© matrix45, 2005. all rights reserved. enhancing one-on-one physician communications through the...
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© Matrix45, 2005. All rights reserved.www.matrix45.com
enhancing enhancing one-on-oneone-on-one physicianphysician communicationscommunications through the use of through the use of evidence-basedevidence-based ee22marketingmarketing
ivo abrahamivo abraham
[email protected]@matrix45.com
center for business intelligencecenter for business intelligence““emarketing for the pharmaceutical industry”emarketing for the pharmaceutical industry”philadelphia, 17 march 2005philadelphia, 17 march 2005
MATRIX45620 Frays Ridge RoadEarlysville, VA 22936 – USA+1.434.978.1045www.matrix45.com
Offices in US and Europe
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overviewoverview
concept of econcept of e22-marketing-marketing
penetration and adoption of best penetration and adoption of best practice guidelinespractice guidelines
knowledge knowledge clinical behavior change? clinical behavior change? macro vs. micro evidence “micro-trialing”
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overviewoverview
case studycase studymanagement of mild asthma in primary care
» drivers» analysis» solution
benefitsbenefits
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ee22-marketing-marketingdefining the conceptdefining the concept
eelectronic lectronic andand eevidence-basedvidence-based capitalizing on the power of the internet harnessing the value of evidence-bases
for clinical practice
stimulating stimulating clinician behavior changeclinician behavior change in complex clinical areas through in complex clinical areas through data-driven, value-added support data-driven, value-added support servicesservices … and to so … and to so improveimprove sales, sales, patient outcomes, clinician patient outcomes, clinician competence, and economics of care.competence, and economics of care.
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ee22-marketing-marketingprocessprocess
building and maintaining physicians’ building and maintaining physicians’ clinical confidence in product-centric clinical confidence in product-centric treatment solutionstreatment solutions product » therapy » treatment solution knowledge-based relationship
pharma ~ physician “tryout trials” + outcomes-focused
feedback reinforcement + renewal
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ee22-marketing-marketingvalue propositionvalue proposition
clinical confidence
clinical behavior change
↑ product adoption
↑ market position
↑ sales ripple effects
treatment solutions, loyalty, cross-over, …
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evidence-based practiceevidence-based practiceideal vs. real-worldideal vs. real-world
meta-analyses▼
randomizedcontrolled trials
▼“quasi-experimental”
studies▼
cohort / observationalstudies
▼case-control studies
▼cross-sectional
studies▼
clinical cases▼
expert opinion
RCTsquasi-
experimental
meta-analyses
case-control
cohort-observational
cross-sectional clinical
cases
(expert)opinion
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two approaches two approaches (Eddy, Health Affairs 2005)(Eddy, Health Affairs 2005)
evidence-based guidelines evidence-based individual decision-
making
(re-)definition(re-)definitiona set of principles and methods intended to ensure that to the greatest extent possible, medical decisions, guidelines, and other types of policies are based on and consistent with good evidence of effectiveness and benefit (Eddy, Health Aff 2005)
evidence-based practiceevidence-based practicedefining the concept(sdefining the concept(s))
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>1000 guidelines created annually>1000 guidelines created annually(Jackson & Feder, BMJ, 1998; Rosser et al., J Fam Practice, 2001) (Jackson & Feder, BMJ, 1998; Rosser et al., J Fam Practice, 2001)
few guidelines lead to consistent few guidelines lead to consistent changes in provider behavior changes in provider behavior (Cabana et al., JAMA 1999; Grol, Med Care, 2002; Timmermans & Mauck, Health Aff (Cabana et al., JAMA 1999; Grol, Med Care, 2002; Timmermans & Mauck, Health Aff 2005)2005)
asthma(Goodman et al., Pediatrics 1999; Johnson et al., Pediatrics 2000; Crim, Chest, 2000; Lagerlof et al., Eur Resp J, 2000)
beyond asthma: mean adherence rate of 54.5% (Burstin et al., Am J Med, 1999) – probability ~ 50% (Med Care, 1994)
evidence-based practiceevidence-based practiceknowledge knowledge clinical behavior change? clinical behavior change?
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asthma: the “ideal” disease asthma: the “ideal” disease (Timmermans & (Timmermans &
Mauck, Health Aff 2005)Mauck, Health Aff 2005)
serious public health concern » most common chronic illness of early
childhood» rising incidence» USA: 5000 deaths/year, 470000 hospital
admissions/year, 13.7 ambulatory care visits/patient
ample guidelines available and among the best known of pediatric guidelines (Flores et al., Pediatrics, 2000)
evidence-based practiceevidence-based practiceknowledge knowledge clinical behavior change? clinical behavior change?
