Tuesday, April 30, 2013

Multi-Pronged Pharmaceutical Company Marketing Can Make "Evidenced-Based Medicine" a Joke

The above quote was taken from a talk by Ben Goldacre at the TED conference.

Of course, readers of this blog know that misleading pharmaceutical company marketing strategies and techniques are a recurring theme here. Deep sixing studies that show that their products don't work very well is just the tip of the proverbial iceberg.

One of the more impressive attributes of their marketing strategies is how multi-faceted they are. They target both physicians and the public at every possible turn, and affect every step of the process of generating the accepted “evidence base” for medical treatment in the minds of anyone potentially involved.

In a new article in the European Journal of Clinical Investigation, authors Emmanuel Stamatakis, Richard Weiler, and John P.A. Loannidis point out that just one drug, Lipitor, brought in $130 billion dollars in 14 years - an amount higher than the 2010 gross domestic product of 129 different countries.

They go on to enumerate many of the misleading marketing strategies, and describe the obvious biases that results from them. I will briefly review them here.

1.   Evidence production:
a.     Pharma designs and controls a large portion of the most influential studies.
b.    Industry-sponsored trials are more likely to compare their drug against an inactive or “straw man” comparator.
c.    They almost never compare their drugs to a variety of different possible interventions – including mere life style changes. I would add that when it comes to child psychiatry, they never compare their results to that of Supernanny-style family therapy. (Come to think of it, neither do most of the purveyors of various psychotherapy treatment paradigms).
d.   Their studies often guide the content of subsequent clinical research.
e.    Their studies are more likely to state favorable results and slyly avoid “inconvenient” findings.
f.     They raise the status of studies that they have actually writen up themselves by attaching the names of well-known academically-affiliated investigators (ghost writing) who are then paid off.

2.   Evidence synthesis
a.      Systematic reviews that they sponsor review prior studies that had asked the wrong questions to begin with.
b.     They limit access to the raw data on which their studies are based.
c.      With meta-analysis, or combining statistics from many previous studies, 100% of industry sponsored meta-analyses recommended using their drug, compared to 0% (you heard right) of independent meta-analyses, even though the actual statistics presented in both cases were quite similar. Conflicts of interest are generally not reported in meta-analyses (not that anyone would pay attention if the were).

3.   Understating risks of drugs
a.      Recent withdrawals of previously FDA-approved drugs seem to indicate that manufacturers intentionally distort the presentation of clinical trial safety data.
b.     Companies carefully train their sales representatives to tactfully avoid physician questions about the safety of their products.

4.   Cost-effectiveness evaluation
a.      Studies funded by industry are more than twice as likely to show good cost-effectiveness of their drug than independently financed studies.
b.     This is accomplished through the use of subtly biased assumptions about the intervention and its comparators.

5.   Clinical practice guidelines
     Because many of the authors of treatment guidelines produced by various medical specialty and subspecialty groups have a financial conflict of interest because they are paid by drug companies via consultancies, research support, or stock ownership, these guideline are often heavily focus on new, costly interventions and only loosely follow all of the available evidence.

6.   Healthcare professional education
a.     Gifts to medical students, which lately have been banned by many medical schools, were routinely given for decades. These are often given during “academic” presentations that are sponsored by industry and which are given by influential medical school professors.
b.   Industry-sponsored continuing medical education (CME) for practicing physicians accounted of approximately half of all CME as recently as 2010.
c.    The doctors who present CME usually use slides provided by the drug companies that manufacture the drugs prominently featured during the presentation.  Pharma also pays the presenters hefty fees.

7.    Direct influence on docs
a.    Drug sales representatives frequently visit doctors’ offices to “share” information with both the doctors and their staffs.
b.   Regular interactions with sales reps increases the chances that a company’s drug will be added to a hospital drug formulary (their list of preferred medications) by over 300%.

8.   Direct of consumer advertising
    Industry spending on TV and media adds increased from $11 billion dollars to $30 billion dollars per year over the period of 1996-2005.

Need they say more?

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