The impact of industry representative's visits on utilization of coronary stents

Selected in American Heart Journal by R. El Mahmoud



Doron Sudarsky, MD, a,b Jahangir Charania, MD, c Alexandra Inman, MD, d Sabrina D'Alfonso, MSc, b and Shahar Lavi, MDa,b Ontario, and British Columbia, Canada


Am Heart J 2013;0:1-8


June 2013


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My Comment


  •  Interaction between physicians and industry is complex but essential to improve medical care but conflict of interests may affect decisions
  • The aim of the study was to test if promotional visits by industry representatives affect use of different stents

Major findings

  • 1109 patients who underwent PCI by 7 interventionalists at London Health Sciences Centre between September 2008 and August 2009 were included in the final analysis
  • A visit day was linked to day of procedure. The representatives were permitted in the catheterization laboratories and could have interaction with the operators and there was no time limit for each visit which was scheduled by the catheterisation laboratory administrator and was not affected by presence of specific operators.
  • 5 companies were present: Company A with only DES; companies B, C, and D with both BMS and DES; company E distributed only anti-CD34 antibodies–coated stents.
  • It was recommended by the institution to use mainly DES by company A and BMS by company B
  • 1,785 stents were deployed: 1,086 (60.8%) were DES, 680 (38.1%) were BMS, and 19 (1.1%) were anti-CD34 antibodies–coated stents.
  • Company A marketed 657 (36.8%) of the deployed stents; company B marketed 596 (33.4%); company C marketed 199 (11.1%); company D marketed 314 (17.6%), and company E marketed 19 (1.1%)
  • When a company representative was present, procedures were more elective, with patients having stable angina
  • No difference was found in the number of treated vessels and in total stent length per case
  • The presence of a sale representative was associated with a higher number of deployed DES per case and higher costs
  • The market share was significantly increased when a representative was present for companies C (21.3% vs 9.5%, P= 0.001) and D (33.5% vs 15.8%, P< 0.001) and with a trend for company A (45.9% vs 35.8%, P = 0.065) and no significant difference for company B (38% vs 32.9%, P = 0.31)
  • There was increase in the use of the company's DES when their sale representative was present. The effect was more pronounced for companies B, C, and D, which didn’t have financial preference
  • With companies marketing BMS and DES, the presence of a representative was associated with an increase in the proportion of the DES

 My comments

  • The presence of a sale representative was more often associated with a higher utilization of stents from his company
  • This effect was more pronounced on use of DES resulting in higher procedural cost and the presence of a representative shifted toward using a DES instead of a BMS
  • These data suggest that high degree of interaction can create conflicts of interest that might compromise patient best care if the indication for DES instead of BMS is not really proved
  • Institutions and industry should have criteria regarding interaction between physicians and industry representatives in order to maintain the quality and development of patient care and of continuing research activities (clinical trials…)

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