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asthma: the realityasthma: the reality adoption of guidelines
» “mixed and disappointing” (Timmermans & Mauck, Health Aff, 2005; Stoloff, Am J Managed Care, 2000)
knowledge about versus following guidelines
» US pediatricians: 88% familiar yet 35% followed guidelines (Flores et al, Pediatrics, 2000)
» hospital-wide implementation: 68% adherence (Smeele et al, Qual in Health Care, 1999)
evidence-based practiceevidence-based practiceknowledge knowledge clinical behavior change? clinical behavior change?
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evidence-based practiceevidence-based practicemore “real world” examplesmore “real world” examples
hypertensionhypertension “real world” practice ≠ trial evidence
and best practice guidelines (JNC7, ESC, …)
» diagnosis (diabetes / nondiabetes)» targets» treatment options and adjustments» risk factors for cardiovascular events» patient outcomes
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evidence-based practiceevidence-based practicemore “real world” examplesmore “real world” examples
anemia management in dialysis anemia management in dialysis patientspatients “real world” practice ≠ trial evidence,
observational studies findings, and best practice guidelines
severe sepsis / septic shock (Xigris®)severe sepsis / septic shock (Xigris®) accelerated approval » commercial failure uncertain area ~ low clinician confidence evidence-base of 1 with hypothesized MOA unlinking product and clinical process
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evidence-based practiceevidence-based practicethe blind adoption problemthe blind adoption problem
randomized controlled trials as the randomized controlled trials as the only parameter of evidenceonly parameter of evidence
““if the wise (wo)men say so, i shall do if the wise (wo)men say so, i shall do so”so”
de-skilling of clinicians – cookbook carede-skilling of clinicians – cookbook care
misunderstanding ethics, feasibility, misunderstanding ethics, feasibility, and knowledge development issuesand knowledge development issues
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macro-evidencemacro-evidence evidence from
studies + meta-analyses
formal learning
micro-evidencemicro-evidence evidence from
one's own clinical experience and experimentation
application in one’s own practice
evidence-based practiceevidence-based practicemacro- vs. micro-evidencemacro- vs. micro-evidence
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macro-evidencemacro-evidence “seeing the
larger picture” – “many-other-patients“ – “what-patients-should-be-like”
mega-knowledge
micro-evidencemicro-evidence “seeing with
one's own eyes" - the "my-patients" picture
micro-trialing
evidence-based practiceevidence-based practicemacro- vs. micro-evidencemacro- vs. micro-evidence
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micro-trialingmicro-trialing knowledge knowledge » confidence » » confidence » behaviorbehavior
anecdoteanecdote “rep has been here several times now” “i’m reading and hearing more about
‘that product’, maybe I should try it out” “let me try it on my next ten patients and
we’ll see”
physician focus on physician focus on systematically systematically tryingtrying the product but the product but ununsystematically examining systematically examining patient patient outcomesoutcomes
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micro-trialingmicro-trialing knowledge knowledge » confidence » » confidence » behaviorbehavior
supporting physicians in supporting physicians in exploring and adopting new treatments changing personal practices and
standards of care going against “established” practices
(from ‘known’ to ‘innovation’) expanding if not changing their “clinical
comfort zone”
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case-studycase-study
backgroundbackground asthma: ↑ incidence = ↑ global market treatment options for asthma are driven by
severity and persistence» inhaled corticosteroids $ 2.76 B» beta-2 antagonists $ 3.74 B» leukotriene anatgonists $ 2.12 B» combinations $ 3.10 B
$ 11.7B2003 global sales; Morgan Stanley, 2004
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case-studycase-study
background: market share of LTRA in background: market share of LTRA in USA vs. Europe/Japan by patient classUSA vs. Europe/Japan by patient class
LTRA market leader in USA, ICS in ROW
number of market number of market number of market number of marketpatients share patients share patients share patients share
severe persistent patients 1,118,000 55.0% 1,312,000 55.0% 1,986,000 20.0% 2,129,000 28.5%moderate persistent patients 3,129,000 40.0% 3,681,000 51.0% 5,712,000 17.5% 5,987,000 23.0%mild persistent patients 1,841,000 29.0% 2,270,000 31.0% 3,611,000 12.0% 4,258,000 12.0%mild intermittent patients 597,000 12.5% 760,000 14.0% 1,024,000 10.0% 1,268,000 10.0%
Morgan Stanley, 2004
USA Europe & Japan2003 2010 2003 2010
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case-studycase-study
background: evidence-basebackground: evidence-base best practice guidelines in usa & europe
» step-up step-down approach» inhaled corticosteroids (ICS) most effective
anti-inflammatory agent to control asthma» LTRA class recommended as “may be
considered” for mild persistent asthma as place in therapy is not fully established
» importance of steroid-sparing therapy
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case-studycase-study
background: evidence-base background: evidence-base (cont’d)(cont’d)
best practice guidelines: canada» ICS as first line therapy» LTRA recommended as alternative therapy» deep dissemination and penetration
