Wednesday, October 1, 2008

Using CME to Build Market Share: The Evidence

In this prior post, I discussed this dodgy literature review recently commissioned by ACCME which concluded that there is "no evidence to support or refute the hypothesis that CME activities are biased." I began by detailing how Cervero and He, the authors of this review, managed to dismiss the results of 29 damning studies by pulling the old "outcome switcheroo."

Today, let's look at one of the
few empirical studies that has actually measured industry CME bias, and see how Cervero and He tweak it.

This study is old (1988) and therefore precedes ACCME's current regulations on commercial support. Nonetheless, it is one of only three studies in the literature to measure the effect of industry CME on prescribing practices, and it was included in the Cervero review. The reference is: Bowman MA and Pearle DL, Changes in drug prescribing patterns related to commercial company funding of continuing medical education, The Journal of Continuing Education in the Health Professions, 1988;8: 13-20.

In a nutshell, researchers evaluated the effects of three industry-sponsored courses at Georgetown University. Each course focused on blood pressure medications, two on calcium channel blockers, and one on beta blockers. According to the authors, the drugs discussed in the courses were "basically similar, with only modest differences in benefits, side effects and cost, i.e., none of the drugs should have major advantage over the others in terms of cost, safety or efficacy."

All physicians taking the courses were asked by the researchers to estimate their use of these drugs over the past month. They were given this questionnaire both before the courses and 6 months afterwards. Researchers were interested in determining whether physicians increased their use of the drug manufactured by the sponsoring company.

Here are the results for the three courses. First, we'll start with the course on calcium channel blockers sponsored by the makers of Procardia (generic name nifedipine). As you can see in the table below, Procardia was already the most popular drug among these doctors, accounting for 47.9% of all new prescriptions of calcium channel blockers during the month before the course. Six months after the course, Procardia's market standing improved to 53.5% of prescriptions. Cardizem (diltiazem), at the time Procardia's arch rival, also improved its standing a bit, but less than Procardia. Calan (verapamil) lost out.

In this case, Pfizer (maker of Procardia) profited from the course, though not dramatically. This course was taught in the late 1980s, when Procardia’s patent expiration was just over the horizon (this happened in 1991). Cardizem was aggressively nipping at Procardia's heels with its own array of CME offerings. With this program, Pfizer's goal was to fend off Cardizem and to maintain their market leading status, and they were successful.

Effect of Procardia-Sponsored CME on Relative Standing of Competing Drugs (percentages indicate proportion of new prescriptions)

Next up, we have another course on calcium channel blockers, but this one was sponsored by Cardizem. As you can see below, when the manufacturer of Cardizem paid for CME, the education had a remarkably different effect on prescribing habits than when Procardia sponsored the same topic. Six months after the course, prescriptions for Cardizem shot up, from 31.4% of the total to 50.1%. Meanwhile, Pfizer's Procardia dipped down to only 29.3%. Clearly, speakers were chosen on the basis of their enthusiasm for Cardizem, and they were able to communicate this to the physicians quite effectively.

Effect of Cardizem-Sponsored CME on Relative Standing of Competing Drugs (percentages indicate proportion of new prescriptions)

Finally, the course on beta-blockers easily met the marketing objectives of the makers of metoprolol, which enjoyed by far the largest prescription boost among all beta-blockers discussed in the course:

Effect of Metoprolol-Sponsored CME on Relative Standing of Competing Drugs (percentages indicate proportion of new prescriptions)

Now, I would say that this study, as old and methodologically limited as it is, constitutes real evidence that industry sponsorship biases CME in favor of the sponsor's product. But Cervero and He--the artful tweakers--portray things differently. In their sketchy description of the Bowman and Searle results, they selectively mention the least impressive findings. For example, in the beta blocker study, their lukewarm summary is that "the sponsor’s drug increased although the number of physicians prescribing the drug for new prescriptions was not statistically significant." But as it turns out, most other differences were statistically significant.

Then they slam the discussion section. Pointing out that these CME courses predate some of ACCME's current standards, they object that "some of the reasons that the authors offer for why prescriptions increased are not allowed under current guidelines." Hmmm. The authors suggest five different explanations that might account for increased prescribing of the sponsoring company’s products. Let's quote each point, and see if any of them are, indeed, not allowed under current guidelines:

"First, the speakers may have favored the company drug in their discussion. The university’s guidelines were designed to prevent this, but do not guarantee success, as evidenced in another study which compared actual content of Courses I and III of this study (5). The sponsoring company’s drug was more frequently mentioned than its competitor’s products for Course I; for both courses the reported clinical effects of drugs made by the sponsoring company noted tended to be positive rather than negative."

