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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Response to Dr Mintzes
Lack of impact of DTCA or consistent effect on prescribing decisions?
The health service burden of "low-impact" Direct-to-Consumer Advertising
Response to Drs Allen and Brody
So Why Does DTCA Stir Us Up So Much?
DTCA helpful, but not the key. So what does cause people to seek care?
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Bennett Parnes, Aurora, colorado. USA physician, University of Colorado
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The comments from Dr Mintzes are much appreciated, especially given her contribution to this area based on her authorship of the earlier study that included patients from the Sacramento area. Dr Mintzes observations as to why the drop in the rate of patient inquiry for prescribed medications are valid. Based on them, I agree that the impact of prescription inquiries may be greater than suggested in the manuscript. However, the rate does appear to have fallen for advertised medications, even among those in private practice (about 5%, compared to 7.2% in the earlier Sacramento study). Our criteria for which prescription medications were advertised was probably more liberal than that used in the Sacramento study (consensus of 3 authors about advertising in the previous few years). Hence the proportion of medications that were advertised in our study were about 2/3rds, compared to only about half in the Sacramento study. Our rate of 5% may have been lower if we used the criteria in the Sacramento study. In support of Dr Mintzes hypothesis that the impact of DTCA is still substantial is the fact that much of the current pharmaceutical advertising is directed toward patients' recognition of new conditions or symptoms. Patients' discussions at clinic visits of new symptoms or conditions based on advertising may be resulting in a substantial number of new prescriptions. In our study, we did not explore this area, and in my opinion, it would be a worthwhile follow up study. Competing interests: None declared |
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Barbara J Mintzes, Vancouver, B.C. Canada Assistant Professor, Department of Anesthesiology, Pharmacology & Therapeutics, UBC
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Dr Parnes and colleagues’ study makes an important contribution to the available research evidence on the effects of direct-to-consumer advertising (DTCA) on prescribing. [1] However, to call the results a ‘lack of impact’, as stated in the title, is highly misleading. In Parnes’ study, if a patient requested a medicine, the physician prescribed it 54% of the time (n=31), but physicians only considered 12/31 (39%) of these medicines to be first choice treatments for the patient. Similarly, in a study of DTCA in Sacramento and Vancouver, we found that physicians only judged half of the requested advertised drugs they prescribed to be very likely treatment choices for other similar patients, as compared with 88% of non-requested drugs. [2] Both results suggest a degree of physician ambivalence about treatment choice. Secondly, Parnes et al. found that physicians felt ‘somewhat’ or ‘significantly’ pressured in a third of consultations in which a patient had requested a medicine. In the absence of comparative information, the authors consider this reassuring. In our study, physicians reported some degree of pressure in 15 (20%) of 74 consultations involving DTCA drug requests. [2] However, in total they only reported pressure in 48 (3%) of 1431 consultations, including these 15. The direction of effect – towards more reported pressure – is unmistakable. In the Sacramento arm of our study, 7.2% of patients requested advertised medicines, a subset of the 15.8% requesting one or more medicine. [2] Parnes reports fewer patient requests: 3.5% overall and 7.2% in private offices, around two-thirds for advertised medicines. Our population was more similar to the private than clinic patients. We included only English-speaking adults, since patients filled in a questionnaire. Parnes’ patients were 44% Hispanic, many non English- speaking, and 24% under 18. These groups likely have lower DTCA exposure. In our study, patients with less self-reported exposure were less likely to request an advertised medicine. Patients in Parnes’ study who could not afford advertised drugs may also have requested fewer. Hansen et al. found that insurance coverage and co-payments affected the likelihood that a patient switched to an advertised proton pump inhibitor. [3] Our results and Parnes’ are in many ways qualitatively similar, yet the interpretation differs dramatically. As Peter Cronholm and colleagues point out, the magnitude of effect on prescribing in Parnes’ study is consistent with billions of dollars in extra sales each year. [4] Is this truly a lack of impact? And if DTCA leads to more prescriptions despite physician ambivalence, are patients protected from another rofecoxib (Vioxx)-like disaster? References
Competing interests: None declared |
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Peter F. Cronholm, MD MSCE, Philadelphia, PA - USA Asst Prof: Univ. of Penn. Department of Fam. Med. and Comm. Health, Cent for Pub. Health Initiatives, Giang T. Nguyen, MD MPH MSCE (nguyeng@uphs.upenn.edu) and Frances K. Barg, PhD (bargf@uphs.upenn.edu), Asst Professors of Family Med. and Com. Health, Cent. for Pub. Health Initiatives, and Leonard David Inst. of Health Economics, Univ. of Pennsylvania.
