A survey of the advertising of nine new drugs in the general practice literature

Quality of pharmaceutical advertising and gender bias in medical journals (1998-2008): a review of the scientific literature

OBJECTIVE

To review the scientific literature on pharmaceutical advertising aimed at health professionals in order to determine whether gender bias has decreased and the quality of information in pharmaceutical advertising has improved over time.

METHODS

We performed a content analysis of original articles dealing with medical drug promotion (1998-2008), according to quality criteria such as (a) the number, validity and accessibility of bibliographic references provided in pharmaceutical advertising and (b) the extent to which gender representations were consistent with the prevalence of the diseases. Databases: PUBMED, Medline, Scopus, Sociological Abstract, Eric and LILACS.

RESULTS

We reviewed 31 articles that analyzed advertising in medical journals from 1975-2005 and were published between 1998 and 2008. We found that the number of references used to support pharmaceutical advertising claims increased from 1975 but that 50% of these references were not valid. There was a tendency to depict men in paid productive roles, while women appeared inside the home or in non-occupational social contexts. Advertisements for psychotropic and cardiovascular drugs overrepresented women and men respectively.

CONCLUSIONS

The use of bibliographic references increased between 1998 and 2008. However, representation of traditional male-female roles was similar in 1975 and 2005. Pharmaceutical advertisements may contribute to reinforcing the perception that certain diseases are associated with the most frequently portrayed sex.

Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: a systematic review

BACKGROUND

Pharmaceutical companies spent $57.5 billion on pharmaceutical promotion in the United States in 2004. The industry claims that promotion provides scientific and educational information to physicians. While some evidence indicates that promotion may adversely influence prescribing, physicians hold a wide range of views about pharmaceutical promotion. The objective of this review is to examine the relationship between exposure to information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing.

METHODS AND FINDINGS

We searched for studies of physicians with prescribing rights who were exposed to information from pharmaceutical companies (promotional or otherwise). Exposures included pharmaceutical sales representative visits, journal advertisements, attendance at pharmaceutical sponsored meetings, mailed information, prescribing software, and participation in sponsored clinical trials. The outcomes measured were quality, quantity, and cost of physicians' prescribing. We searched Medline (1966 to February 2008), International Pharmaceutical Abstracts (1970 to February 2008), Embase (1997 to February 2008), Current Contents (2001 to 2008), and Central (The Cochrane Library Issue 3, 2007) using the search terms developed with an expert librarian. Additionally, we reviewed reference lists and contacted experts and pharmaceutical companies for information. Randomized and observational studies evaluating information from pharmaceutical companies and measures of physicians' prescribing were independently appraised for methodological quality by two authors. Studies were excluded where insufficient study information precluded appraisal. The full text of 255 articles was retrieved from electronic databases (7,185 studies) and other sources (138 studies). Articles were then excluded because they did not fulfil inclusion criteria (179) or quality appraisal criteria (18), leaving 58 included studies with 87 distinct analyses. Data were extracted independently by two authors and a narrative synthesis performed following the MOOSE guidelines. Of the set of studies examining prescribing quality outcomes, five found associations between exposure to pharmaceutical company information and lower quality prescribing, four did not detect an association, and one found associations with lower and higher quality prescribing. 38 included studies found associations between exposure and higher frequency of prescribing and 13 did not detect an association. Five included studies found evidence for association with higher costs, four found no association, and one found an association with lower costs. The narrative synthesis finding of variable results was supported by a meta-analysis of studies of prescribing frequency that found significant heterogeneity. The observational nature of most included studies is the main limitation of this review.

CONCLUSIONS

With rare exceptions, studies of exposure to information provided directly by pharmaceutical companies have found associations with higher prescribing frequency, higher costs, or lower prescribing quality or have not found significant associations. We did not find evidence of net improvements in prescribing, but the available literature does not exclude the possibility that prescribing may sometimes be improved. Still, we recommend that practitioners follow the precautionary principle and thus avoid exposure to information from pharmaceutical companies. Please see later in the article for the Editors' Summary.