Are Cervero and He implying that biased course content was allowed in 1988, but is no longer allowed in 2008? Actually, rules prohibiting bias have not changed in 20 years. Lack of bias is the essence of accredited CME.

The discussion continues:

"Second, the participants may have had contact with drug sales representatives at the course who gave them information."

Okay, fair enough. Drug reps are no longer allowed to have contact with doctors at CME events.

"Third, the sales representatives may have contacted course participants after the course was over."

This is definitely permitted now, and in fact it is precisely how companies leverage the marketing benefits of CME. The medical education companies say that they need participants' contact information to properly evaluate the quality of its courses. But you and I know the real reason they get this information--to pass it on to the sponsoring drug company, which then transmits it to their reps. The reps find out which CME activity you've taken, and can then tailor their pitch to coincide with the promotional--I mean, educational--points of the program. In marketing, this is called "synergy."

"Fourth, the provision of money by the company may have been part of a larger campaign for the drug. The physicians may have been subjected to other sources of information, such as drug advertising, on the same drug."

What? Are they saying that in 1988, drug companies were actually allowed to coordinate their CME programs with their overall promotional message? Surely, that is not permitted now.

"Fifth, the participants may have been generally impressed with the course, and, knowing it was partially underwritten by the company, have been favorably disposed to the company, and, as a result, to the company’s drug."

This remains one of the key marketing strategies underlying CME.

The bottom line: This study provides empirical evidence that industry-funded CME encourages doctors to prescribe the sponsor's drug, even when it has no compelling advantages over competing products.

Why Cervero and He did not incorporate this information into their conclusion is one of life's many mysteries.


Stu Gitlow MD said...

"Second, the participants may have had contact with drug sales representatives at the course who gave them information."

Okay, fair enough. Drug reps are no longer allowed to have contact with doctors at CME events.


Well, sort of. The APA annual meeting is not itself a CME event; however, there are CME-granting "educational" sessions that take place. Although you can't meet with a drug rep AT these sessions, you can certainly meet the drug rep for dinner afterward or see them the next morning on the show floor. At most of the meetings I attend, there's an exhibit hall next door to the CME conference. The exhibit hall contains the reps. So while in a formal sense drug reps aren't allowed at the CME event, I haven't been to any CME events where I didn't have a chance to talk to the reps in close proximity to the event itself.

B. Martin, MD said...

Your proposal that Cardiazem's CME efforts undermined the effects of the Pfizer-funded course highlights the fact that one CME course isn't consumed in a vacuum. Even if you can show a rise in prescriptions for a sponsor's product 6 months after that sponsor's CME course, you don't know that the CME course was responsible--given the wide range of information sources available to practicing physicians.

Daniel Carlat, M.D. said...


I agree. There are many ways in this study is methodologically flawed. The fact that there was no effort to control for other educational events in the 6 months post course is one of them. Others: The number of scripts written was not objectively assessed, and demographics of audience were not controlled for (other studies show that younger doctors are more skeptical of pharma-funded events than older doctors).

My point is that even though the study is not perfect, the findings at least suggest that industry support biases CME content in favor of the sponsor's drug. This is inconsistent with Cervero and He's conclusion that "there is no evidence to support or refute the hypothesis that CME activities are biased."

Rosanna Tarsiero said...

Whenever it comes to the influence Big Pharma has on a doctor's life, one thing never fails to puzzles me... how quick the public and the doctors are to blame Big Pharma for influencing the doctors... why aren't doctors blaming themselves and their own biases for falling prey of these marketing techniques? It often sounds like everything needs to be reformed but the most powerful tool we could use, ie the brains of the doctors!

Anonymous said...

Your comment that the reason names are collected at CME programs is to pass on to drug companies is completely ridulous and unfounded. Making this accusation undermines the validity of the argument you are trying to make. I believe your blog exposes some ills of the idustry, however this conspiracy theory approach calls your credibility into question. I find it ironic that you employ the same tactics to advance your agenda that you are so critical of. Lose the hypocracy if you really want to make a case for change.