Effects of direct-to-consumer advertising of hydroxymethylglutaryl coenzyme a reductase inhibitors on attainment of LDL-C goals

How the operationalization of exposure impacts studies on direct-to-consumer advertising of prescription drugs

Purpose

Without having a shared operationalization of what constitutes a direct-to-consumer advertising (DTCA) exposure, it is impossible to accurately generalize findings about their effects. First, it needs to be established how the variables involved in exposures impact outcomes. This will allow for more accurate operationalizations.

Design/methodology/approach

A sample of 216 participants were recruited from Amazon’s Mechanical Turk and randomly assigned into one of four conditions to take an online survey. A 2 × 2 experiment (active/passive attention × low/high exposure) was conducted to determine if the level of attention, otherwise known as attentiveness, and the number of exposures impacted preferences for a fictitious prescription sleep aid.

Findings

Results indicated a significant difference among active and passive conditions such that active exposures resulted in stronger positive preferences.

Research limitations/implications

Studies using different operationalizations should not be aggregated for generalizations about the effects of DTCA of prescription drugs.

Originality/value

This paper urges researchers to clearly operationalize their definitions for “exposure” and to be hesitant about generalizing findings studies using different definitions.

The Impact of Direct-to-Consumer Pharmaceutical Advertising on Public Knowledge of Gastroesophageal Reflux Disease: A Study on Over-the-Counter Proton Pump Inhibitors

BACKGROUND

The use of direct-to-consumer advertising (DTCA) to promote sales of over-the-counter (OTC) pharmaceuticals used to manage common medical conditions, such as gastroesophageal reflux disease (GERD), is increasing. However, the educational value of these advertisements as well as the public perceptions of this type of advertising remain largely unknown among non-English speaking populations.

OBJECTIVE

The aim of this study was to explore the public perceptions and educational value of a short motion graphic video documenting the lifestyle of person with GERD and presenting a brief introduction to the role of proton pump Inhibitors (PPIs) in relieving the symptoms.

METHODS

This was a prospective quasi-experimental study in which a short mock advertising motion graphic video was shown to a sample of adult individuals in malls and shopping centers in different cities across Saudi Arabia. Participants were required to express their levels of agreement with six statements concerning their perceptions of DTCA of OTC drugs, and answer a quiz consisting of three questions and enquiries about their knowledge of GERD and the OTC drugs used in its treatment.

RESULTS

Two hundred and ninety-five participants were involved in this study, the majority of whom were female (55.30%). After watching the video, the percentages of participants who strongly agreed or agreed that DTCA is a credible source of information and encourages them to purchase the marketed drug have increased significantly (P<0.05). With regard to the quiz, the percentages of participants with correct answers regarding the definition of GERD, knowledge of OTC drugs for GERD, and awareness of the common side effects of PPIs increased from 81.69% to 95.93%, 69.83% to 96.27%, and 46.44% to 91.53%, respectively (P<0.0001).

CONCLUSION

DTCA of OTC drugs for GERD, particularly if the content complies with the regulatory requirements, can promote the public knowledge of the disease and treatment options.

Impact of direct-to-consumer drug advertising during the Super Bowl on drug utilization

BACKGROUND

Direct-to-consumer advertising (DTCA) of prescription drugs impacts patients' requests for medications, and clinician prescribing. However, the impact of DTCA during the Super Bowl has not been previously described.

OBJECTIVE

Evaluate the impact of prescription drug DTCA during the Super Bowl on drug utilization using 2014-2016 Medicare data.

METHODS

Efinaconazole was advertised during Super Bowls XLIX (02/01/2015) and L (02/07/2016). The number of prescriptions for efinaconazole and for a comparator drug, tavaborole, were calculated in 31-day intervals from July 2014-December 2016. Interrupted time-series analysis models were created to test changes in trends of prescriptions for efinaconazole and tavaborole.

RESULTS

Following Super Bowl XLIX, the number of prescriptions per 100,000 Medicare beneficiaries increased by 91% for efinaconazole, and 275% for tavaborole. After Super Bowl L, the number of prescriptions increased significantly for efinaconazole (p-value<0.001), but not for tavaborole (p = 0.70). Interrupted time-series analyses estimated that, in the absence of DTCA during Super Bowl XLIX, prescriptions for efinaconazole would have increased by 40%, instead of the observed 91%. For tavaborole, prescriptions would have increased by 90% instead of 275%.

