HealthAfFdirs
`
`At the Intersection of Health, Health Care and Policy
`
`Cite this article as:
`W. David Bradford, Andrew N. Kleit, Paul J. Nietert, Terrence Steyer, Thomas
`Mcllwain and Steven Ornstein
`
`How Direct-To-Consumer Television Advertising For Osteoarthritis Drugs Affects
`Physicians‘ Prescribing Behavior
`Health Affairs 25, no.5 (2006):1371-1377
`doi: 10.1377/h|thaff.25.5.1371
`
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`1
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`ALL 2069
`MYLAN PHARMACEUTICALS v. ALLERGAN
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`MARKETWATCH
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`MARKETWATCH
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`How Direct-To-Consumer Television Advertising
`
`For Osteoarthritis Drugs Affects Physicians’
`
`Prescribing Behavior
`
`DTC advertising of COX-2 inhibitors appears to have increased the
`
`number of prescriptions written for these products.
`
`by W. David Bradford, Andrew N. Kleit, Paul J. Nietert, Terrence Steyer,
`
`Thomas Mcllwain, and Steven Ornstein
`
`ABSTRACT: Concern about the potential pernicious effect of direct—to-consumer (DTC) drug
`
`advertising on physicians‘ prescribing patterns was heightened with the 2004 withdrawal
`of Vioxx, a heavily advertised treatment for osteoarthritis. We examine how DTC advertising
`
`has affected physicians’ prescribing behavior for osteoarthritis patients. We analyzed
`monthly clinical
`information on fifty—seven primary care practices during 2000-2002,
`
`matched to monthly brand—specific advertising data for local and network television. DTC
`
`advertising of Vioxx and Celebrex increased the number of osteoarthritis patients seen by
`physicians each month. DTC advertising of Vioxx increased the likelihood that patients re-
`ceived both Vioxx and Celebrex, but Celebrex ads only affected Vioxx use. [Health Affairs
`
`25. no. 5 (2006): 1371-1377; 10.1377/hlthaff.25.5.1371]
`
`THE u.5.
`
`r.-'0u1) AND DRu0 Atlministra
`
`tion (FDA) issued new rcgtll-.Lt'inns in
`Augu:-:.t 1997 governing television ad-
`vertising of prescription drugs. Shortly there»
`after, spending on direct»to«consumer (DTC)
`advertising for prescription drugs soared-
`from $596 million in 1995 to approximately
`$1.2 billion in 1997 and an estimated $3.8 bile
`lion by 2004.‘ The effects of this spending
`have been the subject of much debate, al
`though little is known about its actual im»
`
`pacts.Westudiedthisissuebyexaminingthe
`
`use of a popular (and controversial) class of
`prescription drugs: the antidnflammatory
`and pain«re_lieving cyclooXygenase—2 (COX~
`2) inhibitors. The most popular of these were
`Vioxx (Merck) and Celebrex (Pfizer). We
`studied how prescriptions for these two
`drugs for patients with osteoarthritis re«
`sponded to changes in television advertising
`during 2000-2002.
`I The Vioxx effect. One of the most
`
`David Bradford (bradfowd@musc.edu) is a professor at the Centerfor Health Economic and Policy Studies,
`Department ofHealth Administration and Policy, at the Medical University ofSouth Carolina (MUSC) in
`Charleston. Andrew Kleit is a professor in the Department ofMeteorology, Centerfor Health Care and Policy
`Research, at the Pennsylvania State University in University Park. At MUSC, Paul Nietert is an assistant
`professor in the Department ofBiostatistics, Bioinformatics, and Epidemiology; Terrence Steyer is an assistant
`professor in the Department ofFamily Medicine; Thomas Mcllwain is an assistant professor in the Department of
`Health Administration and Policy; and Steven Ornstein is an associate professor in the Department ofFamily
`Medicine.
`
`— 1
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`371
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`HEALTH AFFAIRS ~ Volume 25. Number 5
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`D01 10.1377/h1thuff.25 5 1371 ‘@2006 Project HOPE—Thc Peopleto -People Health Foundation, inc.
