Patient orders: When patients ask for specific drugs

Direct-to-consumer advertising may raise awareness about conditions and treatments, but it also may add a new tension to the physician-patient relationship.

By Janice Rosenberg, amednews correspondent. March 19, 2001.

It's impossible to miss them. Direct-to-consumer advertisements for prescription pharmaceuticals are everywhere -- sandwiched between segments of nightly newscasts; interleaved in popular magazines among articles on how to be thinner, happier and healthier; and highlighted on dozens of easily accessible Web sites.

Between January and November 2000, pharmaceutical companies spent an estimated $1.8 billion on all forms of DTC advertising, according to IMS Health, a health care information company in Westport, Conn. And with new drugs constantly coming on the market, the advertising blitz is unlikely to abate.

Flooding the airwaves
Links

As a result, patients ask physicians about drugs they've seen advertised. Sometimes their questions provoke unpleasant confrontations, but more often they promote better communication and improve the physician-patient relationship. In some cases, questions inspired by DTC can lead to real improvements in patients' health.

"Whether the ads are great or not, they are here to stay," says Richard L. Kravitz, MD, professor of medicine at University of California, Davis School of Medicine and director of the Center for Health Services Research in Primary Care at the University of California, Davis. "We need to push the pharmaceutical industry to educate more and sell less."

According to the National Institute for Health Care Management, a Washington, D.C., nonprofit, nonpartisan organization dedicated to improving the effectiveness, efficiency and quality of America's health care system, the most successfully promoted prescription drugs represent five categories: antidepressants, cholesterol-lowering agents, gastric acid reducers, oral antihistamines and antihypertensives.

DTC ads need not receive Food and Drug Administration approval, but the Federal Food, Drug, and Cosmetic Act requires that all drug advertisements contain, among other things, brief summary information regarding side effects, contraindications and effectiveness. Advertisements must not make false or misleading claims and also must include a balanced representation of the benefits and limitations of the product.

Direct-to-consumer pharmaceutical advertisements do not need Food and Drug Administration approval.

"Advertisements by nature are trying to sell a product, so I worry about their bias," says Martin S. Lipsky, MD, chair of the Dept. of Family Medicine at Northwestern University Medical School in Chicago. "Fair balance is hard to do in a 30-second spot. Printed information tends to contain more information so it tends to be a bit more balanced."

The impetus to create DTC advertisements grew out of the 1980s patients' right-to-know movement, says Elizabeth Moench, president of MediciGroup, a patient-oriented marketing communications company in King of Prussia, Pa.

"Patients are so much more informed today," Moench says. "DTC has played a tremendous role in unlocking health information and information about products and treatments."

But just how much information actually is transmitted by the average DTC advertisement? In a December 2000 Journal of Family Practice article, Dr. Kravitz, along with Robert A. Bell, PhD, and Michael S. Wilkes, MD, PhD, published the results of a study aimed at determining the educational value of DTC ads. They targeted advertisements appearing in 18 popular magazines between 1989 and 1998. The researchers then coded 320 ads to determine whether they included information about specific aspects of the medical conditions for which the drug was promoted, and information about treatment.

The researchers found that most advertisements provided the name of the treated medical condition and its associated symptoms, but the majority did not inform potential patients about basic matters such as the risk factors for the condition or its prevalence. Also, the advertisements seldom educated patients about the mechanism by which the drug treated a particular condition, its success in doing so or alternative treatments. They also did not mention behavioral changes that might augment or supplant treatment.

"I would like to see DTC advertisements place more emphasis on symptoms and their interpretation," Dr. Kravitz says. "If treatment is emphasized, then I'd like to see more quantitative information offered on how effective the drug is. Also I'd like to see more information on alternatives, including nondrug therapy."

The push to prescribe

Because patients are more likely than ever to request particular drugs, physicians are looking for ways of responding that improve communication and contribute to good physician-patient relationships. Matthew F. Hollon, MD, PhD, internist and acting instructor at the University of Washington in Seattle, says that as DTC advertising increased, the expectation among physicians that they would be bombarded by patients demanding things has not been borne out.

Still, patients do ask. Dr. Hollon feels open to patients bringing information to visits and discussing it with them, but because often the advertisements produce misperceptions of what the value of any drug is, he ends up spending valuable time reeducating patients.

"My perspective now is one of, 'How do we adapt as physicians to this in a way that allows us to provide the best care for patients and doesn't seem confrontational?' " Dr. Hollon says. "We might come across as confrontational by saying, 'I don't think that's the best thing for you,' but it's hard to avoid that in a limited time frame. You avoid it by spending time with the patient, but other changes in the health system seem to be driving limitations on the amount of time we have with patients."

