INQUIRY INTO THE INFLUENCE OF THE PHARMACEUTICAL
Memorandum by IMS HEALTH (PI 6)
1. IMS has been at the forefront of the
collection and analysis of healthcare data for more than 50 years.
Its complex databases, sourced from thousands of hospitals, pharmacies
and GP practices around the world are used widely by Governments,
industry, universities and patient organisations to help deliver
change in healthcare policy and delivery. In recent months IMS
UK data have been used to help:
the NHS Prescribing Support Unit
to cost out the implications of the new General Practice Contract
and to help understand why NHS prescribing for controlled drugs
in London is low;
the Department of Health Cancer Team
to analyse the variation of NICE approved cancer drugs;
the National Institute of Clinical
Excellence to examine adherence to its published appraisals;
the Medicines and Healthcare Products
Regulatory Agency to assess the extent of usage of hospital and
OTC medicines in children.
2. IMS is uniquely positioned to help this
Inquiry. IMS collects and processes electronic information on
prescriptions extracted from about half the pharmacies in the
UK. This information has been combined on a confidential, and
anonymised, basis with industry promotional information.
3. In addition IMS collects information
on the overall volume of industry promotion in three key areasrepresentative
calls, direct mail and advertising.
4. This information gives IMS a deep understanding
of the patterns of prescribing in primary care and the impact
of pharmaceutical representative promotion.
5. This response to the Inquiry focuses
on the provision of drug information and promotion, the third
point raised by the Committee in its Terms of Reference. Within
this area IMS' response deals primarily with the effect of representative
6. Given the importance of drugs approved
by the National Institute for Clinical Excellence, this response
focuses specifically on the impact of representative promotion
on those products that have both been analysed by IMS and which
at that point in time had received a favourable review from NICE.
The product areas that form the basis of this review are thus:
Proton pump inhibitorsused
in the treatment of gastro-oesophogeal reflux disease.
in the treatment of schizophrenia.
Cox II inhibitorsused in the
treatment of osteo and rheumatoid arthritis.
Glitazonesused in the treatment
of Type II diabetes.
7. As measured by IMS,
the overall number of representative calls has fallen in recent
years (-6% over five years). This level of effort has also been
concentrated on fewer products, in part due to fewer new products
being launched and corporate mergers. In 1999 16.3% of details
were for the top 10 most detailed products. In 2003 this figure
had risen to 22.4%.
8. Variation in the costs and volume of
GP prescribing is often put down to industry promotion. Certainly
studies have long shown that industry representatives are a primary
source of information on new products. The causes of prescribing
variation cannot, however, be so simply explained.
9. A recent study found that about a third
of the variation in prescribing can be explained by differences
in the breakdown of a practice's list by age, sex and temporary
More than a third of the remainder can be explained by the differences
in the proportion of patients on low incomes.
NHS Scotland's Information Services Division also point out in
their report on the allocation of resources to English regions
that other factors such as the number of GP partners, and the
distance the patient must travel to surgery or hospital also have
a part to play.
10. Nonetheless it is clear from the IMS
analysis of the three examples set out in the table below that
representative promotion of NICE approved products can have a
supportive effect. The growth of prescriptions in those doctors
who received calls from representatives was larger than in those
doctors who had not received any calls. Significantly, moreover,
in a separate analysis done for NICE by an independent health
economics agency using another of IMS databases, there was no
evidence that, in the example common to both analyses, the increase
in prescriptions was inappropriate. The increase in prescribing
occurred in patients with the relevant risk factors.
From these analyses it can be seen, therefore, that representative
promotion has the ability to counter any tendency to under use
|Average growth in number of prescriptions per GP in study period
|GPs receiving no calls by representatives
||GPs called on by representatives|
|Product 1GPs thought to be interested
|Product 1GPs thought to be less interested
11. The IMS evidence below also indicates that the influence
of the representative can be an effective support for NHS' decisions.
At the same time it is clear from the same analysis that it can
be difficult for representatives to have an effect where local
opinion is not favourable.
|Market share (%) at end of study period for Product A where Hospital opinion was:
||Low endorsement||High endorsement
|GPs not seen by rep||1.72
|GPs seen by rep||3.6
|Market share (%) at end of study period for Product A where PCT opinion was:
|GPs not seen by rep||1.25
|GPs seen by rep||2.96
12. It is also clear that doctors exercise their own
judgement. In all the cases of NICE approved products where the
prescribing of competitor products was examined by IMS, representative
promotion was supportive of the therapeutic class, not just the
13. In the case described in more detail below, moreover,
representative promotion also appeared to be associated with an
increased level of use of older, and the less expensive, products.
This phenomenon may be due to one of three factors, or a combination
of all three:
a "halo" effect whereby discussions
about the therapy area encourages doctors to pursue new treatment
doctors receive information from other representatives
to ensure a balanced view;
representatives focus mainly on those doctors
with the highest opportunity, or interest, to prescribe or treat
|Average volume of prescribing per GP at end of study period
|GPs not seen by representative
||GPs seen by representative
|All other drugs in same class||165.6
14. Based upon the evidence analysed above, representatives
do have an effect on doctors' prescribing in general practice
but this is by no means the whole story. Doctors exercise discretion.
Hospitals and PCTs can constrain or promote representative impact.
At the same time, within the subset of products examined here,
it is clear that representative promotion has acted to support
the uptake of NICE approved products or classes of drug.
The Prescribing Support Unit, January 2004: National Prescribing
Cost Implications of the GMS contract. Back
Variations in usage of cancer drugs approved by NICE: Report
of the review undertaken by the National Cancer Director Back
Representative details are measured using a panel of 200 doctors
per quarter who record the number of representative details they
receive and the messages communicated. This is projected to a
national total. Back
Rice et al. Derivation of a needs based capitation formula
for allocating prescribing budgets to health authorities and PCGs
in England: regression analysis BMJ 2000;320:284-8. Back
Prescribing Support Unit: Personal communication. Back
Allocation of Resources to English Areas. ISD Consultancy Services
8 http://www.nice.org.uk/page.aspx?o=202198 Back