Of Gifts From the Pharmaceutical

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METHODS

The data are from the 1994 Kentucky Health Survey (KHS).The KHS is an annual statewide omnibus survey of adult (18years of age and older) Kentucky residents about health issues. Fhe KHS has been gathering data annually since 1988.The KHS aims to gather data regarding health issues and problems in Kentucky. The survey contains questions that areasked annually in an effort to examine trends and questionssubmitted

by investigatorsthat are nonannual but focus on

current specific issues. The questions regarding physicianacceptance of gifts from the pharmaceutical industry wereincluded in the 1994 survey by us.

The survey used random-digit dialing with Waks-berg clustering.18 The design offers every residential telephone line in Kentucky an equal probability of being selected. Further, Waksberg clustering supplies an almostcompletely unbiased sample of households with telephones.19

The 1994 survey had a response rate of 55%, supplying a sample of 649 individuals. The survey's margin of error is slightly less than 4 percentage points at the 95%confidence level. The 1994 KHS averaged 15 minutes tocomplete.

VARIABLES

The American Medical Association guidelines indicate thattrivial gifts that benefit patient care are acceptable. Consequently, for the present study gifts were classified as towhether they could be conceptualized as benefiting patient care (office-use gifts) or as personal gifts to the physician with no benefit for patient care. The following introduction was read to each respondent to indicate thisdichotomy:

Many gifts are given to doctors by companies which pro-

duce medicine and medical equipment. These gifts include things doctors use at their offices like free samplesof medicine or pens and pads of paper with the company'sname on it, as well as larger more personal gifts like clocks,radios, and dinners at expensive restaurants.

Patient awareness of physicians' receipt of office-usegifts was measured by asking the respondents if they wereaware that physicians receive free gifts like samples of medicine or pens and pads of paper. Similarly, the respondentswere asked to indicate their awareness of

physicianre

ceipt of personal gifts like clocks, radios, or dinners at expensive restaurants.

Patients' degree of personal experience with physicians' receipt of gifts was measured by asking the respondents if they had ever received free samples of medicinefrom their physician.

Attitudes toward the impact of physician receipt of giftson the cost of health care were measured for both office-use

gifts and personal gifts. In terms of assessments of office-use gifts, the patients were asked if they thought that accepting free gifts like medicine samples, pens, and pads ofpaper had a negative, positive, or no effect on the cost of healthcare provided. Similarly, the patients were asked about theeffect of accepting personal gifts like clocks, radios, and dinners at expensive restaurants on the cost of care. The receipt of certain gifts by physicians (eg, gifts for office use)could be perceived as enhancing quality of care by allowingthe physician to provide samples of medicine; on the contrary, the receipt of expensive gifts by physicians for personal use could diminish quality of care by implying an influence toward inapproriate clinical decisions. Therefore,attitudes toward the impact of physician receipt of gifts onhealth care quality were assessed for both office-use gifts andpersonal gifts using the same item format as that used in theassessments of the effect of gift receipt on the cost of care.

In an effort to gain a better understanding of patientattitudes toward the professional appropriateness of

pharmaceutical industry, this desire for a public perception of professional independence is clearly expressed.6Position 1 of the paper says

Gifts, hospitality, or subsidies offered to physicians by the pharmaceutical industry ought not to be accepted if acceptance mightinfluence or appear to others to influence the objectivity of clinicaljudgement. A useful criterion in determining acceptable activities and relationships is: Would you be willing to have thesearrangements generally known?6(p624)

Despite the prominence of patient views ofphysician behavior in medical organizational guidelines of physician gift acceptance behavior, essentially no research hasfocused on patient perceptions of pharmaceutical industry influence of physician behavior or patient perceptions of the ethical propriety of the gifts the AmericanMedical Association guidelines suggest to be acceptable.3

The purpose of this study was to assess patient perceptions of professional appropriateness and the potential impact on health care of physician acceptance of gifts

RESULTS

The demographic characteristics of the sample are shownin Table 1. These characteristics are similar to age-adjusted state population parameters.20 Eighty-five percent of the respondents have a regular physician, and thosewho have a physician are very positive about the care thatthey are receiving. Specifically, 49% report excellent quality of care, 43% report that their care is good; 7% believe

that theircare

is fair, and 1% believe the quality of thecare provided by their physician is poor.Patients' awareness of physicians' acceptances of gifts

from pharmaceutical firms varies depending on whetherthe gift had some benefit to patients. Eighty-two percent of individuals were aware that physicians receivedgifts with a possible patient benefit, such as samples ofmedicine, pens, and pads of paper. In contrast, 32% ofrespondents were aware that physicians received personal gifts such as clocks, radios, or dinners at expensive restaurants.

