DIRECT-TO-CONSUMER ADVERTISING PLAYS ON EMOTIONS Nearly all the pharmaceutical ads consumers see on television are based on emotional appeals, and few provide necessary details about the causes of a medical condition, risk factors or lifestyle changes that may be appropriate alternatives to pharmaceutical interventions. In a content analysis of 38 unique pharmaceutical advertisements that ran during peak television viewing times, researchers found that 82 percent made some factual claim and 86 percent made rational arguments for product use, but few (26 percent) described condition causes, risk factors, or prevalence (25 percent). Ninety-five percent used emotional appeals and none mentioned lifestyle change as an alternative to products. The ads often framed medication use in terms of losing (58 percent) and regaining control (85 percent) over some aspect of life.
The authors assert that the use of emotional appeals may sway consumers in favor of a product and prompt viewers to discount information about risks and benefits that is important when considering medication use. These findings are especially important given the marked increase in direct-to-consumer advertising – the average television viewer sees as many as 16 hours of pharmaceutical advertising in a year.
An accompanying editorial by David Kessler, dean of the University of California, San Francisco, School of Medicine and former commissioner of the U.S. Food and Drug Administration, questions who benefits from direct-to-consumer advertising when the ads do not convey important information about drug risks and benefits. He concludes that while there is nothing inherently wrong with pharmaceutical companies communicating directly with consumers, they should adhere to the standards and ethics of medicine, not the standards and ethics of selling consumer products that present minimal risk and that physicians need to use caution before writing a prescription when a patient asks for a product after seeing an ad on television.
Creating Demand for Prescription Drugs: A Content Analysis of Television Direct-to-Consumer Advertising
By Dominick L. Frosch, Ph.D., et al
Direct-to-Consumer Advertising: Is It Too Late to Manage the Risks?
By Douglas A. Levy, J.D.
THE COST OF TREATMENT OPTIONS FOR ACUTE OTITIS MEDIA
Acute otitis media (AOM), or inflammation of the middle ear, is responsible for 13.6 million pediatric office visits annually in the United States at an estimated annual cost of $2.98 billion in 1995.
Using a cost-effectiveness analysis to compare four treatment regimens that include observational and antibiotic treatments, researchers find that treatment for AOM is a trade-off between relieving symptoms and cost. The least costly option was delaying prescription, an approach which involves waiting for 72 hours to see if symptoms improve before instituting antibiotics, while the most effective course of treatment, coming at a greater cost, was seven to 10 days of amoxicillin. The analysis finds that the additional cost per patient for a course of amoxicillin is $22.90, which would result in an additional $311 million in annual health care expenditures if each of the 13.6 million cases of AOM were treated with this regimen. The author suggests that these findings highlight the quantifiable costs and benefits that should be considered when deciding about treatment for AOM, supporting recent guidelines of the American Academy of Family Physicians and the American Academy of Pediatrics that include an observational option for lower-risk children with AOM.
Cost-Effectiveness Analysis of Treatment Options for Acute Otitis Media
Andrew S. Coco, M.D., M.S.
FAMILY AND INTERNAL MEDICINE COLLABORATE ON NEW GUIDELINES FOR VENOUS THROMBOEMBOLISM
This issue of Annals of Family Medicine includes new clinical practice guidelines and an evidence review for diagnosis and treatment of venous thromboembolism, a condition that is associated with over 200,000 deaths each year in the United States. A thromboembolism occurs when a blood clot, formed at one point in the circulatory system, detaches and obstructs circulation at another point. A pulmonary embolism occurs when such a clot, usually originating in the deep venous system of the lower extremities, obstructs the pulmonary artery or one of its branches, which may result in acute heart failure or sudden death. These recommendations are a collaborative effort of the American Academy of Family Physicians and the American College of Physicians.
Key elements of the diagnosis guideline include the use of clinical prediction rules to establish pretest probability of deep vein thrombosis or pulmonary embolism in a patient before further testing, utility of various diagnostic tools such as d-dimmer and ultrasonography. The management guideline supports the use of low molecular weight heparin for patients with deep vein thrombosis in the outpatient setting, when appropriate support services are in place. Each guideline contains several recommendations based on current evidence to clinicians to aid in the diagnosis and treatment of lower extremity deep venous thrombosis and pulmonary embolism.
