1. Canadian Nurse Practitioners and Pharmaceutical Influences
Dr Kimberley Lamarche RN NP, DNP

2. Thank You to the Following Sponsors

3. Prescription decision making is a complex process influenced by other factors in addition to scientific knowledge (Ladd, Mahoney, and Srinivas (2010). The influence of pharmaceutical industry sponsored education, promotions and gifts on the prescribing practices of physicians and medical students has been well documented in the literature. However, the effect of corporate promotions on the prescribing practices of nurse practitioners has not been assessed. (Muncy-Blunt, 2010)

4. The specific objectives of this replication study are to assess Canadian Nurse Practitioners’ (NPs) interactions with pharmaceutical industry promotional activities and their perception of information reliability and self-reported prescribing behaviors (Ladd, Mahoney, and Srinivas, 2010).

5. Background
“There is a large and critical gap in the current literature regarding the pharmaceutical industry's influence on NP prescribing patterns (Ladd, Mahoney & Srinivas 2010)”. Not only has there been less than five NP based studies, but none of these have been Canadian based, where the pharmaceutical industry is different than that of other markets studied (Crigger N, Barnes K, Junko A, Rahal S, Sheek C, 2009). One of the primary differences in terms of Canadian NPs is the challenge of non-sample permission. Much of NPs' prescription writing is invisible, and difficult to track, thereby making it difficult to assess the degree to which pharmaceutical companies affect NPs' prescriptions (Diamond, 2003).

6. One of the primary differences in terms of Canadian NPs is the challenge of non-sample permission. Free samples have been shown to affect physician prescribing behavior. Physicians with access to free samples are more likely to prescribe brand name medication over equivalent OTC medications (Sifrin & Ross, 2008.) This study also found that free samples decreased the likelihood that physicians would follow standard of care practices. Although these reasons are not the reason why Canadian NPs are not currently permitted to dispense samples, it does have a bearing when interpreting research results from other countries.
Canadian Context

7. Comparisons with Previous Studies
In spite of the differences, it is likely that pharmaceutical companies do influence NPs' prescribing practices. Much of NPs' prescription writing is invisible, and difficult to track, thereby making it difficult to assess the degree to which pharmaceutical companies affect NPs' prescriptions (Diamond, 2003). There is literature reporting that physician pharmaceutical prescribing behavior is influenced by pharmaceutical interventions (Ladd, Mahoney & Srinivas 2010, Lewis, 2007; Greene, 2007; Sidiqi, 2006). Comparisons however cannot be made across disciplines, and this likely is the impetus for more targeted published opinion articles and studies related to NPs and in some cases Physician Assistants (Blunt 2010, Crigger 2004, Lee, 2006; Sidiqi, 2006; Ladd et al., 2010). These studies indicated that although NPs acknowledge that there is a positive relationship with pharmaceutical interventions they do not purport that these interactions have any negative impact on their prescribing habits.
There is literature reporting that physician pharmaceutical prescribing behavior is influenced by pharmaceutical interventions (Ladd, Mahoney & Srinivas 2010, Lewis, 2007; Greene, 2007; Sidiqi, 2006). Comparisons however cannot be made across disciplines, and this likely is the impetus for more targeted published opinion articles and studies related to NPs and in some cases Physician Assistants (Blunt 2010, Crigger 2004, Lee, 2006; Sidiqi, 2006; Ladd et al., 2010). These studies indicated that although NPs acknowledge that there is a positive relationship with pharmaceutical interventions they do not purport that these interactions have any negative impact on their prescribing habits.
Data demonstrate that NP practice is influenced by their interactions with pharmaceutical companies. It is unclear from the literature, both grey and evidenced based if the majority of NPs believe that this influence affects their prescribing practice – either positively or negatively. One American author who studies NPs from three US states reports those NPs value pharmaceutical interactions and recognizes the benefits accrued. An important conclusion from this research purports that NPs need to be able to recognize the influence of pharmaceutical company interactions on their practice. (Blunt, E., 2010).
American researchers most recently surveyed members of the American Academy of Nurse Practitioners. (Ladd, 2009) 96% said they have regular contact with pharma-industry reps, 83% said the information they received was reliable and 96% said they’d attended CME courses paid for by big Pharma. One of the inferences we can take from this study is the fact that NPs hold a very positive attitude toward and active engagement with pharma marketing. This is significant as it is an important signal for the nursing profession and those concerned with the influence of marketing to look more closely at the industry’s interaction with NPs.
Dr Crigger (2004) reports that the majority of family nurse practitioners admitted that drug marketing “sometimes” influences their prescribing practices. Most NPs in this study recognized when ethical boundaries are crossed by those who market drugs. She continues to say that the study “points to the need for all FNPs to evaluate their personal attitudes and practices concerning the ethical appropriateness of accepting gifts, meals, educational programs and trips from pharmaceutical companies”. Prescribing decisions for patients should be “based on the best interests of patients and on maintaining the trust of the patients and the public”