Quality of pharmaceutical advertisements in medical journals: a systematic review

Background

Journal advertising is one of the main sources of medicines information to doctors. Despite the availability of regulations and controls of drug promotion worldwide, information on medicines provided in journal advertising has been criticized in several studies for being of poor quality. However, no attempt has been made to systematically summarise this body of research. We designed this systematic review to assess all studies that have examined the quality of pharmaceutical advertisements for prescription products in medical and pharmacy journals.

Methods and Findings

Studies were identified via searching electronic databases, web library, search engine and reviewing citations (1950 – February 2006). Only articles published in English and examined the quality of information included in pharmaceutical advertisements for prescription products in medical or pharmacy journals were included. For each eligible article, a researcher independently extracted the data on the study methodology and outcomes. The data were then reviewed by a second researcher. Any disagreements were resolved by consensus. The data were analysed descriptively. The final analysis included 24 articles. The studies reviewed advertisements from 26 countries. The number of journals surveyed in each study ranged from four to 24 journals. Several outcome measures were examined including references and claims provided in advertisements, availability of product information, adherence to codes or guidelines and presentation of risk results. The majority of studies employed a convenience-sampling method. Brand name, generic name and indications were usually provided. Journal articles were commonly cited to support pharmaceutical claims. Less than 67% of the claims were supported by a systematic review, a meta-analysis or a randomised control trial. Studies that assessed misleading claims had at least one advertisement with a misleading claim. Two studies found that less than 28% of claims were unambiguous clinical claims. Most advertisements with quantitative information provided risk results as relative risk reduction. Studies were conducted in 26 countries only and then the generalizability of the results is limited.

Conclusions

Evidence from this review indicates that low quality of journal advertising is a global issue. As information provided in journal advertising has the potential to change doctors' prescribing behaviour, ongoing efforts to increase education about drug promotion are crucial. The results from our review suggest the need for a global pro-active and effective regulatory system to ensure that information provided in medical journal advertising is supporting the quality use of medicines.

A content analysis of advertisements for psychotherapy workshops: implications for disseminating empirically supported treatments

This study involved a content analysis of 261 unique advertisements for psychotherapy workshops that appeared in two bimonthly clinical magazines, Psychotherapy Networker and Counselor, during a 2-year period. Two independent judges coded each advertisement and documented the type and prevalence of advertising appeals used. From the seminal diffusion of innovations model, Rogers' (2003) five perceived characteristics of innovations found to influence adoption in diverse fields were not well represented in these workshops appeals, appearing less than 10% each. Few advertisements cited specific empirically supported treatments or presented any evidence of treatment effectiveness beyond expert testimonials. The most frequently noted appeals were to benefit the clinician (e.g., earning education credit or developing skills), characteristics that enhance credibility of the workshop (e.g., reference to storied history or mention of faculty), and features of the advertisements itself (e.g., use of superlatives and exclamation points). Promotional strategies to advertise psychotherapy workshops can be used to inform the dissemination of empirically supported treatments.

The effect of advertising in clinical software on general practitioners' prescribing behaviour

OBJECTIVE

To assess the effect of pharmaceutical advertising embedded in clinical software on the prescribing behaviour of general practitioners.

DESIGN, PARTICIPANTS AND SETTING

Secondary analysis of data from a random sample of 1336 Australian GPs who participated in Bettering the Evaluation and Care of Health, a national continuous cross-sectional survey of general practice activity, between November 2003 and March 2005. The prescribing behaviour of participants who used the advertising software was compared with that of participants who did not, for seven pharmaceutical products advertised continually throughout the study period.

MAIN OUTCOME MEASURES

Prescription for advertised product as a proportion (%) of prescriptions for all pharmaceutical products in the same generic class or group.