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`HEALTH TRACKING
`—
`
`heavily advertised products in recent years
`was Vioxx (rofecoxib). In calendar year 2000,
`Merck spent more than $160 million on adver»
`tising this product to consumers? Merck
`withdrew Vioxx from the market in Septem~
`ber 2004 because of evidence of increased risk
`
`of myocardial infarction and stroke associated
`with its use.‘ Its side effects have sparked much
`criticism of Merck's advertising strategy.‘
`I Previous studies. Published studies on
`
`the impact of television advertising for pre
`scription drugs have yielded conflicting re»
`sults. Advancing an argument made by Alison
`Masson and Paul Rubin, Alison Keith found
`that patients’ suggestions regarding drugs (as»
`pirin for cardiovascular disease) were impor«
`tant determinants in prescription decisions
`and that advertising tended to lead to more ap—
`propriate care.‘
`Other studies found that drug companies‘
`TV promotional activities preserved market
`share for existing products and also caused pa
`tients to be less responsive to price.“ The post’
`1997 era presented an opportunity for exami«
`nation of the new policy regime for DTC
`advertising. As Woodie Zachry and Diane
`Ginsburg pointed out, however, few studies
`examine the actual effects of DTC advertising.7
`In one of these studies, john Calfee and col~
`leagues examined whether the 1997 FDA
`policy change increased the demand for statins
`but were unable to find any significant direct
`effect.” There are also studies that examined
`
`DTC advertising, using survey data. These
`studies tended to find that patients were posie
`tively disposed toward DTC advertising and
`that advertising had some effect on patient»
`physician interactions."
`
`Study Data And Methods
`
`To assess the impact of DTC advertising, we
`examined separate models for (1) the average
`patient flow into each physician practice, (2)
`prescribing for Vioxx, and (3) prescribing for
`Celebrex, using the practice as the unit of anal~
`ysis. We examined data on visits to fifty~seven
`primary care practices each month over three
`years (2000-2002). After exclusions (discussed
`below), this resulted in 1,589 observations in
`
`the form of visits per practice per month.
`I Patient data. Data were obtained from
`the Practice Partner Research Network
`
`(PPRNet), located at the Medical University of
`South Carolina (MUSC). PPRNet is a prace
`tice~based learning and research organization
`among primary care practices across the
`United States that use a common electronic
`
`medical record (EMR) (Practice Partner by
`Physician Micro Systems Inc. in Seattle).
`PPRNet pools longitudinal data on diagnoses,
`laboratory studies, medications, vital signs,
`and other nonidentifiable information quar~
`terly for research and quality improvement ac~
`tivities. PPRNet has access to all EMR exe
`
`tracts of ninety~one community»based
`primary care practices in thirty~tw0 states. To
`create our practice—level data set, we extracted
`data on all patients who had a diagnosis for
`osteoarthritis from practices active during
`2000-2002. Because many unobservable fac—
`tors might drive prescribing, we restricted the
`original data to osteoarthritis patients.
`These patient data were then aggregated to
`the practice level by month. Also, we elimi
`nated practices located more than 100 miles
`from the geographic center of the nearest me’
`dia market. We also eliminated practices that
`were in the database for fewer than twenty
`months or that wrote fewer than ten COX»2
`
`inhibitor prescriptions cumulatively over the
`threeryear study period. F1'fty—seven practices
`from forty»four markets remained after these
`restrictions were implemented.
`I Advertising data. We obtained national
`and local advertising information from Com«
`petitive Media Reporting Inc. (CMR), which
`collects data on media advertising for all prod»
`ucts, including pharmaceuticals, at the market
`(for example, city) level. The data are specific
`to the product’s brand name and show which
`products were advertised and how many times
`they were advertised on both national and lo»
`cal television each month. We used counts of
`
`ads broadcast by month as our measure of
`DTC advertising. Patients and practices were
`assigned to the nearest local media market. (In
`the advertising data we received, media mare
`kets were identified by metropolitan area,
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`1372
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`MARKETWATCH
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`such as Philadelphia or Denver.)
`I Dependent variables. We examined
`the impact of DTC ads on three dependent
`variables: (1) the number of visits (for any rea»
`son) to the practice each month by osteoe
`arthritis patients; (2) the fraction of these vis~
`its associated with a prescription (new or re»
`newed) for Celebrex; and (3) the fraction of
`these visits associated with a prescription
`(new or renewed) for Vioxx (Exhibit 1). We
`could not distinguish reliably between the
`number of new and renewed prescriptions, al~
`though this is not a limitation with respect to
`our study’s goal.
