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

New Cardiovascular Drugs: Patterns of Use and Association with Non-Drug Health Expenditures

The potential role of new drugs in reducing expenditures for non-drug health services has received considerable attention in recent policy debates. We estimate expenditure models to determine whether the use of newer drugs to treat cardiovascular conditions is associated with lower (or higher) non-drug expenditures for these conditions. We fail to substantiate the findings of previous research that newer drugs are associated with reductions in non-drug expenditures. We find, however, that increases in the number of drugs used, or the mix of drugs of different ages, are associated with increased non-drug expenditures and find that the number or mix of drugs used are important confounders in the estimated association between drug age and non-drug expenditures.

The Potential Role of Social Media Platforms in Community Awareness of Antibiotic Use in the Gulf Cooperation Council States: Luxury or Necessity?

The increasing emergence and spread of antimicrobial resistance (AMR) is a serious public health issue. Increasing the awareness of the general public about appropriate antibiotic use is a key factor for combating this issue. Several public media campaigns worldwide have been launched; however, such campaigns can be costly and the outcomes are variable and difficult to assess. Social media platforms, including Twitter, Facebook, and YouTube, are now frequently utilized to address health-related issues. In many geographical locations, such as the countries of the Gulf Cooperation Council (GCC) States (Saudi Arabia, United Arab Emirates, Kuwait, Oman, Qatar, and Bahrain), these platforms are becoming increasingly popular. The socioeconomic status of the GCC states and their reliable communication and networking infrastructure has allowed the penetration and scalability of these platforms in the region. This might explain why the Saudi Ministry of Health is using social media platforms alongside various other media platforms in a large-scale public awareness campaign to educate at-risk communities about the recently emerged Middle East respiratory syndrome coronavirus (MERS-CoV). This paper discusses the potential for using social media tools as cost-efficient and mass education platforms to raise awareness of appropriate antibiotic use in the general public and in the medical communities of the Arabian Peninsula.

Antimicrobial Stewardship: The Need to Cover All Bases

Increasing antimicrobial resistance has necessitated an approach to guide the use of antibiotics. The necessity to guide antimicrobial use via stewardship has never been more urgent. The decline in anti-infective innovation and the failure of currently available antimicrobials to treat some serious infections forces clinicians to change those behaviors that drive antimicrobial resistance. The majority of antimicrobial stewardship (AMS) programs function in acute-care hospitals, however, hospitals are only one setting where antibiotics are prescribed. Antimicrobial use is also high in residential aged care facilities and in the community. Prescribing in aged care is influenced by the fact that elderly residents have lowered immunity, are susceptible to infection and are frequently colonized with multi-resistant organisms. While in the community, prescribers are faced with public misconceptions about the effectiveness of antibiotics for many upper respiratory tract illnesses. AMS programs in all of these locations must be sustainable over a long period of time in order to be effective. A future with effective antimicrobials to treat bacterial infection will depend on AMS covering all of these bases. This review discusses AMS in acute care hospitals, aged care and the community and emphasizes that AMS is critical to patient safety and relies on government, clinician and community engagement.

Secular trends in antibiotic consumption in the adult population in Emilia-Romagna, Italy, 2003-2009

