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Healthy Scepticism New Zealand

Feedback about Healthy Scepticism New Zealand newsletter

This edition was sent to GPs, GPTP Registrars, Locums, Registrars N = 4806 and to an unknown but small number of IPA facilitators.

136 feedback forms were returned. We also received 4 letters. This equals a 3% response rate after only 3 editions and despite no reply paid envelope. We do not know what percentage of the recipients actually read HS NZ V2 N2. Respondents are more very likely to be strongly pro HS or strongly anti HS than readers who did not provide feedback. The views of doctors with a tendency to burn out or apathy will be under represented. That is unfortunate because those 2 groups are very important.

The feedback is arranged in accord with the following objectives for Healthy Scepticism NZ:

Improve pharmaceutical prescribers’ understanding of techniques of pharmaceutical promotion and Improve prescribers’ critical appraisal of evidence

Readers’ comments:

“An excellent publication and exposure of advertising gimmicks.”

“Excellent publication. Useful insight in to how we are manipulated by adverts.”

“I find it excellent in making me think about what I read & how this influences my prescribing.”

“Re all adverts: I don’t read any of them, consciously at least but when I read you descriptions I can often picture the advertisement but not the slogan.” (HS had explained that advertising may work subconsciously.)

“1) Makes me realize how misleading ads are, but they all sound so good. 2) Educates me and makes me think.”

Readers’ comments:

“An excellent publication and exposure of advertising gimmicks.”

“Excellent publication. Useful insight in to how we are manipulated by adverts.”

“I find it excellent in making me think about what I read & how this influences my prescribing.”

“Re all adverts: I don’t read any of them, consciously at least but when I read you descriptions I can often picture the advertisement but not the slogan.” (HS had explained that advertising may work subconsciously.)

“1) Makes me realize how misleading ads are, but they all sound so good. 2) Educates me and makes me think.”

“Gives more insight into decision making.”

“Good comments on RRR vs absolute RR.”

“I like the approach of looking at drug company advertising indepth, to make sure their headline claims are substantiated - & as shown most often they are not.”

“Very useful to get the evidence supporting or not from a more indifferent source. Changes my perspective of advertisement messages which have “slipped into my psyche”. I always read the whole thing!!”

“Given the free market we live in, we as providers of services have a responsibility to assess things critically. Given that these companies are trying to make a profit, it is not surprising the advertising may be slanted. Your sheet helps us keep our critical faculties operating.”

“Good to get brief info on the trials claimed to give evidence to support drugs. I usually don’t pay a lot of attention to adverts but drug reps can be persuasive.”

“Excellent objective analysis of the antibiotics advertised! I suspect we have no idea of how the subliminal stuff effects our prescribing. I would strongly support continuing circulation to all GPs.”

“I am concerned that the references given are not helpful (I would not normally go to the references but could be influenced by the fact they are presented with the advert.”

Obtain feed-back from prescribers about pharmaceutical advertising.
We received a range of comments about pharmaceutical advertising in general. As in the last three examples above one of the main issues discussed was whether or not doctors are influenced by promotion.

“I agree doctors are very swayed by Drug Com. reporting. I am particularly concerned about our use of antibiotics for obvious viral infections… [Re Augmentin:] As with all of these ads. I think they are fairly insulting to GPs. What other professionals have such childish images put forward to them.” (HS V2N2 satisfaction score 7)

“I do not look at advertisements at all.” (HS V2N2 satisfaction score 4)

“Not read. GP’s are not stupid as you infer.” (HS V2N2 satisfaction score 1)

“… who reads the ads anyway?… a waste of time. Drs in general very sceptical about colour ads! Sometimes too sceptical (as I may seem in these answers.)” (HS V2N2 satisfaction score 1)

“Obvious. – doctors are not idiots.” (HS V2N2 satisfaction score 2)

“You may not have noticed if you check your New Ethicals Compendium that the drug information it contains mostly use the Trade name when referring to positive effects & the generic name when referring to side effects- scepticism is important – very clever marketing.”

“Good to have all the issues exposed. Drug companies need to be more accountable in their drug advertisements & in the information presented when reps call. Not all that info is accurate.”

We asked readers to comment on the advertisement regardless of their assessment of the antibacterial and some of the feedback was specifically about the appropriateness of the advertising.

 

SKB’s advertisement for Augmentin (amoxycillin/clavulanate) is:
1=Inapropriate
7=Appropriate
U=Unspecified

Augmentin:

“It is pushed as the “for any infection” drug.”

