A statistical analysis of the magnitude and composition of drug promotion in the United States in 1998

BACKGROUND

Although pharmaceutical industry marketing and other factors may influence physician decisions regarding medication prescribing in the United States, little information is available about the composition of promotional efforts by promotional mode and medication class.

OBJECTIVES

The aims of this study were to determine the magnitude of expenditures for common modes of promotion and to delineate patterns of promotional strategies for particular classes of medications.

METHODS

Nationally representative data on expenditures (in US $) for the 250 most promoted medications in the United States in 1998 were available from an independent pharmaceutical market research company for the 5 most commonly used modes of promotion. Key patterns of drug promotion were identified by descriptive statistics, a cluster analysis of expenditures by class, and an analysis of expenditure concentration.

RESULTS

In 1998, the pharmaceutical industry spent $12,724 million promoting its products in the United States, of which 85.9% was accounted for by the top 250 drugs and 51.6% by the top 50 drugs. Direct-to-consumer (DTC) advertising was more concentrated on a small subset of medications than was promotion to professionals. Overall, 1998 expenditures were dominated by free drug samples provided to physicians (equivalent retail cost of $6602 million) and office promotion ($3537 million), followed by DTC advertising ($1337 million), hospital promotion ($705 million), and advertising in medical journals ($540 million). Four distinct patterns of expenditures were observed: promotion to office physicians with little consumer promotion (14 drug classes); dual focus on office physicians and consumer advertising (4 drug classes); predominant DTC advertising (1 class: smoking-cessation products); and promotion to office- and hospital-based professionals without consumer advertising (1 class: narcotic analgesics).

CONCLUSIONS

The present findings reinforce the perception that the pharmaceutical industry invests heavily in promoting its products and demonstrates that promotional expenditures are concentrated on a small number of medications. Although promotion to professionals remains dominant, DTC advertising has become key for a subset of common medications

National trends in asthma visits and asthma pharmacotherapy, 1978-2002

BACKGROUND

Research is limited on physicians' compliance with recent clinical guidelines for asthma treatment.

OBJECTIVE

Our purpose was to investigate the relationships among clinical guidelines, asthma pharmacotherapy, and office-based visits through use of nationally representative data.

METHODS

Nationally representative data on prescribing patterns by office-based US physicians were extracted from the National Disease and Therapeutic Index. We tracked 1978-2002 trends in the frequency of asthma visits and patterns of asthma pharmacotherapy, focusing on the use of controller and reliever medications.

RESULTS

The estimated annual number of asthma visits in the United States increased continuously from 1978 through 1990 (18 million visits); since 1990, it has remained relatively stable. Controller medication use increased 8-fold between 1978 and 2002, inhaled corticosteroids manifesting the biggest increases. The use of reliever medications, particularly short-acting oral beta(2)-agonists, decreased modestly over this period. The aggregate use of controllers (83% of visits) superseded that of relievers (80%) for the first time in 2001. Improved appropriateness of asthma pharmacotherapy was also suggested by an increase in the controller-to-reliever ratio, which reached 92% in 2002. Xanthines, which once dominated asthma therapy (63% of visits in 1978), were used in only 2% of visits in 2002. More recent drug entrants have been adopted rapidly, single-entity long-acting inhaled beta(2)-agonists being used in 9% of visits and leukotriene modifiers in 24% of visits in 2002.

CONCLUSION

Asthma pharmacotherapy has changed extensively in the past 25 years. Practices over the last decade are increasingly consistent with evidence-based guidelines. These changes in medication use might have contributed to the lack of a recent increase in asthma visits.

