thumbs up/thumbs down – march 2002 direct-to-consumer advertising eric j topol md provost and...
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Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
Direct-to-consumer advertising
Special Guest Commentator
Thomas Lee MD M ScAssociate Professor of Medicine, Harvard Medical SchoolBoston, Massachusetts
Thumbs up/Thumbs down – March 2002
Direct-to-consumer advertising
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.
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Direct-to-consumer advertising
Rosenthal MB, et al. N Engl J Med 2002;346:498-
505.
Direct-to-consumer advertising
Dollars in millions
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1996 1997 1998 1999 2000
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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
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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
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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
Califf
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Direct-to-consumer advertising
Rosenthal MB, et al. N Engl J Med 2002;346:498-
505.
Pharma advertising: 2000
Dollars in millions
Direct-to-consumerDirect-to-physician
2467
13 421
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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
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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.
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Direct-to-consumer advertising
Drugs with most DTC advertising:2000
Rosenthal MB, et al. N Engl J Med 2002;346:498-
505.
Dollars in millions
406080
100120140160180
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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
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Direct-to-consumer advertising
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
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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."
Califf
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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
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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
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Direct-to-consumer advertising
"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
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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.
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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.
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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
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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
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Direct-to-consumer advertising
Ads for Viagra®
Source: Pfizer
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$millions inadvertising:
2000
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Direct-to-consumer advertising
Rosenthal MB, et al. N Engl J Med 2002;346:498-
505.
Direct-to-physician advertising: 2000
Dollars in billions
Office-basedpromotion
Hospital-basedpromotion
Journaladvertising
Free samples
7.954.04
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Direct-to-consumer advertising
Drugs with most DTC advertising:2000
Rosenthal MB, et al. N Engl J Med 2002;346:498-
505.
Dollars in millions
406080
100120140160180
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Direct-to-consumer 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.
Good from advertising
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Direct-to-consumer advertising
Rosenthal MB, et al. N Engl J Med 2002;346:498-
505.
Direct-to-physician advertising
Dollars in billions
0
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1996 1997 1998 1999 2000
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"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
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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.
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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