The review, published in the Cochrane Database of Systematic Reviews under the title Pharmaceutical industry information and promotional strategies aimed at prescribers, compiled observational data on prescribers who had received various forms of industry contact, including advertising and education, gifts and payments, and free samples. The technical strength of a Cochrane review lies in its systematic approach: the authors searched, appraised and synthesized studies according to predefined criteria, allowing patterns to emerge across heterogeneous settings rather than relying on any single investigation. What emerged was a coherent signal that exposure to industry promotion changes behavior in measurable ways, shifting prescribing toward promoted products and, in a substantial share of cases, away from prescribing that best serves patients clinically or economically.

Grundy, who also directs the WHO Collaborating Centre for Governance, Accountability, and Transparency in the Pharmaceutical Sector at the University of Toronto and is one of two Canadian authors on the review, emphasizes that these marketing tactics are not confined to any single country or regulatory environment. The same multi-national companies market their drugs worldwide, meaning the dynamics documented in the review likely apply broadly across health systems. In the United States, where the Open Payments system requires companies to publicly report transfers of value to physicians, just over half of all licensed physicians have accepted a payment of some kind, including something as ordinary as a free meal. That figure, Grundy notes, cuts two ways. It shows that companies concentrate their marketing resources on physicians expected to deliver the highest return on investment and to prescribe more of the promoted drug, but it also reveals that a large number of physicians deliberately choose not to interact with pharmaceutical companies at all and remain independent of these influences.

The economics of this influence deserve particular scrutiny. When physicians accept payments or meals, the data show they subsequently prescribe more of the promoted drug, and when that drug is a brand-name product with cost-effective alternatives available, the consequences ripple outward through the health system. Patients face higher co-pays and greater out-of-pocket costs, while payers and public programs absorb inflated drug expenditures that may deliver no additional clinical benefit. In this sense, the review frames industry promotion not merely as an ethical concern about professional independence but as a measurable driver of health system costs and of inequities in what patients pay at the pharmacy counter.

Canada occupies a revealing position in this evidence base. No Canadian studies were included in the review, largely because the country lacks a mechanism to track how much pharmaceutical companies pay physicians and nurse practitioners, or why those payments are made. Unlike the United States, which maintains its public Open Payments database, Canada has no comparable transparency infrastructure at the national level. Grundy points out that surveys and qualitative research outside this review suggest free meals and payments are nonetheless likely common among Canadian prescribers, meaning the absence of Canadian data reflects a gap in transparency rather than an absence of the phenomenon itself. For policymakers, this is a concrete and actionable finding: a country cannot manage or evaluate influences it does not measure.

The review did not stop at documenting the problem. A subset of the included studies examined what happens when institutions adopt conflict-of-interest policies or restrict physician interactions with industry within practice settings such as medical schools and teaching hospitals. The results were encouraging. In environments where such policies were in place, physicians tended to prescribe less overall, or to prescribe more appropriate treatments, suggesting that structural safeguards can meaningfully mitigate the effects of promotional exposure. The review authors argue that more robust conflict-of-interest policies represent an important way forward, shifting the burden of independence from the individual conscience of each clinician to the systems in which care is delivered.

Grundy frames this as a matter of institutional responsibility rather than personal blame. Prescribers, she argues, need independent, evidence-based sources of drug information to maintain their independence in practice and to remain trustworthy and accountable to the people they serve. The studies included in the review demonstrate that practice environments can be deliberately designed to promote and preserve that independence, and that this is best achieved collectively, within health systems and institutions, rather than leaving individual clinicians to resist sophisticated, well-resourced marketing campaigns on their own. This reframing matters, because decades of research on professional behavior suggest that relying solely on individual willpower against systematic commercial pressure is a weak intervention compared with changing the environment itself.

There is also an important scope question raised by the findings. While most of the available research focused on physicians, physicians are no longer the only prescribers in many health systems, including Canada. Descriptive studies using the United States Open Payments data, which were not part of this review, have found that advanced practice nurses, including nurse practitioners and clinical nurse specialists, are also targets of industry promotion. As scope-of-practice expansions place more prescribing authority in the hands of nurses and other non-physician clinicians, the reach of pharmaceutical marketing expands with it. Grundy is explicit on this point: this is not just a problem for medicine, it affects the entire healthcare team, and the goal should be to create healthcare environments that safeguard the independence and integrity of care for every prescriber within them.