Antibiotic resistance is closely related to antibiotic use and Italy is a country with high levels of both antibiotic use and antimicrobial resistance. We analysed the trend in antibiotic use in the community among adults (≥15 years) and elderly, in the period 2003-2009, in Emilia-Romagna, Italy, a region with over 4 000 000 inhabitants. Data regarding antibiotic use were obtained from the regional public health system databases. Between 2003 and 2009 the antibiotic consumption increased from 15.4 to 18.7 defined daily doses/1000 inhabitants per day (DID) (+21.4%, p <0.0001). The prescription rate in 2009 was 2.19 prescriptions/1000 inhabitants per day, an increase of 13.8% compared with 2003. The highest increase in antibiotic use was observed among persons aged 20-59 years (+24.7%). The proportion of inhabitants receiving at least one antibiotic treatment was 36.4% in 2003 and 39.7% in 2009, and the proportions receiving at least three antibiotic treatments were 3.5% and 4.2%, respectively. The H1N1 pandemic was associated, in October and November 2009, with a 37-90% increase in antibiotic use among the 15-19-year and 20-59-year age groups compared with 2007 and 2008. No other difference was observed in any other age group. The analysis per antibiotic class showed increases for penicillin + beta-lactamase inhibitor (from 3.6 to 6.3 DID), quinolones (from 2.6 to 3.0 DID) and macrolides (from 3.1 to 3.7 DID), whereas cephalosporin use was stable (1.4 DID). A steady increase in antibiotic use in the adult population has been observed in the Emilia-Romagna: public health interventions are mandatory to counteract this trend.

Drug samples in dermatology: special considerations and recommendations for the future

BACKGROUND

The use of drug samples is a controversial issue in medicine.

OBJECTIVE

We sought to determine the pros and cons of drug sampling, and how drug sampling in general medicine differs from dermatology.

METHODS

Literature searches were conducted on PubMed, Google, and Yahoo!. Articles were found pertaining to drug sampling in general, and for dermatology specifically.

RESULTS

Numerous pros and cons for drug sampling were found in the literature search. We divided these by cost-related issues, such as the industry-wide cost of sampling and the use of sampling to assist the underinsured and poor, and quality of care issues, such as adherence, patient education, and safety considerations. Articles also suggested that dermatology may differ from general medicine as topical treatments have fewer side effects, are more complicated to use, and come in different vehicles.

LIMITATIONS

We identified few studies specifically focused on issues relevant to sampling in dermatology.

CONCLUSION

There are strong arguments for and against drug sampling involving both cost and quality of care issues. Dermatology-specific medications clearly differ from oral medications in several regards. We ultimately conclude that the benefits of drug sampling outweigh the risks, but give recommendations on how drug sampling can be done ethically and effectively, including limiting personal use, not selling samples, properly documenting sample release, teaching patients about proper use, teaching students and residents ethical use of samples, working with pharmaceutical representatives in an ethical manner, prescribing the drug that is best for the patient, and securing samples appropriately to prevent theft and misuse.

Emergency department visits for antibiotic-associated adverse events

BACKGROUND

Drug-related adverse events are an under-appreciated consequence of antibiotic use, and the national magnitude and scope of these events have not been studied. Our objective was to estimate and compare the numbers and rates of emergency department (ED) visits for drug-related adverse events associated with systemic antibiotics in the United States by drug class, individual drug, and event type.

METHODS

We analyzed drug-related adverse events from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project (2004-2006) and outpatient prescriptions from national sample surveys of ambulatory care practices, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (2004-2005).

RESULTS

On the basis of 6614 cases, an estimated 142,505 visits (95% confidence interval [CI], 116,506-168,504 visits) annually were made to US EDs for drug-related adverse events attributable to systemic antibiotics. Antibiotics were implicated in 19.3% of all ED visits for drug-related adverse events. Most ED visits for antibiotic-associated adverse events were for allergic reactions (78.7% of visits; 95% CI, 75.3%-82.1% of visits). One-half of the estimated ED visits were attributable to penicillins (36.9% of visits; 95% CI, 34.7%-39.2% of visits) and cephalosporins (12.2%; 95% CI, 10.9%-13.5%). Among commonly prescribed antibiotics, sulfonamides and clindamycin were associated with the highest rate of ED visits (18.9 ED visits per 10,000 outpatient prescription visits [95% CI, 13.1-24.7 ED visits per 10,000 outpatient prescription visits] and 18.5 ED visits per 10,000 outpatient prescription visits [95% CI, 12.1-25.0 ED visits per 10,000 outpatient prescription visits], respectively). Compared with all other antibiotic classes, sulfonamides were associated with a significantly higher rate of moderate-to-severe allergic reactions (4.3% [95% CI, 2.9%-5.8%] vs. 1.9 % [95% CI, 1.5%-2.3%]), and sulfonamides and fluoroquinolones were associated with a significantly higher rate of neurologic or psychiatric disturbances (1.4% [95% CI, 1.0%-1.7%] vs. 0.5% [95% CI, 0.4%-0.6%]).