A large majority of the sample has had direct expo-

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physician acceptance of gifts, the respondents were askedtheir opinion of how many dollars worth of free office-useand personal gifts it is acceptable for a physician to receive in 1 year. Rather than use the term "acceptable," thesurvey used the term "okay" so as to make the items understandable to the broad range of respondents with varying educational levels. For the purpose of analyses, the eightpossible response categories were collapsed into the following three: less than $25, $25 to $1000, and "okay forphysicians to accept as much as they are offered."

In addition to standard

demographiccharacteristics

(age, gender, race, education, income, and residence), several variables were measured that may have importance asmediators of patient attitudes regarding physician behavior. These questions were asked as proxies for a positiveor negative relationship with a physician. The respondents were asked if they have a physician whom they canconsult whenever they have medical problems or questions. Further, for those individuals who did have a regular physician, the respondents were asked to rate the quality of care they are receiving from their physician (excellent,good, fair, or poor).

ANALYSIS

Descriptive statistics (eg, frequencies, proportions,means, and SDs) were initially computed, 2 Cross-classification analyses were performed to examine thedifferences between the type of gifts and patient attitudes toward their effect on the cost and quality ofhealth care. 2 statistic was also computed betweenthe types of gifts and the value of gifts that it is acceptable to receive in a year. A substantial proportion ofindividuals responded that they did not know an answerto a variety of the attitudinal questions and these "don'tknow" responses are reported in the descriptive andbivariate statistics. Refusals on each question were eliminated from the analyses. Refusals accounted for no

more than 1% of any item regarding gifts from the pharmaceutical industry.

In an attempt to gain an understanding of patient characteristics that may be influencing the attitudes, several bivariate and multivariate analyses were computed. First, therelation between awareness of personal gifts and the expressed attitudes toward the effect of the acceptance of giftson cost and quality of health care was addressed with a 2statistic. Second, exposure to pharmaceutical industry gifts,as measured by receipt of medication samples, was ana

lyzedvia

2for its relation to the

expressedattitudes to

ward the effect of the acceptance of gifts on cost and quality of health care.

Because an underlying purpose of this study was toexamine patient perceptions of the impact of physicianacceptance of gifts on aspects of the delivery of healthcare, multiple logistic regression analyses were computed to examine characteristics in relation to differentattitudes. Analyses were computed with the dependentvariables of attitudes toward the effect of personal giftson the cost of health care and the quality of health care.In both cases, the attitudes were recoded to 0 for assessments of gifts having a negative effect or to 1 for assessments of gifts not having a negative effect (ie, no effector positive effect). This dichotomization was undertakenbecause it was surmised that patient perceptions of negative effects of gifts was the most important issue relatedto policy guidelines regarding the acceptance of gifts.6No regression was computed for the acceptable yearlyvalue of personal gifts because of the large proportion ofindividuals who responded "don't know." The logisticregressions each entered the following patient characteristics: age, race, gender, education, income, rural orurban residence, awareness of personal gifts, exposure topharmaceutical industry gifts, and the patient report ofhaving a regular physician. The analyses relating patientcharacteristics to expressed attitudes were computedonly with individuals who expressed an attitude.

sure to pharmaceutical industry office-use gifts provided to physicians. Seventy-five percent of the samplereported receiving free samples of medication from theirphysicians, with less than 1% indicating "don't know"to this question.

In addition to differences in awareness of the

receipt of office-use and personal gifts, respondentattitudes regarding the effect of gift acceptance onboth the cost and quality of health care differeddepending on whether the gift had a possible benefitto the patients (Table 2). Compared with office-usegifts, more respondents believed that personal gifts tophysicians have a negative effect on both health carecost and quality.

