1. Elissa Ladd, PhD, RN, FNP-BC ; Diane Mahoney, PhD, RN, GNP ; Sri Emani, PhD “UNDER THE RADAR”: NURSE PRESCRIBERS AND PHARMACEUTICAL INDUSTRY PROMOTIONS

2. Funding Source: US Attorneys General Consumer and Prescriber Grant Program* * Resulted from a $430 million settlement that reconciled allegations of an unlawful marketing campaign for the drug Neurontin ® that violated state consumer protection laws

3. Background : APN Prescribing in the US  Advance Practice Nurse (APN) prescribers: nurse practitioners (NPs), certified nurse midwives (CNMs), mental health clinical nurse specialists, nurse anesthetists  > 150,000 NP APN prescribers (100,000 Family Physicians) – primary care  Statutory authority to prescribe in all 50 states (US) and the District of Columbia  97% write prescriptions: 9 – 25/day; 6200Rx/NP/yr; 500 million prescriptions a year (Bacchetta & Green, 2007; Treise& Rausch, 2005)

4. Pharmaceutical Industry Influence on Prescribing Studies consistently show that promotion increases prescribing (Chren,1994; Lurie,1990; Wazana,2000;Fischer,2009)) Studies consistently show that both physicians and APN prescribers do not believe that promotion affects prescribing (Fisher et al., 2009; Crigger, et al., 2009) NPs have an uncritically positive attitude toward pharmaceutical promotions (Fisher et al., 2009; Crigger, et al., 2009) Paucity of empirical data on nurse prescribing behaviors in relation to pharmaceutical marketing

5. METHODS: peRx: Prescribing Evidence Based Therapies  Web-based educational intervention on pharmaceutical marketing, conflicts of interest, and evidence-based prescribing  Produced in visually engaging entertaining format:

6. Evaluation: Web-based surveys (2007- 2008) Baseline (n = 263) Post 1 (n =208) - immediate Post 2(n=189) – 8 weeks post intervention Three key domains :  Perceived reliability of information provided by industry  Acceptability of promotional items and meals  Self-reported prescribing practices.

7. Selected Results: Baseline: Nurse prescribers had broad interface with pharmaceutical industry promotions at baseline: Representatives Samples Meal events Continuing education

8. Key Domains: Post Intervention

9. Lessons Learned Nurse prescribers (APNs) are clearly “flying under the radar” regarding research and programs that address:  Pharmaceutical industry interface with health care professionals  Programs re: Evidence base prescribing and use of generic medications Broad interest from the academic community to integrate material into pre-professional and post- baccalaureate curricula (> 100 graduate programs)

10. Policy Implications  Advance practice nurses (APNs) have the legal authority to prescribe in seven western European and Anglo Saxan countries; 4 other countries in the process of introducing nurse prescribing*(HAI, 2011; Kroezen et al.,2011)  Significant expansion of promotional activities that are directed to nurse prescribers  Limited integration into programs that foster evidence based prescribing, i.e. academic detailing, rational medicine use education * Australia, Canada, Ireland, New Zealand, Sweden, the UK and the USA; The Netherlands and Spain pending regulatory approval; Finland: proposed Government approval; South Africa regulatory evaluation

11. Nurses as Explicit and Implicit Prescribers Explicit Prescribers : Formal or statutory authority to prescribe Implicit Prescribers : Informal prescribers Active participants in therapeutic choices of both prescribers and patients (medications and non- pharmacologic therapies)  95% of nurses reported being asked by friends, family, or patients about prescription drugs (ANA, 2010)  Improve decision making for “as needed” medications in mental health care (Usher et al. 2009)  Instrumental in avoidance in errors and adverse events in prescribing (Plew-Ogan,et al., 2004)

12. Nurses are the largest segment of the post- professional healthcare workforce worldwide (~ 17.6 million) (WHO,2010) Task shifting Compelling power to influence rational use of pharmacotherapeutics Compelling potential to contribute to inter- professional strategies (research and programmatic models) for appropriate medicine use

13. Thank you eladd@mghihp.edu