`I Explanatory variables. Advertising expo»
`sure. We measured advertising exposure as the
`number of ads broadcast for each brand adver~
`
`tised. We included separate measures for na—
`tional and local advertising, because national
`and local ads tend to be shown during different
`times of the day and during different programs.
`Retained information from ads. Since informa~
`tion presented in ads will not be immediately
`forgotten, we needed to account for retained
`information. To do this, we constructed two
`versions of each of our three models. First, we
`estimated models for the three dependent vari~
`ables that included the number of ads placed
`in the current month. Second, we estimated
`
`models for the three dependent variables that
`included the number of ads placed in both the
`current month and the previous month.”
`Clinical and income variables. We also included
`
`variables we expected to affect either the de«
`mand for treatment by patients or the supply
`of office visits (and therefore treatment) by
`practices. Factors expected to affect patients‘
`demand for treatment were patients‘ clinical
`comorbidities, average age, and sex. These
`clinical variables were calculated using the
`PPRNet data on osteoarthritis patients in the
`practice. The income variable was taken from
`the Area Resource File (ARF) and was mea—
`sured at the county rather than the patient or
`practice level (and is thus a crude measure of
`average patient income for the practice).
`Factors affecting general demand for health care.
`Factors expected to affect the general demand
`for health care were county population;
`county per capita income; the average price of
`a physician office visit; and the percentage of
`county population that is over age sixty«five,
`employed, and either Caucasian or African
`American. We imputed the price of an inter»
`mediatedength office visit with an established
`patient from the Council for Community and
`Economic Research's (ACCRA‘s) quarterly
`Cost of Living Index (using the average price
`
`EXHIBIT 1
`
`Means And Standard Deviations Of Dependent And Key Explanatory Variables, Study
`Of Direct-To-consumer Television Ads And Prescribing For Osteoarthritis (OA), 2000-
`2002
`
`Variable
`
`Number of monthly office visits by OA patients
`Number of monthly Celebrex prescriptions per 0A office visit
`Number of monthly Vioxx prescriptions per OA office visit
`Number of local Vioxx ads
`Number of national Vioxx ads
`Number of local Celebrex ads
`Number of national Celebrex ads
`
`Number of local Vioxx ads. previous month
`Number of national Vioxx ads, previous month
`Number of local Celebrex ads. previous month
`Number of national Celebrex ads, previous month
`
`Mean
`
`341.952
`0.014
`0.012
`0.259
`105.848
`12.296
`102.262
`
`0.243
`104.274
`11.755
`97.820
`
`Standard deviation
`
`420.814
`0.035
`0.028
`0.761
`37.742
`22.980
`54.018
`
`0.727
`38.237
`23.057
`55.620
`
`SOURCE: Authors‘ calculations, using data from PPRNet and the Centers for Medicare and Medicaid Services.
`NOTE: N = 1,589.
`
`HF./=\i_TH AFFAIRS — Volume 25, Number 3
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`HEALTH TRACKING
`
`in the metropolitan area nearest the primary
`care practice site). Finally, we captured the
`marl<et~level supply of services by including
`the number of full«time physicians (both prie
`mary and specialty care) actively engaged in
`patient care in the county per thousand
`population, taken from the ARF.
`I Clinical publications. Besides DTC ad~
`vertising and demand/supply»side economic
`factors, articles in medical journals might af»
`fect physicians‘ prescribing habits. We con»
`trolled for confounding effects of clinical pub»
`lications in two ways. First, we conducted a
`Medline search using the keywords rofecoxib,
`celecoxib, Vioxx, Celebrex, and osteoarthritis
`(restricting the range to English~language
`journals and the years 2000-2002). We in»
`cluded measures of the number of articles each
`month that focused on Celebrex or Vioxx, or
`both. We did not attempt to characterize
`whether the articles were favorable or unfavor~
`
`able. We also included a variable that equals 0
`when the month of publication is before an im—
`portant August 2001 publication by Debabrata
`Mukherjee and colleagues, and 1 otherwise."