“As with all of these ads. I think they are fairly insulting to GPs. What other professionals have such childish images put forward to them.”

“I see many GP’s using Augmentin as a 1st line drug in older children for viral infections. This ad encourages use (without thought) for just about anything.”

 

Lilly’s advertisement for Ceclor (cefaclor) is:
1=Inapropriate
7=Appropriate
U=Unspecified

Ceclor:

“Very naughty advertising – does it contravene the consumer protection act?”

“I try and never Tx bronchitis in children but that isn’t a common occurance. They encourage misuse of a drug with this ad.”

“I find Ceclor has a number of side-effects (it is not gentle on patients) and I rarely use it for the reasons listed in your article.”

 

BMS’s advertisement for Diclocil (dicloxacillin) is:
1=Inapropriate
7=Appropriate
U=Unspecified

Diclocil:

Comment from a paediatrics trainee: “I don’t know much about Tx wound infection or Diclocil. This ad would have made me think about using this. Healthy Scepticism is good for educating me.”

 

Astra’s advertisement for Helicosec (omeprazole, amoxycillin, metronidazole) is:
1=Inapropriate
7=Appropriate
U=Unspecified

MSD’s advertisement for Noroxin (norfloxacillin) is:
1=Inapropriate
7=Appropriate
U=Unspecified

Noroxin:

“This one really pisses me off. The idea that I’m a cruel doctor if I risk severe pain for my patient if I don’t prescribe norfloxacin I find deeply offensive.”

“Very effective ad. Didn’t know trimethoprim was 1st line.”

“I was aware of the overdramatic presentation. I wondered if it implied she had pyelonephritis! This in itself is misleading.”

“I agree – I can’t remember any patient “doubled up” like this with cystitis.”

“I totally agree – not first line therapy & over the top emotional content.”

 

However the qualitative feedback suggests that when answering the questions above most GPs were more focused on assessing whether or not they should use the drug rather than assessing the advertising. This is understandable given that the former is their primary role. For example many readers scores varied in association with statements defending or attacking the use of the antimicrobial. These statements should be addressed. Some readers requested more information to assist their decision making.

General feedback:

“Problems remain in deciding clinically when to diagnose bacterial vs viral infection. Very common problem, needs more/better research.”

 

Augmentin:

“NZ cannot afford (both financially + microbiologically) to overuse Augmentin. Should you have included use of Augmentin for gingivitis or is penicillin/metronidazole still recommended?”

“I have overused this antibiotic in the past and am trying to decrease use. It is very good for skin infections.”

“We still have a major problem with GPs using Augmentin as 1st chioce when they shouldn’t.”

 

Diclocil:

“In a situation where one would use flucloxacillin, dicloxacillin is perhaps a safer alternative.”

 

Ceclor:

“Ad supports a very common misconception. In practice it would be very difficult to distingiush viral/bacterial clinically. How strong is support for no Ads in acute bronchitis?” Attached note: “I think MaLAM is great. Would be nice if PreMeC or Pharmac could produce PreMeC type prescriber info eg ‘choice of antibiotic / no antibiotic in common conditions’ or ‘strategies for reducing antibiotic resistance’ as back up for the MaLAM topics. Best wishes with it.”

“Expensive drug (despite the advert.) compared to more appropriate Atb’s which have a better track record.”

“It’s ok. Ceclor is well tolerated in children especially.”

 

Helicosec:

“Your comment does not take into consideration the patient part charge for clarithromycin.” (This statement is entirely correct. The primary author of Healthy Scepticism didn’t know about it!)

“Clarithromycin regimes impractical due to cost.”

Clarithromycin packs should be available. Alternatively clarithromycin could be made available for the specific indication of H.P. erradication.”

“Given that clarithromycin is too costly this does look the best option – AS STATED IN RECENT PREMEC BULLETIN!! Please reply this to me.” (original emphasis.) ( The primary author of Healthy Scepticism has not yet seen that bulletin. In future MaLAM Adelaide must have access to such relevant NZ publications prior to drafting HS NZ editions.)

 

Noroxin:

“Never a first choice in UTI.”

“As a locum I am shocked at the way Noroxin is now prescribed it seems very commonly for simple UTIs.”

“Each of this type of info received causes one to pause & reflect – the danger of n of 1 episodes say of failed “simple” Rx for UTI influencing further prescribing.”