CONCLUSIONS

Antibiotic-associated adverse events lead to many ED visits, and allergic reactions are the most common events. Minimizing unnecessary antibiotic use by even a small percentage could significantly reduce the immediate and direct risks of drug-related adverse events in individual patients.

"Antibiotics are not automatic anymore"--the French national campaign to cut antibiotic overuse

Benedikt Huttner and Stephan Harbarth discuss the implications of a new study that examined the impact of a national campaign in France to reduce antibiotic overuse.

Understanding the effects of pharmaceutical promotion: a neural network approach guided by genetic algorithm-partial least squares

With escalating healthcare costs and increasing concerns about optimizing use of medicine, there is an unresolved debate over years around the potential impact of pharmaceutical promotion on physicians' prescribing behaviors. What should be the appropriate balance of promotion dollars to physicians? We use three major brands in the US antibiotic universe to explore this issue, presenting a theoretical framework for better understanding the cause-and-effect relationship between common promotional spending and prescription responsiveness. Using simulations we demonstrate that neural networks guided by genetic algorithm-partial least squares is able to provide managers with better understanding of physicians' prescribing activities without an appreciably lower predictive accuracy when compared to that obtained by a standalone neural network modeling.

Modeling the effects of physician‐directed promotion using genetic algorithm‐partial least squares

Purpose

The aim is to explore the potential of a hybrid genetic algorithm‐partial least squares (GA‐PLS) modeling approach to understand the important promotional spending variables that influence physicians' prescribing habits and to help leverage managers' insight to plan better spend on their promotional activities.

Design/methodology/approach

A GA was used as a variable‐selecting tool, and PLS analysis was employed for correlating these variables with the observed variation in the volume of prescriptions. This approach is illustrated using database from a marketing consultant on four major brands in the US antibiotic universe.

Findings

Good statistical models were derived that permit simpler and faster computational prediction of the effects of physician‐directed promotion. All final models established had r2 values ranging from 0.835 to 0.922 and cross‐validated r2 (q2) values ranging from 0.791 to 0.911 whereas the mean absolute percentage error (MAPE) values were confined within 5 percent range on averaging all brand models. Further, thorough statistical analyses revealed the usefulness of promotional spending as a variable and the robustness of GA‐PLS as a correlation tool.

Research limitations/implications

Modeling frame was comprised of only antibiotic category, which may limit its general utility.

Practical implications

Managers can become more adept at interpreting the effects of promotion on prescribing behaviors of physicians and are able to build predictive models that would help identify where and how their curious blend of promotional cocktail would yield the highest future returns. Moreover, if the impact of individual promotional spending element can be measured, then this is perhaps a testament to the way the efficacy of interventions to reduce the harmful consequences of pharmaceutical marketing could be validated given a growing number of public beliefs that physician‐directed promotion has grown too heavy‐handed and is undermining medical professionalism.

Originality/value

This area of research has not received much attention in the pharmaceutical marketing literature until recent years, and hopefully this study will stimulate some interest.

How is research evidence used to support claims made in advertisements for wound care products?

AIMS AND OBJECTIVE

To investigate the amount, type and accuracy of citations use in support of product related claims from advertisements of wound care products.

BACKGROUND

Although articles submitted to most medical journals are subjected to peer review, such scrutiny is often not required for the content of advertisements.

DESIGN

A contents survey of advertisements from two wound care journals (Journal of Wound Care and Ostomy Wound Management) from 2002-2003 and the British Medical Journal, 2002-2003.

