Medical Marketing in the United States, 1997-2016

Effect of pharmaceutical promotion and incentives offered by pharmaceutical companies on the prescribing pattern of medical students: a cross-sectional study from a developing nation Pakistan

Background

Pharmaceutical companies continuously pursue healthcare professionals, starting from the medical college level, which can ultimately lead to irrational prescribing of drugs and antibiotics. Therefore, our main aim was to evaluate the opinions and attitudes of medical students toward pharmaceutical promotion.

Methods

This study utilized a cross-sectional online survey that applied the snowball sampling technique. Data were collected from three public and three private sector medical colleges in Punjab, Pakistan using snowball sampling. A modified version of a pre-structured questionnaire was used to collect data between October 2020 and January 2021. Medical students from the third year onward were captivated. The tool was made available on Google Forms and students could access it by clicking the link shared. The effect of promotion on prescribing pattern and future prescribing of antibiotics were measured. Descriptive statistics, chi-square, and t-test were used to analyze the data.

Results

A total of 1,301 students filled out the survey, but only 1,227 responses were acceptable. The average age was found to be 23.4 ± 1.59 years. Slightly more than half of the respondents were male participants (57.7%), and a significant proportion (84.1%) reported being aware of pharmaceutical promotion. A smaller number (27.7%) felt that physicians who meet medical representatives more frequently tend to prescribe more antibiotics and 46.3% indicated they would be willing to prescribe antibiotics under the promotional influence. Medical students who were male, in senior college years, attended government institutions, and had lower parental income showed significantly higher perception and attitude scores (p < 0.05) which, in turn, may show their inclination to promotional activities. Many students agreed with the view that pharmaceutical promotion (PP) activities may alter prescribing practices and also believed that they contribute to the increased irrational prescribing of drugs and antibiotics.

Conclusion

The study revealed that only a small number of students are willing to engage in promotional activities and accept rewards, which influences their choice toward selection of drugs and antibiotics. This study highlighted the necessity of giving proper educational instructions regarding the promotion of drugs to medical students. This study also focused on the educational prerequisites of the students.

Progress in Wound-Healing Products Based on Natural Compounds, Stem Cells, and MicroRNA-Based Biopolymers in the European, USA, and Asian Markets: Opportunities, Barriers, and Regulatory Issues

Wounds are breaks in the continuity of the skin and underlying tissues, resulting from external causes such as cuts, blows, impacts, or surgical interventions. Countless individuals suffer minor to severe injuries, with unfortunate cases even leading to death. In today's scenario, several commercial products are available to facilitate the healing process of wounds, although chronic wounds still present more challenges than acute wounds. Nevertheless, the huge demand for wound-care products within the healthcare sector has given rise to a rapidly growing market, fostering continuous research and development endeavors for innovative wound-healing solutions. Today, there are many commercially available products including those based on natural biopolymers, stem cells, and microRNAs that promote healing from wounds. This article explores the recent breakthroughs in wound-healing products that harness the potential of natural biopolymers, stem cells, and microRNAs. A comprehensive exploration is undertaken, covering not only commercially available products but also those still in the research phase. Additionally, we provide a thorough examination of the opportunities, obstacles, and regulatory considerations influencing the potential commercialization of wound-healing products across the diverse markets of Europe, America, and Asia.

Discrepancies in Conflict-of-Interest Disclosures Among Physicians Receiving Compensation for Monoclonal Antibody Drugs

BACKGROUND

Monoclonal antibody drugs are widely used, highly marketed, expensive compounds. Relationships between these drug manufacturers and physicians may increase the potential for bias in relevant studies.

OBJECTIVE

The aim of this study is to determine the rate of disclosures among physicians receiving compensations for monoclonal antibody drugs (MAbDs).

DESIGN

This is a retrospective, population-based, cross-sectional study.

PARTICIPANTS

The 50 physicians who received the highest financial compensation for selected MAbDs from 2016 to 2020 were included.

MAIN MEASURES

Payment data were obtained from the Open Payments Database, bibliometric data were obtained from SCOPUS, and disclosure data were obtained from relevant publications found in PubMed. The primary outcome was rate of disclosure concordance between self-declared conflict-of-interest and industry-reported payments documented in the Open Payments Database.

KEY RESULTS

Of the 50 physicians examined, 74% (N = 37) had publications examined. A cumulative 6170 payments totaling $18,484,228 were analyzed. A total of 418 relevant papers were reviewed. The rate of full disclosure (all relevant financial relationships disclosed) was 39.5%, partial disclosure (some but not all financial relationships disclosed) was 28.0%, and no disclosure was 26.3%. 6.2% did not require disclosure. Publications authored by dermatologists had the highest rate of full disclosure at 49.3%. There was no association between h-index and disclosure rate. Practice guidelines had the highest rate of full disclosure at 69.2% while basic science papers had the lowest (0%). Lastly, substantial variations in specific journal disclosure policies were found.

CONCLUSIONS

Substantial inconsistencies were found between self-reported disclosures and the Open Payments Database among physicians receiving high compensation for MAbDs. A policy of full disclosure for all publications should be adopted.

AOA Critical Issues: A Culture of Safety Across All Orthopaedic Professional Endeavors

ABSTRACT

Medical professionals strive for a culture of safety in which error is anticipated, systems are designed to catch an error before it causes harm, and each event is an opportunity for specific clinicians and the system they work in to improve. A culture of safety is based on behavioral ethics, which recognizes that the automatic functions of the human mind can lead good people to misstep, and it incorporates tools such as checklists that embody critical thinking in order to help limit missteps and associated harm. Although the discussion surrounding a culture of safety often focuses on patient care, the social contract between physicians and society involves expectations that physicians will use their expertise to promote the public good in all of their professional endeavors. For example, lapses in professional conduct in the management of conflicts of interest and in ethical marketing have led to restrictions in physician self-regulation. Orthopaedic surgeons can cultivate a culture of safety and a growth mindset across all aspects of the profession, including media coverage of musculoskeletal illness, surgeon participation in informational media (e.g., podcasts and blogs), the marketing of oneself or one's practice, practice patterns and variations, academic discourse, expert legal testimony, the development and implementation of policy and law, and commercial ventures. Systems that anticipate the human potential for missteps; create tools, tactics, and structures to limit missteps and associated harm; and support surgeons and their teams in all professional endeavors can contribute to the effective and fulfilling promotion of the public good.

Is society caught up in a Death Spiral? Modeling societal demise and its reversal

Just like an army of ants caught in an ant mill, individuals, groups and even whole societies are sometimes caught up in a Death Spiral, a vicious cycle of self-reinforcing dysfunctional behavior characterized by continuous flawed decision making, myopic single-minded focus on one (set of) solution(s), denial, distrust, micromanagement, dogmatic thinking and learned helplessness. We propose the term Death Spiral Effect to describe this difficult-to-break downward spiral of societal decline. Specifically, in the current theory-building review we aim to: (a) more clearly define and describe the Death Spiral Effect; (b) model the downward spiral of societal decline as well as an upward spiral; (c) describe how and why individuals, groups and even society at large might be caught up in a Death Spiral; and (d) offer a positive way forward in terms of evidence-based solutions to escape the Death Spiral Effect. Management theory hints on the occurrence of this phenomenon and offers turn-around leadership as solution. On a societal level strengthening of democracy may be important. Prior research indicates that historically, two key factors trigger this type of societal decline: rising inequalities creating an upper layer of elites and a lower layer of masses; and dwindling (access to) resources. Historical key markers of societal decline are a steep increase in inequalities, government overreach, over-integration (interdependencies in networks) and a rapidly decreasing trust in institutions and resulting collapse of legitimacy. Important issues that we aim to shed light on are the behavioral underpinnings of decline, as well as the question if and how societal decline can be reversed. We explore the extension of these theories from the company/organization level to the society level, and make use of insights from both micro-, meso-, and macro-level theories (e.g., Complex Adaptive Systems and collapsology, the study of the risks of collapse of industrial civilization) to explain this process of societal demise. Our review furthermore draws on theories such as Social Safety Theory, Conservation of Resources Theory, and management theories that describe the decline and fall of groups, companies and societies, as well as offer ways to reverse this trend.

