September 28, 2020

The effect of free meal payments on medical prescribing.

Regular readers will know that I have posted several times on the band of orthodontic KOLs who
promote certain orthodontic products. However, I have not looked at the effect of other industry payments on practitioners’ practices. This post is about two papers that investigated this subject in medicine.

We are all familiar with the orthodontic suppliers providing entertainment in the form of meals and other payments. . Furthermore, we participate in industry-sponsored conferences and other events. We need to consider whether this influences our treatment. There has been no research on this in orthodontics.

However,there have been several studies looking at this in medicine. I thought that I should have a quick look at two of these studies.

A Californian and Hawaii based team did this study. The Journal of the American Medical
Association published the paper.

They based this research on the concept that industry-sponsored meals and payments may influence prescribing behaviour.

What did they ask?

They asked this straightforward question;

“Is there an association between physicians receipt of industry-sponsored meals and prescription rates”?

What did they do?

They did a cross-sectional study. In the first stage, they obtained information on prescription patterns from Medicare of four commonly used drugs.  These included statins, beta-blockers and ACE inhibitors.  These drugs all had generic, cheaper alternatives.

Then they used the Open Payments database to identify payments promoting the drugs to the selected physicians.  The primary exposure of interest was industry-sponsored events.

The Open Payments database is a source of information on all the payments made by industry to medical and dental care providers in the United States.  You can find it here. 

Finally, they ran multivariate analyses across the data to identify predictors of prescription.  

What did they find?

They looked at data from 280,000 physicians and 63,000 payments. 95% of these were for sponsored meals.

Their detailed statistical analysis showed that physicians who received payments were associated with increased prescription of brand name drugs compared to cheaper generic versions.

They pointed out that the association was not causation.


The other paper used a similar methodology.


Association between industry payments and prescribing costly medications: an observational study using open payments and medicare part D data

Manvi Sharma et al

Sharma et al. BMC Health Services Research (2018) 18:236

A team from Texas did this study.


What did they ask?

They asked;

“Is there an association between payments made to physicians and prescription of costly brand name drugs”?

What did they do?

They did a retrospective cross-sectional study. Again, they used the Open Payments database and a Medicare source for prescription practices.  They identified six brand name drugs with cheaper generic drugs.

What did they find?

They analysed data from 837,000 prescribers. Importantly, 38% received at least one payment from a pharmaceutical company.  Interestingly, their findings were similar to the previous study.  They concluded that;

“A physician’s industry financial payments were associated with increased odds of prescribing costly brand name drugs over cheaper generic drugs”.

What did I think?

Firstly, I thought these were two interesting papers.  When I considered the shortcomings of the research, the most critical factor was that these were  retrospective studies.  However, the investigators had interrogated established databases. Nevertheless, the contents were outwith their control, and there is a possibility of inaccuracies.

Importantly, we also need to remember that association is not causation.

There have also been several other studies looking at this question, and they reached the same conclusion.  Payment (even meals) influences prescribing practices.

Is this relevant to orthodontics?

Firstly, we have to consider if there is a problem concerning our company colleagues promoting their products via advertising.  There is nothing wrong with this approach.  This is because clinicians can evaluate the evidence on any new development.

However, this becomes a little unclear when We consider the effects of being entertained by a company. Many of us will have experienced entertainment. It varies from being invited to meals, the lunchtime pizza event and the industry-sponsored conference.

I think that this only becomes a problem when we use the promoted products and charge more or make claims that are not supported by any research.  Unfortunately, this happened with self-ligation, vibration and a seemingly endless list of magic developments.

I also wonder if this becomes more marked when clinicians attend industry-sponsored meetings. At these events, clinical salespeople (KOLs) promote products.  I could not help feeling that this is  particularly relevant at the moment where HSO and Align have sponsored several sessions at the PCSO meeting, and 3 of their clinical salespeople are speaking.

Final comments

I think that the editor of JAMA in their comments made a fascinating comment when they stated;

“If drug and device manufacturers were to stop sending money to physicians for promotional speaking, meals, and other activities without clear medical justifications and invest more in independent bona fide research on safety, effectiveness, and affordability, our patients and the health care system would be better off”.

Finally, this all goes back to self-declaration. Should a clinician declare that they received a payment from a company to their patients when they prescribe a new bracket or device which is more costly than others?  This has been suggested for medicine. Let us have a discussion?


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Have your say!

  1. ‘Bad Pharma’ by Ben Goldacre – it is full of issues about ‘freebies’ influencing purchasing, prescribing etc
    Including how you invent a ‘disease’ when you have a cure for it (eg Halitosis was invented by Warner Lambert to sell Listerine)

  2. Thankyou Kevin

    Always insightful- love your work.

    It’s no different to the customer seeking Coke V Pepsi. Advertising matters.

    Educated empathetic doctors will write generic prescriptions if possible and understand the hyperbole.

    There is never a free lunch.

    Someone always pays.

    • I think the difference between this and Coke V Pepsi is that when you’re choosing between Coke and Pepsi, you’ve already decided to have fizzy drinks instead of water.

  3. Conference organizers have some culpability for the KOLs by refusals to even cover the costs of speakers travel much less an honorarium, which leaves companies to sponsor their own speakers.

    • do you have any research or even advice on how to objectively do analysis to assess if one of these products or systems improves an individual’s practice or not? i appreciate reading this blog routinely tells me that XYZ makes no demonstrable difference over ABC on a given set of parameters, but there will always be the temptation to try to find out will it improve my ortho activity?

      I found self ligating brackets (one particular brand) took about 10% off my treatment durations and the torque/prescriptions meant I was doing less wire bending. I combined that with self etching primer and my debond rate is quite low compared to reported debond rates in BOS clinical effectiveness bulletins. I don’t know what chair time I am saving or not with the ligating or SEP, but it seems to make the day easier.

      are there many instances of orthodontic orthodoxy that don’t have support in research? Preadjusted brackets? Niti wires? Bonded brackets instead of banded? And if they are supported in research, was it the research that drove us there or an opinion leader or a rep from a company?

      Stephen Murray
      Swords Ortho

  4. Good for you Prof. O’Brien for initiating this constructive self-analysis. And who might dare disagree that a retrospective study framework, whilst a weak platform for deriving robust data, is pretty much the most reliable format given IRB requirements that would preclude prospective analysis of clinicians who might enjoy manufacturer incentive kickbacks vs. a control group who did not.

    Thank you again for initiating this constructive dialectic.

  5. Thanks Kevin. Don’t retire. You have also identified some of the ongoing problem areas in orthodontics. As we know, KOLs are KOLs because they have the gift of the gab, are charismatic and can convince many the product is the best thing since sliced bread; perhaps even an offshoot of advanced alien technology! Scientific/clinical researchers are generally measured, cautious about claims and outline the side effects and risks. We in the profession are part of the problem and we need to be discerning and skeptical. As Charpak (Nobel Prize winner in physics) wrote – the burden of proof is always on those who assert something new. The more the new claim lies outside previously established natural laws, the stronger the evidence to support it must be. The government in Australia recognised the problem with the pharmaceutical industry in medicine some years back and introduced regulations (enough?) regarding the freebies.

  6. The art of persuasion in action…works on a date so why not in seminars. We also see this on dental councils/boards where they get free meals, golf, booze and even free seminars that later become the ones approved for competence.

  7. Dear Kevin,
    We haven’t look for this relation in orthodontic field, but certainly, the industry have already done and they know that this works, otherwise, the wouldn’t spend so much money. We should look for studies in the commercial and marketing fields. We probably will find these kind of studies.

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