9. According to the Canadian Food and Drug Act, as of Jan 2012, in your current understanding are NPs authorized to currently dispense samples?

10. Do NPs in your practice currently dispense drug samples?

11. Pharmaceutical marketing has become ubiquitous in today's society
Pharmaceutical marketing has become ubiquitous in today's society. Acquisition of nonbiased, evidence-based information on drugs is essential for prescribers and is a key component of continuing professional development in the health professions. Prescription decision making is a complex process influenced by other factors in addition to scientific knowledge (Ladd, Mahoney, and Srinivas (2010). The influence of pharmaceutical industry sponsored education, promotions and gifts on the prescribing practices of physicians and medical students has been well documented in the literature. However, the effect of corporate promotions on the prescribing practices of nurse practitioners has not been assessed. (Blunt, E., 2010)

12. There is a large and critical gap in the current literature regarding the pharmaceutical industry's influence on NP prescribing patterns. Data demonstrate that NP practice is influenced by their interactions with pharmaceutical companies. It is unclear from the literature, both grey and evidenced based if the majority of NPs believe that this influence affects their prescribing practice – either positively or negatively. Prescriber contact and interface with pharmaceutical industry promotions have been found to contribute to non–evidence-based prescribing by physician and NPs.

13. This study is a replication of a study with NPs in the United States (Ladd, Mahoney & Srinivas, 2010) and is being conducted with the permission of the original author. The specific objectives of study are to assess Canadian NPs interactions with pharmaceutical industry promotional activities and their perception of information reliability and self-reported prescribing behaviors. This study will be accomplished through a self-administered online survey using a sample of Canadian nurse practitioners. What are the prescribing behaviors and beliefs of advanced practice nurses in relation to pharmaceutical marketing practices? What are the factors that influence prescribing behaviors in relation to pharmaceutical marketing practices?

14. References
Crigger N, Barnes K, Junko A, Rahal S, Sheek C. Nurse practitioners' perceptions and participation in pharmaceutical marketing. J Adv Nurs. 2009;65(3): Diamond F (2003). Nurse practitioners inch onto the field. Managed Care Magazine. Hall, KB, Tett, SE., & Nissen, LM. Perceptions of the influence of prescription medicine samples on prescribing by family physicians. Med Care, Vol 44(4), April 2006, Jutel A, Menkes DB. Soft targets: nurses and the pharmaceutical industry. PLoS Med Feb; 5(2):e5. Ladd, E., Mahoney, D., and Srinivas, E. (2010). Under the Radar: Nurse Practitioner Prescribers and Pharmaceutical Industry Promotions. American Journal of Managed Care; 16(12 Lee, S. (2006). Invisible Prescribers: What you don’t know about NPs and Pas. Pharmaceutical Executive; 26 (3) pg Lewis, PR. Advertising, sponsorship, and conflict of interest. J Family Practice. 56(5):344, May Morris L, Taitsman JK. The agenda for continuing medical education: limiting industry's influence. N Engl J Med 2009;361(25): Muncy-Blunt E. The influence of pharmaceutical company sponsored educational programs, promotions and gifts on the self-reported prescribing beliefs and practices of certified nurse practitioners in three states [Drexel theses and dissertations]. March 17, Pegler, S. & Underhill, J. Evaluating promotional material from industry: an evidence-based approach. Pharmaceutical Journal, March 5, 2005, 274, Sidiqi, S. (2006). Pharmaceutical Influence?. The Nurse Practitioner; 28 (5). Spurling, G. & Mansfield, P. General practitioners and pharmaceutical sales representatives: quality improvement research. Quality & Safety in Health Care. 16(4): Sufrin CB, Ross JS (September 2008). "Pharmaceutical industry marketing: understanding its impact on women's health". Obstet Gynecol Surv 63 (9): 585–96

15. Dr Kimberley Lamarche, RN NP, DNP