# Presentation: 692668

## Direct-to-Consumer Advertising of Prescription Drugs—Review of Literature Relating to Population Subsets

**Eastern Research Group, Inc.**
**Lexington, MA**

## DTCA and Subsets of the Population

_**Who are underserved populations?**_
**Groups studied in DTCA research:**
- Elderly
- African-Americans, Hispanics, and other racial or ethnic minorities
- Lower income level
- Lower education level
- Lower English literacy
**Note: **Research on** **DTCA impacts on **children’s health** is limited.

## Top 20 Pharmaceutical Products in Terms of Spending on Direct-to-Consumer Advertising in 2005 (from Donohue et. al. 2007, Table 3)

## U.S. Population SubsetsU.S. Census 2006 American Community Survey

**Adult U.S. population: **
**	****75.4% (225,746,000) ≥18 years**
**Elderly/Seniors**
**17%** (50,983,000) ≥ 60 years.
**6.1% **(18,293,000) ≥ 75 years.
**Race, Ethnicity, and Language**
**66.2%** White (non-Hispanic or Latino)
**14.8%** Hispanic or Latino
**12.4%** Black or African American
**4.4%**   Asian
**8.7%**   speak English less than very well.
**(Census, 2008)**

## 
Household Income
$15,000 - $24,999-11.4%
$25,000- $34,999- 11.2%
$35,000- $49,999- 14.8%
$50,000- $74,999- 19.0%
$75,000- $99,999- 11.8%

Median Household Income by Race
White  $52,375
Asian  $63,642
Hispanic or Latino  $38,747
American Indian and Alaska Native $33,762
Black or African American- $32,372

**Household Income**
- $15,000 - $24,999-11.4%
- $25,000- $34,999- 11.2%
- $35,000- $49,999- 14.8%
- $50,000- $74,999- 19.0%
- $75,000- $99,999- 11.8%
**Median Household Income by Race**
- White  $52,375
- Asian  $63,642
- Hispanic or Latino  $38,747
- American Indian and Alaska Native $33,762
- Black or African American- $32,372

**U.S. Population Subsets****U.S. Census 2006 American Community Survey:****225,746,000 people ≥18 years**

## U.S. Population SubsetsU.S. Census 2006 American Community Survey:225,746,000 people ≥18 years

**Education Level (over 18 years)**
**16.2%** non-high school graduate
**30.7%** high school graduate
**24.6%** Bachelor’s degree or higher
**Poverty Rate and Median Income by Education (over 25 years)**
**23.7% **non-high school graduate—**$18,641**
**11.5% **high school graduate—**$26,123**
**4.1% **bachelor’s degree—**$45,221**
**3.1% **graduate or professional degree—**$59,804**

## 	Comparing underserved populations with the general population: 

What data have been reported regarding DTCA and U.S. consumers?

What data have been reported regarding DTCA and underserved populations?

Are there differences in exposure to, attitude toward, comprehension of, and behavior in response to DTCA?

- What data have been reported regarding DTCA and U.S. consumers?
- What data have been reported regarding DTCA and underserved populations?
- Are there differences in exposure to, attitude toward, comprehension of, and behavior in response to DTCA?

## Exposure to DTCA

_**General Population**_
**96%** percent report having seen at least one DTCA (Prevention, 2004).
**83%** saw DTCA in previous 12 months (Murray et al., 2004).

_**Population Subsets**_
**93%** of subjects ≥**60** years have seen at least one DTCA (Prevention 2004).
**88%** of subjects ≥**60** years have seen DTCA on TV (Marinac et al. 2004).
**90%** of subjects ≥**50** years have seen a DTCA (Barrett, 2005).

## Exposure to DTCA

_**General population**_
**91%** have seen or heard some type of DTCA (Kaiser, 2008).
**81% **have seen or heard a DTCA for prescription drugs in the past 30 days** **(Consumer Reports, 2008).

_**Population Subsets**_
**76%** of African-American patients* in doctors’ waiting rooms had seen a DTCA in previous two months (Allison-Ottey et al., 2003).
- *sample was 91% African-American, 5% Hispanic

## Behavioral Response to DTCA—Talking to Physicians

_**General Population**_
**32%** of DTCA-exposed  consumers talked to a physician about DTCA drug; **8.3%** of exposed consumers asked for a prescription (Prevention, 2004).
**12%** of exposed subjects talked to physician about information in a DTCA (Murray et al., 2004).

