Pharmaceutical Industry Interactions with Physicians: A Systematic Review of Prescribing Quality, Clinical Protocols, and Patient Perceptions.

Abstract:

Objective: The relationship between health personnel and the pharmaceutical industry continues to be among the predominant, though under-investigated, predictors of prescribing behaviors, especially in Low- and Middle-Income Countries. The present systematic review intends to collate international evidence on the relationship between these collaborations and (1) quality and cost of prescribing, (2) the development of clinical protocols, and (3) patient perceptions. Methods: A systematic search was conducted on the Internet (PubMed, Scopus, and Web of Science), covering the period from January 2000 through to March 2026. We also searched Google Scholar for the first 100 results and did manual reference screening (snowballing). Observational, experimental, and qualitative research on actual industry-physician contacts was considered. Methodological quality was evaluated using ROBINS-I for cohort studies, CASP for qualitative studies, AMSTAR-2 for systematic reviews, and AGREE II for guidelines. A thematic narrative synthesis was conducted. A random-effects meta-analysis was performed (DerSimonian-Laird method) when available. The heterogeneity was evaluated by the I² statistic. We reported following the PRISMA 2020 guidelines. Results: Of the 1,323 identified references, met all eligibility criteria and were included in the narrative synthesis (all of which were empirical studies or systematic reviews; no clinical practice guidelines met the inclusion criteria). In total, six studies gave adequate data for meta-analyses. The meta-analysis found a significant positive association between exposure in industry and irrational prescribing, with a pooled odds ratio (OR) of 2.52 (95% confidence interval l (CI), 1.82–3.50). There was significant heterogeneity (I² = 64%), which likely reflects differences in study designs, in populations, and in exposure measures. Subgroup analyses for exposure type conducted as exploratory analyses due to the limited number of studies available yielded similar effects: gifts and meals generated an OR of 3.16 (95% CI: 1.48–6.76; based on 4 studies), detailing visits an OR of 2.57 (95% CI: 1.91–3.45; based on 2 studies), and continuing medical education funding an OR of 2.77 (95% CI: 0.73–10.46; based on 2 studies). The test for differences by subgroups was not significant (p = 0.88). The test for differences by subgroups was also not significant (p= 0.88). The qualitative synthesis (six studies) revealed three primary mechanisms of influence: normalization of acceptance, where incentives have transformed into a professional norm and it is not a personal consideration that physicians attribute their actions (they “affect others, not me”), strategic targeting, where sales representatives “grade” the physician based on “business potential” (patient volume, specialty) and tailor their offering for that; and regulatory contradictions, through policy ambiguities and weak enforcement providing an environment conducive to abuse. A remarkable result was that no eligible empirical studies were identified looking into industry influence over national or local clinical protocol development. Several of the most prominent findings were variable but generally present awareness of relationship with industry physicians; diminished trust in doctor-patients; perception of unnecessary prescribing; and strong demand for transparency and disclosure of conflicts of interest. Conclusion: We found that industry physician interactions are invariably linked to poorer quality, more expensive, and less informed prescriptions. The effect is dose-dependent and continues even in small gifts. However, large gaps persist in the evidence surrounding systemic influence through clinical protocols and clinical experiences, especially in sub-Saharan Africa. There is an urgent need for context-specific research and regulations.