How physicians weigh their choices

October 1, 2002
Christopher E. McCarthy

Pharmaceutical Representative

The nine scales of drug selection.

Being a pharmaceutical rep requires multiple job skills. You have to be a scientist, a marketing expert, a concierge and, lastly, a mind reader. Unfortunately, mind-reading probably wasn't covered very well in your training. It involves careful observation, listening skills, intuition and sometimes just plain luck. Even when you think you have physicians figured out, something happens that seems to make no sense at all. Why don't they write for my product? I did a great job of detailing, they like me and I have great speaker programs. Why isn't it as obvious to them as it is to me that my product is the best? It seems so simple to make the right choice!

Common criteria for selection

Believe it or not, there are rational thought processes involved in making pharmaceutical selections. Experience, personal biases and knowledge of the various medications guide each individual physician's choices. With so many variables, it can be difficult to predict what a physician may decide. Nonetheless, there are a number of common criteria that every physician uses in making these decisions – the nine scales of drug selection.

Efficacy. Frequently this is the most important scale when choosing a drug, but not always. If all the drugs in the class are very efficacious, then this falls to the bottom of the list. Efficacy data can frequently be slanted to make your drug appear to be the best. Therefore, physicians often take efficacy data with a grain of salt, especially if your company sponsored the studies. Even head-to-head comparisons often appear biased in one way or another. Physicians look at data published in the major peer-reviewed journals more favorably, even if the studies are industry-sponsored. The clinical experience of the physician is often critical to this scale. No matter what the clinical studies say, if the physician loses confidence in the efficacy of a drug, it is doomed. Sadly, the physician may never tell you this, wishing not to appear rude.

Cost. As the cost of the drug goes up, so does the importance of this scale. When medications are running more than $2 per day, small differences in price can become much more important. If all other scales are approximately equal, price may well be the deciding factor. Most patients are on more than one drug, and the cost of medications can add up very quickly. Cost information frequently appears contradictory and confusing to physicians. It seems easy to manipulate the information to make your drug look like the best bargain for the patient. Sometimes the price a rep gives a physician may not be what the patient actually ends up paying; this can seriously undermine the patient's confidence in the physician and the physician's confidence in you.

Dosage schedule. The cost of medication noncompliance is staggering. Some estimates of the direct and indirect costs have gone as high as $100 million dollars annually in the United States. It is estimated that 10% of all hospital admissions and 25% of all nursing home admissions can be attributed to medication noncompliance. One of the best ways to maintain compliance is to have a once-daily drug. Twice daily is acceptable, but anything beyond that is definitely a problem. Multiple dosing and complex dosing schedules will drag down a drug's profile very quickly. This is especially true if there are drugs in the same class that are dosed once daily. When drugs have similar profiles in all the other scales, the dosage schedule can end up being the deciding factor. If there are significant differences in other scales between various members of a class of drugs, however, dosage schedule is rarely the deciding factor.

Insurance coverage. Many patients consider insurance coverage the most important scale of drug selection. They are very concerned about the prices they pay for their medications. Yet despite their concern about prescription drug costs, they still want the latest and best medications. A number of years ago, insurers attempted to limit access to expensive medications with closed formularies. Under intense pressure from consumers and employers, the formularies were opened up and the tiered co-pay system was born. This improved the availability of many drugs to the general public. The insurance industry then responded by steadily increasing the amount of the co-pays. In some plans, third-tier co-pays have reached as high as $50. With such high co-pays, a drug's tier is sometimes the deciding factor between similar medications, particularly if the patient is prescribed multiple third-tier drugs. Significant differences in efficacy, side effects and safety can be enough for physicians to disregard the higher co-pay and use a third-tier product. However, differences in drug monitoring and drug interactions are usually not enough to do so. The effect of samples on the use of third-tier drugs is somewhat variable. Most physicians will switch to a second-tier drug when the patient runs out of the samples if the difference in the co-pays is significant, and most patients consider anything more than $5 to $10 significant.

Safety. Physicians generally assume that the prescription drugs available today are safe. Why else would the Food and Drug Administration have approved them? The less safe a drug is, the more caution physicians will have in prescribing it. The degree of comfort with the safety of a drug is directly related to the nature of the disease being treated and the seriousness of the potential reaction. In some cases, the risks of certain medications are worth the potential benefit, such as in cancer chemotherapy. If the illness is not serious, however, every drug in the class should be very safe. Patients place a great deal of trust in the FDA, in the pharmaceutical industry and in their physicians in this regard. When unforeseen drug safety issues arise, it greatly undermines the public's confidence in all of us.