_**Population Subsets**_
**27% of DTCA-exposed subjects ≥60 years talked to physician about DTCA drug; 4.1% asked for a prescription** (Prevention, 2004).
**18% of exposed subjects ≥50 years asked physician for DTCA prescription** (Barrett, 2005).
**5% of subjects asking physician about DTCA drug were ≥75 years. They were less likely (OR=.58) to make RX requests than other groups.** (Datti and Carter, 2006).

## Behavioral Response to DTCA—Talking to Physicians

_**General Population**_
**22%** of high school graduates or higher scheduled a physician visit in response to DTCA (Murray et al., 2004).
**32%** of exposed subjects (29.1% of all) asked physician about the specific drug they saw advertised (Kaiser, 2008).

_**Population Subset**_
**58%** of high school non-graduates scheduled a physician visit in response to DTCA (Murray et al., 2004).

## Behavioral Response to DTCA—Talking to Physicians

_**General Population**_
**31%** of DTCA-exposed patients asked physician about DTCA drug (Datti and Carter, 2006).
**33%** of subjects who had a question for their physician were prompted by a TV ad, **19%** by a print ad (Aikin et al., 2004).

_**Population Subsets**_
**c. 29%** of African-American patients* in doctors’ waiting rooms said they had once asked physician for DTCA prescription (Allison-Ottey, et al. 2003).*sample was 91% African-American, 5% Hispanic.
- Odds of African-   Americans requesting a  DTCA prescription were  **58% higher **than survey counterparts (Datti and Carter, 2006).

## Physician Responses to Patient Requests

_**General Population**_
**84%** of direct DTCA prescription requests granted by physicians (**7.0%** of all DTCA-exposed subjects), (Prevention, 2004).
**50%** of patients discussing DTCA drug were given a prescription—**25%** for DTCA drug, **25%** for another drug. Equals **10.9%** of all DTCA-exposed subjects (Prevention, 2004).

_**Population Subsets**_
**5%** of subjects receiving a DTCA prescription were ≥75 years. (Datti and Carter, 2006).
**51%** of patients ≥50 years requesting DTCA drug (**8.3%** of all subjects ≥50 years) were given prescription by physician (Barrett, 2005).

## Physician Responses to Patient Requests

_**General Population**_
**58% **of high school graduates and higher** **requesting DTCA-inspired “intervention” received what they requested (Murray et al., 2004).
**63% of **white subjects requesting DTCA-inspired “intervention” received what they requested (Murray et al., 2004).

_**Population Subsets**_** **
**29%** of non-high school graduates requesting DTCA-inspired “intervention” received what they requested (Murray et al., 2004).
**30% **of non-white subjects requesting DTCA-inspired “intervention” received what they requested (Murray et al., 2004).

## Physician Responses to Patient Requests

_**General Population**_
**69%** of subjects asking about DTCA drug received a prescription (Datti and Carter, 2006).
**44%** of patients discussing DTCA (**14.1%** of all DTCA-exposed subjects) received the specific prescription (Kaiser, 2008).

_**Population Subsets**_
- c. 28% of African-American patients* who had ever asked for DTCA drug (8.1% of all subjects) were given Rx (Allison-Ottey et al., 2003). *sample was 91% African-American, 5% Hispanic.
- Odds of African-Americans receiving prescription were **63% lower** than other subjects (OR=0.37) (Datti and Carter, 2006)

## What happens when patients ask doctors for drugs? (Kravitz et al., 2005)

**Standardized Patients Asking for Non-Specific Prescription Drugs**

**Percentage of Patients Receiving Drug**

**What happens when patients ask doctors for drugs? (Kravitz et al., 2005)**

## Standardized Patients Asking for Paxil

**Standardized Patients Asking for Paxil**

**What happens when patients ask doctors for drugs? (Kravitz et al., 2005)**

## What happens when patients ask doctors for drugs? 

**Standardized Patients Getting Some Treatment**
**(Prescription, Therapeutic Referral, or Follow-up Visit)**

**What happens when patients ask doctors for drugs? **
**(Kravitz et al., 2005)**

## Perception of Risks and Benefits

_**General Population**_
- Consumers overestimate side effect rates by up to **10 times** when no risk data is given in DTCA (Young and Oppenheimer, 2006).
- The presentation of specific, numerical risk data in DTCA correlates to reduced fear levels and increased intention to comply with** **the drug regimen (Young and Oppenheimer, 2006).

_**Population Subsets**_
- A mean of **59% **of true-false comprehension questions about recently-viewed DTCAs were answered correctly by limited English literacy subjects. (Kaphingst et al., 2005). Odds of risk questions being correctly answered were lower than for benefits.