Antidepressants use in Italy: an ecological study of national and regional trends and associated factors

The present study aimed to (1) provide an update on trends in AD consumption both at the national and regional unit of analysis for the period 2000-2020 in Italy and (2) analyze sociodemographic and healthcare system-related factors associated with AD prescribing at the regional-population level between 2000 and 2019. Data were extracted from reports of the Italian Medicines Agency and databases of the Italian National Institute of Statistics. Linear regression and mixed models were applied to analyze trends in AD use (DDD/1000/day) and ecological factors associated with AD prescribing. Between 2000 and 2010 AD prescription rates constantly increased. Thereafter they stabilized until 2017 when a positive trend began again. There was a positive ecological association between AD prescribing and rates of hospital discharge due to affective disorders, antibiotics prescribing, public non-drug healthcare spending per capita, and Northern regions compared to Southern regions. AD consumption increased massively during the 2000s, flattened during the 2010s but thereafter increased again until 2020. The ecological correlation between healthcare provision/spending and AD consumption suggests that health-economic factors may play an important role.

The Association of Subspecialty and Sex with Industry Payments to Internal Medicine Physicians Who Recently Completed Training

BACKGROUND

Financial relationships with drug and medical device companies may impact quality of care and academic research. However, little is known when and how these financial relationships develop among newly independent physicians who recently completed from residency or fellowship programs in internal medicine (IM).

OBJECTIVE

To compare patterns of industry payments among IM graduates.

DESIGN

Retrospective, observational cohort study.

SUBJECTS

IM graduates from residency or fellowship programs between January 2015 and December 2019.

MAIN MEASURES

We analyzed Open Payments reports made between July 2015 and June 2021 to recent graduates of U.S. Accreditation Council for Graduate Medical Education (ACGME)-accredited residency and fellowship programs in IM. The primary outcome was general payments accepted by these physicians, stratified by procedural (i.e., critical care medicine/pulmonary medicine, cardiac/cardiovascular disease, and gastroenterology) and non-procedural (i.e., infectious disease, general internal medicine, and other specialties) subspecialties. The secondary outcomes included general payments stratified by sex and age at residency or fellowship training completion.

KEY RESULTS

There were 41,669 IM physicians with a median age of 33.0 years. In the first 3 years after completion, the proportion of physicians accepting any general payments was 72.6%, 91.9%, and 86.8% in Critical Care Medicine/Pulmonary Medicine, Cardiac/Cardiovascular Disease, and Gastroenterology, compared to 56.1%, 52.6%, and 52.3% in Infectious Disease, General Internal Medicine, and Other Specialties (p<0.0001). After adjusting for confounding variables, the procedural group showed an increased hazard ratio (HR) for accepting any general payments and at least $5000 of general payments compared to the non-procedural group. The HRs of accepting any general payments in the procedural subspecialty were 2.26 (95% CI, 2.11-2.42) and 2.83 (95% CI, 2.70-2.97) in female and male physicians, respectively (p-value < 0.0001).

CONCLUSION

Industry financial relationships among newly independent physicians in IM exist immediately after completion of training and are influenced by subspecialty, sex, and age.

Direct-to-Consumer Telemedicine Practices in the Health and Fertility of Men: A Systematic Review of the Literature

PURPOSE

Men are increasingly turning toward online direct-to-consumer (DTC) men's health platforms to fulfill their health needs. Research surrounding these platforms is lacking and the motivations and predictors underlying this online health-seeking behavior is largely unknown. This review scopes the existing literature concerning DTC men's health and identifies factors influencing engagement, as well as health outcomes of this platform.

MATERIALS AND METHODS

A structured search was performed following PRISMA guidelines. CINAHL via EBSCO, Embase, MEDLINE via Ovid, PsycINFO, PubMed and Web of Science were searched.

RESULTS

Peer-reviewed quantitative and qualitative studies with a focus on demographics and characteristics of those using DTC men's health platforms, as well as studies related to patient outcomes using such platforms, were included. Ten of the 3,003 studies identified met the inclusion and exclusion criteria. Four cross-sectional descriptive studies evaluated the motivations behind men's engagement with DTC platforms. Convenience, embarrassment and health motivation were identified as predominant factors associated with DTC platform use. The review identified a lack of qualitative studies, and major limitations were noted in the quantitative studies that impacted the accuracy of findings. Six further quantitative studies explored the quality of care provided by DTC platforms. DTC platforms were found to have a varying level of adherence to established clinical guidelines, but appeared to provide satisfactory patient outcomes with low levels of patient-reported side effects and adverse events.

CONCLUSIONS

There is a lack of research within the DTC men's health space given the infancy of the field. Important predictors and motivations underlying men's choices in accessing these platforms have been noted across several studies. However, further studies need to be conducted to investigate the psychosocial underpinnings of this behavior. Studies across a wider variety of male health conditions treated by these platforms will also help to provide insights to guide patient-centered care within the DTC landscape.

Characteristics of men who use direct-to-consumer men's health telemedicine services

The characteristics of men who use direct-to-consumer (DTC) men's health services are not well understood. We conducted an online survey of adult men via ResearchMatch, assessing sociodemographic data, health behaviors, and concern for low testosterone and infertility. Logistic regression estimated the association between participant characteristics and familiarity with and reported use of DTC services such as Hims® and Roman®. Among 1276 men surveyed, 62.2% were concerned about low testosterone. While almost half (48.5%) were familiar with men's DTC health services, only 37 (2.9%) reported using these services. On multivariable analysis, men who used DTC men's health services were more likely to be younger (age 18-39: odds ratio [OR] 2.94, 95% confidence interval [CI] 1.03-8.38, p = 0.04; age 40-59: OR 3.26, CI 1.17-9.10, p = 0.02; referent age ≥60), have annual income between $75k and $100k (OR 5.25, CI 1.39-19.87.45, p = 0.02), and be concerned about low testosterone (OR 3.81, CI 1.46-9.96, p = 0.01). In conclusion, younger men and those with mid-range incomes were more likely to use online DTC men's health services compared to older or wealthier men. Likewise, men with concerns about low testosterone were more likely to use DTC services, but other health-conscious behaviors and frequency of doctor visits did not predict use.

Brand Experience and Customer Loyalty in Dentistry: The Role of Perceived Brand Authenticity

This study investigates the impact of brand experience (BE) on customer loyalty (CL) and examines the possible mediating effect of brand authenticity (BA) and the moderating effect of frequency of visits on the original relationship between BE and CL in dental practices. A descriptive, deductive, and quantitative research methodology was applied, with a self-administrated survey questionnaire over a cross-sectional convenience sample from dental clinics and centers in Erbil, Sulaymaniyah, and Duhok (Iraqi Kurdistan). Data were collected in July and August 2022. SPSS AMOS 26 was used for analyzing 952 patients' responses. The results indicate that BE has a statistically significant positive effect on CL. However, only affective experiences, cognitive experiences, and behavioral experiences have a statistically positive effect on CL. BA has a significant direct mediation effect on the original relationship between BE and CL. In addition, a greater frequency of dental visits improves the BE and impacts CL. Discussion, recommendations, and future research orientation are provided.