`This article was the first in a major clinical
`journal to document concerns about Vioxx’s
`cardiovascular side effects.
`
`I Statistical analysis. Two of the three
`models had dependent variables that were
`numbers of prescriptions written to osteo~
`
`EXHIBIT 2
`
`arthritis patients divided by the number of vis~
`its by such patients. By measuring these de»
`pendent variables as percentages of the potene
`tially “treated" population, we normalized the
`results for differences in practice size. We also
`included practiceelevel fixed effects in each of
`the three models (which controlled for any
`tiIne»invariant practice characteristics). We
`estimated these models as linear regressions
`and adjusted the standard errors for clustering
`at the practice level (to control for the fact that
`we had repeated monthly observations on
`each practice) using the Stata “xtreg" proce
`dure. We adjusted for clustering at the prac»
`tice level rather than at the media»market level
`
`because we generally have only one practice
`per media market.
`
`Study Results
`
`Although Merck (Vioxx) invested in nearly
`twice as many ads as Pfizer (Celebrex) for the
`first nine months of 2000, advertising expo»
`sure for the two brands was roughly compara~
`ble over the remaining 2000-2002 time period
`(Exhibit 2). However, a different picture
`emerged at the local level throughout this pe»
`riod: Celebrex local ads aired slightly more
`than twelve times a month on average, while
`Vioxx local ads aired fewer than once a month
`
`on average (data not shown). There was also
`evidence in the raw data of a more concentrated
`
`Monthly Counts Of Direct-To-consumer Television Advertising Of Drugs For
`Osteoarthritis, Nationally And In Local Markets, By Brand Name, 2000-2002
`Number of monthly ads
`Total Vioxx ads
`200
`—----- Total Celebrex ads
`
`
`
`
`
`150
`
`100
`
`
`
`1
`
`7
`
`19
`13
`Months since January 2000
`
`25
`
`31
`
`SOURCE: Authors’ analysis of data from Competitive Media Reporting Inc.
`
`—
`1374
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`September/October 2006
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`5
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`

`MARKETWATCH
`
`
`strategy for VioXx—vvith ads appearing often
`in some local markets and never in others.”
`I Ads’ impact on physician visits. Here
`We discuss results from the fiXed~effects re»
`
`gressions on the number of monthly visits to a
`practice by osteoarthritis patients. Because we
`estimated linear models, the parameters have a
`straightforward interpretation, implying how
`much of a change in the dependent variable
`would be induced by one additional television
`ad per month (in either a local or national con~
`text). We found consistent evidence in favor of
`the hypothesis that DTC advertising attracted
`patients to practices. Current~month local
`Vioxx advertising had a positive and signifi~
`cant (p = .01 or better) effect in both specifica
`tions. National Vioxx advertising also had a
`positive and significant effect in the first speci—
`fication. In terms of magnitudes, a 100 percent
`increase in local Vioxx ads would, on average,
`have increased the number of osteoarthritis
`
`visits per month by approximately 0.8 percent,
`While a 100 percent increase in national Vioxx
`ads would have led to a 7.4 percent increase in
`physician visits per month. In the second spec~
`ification, a similar national Vioxx effect was
`
`measured for the lagged monthly advertising,
`although not for the current-month DTC ad»
`vertising.
`Celebrex TV advertising was effective only
`at inducing changes in patient flows at the na
`tional level (and only in our second specifica~
`tion), although the effect was somewhat com-
`plex. We found that currentxmonth national
`DTC ads increased osteoarthritis patient flow,
`while lagged»month national DTC ads reduced
`patient flow. However, the net effect was posi/
`tive, such that a 100 percent increase in DTC
`advertising for both time periods would have
`led to a 2 percent increase in monthly visits
`from osteoarthritis patients. Thus, on net, we
`did find support for the hypothesis that DTC
`advertising for COX»2 inhibitors increased pa
`tient flow into physician practices.”