RESULTS

GP age, practice location, accreditation status, patient bulk-billing status and hours worked were significantly associated (P < 0.05) with use of advertising software. We found no significant differences, either before or after adjustment for these confounders, in the prescribing rate of Lipitor (adjusted odds ratio [AOR], 0.90; P = 0.26); Micardis (AOR, 0.98; P = 0.91); Mobic (AOR, 1.02; P = 0.89); Norvasc (AOR, 1.02; P = 0.91); Natrilix (AOR, 0.80; P = 0.32); or Zanidip (AOR, 0.88; P = 0.47). GPs using advertising software prescribed Nexium significantly less often than those not using advertising software (AOR, 0.78; P = 0.02). When all advertised products were combined and compared with products that were not advertised, no difference in the overall prescribing behaviour was demonstrated (AOR, 0.96; P = 0.42).

CONCLUSION

Exposure to advertisements in clinical software has little influence on the prescribing behaviour of GPs.

Increased Introduction, Advertising, and Sales of Preventive Drugs During 1986–2002 in Sweden

The objective of this study was to survey how introduction of new drugs and promotional activities influence drug sales in Sweden. All drugs on the Swedish market were categorized as curative, symptom-alleviating, substitutive, or preventive. The number of new drugs introduced, drug sales in volume and value, and the number of drug advertisements appearing in the major Swedish medical journal during 1986-2002 were determined for each of the 4 drug categories. Between 1986 and 1998, the relative shares of the 4 drug categories were relatively constant. From 1998 to 2002, the share of new preventive drugs increased from 24% to 30%, their share of advertisements increased from 20% to 35%, and their sales value increased from 25% to 30%. During the same period, the shares of other drugs decreased correspondingly. Pharmaceutical companies have shifted their attention to the introduction, advertising, and sales of preventive drugs in an attempt to exploit preventive medicine. This might lead to waste of resources when expensive preventive drugs are used by numerous patients over many years, as the benefit of preventive drugs for the individual patient cannot be judged easily.

Excessive and disproportionate advertising in peer-reviewed journals

The International Committee of Medical Journal Editors (ICMJE) has outlined ethical guidelines concerning the advertising practices of peer-reviewed journals that briefly discuss issues of excessive and disproportionate advertising. The authors evaluated these guidelines using quantitative data, assessing the types and frequencies of advertising in 2001 print issues of NEJM and JAMA, two principal members of ICMJE. Advertising ratios (ratio of advertisements to editorial content) were near unity in NEJM and 0.30 in JAMA, compared with reported ratios of 0.15 among low-circulation specialty science journals and 0.80 among high-circulation consumer magazines. In both journals, five corporations placed more than 50% of all display advertisements. The findings suggest a dissonance between the ethical guidelines and the de facto advertising practices of arguably the two most important member journals of the ICMJE. There is a need to define and apply standards for excessive and disproportionate advertising.

Communicating safety information to physicians: an examination of dear doctor letters

PURPOSE

Recent research suggests that letters to healthcare providers may not effectively communicate safety-related information. This study examined whether content, organization, and formatting of dear doctor letters (DDLs) influences physicians' responses to the letters.

METHODS

Drugs with warning label changes during 2000 and 2001 were identified, and corresponding DDLs were obtained. Letters were coded for content, organization, and formatting. Ten physicians rated letters on presentation, criticalness of the information, and likelihood of changing practice as a result of the letter. Areas of deficiency were identified. The relationships between key characteristics of the letters and physicians' ratings were examined using correlations; reliability of physicians' ratings was estimated using generalizability theory.

RESULTS

For 2000 and 2001, 124 drugs were identified as having had changes to the warning section of the label; DDLs were sent in 32 (25.8%) instances. Letters varied in terms of the placement of key information, use of formatting, and length. Physicians' ratings suggested 25% of the letters were deficient in clarity, 28% in readability, 36% in the ratio of relevant information to supporting information, 36% in key information easily discernable, and 28% in overall effectiveness of communication. Letters with formatting highlighting key information were preferred. Letter length and placement of key information were not correlated with physicians' ratings.

CONCLUSIONS

Many DDLs do not communicate labeling changes clearly and effectively. If DDLs are used to communicate safety information to physicians, special formatting and explicit wording should be used to emphasize new information.