The Changing Medical Publishing Industry: Economics, Expansion, and Equity

Medical journal publishing has changed dramatically over the past decade. The shift from print to electronic distribution altered the industry's economic model. This was followed by open access mandates from funding organizations and the subsequent imposition of article processing charges on authors. The medical publishing industry is large and while there is variation across journals, it is overall highly profitable. As journals have moved to digital dissemination, advertising revenues decreased and publishers shifted some of the losses onto authors by way of article processing charges. The number of open access journals has increased substantially in recent years. The open access model presents an equity paradox; while it liberates scientific knowledge for the consumer, it presents barriers to those who produce research. This emerging "pay-to-publish" system offers advantages to authors who work in countries and at institutes with more resources. Finally, the medical publishing industry represents an unusual business model; the people who provide both the content and the external peer review receive no payment from the publisher, who generates revenue from the content. The very unusual economic model of this industry makes it vulnerable to disruptive change. The economic model of medical publishing is rapidly evolving and this will lead to disruption of the industry. These changes will accelerate dissemination of science and may lead to a shift away from lower-impact journals towards pre-print servers.

Skin tone representation in dermatologic direct-to-consumer advertisements: a cross-sectional analysis and call to action

Background

Direct-to-consumer advertisements (DTCAs) in medical marketing serve as a prominent modality to deliver information to an increasingly diverse audience of consumers and increase prescription sales. In dermatology, advertisements have the potential to shape the public's opinions, aid in the understanding of skin conditions, and raise awareness of available treatments.

Objective

To investigate and characterize the representation of skin tones in DTCAs.

Methods

Nielsen ratings were utilized to identify the networks most watched by Black viewers in 2022. Programming on NBCUniversal, ABC, CBS, and FOX that aired in the District of Columbia, suburban Maryland, and Northern Virginia from June 2022 to July 2022 was reviewed for DTCAs. DTCAs were then analyzed to determine the skin tones of models and skin conditions depicted on models with darkly pigmented skin.

Results

Of the 106 DTCAs related to dermatologic conditions, there were 13 unique advertisements featuring 32 unique models. Four advertisements depicted the skin condition on darkly pigmented skin tones. Using the Monk Skin Tone (MST) scale to assess the 32 unique individuals, only 25% (n = 8) were rated at an MST 7 or above, and 6.25% (n = 2) were rated at an MST 10.

Limitations

This study has the limitation of only sampling DTCAs from Washington, District of Columbia which does not fully represent all dermatology-related DTCAs in the United States.

Conclusion

Results of this content analysis demonstrate that the number of persons of color within dermatologic DTCAs is 23%, whereas there are 13.6% Black individuals in the 2021 US census. This suggests that DTCAs are becoming more diverse since 2018. However, findings also show that the vast majority of DTCAs do not include models with darkly pigmented skin, and there remains a lack of advertisements depicting skin disease among people of color. Given the role of DTCAs in informing and aiding patients' requests for prescription drugs, representation of all skin tones is essential for this communication to be effective, especially in the field of dermatology.

Hospital Expenditures Under Global Budgeting and Single-Payer Financing: An Economic Analysis, 2021-2030

U.S. hospitals provide large amounts of low-value care and devote inordinate resources to administration, while some hospitals leverage market power to realize large profits. Meanwhile, many rural and safety net hospitals are financially distressed. The coexistence of waste and want suggests that U.S. hospital financing is neither efficient nor equitable. We model the economic consequences of adopting the mode of hospital payment used in Canada and the U.S. Veterans Health Administration and proposed in the leading congressional single-payer Medicare-for-All bill: global budgeting. Our models assume increased utilization due to expanded and upgraded coverage; gradual reductions in administrative costs from simplified payment; and the elimination of hospital profits, with hospital capital expenditures funded by explicit grants rather than from profits or borrowing. We estimate that non-federal hospital operating budgets will total $17.2 trillion between 2021 and 2030 under current law versus $14.7 trillion under single-payer with global budgeting. This difference reflects $520 billion in foregone profits and $1,984 billion in reduced expenditures on hospital administration; expenditures on clinical operating budgets, however, would be higher than under current law, funded out of profits.

The Racial and Socioeconomic Characteristics of Men Using Mail-in Semen Testing Kits in the United States

OBJECTIVE

To describe the racial and socioeconomic characteristics of men using mail-in semen testing kits for their fertility care in the United States over 3 years.

METHODS

A cross-sectional analysis was conducted of men who used mail-in semen analyses from a single direct-to-consumer (DTC) fertility platform between 2020 and 2022. Age, race/ethnicity, place of residence, and education level of men using mail-in semen analysis kits was collected from user questionnaires. Zip code level socioeconomic status was estimated using the Area Deprivation Index (ADI). These characteristics were compared to the overall population of the United States.

RESULTS

4342 men used mail-in semen analyses from a single DTC fertility company between 2020 and 2022 and completed the questionnaire. The median age of this cohort was 36 (IQR: 32,40) years. The group consisted of predominantly white men (72%), with 7.9% Asian and only 5.1% Black, 3.2% Hispanic, 0.4% Indian American, 0.1% pacific islander, 5.8% mixed race, and 2.8% other groups. 45.8% of the group had completed college, 22% had a master's degree, and 9% had a doctoral degree. The mean ADI was 83.47 (SD 21.44) compared to the average ADI of 100 for the general US population (P < .005).

CONCLUSION

DTC mail-in semen analyses have the potential to improve access to affordable fertility care. Racial and ethnic minorities and lower socioeconomic classes are underrepresented for men seeking DTC fertility testing as they are for men presenting for in-office fertility care. Additional studies are needed to determine the factors responsible for these discrepancies.

The promise and peril of using a large language model to obtain clinical information: ChatGPT performs strongly as a fertility counseling tool with limitations

OBJECTIVE

To compare the responses of the large language model-based "ChatGPT" to reputable sources when given fertility-related clinical prompts.

DESIGN

The "Feb 13" version of ChatGPT by OpenAI was tested against established sources relating to patient-oriented clinical information: 17 "frequently asked questions (FAQs)" about infertility on the Centers for Disease Control (CDC) Website, 2 validated fertility knowledge surveys, the Cardiff Fertility Knowledge Scale and the Fertility and Infertility Treatment Knowledge Score, as well as the American Society for Reproductive Medicine committee opinion "optimizing natural fertility."

SETTING

Academic medical center.

PATIENT(S)

Online AI Chatbot.

INTERVENTION(S)

Frequently asked questions, survey questions and rephrased summary statements were entered as prompts in the chatbot over a 1-week period in February 2023.

MAIN OUTCOME MEASURE(S)

For FAQs from CDC: words/response, sentiment analysis polarity and objectivity, total factual statements, rate of statements that were incorrect, referenced a source, or noted the value of consulting providers.

FOR FERTILITY KNOWLEDGE SURVEYS

Percentile according to published population data.

FOR COMMITTEE OPINION

Whether response to conclusions rephrased as questions identified missing facts.

