Elissa Ladd, PhD, RN, FNP-BC ; Diane Mahoney, PhD, RN, GNP ; Sri Emani,

PhD

“UNDER THE RADAR”: NURSE PRESCRIBERS

AND PHARMACEUTICAL

INDUSTRY PROMOTIONS

Funding Source:

US Attorneys General Consumer and Prescriber Grant Program*

* Resulted from a $430 million settlement that reconciled allegations of an unlawful marketing campaign for the drug Neurontin ® that violated state consumer protection laws

Background: APN Prescribing in the US

Advance Practice Nurse (APN) prescribers: nurse practitioners (NPs), certified nurse midwives (CNMs), mental health clinical nurse specialists, nurse anesthetists

> 150,000 NP APN prescribers (100,000 Family Physicians) – primary care

Statutory authority to prescribe in all 50 states (US) and the District of Columbia

97% write prescriptions: 9 – 25/day; 6200Rx/NP/yr; 500 million prescriptions a year (Bacchetta & Green, 2007;

Treise& Rausch, 2005)

Pharmaceutical Industry Influence on Prescribing• Studies consistently show that promotion increases

prescribing (Chren ,1994; Lurie,1990; Wazana,2000;Fischer,2009))

• Studies consistently show that both physicians and APN prescribers do not believe that promotion affects prescribing (Fisher et al., 2009; Crigger, et al., 2009)

• NPs have an uncritically positive attitude toward pharmaceutical promotions (Fisher et al., 2009; Crigger, et al., 2009)

• Paucity of empirical data on nurse prescribing behaviors in relation to pharmaceutical marketing

METHODS:peRx: Prescribing Evidence Based Therapies Web-based educational intervention on pharmaceutical marketing, conflicts of interest, and evidence-based prescribing

Produced in visually engaging entertaining format:

Evaluation: Web-based surveys (2007-2008)

• Baseline (n = 263)• Post 1 (n =208) - immediate• Post 2(n=189) – 8 weeks post intervention

Three key domains:

Perceived reliability of information provided by industry Acceptability of promotional items and meals Self-reported prescribing practices.

Selected Results:

Baseline:

• Nurse prescribers had broad interface with pharmaceutical industry promotions at baseline:

• Representatives• Samples• Meal events• Continuing education

Key Domains: PostIntervention

Lessons Learned

• Nurse prescribers (APNs) are clearly “flying under the radar” regarding research and programs that address:

Pharmaceutical industry interface with health care professionals

Programs re: Evidence base prescribing and use of generic medications

• Broad interest from the academic community to integrate material into pre-professional and post-baccalaureate curricula (> 100 graduate programs)

Policy Implications Advance practice nurses (APNs) have the legal

authority to prescribe in seven western European and Anglo Saxan countries; 4 other countries in the process of introducing nurse prescribing*(HAI, 2011; Kroezen et al.,2011)

Significant expansion of promotional activities that are directed to nurse prescribers

Limited integration into programs that foster evidence based prescribing, i.e. academic detailing, rational medicine use education

* Australia, Canada, Ireland, New Zealand, Sweden, the UK and the USA; The Netherlands and Spain pending regulatory approval; Finland: proposed Government approval; South Africa regulatory evaluation 

Nurses as Explicit and Implicit Prescribers

• Explicit Prescribers: Formal or statutory authority to prescribe

• Implicit Prescribers: Informal prescribers• Active participants in therapeutic choices of both

prescribers and patients (medications and non-pharmacologic therapies)

95% of nurses reported being asked by friends, family, or patients about prescription drugs (ANA, 2010)

Improve decision making for “as needed” medications in mental health care (Usher et al. 2009)

Instrumental in avoidance in errors and adverse events in prescribing (Plew-Ogan,et al., 2004)

• Nurses are the largest segment of the post-professional healthcare workforce worldwide

(~ 17.6 million) (WHO,2010)

• Task shifting

• Compelling power to influence rational use of pharmacotherapeutics

• Compelling potential to contribute to inter-professional strategies

(research and programmatic models) for appropriate medicine use

Thank you

eladd@mghihp.edu