Direct-to-consumer print ads for drugs: Do they undermine the physician-patient relationship?

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Original Research

Direct-to-consumer print ads for drugs: Do they undermine the physician-patient relationship?

J Fam Pract. 2005 December;54(12):1049-1057

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References

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TABLE 1
References to physician(s) and to communication with physician(s) by medical condition

		PHYSICIAN REFERENCES		COMMUNICATION REFERENCES
MEDICAL CONDITION	N*	M	SD	M	SD
Allergies	35	1.83	95	1.74	.89
Cancer	5	4.00	.71	3.20	.45
Cardiovascular	14	6.29	1.44	4.86	1.03
Dermatologic	12	3.58	2.81	2.00	1.04
Diabetes	15	5.93	4.28	5.27	.77
Gastrointestinal/nutritional	14	2.43	1.09	2.07	.83
HIV/AIDS	39	1.92	1.48	1.79	1.28
Infectious (non-HIV)	8	2.63	1.85	2.63	1.85
Musculoskeltal	14	2.64	.63	2.14	.66
Obstetric/gynecologic	22	2.36	1.65	2.09	1.41
Psychiatric/neurologic	16	4.06	1.69	2.94	1.06
Respiratory	4	4.00	1.63	3.00	1.63
Tobacco/addiction	8	4.38	.74	4.13	.64
Urological	13	3.69	2.06	2.85	1.07
Undisclosed	6	.17	.41	.17	.41
TOTAL	225	3.06	2.30	2.55	1.82
*N refer to number of advertisements.

Coding procedures

A coder was trained, and initially acceptable inter- and intra-rater reliability levels were established. To eliminate effects due to particular magazines, products, etc, the 225 ads were placed in random order. The coder independently coded the randomlyordered sample of 225 advertisements. In addition, to assess reliability, the coder recoded (and the second author coded) a randomly selected subset of 25 ads. Final intra-rater reliabilities (percentage of agreement) and inter-rater reliabilities (Cohen’s kappa) were: initiator of interaction: 93.8%, κ=.93; relational control: 90.6%, κ=.89; and interaction topic: 92.2%, κ=.92.

TABLE 2
References regarding who initiates communication: Percentages by category

MEDICAL CONDITION	N*	EXPLICIT	IMPLICIT	PHYSICIAN	EITHER
Allergies	61	80.3	8.2	3.3	8.2
Cancer	16	37.5	12.5	37.5	12.5
Cardiovascular	68	89.7	1.5	4.4	4.4
Dermatologic	24	54.2	20.8	20.8	4.2
Diabetes	79	53.2	8.9	29.1	8.9
Gastrointestinal/nutritional	29	72.4	3.4	6.9	17.2
HIV/AIDS	70	81.4	2.9	4.3	11.4
Infectious (non-HIV)	21	100.0	0.0	0.0	0.0
Musculoskeletal	30	60.0	3.3	23.3	13.3
Obstetric/gynecologic	46	63.0	0.0	2.2	34.8
Psychiatric/neurologic	47	61.7	8.5	27.7	2.1
Respiratory	12	58.3	25.0	16.7	0.0
Tobacco/addiction	33	54.5	12.1	30.3	3.0
Urological	37	75.7	5.4	10.8	8.1
Undisclosed	1	100.0	0.0	0.0	0.0
TOTAL	574	69.7	6.4	14.1	9.8
* N refers to number of references to physician-patient communication. Codes: Explicit=explicit directives to patients to initiate communication; Implicit=implicit directives to patients to initiate communication; Physicians=references to physician initiated communication; Either=either party can initiate communication.

Results

References to physicians

The number of references to physicians per ad ranged from 0 to 12; the average exceeded 3 (TABLE 1). All but 4.4% of ads made reference to physicians. The major exception, mostly reminder ads for undisclosed conditions, contained little text. Numbers of references to physicians varied by disclosed medical condition, from lows of less than 2 (allergies, HIV/AIDS), to a high exceeding 6 (cardiovascular).

FAST TRACK

DTCA steers topics toward products’ benefits and away from deficits

Physician-patient communication messages

The number of statements that focused on physician-patient communication ranged from 0 to 10 per ad. Most references to physicians (83.8%) focused on communication; typically ads contained more than 2 communication messages. Average numbers of communication messages varied by disclosed medical condition, from less than 2 (allergies, HIV/AIDS), to a high exceeding 5 (diabetes).

Cues regarding how to communicate with physicians

Who should initiate interaction. More than three quarters (76.1%) of communication references indicated that consumers should initiate communication; most did so explicitly (69.7%) (TABLE 2). The percent age of explicit directives to consumers to initiate communication varied widely by condition, from 37.5% (cancer) to 100% (non-HIV infection, undisclosed conditions). More than 50% of communication references, in all conditions except cancer, explicitly indicated the consumer as initiator. Implicit directives to consumers to initiate communication ranged from 0% (non-HIV infection) to 25% (respiratory).

FAST TRACK

Patients’ questions may simply indicate a desire for greater participation, and not a demand for a prescription

Relatively few messages indicated the physician as initiator (14.1%), varying by medical condition from 0% (non-HIV infection, undisclosed) to 37.5% (cancer).

Messages indicating either party could initiate communication appeared in less than 10% of the statements (9.8%) and varied by medical condition from 0% (non-HIV infection, respiratory, undisclosed) to 34.8% (obstetric/gynecologic); this type of message appeared in less than 10% of communication messages in ads for 10 conditions.

Who should have relational control. The majority (54.5%) of communication messages placed physicians in control (TABLE 3). Nearly one third (30%) indicated shared (or unknown) control, while only about 15.5% cast consumers in control. However, relational control cues varied widely by medical condition. Physicians were cast in exclusive control in ads for undisclosed conditions (100%), although these numbers were small. For disclosed medical conditions, physician control ranged from 17.4% (obstetric/gynecologic) to 75% (dermatologic, respiratory). Consumer control ranged from 0% (gastrointestinal/nutritional, dermatologic, and undisclosed) to 38.2% (cardiovascular). One of the most striking differences due to medical condition occurred for obstetric/gynecologic ads, in which shared/unknown control dominated (80.4%).

FAST TRACK

DTCAs do not urge patients to take control, or undermine physicians’ prescribing authority

Appropriate interaction topics. The most frequently suggested interaction topic was clinical appropriateness (41.8%), followed by general product information (32.1%) (TABLE 4). Fewer than 1-in-5 suggested topics focused on products’ negative aspects (8.5% each for side effects and risks). For 9.1% of the statements, no topic was suggested, or the suggested topic was unclear. Suggested topics varied by disclosed medical condition. Clinical judgment accounted for 30% or more of suggested topics in most disclosed medical conditions, ranging from 20% (dermatologic) to 67% (respiratory). General information accounted for 25% or more of suggested topics in most of the disclosed conditions, ranging from 12.5% (cancer) to 59% (allergies). The topic of side effects ranged from 0% (allergies, gastrointestinal/nutritional, tobacco/addiction, undisclosed conditions) to 19.1% (cardiovascular). Similarly, the topic of risks ranged from 0% (5 conditions) to 41.3% (obstetric/gynecologic). Follow-up analyses revealed that when the suggested topic was negative (risks or side effects), in only 10 of 98 cases (10.2%) was the physician indicated as initiating communication.