RESULT(S)

When administered the CDC's 17 infertility FAQ's, ChatGPT produced responses of similar length (207.8 ChatGPT vs. 181.0 CDC words/response), factual content (8.65 factual statements/response vs. 10.41), sentiment polarity (mean 0.11 vs. 0.11 on a scale of -1 (negative) to 1 (positive)), and subjectivity (mean 0.42 vs. 0.35 on a scale of 0 (objective) to 1 (subjective)). In total, 9 (6.12%) of 147 ChatGPT factual statements were categorized as incorrect, and only 1 (0.68%) statement cited a reference. ChatGPT would have been at the 87th percentile of Bunting's 2013 international cohort for the Cardiff Fertility Knowledge Scale and at the 95th percentile on the basis of Kudesia's 2017 cohort for the Fertility and Infertility Treatment Knowledge Score. ChatGPT reproduced the missing facts for all 7 summary statements from "optimizing natural fertility."

CONCLUSION(S)

A February 2023 version of "ChatGPT" demonstrates the ability of generative artificial intelligence to produce relevant, meaningful responses to fertility-related clinical queries comparable to established sources. Although performance may improve with medical domain-specific training, limitations such as the inability to reliably cite sources and the unpredictable possibility of fabricated information may limit its clinical use.

Evaluating the impact of marketing interventions on sugar-free and sugar-sweetened soft drink sales and sugar purchases in a fast-food restaurant setting

BACKGROUND

Beverages high in added sugar, such as sugar-sweetened soft drinks, continue to be associated with various health issues. This study examines the effects of a manufacturer-initiated multicomponent intervention on the sales of sugar-free (SFD) and sugar-sweetened (SSD) soft drinks and the amount of sugar people purchase from soft drinks in a fast-food restaurant setting.

METHODS

A database of monthly sales data of soft drinks from January 2016 to December 2018 was obtained from three treatment and three control fast-food restaurants. A multicomponent intervention consisting of free coupons, point-of-purchase displays, a menu board, and two sugar-free replacements for sugar-sweetened soft drinks was introduced in August 2018 for five months in Western Sydney, Australia. A retrospective interrupted time series analysis was used to model the data and examine the effects of the interventions on SFD and SSD sales and their consequential impact on sugar purchases from soft drinks. The analyses were carried out for volume sales in litres and sugar in grams per millilitre of soft drinks sales. A comparison of these measures within the treatment site (pre- and post-intervention) and between sites (treatment and control) was conducted.

RESULTS

The interventions had a statistically significant impact on SFDs but not SSDs. On average, SFD sales in the treatment site were 56.75% higher than in the control site. Although SSD sales were lower in the treatment site, the difference with the control site was not statistically significant. The net reduction of 6.34% in the amount of sugar purchased from soft drinks between sites during the experimental period was attributed to the interventions.

CONCLUSIONS

The interventions significantly increased SFD sales and reduced sugar purchases in the short run. Aside from free coupons, the findings support the recommendation for fast food restaurants to nudge customers towards choosing SFDs through point-of-purchase displays and the replacement of popular SSDs with their SFD counterparts.

Characterizing internet search patterns for neurologic and neurosurgical conditions following celebrity diagnosis

Social media and internet platforms have become significant drivers of mass-information. Highly publicized events, such as John McCain's announcement of his glioblastoma diagnosis, often drive national public interest in medical topics. Improved understanding of the temporality of interest spikes as well as the nature of the information that garners attention from outside the medical community can help inform ways in which the medical community can boost awareness of (and interest in) the field of neurosurgery. We utilized the "explore topics" feature on Google Trends to obtain web, news, and YouTube search data from May 1, 2015, to May 1, 2019 for the terms "glioblastoma," "brain tumor," "stroke," and "multiple sclerosis" to identify periods of visibly increased search interest. Search results for "glioblastoma" showed significantly elevated average interest during the period of July 3-23, 2017, as compared to that generated since this specific time period (42.6 vs. 8.73, P<0.001). This increased search activity therefore directly correlated with John McCain's public announcement of his glioblastoma diagnosis, and a similar search interest spike was evident using the search term "brain tumor" (87.3 vs. 64.2, P<0.001). Search results for "multiple sclerosis" showed - as a result of the online buzz created by Selma Blair's battle with the disease - significantly elevated average interest from October 8, 2018, to October 28, 2018, and February 11, 2019, to March 3, 2019, when compared to the average interest of the remaining time (59 vs. 40.16, P<0.001 and 69 vs. 40.16, P<0.001). Finally, there were no corresponding elevations in YouTube search interest for any of the terms associated with increased interest on Google Trends. Following major events related to the neurological disease of public figures there is an expected rise in Google search interest relevant to these topics. Our findings suggest that there is an optimal window of approximately 2 weeks following each of these events for activist and clinical groups to publicize their desired message, and for the field of neurosurgery and neurological science to increase public awareness regarding specific diseases, with a regression to baseline interest by 4 months following the event.

Complexity of Data Displays in Prescription Drug Advertisements for Healthcare Providers

BACKGROUND

Healthcare providers (HCPs) often encounter clinical trial results in the form of data displays in prescription drug promotions. Information conveyed in data displays vary in their presentation and complexity. This study describes characteristics of data displays in prescription drug advertising targeted to HCPs.

METHODS

This study characterized the content of 140 data displays in 98 unique print advertisements from 2009 to present and identified in AdPharm, an online database of pharmaceutical advertisements. Two reviewers independently coded the advertisements for characteristics (κ = 0.85) including complexity, format, and quality.

RESULTS

About one-third (32%) of the advertisements contained multiple data displays (range 2 to 6) and 44% showed clinical data from oncology trials; other disease domains were mental and behavioral health (14%), rheumatology and autoimmune disorders (8%), endocrinology (7%), cardiology (6%), infectious disease (6%), pulmonology and allergy (4%), and others (< 2% each). About one-half (51%) of displays were classified as "simple" which included "pseudographs" and basic tables or charts. "Complex" displays appeared as survival curves, line graphs, or bar graphs with complex features. Most complex displays included a comparator drug (90%), plain language restatement of the key finding (93%) and disclosure statements (91%) with additional study details, although their placement varied. Complex displays were of high quality, according to our selected indicators; our analysis found no data distortion or errors.

CONCLUSION

Data displays in prescription drug advertising are often highly complex. Future research assessing understanding of data displays and the potentially beneficial effect of disclosures and other features is warranted.

The healthcare field as a marketplace: general practitioners, pharmaceutical companies, and profit-led prescribing in Pakistan

Incentivisation of general practitioners (GPs) by pharmaceutical companies is thought to affect prescribing practices, often not in patients' interest. Using a Bourdieusian lens, we examine the socially structured conditions that underpin exchanges between pharmaceutical companies and GPs in Pakistan. The analysis of qualitative interviews with 28 GPs and 13 pharmaceutical sales representatives (PSRs) shows that GPs, through prescribing medicines, met pharmaceutical sales targets in exchange for various incentives. We argue that these practices can be given meaning through the concept of 'field' - a social space in which GPs, PSRs, and pharmacists were hierarchically positioned, with their unique capacities, to enable healthcare provision. However, structural forces like the intense competition between pharmaceutical companies, the presence of unqualified healthcare providers in the healthcare market, and a lack of regulation by the state institutions produced a context that enabled pharmaceutical companies and GPs to use the healthcare field, also, as space to maximise profits. GPs believed the effort to maximise incomes and meet socially desired standards were two key factors that encouraged profit-led prescribing. We conclude that understanding the healthcare field is an important step toward developing governance practices that can address profit-led prescribing.

Is exposure to pharmaceutical direct-to-consumer advertising for heart disease and diabetes associated with physical activity and dietary behavior?

CONTEXT

Scholars have suggested that direct-to-consumer advertising (DTCA) of prescription drugs may discourage or encourage changes in lifestyle to improve health. The current paper informs this debate by examining associations between estimated exposure to DTCA for drugs focused on heart disease/cholesterol and diabetes and self-reported exercise and consumption of a variety of unhealthy foods (candy, sugary drinks, alcohol, and fast food).