For readers weighing the practical implications, the review offers a clear evidence-based agenda. Health professional schools, hospitals, professional societies and health systems can adopt and enforce conflict-of-interest policies that limit promotional contact, particularly during training when prescribing habits are formed. Jurisdictions without transparency mechanisms, Canada among them, can establish mandatory disclosure of industry payments to all prescribers, not only physicians. Clinicians and educators can prioritize independent sources of therapeutic information. And patients, whose co-pays and out-of-pocket costs absorb much of the financial consequence, have a stake in demanding that prescribing decisions rest on clinical evidence rather than commercial relationships. The Cochrane evidence indicates that none of these changes requires a scientific breakthrough, only the institutional will to act on what the data already show.

What makes this review resonate beyond academic circles is its scale and its consistency. With evidence from more than 93 studies and the observed practices of millions of prescribers, the association between industry payments and prescribing behavior is no longer a contested curiosity of health services research; it is a documented, repeatable pattern across health systems and regulatory regimes. The finding that conflict-of-interest policies measurably improve prescribing adds a constructive counterweight, demonstrating that the influence of promotion is neither inevitable nor irreversible. As Grundy and her colleagues make clear, the task now is to translate that evidence into policy, so that the environments in which clinicians train and practice actively protect the independence on which safe, appropriate and affordable prescribing depends.

Subject of Research: The influence of pharmaceutical industry marketing and payments on physician prescribing behavior

Article Title: Study links pharmaceutical industry payments to changes in physicians’ prescribing practices

Article References: Study links pharmaceutical industry payments to changes in physicians’ prescribing practices. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: pharmaceutical industry, prescribing practices, Cochrane review, conflict of interest, Open Payments, physician payments, drug marketing, health policy, inappropriate prescribing, healthcare costs, Quinn Grundy, University of Toronto

The controversy began when Boland and collaborators systematically examined the individual references cited in support of the STOPP/START version 3 criteria, a 2023 revision of the screening tool for older persons’ prescriptions. Their appraisal, published in the same journal, examined the quality of the evidence underpinning each recommendation, classifying studies according to established hierarchies of evidence such as the GRADE framework, which rates the certainty of evidence from high to very low and ties the strength of a recommendation to that rating. The findings were sobering. A substantial proportion of the criteria rested on studies with weak designs, and only a minority were anchored in randomised controlled trials or systematic reviews. For a tool that clinicians use to justify starting or stopping drugs in frail patients, the appraisal implied that many recommendations were grounded more in expert consensus than in high-certainty trials.

O’Mahony and colleagues, the architects of the STOPP/START criteria, responded forcefully. They argued that applying randomised-trial standards to prescribing criteria for older people misreads the nature of the evidence base in geriatric medicine. Very few trials enrol the oldest, most polymedicated, most comorbid patients in whom these tools are deployed; much of the relevant knowledge comes from observational studies, pharmacovigilance data and accumulated clinical experience. In their view, the absence of high-grade trial evidence does not invalidate a criterion that is biologically plausible, clinically coherent and consistent with decades of observed practice. Expecting each criterion to meet the evidentiary bar of a drug-approval dossier, they suggested, would paralyse the development of guidance in a field where such trials are frequently infeasible or unethical.

In their letter, Van der Linden, Shao and Tournoy take a middle path that is nonetheless critical of the status quo. They acknowledge the practical constraints O’Mahony’s team describes, but contend that the debate reveals an unresolved structural problem: medication optimisation tools are being updated and disseminated without an agreed, transparent framework for grading the evidence behind each criterion. The Leuven authors point to their own experience developing the RASP_CARDIO list, a consensus-validated screening tool for cardiovascular pharmacotherapy in geriatric patients derived from an adjusted STOPP list. That project, they note, required explicit consensus methods to validate each recommendation, illustrating an alternative model in which the provenance and strength of every criterion is documented from the outset rather than defended after criticism.

