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To the Editor: We recently discovered a sudden and sustained 3-fold increase in the pharmacy expenditures for quetiapine fumarate, an atypical antipsychotic agent, at the Minneapolis Veterans Affairs Medical Center (VAMC). This occurred in April 2000, which was 28 months after the drug became available in the United States and 5 months after it was placed on the hospital formulary. We investigated this sudden and dramatic increase in prescription costs for this drug at our institution.

Methods
Because the VAMC has a closed panel of prescribers, we were able to obtain data about prescribing behavior at the individual level, as well as the cost and dosage per prescription. Pharmaceutical representatives must sign in prior to visiting the medical staff, and thus we were able to examine the frequency of visits from representatives of the manufacturer. We also looked at the content and sponsorship of all presentations made to the medical staff during this time.

Results
The average monthly prescription cost, total pharmacy costs, and numbers of prescriptions and prescribers for quetiapine, by month, are displayed in Table 1. The increase in expenditures does not appear to have been due to an increase in the average cost per prescription. Although we were unable to gather data about each interaction between industry representatives and physicians, there was no significant increase in the total number of visits by the manufacturer's representatives during this time. We were unable to gather data about after-hours contact between physicians and industry representatives, although anecdotally this appears to be rare at our institution.

View this table: [in this window] [in a new window] Table. Prescriptions for Quetiapine Fumarate at the Minneapolis Veterans Affairs Medical Center

We discovered that a psychiatry grand rounds at the VAMC on March 10, 2000, had addressed the topic of atypical antipsychotic agents, and that the speaker was sponsored by the manufacturer of quetiapine. Of the 19 new prescriptions for quetiapine in March, 2 were written before the grand rounds and 17 after it. The title of the grand rounds was "Psychotic features and the comorbidity of posttraumatic stress disorder."

Finally, we counted the number of new prescriptions for olanzapine, a competing atypical antipsychotic agent, during this time. There were an average of 18.7 new prescriptions for olanzapine in the 3 months prior to the grand rounds, and an average of 19.3 new prescriptions per month in the 3 months following it.

Comment
In the past 2 years, 20 of 71 (28%) psychiatry grand rounds at the Minneapolis VAMC have featured industry-sponsored speakers. Despite a growing concern regarding the influence of the pharmaceutical industry on continuing medical education in general¹ and grand rounds in particular,² little is known about the influence of industry sponsorship of grand rounds. The circumstances of this particular grand rounds suggest that the increase in quetiapine fumarate prescriptions was influenced by this presentation and that this effect lasted for at least 3 months. The sudden increase in prescriptions was not due to the drug being newly marketed, or to a recent local formulary change. There was not a comparable increase in prescriptions for olanzapine, which has a similar range of indications and adverse effects.

We note several limitations of our investigation. We were unable to assess other concomitant interactions between physicians and pharmaceutical representatives, publication of important scientific articles or media reports, which may have explained part of this phenomenon. We do not have comparative prescribing data from the local community, with which our findings could be compared. Our data also do not allow us to assess the appropriateness of the increase in prescriptions of quetiapine fumarate. It is possible, for example, that this medication was being inappropriately underprescribed prior to the grand rounds.

Pharmaceutical companies have an interest in and influence on prescribing habits of physicians³ and it appears that grand rounds sponsorship may be another way to affect physicians' prescribing behavior. We urge prescribers to be cautious when interpreting and acting on data presented in industry-sponsored grand rounds. We also think that teaching institutions should demand full financial disclosure and prominently acknowledge sponsorship in both advertisements and speaker introductions for grand rounds.

Michael E. Dieperink, MD,PhD
University of Minnesota
Veterans Affairs Medical Center
Minneapolis

Lisa Drogemuller, RPH,BCPP
Veterans Affairs Medical Center
Minneapolis

1. Lexchin J. Interactions between physicians and the pharmaceutical industry: what does the literature say? CMAJ. 1993;149:1401-1407. ABSTRACT 2. Springarn RW, Berlin JA, Strom BL. When pharmaceutical manufacturers' employees present grand rounds, what do residents remember? Acad Med. 1996;71:86-88. ISI | PUBMED 3. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA. 2000;283:373-380. FREE FULL TEXT

Letters Section Editors: Stephen J. Lurie, MD, PhD, Senior Editor; Jody W. Zylke, MD, Contributing Editor.

JAMA. 2001;285:1443-1444.

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