`I Ads’ impact on prescribing. In general,
`we found little effect from DTC ads on the rate
`
`Celebrex prescriptions per patient visit. How‘
`ever, none of the other measures of the DTC
`levels was significantly associated with
`changes in Celebrex prescribing. Thus, al»
`though there could be a cross«brand effect for
`Celebrex, it appeared only weakly in our data.“
`Our results were somewhat stronger for
`Vioxx prescribing. Current«month local Vioxx
`DTC ads had a positive and significant effect (p
`= .04 or better) in both specifications. The
`magnitude of the effect was more modest,
`however,‘ our results suggest that a tenfold in»
`crease in local Vioxx DTC spots (0.25—2.5, on
`average) would have induced about a 0.5 per»
`cent increase in the rate of Vioxx prescribing
`each month. Interestingly, national Celebrex
`ads had a positive and significant (p = .01 or
`better) effect on the rate of Vioxx prescribing.
`The effect was larger than the impact of local
`Vioxx DTC advertising; a 50 percent increase
`in monthly national Celebrex advertising (102-
`153, on average) would have led to an increase of
`about 0.5 percent in Vioxx prescribing.
`I Impact of other factors. There was no
`evidence that journal articles on Celebrex and
`Vioxx affected prescribing.” In particular,
`while there has been much discussion of
`
`Mukherjee and colleagues’ paper, we could not
`find a consistent effect of the publication in
`our linear model of prescribing.”
`
`Discussion
`
`The issue of what impact, if any, DTC adver»
`tising has on the behavior of patients and phye
`sician practices is of major policy importance.
`Pharmaceutical spending represents a large
`percentage of total spending in state Medicaid
`programs. Even moderate changes in prescribr
`ing for a small number of products can lead to
`dramatic changes in Medicaid spending. The
`FDA has recently held public hearings to
`gather input for a reevaluation of its policy
`toward DTC advertising.
`This paper sheds light on the impact of ad»
`vertising of the two major COX»2 inhibitors
`available from 2000 to 2002: Vioxx and Cele»
`
`of prescribing for Celebrex. Local DTC adver»
`tising for Vioxx had a marginally significant (p
`= .06) and a positive effect on the number of
`
`brex. Following Mercl<‘s withdrawal of Vioxx,
`the New England journal of Medicine published an
`editorial that expressed skepticism about the
`
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`HF./-\I.TI-I AFFAIRS — Volume 25. Number 3
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`HEALTH TRACKING
`—
`
`benefits to society from DTC advertising of
`COX—2 inhibitors.”
`
`I Patient flow. The results presented here
`bear directly on these issues. In general, we
`found that DTC advertising for Vioxx and
`Celebrex had positive effects on the flow of
`osteoarthritis patients into physician prac«
`tices. Advertising of both drugs generated an
`effect similar to that hypothesized by Keith
`and by Masson and Rubin, where increases in
`the potential ad exposure were associated
`with increases in patient flow.“ This effect,
`however, was somewhat attenuated for Celer
`brex advertising.
`Once patients arrived at the physicians of»
`fice, it was clear that DTC advertising tended
`to change the rate at which COX«2 inhibitors
`were prescribed. The effect of Vioxx DTC ads
`was consistently positive, increasing the pro’
`portion of visits at which a prescription was
`written for Vioxx. Vioxx DTC ads might also
`have had a positive effect on Celebrex pre~
`scribing rates, although the effect was only
`marginally significant for currentemonth local
`DTC ads. More national Celebrex DTC adver~
`
`using was associated with higher rates of Vioxx
`prescribing but was not associated with signifi»
`cant changes in prescribing for Celebrex.
`I “Detailing" versus advertising. There
`are a number of possible explanations for the
`lack of an own»effect from Celebrex DTC ad~
`
`vertising. For example, data from IMS Health
`indicate that Pfizer devoted relatively more cf»
`fort in 2000 to direct/to~physician marketing
`for Celebrex in the form of visits by pharma«
`ceutical representatives, who provided sam~
`ples (known in the industry as detailing) than
`Merck did on behalf of Vioxx. It is possible
`that this relative emphasis on detailing is re»
`flected in the relative ineffectiveness of DTC
`
`advertising at generating prescriptions. It is
`also possible that since Merck advertised rela~
`tively more heavily on behalf of Vioxx early in
`the life cycle of the drugs, the class~level effects
`were exhausted early on, leaving little room for
`Celebrex advertising to increase the number of
`prescriptions. In the end, we did not have suf
`ficient data to untangle why Vioxx advertising
`had a broader class effect and an own«effect,
`
`while Celebrex DTC advertising seems to only
`have exhibited class effects for prescribing.
