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Comment on Wengel et al.'s Letter: Physicians and the Pharmaceutical Industry

Key Words: Ethics • Somatic Therapies • Long-Term Care

SIR: Wengel et al. [see above] provide valuable observations regarding the pharmaceutical industry's recognition of nursing homes as an area for direct marketing. They note that nursing staff, in the absence of physician colleagues, may be especially vulnerable to biased presentations; and despite evidence to the contrary, there are persistent concerns about the use of psychotherapeutic agents as chemical restraints.^1,2

As Wengel et al. point out, the potential for mischief is obvious. Yet, there may be benefits, as well. There have been marked changes in prescribing patterns in nursing homes, some of which have been driven by regulatory mandate as well as scientific data. For example, over the last decade, there has been a 59% decrease in the use of antipsychotics and a 97% increase in antidepressants.³ It remains unclear whether the shift to antidepressants represents better care, better detailing, or a defense against the view that an antipsychotic in the nursing home is a chemical restraint until proven otherwise. However, the pharmaceutical industry's interest in long-term care is unlikely to diminish, nor should it, given the need for advances in the pharmacologic treatment of nursing home residents. But who polices the content of presentations in the nursing home to ensure that undue influence from industry representatives is minimized, if not prevented?

At the American Association for Geriatric Psychiatry (AAGP) annual meeting, special steps are taken to guard against undue influence by corporate sponsors of scientific sessions. When a program is proposed for presentation, corporate sponsors sign an agreement that their products cannot be promoted, either directly or indirectly. The content of the presentation cannot be "scripted" by industry agents, and advertisements cannot be displayed. Before the meeting, AAGP volunteers review all material to be presented and may require additional speakers, the inclusion of potentially unfavorable data regarding the products, changes in content to correct perceived bias, and caveats about off-label use or preliminary findings. When data are provided by the industry but not published, they must be clearly labeled as such. Also, Board members and trainees are assigned to each industry-supported presentation to provide feedback from direct observation. When presentations have seriously deviated from the vetted material, privileges to submit at subsequent annual meetings have been suspended. AAGP, not the industry, sets the standards for reimbursement of travel and for honoraria, such that no hidden "extras" are allowed for the presenters. These cumbersome procedures and safeguards are required for accreditation of Continuing Medical Education credits but are also enforced by the Annual Program Committee to avoid any appearance of improper influence. However, short of barring pharmaceutical representatives from the nursing home or having an institutional review process, the staff will always be vulnerable to bias. And AAGP cannot act as the overseeing authority. What AAGP can do is to raise awareness among our members, as well as related organizations, so that undue influence can be anticipated, recognized, countered, and prevented from recurring.

Nursing facilities and those of us who practice and teach in them need to openly seek the correct balance between taking advantage of the opportunity to use industry support to educate staff and becoming an odious advertisement for a product. Some facilities may choose to forgo the experience altogether. Others, through the medical director or other administrative entity, can set guidelines for the ethical use of industry-generated educational materials. Awareness of the potential for harm is the first step toward protecting all the interested parties, the residents, the practitioners, the facility, and the industry. This is why the letter from Wengel et al. is so timely.

REFERENCES

1. Department of Health and Human Services: Office of Inspector General: Psychotropic Drug Use in Nursing Homes. OEI-02-00-00490, January 2001; http://www.hhs.gov/oig/oei
2. Department of Health and Human Services: Office of Inspector General: Psychotropic Drug Use in Nursing Homes: Supplemental Information:10 Case Studies. OEI-02-00-00490, January 2001; http://www.hhs.gov/oig/oei
3. Health Care Financing Administration: http/www.hcfa.gov/Medicaid/exactv2.htm , 1999

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