Healthcare expenditure in patients treated with venlafaxine or selective serotonin reuptake inhibitors for depression and anxiety

We compared healthcare expenditure over a six-month period following initiation of therapy with either venlafaxine (immediate and extended-release) or a selective serotonin reuptake inhibitor (SSRI) in depressed patients with or without anxiety. Patients beginning treatment for a new depressive episode were identified retrospectively using the administrative data of the MEDSTAT MarketScan database for the period 1994-1999. Before beginning therapy, patients prescribed venlafaxine had more non-mental illnesses (0.85 vs 0.76; p<0.01) and hospitalisations for mental illness (0.53 vs 0.29; p<0.05) than patients prescribed SSRIs. In the six months after initiating treatment, venlafaxine was associated with lower hospitalisation expenditure for non-mental illness ($177 vs $526; p<0.01) than SSRIs, although total healthcare expenditure was not significantly different. Venlafaxine was associated with a 50% decrease in the odds of hospitalisation for non-mental illness compared with SSRIs, with significantly lower inpatient expenditure.

Treatment costs of venlafaxine and selective serotonin-reuptake inhibitors for depression and anxiety

In this article, health care expenditures are assessed for patients diagnosed with depression who are being treated with either venlafaxine (immediate or extended release) or a selective serotonin-reuptake inhibitor (SSRI). Patients beginning treatment for a new depressive episode were identified retrospectively from 1994 to 1998. Before beginning therapy, patients prescribed venlafaxine (N = 353) had more nonmental illnesses (0.84 vs. 0.75 clinical events/patient, respectively; P < .01) and hospitalizations for mental illness (0.56 vs. 0.30 hospitalizations/patient; P = .06) than patients prescribed SSRIs (N = 7,330). In the six months after initiating treatment, venlafaxine was associated with lower hospitalization expenditures for nonmental illness than were SSRIs ($206 vs. $472, respectively; P = .02), but total health care expenditures were not significantly different.

National Patterns of Medication Treatment for Depression, 1987 to 2001

BACKGROUND: We investigated trends in antidepressant use, as well as broader changes in depression treatment, following the availability of selective serotonin reuptake inhibitors (SSRIs). METHOD: Using data from the National Disease and Therapeutic Index, a nationally representative survey of U.S. office-based physicians conducted by IMS HEALTH, we analyzed trends in antidepressant prescribing patterns from 1987 through the third quarter of 2001. Annual sample sizes of physician visits by patients reported to have depression ranged from 3901 visits in 1987 to 6639 in 1998. Outcomes examined included the frequency of depression visits, the likelihood of antidepressant therapy, and the use of specific medications. RESULTS: The estimated national number of physician visits by patients with depression increased from 14.4 million visits in 1987 to 24.5 million in 2001 (annualized). The rate of antidepressant medication treatment in these patients also increased from 70% in 1987 to 89% in 2001. In 1987, tricyclic antidepressants were prescribed to 47% of patients with depression. The most common individual antidepressants were amitriptyline (14%), trazodone (12%), doxepin (8%), and desipramine (6%). In 1989, a year after its introduction, fluoxetine was prescribed to 21% of patients with depression. The introduction of other SSRIs led aggregate SSRI use to grow to 38% in 1992, 60% in 1996, and 69% in 2000. In 2001, sertraline (18%), paroxetine (16%), fluoxetine (14%), citalopram (13%), and bupropion (9%) were the leading antidepressants, while tricyclics were used in only 2% of patients. The use of benzodiazepines in depression declined from 21% of patients in 1987 to 8% in 2001. CONCLUSION: The increasing therapeutic dominance of SSRIs may have contributed to other changes in depression treatment, including declining benzodiazepine use, increased aggregate antidepressant treatment rates, and increased reporting of depression.

Health care use and at-work productivity among employees with mental disorders

This study examines the differential medical care use and work productivity of employees with and without anxiety and with other mental disorders at a large national firm. A unique aspect of this study is that we integrate medical claims and employer-provided, objective productivity data for the same employees. We find extensive mental health comorbidities among anxious employees. Although medical care use differs considerably among employees having no, one, or several treated mental disorders, in most cases their annual average absenteeism and average at-work productivity performance do not differ. Differences among subgroups are observed for job tenure and maternity claims. We discuss these long-term average productivity findings in relation to other literature encompassing shorter time periods.

