"Caught In Each Other's Traps": Factors Perpetuating Incentive-Linked Prescribing Deals Between Physicians and the Pharmaceutical Industry.

BACKGROUND: Despite known adverse impacts on patients and health systems, 'incentive-linked prescribing', which describes the prescribing of medicines that result in personal benefits for the prescriber, remains a widespread and hidden impediment to quality of healthcare. We investigated factors perpetuating incentive-linked prescribing among primary care physicians in for-profit practices (referred to as private doctors), using Pakistan as a case study. METHODS: Our mixed-methods study synthesised insights from a survey of 419 systematically samples private doctors and 68 semi-structured interviews with private doctors (n=28), pharmaceutical sales representatives (n=12), and provincial and national policy actors (n=28). For the survey, we built a verified database of all registered private doctors within Karachi, Pakistan's most populous city, administered an electronic questionnaire in-person and descriptively analysed the data. Semi-structured interviews incorporated a vignette-based exercise and data was analysed using an interpretive approach. RESULTS: Our survey showed that 90% of private doctors met pharmaceutical sales representatives weekly. Three interlinked factors perpetuating incentive-linked prescribing we identified were: gaps in understanding of conflicts of interest and loss of values among doctors; financial pressures on doctors operating in a (largely) privately financed health-system, exacerbated by competition with unqualified healthcare providers; and aggressive incentivisation by pharmaceutical companies, linked to low political will to regulate and an over-saturated pharmaceutical market. CONCLUSION: Regular interactions between pharmaceutical companies and private doctors are normalised in our study setting, and progress on regulating these is hindered by the substantial role of incentive-linked prescribing in the financial success of physicians and the pharmaceutical industry employees. A first step towards addressing the entrenchment of incentive-linked prescribing may be to reduce opposition to restrictions on incentivisation of physicians from stakeholders within the pharmaceutical industry, physicians themselves, and policymakers concerned about curtailing growth of the pharmaceutical industry

Frequency of Modifiable Risk Factors in Ischemic Stroke Patients at a Tertiary Care Hospital in Lahore Pakistan

Objective: The objective was to find out the frequency of modifiable risk factors among patients of ischemic stroke at a tertiary care hospital in Lahore Pakistan. Study type,settings& duration:This observational cross-sectional study was conducted at Medical Department Services Hospital, Services Institute of Medical Sciences, Lahore Pakistan from January 2019 to January 2020. Methodology:After an informed consent 105 patients with ischemic stroke aged between 18-65 years from both sex wasincluded in this study. Patients with trauma, tumor, arteriovenousmalformations, unstable cardiopulmonary condition, psychiatric disease and hemorrhagic stroke were excluded. Demographic information and detailed history with physical examination was noted. Blood pressure and sugar levels were measured for all patients. All bloods test including fasting lipid profile were determined. SPSS version 17.0 was used for data analysis. Results:A total of 105 patients of ischemic stroke were enrolled in the present study. Mean age of the patients was 51.2±8.4 years and 73 (69.5%) were male. Mean BMI was 29.3±2.9 kg/m2. Hyperlipidemia was the most frequent risk factor seen in 53 (50.5%) patients with ischemic stroke followed by obesity in 48 (45.8%) patients, smoking in 43 (40.9%), hypertension in 41 (39.1%) and diabetes mellitus in 41 (39.1%) patients. Conclusion:Hyperlipidemia was the leading risk factor in ischemic stroke patients in the present study followed by obesity, smoking, diabetes mellitus and hypertension respectively

Thrombocytopenia and its Comparison with Plasmodium Vivax and Plasmodium Falciparum in Malaria Patients