CONCLUSIONS

DTCA during the Super Bowl resulted in sharp increases in utilization of the prescription drug advertised, which supports further regulation of DTCA.

Does e-cigarette advertising encourage adult smokers to quit?

We provide the first causal evidence on whether e-cigarette advertising on television and in magazines encourages adult smokers to quit. We find the answer to be yes for TV advertising but no for magazine advertising. Our results indicate that a policy banning TV advertising of e-cigs would have reduced the number of smokers who quit in the recent past by approximately 3%. If the FDA were not considering regulations and mandates, e-cig ads might have reached the number of nicotine replacement therapy TV ads during that period. That would have increased the number of smokers who quit by around 10%.

Effect of Direct-to-Consumer Advertising on Statin Use in the United States

IMPORTANCE

The value of direct-to-consumer advertising (DTCA) of prescription drugs is widely debated, as is the effect of DTCA on prescription sales and health care utilization.

OBJECTIVE

We examined the association between DTCA intensity for statin medications and prescription sales and cholesterol-related health care utilization.

DESIGN, SETTING, AND PARTICIPANTS

We conducted an ecological study for 75 designated market areas from 2005 to 2009 in the United States using linked data regarding televised DTCA volume, non-DTCA marketing and promotion, retail, mail order and long-term care prescription drug sales, prescription drug and ambulatory care health care utilization, and contextual factors such as health care density and socioeconomic status. Main outcomes and measures were volume of sales, number of dispensed prescriptions, and high cholesterol-related outpatient visits. Analyses were conducted in 2016.

RESULTS

The intensity of rosuvastatin and atorvastatin ad exposures per household varied substantially across designated market areas. After adjustment for socioeconomic, demographic, and clinical characteristics, each 100-unit increase in advertisement viewership was associated with a 2.22% [95% confidence interval (CI), 0.30%-4.19%] increase in statin sales. Similar patterns were observed between DTCA and statin dispensing among the commercially insured. DTCA was associated with increases in high cholesterol-related outpatient visits among adults 18-45 years of age (3.15% increase in visits per 100-unit increase in viewership, 95% CI, 0.98%-5.37%) but not among those 46-65 years of age (0.51%, 95% CI, -1.49% to 2.55%).

CONCLUSION

DTCA for statins is associated with increases in statin utilization and hyperlipidemia-related outpatient visits, especially for young adults.

The effects of direct-to-consumer advertising on medication use among Medicaid children with asthma

Asthma medication adherence is low, particularly among Medicaid enrollees. There has been much debate on the impact of direct-to-consumer advertising (DTCA) on health care use, but the impact on medication use among children with asthma has been unexamined. The study sample included 180,584 children between the ages of 5 and 18 with an asthma diagnosis from a combined dataset of Medicaid Analytic eXtract and national advertising data. We found that DTCA expenditure during the study period was significantly associated with an increase in asthma medication use. However, the effectiveness declined after a certain level.

Impact of FDA Actions, DTCA, and Public Information on the Market for Pain Medication

Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most important classes of prescription drugs used by primary care physicians to manage pain. The NSAID class of products has a somewhat controversial history, around which a complex regulatory and informational environment has developed. This history includes a boxed warning mandated by the Food and Drug Administration (FDA) for all NSAIDs in 2005. We investigate the impact that various information shocks have had on the use of prescription medications for pain in primary care in the USA. We accomplish this by extracting data on nearly 600,000 patients from a unique nationwide electronic medical record database and estimate the probability of any active prescription for the four types of pain medications as a function of FDA actions, advertising, media coverage, and patient characteristics. We find that even after accounting for multiple sources of information, the FDA label changes and boxed warnings had a significant effect on pain medication prescribing. The boxed warning did not have the same impact on the use of all NSAID inhibitors. We find that the boxed warning reduced the use of NSAID COX-2 inhibitor use, which was the focus of much of the press attention. In contrast, however, the warning actually increased the use of non-COX-2 NSAID inhibitors. Thus, the efficacy of the FDA's black box warning is clearly mixed.

The relationship between direct to consumer advertising (DTCA) and asthma-related emergency department use among Medicaid-enrolled children

OBJECTIVE

Asthma is a leading cause of emergency department (ED) visits. There has been much debate on the impact of direct to consumer advertising (DTCA) on healthcare. This study seeks to examine the association between DTCA expenditure and asthma-related ED use.

