time, we at Stanford really felt that samples were a very important part of our practice,” Lane said. “It seemed a good way to help poorer patients, who maybe couldn’t afford to pay for medications out-of-pocket, and we had the perception that this was very beneficial for patients. But the important question physicians should be asking themselves now is whether any potential, and as yet unproven, benefit in patient compliance, satisfaction or adherence is really worth the increased cost to patients and the health-care system.”

“Free drug samples can alter the prescribing habits of physicians away from the use of less expensive generic medications. The benefits of free samples in dermatology must be weighed against potential negative effects on prescribing behavior and prescription costs,” the study concludes.

In an accompanying commentary, physicians from The Permanente Medical Group Inc. in Pleasanton, CA, the University of Pennsylvania in Philadelphia, the University of California in San Francisco and the San Francisco Veterans Affairs Medical Center point out that the study raises important questions about the practice of drug sampling.

“Is drug sampling—when physicians give samples of prescription medicines provided by pharmaceutical companies to their patients—good or bad? Is the answer different for dermatologists than it is for other physicians? Many dermatologists have already answered those questions: ‘bad’ and ‘no,’” they write.

The commentators also point out that numerous institutions have banned or restricted drug sampling, including the Veterans Health Administration, the U.S. military, many universities, and Kaiser Permanente, while organizations such as the Association of American Medical Colleges, the American Society of Health-System Pharmacists, the Institute of Medicine, and the Joint Commission, have also recommended curtailing and/or controlling drug sampling.





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