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Impact of drug promotions and advertising
Patients are hurt while doctors and drugmakers benefit
Based on the Congressional
testimony of Michael Wilkes, M.D., Ph.D. Vice Dean, Medical
Education Professor of Medicine and Public Health, University of
California, Davis in front of the Committee on Government Reform
with respect to safety of Vioxx.
| Does promotion have an impact on overall drug sales?
Perhaps the most obvious answer to this question is “well, of course it does, why else
would drug companies spend $20 billion dollars!” |
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Some studies have tried to answer this question by observing prescribing changes before,
during or after promotional activities. These studies are relatively simple and inexpensive
and provide convincing evidence of the impact on promotion. Cleary looked at what
happened when the level of promotion varied naturally over time, say when a sales
representative was away on a sales training course. He examined trends in numbers of
new prescriptions for three third- generation antibiotics in one
hospital. He found that
when the sales representative was away the numbers of new prescriptions for this product
dropped. This did not happen to the other products studied, and there was no correlation
between the pattern in this hospital or regional or national sales. Dieperink and
Drogemuller looked at one psychiatric medicine. They found that the reason for a
dramatic increase in the use of an atypical antipsychotic agent in their Minneapolis
hospital was a Grand Rounds presentation sponsored by the manufacturer of the product.
Of course the ideal way to find out about the impact of promotion on prescribing is to ask
manufacturers to experimentally vary promotion over regions and times, monitor the
effect of this and publish the results. There is no doubt that drug companies have done
this many times over, but the information is proprietary. None-the-less, it seems clear
that promotion leads to increased sales.
Are promotions aimed at doctors the only effective way to alter drug prescribing?
No. Direct to consumer advertising (DTCA) is the fastest growing part of the advertising
pie accounting for 20% ($8 billion) of promotional activities (depending on how you
count other activities). Like other promotional activities, the vast majority of advertised
products are for new, expensive, “me-to” drugs that have little if any benefit over older
more reliable drugs. The evidence that DTAs work is overwhelming. It works at
defining disease, it works at setting patient expectations that they need a drug for their
disease, it works at guilty doctors in to writing a prescription so as to maintain patient
satisfaction or saving time, and most importantly, it works at selling drugs.
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A growing number of studies have examined the effects of DTC advertising on consumer
and clinician behavior, but few have directly addressed the issue of
over-prescribing. Last week we published in JAMA a randomized controlled trial using standardized patients
(SPs) to address 3 research questions:
- What are the effects of patients’ requests for a prescription on physician
prescribing?
- Does it make a difference whether patients’ requests are brand-specific (as
might be prompted by viewing a DTC television advertisement) or general (as might arise
from watching a television program about a health condition)?
- What are the effects of brand-specific and general requests on 2 other health
care indicators: referral and follow-up?
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The results confirm that patients’ requests have a profound effect on physician
prescribing, quality of medical care, and health care costs.
A major problem with DTCA is that there is no one at home guarding the
hens and the fox is running around wild in the hen house. The FDA does not take their responsibility
to monitor these medical messages seriously. It has less than 40 experts to review tens of
thousands of print and electronic promotions. Even when the FDA does send out a
disciplinary letter it is rarely effective at changing the manufacturers’ behavior. My
research has shown that the public strongly believes that the FDA is monitoring and
correcting drug advertisements to assure their accuracy in ways not done with other
products.
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