Lost human capital from early-onset chronic depression

OBJECTIVE

Chronic depression starts at an early age for many individuals and could affect their accumulation of "human capital" (i.e., education, higher amounts of which can broaden occupational choice and increase earnings potential). The authors examined the impact, by gender, of early- (before age 22) versus late-onset major depressive disorder on educational attainment. They also determined whether the efficacy and sustainability of antidepressant treatments and psychosocial outcomes vary by age at onset and quantified the impact of early- versus late-onset, as well as never-occurring, major depressive disorder on expected lifetime earnings.

METHOD

The authors used logistic and multivariate regression methods to analyze data from a three-phase, multicenter, double-blind, randomized trial that compared sertraline and imipramine treatment of 531 patients with chronic depression aged 30 years and older. These data were integrated with U.S. Census Bureau data on 1995 earnings by age, educational attainment, and gender.

RESULTS

Early-onset major depressive disorder adversely affected the educational attainment of women but not of men. No significant difference in treatment responsiveness by age at onset was observed after 12 weeks of acute treatment or, for subjects rated as having responded, after 76 weeks of maintenance treatment. A randomly selected 21-year-old woman with early-onset major depressive disorder in 1995 could expect future annual earnings that were 12%-18% lower than those of a randomly selected 21-year-old woman whose onset of major depressive disorder occurred after age 21 or not at all.

CONCLUSIONS

Early-onset major depressive disorder causes substantial human capital loss, particularly for women. Detection and effective treatment of early-onset major depressive disorder may have substantial economic benefits.

Cost effectiveness, quality-adjusted life-years and supportive care. Recombinant human erythropoietin as a treatment of cancer-associated anaemia

OBJECTIVE

To measure the cost effectiveness of a supportive care intervention when the no-treatment option is unrealistic in an analysis of recombinant human erythropoietin (epoetin) treatment for anaemic patients with cancer undergoing chemotherapy. Further, to assess whether quality-adjusted life-years (QALYs) can provide the basis for an appropriate measure of the value of supportive care interventions.

DESIGN

A modelling study drawing cost and effectiveness assumptions from a literature review and from 3 US clinical trials involving more than 4500 patients with cancer who were treated with chemotherapy, radiotherapy, epoetin and blood transfusions as needed under standard care for patients with cancer.

MAIN OUTCOME MEASURES AND RESULTS

When compared with transfusions, epoetin is cost effective under varying assumptions, whether effectiveness is measured by haemoglobin level or quality of life. Specifically, under a base-case scenario, the effectiveness resulting from $US1 spent on standard care can be achieved with only $US0.81 of epoetin care. Due in part to the health-state dependence of the significance patients attach to incremental changes in their responses on the linear analogue scale, cost per QALY results are ambiguous in this supportive care context.

CONCLUSIONS

Under a broad range of plausible assumptions, epoetin can be used cost effectively in the treatment of anaemic patients with cancer. Further, QALYs have limited applicability here because, as a short term supportive treatment, epoetin enhances the quality but not the length of life. Future research would benefit from the establishment of consistent values for quality-of-life changes across patients and health status, and the extension of the QALY framework to supportive care.

Loss of work productivity due to illness and medical treatment

We examined the effects on work productivity of treatment with antihistamines in a retrospective study using linked health claims data and daily work output records for a sample of nearly 6000 claims processors at a large insurance company, between 1993 and 1995. We explained the variation in work output depending on the subjects' demographic characteristics, their jobs, and whether they were treated with "sedating" versus "nonsedating" antihistamines for nasal allergies. Differences of up to 13% in productivity were found after the subjects took sedating or nonsedating antihistamines. The observed effect suggests substantial indirect economic costs, which up to now have been largely overlooked because work productivity has proved difficult to measure objectively.