METHODS

We estimated exposure to DTCA by combining data from Kantar Media Intelligence (Kantar) on televised pharmaceutical DTCA airings in the U.S. from January 2003 to August 2016 (n = 7,696,851 airings) with thirteen years of data from the Simmons National Consumer Survey (Simmons), a mailed survey on television viewing patterns. We estimated associations between exposure to advertising (both overall and for advertisements with specific content) and self-reported physical activity and dietary behavior using Simmons data from January 2004 to December 2016 (n = 288,483 respondents from n = 157,621 unique households in the U.S.). Our analysis controls for many potential confounders including respondent demographics, temporal trends, and program placement to account for purposeful ad targeting to higher-risk adults.

FINDINGS

Higher estimated exposure to DTCA for heart disease and diabetes drugs were not consistently associated with meaningful differences in the frequency of engaging in regular physical activity. Greater estimated exposure to DTCA for both diseases were, linked to small but consistently higher volume of consumption of candy, sugar-sweetened beverages, alcohol, and fast food. Specific DTCA message content about diet and exercise explained very little of the observed association between overall DTCA exposure volume and study outcomes.

CONCLUSIONS

Many Americans were regularly exposed to pharmaceutical DTCA for heart disease and diabetes from 2003 to 2016. Widespread exposure to such DTCA is associated with higher levels (though small in magnitude) of consuming alcohol, fast food, candy, and sugar-sweetened beverages.

Pharmaceutical policies: effects of policies regulating drug marketing

BACKGROUND

The costs of developing new treatments and bringing them to the market are substantial. The pharmaceutical industry uses drug promotion to gain a competitive market share, and drive sale volumes and industry profitability. This involves disseminating information about new treatments to relevant targets. However, conflicts of interest can arise when profits are prioritised over patient care and its benefits. Drug promotion regulations are complex interventions that aim to prevent potential harm associated with these activities.

OBJECTIVES

To assess the effects of policies that regulate drug promotion on drug utilisation, coverage or access, healthcare utilisation, patient outcomes, adverse events and costs.

SEARCH METHODS

We searched Epistemonikos for related reviews and their included studies. To find primary studies we searched MEDLINE, CENTRAL, Embase, EconLit, Global Index Medicus, Virtual Health Library, INRUD Bibliography, two trial registries and two sources of grey literature. All databases and sources were searched in January 2023.

SELECTION CRITERIA

We planned to include studies that assessed policies regulating drug promotion to consumers, healthcare professionals or regulators and third-party payers, or any combination of these groups.In this review we defined policies as laws, rules, guidelines, codes of practice, and financial or administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug utilisation, coverage or access, healthcare utilisation, patient health outcomes, any adverse effects (unintended consequences), and costs. The study had to be a randomised or non-randomised trial, an interrupted time series analysis (ITS), a repeated measures (RM) study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies. When consensus was not reached, any disagreements were discussed with a third review author.  We planned to use the criteria suggested by Cochrane Effective Practice and Organisation of Care (EPOC) to assess the risk of bias of included studies. For randomised trials, non-randomised trials, and CBA studies, we planned to estimate relative effects, with 95% confidence intervals (CI). For dichotomous outcomes, we planned to report the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For ITS and RM, we planned to compute changes along two dimensions: change in level and change in slope. We planned to undertake a structured synthesis following EPOC guidance.  MAIN RESULTS: The search yielded 4593 citations, and 13 studies were selected for full-text review. No study met the inclusion criteria.

AUTHORS' CONCLUSIONS

We sought to assess the effects of policies that regulate drug promotion on drug use, coverage or access, use of health services, patient outcomes, adverse events, and costs, however we did not find studies that met the review's inclusion criteria. As pharmaceutical policies that regulate drug promotion have untested effects, their impact, as well as their positive and negative influences, is currently only a matter of opinion, debate, informal or descriptive reporting. There is an urgent need to assess the effects of pharmaceutical policies that regulate drug promotion using well-conducted studies with high methodological rigour.

Prescription Drug Advertising and Drug Utilization: The Role of Medicare Part D

This paper examines how direct-to-consumer advertising (DTCA) for prescription drugs influences utilization by exploiting a large and plausibly exogenous shock to DTCA driven by the introduction of Medicare Part D. Part D led to larger increases in advertising in geographic areas with higher concentrations of Medicare beneficiaries. We examine the impact of this differential increase in advertising on non-elderly individuals to isolate advertising effects from the direct effects of Part D. We find that exposure to advertising led to large increases in treatment initiation and improved medication adherence. Advertising also had sizeable positive spillover effects on non-advertised generic drugs. Our results imply significant spillovers from Medicare Part D on the under-65 population and an important role for non-price factors in influencing prescription drug utilization.

Gender bias in antidepressant direct-to-consumer pharmaceutical advertising

BACKGROUND

Direct to consumer pharmaceutical advertising (DTCPA) may have significant impacts on public perception of diseases and treatments. Our objective was to examine whether DTCPA for antidepressants disproportionately portray and hence target women in the United States.

METHODS

DTCPA for branded medications for depression, psoriasis and diabetes were analyzed to determine the gender of the main "patient" portrayed, as well as the content of the disease depiction.

RESULTS

DTCPA for antidepressants included only women in 82% of ads, only men in 10.1% of ads, and both genders in 7.8% of ads. There were significantly higher representations of women versus men in DTCPA for antidepressants (82%) compared to either psoriasis (50.4%) or diabetes (37.6%) medications. These differences remained statistically significant even after adjusting for gender disparities in disease prevalence.

CONCLUSIONS

Antidepressant DTCPA in the United States disproportionately target women. There are potential adverse consequences for both women and men resulting from unequal representations in DTCPA for antidepressant medications.

Industry Payments During the COVID-19 Pandemic to Cardiologists in the United States

In the US, research has established that a funding relationship exists between pharmaceutical industries and physicians, particularly cardiologists. This study aimed to fill a research gap via an in-depth data analysis of the impact that the coronavirus 2019 restrictions had on this dynamic. The payments per cardiologist declined by 55.7% (95% confidence interval: 52.0%‒-59.0%, P < 0.001) in monetary amounts, and by 66.6% (95% confidence interval: 66.1%-67.1%, P < 0.001) in the number of payments right after the COVID-19 pandemic onset, respectively. Cardiologists must consider the ethical implications of the potential for their clinical practice to be influenced by industry payments.

Oversight of in-office dispensing and samples in dermatology

The provision of samples and in-office dispensing of products and medications to patients are important, yet often controversial, practices in dermatology. Opinions on the practices of sampling and in-office dispensing vary greatly among dermatologists. Ultimately, there are several advantages and disadvantages associated with each practice, and common topics of discussion include ethics, costs, safety, and adherence. Many of the concerns associated with the practices of sampling and dispensing in dermatology may be mitigated by careful consideration and action by prescribers. Providers should be aware of their current practices surrounding these issues and, if used, methods by which these practices can be improved to optimize patient care. With careful consideration, it may be possible to practice sampling and dispensing of products and medications safely, ethically, and to the patients' advantage as an integral part of the dermatology practice.

A scoping review of empirical research on prescription drug promotion

BACKGROUND

Pharmaceutical spending on prescription drug promotion is considerable, and exposure to advertising can influence demand and behavior. The U.S. Food and Drug Administration (FDA) provides industry guidance to help ensure that communications to consumers and health care providers about prescription drug promotion are truthful, balanced, and accurately communicated. As empirical research has accelerated on this topic in the past decade, an understanding of the current landscape of the science will help inform future research.