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While reassuring that the impact of Direct to Consumer Advertizing (DTCA) described in Dr. Parnes’ article was lower than in previous estimates, even the conservative numbers presented have a significant impact on society when framed using a population perspective. With approximately 250 billion dollars spent on pharmaceutically-related healthcare expenditures estimated for 2008, the most conservative estimate one could calculate based on half of 3.5% of visits resulting in the use of a DTCA medication would be close to 4.5 billion dollars [1]. The rate doubles for patients seen in private offices where 82% of outpatient visits take place [2]. As DTCA intentionally focuses on the most expensive drugs available, the true economic impact would likely represent an order of magnitude or more within the current US healthcare system and its regretfully low return on investment. We remain skeptical that DTCA has a “low impact” on healthcare and concerned that almost two-thirds of providers in the study reporting regular contact with the pharmaceutical sales industry. We also express some concern about the increased time burden on healthcare providers that may result from DTCA. While this report suggests that patient request may have the “benefit” of increased patient education and discussion, the specific characteristics of such discussions have not been described. For example, DTCA-prompted medication requests might require providers to educate patients about why the requested medications are not necessarily the best choice; consequently, DTCA may be generating a need for providers to correct misconceptions and supplement incomplete marketing messages. If 37.9% of visits are lengthened as a result of DTCA, a provider in a solo private practice would potentially need to do this type of counseling about 200 times per year (37.9% of visits x 7.2% of patients x 30 patients/day x 5 days/week x 48 weeks). In an era when primary care physicians do not even have adequate time in a typical workday to provide age-appropriate preventive services, the need to spend added time for such conversations may lead to further displacement of medically important services [3]. [1] Centers for Medicare and Medicaid Services. <http://www.cms.hhs.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp#TopOfPage >. Accessed 2009 January 16. [2] Fairbrother G, Gusmano MK, Park HL, Scheinmann R. Care For The Uninsured In General Internists' Private Offices. Health Aff. 2003 November 1, 2003;22(6):217-24. [3] Yarnall, K.S., et al., Primary care: is there enough time for prevention? Am J Public Health, 2003. 93(4): p. 635-41. Competing interests: None declared |
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Bennett L Parnes, Aurora, CO, USA physician, Associate Professor of Family Medicine, University of Colorado
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Thanks much to both of you for your thoughtful comments. This is indeed a topic that generates strong opinions. As an aside, I would like to note that the idea for this project came from a practicing clinician in our PBRN--this is clearly not just a topic for academics. Dr Allen, I agree with your thoughts about the trend toward advertising diseases and symptoms. Suppose a company has a large market share for a certain condition, such as BPH, then advertises the drug in order to gain market share from a competitor. This will probably not lead to as many new prescriptions compared to getting new patients with the condition in for treatment. These new patients are likely to be prescribed the company's product because of its large market share. Another advantage of this approach is that when a condition is advertised, there is no requirement to state all the unpleasant side effects that may occur. I am pleased to hear that you, like many of the clinicians from our survey, have found a way to make patient medication inquiries into a positive experience for the patient's health. Related to this, given the vast amount of DTCA, clinicians and patients are accustomed to discussing it in clinical encounters, compared to several years ago when patient inquiries may have caused more clinician discomfort. Dr Brody, perhaps the only outlet for clinicians to express their discontent is in seminars like the ones you present. Your suggestion for a focus group follow up project is a good one. Point of care surveys by necessity need to be very brief, and this is both a strength in obtaining a large sample size and limiting recall bias, and a limitation in the lack of detail that can be obtained. Competing interests: None declared |