STUDY DESIGN

In this study, we combined Medicaid administrative data and a national advertising data on asthma medications. The sample size consisted of 180,584 Medicaid-enrolled children between the ages of 5 and 18 years who had an asthma diagnosis. Twenty percent of the Medicaid-enrolled children in the sample had asthma-related ED visits.

RESULTS

We found that DTCA expenditure is associated with a decrease in asthma-related ED visits (OR = 0.75; CI: 0.64-0.89). However, at higher levels of DTCA expenditure, the likelihood of asthma-related ED visits increases (OR = 1.25; CI: 1.05-1.49), indicating a decreased relationship between DTCA and asthma-related ED visits.

CONCLUSIONS

Our findings suggest that DTCA may be associated with improved health outcomes for Medicaid-enrolled children with asthma.

Pharmaceutical advertising and Medicare Part D

We explore how and to what extent prescription drug insurance expansions affect incentives for pharmaceutical advertising. When insurance expansions make markets more profitable, firms respond by boosting advertising. Theory suggests this effect will be magnified in the least competitive drug classes, where firms internalize a larger share of the benefits from advertising. Empirically, we find that the implementation of Part D coincides with a 14-19% increase in total advertising expenditures. This effect is indeed concentrated in the least competitive drug classes. The additional advertising raised utilization among non-elderly patients outside the Part D program by about 3.6%. This is roughly half of the direct utilization effect of Part D on elderly beneficiaries. The results suggest the presence of considerable spillover effects from publicly subsidized prescription drug insurance on the utilization and welfare of consumers outside the program.

Impact of oncology-related direct-to-consumer advertising: association with appropriate and inappropriate prescriptions

BACKGROUND

Little is known about the impact of direct-to-consumer advertising (DTCA) on appropriate versus inappropriate prescribing. Aromatase inhibitor (AI) therapy for breast cancer provides an ideal paradigm for studying this issue, because AIs have been the focus of substantial DTCA, and because they should only be used in postmenopausal women, age can serve as a simple surrogate marker of appropriateness.

METHODS

Data regarding national DTCA spending for the AIs were obtained from TNS Multimedia; hormonal therapy prescription data were obtained from IMS Health. Time series analyses were performed to characterize the association between monthly changes in DTCA spending for the AIs and monthly changes in the proportion of all new hormonal therapy prescriptions represented by the AIs from October 2005 to September 2007. Analyses were stratified by age, considering prescriptions for women ≤ 40 (likely premenopausal) to be inappropriate and those for women > 60 (likely postmenopausal) to be appropriate.

RESULTS

Monthly dollars spent on AI-associated DTCA varied considerably ($118,600 to $22,019,660). Time series analysis revealed that for every million dollars spent on DTCA for the AIs, there was an associated increase 3 months later in the new AI prescription proportion of 0.15% for all ages (P < .0001) and 0.18% for those > 60 years (P < .0001), but no significant change for those ≤ 40 at any time from 0 to 6 months.

CONCLUSIONS

DTCA for the AIs was associated with increases in appropriate prescriptions with no significant effect on inappropriate prescriptions, suggesting that DTCA may not foster inappropriate medication use for certain drug classes.

Advertising of prescription-only medicines to the public: does evidence of benefit counterbalance harm?

Since the global withdrawal of rofecoxib (Vioxx) in 2004, concerns about public health effects of direct-to-consumer advertising (DTCA) have grown. A systematic review of the research evidence on behavioral, health, and cost effects, published in 2005, found four studies meeting inclusion criteria, which showed that DTCA increases prescribing volume and patient demand, and shifts prescribing. From 2005 to 2010, nine studies met similar criteria. These largely confirm previous results. Additional effects include a shift to less appropriate prescribing, differential effects by patient price sensitivity and drug type, switches to less cost-effective treatment, and sustained sales despite a price increase. Claimed effects on adherence do not stand up to scrutiny and are based mainly on negative trials. There is no evidence of improved treatment quality or early provision of needed care. If policy is to be informed by evidence, the strength of research methods and ability to assess causality need to be considered.

Direct to consumer Internet advertising of statins: an assessment of safety

PURPOSE

To evaluate a sample of Internet sites advertising statins for sale to the general public.

METHODS

A simulated customer search and evaluation of retrieved sites using evaluation tools focussing on quality (Q) and safe medicine use (SMU). Sites retrieved on 17 November 2010 were systematically analysed from 19 November to 23 December 2010.