METHODS

Data collected from advertisements included identification of product related claims made and any corresponding citations. Where journal articles were cited to support claims, the articles were obtained. Where data on file were cited, this material was requested. In each case the accuracy of claims in relation to the content of the supporting citation was assessed.

RESULTS

The use of citations to support product related claims was infrequent in advertisements from wound care journals, where 35% of advertisements containing a product related claim also contained at least one citation, compared with 63% of advertisements from the British Medical Journal. Of citations that were supplied, journal articles were less common in the wound journals (40% vs. 73% in the British Medical Journal) and data on file more common (38% vs. 6% in the British Medical Journal). Where journal articles were obtained, 56% of claims in the wound care journals advertisements were not supported by the cited article, compared with 12% of claims in the British Medical Journal.

CONCLUSION

The wound journals advertised predominantly medical devices. The use and accuracy of referencing in advertisements from wound care journals was poor.

RELEVANCE TO CLINICAL PRACTICE

Nurses have increasing responsibilities for the prescribing of both drugs and devices, which must be accompanied by the ability to interpret marketing materials and research evidence critically. Nurse educators must ensure that nurse education generally and nurse prescriber training particularly, builds skills of information retrieval and critical appraisal.

Suitability and readability of consumer medical information accompanying prescription medication samples

OBJECTIVE

To examine readability and formatting characteristics of consumer medication information (CMI) accompanying prescription medication samples.

METHODS

We collected the most commonly used prescription medication samples (n=100) from four out-patient clinics at a large teaching hospital in the Southeastern US. Seventeen percent of samples were not pills/tablets and of such diverse nature (e.g., injections, drops, and creams) that there were not enough in any category to draw conclusions. Therefore, our analyses were limited to 83pill/tablet samples, belonging to 11 drug classes (e.g., cardiovascular, and psychiatric). We noted if CMI was present, and if so we assessed it for how instructions were presented, reading level, text size, format/layout, and comprehensibility.

RESULTS

No CMI was present in 39 (46.9%) samples. In 19 (22.9%), CMI was contained in a package insert and in 25 (30.2%) it was printed on the medication package. Average reading difficulty of CMI was at the 10th grade level (range=6-15) using the Fry formula, and text point size was small (mean 9.9+/-2.2 on package inserts and 9.4+/-2.6 when printed on packages).

CONCLUSIONS

Almost half of samples did not include any type of CMI. For those that had CMI, it was often written at a reading difficulty level higher than the average reading skills of American adults, and the format of most CMI was not optimal for comprehensibility. It is likely that many patients do not understand the instructions accompanying medication samples they receive from clinicians.

PRACTICE IMPLICATIONS

Clinicians should be cognizant of the shortcomings of CMI accompanying medication samples and thereby, distribute them to patients with caution. Manufacturers too should consider revising CMI to comply with low-literacy guidelines.

Characteristics of recipients of free prescription drug samples: a nationally representative analysis

OBJECTIVES

Free prescription drug samples are used widely in the United States. We sought to examine characteristics of free drug sample recipients nationwide.

METHODS

We analyzed data on 32681 US residents from the 2003 Medical Expenditure Panel Survey (MEPS), a nationally representative survey.

RESULTS

In 2003, 12% of Americans received at least 1 free sample. A higher proportion of persons who had continuous health insurance received a free sample (12.9%) than did persons who were uninsured for part or all of the year (9.9%; P<.001). The poorest third of respondents were less likely to receive free samples than were those with incomes at 400% of the federal poverty level or higher. After we controlled for demographic factors, we found that neither insurance status nor income were predictors of the receipt of drug samples. Persons who were uninsured all or part of the year were no more likely to receive free samples (odds ratio [OR]=0.98; 95% confidence interval [CI]=0.087, 1.11) than those who were continuously insured.

CONCLUSIONS

Poor and uninsured Americans are less likely than wealthy or insured Americans to receive free drug samples. Our findings suggest that free drug samples serve as a marketing tool, not as a safety net.

