Antipsychotic prescribing: do conflict of interest policies make a difference?

Physicians’ interactions with the pharmaceutical industry begin early in training,1 and take many forms including receipt of gifts, promotional contact with sales representatives, and participation in industry-sponsored continuing medical education and research.2 These interactions have been shown to influence physicians’ choice of medication, which in some cases is associated with higher costs.3 Increasingly, the financial relationships between physicians and industry and the potential conflicts of interest (COI) arising from these relationships has garnered substantial policy attention.4 Regulating professional-industry interactions to mitigate COI may be most challenging in academic medical centers (AMCs), where physicians conduct research, teach students, and supervise residents and fellows in addition to providing patient care. Initial recommendations on regulation of physician-industry interactions in academic settings was focused on human subjects research activities.4 Between 2007 and 2009, the Institute of Medicine (IOM),4 American Association of Medical Colleges (AAMC),5,6 and the American Medical Association (AMA)7 issued new policy recommendations focused on physician-industry interactions pertaining to clinical practice and medical education within AMCs. Institutions responded with a host of policies including public disclosure of remuneration from industry, which can approach income from patient care for some physicians,8,9 bans on gifts and other forms of promotion known to influence prescribing,10,11 and restrictions on funding of continuing medical education.12 It is important but challenging to determine the influence such COI policies have on physician prescribing. The IOM states the objectives of policies include preserving public trust and professional integrity but also pointed to more measurable effects such as increasing “evidence-based physician prescribing practices.”4 This point is particularly salient for drug classes such as antipsychotics, for which numerous choices exist without a clear first line treatment but with variation in prices and side effect profiles. Research on the impact of COI policies has focused on trainees only with mixed results13,14,15 while no studies have been examined the impact of policies on practicing physicians. Nor do we know how the prescribing practices of academic physicians compare with those in the community where restrictions on physician-industry relationships are far less common. We examined prescribing of heavily-promoted antipsychotics among psychiatrists affiliated AMCs with varying adoption of COI policies as well as psychiatrists in non-academic settings between 2008 and 2011. Secondly, we examined prescribing of new and reformulated antipsychotics, which have been introduced and adopted during the era of COI regulation. We chose antipsychotics for several reasons. Antipsychotics have consistently ranked among the five highest selling drug classes in recent years.16 Physicians have many brand and generic options within the antipsychotic category with large randomized trials reporting comparable effectiveness among newer and older antipsychotics.17-19 Yet, new antipsychotics were rapidly adopted by physicians20 due to the lower risk of some side effects but also due to widespread off-label marketing and use.21-23 Thus, we expect antipsychotic prescribing patterns to be sensitive to changes in policies restricting physician-industry interactions.