Technical questions about evidence appraisal are far from academic. A medication optimisation tool functions as a decision-support algorithm: it maps patient characteristics, drugs and clinical events to recommendations. Like any algorithm, its reliability depends on the quality of the data and rules encoded within it. When a criterion such as ‘avoid long-term benzodiazepines in older adults’ is supported by high-certainty evidence, clinicians can apply it with confidence. When a more nuanced criterion depends on a single retrospective cohort or a small case series, the tool effectively embeds an assumption rather than a demonstrated effect. Users of the tool, and the health systems that build electronic prescribing alerts around it, generally cannot see that distinction unless the underlying evidence grading is published alongside the criteria themselves.

The Leuven authors observe that this problem is not unique to prescribing tools. A comparative analysis of 50 European Society of Cardiology guidelines published between 2011 and 2022 found that only a minority of recommendations across cardiology practice were supported by the highest level of evidence, and that many rested on class IIb or expert-opinion grounds. Even in cardiology, arguably the most trial-rich specialty in medicine, the pyramid of evidence narrows sharply near the top. If high-certainty evidence is scarce even there, the argument goes, geriatric medicine, whose patient populations are chronically under-represented in trials, cannot reasonably be judged by the same yardstick, and blanket criticism of consensus-based criteria risks throwing away genuinely useful guidance.

Yet the letter also insists that scarcity of trials does not exempt a tool from scrutiny; it changes the kind of scrutiny required. Where randomised evidence is unavailable, the Leuven team argues, developers should make the evidential basis of each criterion explicit: whether it derives from meta-analysis, observational data, pharmacological reasoning or expert consensus, and how confident the developers are that applying the criterion improves patient outcomes. Tools should also be evaluated on the outcomes that matter. A screening list can flag potentially inappropriate prescriptions with perfect sensitivity, but if applying it does not reduce falls, hospitalisations or adverse drug events, and does not preserve quality of life, its clinical value remains unproven. Outcome-based validation studies, not reference appraisals alone, are ultimately what justify clinical use.

The exchange also touches on the economics and governance of guideline production. STOPP/START version 3 was produced by a large European expert panel, and its criteria are increasingly embedded in electronic health record systems, prescribing software and national deprescribing programmes across multiple countries. The letter’s authors note that once a tool reaches this level of adoption, its recommendations acquire de facto regulatory weight: a flagged prescription may be challenged, deprescribed or denied reimbursement on the basis of a criterion whose evidentiary pedigree few end users will ever examine. In their view, this asymmetry between the influence of a tool and the transparency of its foundations is precisely why systematic appraisal efforts such as Boland’s, though unwelcome to the tool’s developers, perform a necessary public service. The appropriate response to criticism, they suggest, is not to lower the bar for appraisal but to build evidence grading into the tool itself, version by version.

What emerges from the three-way exchange is less a verdict on STOPP/START than a blueprint for the next generation of medication optimisation instruments. The Leuven authors propose that developers adopt explicit, published evidence-grading schemes; that consensus methods be documented so that panels’ reasoning is reproducible; that criteria be linked wherever possible to outcome data; and that revision cycles incorporate external appraisal as a feature rather than a threat. They also stress that geriatricians should keep using validated tools in practice, since unsupported prescribing is far riskier than criteria supported by imperfect evidence, while recognising that imperfect evidence is an argument for transparency and continued validation, not complacency. As polypharmacy grows with ageing populations and electronic prescribing systems automate the application of criteria at scale, the question the letter poses, how evidence should be judged for medication optimisation tools, will shape whether these algorithms earn the trust that clinical practice, and the patients they serve, already place in them.

Subject of Research: Evidence standards for medication optimisation tools such as the STOPP/START criteria in geriatric prescribing

Article Title: How should evidence be judged for medication optimisation tools? Reflections on Boland et al. and O'Mahony et al.

Article References: How should evidence be judged for medication optimisation tools? Reflections on Boland et al. and O'Mahony et al.. (n.d.). https://doi.org/10.1007/s41999-026-01545-4

Image Credits: AI Generated

DOI: 10.1007/s41999-026-01545-4

Keywords: STOPP/START criteria, medication optimisation, deprescribing, geriatrics, polypharmacy, evidence-based medicine, GRADE framework, inappropriate prescribing, clinical decision support, consensus validation, pharmacotherapy, older adults