What is the Real Impact of DTC Advertising on the Physician-Patient Dialogue?

Over the past several years, the impact of DTC on the physician-patient interaction – and on the quality of health care – has been hotly debated. Supporters of DTC advertising believe it is a major source for public education about a wide variety of symptoms and health conditions. They believe that it directly stimulates visits to the physician to discuss health concerns, helps encourage patients to fill their medication prescriptions, to take their medication correctly, and to keep taking their medication as directed by their physicians.

Critics of DTC advertising have countered with the concern that it has negatively affected physician-patient interactions – that patients are commonly requesting unneeded or expensive medications they saw on television. They maintain that physicians are writing prescriptions for these medications without a thorough discussion of risk and benefits and not providing a recommendation based solely on the patient’s medical needs.

These opinions have come from a variety of sources, all of them secondary reports of what is said to happen or what could happen, all research drawn from surveys of physicians, patients and from detailed analysis of the content and form of DTC advertisements themselves.

What has not been available are data derived from direct recording and analysis of actual physician-patient visits – and so, in a real sense, both supporters and critics of DTC advertising have been “flying blind”. Until now.

We know DTC advertising works … we may not know how

While we know that DTC advertising has an impact on patient and physician behavior — many studies have shown that DTC advertising leads to near-immediate changes in prescribing behavior, in the number of patients coming to the office for specific conditions, and in raising awareness about conditions and brands. Until now, the assumption has been that DTC advertising directly changes the content and tone, for better or worse, of the physician-patient visit. The results of an observational linguistic analysis of physician-patient interactions conducted by CommonHealth has shed new and essential light on what is – and is not – the impact of DTC advertising on real-world physician-patient visits. And, the results have surprised and challenged many assumptions – and conventional wisdoms – about this form of communication regarding health conditions and treatments.

The study found that:

• Patient-initiated Rx requests are minimal – direct DTC advertising references occurred in only 16 of 440 (3.7%) of office visits and ambiguous references occurred in 25 (5.7%) of office visits
• DTC advertising is rarely referenced by patients and never as directly as “I saw/heard this advertisement and want this Rx”
• DTC advertising spend does not appear to increase the amount of benefit presentation by physician in relation to risk presentations — and in categories with high DTC advertising spend (cholesterol, allergy), “risk-benefit” discussion is more common than in hypertension (with a negligible DTC advertising spend)
  

A unique source of insight

The data from this study is unique in several ways. It is the first direct observation and analysis of the “nexus” of all professional, DTP and DTC education and promotion – the “moment of truth” when the physician and the patient are together discussing diagnosis and treatment. It is also the only body of data of sufficient size to analyze overall patterns of discourse relating to numerous medication categories.

This observational study is based on 440 individual patient visits with 172 healthcare providers, recorded between 2001 and 2005. The data were created using a research methodology that is designed to capture most naturally-occurring office visits as possible. Physicians are recruited randomly (no physician panels are used). Participating physicians know the therapeutic category (i.e., seasonal allergies, dyslipidemia) of interest – they do not know the sponsoring company or brand, or even the nature of the sponsors’ interest in the study findings. Patients are chosen from appointments scheduled for the day of testing (no patient recruiting is allowed). Those patients agreeing to participate review and sign a HIPPA-compliant consent form. The exam room contains a small video camera, there are no observers in the room at the time of the visit, and no special wiring or lighting is required. Post-visit interviews are conducted with the physician and patient separately on the day of the visit. Complete transcriptions are made from the visit and post-visit interviews, upon which linguistic comprehensive analysis is performed.

For the retrospective analysis of the data, three therapeutic categories were chosen to test the impact of DTC advertising – allergy, cholesterol, and hypertension. All mentions of name brand medications, both those supported by DTC investments and those that were not, were tagged. DTC advertising spend data* was matched to the office visit. Those medications supported by DTC at the time of the recorded office visits were designated “DTC-supported” and those that did not were designated “non-DTC-supported.” These demarcations formed the basis for comparisons between DTC/non-DTC within and between therapeutic categories.