RESULTS

One hundred eighty-four sites met the inclusion criteria: 40 each for atorvastatin, pravastatin, rosuvastatin, and simvastatin and 24 for fluvastatin. Sites originated from 17 different countries. Most sites scored less than half the maximum Q score (26; range 5-17). Mean total SMU scores for each statin group were lower than 50% of the maximum (45; range of 0-28). There were no statistically significant differences between statins. General contraindications were absent in 92.4% of sites and contraindicated medicines in 47.3%. Key warnings on the appearance of symptoms associated with myopathy, liver disease, hypersensitivity, and pancreatitis were absent in 37, 48.4, 91.3, and 96.2% of sites, respectively. Most websites presented a chaotic and incomplete list of known side effects; just 13 (7.1%) presented a list compatible with current prescribing information. Only two-thirds (65.8%) attempted to describe any in lay language.

CONCLUSIONS

A potential purchaser of statins is likely to encounter websites from a wide geographical base and of generally poor quality. This has potentially serious implications for the safety of purchasers who may not be aware of the problems associated with ordering medicines online or the actual medication, which they receive. Direct to consumer advertising websites need tighter controls.

Does prescription drug adherence reduce hospitalizations and costs? The case of diabetes

PURPOSE

To estimate the impact of diabetic drug adherence on hospitalizations, emergency room (ER) visits, and hospital costs.

METHODS

It is often difficult to measure the impact of drug adherence on hospitalizations since both adherence and hospitalizations may be correlated with unobservable patient severity. We control for such unobservables using propensity score methods and instrumental variables for adherence such as drug coinsurance levels and direct-to-consumer advertising.

FINDINGS

We find a significant bias due to unobservable severity in that patients with more severe health are more apt to comply with medications. Thus, the relationship between adherence and hospitalization will be underestimated if one does not control for unobservable severity. Overall, we find that increasing diabetic drug adherence from 50% to 100% reduces the hospitalization rate by 23.3% from 15% to 11.5%. ER visits reduce by 46.2% from 17.3% to 9.3%. Although such an increase in adherence increases diabetic drug spending by $776 a year per diabetic, the cost savings for averted hospitalizations and ER visits are $886 per diabetic, a cost offset of $1.14 per $1.00 spent on diabetic drugs.

ORIGINALITY

Most of the drug cost-offset literature focuses only on the impact of cost-sharing and drug spending on cost-offsets, making it impossible to back-out the empirical impact of actual drug adherence on cost-offsets. In this chapter, we estimate the direct impact of adherence on hospitalizations and costs.

A decade of controversy: balancing policy with evidence in the regulation of prescription drug advertising

Direct-to-consumer advertising (DTCA) of prescription drugs has remained controversial since regulations were liberalized by the Food and Drug Administration in 1997. We reviewed empirical evidence addressing the claims made in the policy debate for and against DTCA. This advertising has some benefits, but significant risks are evident as well, magnified by the prominence of DTCA in population-level health communications. To minimize potential harm and maximize the benefits of DTCA for population health, the quality and quantity of information should be improved to enable consumers to better self-identify whether treatment is indicated, more realistically appraise the benefits, and better attend to the risks associated with prescription drugs. We propose guidelines for improving the utility of prescription drug advertising.

The Cost-Effectiveness of Direct-to-Consumer Advertising for Prescription Drugs

In this paper we use published information to analyze the economic value of Direct to Consumer Advertising (DTCA). The reviewed research finds that DTCA leads to increased demand for the advertised drug and that the effect of the drug tends to be class-wide rather than product specific. There is weak evidence that DTCA may increase compliance and improve clinical outcomes. However, there is little research on the effect of DTCA on inappropriate prescribing or on the characteristics of patients who respond to treatment. On net, if the advertised drugs are cost effective on average and the patients using the drugs in response to the advertisement are similar to other users, DTCA is likely cost effective. Overall, the literature to date is consistent with the idea that DTCA is beneficial, but further research is needed before definitive conclusions can be drawn.

An Assessment of Direct-to-Consumer Advertising of Prescription Drugs

Advertising is widely seen by economists and regulators as beneficial to markets and consumers. The prescription drug market offers exceptional opportunities for direct-to-consumer advertising (DTCA) to provide new-product information, improve compliance, alleviate widespread underdiagnosis and undertreatment, and motivate new-product development.5 DTCA can also induce excess or even dangerous prescribing, however, partly because patients are poorly informed and usually pay far less than the full cost of drugs. Empirical research can help resolve these issues.