Lessons from a slow start?

I’ve been saving a folded section of newspaper with Elisabeth Rosenthal’s New York Times article from February 28 on my crowded desk ( New York Times article). In it, she points out that the health care industry spent $14 billion on advertising in 2014.

Only the US and New Zealand allow direct to consumer (DTC) advertising for drugs, and I suspect (admittedly without data) that the problem is much greater in the US. You know that this is a major problem when the AMA recommends a ban on DTC ads.

Interestingly, pharmaceutical companies are not the only players in the field. Hospital advertising has increased 38% from 2011 thru 2014, to $2.3 billion a year.

Now, my industry experience has taught me that the people who decide to spend this kind of money are NOT stupid! Even if we don’t agree with their use of resources, we ought to respectfully ask, “Why are you doing this?” A hint of an answer surfaced in an unreferenced statement by Boston Globe correspondent Katherine Whittemore, who wrote that some 87% of patients who saw a drug advertised and requested a prescription for it actually received the prescription

Additional confirmation for the concept comes from an interview on NPR. “Something like a third of consumers who’ve seen a drug ad have talked to their doctor about it,” Julie Donohue, a professor of public health at the University of Pittsburgh, told NPR. “About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored.”

The answer to “Why advertise?” seems clear. “It works.” Or, at least, it has worked so far.

Now comes the really difficult question, “Is this a wise and constructive use of resources?”

Some serious thinkers believe that the era of blockbuster drugs is coming to an end. Could the dollars that have poured into advertising be re-channeled into more useful and productive activities?

I’ve just come back from the American College of Cardiology meeting in Chicago, and I think the launch of a major new heart failure compound, sacubitril/valsartan branded as Entresto, may hold some clues. Entresto had very positive phase III trial results for the management of chronic heart failure patients with impaired contractile function, and it has an engaging DTC television ad campaign, yet it has been a slow-starter. I did an entirely informal, non-randomized set of talks with colleagues to try to understand why. Two reasons emerged. First, with more and more physicians employed by large organizations, there’s pressure to hold back on “early adoption” of new agents until “the guidelines” clarify their status. Guidelines have become a huge issue. Second, generics dominate the chronic heart failure market, and because the sponsor has pegged the cost of the drug in the $400/month range there are substantial financial constraints on switching to it.

Perhaps, just perhaps, we are seeing something new and important here. Based on the available clinical trial data, I think Entresto is an important advance in heart failure treatment. But “ask your doctor about it” is not working as well as it has in the past. Maybe those advertising dollars would be better spent on another trial or two, and some physician education?

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