A. Competing for Attention

The uptake of HTA findings depends in part on the responsibilities, incentives, behavior, other attributes of the target audiences, and various contextual factors. It also depends on the existing knowledge and perceptions of these target audiences. HTA dissemination efforts must compete with the burgeoning flow of health-related information being transmitted via diverse media using increasingly sophisticated means. Advanced communications technologies provide alternative means to transmit more information where and when it can influence clinicians and other decision makers. Health technology companies are highly adept at using advanced and continually evolving marketing techniques that are being adapted throughout the health care sector.

The matter of the accuracy and consistency of information presented in health technology promotional information to clinicians and consumers remains a great challenge in many regions around the world (Mali 2010) and will continue to affect the ability of HTA dissemination efforts to inform evidence-based behavior change in practice. Three particularly relevant areas are direct-to-consumer advertising (DTCA), promotion of off-label use of drugs and other health technologies, and making economic claims about health technologies, as described briefly, below.

In many countries, the interest in DTCA includes whether it should be permitted at all and, if so, what regulatory requirements should pertain to the content and format of its messages and whether such requirements are being sufficiently enforced (Donohue 2007; Mintzes 2009). Steep increases in DTCA spending since the late 1990s, especially in the US, have contributed to increased prescription drug sales and changed consumer behavior. Although DTCA can avert underuse of appropriate indications of prescription drugs, it may contribute to overuse, though the evidence on inappropriate prescribing is limited (Atherly 2009; (Donohue 2007; Lyles 2002). The increase in the volume of drug purchasing may be class-wide rather than product specific (Atherly 2009). DTCA appears to increase public awareness of prescription drugs but may be less effective at educating patients about appropriate use of medications for their condition. With DTCA exposure, patients are reported to be more likely to ask about advertised conditions, request prescriptions, and seek further information about medications, with some evidence that patients have expressed some caution about DTCA due to publicity about drug recalls, e.g., pertaining to certain pain medications (Liu 2008). All of these factors affect the receptiveness of target audiences to HTA findings and recommendations.

A related area of interest is the ability of health product companies to distribute published and unpublished reports of clinical trials of their products for indications that have not been cleared for marketing by the appropriate regulatory authority, known as “off-label” use. In the US, the FDA does not regulate the practice of medicine, and physicians may prescribe drugs and other regulated technologies for indications other than those for which they were approved by the FDA, unless doing so violates certain safety regulations or ethical standards. Off-label use of drugs is widespread. According to a comprehensive study of outpatient drug prescribing patterns in the US during 2001, 21% of prescriptions were off-label, led by cardiac medications and anticonvulsants; with 31% off-label prescriptions of psychiatric drugs. A majority (73%) of the off-label prescriptions were reported to have had little or no scientific support (Radley 2006). A study of primary physician prescribing patterns in Quebec, Canada, during 2005-2009 found that the prevalence of off-label use was 11%, 79% of which lacked strong scientific support. Off-label use was highest for central nervous system drugs (26%), particularly anticonvulsants, antipsychotics, and antidepressants (Eguale 2012). Among the legal concerns is whether providing “truthful information” about “widely accepted” off-label use of a drug, whether or not there is supportive scientific evidence, should be permissible (Gilhooley 2011). In the US, current FDA guidance addresses the types of literature that may be distributed to health care providers (e.g., it should be peer-reviewed, not in special journal supplements, and not significantly influenced by the manufacturer) and how that literature can be disseminated (unabridged, accompanied by approved product labeling, etc. ), including that it must state that the uses described in the information have not been approved or cleared by the FDA, and other requirements (US FDA 2009).

Another aspect of information dissemination concerns the conditions under which heath technology companies can make economic claims (regarding prices, market share, cost-effectiveness, etc.) in their marketing information, what the rigor of supporting evidence should be, and which agencies should have regulatory oversight for such economic claims (Neumann 2000). Although patterns of economic claims by pharmaceutical and medical device companies about their products have changed in recent years, the use of supporting evidence in pharmaceutical formulary claims and medical device advertisements in particular remains low (Ackerly 2010; Palmer 2008).

“Academic detailing” has arisen in part to balance or offset the industry-based information dissemination efforts noted above. Academic detailing is a form of evidence-based educational outreach to physicians and other drug and device prescribers by health care professionals with no ties to industry. It is patterned after the highly effective practice in the US and some other countries of physician “detailing” (in-person visits) by pharmaceutical and device company representatives to promote prescribing of their products by practicing physicians (Solomon 2001; Soumerai 1990). To the extent that is provides clinicians with unbiased evidence-based syntheses of the best available evidence, academic detailing is intended to overcome challenges of interpreting evidence, provide trusted sources of information, and translate research findings into clinical practice (Fischer 2012).

Findings of a systematic review suggest that printed educational materials may improve process outcomes (e.g., certain physician and patient behaviors) but do not lead to significant improvement in patient outcomes. Further, there is insufficient knowledge about how to improve the effectiveness of educational materials and the effectiveness of educational materials compared to other interventions (Farmer 2008).