Pharmacy residents' attitudes toward pharmaceutical industry promotion

PURPOSE

The attitudes of pharmacy residents toward pharmaceutical industry promotion and the perceived effects of such promotion on the knowledge and professional practice of the residents were studied.

METHODS

A questionnaire study of current postgraduate year 1 and postgraduate year 2 pharmacy residents was conducted. Questions were adapted from instruments used in studies of medical student or physician attitudes regarding the pharmaceutical industry. The questionnaire requested demographic information about the resident, information regarding the resident's exposure to specific types of pharmaceutical company-related activities, and the resident's perception of whether the residency program or department had policies or guidelines regarding interactions with the pharmaceutical industry. Questions investigated the attitudes toward pharmaceutical industry promotion and the perceived influence of pharmaceutical industry promotion on the professional knowledge and behavior of the residents.

RESULTS

Responses were received from 496 pharmacy residents. Nearly all (89%) residents agreed that pharmaceutical company-sponsored educational events enhance knowledge. Almost half (43%) of the respondents reported that information from educational events influences therapeutic recommendations. One quarter (26%) of the pharmacy residents indicated prior training regarding pharmacist-industry interactions, and most (60%) residents indicated that their institution's residencies or departments have policies regarding interactions with the pharmaceutical industry.

CONCLUSION

Most surveyed pharmacy residents believed that educational events sponsored by pharmaceutical companies enhance knowledge. Respondents whose institutions had policies or who had received training about such events were less likely than other respondents to perceive an influence of the events on their knowledge and behavior.

Disseminating evidence-based practices in substance abuse treatment: a review with suggestions

Although substance abuse professionals are generally open to new and better therapeutic methods, most evidence-based treatments do not easily find their way into practice. Natural diffusion processes for innovations in substance abuse treatments are relatively informal and have yielded a widely acknowledged gap between science and community practice. This review focuses on methods for effectively disseminating new treatment methods into practice. Therapist manuals and one-time workshops are in themselves relatively ineffective in helping practitioners gain proficiency in new clinical approaches. Individual performance feedback and coaching improve the acquisition of clinical skills. Specific incentives for implementation may also be needed to encourage treatment providers, programs, and systems to adopt new approaches.

What patients think about promotional activities of pharmaceutical companies in Turkey

OBJECTIVE

Drugs, as commercial products, are subject to diverse marketing methods including promotional activities. Although the legal/ethical aspects of promotional activities have been discussed in a limited manner, the patient has remained the neglected variable of this equation. The goal of our study, therefore, is to investigate the patients' opinion on the promotional activities of pharmaceutical companies.

METHOD

A descriptive study was conducted at 44 primary health care centers in Turkey and 584 volunteers who applied to these centers were included. A questionnaire consisting of 42 questions was developed with demographic information in the first section, and drug ads and promotions included in the second section. Chi-square test and logistic regression analysis were used for statistical analysis.

MAIN OUTCOME MEASURE

The awareness and ethical evaluation of patients of the promotional activities.

RESULTS

Nearly 83% of the participants were aware of the promotion issue. Eighty percent found it unethical, 82% suggested that promotional activities should be forbidden, restricted or regulated. 1/3 of the participants believed that physicians made their drug choices based on the gifts and ads of pharmaceutical companies. Half of them had low confidence in the prescriptions of physicians who accepted gifts from the pharmaceutical companies. 54.5% of patients also considered promotional activities as a factor which increased drug prices.

CONCLUSIONS

In our study, a considerable number of patients were aware of promotions and the effects of promotion on prescriptions. The findings of our study may contribute to the development of effective regulations on this issue. Very strict measures controlling drug companies' promotion activities must be formulated. Further, these regulations must incorporate and take into consideration the patients' opinion. Today, the basic need for the proper use of drugs does not rest in pharmaceutical promotion, but in providing adequate health services and effective education for both people and physicians.