Background: Malaria in Pakistan is a serious public health problem and thrombocytopenia can serve as diagnostic predictive marker. Objective: The objective of present study was to find out the frequency of plasmodium vivax and falciparum in malaria patients and to compare the frequency of thrombocytopenia in patients effected by plasmodium falciparum versus vivax. Study type, settings & duration: This observational cross-sectional study was conducted at Department of Medicine, Jinnah Hospital, Lahore from February 2018 to July 2018. Methodology: Fever more than 100°F for >3 days and >2 hours daily along with evidence of presence of >1 parasite of plasmodium on microscopic examination of thick smear of blood was labeled as malaria. Subsequently, depending on the type of parasite on microscopic examination of thin smear of blood (>1per film) the patients were labeled plasmodium falciparum and plasmodium vivax. Thrombocytopenia was defined as a platelet count <150,000 per mm3. After taking informed written consent, 236 patients of malaria were enrolled using non-probability consecutive sampling technique. Approximately three ml of blood was taken from each patient for microscopic examination of plasmodium type and platelet count measurement. SPSS version 17.0 was used for data entry and analysis. Data was stratified and chi square test applied keeping p-value <0.05 significant. Results: Mean age was 42.14±13.5 years with 123(52.1%) females. Seventy two (30.5%) patients had previous history of malaria. Mean duration of fever was 4.61±0.6 days. There were 88 (37.3%) patients with plasmodium falciparum and 148 (62.7%) had plasmodium vivax. Thrombocytopenia was seen in 41 (17.3%) patients. Out of the 88 patients with plasmodium falciparum, 11 (12.5%) patients had thrombocytopenia while it was seen in 30 (20.27%) patients out of 148 with plasmodium vivax. Conclusion: Plasmodium vivax was more commonly seen in our population. Over all, thrombocytopenia was seen in 17.3% malaria patients while frequency of thrombocytopenia was higher in malaria patients affected by plasmodium vivax as compared to those affected from plasmodium falciparum

The healthcare field as a marketplace: general practitioners, pharmaceutical companies, and profit-led prescribing in Pakistan.

Incentivisation of general practitioners (GPs) by pharmaceutical companies is thought to affect prescribing practices, often not in patients' interest. Using a Bourdieusian lens, we examine the socially structured conditions that underpin exchanges between pharmaceutical companies and GPs in Pakistan. The analysis of qualitative interviews with 28 GPs and 13 pharmaceutical sales representatives (PSRs) shows that GPs, through prescribing medicines, met pharmaceutical sales targets in exchange for various incentives. We argue that these practices can be given meaning through the concept of 'field' - a social space in which GPs, PSRs, and pharmacists were hierarchically positioned, with their unique capacities, to enable healthcare provision. However, structural forces like the intense competition between pharmaceutical companies, the presence of unqualified healthcare providers in the healthcare market, and a lack of regulation by the state institutions produced a context that enabled pharmaceutical companies and GPs to use the healthcare field, also, as space to maximise profits. GPs believed the effort to maximise incomes and meet socially desired standards were two key factors that encouraged profit-led prescribing. We conclude that understanding the healthcare field is an important step toward developing governance practices that can address profit-led prescribing

Incentivisation practices and their influence on physicians\u27 prescriptions: A qualitative analysis of practice and policy in Pakistan

Focus on profit-generating enterprise in healthcare can create conflicts of interest that adversely impact prescribing and pricing of medicines. Although a global challenge, addressing the impacts on quality of care is particularly difficult in countries where the pharmaceutical industry and physician lobby is strong relative to regulatory institutions. Our study characterises the range of incentives exchanged between the pharmaceutical industry and physicians, and investigates the differences between incentivisation practices and policies in Pakistan. In this mixed methods study, we first thematically analysed semi-structured interviews with 28 purposively selected for-profit primary-care physicians and 13 medical sales representatives from pharmaceutical companies working across Pakistan\u27s largest city, Karachi. We then conducted a content analysis of policies on ethical practice issued by two regulatory bodies responsible in Pakistan, and the World Health Organization. This enabled a systematic comparison of incentivisation practices with what is considered \u27prohibitive\u27 or \u27permissive\u27 in policy. Our findings demonstrate that incentivisation of physicians to meet pharmaceutical sales targets is the norm, and that both parties play in the symbiotic physician-pharma incentivisation dynamics. Further, we were able to categorise the types of incentive exchanged into one of five categories: financial, material, professional or educational, social or recreational, and familial. Our comparison of incentivisation practices with policies revealed three reasons for such widespread incentivisation linked to sales targets: first, some clear policies were being ignored by physicians; second, there are ambiguous or contradictory policies with respect to specific incentive types; and third, numerous incentive types are unaddressed by existing policies, such as pharmaceutical companies paying for private clinic renovations. There is a need for policies to be clarified and updated, and to build buy-in for policy enforcement from pharmaceutical companies and physicians, such that transgressions on target-driven prescribing are seen to be unethica