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Howard Brody, Galveston, TX, USA Director, Institute for the Medical Humanities, University of Texas Medical Branch
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Compare these two phenomena: On the one hand is the experience reported in this paper. It is very rare that physicians encounter a patient seeking a drug based on DTCA. When it happens, the physicians seem to regard the event as neutral or positive within their relationship with the patient. On the other hand is the anecdotal experience I can report as a speaker who commonly talks about the ethics of the relationship between us and the drug industry. I generally do not mention DTCA in the main talk as it is peripheral to the question of OUR relationship with Pharma, and whether we act in trustworthy ways in that relationship. It seems that the first, second or third question from the audience will be about DTCA and will suggest a criticism of the practice, with the suggestion that I did not tell the whole story of the drug industry's misdeeds because I did not condemn DTCA. If DTCA is no big deal in this practice-based study where encounters were tracked in real time, why do so many of us think it is such a big deal when the topic is raised in the abstract? What is it about DTCA that grinds on us as much as it does? One area that this study just hints at is the interesting fact that we say that the impact is either neutral or positive; that we say we feel little pressure to prescribe the drug--but we then proceed to prescribe the drug the majority of the time. So something here does not match up, and maybe the feelings that stirs up are more intense than the surface impression. Anyone for a follow-up round of focus group research? Competing interests: None declared |
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Richard E Allen, Salt Lake City, USA St. Mark's Family Medicine Residency, Associate Director
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I appreciate the authors attempt to quantify some of the effects of DTCA. This is an area rich in research opportunities, and important for financial and public health impacts. I am shocked by the low rates of medication requests, and perhaps so are the drug companies. However, as noted in the discussion, this "may reflect recent industry strategies focused on promoting diseases and symptoms... rather than specific medications." In other words, Big Pharma knows that if they can just get the right patients into the clinic, chances are they'll be prescribed the "right" (brand) drug even if not requested. This is especially true for osteoporosis, BPH, and hyperlipidemia where the brand selection is fairly limited (3-5). Note that we rarely see DTCA for anti-hypertensives where there is a myriad of generic and brand-name choices. The study plays on a strong hypothesis of mine for a recent STFM conference lecture, "Dance with the devil: using DTCA to your advantage” [Nov. 2007]. Displaying current t.v. ads, we reiterated a discussion point of the authors, "One potential benefit of DTCA is that patient requests may provide the impetus for increased discussion and education about chronic conditions." Whether or not we prescribe the requested drug (and more often than not we are), the drug companies have effectively brought that couch potato in to see a primary-care doctor. That's a feat that our public health system is wont to succeed at. I consider myself a big anti-brand-name prescriber, and I turn a cold shoulder to biased Pharma reps passing through the office. But I relish the patient visit brought on by DTCA, even for "lifestyle" drugs like erectile dysfunction and the like. Every visit is an opportunity to discuss lifestyle and health risks, and I'd rather see a patient driven in by DTCA for prevention than forced in for secondary treatment. Encounters that are 90% positive is a great result, in the authors' words, "though clinicians were commonly prescribing medications that were not their first treatment choice, there was an overall negative impact of the medication inquiry in only 10%." I'm pleased to see the rare public health ads using the creativity and effective marketing strategies which DTCA has used: catchy music, memorable phrases, and real-life stories to help my patients see the importance of smoking cessation, cancer screening, and cardiovascular risk factors. But in that vein, this study reveals a disappointing rate of return (2.6 - 3.5%). If not advertising, then what are the factors which motivate people to seek preventive care? Competing interests: None declared |
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