A National Survey of the Frequency of Drug Company Detailing Visits and Free Sample Closets in Practices Delivering Primary Care

Pharmaceutical companies spend more on clinician office visits (also known as detailing) and free drug samples (also known as sample closets) than any other forms of professional marketing in the United States (totaling $18.5 billion in 2016).¹ Detailing and free samples affect prescribing quality and expenditures, often by promoting new and expensive brand-name drugs over equally effective, older, and less expensive options.² Some hospitals and medical centers have restricted these activities.³ We surveyed a national sample of US outpatient practices delivering primary care to determine the prevalence of detailing and sample closets.

Data are from the National Survey of Healthcare Organizations and Systems (NSHOS), which assessed primary care delivery in the context of alternative payment models. The NSHOS drew a stratified national sample (drawn from IQVIA) of independent and health system–associated practices with 3 or more primary care physicians. The survey was piloted in 5 practices with diverse characteristics (more information about the survey: eMethods in the Supplement). The study was approved by the Dartmouth College institutional review board, with participants’ informed consent implied by completing and returning the survey.

Practices associated with health care systems were selected by sampling systems and then practices by size. Target respondents were individuals able to represent the practice (eg, a medical director). Practices were characterized by ownership as independent multiphysician practices, medical groups (>1 multiphysician practice), simple systems (≥1 multiphysician practice with ≥1 affiliated hospital) and complex systems (multiple simple systems). Pharmaceutical industry promotional access was assessed with 2 questions about detailing and sample closets (Table).

We compared detailing visit frequency and presence of sample closets overall and by ownership, practice size, geographic location, and academic affiliation. We present crude results, since adjustment (weighted logistic regression) for these characteristics was found to make little difference. All results were weighted to create national estimates, and account for the complex sample design. All analyses were done with Stata version 15.1 (StataCorp). Two-sided P values less than .05 were considered significant.

Between June 2017 and August 2018, 2333 of the 4976 practices surveyed responded. After removing ineligible responses, 2190 responses were analyzed (a 44.0% response rate, similar across practice size and system association). Most practices were independent (612 [41.0% (by weighted percentage)]) or part of a complex system (873 [33.5%]); most (1580 [75.8%]) were small (<10 physicians), and one-quarter (670 [25.9%]) were affiliated with an academic medical center (Table). About half (1060 [49.7%]) reported weekly detailing visits, and 1181 (59.6%) had sample closets.

Weekly detailing was more common in independent multiphysician practices than those in complex systems (60.4% [95% CI, 54%-66%] vs 39.3% [95% CI, 34%-45%]; P < .001), smaller practices (<10 physicians, 54.8% [95% CI, 51%-59%] vs >20 physicians, 27.4% [95% CI, 18%-39%]; P < .001), non–academic-affiliated practices vs those with academic affiliations (55.9% [95% CI, 52%-60%] vs 32.3% [95% CI, 26%-39%]; P < .001) and those in the South (65.7% [95% CI, 60%-71%]; Figure). The same pattern was seen for the presence of a free sample closet.

In 2017 and 2018, industry promotional access was substantial in outpatient practices delivering primary care in the United States, particularly in smaller practices, those outside of systems, or those without academic affiliation. These findings, consistent with a study in broader physician populations from 2007,⁴ may reflect limited infrastructure in these practices to impose access restrictions or provide independent drug information. Although our findings are insufficient to fully explain the higher level of promotional access in the South, it is notable that health care spending is also higher in the South than in other regions of the United States.⁵

These results could be biased if respondents did not provide correct information about industry access to their practices or by nonresponse. In a worst-case sensitivity analysis, assuming all nonrespondents prohibited detailing, we would have estimated that 21.3% of practices had weekly visits, not 49.7%. Furthermore, the question about sample closets only established whether a practice had a sample closet, not if or how the closet was used.

The generalizability of these findings may be limited because we only sampled practices with 3 or more primary care physicians. Such practices account for approximately 29% of all US practices delivering primary care, but given their larger size, they account for more than 60% of patients receiving primary care in practice settings.

Despite the association of detailing visits and sample closets with less evidence-based and more expensive prescribing,² these forms of promotion remain common. If reducing industry influence on prescribing is a priority, these findings indicate that further measures are needed, at least in practices delivering primary care and particularly in smaller practices and those outside of health systems or academic settings.

Accepted for Publication: November 21, 2019.

Corresponding Author: Steven Woloshin, MD, MS, The Center for Medicine in the Media, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Level 5, WTRB, One Medical Center Drive, Lebanon, NH 03756 (steven.woloshin@dartmouth.edu).

Published Online: January 27, 2020. doi:10.1001/jamainternmed.2019.6770

Author Contributions: Dr Woloshin and Ms King had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Woloshin, Schwartz.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Obtained funding: Woloshin.

Administrative, technical, or material support: King, Schwartz.

Supervision: Woloshin, Schwartz.

Conflict of Interest Disclosures: Drs Woloshin and Schwartz receiving personal fees from Ross Feller Case LLP for serving as medical experts in testosterone litigation and are cofounders of Informulary Inc, a company that provided data about the benefits and harms of prescription drugs and ceased operations in December 2016. Ms King reported grants from Agency for Healthcare Research and Quality during the conduct of the study. No further disclosures were reported.

Funding/Support: This work was supported by the Agency for Healthcare Research and Quality Comparative Health System Performance Initiative (grant 1U19HS024075), which studies how health care delivery systems promote evidence-based practices and patient-centered outcomes research in delivering care.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors thank Jonathan Skinner, PhD, Dartmouth Institute for Health Policy and Clinical Practice, for helpful comments. Dr Skinner was not compensated for his help.

Additional Information: Coauthor Lisa Schwartz, MD, MS, died before publication of this article.