Association between gifts from pharmaceutical companies to French general practitioners and their drug prescribing patterns in 2016: retrospective study using the French Transparency in Healthcare and National Health Data System databases

We strongly disagree with Prof. Francois Schiele’s misrepresentation of our article.

First, the actual French law authorizes gifts from pharmaceutical companies. Indeed, there are
several exemptions to the anti-gift law;, such as gifts for "promotional activities"; and
"hospitality" (1). Nowhere in our paper, we suggested that these gifts were not legal.
However, we must call a spade a spade. We described without ambiguity what kind of gifts
are reported in the Transparency in Healthcare site (Box 1)(2). Gifts include donations of
equipment, invitations, catering expenses, travel expenses, and cash payments (e.g.,
commissions, rebates, or reimbursement of expenses). Prof. Schiele argues that these
payments (e.g., meals and/or hotel fees, congress registration/travel expenses) can be seen as
“education support by industry”. Still, such "educational support" is associated with worse
prescription patterns for nine of the twelve indicators tested in our study (3).

Second, while we agree that there is no gold standard for assessing the quality of prescription
patterns (3), Prof Schiele’s argument about the “pay for performance” programme of the
French social security system seems out of scope because prescription indicators are only a
small part of this programme (11/28 indicators). Furthermore, he criticizes the chosen
indicators. However, most of them are consistent with those already validated and used
internationally, for instance by the UK Quality and Outcomes Framework (QOF) and the US
National Quality Forum programmes (4).

He claims that the Pay for Performance programme is unrelated with quality indicators,
compliance with guidelines, and length of consultation. This last claim is based on a small
observational trial that included 128 GPs, dealing with an old Pay for Performance system
"Contract for Improving Individual Practices" (5). This study did not find any significant
association between the previous Pay for Performance programme and French GPs';
consultation length after adjustment, a result highly suggestive of confounding.

We think that our article and the reactions (even when negative) it gave rise to in France are a
very good starting point for rethinking our collective attitude towards the pharmaceutical
marketing activities and particularly their involvement in the continuous training of French
physicians.

References
1.French Public Health Code. Article L1453-7
https://www.legifrance.gouv.fr/affichCodeArticle.do?idArticle=LEGIARTI00...
dTexte=LEGITEXT000006072665&dateTexte=20190727 [PF1]
2. https://www.transparence.sante.gouv.fr
3.Goupil B, Balusson F, Naudet F, Esvan M, Bastian B, Chapron A, Frouard P: Association
between gifts from pharmaceutical companies to French general practitioners and their drug
prescribing patterns in 2016: retrospective study using the French Transparency in Healthcare
and National Health Data System databases. BMJ 2019;367:l6015.
4.European Observatory on Health Systems and Policies Series. Paying for Performance in
Health Care: Implications for Health System Performance and Accountability [Internet]. Open
University Press; 2014 [cited 2019 Sep 17]. 338 p.
5. Saint-Lary O, Sicsic J: Impact of a pay for performance programme on French GPs';
consultation length. Health Policy 2015;119 (4):417-26.