Drug interactions. With more and more becoming known about drug interactions, physicians will soon be overwhelmed by the amount of information they will have to know. Not only that, with more and more powerful drugs coming out and the increasing use of poly-pharmacy, the problem will only get worse. Documented drug interactions can play a major role in drug selection, especially if the drug interaction is serious. Theoretical drug interactions are more problematic for physicians. How much theoretical interactions will affect drug selection depends on the concern of the individual physician. The weight of this scale depends heavily on the number of drug interactions and their potential consequences, but drug interaction profile is rarely the deciding factor in drug selection.

Monitoring. For most drugs, monitoring does not play a major role in drug selection. However, monitoring is becoming an increasingly important issue. There are two forms of drug monitoring: The first involves the proper monitoring of the blood levels of a particular drug. If there is a specific therapeutic range a drug is supposed to be in, what is that range? What drug interactions or other health problems can affect that range? How often does this blood level need to be monitored? The second issue has to do with the effects of a drug on the functioning of other organ systems. Are there specific recommendations on how often liver or kidney function should be tested? What about blood and platelet counts? Physicians need to know exactly what the guidelines are since they are at substantial medico-legal risk if they do not follow them. There is no defense against a charge of medical malpractice when physicians do not follow published drug monitoring guidelines. If a drug has a monitoring protocol that has to be followed to ensure safe use, this is a strike against it. The more complicated the regimen, the less likely the drug is to be used.

Side effects. Either side effect profiles are a key determinant in drug selection or they do not influence the decision at all. It is when the potential for serious drug side effects exists that this scale becomes critically important. In many ways, it is thesingle most important piece of clinical information used in making a medication selection. It does no good to give a patient a safe, efficacious, inexpensive medication if he or she cannot tolerate it. Physicians match a drug's side effect profile against the patient's age, co-existent illnesses, concomitant medications and other variables. A decision is made regarding the potential adverse drug reactions the patient might experience. Once the risk of side effects has been determined, the other scales are evaluated.

Samples. Does the availability of samples influence drug prescribing? Absolutely! In response to a recent survey, 91% of physicians said they would dispense samples that differed from their preferred choice if their preferred choice was not available in the office. Additionally, 27% of these physicians stated that they would give samples and start a patient on one of the newer anti-hypertensive medications despite the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure recommendations to start a beta-blocker or diuretic. The influence of samples on drug prescribing does vary according to the type of drug being sampled. Samples of drugs that are for chronic use, such as anti-hypertensives, cholesterol-lowering agents, etc., are more likely to generate actual prescriptions than short-term-use medications such as antibiotics. On the positive side, however, as physicians get used to using the short-term medications, they are more likely to prescribe them at other times also.

Now that you know the nine scales, it is important to remember a number of things: Every drug is assigned a ranking within a particular scale, relative to the other drugs in that class. These nine scales are then weighted, according to the disease the drugs treat and characteristics of the drugs themselves. This ultimately results in a database or profile in each physician's mind concerning each drug. The ranking of each scale in order of importance is never static; it will vary from patient to patient and physician to physician. The nine scales must be applied to each patient's unique situation. Cost may be more important for one patient, and drug interactions may be more important for another. One physician may have had a few bad experiences with a drug and never use it, while most others may have had no problems at all. The entire process of choosing a drug while in the examination room with a patient takes about 30 seconds. If the database on your drug is incomplete in a physician's mind, he or she will probably not use it. It simply takes too much time to get the Physician's Desk Reference and look up the dose, the monitoring schedule, potential drug interactions, etc.

It is imperative that you understand how your physicians rank your drugs. It is even more important to be sure each physician's database is complete. Without this knowledge, you will have no idea how your physicians make their medication decisions. How can you find out? Ask your physicians. Are there any holes in the database (ask them very specifically: efficacy, cost, side effects, monitoring, etc.)? How do they rate your drug on any or all of the nine scales? Where does your drug fall in comparison with your competition? From this assessment, you should gain a very good idea of the strengths and weaknesses of your drug. This will allow you to focus your marketing efforts on those areas that need the most work. Sometimes it is more important to spend time with your physicians learning about their experience with your product than showing them your latest sales aid. It is never a mistake to occasionally review your drug's "database" with physicians in a concise fashion. You may be surprised by what they have forgotten. PR

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