Using drug samples can hinder quality

Docs may opt for pricier drugs, even if less safe

The University of Michigan Hospitals and Health Centers in Ann Arbor, as well as a number of other academic health centers, prohibits distributing drug samples to patients.

The rationale? When the free samples are gone, patients are left to pay for these drugs on their own — often at a cost much higher than that of the generics. And in some cases, physicians end up prescribing drugs that actually may have more side effects than their generic counterparts.

"It’s not that unusual for academic centers to limit access to free samples," notes Peter A. Ubel, MD, associate professor of internal medicine at the University of Michigan Medical School and director of the U-M Health System’s Program for Improving Health Care Decisions.

"There are clearly things you can learn from sales representatives about new formulations, new dosages, and drug combinations you didn’t know about, so it’s a fairly efficient way to keep on the cutting edge; but I believe more often than not, people learn about the latest things out there anyway."

In addition to being more expensive, the drugs provided in samples create habits among physicians, Ubel says. "I can’t keep 50 drug starting doses in my head. If there are five ACE inhibitors, for example, I’ll know one, not five. When there are samples, the drug I become familiar with will come off my pen."

Sometimes, these tendencies might not hurt patients, he adds. "But look at antibiotics — broad spectrum vs. generic. Do you pull out the big guns right away when the generic has a chance of working? I’d rather save the big guns for when you really need them, so patients don’t develop a tolerance to them."

In a recent study co-authored by Ubel, physicians were most likely to recommend ACE inhibitors as their first treatment choice in treating uncomplicated high blood pressure, despite numerous clinical trials that have shown diuretics and beta-blockers to be equally effective.

The physicians surveyed rated diuretics significantly less effective than the other three drugs and felt beta-blockers were more likely to cause side effects, while in reality ACE inhibitors tend to have more side effects than diuretics or beta-blockers.

Looking to control costs

The study, published in the December 2003 issue of the Journal of General Internal Medicine, was borne of Ubel’s keen interest in the role physicians play in helping to control health care costs.

"I’ve seen many physicians say that money doesn’t matter, and if a patient can be touched in a better way, they don’t care how expensive the treatment is," he notes. "But in blood pressure treatment, I noticed that the best meds were the cheapest, yet I saw people coming into my office with the more expensive drugs."

The study — Misperceptions About Beta-Blockers and Diuretics: A National Survey of Primary Care Physicians — involved 1,700 primary care physicians. It presented a hypothetical patient whose blood pressure was 170/105 (anything higher than 140/90 is considered abnormal).

The patient had tried to control his blood pressure for a year using diet and exercise, but it remained high; he had no other medical problems. Physicians were asked to estimate the effectiveness in this situation of ACE inhibitors, beta-blockers, calcium channel blockers, and diuretics. They also were asked what medication they initially would prescribe for this patient.

Diuretics and beta-blockers are recommended by the Joint National Commission on High Blood Pressure Treatment as the first-line treatment for uncomplicated high blood pressure, yet in the survey, diuretics and beta-blockers were rated less effective at lowering blood pressure and were thought to have more side effects than the newer calcium channel blockers and ACE inhibitors. Further, physicians who favored prescribing the more expensive drugs were more likely to give patients free drug samples from pharmaceutical representatives.

"It is crystal clear from the literature that there’s no advantage to ACE inhibitors in these cases," Ubel explains. "If the patient had diabetes or a big prostate, that’s a different story." In terms of side effects, "The main side effect in ACE inhibitors is the dry cough. It goes away when you stop taking the medicine, and it’s not dangerous, but otherwise all the drugs have the same side effects."

In some cases, he points out, receiving the free samples affected physicians’ prescribing habits without affecting their beliefs. "I expected misperceptions about generics, but the people who gave away drug samples to their patients were no more wrong, just more likely to prescribe them because of habit, even if they didn’t think more favorably about them than anyone else did."

Effective communication

Basically, says Ubel, the big pharma companies know how people learn and retain information, and they do a better job of informing physicians than the medical journals. "They hit you with the message in a way that sticks," he says. "We need to do a better job in that context."

According to Ubel, the policy of most scientific/medical journals is to refer to medications by their generic names not trade names. For example, an article will discuss the effectiveness of omeprazole without any mention of Prilosec. That likely reduces the "stickiness" of the information. Trade names often are catchier and easier to remember than generic names. So a physician who is used to thinking about the risks and benefits of Prilosec may not remember what he or she read about omeprazole.

What does Ubel recommend to readers of Healthcare Benchmarks and Quality Improvement?

"If you’re trying to improve the quality of care at your institution, you should think like a pharmaceutical rep and send the message to the docs that you want them to get," he advises.

"Pharmaceutical sales reps call what they do detailing; what is needed is what has been called counterdetailing," Ubel adds.

"Walk in like a sales rep, set up a table of donuts, and teach people about the most inexpensive and effective ways to treat patients. Before your presentation, just ask yourself, What would a pharmaceutical rep do?’"

Need More Information?

For more information, contact:

• Peter A. Ubel, MD, Associate Professor of Internal Medicine, University of Michigan Medical School; Director, Program for Improving Health Care Decisions, U-M Health System, Ann Arbor, MI. E-mail: