Patient Information in an Era of Change

Louis A. Morris, Ph.D.

Senior Vice President

PRR, Inc.

Communications Change• Source

– from HCP to Manufacturer

• Channel– from personal and print to mass customization– internet

• Message– from health education to marketing

• Audience– from dumb terminal to active decision maker

Thesis• Redefinition of communications structure

creates new opportunities• We need new thinking

– marketing approach to patient education

• Implications for Pharmacy– public health advocates– implementers of cultural change– who pays?

Patient Info Sources: Traditional

Manufacturer

Independent

Face to Face Mass Media

ThroughHCPs

Through HCPs

Help Seeking/Reminder Ads

PublicService Ads

Patient Info Sources: Modern

Manufacturer

Independent

Face to Face Mass Mass Media Customization

1-800 #s

HCPs

DTCA

PSA/En-dorsemts

DatabaseMarketing

Infotisements

Registries

HCP/Com-mercial

HCPs - Start Kits

PublicRelations

Blending

– Starter Kits - info packages– Disease/Drug Newsletters– Registries – Clinical Experience Trials– Direct mail– Ads in direct mail pubs– Ads in patient information at Pharmacy

Blending on the Internet

• Is it independent content or an ad?• What is the Source?• Search Engine Results?• Paid Linkages?• Future Increase in Internet Use

– Multimedia Content– Faster Access, Smart Slaves, Always On less

active search, more passive use

Blending - Resch Questions

• How important is source credibility in patient information?

• How important is face-to-face?– Hi tech/Hi touch

• How does this affect pharmacy?– Pharmacist rated highest in credibility– Pharmacists viewed as most accessible– Ability to take advantage?

Why DTCA?

HCPs MCOs Pat’s

Gatekeeper + + ++

Influencer +++ + ++

Therapy Selector +++ + +

Buyer + +

User + ++

Message Evolution

• User:– “Finish all your medicine, even if you feel

better”

• Gatekeeper: – “The doctor has treatment programs that can

help”

• Influencer: – “Easy to swallow”

New Messages

• User: Medication Compliance - Will there be a rebirth?– Barrier Assessment Tools– AARDEX (MEMS Monitor) as a feedback tool

• Influencer: Quality of Life– FDA barriers– Implicit, “benefit-related” messages– symbolism

Message / Audience Interaction: Patient Information Processing

• Willingness and Ability to Learn– Motives - Message Involvement/Goals– Ability - Literacy/Self-efficacy– Opportunity - Task Constraints

• Perceived and Actual Cognitive Load– Simplification– Signals

Audience Tailoring - Stages

• Smoking Cessation:• Precontemplation, Contemplation, Preparation, Action,

Maintenance

• Abstinence at 18 mo:– Single Brochure 11.0– Individualized to Stage 18.5– Interactive feedback 25.2– Personalized (calls) 18.0

Velicer et al., 1993

Information Search ClustersFactors Ambivalent Uncertain Risk Assertively

Learners Patients Avoiders Self-Reliant n=140 n=132 n=200 n=153

InformationInvolvement .502 .069 -.275 -.160

Self-Care Orientation -.124 .575 -.483 .249

Regimen Barriers .170 1.056 -.563 -.365

Information Avoidance 1.167 -.603 -.327 -.121

Risk Aversion .239 .056 .302 -.664

Question-Asking .013 -.163 -.542 .838

New Role for Pharmacy• Message Tailoring

– New “diagnostic” tools?

• Feedback Provider (Compliance Coach)– Computer records to measure refill compliance

• Financial Barriers– Can this be provided through manufacturer– mass customization? - privacy favors Pharmacy– Pharmacist user fees?

New Role for Pharmacy (2)

• Location for services:– in pharmacy (face to face)– in central location (mass customization)

• Activity– initiator or responder to patient requests– passive or active service implementation

Health Education and Marketing• Health Education:

– combination of interventions to change behavior (info transfer)

– select by “what works”• focus on trials to establish efficacy

• Marketing– facilitating equitable exchanges (2 way flow)– select by communications goal

• focus on efficient resource use

Marketing Perspective

Health Behavior Change is more likely if:– people are involved with healthcare decisions

• educate and empower patients

– people actively plan how to comply• planning helps overcome barriers

– health professionals teach and explain treatment• people do what MDs and RPhs tell them to do

3 Inverse Relationships

Behavior Change

Low Involvement High Involvement

Persuadable (weak messages)

Ease of Adoption

Thought/Planning

Behavior Maintenance

Complex Messages

Frequency/ Reach

Behavior Change

Marketing Insights• People Change Behavior

– when it is easy– when they want to – when it serves their needs/interests

• People Maintain Behavior– when they internalize beliefs/culturally driven

• Population Interventions: Cost-effectiveness• Targeting/Relationships/Market tests

When is 7% change successful?

• Health Education– significantly better than control– depends on sample size

• Marketing– major success– define in terms of $$ made, share of market,

meeting projections

Relationship Era

Time Era Attitude20’s Production A Good Product Sells Itself

50’s Sales Creative Advertising

80’s Marketing Find a Need and Fill it

90’s Relationship Long-term Relationships

Pharmacy

• Pharmacy as Cultural Change Agents– technology, cross-(sub)cultural, dramatic events

– intercept strategies for nonsearchers– tailoring interventions

• Take advantage of relationships– database marketing

• How to make it pay?

Why Pharmacy?

• Credibility (Expertise and Trust)– Decision making - Framing

• Accessibility

• Close to the Consumer– understand people’s interest

• Existing relationships– keep info private

Segmentational Bases

• Demographics- age, gender, literacy

• Disease- severity, stage, timing

• Geographies- location, Prizm characteristics

• Psychographics- Customized AIOs, VALS

• Volume- % consumed, concurrent therapy

• Outcome- responders, compliers, QoL

• Benefits Sought- motives for therapy, info

Implications for Pharmacy

• Credibility

• Economics - little face-to-face– lost opportunity - OBRA ‘90

• New Switches– renewed call for 3rd class of drugs

• Nutrition Supplements

Historical Perspective“Let no physician teach the people about

medicines or even tell them the names of the medicines, particularly the potent ones, such a purgatives, opiates, narcotics, abortifacients, emetics or any other which are particularly dangerous: for the people may be harmed by their improper use. This under penalty of forty shilliings” - Royal College of Physicians, 1555

Why Advertise to Consumers?

DTC Promotion

PatientMD

RPh

Manufacturer

Objectives

• Why advertise to consumers?

• How is consumer marketing different?

• What role does FDA play?

• What will be the ultimate effect of DTC?

8 FDA Concerns• Reminder/Institutional

• Implied Claims

• Disclosure Adequacy

• Contextual Fair Balance

• Limits on Effectiveness

• Overall Fair Balance

• Unsubstantiated Claims

• Distractions“RID the CLOUD of DDMAC Response”

DTC Considerations• Hot, Hot, Hot

– FDA Guidance relaxes TV disclosures– $800 mil in 1997, $1.3 bil in 1998

• Multiple Media– TV, magazines, internet, professional distribution,

direct mail, outdoor

• Different Challenges and Still Learning• FDA Very Sensitivity to TV: 11 of 20 DTC ads

had an FDA letter

What Evidence Suggests: Hypotheses

• DTC increases MD visits (Pravacol)

• DTC increases patient requests for drugs

• People want risks but info may be confusing

• Physicians still don’t like it (fluid)– MCO hate DTC

• Risk information may be problematic– may also detract from benefits

• Additional disclosures may be problematic– information overload, supers have min impact

What Evidence is Needed: Too Early to Form Hypotheses

• How are TV claims interpreted?– Uses / risks / info availability

• How prices/costs/liability will change?• Impact on consumer as influencer, user • Cumulative effects (trivialization)• What is a “positive/negative” outcome?

– Eye of the beholder, consensus needed– Need research agenda

Truthfulness, Balance, Disclosure• Roth:

– 1/3 of ads lack fair balance (unclear what definition was used)

• General Concerns– Multiple streams of info (see pictures, hear/see words,

hear background)/ Limited take away (only 49% of supers are comprehended)

– Explicit and Implicit Claims– Limited internal “context-availability”

• Disclosure as a remedy?

Future of DTC

• More, More, More– Patient as central in future marketing– Marketing as part of drug development

• Mixed Media– campaigns designed to “move through process”

• Pharmacists as Implementers– passive or active role?

Audience Evolution

• Information Hungry Segment– Remains Stable for 2 Decades (about 12%)

• Heterogeneous Elderly– Multiple Meds– Aging Boomers– More willing to question HCPs– Service Directed