Direct-to-consumer advertisements for prescription drugs: what are Americans being sold?

BACKGROUND

Pharmaceutical companies spent US$1.8 billion on direct-to-consumer advertisements for prescription drugs in 1999. Our aim was to establish what messages are being communicated to the public by these advertisements.

METHODS

We investigated the content of advertisements, which appeared in ten magazines in the USA. We examined seven issues of each of these published between July, 1998, and July, 1999.

FINDINGS

67 advertisements appeared a total of 211 times during our study. Of these, 133 (63%) were for drugs to ameliorate symptoms, 54 (26%) to treat disease, and 23 (11%) to prevent illness. In the 67 unique advertisements, promotional techniques used included emotional appeals (45, 67%) and encouragement of consumers to consider medical causes for their experiences (26, 39%). More advertisements described the benefit of medication with vague, qualitative terms (58, 87%), than with data (9, 13%). However, half the advertisements used data to describe side-effects, typically with lists of side-effects that generally occurred infrequently. None mentioned cost.

INTERPRETATION

Provision of complete information about the benefit of prescription drugs in advertisements would serve the interests of physicians and the public.

Prescribing new drugs: qualitative study of influences on consultants and general practitioners

OBJECTIVE

To explore consultants' and general practitioners' perceptions of the factors that influence their decisions to introduce new drugs into their clinical practice.

DESIGN

Qualitative study using semistructured interviews. Monitoring of hospital and general practice prescribing data for eight new drugs.

SETTING

Teaching hospital and nearby general hospital plus general practices in Birmingham.

PARTICIPANTS

38 consultants and 56 general practitioners who regularly referred to the teaching hospital.

MAIN OUTCOME MEASURES

Reasons for prescribing a new drug; sources of information used for new drugs; extent of contact between consultants and general practitioners; and amount of study drugs used in hospitals and by general practitioners.

RESULTS

Consultants usually prescribed new drugs only in their specialty, used few new drugs, and used scientific evidence to inform their decisions. General practitioners generally prescribed more new drugs and for a wider range of conditions, but their approach varied considerably both between general practitioners and between drugs for the same general practitioner. Drug company representatives were an important source of information for general practitioners. Prescribing data were consistent with statements made by respondents.

CONCLUSIONS

The factors influencing the introduction of new drugs, particularly in primary care, are more multiple and complex than suggested by early theories of drug innovation. Early experience of using a new drug seems to strongly influence future use.

Proton pump inhibitors: a study of GPs' prescribing

BACKGROUND

There has been a rapid increase in proton pump inhibitor (PPI) prescribing in recent years, and controlling the cost and improving the quality of prescribing is an issue of concern to many GPS:

OBJECTIVE

Our aim was to compare GPs' usage of different PPIs and explore how GPs' PPI prescribing changes following the introduction of a cheaper competitor.

METHODS

PPI prescribing data (PACT) for 53 GPs, who were selected as regular users of a teaching hospital, were monitored from January 1995 to December 1997. The GPs were located in two adjoining health districts and had been interviewed about influences on their decisions to begin prescribing lansoprazole. The PPI prescribing data were collected for the teaching hospital and the general hospital in the adjoining district.

RESULTS

Complete prescribing data were available for 50 GPS: Total PPI prescribing increased throughout the study due mainly to increasing use of the new PPIS: Use of the new PPIs increased from 6 to 24% over 3 years. The proportion of maintenance doses prescribed increased from 3 to 12%. There was a 23-fold difference in total PPI prescribing and an 87-fold difference in lansoprazole prescribing between the highest and lowest prescribers. The uptake of pantoprazole was slower than that of lansoprazole. A rapid increase in the use of lansoprazole by the GPs followed an increase in use in the teaching hospital.

CONCLUSION

Hospital prescribing was an important influence on the choice of PPI used by GPS: The wide variation in PPI prescribing suggests that there is scope for improvement in the quality and cost of PPI prescribing.