Table 2 presents patient attitudes toward the valueof gifts that it is acceptable for physicians to accept in ayear. The acceptable value of received gifts differs significantly (P=.0001) depending on whether the gifts havea potential patient benefit. Particularly striking is the difference in patient attitudes regarding the acceptable limitfor office-use and personal gifts. Nine percent of the respondents believed that office-use gifts should be lim-

ited to less than $25 per year, while 32% of respondentsbelieved that personal gifts should be limited to less than$25 per year.

Patient attitudes toward the effects of personal giftson health care cost and quality was not significantly associated with prior patient awareness of personal gifts tophysicians. Patients who were aware-of-such gifts were

just as likely as those with no awareness to have negative opinions about the effect of such gifts on the cost(P=.34) and quality (P=. 12) of health care. Likewise, priorawareness of personal gifts was not significantly associated with the dollar amount that a patient believed physicians should accept in 1 year (P=.31).

Whether a patient had received medication sampleswas associated with differences in attitudes toward gifts(Table 3). Those who had been exposed to pharmaceutical gifts through medication samples were more likelythan nonexposed respondents to view personal gifts ashaving a negative effect on the cost of health care. Patients who had received medication samples were alsoless likely to believe that personal gifts had a positive effect on health care quality. Exposure to medication



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and quality of health care. Receipt of gifts that may beperceived as innocuous, like pens and pads of paper, areperceived by more than a quarter of the patients as having a negative effect on the cost of health care. Consequently, a rvaluation of physician attitudes toward theseseemingly benign gifts may also be in order.

Only the patient's educational level was significantly related to attitudes toward gifts after controllingfor other demographic variables. Higher-educated patients are more likely to view personal gifts to physicians as having negative effects on health care cost and

qualityeven

after controlling for such factorsas

place ofresidence and income. Educational attainment is not synonymous with an awareness of these gifts and so the results suggest that more educated patients, even if initially unfamiliar with the practice, may be assessing theimpact of gifts based on other perspectives provided bytheir profession or social setting.

The lack of patient knowledge regarding physician receipt of gifts from the pharmaceutical industryis not totally surprising. Patients tend to be unaware ofa variety of aspects of their physicians and their practices.21 This ignorance of gift acceptance has morethan likely contributed to a lack of discussion of the

ethics of pharmaceutical industry gifts to physiciansoutside the medical community. However, althoughseveral individuals within the medical communityhave discussed the ethics of accepting gifts,1,4,22 thislack of discussion in the general community may contribute to a shortage of physician self-reflection on thisissue. Evidence has suggested that the greater a physician's exposure to pharmaceutical representatives, andthe more likely an individual is to receive gifts fromthe pharmaceutical industry, the more likely physicians are to believe in the appropriateness of giftacceptance.11,13 Moreover, physicians tend to believethat prescribing habits are not affected by accepting

gifts,10,23even

though current evidence suggests thatphysician interactions with pharmaceutical companiesdoes affect physician behavior.16

This study has several limitations. First, althougha probability sampling design was used, the responserate was of a level suggesting that a nonresponse biasshould be considered in interpretations of the findings. Unfortunately, response rates to random-digitdialing telephone surveys have been declining in thepast decade, and although methods to increaseresponse rates have been instituted at significant cost,it has been noted that very little change occurs in survey results by including the originally hard-to-obtain

respondents.24 Second, the study is basedon a telephone survey, thereby limiting the sample to individu

als with telephones. This limitation will omit only asmall proportion of the general population,25 but apossible exclusion of some individuals from lowersocioeconomic backgrounds must be considered.26Third, the data are limited to the adult residents of onestate (Kentucky). Consequently, the results may notbe generalizable to other states.

Despite the limitations noted, this study suggests thatthe public is generally uninformed about personal giftsfrom pharmaceutical companies to physicians. Guide-

lines from various medical associations6 suggest that physicians should only accept gifts if they would be willingto have their patients know about them. Because few individuals are aware of these gifts, the utility of this strategy of ethical assessment of physicians accepting personal gifts from the pharmaceutical industry isquestionable. The proposed voluntary policies concerning these practices may warrant further scrutiny.

Accepted for publication November 28, 1994.Correspondence to Department of Family Practice,

University of Kentucky, Chandler Medical Center, Lexington, KY 40536-0284 (Dr Mainous).