Sometimes when parents asks about a particular drug shown in an ad, Brian Bates, MD, director of the emergency department at Methodist Children's Hospital in San Antonio, has to say, "It's just not indicated," or "There's not enough proof it will work."

"People take that fairly well, usually," Dr. Bates says. "If they ask about something I don't know about, I'll look into it. Sometimes patients are right about the drugs they suggest. Sometimes it's another option. As long as it's not going to cause harm and is indicated for the condition, I'd prescribe it."

When patients ask about inappropriate drugs, individual physicians can keep the channels of dialogue open by turning the conversation away from the advertised drug and focusing on the symptoms and problems that brought the patient to the office in the first place, Dr. Kravitz says.

To counteract the effects of DTC advertising on a larger scale, Dr. Kravitz would like to see organized medicine produce alternative materials for physicians to give to their patients. When a patient brought in an advertisement, the doctor could say, "I don't think you're a candidate for that, but take a look at this handout from my professional society, and let's discuss this at your next appointment."

DTC advertising also can subtly affect physicians' test-ordering habits. For instance, patients who see advertisements for osteoporosis drugs may pressure their physicians to order bone density tests, which might represent an inappropriate use of medical resources, Dr. Hollon says.

"On the other hand, DTC advertising might get a doctor to order this test for a person who needs it, when he might otherwise not have," Dr. Hollon says. "In this case, a woman becomes primarily responsible for her own health care and appropriately receives testing."

Similarly, widespread advertising of cholesterol-lowering agents has brought many patients to their doctors' offices for testing. Dr. Lipsky views that as beneficial, but he worries that it could promote the overutilization of drugs to treat high cholesterol.

"With cholesterol, lifestyle management is your first goal," Dr. Lipsky says. "Too much advertising over-medicalizes society. For every ill people feel, they think there's a pill, and they want to take it instead of first addressing diet and exercise changes that might affect their condition."

Overall, though, DTC advertising has had a tremendous effect on the continuing evolution of the physician-patient relationship, Dr. Hollon says. In his view, the relationship has evolved from paternalism to shared decision-making and, with a push from DTC advertising, is moving to a new model, consumerism.

"DTC will be a driving force in the changing dynamics of the doctor-patient relationship," Dr. Hollon says. "It will require interesting adaptation by physicians to see what their role is in health care consumerism and probably new teaching strategies for educating physicians on how to best serve patients in a relationship driven largely by health care consumerism."

ADDITIONAL INFORMATION:

Flooding the airwaves

In 1999, pharmaceutical companies spent about $1.8 billion on direct-to-consumer advertising. This represented an increase in spending of more than 1,000% since 1993. This was largely fueled by a boom in television advertising, which increased by more than 4,000% in that period. The numbers represent spending in thousands.

            TV ads    Print ads
         ----------   ---------
   1993     $24,879    $125,089
   1994     $35,738    $229,798
   1995     $54,816    $319,525
   1996    $219,983    $564,697
   1997    $309,584    $740,828
   1998    $664,413    $630,387
   1999  $1,127,107    $711,602

Source: IMS Health and Competitive Media Reporting and Publishers Information Bureau

Internet provides direct hit for drug ads

A huge amount of direct-to-consumer advertising is reaching patients. And the Internet is one of the hot spots, both in providing the latest sources of drug information and in reaching a large audience.

"At least there's the chance that Web sites are providing more educational value than print or broadcast advertising," says Richard L. Kravitz, MD, professor of medicine at the University of California, Davis School of Medicine and director of the Center for Health Services Research in Primary Care at University of California, Davis. "But how accurate or misleading are they? It depends on a review of the content, which would be extremely time consuming."

Take a look for yourself. Internet surfers can glean knowledge of specific products such as Prilosec (http://www.acidcontrol.com/) -- with its complmentary "Purple Pill" (http://www.purplepill.com/) campaign -- by AstraZeneca LP, Zilactin (http://www.mouthsores.com/) by Zila Inc., and Prempro (http://www.prempro.com/newindex.html) by Wyeth-Ayerst Laboratories. There are also other sites that give more general health information. Examples include Roche Laboratories, which offers weight-loss hints and markets Xenical, the company's weight-loss medication (http://www.knowyourbmi.com/), and Novartis Pharmaceuticals Corp.'s Cafe Herpe, a "genital herpes resource information spot for U.S. audiences" (http://www.cafeherpe.com/). The site also markets the drug Famvir.

Weblink

National Institute for Health Care Management Research brief on "Prescription Drugs and Mass Media Advertising" (http://www.nihcm.org/DTCbrief.pdf)

Full text of "The Educational Value of Consumer-Targeted Prescription Drug Print Advertising," The Journal of Family Practice, December 2000 (vol. 49, issue 12) (http://jfponline.com/content/2000/12/jfp_1200_10920.asp)