Thumbs up/Thumbs down – March 2002 Direct-to-consumer advertising Eric J Topol MD Provost and Chief Academic Officer Chairman, Department of Cardiovascular

Thumbs up/Thumbs down – March 2002

Direct-to-consumer advertising


Eric J Topol MDProvost and Chief Academic OfficerChairman, Department of Cardiovascular MedicineThe Cleveland Clinic FoundationCleveland, Ohio

Robert M Califf MDProfessor of MedicineAssociate Vice Chancellor for Clinical ResearchDirector, Duke Clinical Research InstituteDuke University Medical CenterDurham, North Carolina




Special Guest Commentator

Thomas Lee MD M ScAssociate Professor of Medicine, Harvard Medical SchoolBoston, Massachusetts



Hot topicRosenthal MB, Berndt ER, Donohue JM, et al. Promotion of prescription drugs to consumers. N Engl J Med 2002;346:498-505.

Wolfe SM. Direct-to-consumer advertising -- education or emotion promotion? N Engl J Med 2002;346:524-6.

Holmer AF. Direct-to-consumer advertising -- strengthening our health care system. N Engl J Med 2002;346:526-8.

Lee TH, Brennan TA. Direct-to-consumer marketing of high-technology screening tests. N Engl J Med 2002;346:529-31.

Mintzes B, Barer ML, Kravitz RL, et al. Influence of direct to consumer pharmaceutical advertising and patients' requests on prescribing decisions: two site cross sectional survey.BMJ 2002; 324: 278-279.



Rosenthal MB, et al. N Engl J Med 2002;346:498-

505.


Dollars in millions

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1996 1997 1998 1999 2000



Consumer culture

We're in a consumer's culture, people want information to make their own choices.

"However, I think it [DTC advertising] can do a lot of

damage to medicine in general. It's jacking up the prices, the amount of money being spent on drugs, as well as radiology."

Lee



EBCT

It doesn't seem to add information beyond a typical clinical risk score.

Some people believe it works, some do not and are just doing this for money.

"My feeling is, it's a great technology, it's an interesting technology, but it just has not been shown to be useful yet."

Lee



Three counter arguments

Three points to consider•Those who make medical products or

diagnostic technology are obligated to inform patients about them

•The real issue isn't medical product advertising, it's professionalism of doctors

• It is critical to separate out reimbursement from the issue of people choosing to use a particular diagnostic technology

Califf




505.

Pharma advertising: 2000

Dollars in millions

Direct-to-consumerDirect-to-physician

2467

13 421



Consumer choice"I would not advocate […] having

insurance cover it. But if someone wants to pay out of their pocket and they make their own choice to do that, more power to them. From my perspective, that's the American way and I'm all for it."

Califf

We must separate proven technologies from those which are still questionable



Flip side of consumerism

"You know, ma'am, this isn't a grocery store and I'm not a waiter in a restaurant. You can't just come in and tell me what you want."

Lee

The flip side of consumerism is the patient demanding the tests they want because they can pay for them.



Drugs with most DTC advertising:2000


505.

Dollars in millions

406080

100120140160180



Ads for statins

Source: Merck



Patient information

"The problem really is that health systems and doctors have not created their own information which informs patients adequately […] about what their options are and what their risks and benefits are."

Califf



VIGOR

0.1%0.4%MI

Event

0.2%0.2%CV death

0.4%0.5%Mortality

Naproxen1000 mg

Rofecoxib50 mg

Bombardier CA, et al. N Engl J Med

2000;343:1520-28



Doctors need to give information

"If you survey patients, they would much rather get information from their doctors than from anyone else.

"They're not getting their information from the doctors or the doctors don't have time or the systems aren't set up so that it's easy for them to get information related to medical products or therapeutics."

Califf



Where to spend the money?"Do you think that it's appropriate that a quarter of a billion dollars is spent on television advertising, when there's important issues that haven't been studied appropriately?"

Topol

"I don't think we have the right to tell people they can't advertise if they have a product which is in a market, which is being used by a lot of people."

Califf



Different rules

What if it is the wrong message?•FDA is understaffed to monitor ads•The rules are different for advertising

sneakers than for advertising drugs•There will always be a tendency to

make the downside appear as small as possible

Califf



"The reason I get so upset [about EBCT] is that our own colleagues are doing the things that upset us when the drug companies do them."

Lee

Physicians hawking unproven tests for patients paying out of pocket is a violation of professional ethics.

Professional ethics



How do we prioritize?

"We live in a society where we spend more on potato chips then we do on the treatment of cancer."

Califf

We shouldn't control the problem through regulation.

We don't know enough yet on the CT score.



Professionalism

"I would err less on the side of regulating or eliminating the things and err more on the side of working harder in medical schools to teach doctors what they need to know."

Califf

Professionalism is the key.



Rising costs

Everything rising faster than doctors' salaries is a possible area of waste•Radiology costs increasing 25-30%

annually•Pharmacy costs increasing 15-20%

annually•Tests must be tied to better outcomes

for the patients

Lee



Discretionary income

"People's discretionary income, they can spend it on a new car, or they can spend it on a CT scan."

Califf

"When the patient spending his or her own bucks affects the rest of the health care system, I do think it's fair game for us to talk about it as a profession."

Lee



Ads for Viagra®

Source: Pfizer

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$millions inadvertising:

2000




505.

Direct-to-physician advertising: 2000

Dollars in billions

Office-basedpromotion

Hospital-basedpromotion

Journaladvertising

Free samples

7.954.04



Drugs with most DTC advertising:2000


505.

Dollars in millions

406080

100120140160180



"Just because some good things may happen from something like advertising, it doesn't mean that I want to support that as the main way of making those good things happen."

Lee

The drug companies have not proven able to regulate themselves.

Good from advertising




505.

Direct-to-physician advertising

Dollars in billions

0

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1996 1997 1998 1999 2000



"It's hard enough to learn what you need to learn just to take care of people without having to worry about weeding out the stuff that doesn't add any value."

Lee

Learning



Eroding trust in doctors

Public trust in physicians has eroded•Rise in the use of alternative medicines•The use of the internet for information•Direct-to-consumer advertising•The ability to order their own tests

Topol

Physicians have to practice evidence-based medicine to regain the trust of patients.



Physician education

"Don't you think that the medical schools have been an abject failure in this regard of really training physicians to be prepared to practice as opposed to serving as farm schools for basic science laboratories?"

Califf

"If there aren't any checkpoints in this […] then it's quite dangerous."

Topol



"The last thing I would say is that if physicians don't do it, someone is going to do it for us and that will not be pretty."

Lee

Physicians have to practice evidence-based medicine to regain the trust of patients.

Drawing a line

Documents

Thumbs up/Thumbs down – March 2002 Direct-to-consumer advertising Eric J Topol MD Provost and Chief Academic Officer Chairman, Department of Cardiovascular