More Consumer Ad Spending for Drugs With Lower Benefit

Of the top-selling drugs in the U.S. in 2020, lower added clinical benefit ratings and higher total drug sales were associated with a higher proportion of manufacturer total promotional spending on direct-to-consumer (DTC) advertising, according to an exploratory cross-sectional study.

After adjusting for drug characteristics for 134 drugs, the mean proportion of total promotional spending allocated to DTC advertising was an absolute 14.3% (95% CI 1.43-27.2, P=0.03) higher for drugs with low added clinical benefit compared with those with high added clinical benefit and an absolute 1.5% (95% CI 0.44-2.56, P=0.005) higher for each 10% increase in total sales, reported Michael DiStefano, PhD, of the Johns Hopkins Bloomberg School of Public Health in Baltimore, and colleagues in JAMA.

“We were intrigued when we noticed that the share of promotional spending allocated to DTC advertising varied widely across drugs and wanted to understand what might explain this,” DiStefano told MedPage Today in an email. “The first finding is interesting since it suggests manufacturers may see less value in appealing to clinicians to drive sales for drugs with low added benefit. However, clinicians might be more likely to prescribe these drugs if the patient asks for them.”

“People who see drug ads should question whether it is the best treatment for them,” he added. “It may be, but it is also possible there is a cheaper or more effective option. Clinicians and patients should be open to having these conversations.”

“We would like to look more granularly at the different DTC advertising channels and understand, for example, whether there has been a shift toward digital or online [and] for which types of drugs,” he said.

Overall, the 2020 median proportion of promotional spending on DTC advertising was 13.5% (interquartile range [IQR] 1.96-36.6). Median promotional spending was $20.9 million (IQR 2.72-131), and median total sales were $1.51 billion (IQR 0.97-2.26).

A statistically significant lower proportion of total promotional spending on DTC advertising was allocated for drugs in the alimentary tract and metabolism classification category (i.e., insulins and antihyperglycemics) than on drugs in all other categories (range 19.4%-38.6%, P<0.05).

“The U.S. is an outlier in its use of markets to deliver healthcare,” wrote Amanda Starc, PhD, of the Kellogg School of Management at Northwestern University in Chicago, in an editorial accompanying the study. “And markets can fail to deliver high-quality healthcare at affordable prices to its entire population. It is important to understand the incentives that all market actors face and explore the extent to which policy can improve outcomes.”

“Promotional activities — and direct-to-consumer advertising in particular — do not have universally negative effects on physicians and patients,” Starc added. “On the contrary, the literature suggests it causally increases the patient-physician interaction, increases use of valuable drugs, improves adherence, and increases productivity. Future work should explore heterogeneity across drug classes, patients, and physicians.”

For the study, DiStefano and colleagues included the 150 top-selling branded prescription drugs in the U.S. in 2020 as identified from IQVIA National Sales Perspectives data. Promotional spending data were provided by IQVIA ChannelDynamics. Of these drugs, 16 were missing data and were excluded from the analysis.

The authors adjusted for drug characteristics, including total 2020 sales, total 2020 promotional spending, clinical benefit ratings, number of indications, off-label use, molecule type, nature of condition treated, administration type, generic availability, FDA approval year, WHO anatomical therapeutic chemical classification, Medicare annual mean spending per beneficiary, percent sales attributable to the drug, market size, and market competitiveness, assessed from health technology assessment agencies.

The analysis included a limited number of product characteristics using a single year of promotional and sales data, which was a limitation, DiStefano and colleagues noted.

Furthermore, the data used do not capture certain promotional elements, such as spending on patient coupons and assistance programs.

In addition, because drugs often enter the market or may be used for new indications earlier in the U.S. than in other markets, DiStefano and team said that their measure of added clinical benefit may omit some drugs or uses. However, they mitigated the limitation by incorporating assessments conducted after 2020, they added.