Advertising in medical journals: should current practices change?

Fugh-Berman and colleagues surveyed medical journals' policies and practices on advertising. Pharmaceutical products, they say, dominate journals' advertising pages, creating conflicts of interests.

Hormone replacement therapy, cancer, controversies, and women's health: historical, epidemiological, biological, clinical, and advocacy perspectives

Routine acceptance of use of hormone replacement therapy (HRT) was shattered in 2002 when results of the largest HRT randomised clinical trial, the women's health initiative, indicated that long term use of oestrogen plus progestin HRT not only was associated with increased risk of cancer but, contrary to expectations, did not decrease, and may have increased, risk of cardiovascular disease. In June 2004 a group of historians, epidemiologists, biologists, clinicians, and women's health advocates met to discuss the scientific and social context of and response to these findings. It was found that understanding the evolving and contending knowledge on hormones and health requires: (1) considering its societal context, including the impact of the pharmaceutical industry, the biomedical emphasis on individualised risk and preventive medicine, and the gendering of hormones; and (2) asking why, for four decades, since the mid-1960s, were millions of women prescribed powerful pharmacological agents already demonstrated, three decades earlier, to be carcinogenic? Answering this question requires engaging with core issues of accountability, complexity, fear of mortality, and the conduct of socially responsible science.

A history of drug advertising: the evolving roles of consumers and consumer protection

Direct-to-consumer advertising (DTCA) of prescription drugs in the United States is controversial. Underlying the debate are disagreements over the role of consumers in medical decision making, the appropriateness of consumers engaging in self-diagnosis, and the ethics of an industry promoting potentially dangerous drugs. Drug advertising and federal policy governing drug advertising have both responded to and reinforced changes in the consumer's role in health care and in the doctor-patient relationship over time. This article discusses the history of DTCA in the context of social movements to secure rights for health care patients and consumers, the modern trend toward consumer-oriented medicine, and the implications of DTCA and consumer-oriented medicine for contemporary health policy debates about improving the health care system.

Underutilization of aspirin persists in US ambulatory care for the secondary and primary prevention of cardiovascular disease

BACKGROUND

Despite the proven benefits of aspirin therapy in the primary and secondary prevention of cardiovascular disease (CVD), utilization rates of aspirin remain suboptimal in relation to recommendations. We studied national trends of aspirin use among intermediate- to high-risk patients in the US ambulatory care settings and compared the priority given to aspirin versus statins for CVD risk reduction. We also examined patient and health care provider contributors to the underuse of aspirin.

METHODS AND FINDINGS

We used the 1993-2003 US National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to estimate aspirin use by cardiovascular risk. Physician-noted cardiovascular diseases defined high risk. Intermediate risk was defined as having diabetes mellitus or multiple major risk factors. The proportion of patient visits in which aspirin was reported increased from 21.7% (95% confidence interval: 18.8%-24.6%) in 1993-1994 to 32.8% (25.2%-40.4%) in 2003 for the high-risk category, 3.5% (2.0%-5.0%) to 11.7% (7.8%-15.7%) for visits by patients diagnosed with diabetes, and 3.6% (2.6%-4.6%) to 16.3% (11.4%-21.2%) for those with multiple CVD risk factors. Beginning in 1997-1998, statins were prioritized over aspirin as prophylactic therapy for reducing CVD risk, and the gaps remained wide through 2003. In addition to elevated CVD risk, greater aspirin use was independently associated with advanced age, male gender, cardiologist care, and care in hospital outpatient departments.

CONCLUSION

Improvements in use of aspirin in US ambulatory care for reducing risks of CVD were at best modest during the period under study, particularly for secondary prevention, where the strongest evidence and most explicit guidelines exist. Aspirin is more underused than statins despite its more favorable cost-effectiveness. Aggressive and targeted interventions are needed to enhance provider and patient adherence to consensus guidelines for CVD risk reduction.