The economic burden of anxiety disorders in the 1990s

BACKGROUND

We assess the annual economic burden of anxiety disorders in the United States from a societal perspective.

METHOD

Using data from the National Comorbidity Study, we applied multivariate regression techniques to calculate the costs associated with anxiety disorders, after adjusting for demographic characteristics and the presence of comorbid psychiatric conditions. Based on additional data, in part from a large managed care organization, we estimated a human capital model of the societal cost of anxiety disorders.

RESULTS

We estimated the annual cost of anxiety disorders to be approximately $42.3 billion in 1990 in the United States, or $1542 per sufferer. This comprises $23.0 billion (or 54% of the total cost) in nonpsychiatric medical treatment costs, S13.3 billion (31%) in psychiatric treatment costs, $4.1 billion (10%) in indirect workplace costs, $1.2 billion (3%) in mortality costs, and $0.8 billion (2%) in prescription pharmaceutical costs. Of the $256 in workplace costs per anxious worker, 88% is attributable to lost productivity while at work as opposed to absenteeism. Posttraumatic stress disorder and panic disorder are the anxiety disorders found to have the highest rates of service use. Other than simple phobia, all anxiety disorders analyzed are associated with impairment in workplace performance.

CONCLUSION

Anxiety disorders impose a substantial cost on society, much of which may be avoidable with more widespread awareness, recognition, and appropriate early intervention.

Workplace performance effects from chronic depression and its treatment

Utilizing data from a clinical trial and an econometric model incorporating the impact of a medical intervention and regression to the mean, we present evidence supporting the hypotheses that for chronically depressed individuals: (i) the level of perceived at-work performance is negatively related to the severity of depressive status; and (ii) a reduction in depressive severity improves the patient's perceived work performance. Improvement in work performance is rapid, with about two-thirds of the change occurring already by week 4. Those patients having the greatest work improvement are those with both relatively low baseline work performance and the least severity of baseline depression.

The economic burden of depression in 1990

BACKGROUND

We estimate in dollar terms the economic burden of depression in the United States on an annual basis.

METHOD

Using a human capital approach, we develop prevalence-based estimates of three major cost-of-illness categories: (1) direct costs of medical, psychiatric, and pharmacologic care; (2) mortality costs arising from depression-related suicides; and (3) morbidity costs associated with depression in the workplace. With respect to the latter category, we extend traditional cost-of-illness research to include not only the costs arising from excess absenteeism of depressed workers, but also the reductions in their productive capacity while at work during episodes of the illness.

RESULTS

We estimate that the annual costs of depression in the United States total approximately $43.7 billion. Of this total, $12.4 billion-28%-is attributable to direct costs, $7.5 billion-17%-comprises mortality costs, and $23.8 billion-55%-is derived from the two morbidity cost categories.

CONCLUSION

Depression imposes significant annual costs on society. Because there are many important categories of cost that have yet to be estimated, the true burden of this illness may be even greater than is implied by our estimate. Future research on the total costs of depression may include attention to the comorbidity costs of this illness with a variety of other diseases, reductions in the quality of life experienced by sufferers, and added out-of-pocket costs resulting from the effects of this illness, including those related to household services. Finally, it may be useful to estimate the additional costs associated with expanding the definition of depression to include individuals who suffer from only some of the symptoms of this illness.

Depression: a neglected major illness

BACKGROUND

To illustrate the burden depression imposes on society, we present estimates of the annual costs of depression--$44 billion--as well as the number of individuals it affects per year--almost 11 million. Although these estimates point to depression as a major illness, this study examines why it is not generally considered as such by the medical and public health communities or by society at large.

METHOD

We develop a framework that compares depression with major illnesses such as coronary heart disease, cancer, and AIDS by highlighting salient characteristics of each illness. This comparative illness framework considers the costs, prevalence, distribution of sufferers, mortality, recognition, and treatability of each disease. This comparison underscores many of the similarities and differences among the illnesses examined.

