Attitudes of residents and faculty members in 3 academic hospitals in Beirut toward gifts offered by pharmaceutical companies.

Sani Hlais, MD, MPH; Claudine Nasr, MD;

Hassane Awada, MD; Grace Abi Rizk, MD.

Beirut, Nov 12th 2006.

Background

“Dancing with the porcupines” (Lewis et al, CMAJ 2001).

Promotional activities influence prescription of medications. (…)

Early interaction with residents can have a long lasting effect on their future attitude and behavior. (McCormick et al, JAMA 2001).

Academic institutions have been slow to regulate such interactions. .(Wager, BMJ 2003).

Lebanon

Lack of any national or institutional code of ethics dealing with pharmaceutical promotional activities.

No official restrictions on accepting gifts from companies.

No published data about interactions of residents and physicians with pharma.

objectives

Assess the attitudes of residents and faculty members toward gifts offered by pharmaceutical companies.

Identify predictors of respondents’ attitudes.

Population

All residents and FM @ HDF, AUH, St- Georges.

Except radiol and lab. 1030: 615 faculty members and

415 residents.

The tool:Questionnaire:

1- 24 questions about gifts 4- point Likert scale ranging from 0 (not

problematic) to 3 (very problematic). Questions varied with respect to the type

of gifts, their monetary and academic values, as well as the receiver .

2- demographic and identification data.

Questionnaire

Anonymous direct contact of respondents the local mailbox in the hospital double envelope

Statistical analysis

Unpaired t-tests and χ2 tests: compare faculty members and residents’ responses.

Paired t-tests: compare different pairs of responses for the same respondent.

Factor or Principal component analysis with oblique rotation: data reduction and factor structure.

Statistical analysis (cont’d) Two- step cluster analysis. Discriminant analysis: determine the

predictors of membership in different clusters.

Results:

Rate of response: 45% (460 of 1030). Residents : 61 % (255). FM: 33 % (205).

(17 % of FM: more than 10,000 $/ month).

The least problematic:

15$ antibiotic guide.

The most problematic: 300$ cell phone

2 respondents (1 resident, 1 FM): all gifts problematic

13 respondents(9 residents, 4 FM): nothing problematic

Results (cont’d)

Attitudes res = attitudes FM, but FM significantly more critical toward many expensive and/or non academic gifts.

Results (cont’d)

By receiver: practically same attitude.

By monetay value: expensive more controversial.

By academic value: lower more controversial.

Results: Factor analysis

Expensive. Common. Non- academic.

Results: 5 Clusters:

A-R factor score 2 for analysis 1

A-R factor score 1 for analysis 1

A-R factor score 3 for analysis 1

Var

iab

le

-30 -20 -10 0

Student's t

Critical Value

Test Statistic

Bonferroni Adjustment Applied

TwoStep Cluster Number = 1

A-R factor score 3 for analysis 1

A-R factor score 2 for analysis 1

A-R factor score 1 for analysis 1

Va

ria

ble

-10 0 10 20 30

Student's t

Critical Value

Test Statistic

Bonferroni Adjustment Applied

TwoStep Cluster Number = 3

Results: 5 clustersExpensive Common Non-

academic

Cluster 1 Not probl 2-

Not probl 2-

Not probl 3-

Cluster 2 Neutral Problem 1+

Problem 3+

Cluster 3 Problem 3+

Not probl 1-

Neutral

Cluster 4 Probl 1+ Probl 3+ Neutral

Cluster 5 Not probl 2-

Not probl 3- Probl 2+

Results: 5 clusters Resident Faculty Total Expensive Common Non-

academic Cluster 1

74 (29 %) 43 (22%)

117 (26%)

Not problematic 2-

Not problematic 2-

Not problematic 3-

Cluster 2

29 (11%) 31 (16%)

60 (13%)

Neutral

Problematic 1+

Problematic 3+

Cluster 3

75 (30%) 50 (26%)

125 (28%)

Problematic 3+

Not problematic 1-

Neutral

Cluster 4

17 (7%) 16 (8%) 33 (7%) Problematic 1+

Problematic 3+

Neutral

Cluster 5

58 (23%) 54 (28%)

112 (25%)

Not problematic 2-

Not problematic 3-

Problematic 2+

Results: Discriminant analysis:

Residents: 2nd hospital more critical toward

common gifts. Female: less critical toward common

& expensive gifts. Measures of restriction more

critical toward common gifts

Results: Discriminant analysis:(cont’d)

FM: Measures of restriction during

residency more critical toward gifts, especially common ones.

High income tolerant attitude toward expensive gifts.

Discussion:

Faculty members more critical. Factors determining attitudes:

monetary and academic value. Results comparable to literature

(Brett et al, Arch Intern Med 2003).

Some attitudes in violation of codes (UK and Australia) (acceptance of recreational gifts: music CD …)

Discussion: All gifts large and small

2 respondents : all gifts problematic.

« no free lunch ». Social science approach:

indebtedness, obligation and reciprocity.(Katz D, Am J Bioethics 2003).

Measures of restriction:

Associated with negative attitude toward common gifts in both residents and FM.

Interest of early interventions.(Mc Cormick, et al. Effect of restricting contact between pharmaceutical company representatives and Internal Medicine residents on posttraining attitudes and behavior. JAMA 2001).

Strength of the study: First in Lebanon and Middle East. Anonymity and double enveloppe:

reduce social desirability bias. Clear question : ethically

problematic. Analysis : detection of the factor

structure. Excellent reliability: Cronbach’s α =

0.91

Limitations Generalizability to a non- academic setting. Data reduction = data loss. Risk of error

inflation by using factors in cluster analysis, and then clusters in discriminant analysis.

Cross- sectional study: generating hypotheses about measures of restriction, no causality.

Other variables not assessed (type and frequency of contact with pharmaceutical companies)

Conclusion:

Monetary and academic values were the main deterinants of attitudes toward gifts.

Residents less critical in accepting gifts.

Measures of restriction during residency were significant predictors of residents and later faculty members’ attitudes.

Conflict of interest:

NONE DECLARED!!!