`I Study limitations. Despite the impor—
`tance of our study, it has limitations. First,
`without monthly data for pharmaceutical de~
`tailing, we were unable to account directly for
`the impact and interaction of detailing. Such
`physicianebased marketing remains a larger
`component of pharmaceutical marketing cf»
`forts than DTC advertising.” It is possible that
`DTC advertising and detailing were coordie
`nated; if so, the DTC advertising effects mea«
`sured here might have included some detailing
`effect. Personal communication with drug
`company representatives, however, suggested
`that since both Vioxx and Celebrex were im~
`
`portant products to their manufacturers, the
`reps discussed these products at every oppor~
`tunity. This implies that there would be little
`correlation between the levels of detailing and
`local or national variation in advertising,
`which in turn would minimize the potential
`for bias in the results. Second, practices also
`generally have a supply of drug samples on
`hand to give to patients when they write a pre
`scription. The availability of samples might in
`fluence which product is prescribed. Again,
`personal communication with physicians and
`drug reps suggested that most physicians
`would typically have had a stock of samples of
`both drugs on hand, which implies that the
`potential for omitted variables bias is limited.
`Also, the practice/level fixed effects included
`in the models capture any general tendency to
`favor one drug over another.
`
`IN SIJMMARY, DTC ADVIERTISING fDi'
`
`C'.0X—2 inhibitors appears to have affected
`physician practices and patients. Pfizer's
`and Merck's DTC advertising had positive net
`effects in moving people toward more contact
`with their physicians. Once patients had con»
`tact with physicians, Merck’s DTC advertis»
`ing for Vioxx tended to stimulate Vioxx pre~
`scriptions and might have had a margin ally
`important effect on Celebrex prescribing;
`however, Pfizer‘s DTC advertising for Cele»
`brex seems to only have affected (in a positive
`way) prescribing for Vioxx.
`
`_
`1376
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`uJ2e_|_MHAq“oz*9qoiewuosJ_Ie,uVq;/eaHAq/5J0'SJ!E_.].}El.|1|B6u'1U61U00//IdJ,1l.|moi;pepeoiumoq
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`7
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`

`This paper wasfunded by grantsfrom the Agencyfor
`Healthcare Research and Quality (1 R01 HSOl1326«
`OIA2) andfrom the National Heart, Lung, and Blood
`Institute (1 R01 HLO7784l«Ol). The authors thank
`Ruth jenhinsfor assistance in extracting clinical data
`from the PPRNet system, and Olena Verbenho and
`Michael Kunzfor assistance in constructing the
`analysis data sets.
`
`NOTES
`1.
`
`T. Nordenberg, “TV Drug Ads That Make Sense,“
`Consumers’ Research Magazine 81, no. 3 (1998): 28-31;
`and S. Elliot, “With or Without Vioxx, Drug Ads
`Proliferate,“ New York Times, 6 December 2004.
`M. Schumann, “Top 100 Megabrands: Chevrolet
`Leads the Race along Megabrand Road, but Mar-
`keters Hit 2001 Potholes," Advertising Age 72, no. 1
`(2001): 1.
`G. Kolata, “A Widely Used Arthritis Drug Is
`Withdrawn," New York Times, 1 October 2004.
`E]. Topol, “Failing the Public Health—Rofe~
`coxib, Merck, and the FDA,” New Englandjoumal of
`Medicine 351, no. 17 (2004): 1707-1709; and D.
`Mukherjee, S.E. Nissen, and E]. Topol, “Risk of
`Cardiovascular Events Associated with Selective
`COX—2 Inl1ibitors,"]ournal of the American Medical
`Association 286, no. 8 (2001): 954-959.
`A. Masson and PH. Rubin, “Matching Prescrip—
`tion Drugs and Consumers: The Benefits of Di«
`rect Advertising," New England journal of Medicine
`313, I10. 8 (1985): 513-515; and A. Keith, “Regulat—
`ing Information about Aspirin and the Preven—
`tion of Heart Attack," Ameiican Economic Review
`85, no. 2 (1995): 96-99.