OBJECTIVES

Using systematic methods, this rigorous scoping review of the literature over the past decade (2012-2021) (1) examined the extent to which prescription drug promotion has been empirically investigated with consumers, patients, and health care providers; (2) examined the extent to which content and features of prescription drug promotion have been empirically investigated; and (3) identified themes across the literature to better understand the current landscape of prescription drug promotion.

METHODS

Databases searched include PubMed, Web of Science, CINAHL, APA PsycInfo, Business Source Corporate, Communication Source, Cochrane Library, and ClinicalTrials.gov for original research published in English from January 1, 2012, through November 10, 2021, using terms related to direct-to-consumer advertising, prescription drugs, and outcomes of interest (e.g., attitudes, perceptions, intentions, behaviors).

RESULTS

Of 804 screened references, 151 studies addressed the first research question, and 40 studies addressed the second. The most common theme across the body of evidence focused on testing of features and content in prescription drug promotional materials (84), followed by studies examining attitudes, perceptions, and behaviors toward prescription drug promotion more generally (43). Some (27) studies focused on targeted populations, such as patients, the elderly, non-English speaking people or individuals of a non-white race/ethnicity. Twenty-four studies assessed influence of exposure to prescription drug promotion on actual clinical outcomes, while 11 studies examined emerging technologies around prescription drug promotion. Seven studies evaluated the extent to which prescription drug promotion complied with existing guidelines and requirements.

CONCLUSIONS

Findings from this scoping review suggest there has been an increase in the number of empirical studies conducted on prescription drug promotion over the past decade. Potential areas that warrant further study include examination of emerging technologies, an expanded focus on targeted populations, and construct measurement.

Consumer perceptions of information features in healthcare service advertisements and attitudes toward advertising

Purpose

With the increasing dependence on market-based distribution of health-care resources in the USA, spending on health-care service advertisements directly targeting consumers has also increased. Previous research has shown that the ads fail to deliver information deemed essential by regulators. Nevertheless, the attitude of consumers toward health-care service advertising has been more positive than negative. The purpose of this study is to create a taxonomy of advertising information features to better describe the relationships between information features in the advertisements and consumer attitudes toward them.

Design/methodology/approach

A cross-sectional survey was conducted with 128 health-care consumers in a western state in the USA.

Findings

Factor analysis generated seven groups of information features. Among them, information features about access, cost and quality of care were rated as most helpful, whereas providers’ clinical qualifications and communication were rated least helpful. The advertising attitude measure was validated to contain two subscales, one regarding health-care service advertising and the other regarding physicians who advertise. People who highly rated the consumerism features had more positive attitudes toward health-care service advertising and people who highly rated provider clinical qualification features had more negative attitudes toward advertising physicians.

Originality/value

This study made methodological improvements in health-care service advertising research that would be crucial for its theoretical development. It also shed light on consumer characteristics and perceptions about information features that could influence their attitudes toward health-care service advertising.

Association Between Drug Characteristics and Manufacturer Spending on Direct-to-Consumer Advertising

Importance

Some drugs are heavily marketed through direct-to-consumer advertising.

Objective

To identify drug characteristics associated with a greater share of promotional spending on advertising directly to consumers.

Design, Setting, and Participants

Exploratory cross-sectional analysis of drug characteristics and promotional spending for the 150 top-selling branded prescription drugs in the US in 2020 as identified from IQVIA National Sales Perspectives data. Promotional spending data were provided by IQVIA ChannelDynamics.

Exposures

Drug characteristics (total 2020 sales; total 2020 promotional spending; clinical benefit ratings; number of indications, off-label use; molecule type; nature of condition treated; administration type; generic availability; US Food and Drug Administration [FDA] approval year, World Health Organization anatomical therapeutic chemical classification; Medicare annual mean spending per beneficiary; percent sales attributable to the drug; market size; market competitiveness) assessed from health technology assessment agencies (France's Haute Autorité de Santé and Canada's Patented Medicine Prices Review Board) and drug data sources (Drugs@FDA, the FDA Purple Book, Lexicomp, Merative Marketscan Research Databases, and Medicare Spending by Drug data).

Main Outcomes and Measures

Proportion of total promotional spending allocated to direct-to-consumer-advertising for each drug.

Results

The 2020 median proportion of promotional spending allocated to direct-to-consumer advertising was 13.5% (IQR, 1.96%-36.6%); median promotional spending, $20.9 million (IQR, $2.72-$131 million); and median total sales, $1.51 billion (IQR, $0.97-$2.26 billion). Of the 150 best-selling drugs, 16 were missing data and key covariates; therefore, the primary study sample comprised 134 drugs. After adjustment for multiple drug characteristics, the mean proportion of total promotional spending allocated to direct-to-consumer advertising for the remaining 134 drugs was an absolute 14.3% (95% CI, 1.43%-27.2%; P = .03) higher for those with low added clinical benefit than for those with high added clinical benefit and an absolute 1.5% (95% CI, 0.44%-2.56%; P = .005) higher for each 10% increase in total sales.

Conclusions and Relevance

Among top-selling US drugs in 2020, a rating of lower added benefit and higher total drug sales were associated with a higher proportion of manufacturer total promotional spending allocated to direct-to-consumer advertising. Further research is needed to understand the implications of these findings.

An Online Investigation Into Direct-to-Consumer Men's Health Clinics: The Who, What, and Where

OBJECTIVE

To characterize direct-to-consumer (DTC) men's health clinics by reviewing their online content. Increasing numbers of patients are seeking treatment for erectile dysfunction (ED) and hypogonadism from DTC "men's health" clinics. Treatments are often used off-label, with lack of transparency of provider credentials and qualifications.

METHODS

We identified DTC Men's Health Clinics in the United States by internet search by state using the terms, "Men's Health Clinic," and "Low T Center." All stand-alone clinics were reviewed.

RESULTS

Two hundred and twenty-three clinics were reviewed, with 147 (65.9%) offered ED treatments and 196 (87.9%) offering testosterone replacement, and 120 (53.8%) offering both ED treatment and testosterone replacement. Of those clinics offering ED treatments, 93 (63.3%) advertised shockwave therapy and 84 (57.1%) PRP therapy. There were 56 (38%) who offered shockwave therapy and PRP. ICI was significantly more likely to be offered if there was a urologist on staff (p <.001). Clinic providers represented 20 different medical and alternative medicine specialties. Internal medicine was most common (17.4%), followed by family medicine (11.1%). A nonphysician (nurse practitioner or physician assistant) was listed as the primary provider in 10 clinics (4.5%) and 45 clinics (20.1%) did not list their providers. Urologists were listed as the primary provider in 10.3% of clinics. A naturopathic provider was listed as a staff member in 22 (11.6%) of clinics.

CONCLUSION

There is significant heterogeneity and misinformation available to the public regarding men's health. Familiarity with and insight into practice patterns of "men's health" clinics will help provide informed patient care and counseling.