role of biopharma companies with vested interests
blind adoption trend in primary care
evidence related to LTRA continues to accumulate
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analysisanalysis
innovation
best practiceguidelines:geographicalboundaries in a global medical community
disseminating toa nonspecialist,(relatively)research-naïve physicianpopulation
positioning
at the interface of marketing andmedical affairs
conventional salesstrategies and tactics:• necessary but not sufficient• change pharma- to physician relationship
relationship
informationtransfer knowledge-based
value-added
in line withphysician values
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analysisanalysis
physicians
getting out of“clinical comfortzone”
gain and maintainconfidence inproduct & therapy:• knowledge• experience
outcomes and risk managementframe-work
market
investment market strength
evidence-based(e)Learning
postmarketingstudy fatigue:• perceived return• beyond just money• value-added services
e2-marketing
electronic andevidence-based
growing demand• specialty care• primary care
competitiveadvantage
beyond e-gimmicks
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case-studycase-study
objectivesobjectives create an evidence-based platform for
effecting clinical behavior change in primary care physicians in the management of asthma
increase experience base of clinicians in managing asthma with through micro-trialing
» systematic data framework» feedback to examine outcomes in their patients» technology-enabled
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case-studycase-study
objectives objectives (cont’d)(cont’d)
improve and maintain physician confidence in target therapy
increase persistent product adoption strengthen market position increase market share and sales
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RiskScreening
RiskManagement
ClinicalSupport
Clinical Outcomes@ Patient Level
Clinical Outcomes@ Practice Level
Evidence-BasedBenchmarks
case-studycase-study framework framework
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case-studycase-study process process
large cohortparticipatingphysicians /
centers
retrospectivechart audit
conversiondecision per
physicianbest judgment
newpatients
startdecision per
physicianbest judgment
longitudinaldata
collectionon Rx and
patientoutcomes
datatransmission
feedbackreports to
physicians:
patient Xmy patientsall patients
benchmarks
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case-studycase-study flowchart flowchart
case-studycase-study flowchart flowchart
analyticaldatabase
entry of patient
dataMD
web-basede-reports
analysespatient X
my patientsmy pts vs. all pts
my pts vs. benchmarks
1:1pharma tophysician
plan-driven and ad hoc analyses
on aggregate sample
dissemination
pharmadatabases
pharma
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ee22-marketing-marketingbenefits to physiciansbenefits to physicians
researchparticipation
new model ofresearch participation
micro-trialing
contribution to larger study
bridging the chasmefficacy effectiveness
safety monitoring
new relationshipwith pharma
one-on-oneknowledge-based
on exchange basis:data value-addedservices in return
in line with values
experience, confidence,clinician decision-making,patient outcomes
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ee22-marketing-marketingbenefits to pharmabenefits to pharma
integrated approach
physician-focused support
accumulating real-worldeffectiveness data
databases on practice patterns and outcomes
safety monitoring
conventional scientificproductivity is enhanced
one-on-one physicianrelationship
knowledge exchange information transfer
aligned with current thinkingin medicine
overcomes limitations of andreframes evidence-based practice
interface with (e-)detailing
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ee22-marketing-marketingbenefits to pharmabenefits to pharma
efficiency
large coverage atminimal incremental cost
coordination marketing ~medical affairs
pays for itself throughongoing product sales andripple effect
effectiveness
data on practice patterns andoutcomes support strategy
extended pharmaco-vigilance
market position: what is theeffect on sales?
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global expansion of survey (1998-2002) within and across indications ~ worldwide sales growth from $1.5 billion (1998) to $4.2 billion (2002)
-5
0
5
10
15
20
25
30
35
40
implementation of 6-month
longitudinal study
state-of-the-art symposium
ee22-marketing-marketingimpact on salesimpact on sales
% change in sales of blockbuster in western europe
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ee22-marketing-marketingrevisited & summarizedrevisited & summarized
e-marketing e-marketing e e22-marketing-marketing electronic and evidence-based to effect clinical behavior change
product adoption market position
sales ripple effects
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ee22-marketing-marketingrevisited & summarizedrevisited & summarized
challenges of adopting best practice challenges of adopting best practice guidelinesguidelines micro-evidence micro-trialing
model and model and serviceservice of evidence-based of evidence-based supportsupport asthma extendable to other diseases and drugs
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ee22-marketing-marketingrevisited & summarizedrevisited & summarized
the value of value-added services the value of value-added services
benefitsbenefits physicians biopharmaceutical companies
impact on patient care?impact on patient care?
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