The Annals of Family Medicine and the Annals of Internal Medicine have joined together in publishing the new guidelines. Both guidelines and an evidence review for the diagnosis guideline are published in this issue of Annals of Family Medicine. The management guideline and companion evidence review are published in the February 6, 2007, issue of Annals of Internal Medicine. Annals of Internal Medicine will publish the diagnosis guideline online at www.annals.org on the same day it is published in the Annals of Family Medicine.
Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians
By Amir Qaseem, M.D., Ph.D., et al
Management of Venous Thromboembolism: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians
Vincenza Snow, M.D., et al
Review of the Evidence on Diagnosis of Deep Venous Thrombosis and Pulmonary Embolism
Jodi B. Segal, M.D., M.P.H., et al
OTHER STUDIES IN THIS ISSUE
CHRONIC CARE MODEL ASSOCIATED WITH IMPROVED DIABETES CARE
Incorporating elements of the Chronic Care Model (CCM) in small independent primary care practices can be done with ease and is associated with better intermediate outcomes of diabetes care. This study of 90 clinicians and 886 patients found that clinician-reported use of CCM elements was significantly associated with lower glycosylated hemoglobin levels (the standard measure of the degree of control of diabetes) and ratios of cholesterol to high-density lipoprotein cholesterol. Specifically, for every unit increase in clinician-reported CCM use (e.g., from "rarely" to "occasionally"), there was an associated 0.30% reduction in glycosylated hemoglobin values and a 0.17 reduction in the lipid ratio.
Use of Chronic Care Model Elements Is Associated with Higher-Quality Care for Diabetes
By Paul A. Nutting, M.D., M.S.P.H., et al
VALIDATION OF PATIENT CONCERNS IMPROVES QUALITY OF DEPRESSION CARE
Quality of care for depression is improved when patients participate actively in the patient-physician encounter and when physicians explore and validate patient concerns. This analysis of data from a randomized trial that included 152 primary care physicians found that physician exploration and validation of patients’ concerns – including the patient’s symptoms, ideas, expectations, functioning and feelings – is linked to quality of care for depression. Higher levels of validation of patients’ concerns are associated with higher rates of prescribing antidepressants for patients who will likely benefit from them, and with a weakened effect of patient requests on prescribing behavior, lowering the likelihood that patients will receive unnecessary medication.
Exploring and Validating Patient Concerns: Relation to Prescribing for Depression
By Ronald M. Epstein, M.D., et al
A SNAPSHOT OF PRIMARY CARE VISITS
This study compares clinical encounters in 20 U.S. practice-based research networks (PBRNs) with those of the National Ambulatory Medical Care Survey (NAMCS) and finds that there are important differences. For example, a larger proportion of the PBRN visits involve preventive care and were made by children, members of a minority racial group and individuals who did not have private health insurance. The authors state that this information fulfills a need for more comprehensive information about primary care clinicians, their patients, and services they provide that can be used by researchers, policy makers and the public. Such information may help to identify strengths and additional area for improvement in services.
Describing Primary Care Encounters: The Primary Care Network Survey and the National Ambulatory Medical Care Survey
By Helen J. Binns, M.D., M.P.H., et al
HIP FRACTURE PREDICTION TOOL PRACTICAL FOR PRIMARY CARE USE
A clinical predictor of hip fracture and mortality risk, the Fracture and Mortality Index (FRAMO Index) is practical for routine use in the primary care setting according to this population-based cohort study of 1,248 patients. This tool uses four risk factors – older age, low weight, prior fragility fracture and using arms to rise from a sitting position – that in this study are found to predict two-year hip fracture risk.
Validation of a 4-Item Score Predicting Hip Fractures and Mortality Risk Among Elderly Women
By Daniel M. Albertsson, M.D., et al
A HEADACHE AT THE END OF THE DAY
This family physician’s reflection of a patient visit with a child and his parents demonstrates the dance a family physician must play during an office visit, weaving together the many medical and behavioral concerns of the patient with his own efforts to understand, develop a therapeutic relationship, diagnose and treat. The author demonstrates the mental challenge of connecting all of these threads, paying appropriate attention to each, and all the while completing the visit in a timely fashion.
A Headache at the End of the Day
By Howard Brody, M.D., Ph.D.
Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Annals is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors and the North American Primary Care Research Group. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal’s Web site, www.annfammed.org.
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The Annals of Family Medicine