Health education via "empowerment" digital marketing of consumer products and services: Promoting therapeutic benefits of self-care for depression and chronic pain

Increasing health care costs and high economic burden exemplify the impact of chronic diseases on public health. Multifaceted approaches to treating chronic diseases include pharmaceutical drugs, digital therapeutics, and lifestyle medicine. Chronic diseases are largely preventable, and health promotion yields positive outcomes. However, despite positive return on investment (ROI) and cost-to-benefit ratio (CBR) for health promotion (median ROI 2.2, median CBR 14.4), commercial marketing of healthy lifestyles and self-care is limited. The objective of this perspective article is to discuss how digital marketing of consumer goods and services that support therapeutic self-care can also bridge public health and for-profit interests. We describe how "empowerment" marketing campaigns can provide evidence-based associations between products/services and self-care benefits for people living with chronic pain and depression. Such a "health education as marketing" strategy is illustrated by educational ads describing how contact with nature, music, and yoga can improve chronic pain and reduce depressive symptoms. Creating associations between health-related benefits of these activities with products (outdoor and yoga apparel, audio equipment) and services (music streaming services, music mobile apps, eco-tourism, yoga studios) that support them expand their value proposition, thus incentivizing profit-driven companies to engage in public health campaigns. Long-term success of companies that incorporate evidence-based health education as marketing and branding strategies will depend on following ethical considerations and advertising guidelines defined by consumer protection regulatory agencies, such as the Federal Trade Commission (FTC). In conclusion, integration of health education about self-care and commercial marketing can support health care outcomes and disease prevention.

Therapeutic Value of Drugs Frequently Marketed Using Direct-to-Consumer Television Advertising, 2015 to 2021

This cohort study assesses whether drugs with the most direct-to-consumer television advertising represent advances over existing treatments.

Medical journals and advertiser tracking-Consequences for patients, clinicians, and editors

Medical journal websites frequently contain tracking code that transfers data about journal readers to third parties. These data give drug, device, and other medical product companies a potentially powerful resource for targeting advertisements and other marketing materials to journal readers based on unique attributes and medical interests that can be inferred from the articles they read. Thus, while editors may strictly regulate the content of advertisements that such companies place in their journals' pages, they simultaneously provide those companies with the means to target readers in other forums, possibly in ways that subvert editorial guidelines. We examine the implications of third-party tracking on medical journal webpages, and recommend actions that publishers, editors, and academic societies can take to curb it.

Tip of the Iceberg? Country- and Company-Level Analysis of Drug Company Payments for Research and Development in Europe

BACKGROUND

Creating new therapies often involves drug companies paying healthcare professionals and institutions for research and development (R&D) activities, including clinical trials. However, industry sponsorship can create conflicts of interest (COIs). We analysed approaches to drug company R&D payment disclosure in European countries and the distribution of R&D payments at the country and company level.

METHODS

Using documentary sources and a stakeholder survey we identified country- regulatory approaches to R&D payment disclosure. We reviewed company-level descriptions of disclosure practices in the United Kingdom, a country with a major role in Europe's R&D. We obtained country-level R&D payment data from industry trade groups and public authorities and company-level data from eurosfordocs.eu, a publicly available payments database. We conducted content analysis and descriptive statistical analysis.

RESULTS

In 32 of 37 studied countries, all R&D payments were reported without named recipients, following a self-regulatory approach developed by the industry. The methodological descriptions from 125 companies operating in the United Kingdom suggest that within the self-regulatory approach companies had much leeway in deciding what activities and payments were considered as R&D. In five countries, legislation mandated the disclosure of R&D payment recipients, but only in two were payments practically identifiable and analysable. In 17 countries with available data, R&D constituted 19%-82% of all payments reported, with self-regulation associated with higher shares. Available company-level data from three countries with self-regulation suggests that R&D payments were concentrated by big funders, and some companies reported all, or nearly all, payments as R&D.

CONCLUSION

The lack of full disclosure of R&D payments in countries with industry self-regulation leaves considerable sums of money unaccounted for and potentially many COIs undetected. Disclosure mandated by legislation exists in few countries and rarely enhances transparency practically. We recommend a unified European approach to R&D payment disclosure, including clear definitions and a centralised database.

Evaluation of financial conflicts of interest and quality of evidence in Japanese gastroenterology clinical practice guidelines

BACKGROUND

Clinical practice guidelines assist healthcare professionals in providing evidence-based care. However, pharmaceutical companies' financial interests often influence guideline content. This study aimed to elucidate the magnitude of financial ties among Japanese gastroenterology guideline authors and the pharmaceutical industry.

METHODS

Using pharmaceutical company disclosed payment data, we evaluated financial conflicts of interest (COI) among Japanese Society of Gastroenterology guideline authors between 2016 and 2021. Additionally, we assessed the evidence quality supporting guideline recommendations and associations with financial COI. Finally, we evaluated author COI management during guideline development against global standards.

RESULTS

Overall, 88.2% (231/262) of guideline authors received a median of $12 968 (interquartile range [IQR]: $1839-$70 374) in payments between 2016 and 2019 for lectures, writings, and consulting. Chairpersons received significantly higher payments (median: $86 444 [IQR: $15 455-$165 679]). Notably, 41 (15.6%) authors had undeclared payments exceeding declaration requirements. Low or very low-quality evidence supported 41.0% of recommendations. There was a negative association between the median 4-year payment per author and the proportion of recommendations based on low-quality evidence (odds ratio: 0.966 [95% confidence interval [95% CI]: 0.945-0.987], P = 0.002) and positive association with moderate-quality evidence (odds ratio: 1.018 [95% CI: 1.011-1.025], P < 0.001). Still, the Japanese Society of Gastroenterology guideline development process remains less transparent, with insufficient COI policies relative to global standards.

CONCLUSION

There were extensive financial COI between pharmaceutical companies and guideline authors, and more than 40% of recommendations were based on low-quality evidence. More rigorous and transparent COI policies for guideline development adhering to global standards are warranted.

Qualitative Analysis of Patient-Physician Discussions Regarding Anticoagulation for Atrial Fibrillation

Importance

For patients with atrial fibrillation (AF), the decision to initiate anticoagulation involves the choice between warfarin or a direct oral anticoagulant (DOAC). How physicians engage patients in this decision is unknown.

Objective

To describe the content of discussions between patients with AF and physicians regarding choice of anticoagulation.

Design, Setting, and Participants

This qualitative content analysis included clinical encounters between physicians and anticoagulation-naive patients discussing anticoagulation initiation between 2014 and 2020.

Main Outcomes and Measures

Themes identified through content analysis.

Results

Of 37 encounters, almost all (34 [92%]) resulted in a prescription for a DOAC. Most (25 [68%]) patients were White; 15 (41%) were female and 22 (59%) were male; and 24 (65%) were aged 65 to 84 years. Twenty-one physicians conducted the included encounters, the majority of whom were cardiologists (14 [67%]) and male (19 [90%]). The analysis revealed 4 major categories and associated subcategories of themes associated with physician discussion of anticoagulation with anticoagulation-naive patients: (1) benefit vs risk of taking anticoagulation-in many cases, this involved an imbalance in completeness of discussion of stroke vs bleeding risk, and physicians often used emotional language; (2) tradeoffs between warfarin and DOACs-physicians typically discussed pros and cons, used persuasive language, and provided mixed signals, telling patients that warfarin and DOACs were basically equivalent, while simultaneously saying warfarin is rat poison; (3) medication costs-physicians often attempted to address patients' questions about out-of-pocket costs but were unable to provide concrete answers, and they often provided free samples or coupons; and (4) DOACs in television commercials-physicians used direct-to-consumer pharmaceutical advertising about DOACs to orient patients to the issue of anticoagulation as well as the advantages of DOACs over warfarin. Patients and physicians also discussed class action lawsuits for DOACs that patients had seen on television.

