Research Article

Rational Prescribing in Primary Care (RaPP): A Cluster Randomized Trial of a Tailored Intervention

  • Atle Fretheim mail,

    To whom correspondence should be addressed. E-mail:

    Affiliation: Norwegian Knowledge Centre for Health Services, Oslo, Norway

  • Andrew D Oxman,

    Affiliation: Norwegian Knowledge Centre for Health Services, Oslo, Norway

  • Kari Håvelsrud,

    Affiliation: Norwegian Knowledge Centre for Health Services, Oslo, Norway

  • Shaun Treweek,

    Affiliation: Tayside Centre for General Practice, University of Dundee, Dundee, United Kingdom

  • Doris T Kristoffersen,

    Affiliation: Norwegian Knowledge Centre for Health Services, Oslo, Norway

  • Arild Bjørndal

    Affiliation: Norwegian Knowledge Centre for Health Services, Oslo, Norway

  • Published: June 06, 2006
  • DOI: 10.1371/journal.pmed.0030134

Reader Comments (2)

Post a new comment on this article

Authors' response to AD Gowdy

Posted by plosmedicine on 30 Mar 2009 at 23:56 GMT

Author: Atle Fretheim
Position: Research Director
Institution: Norwegian Knowledge Centre for the Health Services
Additional Authors: Andrew D Oxman
Submitted Date: June 30, 2006
Published Date: July 3, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

We thank AD Gowdy for his comments [1]. He suggests that the NHS and other health care providers have a lot to learn from the pharmaceutical industry. Where is the evidence?

We are not aware of data that convincingly demonstrate the impact of outreach visits by pharmaceutical representatives. Gowdy indicates that such information exists ("Progress is tracked meticulously"). We would very much like to see it!

We have had informal discussion with executives from companies in Norway, and we have been struck by how they, themselves, question the effectiveness of their marketing strategies. At a recent conference in Denmark, the medical director of a major pharmaceutical company gave a talk on the impact of industry marketing on prescribing habits [2]. He had no other data to show than a handful of anecdotes, and when questioned about this he insisted that neither he nor his marketing department was aware of more rigorous evaluations.

The degree of interaction between industry and the medical profession is associated with differences in prescribing patterns [3]. Thus, what industry is doing in terms of marketing does seem to work, at least to some extent. However, the marketing effort made by industry is massive and includes a wide range of interventions. It is difficult to know what the relative merit of each component is.

Even more difficult to estimate is the cost-effectiveness of various marketing strategies. Considering that the pharmaceutical industry spends a five-digit amount ($US) per doctor per year on marketing alone [3], they should achieve substantial effects to compare favourably with, for instance, our results: We spent $US 500 per doctor and achieved a doubling of thiazide-prescribing [4].

The only study cited by Gowdy did indeed show promising results. However, changes in prescribing was compared between practices that chose to participate in the programme and practices that chose not too [5], and whether this is a fair comparison is uncertain. More over, he does not put this study into the context of a systematic review of the relevant research.

Gowdy thinks our intervention sounds like "a policing approach". This does not fit with our perception. The doctors were satisfied with the chance of meeting an industry-independent source of information and appreciated the opportunity to reflect on their own practice in light of the information and feedback that we provided them.

Gowdy's use of the term "evidence-based" when describing the messages conveyed by pharmaceutical companies begs a brief comment. Several investigators have assessed the quality of advertisements and promotional material distributed by industry. They consistently conclude with a word of caution against basing clinical practice on claims made by pharmaceutical companies [6-9].

1. Gowdy AD: What guidelines? Never saw them! PLoS Medicine 2006.
2. (28-6-2006).
3. Wazana A: Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000, 283: 373-380.
4. Fretheim A, Aaserud M, Oxman AD: Rational Prescribing in Primary Care (RaPP): Economic Evaluation of an Intervention to Improve Professional Practice. PLoS Med 2006, 3: e216.
5. (29-6-2006).
6. Cardarelli R, Licciardone JC, Taylor LG: A cross-sectional evidence-based review of pharmaceutical promotional marketing brochures and their underlying studies: is what they tell us important and true? BMC Fam Pract 2006, 7: 13.
7. Loke TW, Koh FC, Ward JE: Pharmaceutical advertisement claims in Australian medical publications. Med J Aust 2002, 177: 291-293.
8. Villanueva P, Peiro S, Librero J, Pereiro I: Accuracy of pharmaceutical advertisements in medical journals. Lancet 2003, 361: 27-32.
9. Solhaug HR, Indermo H, Slordal L, Spigset O: [Written drug advertisements--are they reliable?]. Tidsskr Nor Laegeforen 2006, 126: 1314-1317.

Competing interests declared: Both authors are employed by the Norwegian government.