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What Are “Negative Results on Clinical Care”?

Brennan et al. do not define them. It was not among the outcome measures cited in Wazana’s paper. Brennan and colleagues do not themselves establish any connection, associational or causal, between the “negative outcome” measures Wazana actually reports and the outcome “clinical care,” which insinuates without actually saying “patient outcome.” Brennan et al. have never admitted nor corrected their inaccurate citation. Scholars (e.g., Mayes and Laing) continue to rely on Brennan’s citation of Wazana to this day.

Howard Brody, one of the most trenchant critics of MPI relationships with physicians did not rely on Wazana’s review. Indeed, he found (Brody 2010) that the Wazana paper is “ nearly worthless for two reasons. First, it’s woefully out of date; second, if you read it carefully, it “proves” almost nothing—perhaps that more contact with drug reps makes docs who serve on formulary committees more likely to recommended company drugs.”

Wazana’s 2000 paper was “a systematic review.” It assembled, organized, and assessed the quality of 29 studies already in the literature. Is it fair to trash Wazana’s review for failing to produce proof stronger than the reviewed articles? Assembling evidence from studies showing an association between marketing and changed prescribing behavior, some positive, some negative, cannot add up to a strong negative proof.

Wazana did include a fairly old study (Haayer 1982) done in the Netherlands, which found a significant association between reliance on industry-provided information, older-age physicians, and “non-rational prescribing.” But overall, less than half (48%) of physicians’ prescribing decisions were judged “rational” by an expert panel composed of a clinical pharmacologist, a pharmacologist, a general practitioner physician, two pharmacists, and a physician who advised on pharmacology for a health insurance fund.

Haayer does not suggest it, but his study provides some evidence that the prescribing privilege, currently monopolized by physicians, should be at least shared with pharmacists or perhaps wrested from physicians entirely and given over to pharmacists, who would more rationally dispense medications for conditions diagnosed by physicians. Pharmacists dominated the panel that set the “gold standard” for rational prescribing. Despite the age on the Haayer study, Brody (2007) relied on that 1982 Dutch paper as well.

What about Mackey and Liang? Neither do they produce data-evidence of their own. For authority, they rely on the Brennan paper (which cites Wazana), on the Wazana paper, and on a Pew study discussing conflict of interest. The Pew paper provides no data-evidence that branded-product marketing is significantly associated with patient harm, let alone that marketing tends to cause patient harm.

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