REFERENCES

1. Waud DR. Pharmaceutical promotions\p=m-\afree lunch? N Engl J Med. 1992;327:351-353.

2. Squires BP. Physicians and the pharmaceutical industry. Can Med Assoc J.1993;149:1391-1392.

3. Meyer DL. Pharmaceutical company-sponsored educational activities: who ben-efits? who pays? Fam Med. 1992;24:565-568.

4. Chren MM, Landefeld CS, Murray TH. Doctors, drug companies, and gifts. JAMA.1989;262:3448-3451.

5. American Medical Association Council on Ethical and Judicial Affairs. Gifts tophysicians from industry. JAMA. 1991;265:501.

6. Physicians and the pharmaceutical industry:a

position paper of the AmericanCollege of Physicians. Ann Intern Med. 1990;112:624-626.7. Bowman MA. Pharmaceutical company/physician interactions: finding the bal-

ance. Arch Fam Med. 1994;3:317-318.8. Levy R. The role and value of pharmaceutical marketing. Arch Fam Med. 1994;

3:327-332.9. Waud DR. Gifts from industry: laundering money or supporting education?

JAMA. 1994;271:505.10. McKinney WP, Schiedermayer DL, Lurie N, Simpson DE, Goodman JL, Rich

EC. Attitudes of internal medicine faculty and residents toward professionalinteraction with pharmaceutical sales representatives. JAMA. 1990;264:1693\x=req-\1697.

11. Banks JW III, Mainous AG III. Attitudes of medical school faculty toward giftsfrom the pharmaceutical industry. Acad Med. 1992;67:610-612.

12. Reeder M, Dougherty J, White LJ. Pharmaceutical representatives and emer-gency medicine residents: a national survey. Ann Emerg Med. 1993;22:1593\x=req-\1596.

13. Brotzman GL, Mark DH. The effect of resident attitudes of regulatory policies

regarding pharmaceutical representative activities. J Gen Intern Med. 1993;8:130-134.14. Lurie N, Rich EC, Simpson DE, et al. Pharmaceutical representatives in aca-

demic medical centers: interaction with faculty and housestaff. J Gen InternMed. 1990;5:240-243.

15. Lexchin J. Interactions between physicians and the pharmaceutical industry:what does the literature say? Can Med Assoc J. 1993;149:1401-1407.

16. Chren MM, Landefeld CS. Physicians' behavior and their interactions with drugcompanies: a controlled study of physicians who requested additions to a hos-pital drug formulary. JAMA. 1994;271:684-689.

17. Caudill TS, Rich EC, Johnson MMS, McKinney PW. Physicians, pharmaceuti-cal representatives, and the cost of prescribing. Clin Res. 1992;40(4):597A.Abstract.

18. Waksberg J. Sampling methods for random digitdialing. J Am Stat Assoc.1978;73:40-46.

19. Sudman S. Applied sampling. In: Rossi PH, Wright JD, Anderson AB, eds.Handbook of Survey Research. New York, NY: Academic Press; 1983:145-94.

20. US Bureau of the Census. 1990 Census of Population: General Population Char-

acteristics: Kentucky. Washington, DC: US Government Printing Office; 1992.Publication 1990 CP-1-19.21. Mainous AG III, Hagen MD, Rich EC. Patient awareness of and attitudes to-

ward physician board certification. J Am Board Fam Pract. 1993;6:403-406.22. Margolis LH. The ethics of accepting gifts from pharmaceutical companies.

Pediatrics. 1991;88:1233-1237.23. Reeder M, Dougherty J, White LJ. Pharmaceutical representatives and emer-

gency medicine residents: a national survey. Ann Emerg Med. 1993;22:1593\x=req-\1596.

24. Kristal AR, White E, Davis JR, et al. Effects of enhanced calling efforts on re-sponse rates, estimates of health behavior, and costs in a telephone healthsurvey using random-digit dialing. Public Health Rep. 1993;108:372-379.

25. Marcus AC, Crane LA. Telephone surveys in public health research. Med Care.1986;24:97-112.

26. Corey CR, Freeman HE. Use of telephone interviewing in health care research.Health Serv Res. 1990;25:129-144.


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Of Gifts From the Pharmaceutical