RESULTS

Because depression often is not properly recognized and begins to affect many people at a relatively early age, it exacts costs over a longer period of time and in a more subtle manner than other major illnesses. It also imposes a particularly heavy burden on employers in the form of higher workplace costs.

CONCLUSION

We conclude that, because of the potential for successful treatment, increased attempts to reach untreated sufferers of depression appear to be warranted. Employers as a group have a particular incentive to invest in the recognition and treatment of this widespread problem, in order to reduce the substantial costs it imposes upon them each year.

Factors associated with clinical dental faculty research productivity

The purpose of this study was to determine factors that are associated with increased individual research productivity among clinical faculty in 67 United States and Canadian schools of dentistry. Individual faculty research productivity was defined as the total number of articles in refereed journals and book chapters published during an academic career. The 328 respondents represented a response rate of 62.8 percent from a 25 percent stratified random sample of faculty who (1) had full-time appointments and held at least the D.M.D./D.D.S. or foreign equivalent, (2) taught in a clinical department of the dental schools, and (3) were not department chairpersons and did not hold administrative positions (assistant dean, associate dean, or dean) within the dental school. Respondents reported a mean of 9.9 years in full-time dental education, a mean of 10.8 publications, and a mean of 7.5 hours spent in research per week. Forward addition multiple regression analysis demonstrated that five predictor variables, from a total of 20 variables evaluated, accounted for 59.9 percent of the variance in individual faculty research productivity. These predictor variables were total dollar amount of past research funding, career age, training status, colleague utilization in conducting research, and conducting research from planned goals.

Assessing technology for rehabilitation. Three cases and three countries

The rehabilitation field has not always been regarded as the most glamorous or commercially promising section of medical care. But changing attitudes and demographics in many industrial countries have led to increased recognition of opportunity to provide services for individuals with disabilities and those in need of chronic care. As hospitals are under increasing pressure to offer rehabilitation services, this article focuses on three different technologies developed in three different countries, Sweden, the United Kingdom, and the United States.

The process of evaluating medical technologies for third-party coverage

A detailed review of records and documentation considered more than 100 technology evaluations performed in conjunction with coverage decisions by the Medicare program and by a major Blue Cross/blue Shield plan. Medicare evaluations were highly structured, synthesizing thorough literature reviews, recommendations from the National Institutes of Health and other governmental agencies, and information solicited from medical specialty societies and independent practitioners; however, the material supplied by nongovernmental sources seldom influenced the coverage recommendations. In contrast, the Blue plan's evaluations were based largely on presentations and discussions at advisory committee meetings, after receiving informational inputs that were more limited than those used in Medicare evaluations. The fraction of technologies recommended for coverage was slightly over 50% for each carrier. If information was strongly positive about either a technology's safety, its effectiveness, or both, then coverage was nearly always recommended. Still, the carriers differed significantly in the stage of development of the practices evaluated and in their willingness to make a coverage decision in the face of both safety and effectiveness data that were regarded as tentative. Because coverage decisions, and the speed with which they are conducted, may be crucial to the rate of a technology's diffusion--and possibly even to the rate of innovation--the authors conclude that it is important to understand clearly the process by which this type of technology assessment is performed.

Technological change and clinical laboratory utilization

Many believe that improvement in laboratory automation has been responsible for the considerable growth in the volume of tests that has occurred in recent years. Results are presented from an 8-year national survey of hospital laboratory utilization that show no definitive correlation between technological change and growth in volume of well-established clinical laboratory tests. These results leave room for hypothesizing other major contributory factors to volume increases such as a behavioral change on the part of practitioners who order tests and place increased diagnostic importance on laboratory results in addition to medical histories and physical examinations. If the findings prove correct, successful regulatory strategies for the containment of laboratory costs might be as likely to come from those that directly address practitioners' behavior as from those that limit capacity by requiring prior approval for acquisition of new laboratory equipment.