`M.A. I-Iurwitz and RE. Caves, “Persuasion or In»
`formation? Promotion and the Shares of Brand
`Name and Generic Pharmaceuticals,“ journal of
`Law and Economics 31, no. 2 (1988): 299-320; C.
`King, “Marketing, Product Differentiation, a.nd
`Competition in the Pharmaceutical Industry"
`(Working Paper, Massachusetts Institute of
`Technology, Department of Economics, 1996);
`and] A. Rizzo, “Advertising and Competition in
`the Ethical Pharmaceuncal Industry: The Case of
`Hypertensive Drugs,“ journal of Law and Economics
`42, no. 1 (1999): 89-116.
`VVM. Zachry III and D.B. Ginsburg, “Patient Au«
`tonomy and the Regulation of Direct~to—Con«
`sumer Advertising,“ Clinical Therapeutics 23, no. 12
`(2001): 2024-2037.
`].E. Calfee, C. Winston, and R. Stempski, “Di~
`rect»to~Consumer Advertising and the Demand
`for Cholesterol~Reducing Drugs," journal of Law
`and Economics 45, no. 2, part 2 (2002): 673-690.
`F.F. Gonul, F. Carter, and]. Wind, “What Kind of
`
`8.
`
`lVlARKETV\7ATCH
`
`Patients and Physicians Value Direct~to«
`Consumer Advertising of Prescription Drugs?“
`Health Care Management Science 3, no. 3 (2000): 215-
`226; N. Sumpradit, S.W. Fors, and L.
`McCormick, “Consumers Attitudes and Behave
`ior toward Prescription Drug Advertising,“ Amer~
`ican journal of Health Behavior 26, no. 1 (2002): 68-
`75; WM. Zachry III, ].E. Dalen, and T.R.]ackson,
`“Clinicians’ Responses to Direct«to»Consumer
`Advertising of Prescription Medications," Ar-
`chives oflnternal Medicine 163, no. 15 (2003): 1808-
`1812; and ].S. Weissman et al., “Consumers’ Re~
`ports on the Health Effects of D'1rect~to—Con»
`sumer Drug Advertising," Health Aflairs 22 (2003):
`W82-W95 (published online 26 February 2003;
`10.1377/hlthaff.w3.82).
`We explored alternative measures ofDTC advere
`tising. in one, we included current—month and
`six~month cumulative lagged ad measures. The
`six-month lagged measures were not significant,
`and the current~month effects were unchanged.
`In a second, we included current—month and
`one» and two~month lagged measures. The par
`rarneters on the current«month DTC ads were
`largely unchanged, but the significance level on
`all measures was lower as a result of collinearity
`between the three monthly measures included in
`the same model.
`
`Mukherjee et al., “Risk of Cardiovascular Events.“
`The regression results are available as online eX—
`hibits. See Online Supplemental Exhibit 1 at
`http://contenthealthaffairs.org/cgi/content/full/
`25/4/1371/DCI.
`
`See Online Supplemental Exhibit 2, ibid.
`See Online Supplemental Eihibit 3, ibid.
`See Notes 13 and 14.
`
`Mukherjee et al., “Risk of Cardiovascular
`Events.“ This article had a significant effect in
`models where we estimated the DTC effect
`nonlinearly, but it had an insignificant effect in
`the linear models we present here, Since this was
`not a major focus of the paper, we presented the
`more straightforward linear models here.
`Topol, “Failing the Public Health."
`Keith, “Regulating Information"; Masson and
`Rubin, “Matching Prescription Drugs"; P.H. Ru»
`bin, “Economics of Prescription Drug Advertis~
`ing," journal ofPharmaceutical Finance, Economics, and
`Policy 3, no. 4 (1991): 29-39,’ and PH. Rubin and
`>].L. Schrag, “Mitigating Agency Problems by Ad»
`vertising, with Special Reference to Managed
`Health Care,” Southern Economic journal 66, no. 1
`(1999); 39-60.
`U.S. Government Accountability Office, Prescrip—
`tion Drugs: FDA Oversight of Direct«to~Consumer Ad-
`vertising Has Limitations (Washington: GAO,
`2002).
`
`10.
`
`12.
`
`14.
`15.
`16.
`
`17.
`18.
`
`19.
`
`HF./-\LTI-I AFFAIRS ~ Volume 25, Number 5
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