Conclusions and Relevance

This qualitative analysis of anticoagulation discussions between physicians and patients during clinical encounters found that physicians engaged in persuasive communication to convince patients to accept anticoagulation with a DOAC, yet they were unable to address questions regarding medication costs. For patients who are ultimately unable to afford DOACs, this may lead to unnecessary financial burden or abandoning prescriptions at the pharmacy, placing them at continued risk of stroke.

The Trend in Industry Payments During the COVID-19 Pandemic Among Gastroenterologists and Hepatologists in the United States

Background Although the sudden coronavirus disease 2019 (COVID-19) pandemic would have significantly influenced financial relationships between the healthcare industry and gastroenterologists and hepatologists, little is known about the trend in financial relations in the United States. This study, thus, aimed to examine the trends in industry payments made to gastroenterologists and hepatologists during the COVID-19 pandemic. Materials and methods Using the Open Payments Database between 2013 and 2021, we evaluated trends in financial relationships between the healthcare industry and gastroenterologists and hepatologists in the United States. Trends in general payments during the COVID-19 pandemic were evaluated by interrupted time series analysis with monthly and yearly payments at the physician level. Results A total of 16,808 or 89.4% of all active gastroenterologists received general payments totaling $393,823,094 from the pharmaceutical and medical device companies between 2013 and 2021. The payment per gastroenterologist and the number of gastroenterologists receiving payments decreased by 70.9% (95% CI: -73.4% - -68.1%, p<0.001) and by 51.5% (95%CI: -52.2% - -50.7%, p<0.001) due to the onset of the COVID-19 pandemic, respectively. However, both payments and the number of physicians with payments have recovered monthly since the COVID-19 pandemic, with relative monthly change rates of 4.1% (95% CI: 3.5% ‒ 4.7%, p<0.001) and 3.2% (95%CI: 3.1% ‒ 3.2%, p<0.001). Additionally, the general payments per gastroenterologist significantly decreased by 2.5% (95%CI: -3.9% - -1.1%, p<0.001) each year before the COVID-19 pandemic, while there was a very small change in the number of gastroenterologists with payments. Conclusions The industry payments to gastroenterologists and hepatologists significantly decreased due to the COVID-19 pandemic, but the payments have recovered right after the pandemic in the United States.

Technology adoption and market allocation: The case of robotic surgery

The adoption of health care technology is central to improving productivity in this sector. To provide new evidence on how technology affects health care markets, we focus on one area where adoption has been particularly rapid: surgery for prostate cancer. Within just eight years, robotic surgery grew to become the dominant intensive prostate cancer treatment method. Using a difference-in-differences design, we show that adopting a robot drives prostate cancer patients to the hospital. To test whether this result reflects market expansion or business stealing, we also consider market-level effects of adoption and find effects that are significant but smaller, suggesting that adoption expands the market while also reallocating some patients across hospitals. Marginal patients are relatively young and healthy, inconsistent with the concern that adoption broadens the criteria for intervention to patients who would gain little from it. We conclude by discussing implications for the social value of technology diffusion in health care markets.

A Policy Approach to Reducing Low-Value Device-Based Procedure Use

Policy Points Low-value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low-value care stems from the use of medical device-based procedures. We describe here a novel academic-policymaker collaboration in which evidence-based clinical coverage for device-based procedures is implemented through prior authorization-based policies for Louisiana's Medicaid beneficiary population. This process involves eight steps: 1) identifying low-value medical device-based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low-value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low-value device-based care.

Pharmaceutical marketing: the example of drug samples

Branded drug samples are one of the most important promotional tools that pharmaceutical manufactures employ. Pharmaceutical sales representatives (“drug reps”) use samples to gain access to physicians and other prescribers. Sample provision is closely intertwined with visits by drug reps; detailing visits convince physicians to try new products, while sampling maintains the flow of prescriptions. Only drugs with the highest profit margins are sampled. Although physicians believe that samples save patients money, patients who receive samples have higher overall out-of-pocket costs. Most studies have found that patients in financial need are least likely to receive samples. Pharmaceutical marketers pitch samples as a low-risk way to deal with diagnostic uncertainty. In fact, there is no evidence that samples aid diagnosis. Sample availability may compromise patient safety by reducing compliance with guidelines and steering patients towards newer drugs, for which adverse effects have not been well-delineated. Although physicians believe that samples improve adherence for low-income patients, branded samples do not improve access or adherence Samples are not a charitable activity, but are instead a highly effective form of drug marketing. Sampling of branded drugs increase drug costs for everyone. Only a cohesive effort by clinicians, legislators and policymakers can end this practice. Evidence supports a ban on sample distribution of branded products.

Detecting and Reporting Deceptive Prescription Drug Promotion: Differences Across Consumer and Physician Audiences and by Number and Type of Deceptive Claims and Tactics

The U.S. Food and Drug Administration's (FDA) Bad Ad program provides an avenue for healthcare providers to report false or misleading prescription drug promotion. Yet, whether healthcare providers can detect such promotion, and whether they believe it should be reported to FDA, remain open questions. Consumer audiences may also be capable of detecting such promotion and believe it should be reported, but even less is known about capability and belief in this population. Across two experiments using mock pharmaceutical websites, this research investigated capability to detect and inclination to report deceptive prescription drug promotion among a sample of primary care physicians and consumers. Study 1 varied the number of deceptive claims and tactics on a website for a chronic pain medication, operationalized as none, two, or five. Study 2 varied the type of deceptive content on a website for a weight loss medication, operationalized as none, implicit, or explicit. Findings reveal that, in line with expectations from FDA's Bad Ad program, physicians can detect deceptive promotion and tend to believe it should be reported. Consumers are also capable of detecting deceptive promotion and tend to believe it should be reported, but their capabilities and beliefs regarding reporting are generally lower.

Evaluation of Industry Payments to US Advanced Practice Clinicians in 2021

IMPORTANCE

Advanced practice clinicians (APCs) are a growing part of the US health care system, and their financial relationships with pharmaceutical and medical device companies have not been well studied.

OBJECTIVES

To examine the value, frequency, and types of payments made to APCs and the association of state scope-of-practice laws with these payments.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used 2021 Open Payments Program data to analyze payments from pharmaceutical or medical device companies to physicians or APCs between January 1 and December 31, 2021. Doctors of medicine and osteopathy were categorized as physicians, and nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, and anesthesiologist assistants as APCs.

MAIN OUTCOMES AND MEASURES

The total value and total number of payments were calculated in aggregate and per clinician for each type of APC, all APCs, and physicians. These calculations were repeated by submitting manufacturer, form of payment, nature of payment, and state scope-of-practice law for nurse practitioners, physician assistants, and physicians.

RESULTS

A total of 412 000 physicians and 232 000 APCs collectively received $1.99 billion in payments from industry in 2021, of which APCs received $121 million (6.1%). The median total value of payments per clinician for physicians was $167 (IQR, $45-$712) and for APCs was $117 (IQR, $33-$357). The median total number of payments per clinician was equal for physicians and APCs (n = 4). The most common payments to APCs included food and beverage ($69 million [57.6%]), compensation for services other than consulting ($32 million [26.4%]), and consulting fees ($8 million [6.6%]). Advanced practice clinicians in states with the most restrictive scope-of-practice laws received 15.9% lower total value of payments than those in the least restrictive states (P = .002). Physician assistants received 7.6% (P = .005) higher value and 18.1% (P < .001) greater number of payments than nurse practitioners.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, 232 000 APCs collectively received $121 million in industry payments in 2021. The frequency of industry interactions with APCs was similar to that for physicians, but the average value was lower. The greater value of payments to APCs who practice in states with the least restrictive scope-of-practice laws suggests that industry payments may be related to clinician autonomy.