## Perception of Risks and Benefits

_**General Population**_
**36%** of high school graduates, **28%**  with some college, and **23%** of college graduates said DTCA provided enough information to make a risk/benefit decision (Prevention, 2004).
**7%** of prescription drug users stopped taking their prescription after viewing a DTCA, and **7%** switched to an OTC medication (Prevention, 2004).

_**Population Subsets**_
**43% **of non-high school graduates said DTCA provided enough information to make a risk/benefit decision. (Prevention, 2004).
**71%** of consumers with high school degrees or less can comprehend numerical risk/benefit data presented in an experimental benefits table for print DTCAs (Schwartz et al., 2007).
- Subjects with high school degrees or less understood a “drug facts box” slightly less than those with at least some college (Schwartz et al., 2007)

## Perception of Risks and Benefits

_**General Population**_
- Subjects told side effect is “common” estimated their own probability of suffering side effect at 56.6% versus actual rate of 6%. (Berry et al., 2003).
- Subjects given actual numerical side effect rate (6%), then asked what their probability of suffering side effect was, gave mean response of 19.9% (Berry et al., 2003).

_**Population Subsets**_
**60%** of seniors in a Kansas City-area survey reported that DTCA were often confusing and difficult to understand (Marinac et al., 2004).

## Perception of Risks and Benefits

_**General Population**_
**59%** of national adults recall some knowledge about risks associated with DTCA (Prevention 2007).
- Risks are recited nearly** 50% faster than benefits** in a sample of television DTCAs (Kaphingst et al., 2004).
**91%** of a sample of television DTCAs recite risks faster than benefits (Kaphingst et al., 2004).

## DTCA and Children

**Research data on DTCA and children’s health is limited.**
**16% **of U.S. adults provide medical care for children for a specific condition, **56%** for ADD/ADHD (Prevention 2004).
**40% **of caregivers for children have talked to physician about DTCA drug for others, vs. **18%** of all caregivers (Prevention 2004).

## DTCA and Children

- Subjects with one child ≤18** **years were** 13% **more likely to request DTCA drug from a physician than others (Datti and Carter, 2006).  Odds increased by 13% with each additional child.
- DTCA for depression and ADHD may de-stigmatize and “legitimate” these and other disorders (Feinberg, 2005).

## DTCA and the Internet

**5** million consumers import drugs from outside the U.S. via pharmaceutical Web sites, according to PHRMA survey (Hoffman 2007).
**2** million do so without a prescription.
- Price was given as the primary reason (**85%**).
- Most Web-imported drugs were antibiotics for infections, and drugs to treat allergies, pain, digestive problems, hypertension, and high cholesterol.

## Population Subsets and DTCA: Summary

- Population subsets see as much DTCA as others.
- Population subsets differ in their responses to DTCA:
- Seniors tend to request prescriptions less often.
- Seniors requesting prescription medication from physicians are likely to be referred for further treatment.

## Population Subsets and DTCA: Summary

- African-Americans tend to request prescriptions more often than other groups.
- African-Americans apparently do not receive requested prescriptions as often as other groups.

## Population Subsets and DTCA: Summary

- People with high school or less education view DTCA more favorably.
- People with high school or less education are more likely to agree that DTCA provides enough information to decide if drug benefits outweigh the risks.

## Population Subsets and DTCA: Summary

- Physicians may provide treatment and prescriptions more frequently to patients that request drugs than to those who do not.
- Consumers may overestimate a drug’s risks when given either vague or specific risk information.

## REFERENCES

- Aikin KJ, Swasy JL, Braman AC. 2004. Patient and physician attitudes and behaviors associated with DTC promotion of prescription drugs—summary of FDA survey research results. Washington, DC: U.S. Department of Health and Human Services, Food and Drug Administration.
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- Barrett L. 2005. Prescription Drug Use Among Midlife and Older Americans. AARP. The Roper public Affairs and Media group of NOP World.
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- Census. 2008. Fact Finder. _[http://factfinder.census.gov/servlet/STTable?_bm=y&-geo_id=01000US&-qr_name=ACS_2006_EST_G00_S0101&-ds_name=ACS_2006_EST_G00_](http://factfinder.census.gov/servlet/STTable?_bm=y&-geo_id=01000US&-qr_name=ACS_2006_EST_G00_S0101&-ds_name=ACS_2006_EST_G00_)_ Accessed on May 11, 2008.
- Consumer Reports National Research Center. 2008. Direct-to-consumer prescription drug advertisement poll. NRC #2008.15. February 25, 2008.
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## REFERENCES 

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## REFERENCES 

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