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Detailed study findings: DTC-driven patient Rx requests

The study took several approaches to the analysis of the data, making a comprehensive review of all target Rx medication mentions by patient, in all visits. For the DTC advertising analysis, every reference of DTC advertising made by the physician or patient was tagged and recorded. Each mention was coded as “direct DTC reference” or “ambiguous DTC reference” to ensure that any utterance that could possibly be connected to DTC advertising would be included. 291 of the 440 visits sampled contained a discussion of allergy, cholesterol, or hypertension medications.

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Overall, there were very few references to DTC advertising, and most of those were made by healthcare providers.

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In addition, direct patient requests for Rx medications were minimal, much less than was expected, given the published survey data about the DTC advertising impact on patient requests for medications. There were requests for medications from the 3 categories studied (by name or otherwise) in 2.7% of visits (8/291).

• In the six cases where patients request a medication, that request is fulfilled
  
• In the two cases where a patient raises a concern about a medication, that patient got a new Rx (1) or was told to stop the medication in question (1)
  
• In NO CASE did a patient reference a DTC ad directly as the motivation for the request

Detailed study findings: Risk-benefit presentation

For the analysis of risk/benefit, all transcripts including any mention of targeted medications (291) were reviewed and every instance of “risk” or “benefit” was coded and counted. “Risk” was defined as any potential negative consequence of a targeted medication. “Benefit” was defined as any potential positive consequence of a targeted medication.

The study found that there is minimal risk-benefit presentation by physicians, and even less lengthy discussion of risks and benefits between physicians and patients regarding Rx medications. Over half of the visits in which a medication was discussed had no risk or benefit discussion for that medication:

• Allergy -- 43% of visits; Cholesterol -- 41% of visits; Hypertension -- 29% of visits

The majority of medication mentions do NOT have an associated risk or benefit

• Cholesterol -- 26% of medication mentions; Allergy -- 16%; Hypertension -- 13%

All categories show more benefits being presented than risks; allergy medications show the highest ratio, hypertension the lowest

• Allergy medication “risks” typically involved drowsiness or discomfort
  
• Cholesterol and hypertension “risks” typically involved liver functions, neuralgias, or other signs of serious side-effects

Overall, few physician mentions of Rx medications (between 12% and 24%) have a risk or benefit presented, and DTC advertising spend does not appear to influence the presentation of risk/benefit in cardiovascular conditions; allergy, with a lower consequence of risks, has a higher risk-benefit.

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The implication is that disease category, not DTC advertising spend, influences how frequently patients initiate a discussion of specific Rx medications.

If not in the dialogue… where?

We know that DTC advertising has a demonstrable, positive impact on office visits and prescriptions for medications. And so, these data beg the question – “if DTC advertising is not impacting direct patient requests for DTC-supported medications, then what accounts for its impact on prescriptions?” Several hypotheses immediately suggest themselves. DTC advertising may increase:

• Overall number of visits from a “pre-selected” patient population
• Patient receptivity to a discussion of DTC-supported medications
• Physician top-of-mind awareness of an advertised medication
• Patient discussion of medication – friends/family, on-line research, and Allied Health Professionals outside the exam room
• First fill of Rx and subsequent adherence to medication

An unprecedented opportunity

The debate about the impact of DTC advertising will continue. The results from this research, the first to be based entirely on observed, real-world office visits sheds new light on what impact DTC advertising does – and does not – have on the physician-patient dialogue. These data presents the Life Sciences industry with great opportunities. First, they point the way for new research that can more clearly define what is the real impact of DTC advertising on physician-patient interactions. And secondly, based on these insights, an expanded view of how DTC advertising can serve the needs of both physician and patient can be conceived and acted upon.

Figure 1: DTC Spend by Category, 2001-2005

Source: TNS Media Intelligence Copyright 2006. Magazine Publishers of America Inc.

Figure 2: Rules for inclusion of “Direct” and “Ambiguous” DTC References

Figure 3: DTC References for Allergy, Cholesterol, and Hypertension Medication

Figure 4: Physician Presentation of Risk-Benefit, by Category

*All Allergy medications analyzed had DTC between 2001-2005
** Individually, “Hypertension with DTC” and “Hypertension without DTC” did not have a sufficient number of risk-benefit statements for statistical comparison, however both “with” and “without” categories mirror the overall finding directionally.