Transcript Direct-to-consumer advertising

Direct-to-consumer advertising
Direct-to-consumer advertising
Eric J Topol MD
Provost and Chief Academic Officer
Chairman, Department of Cardiovascular Medicine
The Cleveland Clinic Foundation
Cleveland, Ohio
Robert M Califf MD
Professor of Medicine
Associate Vice Chancellor for Clinical Research
Director, Duke Clinical Research Institute
Duke University Medical Center
Durham, North Carolina
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
Direct-to-consumer advertising
Special Guest Commentator
Thomas Lee MD M Sc
Associate Professor of Medicine,
Harvard Medical School
Boston, Massachusetts
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
Hot topic
Rosenthal 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 hightechnology 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.
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
Direct-to-consumer advertising
Dollars in millions
3000
2500
2000
1500
1000
500
0
1996
1997
Thumbs up/Thumbs down – March 2002
1998
1999
2000
Rosenthal MB, et al.
N Engl J Med
2002;346:498-505.
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Califf
Direct-to-consumer advertising
Pharma advertising: 2000
Dollars in millions
2467
13 421
Thumbs up/Thumbs down – March 2002
Direct-toconsumer
Direct-tophysician
Rosenthal MB, et al.
N Engl J Med
2002;346:498-505.
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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.
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
Drugs with most DTC
advertising:2000
Dollars in millions
180
160
140
120
100
80
60
40
X
X
E
R
B
LE
E
C
A
R
G
IA
V
R
O
C
O
Z
IL
X
A
IN
P
IT
R
LA EC
C
S
O
IL
R
P
X
IO
V
Thumbs up/Thumbs down – March 2002
Rosenthal MB, et al.
N Engl J Med
2002;346:498-505.
Direct-to-consumer advertising
Ads for statins
Thumbs up/Thumbs down – March 2002
Source: Merck
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
VIGOR
Rofecoxib
50 mg
Naproxen
1000 mg
Mortality
0.5%
0.4%
CV death
0.2%
0.2%
MI
0.4%
0.1%
Event
Thumbs up/Thumbs down – March 2002
Bombardier CA, et al.
N Engl J Med
2000;343:1520-28
Direct-to-consumer advertising
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."
Thumbs up/Thumbs down – March 2002
Califf
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
Professional ethics
"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.
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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.
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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.
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
Ads for Viagra®
100
90
80
70
60
50
40
30
20
10
0
Source: Pfizer
Thumbs up/Thumbs down – March 2002
$millions in
advertising:
2000
Direct-to-consumer advertising
Direct-to-physician advertising:
2000
Dollars in billions
Office-based
promotion
4.04
7.95
Hospital-based
promotion
Journal
advertising
Free samples
Thumbs up/Thumbs down – March 2002
Rosenthal MB, et al.
N Engl J Med
2002;346:498-505.
Direct-to-consumer advertising
Drugs with most DTC
advertising:2000
Dollars in millions
180
160
140
120
100
80
60
40
X
X
E
R
B
LE
E
C
A
R
G
IA
V
R
O
C
O
Z
IL
X
A
IN
P
IT
R
LA EC
C
S
O
IL
R
P
X
IO
V
Thumbs up/Thumbs down – March 2002
Rosenthal MB, et al.
N Engl J Med
2002;346:498-505.
Direct-to-consumer advertising
Good from advertising
"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.
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
Direct-to-physician advertising
Dollars in billions
14
12
10
8
6
4
2
0
1996
1997
Thumbs up/Thumbs down – March 2002
1998
1999
2000
Rosenthal MB, et al.
N Engl J Med
2002;346:498-505.
Direct-to-consumer advertising
Learning
"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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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.
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
Drawing a line
"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.
Thumbs up/Thumbs down – March 2002