A reader who rated HS V2N2 7, rated intention to change prescribing 6 and rated all the advertisements 1 or 2 except Noroxin rated 4 wrote:
“Clinical experience suggests a lower than acceptable hit rate with trimethoprim and this may be the reason norfloxacin is used so much. Nitrofurantoin is probably not used enough.”

“I try hard to stick to triprim, nitrofurantoin and Amoxyl (the later has the highest success rate here). Have never needed to use Noroxin.”

“A lot of the UTI bugs in our area are resistant to trimethoprim & sensitive to Augmentin (in the Petri dish!)” (HS NZ V2N2 had mentioned the difference between effectiveness in the Petri dish vs clinical effectiveness. It appears the point got across to this reader.)

“Having had a trimethoprim resistant E.coli UTI & felt exactly the way depicted [in the advertisement] I was irritated that I didn’t know 20% E.coli were resistant & would use norfloxacin again personally.” MaLAM’s response is: Immobilising pain from UTIs requiring house calls, narcotic analgesia and/or hospitalisation does occur but most UTIs are less severe. Women with less severe UTIs are likely to recover with trimethoprim even if their infection is resistant to it. If norfloxacin is used 1st line for all UTIs then resistance will increase and there may be no effective therapy for those who suffer immobilizing pain.

“Norflox is appropriate for more severe UTIs when one cannot risk using inappropriate empirical Rx. It does not preclude the use of simpler regimens in milder cases.” That is a very reasonable hypothesis that deserves testing with a clinical trial. Meanwhile MaLAM is not aware of any controlled trial evidence to support or refute that hypothesis. (This reader’s HS NZ satisfaction score was 1 = Very dissatisfied.)

“No thought given to emergence of resistance to norfloxacin. Unfortunately, ad. reinforces belief of many local GPs.”

“Agree norfloxacin isn’t first line but seeing so much resistance to trimethoprim & UTIs are painful. I’ve been doubled over on the couch like that before – I give norfloxacin as a backup scrip to be filled if Triprim not helping + after MSU taken to test sensitivities.”

“Gives more insight into decision making.”

“Good comments on RRR vs absolute RR.”

“I like the approach of looking at drug company advertising indepth, to make sure their headline claims are substantiated - & as shown most often they are not.”

“Very useful to get the evidence supporting or not from a more indifferent source. Changes my perspective of advertisement messages which have “slipped into my psyche”. I always read the whole thing!!”

“Given the free market we live in, we as providers of services have a responsibility to assess things critically. Given that these companies are trying to make a profit, it is not surprising the advertising may be slanted. Your sheet helps us keep our critical faculties operating.”

“Good to get brief info on the trials claimed to give evidence to support drugs. I usually don’t pay a lot of attention to adverts but drug reps can be persuasive.”

“Excellent objective analysis of the antibiotics advertised! I suspect we have no idea of how the subliminal stuff effects our prescribing. I would strongly support continuing circulation to all GPs.”

“I am concerned that the references given are not helpful (I would not normally go to the references but could be influenced by the fact they are presented with the advert.”

Obtain feed-back from prescribers about the effectiveness of the newsletters themselves.
Satisfaction with HSNZ V2N2 Antimicrobials
1=Very dissatisfied
7=Very satisfied
U=unspecified

Satisfaction score unspecified

“Please don’t give up this publication!! Doctors need it even if they don’t admit it!”

“I find it excellent in making me think about what I read & how this influences my prescribing.”

“Generally excellent publication. I hope you can continue.”

“One thing has really struck me about this publication * the small size of the typeface… it is really important to appeal & readability to have the content in a size which is easy on the eye.”

“Good to consider the pressures on prescribers that we often overlook.”

Satisfaction score 1

“I think there is a reasonable point being made about overuse of antibiotics – but it is being made in all the other magazines. I find the interpretations (possible) of ads patronizing and a waste of paper – who reads the ads anyway? A waste of time. Drs in general very sceptical about colour ads! Sometimes too sceptical (as I may seem in these answers.)”

“Cannot see a reason for your organisation. PHARMAC’s decisions often seem arbitrary… [sections on advertisements] Not read \ no comment… Presume you are not really interested in feedback [because] no envelope or “freepost” [provided]… Not read, GPs are not stupid as you infer.”

Satisfaction score 2

“Obvious – doctors are not idiots.”

“I feel it is far too negative. I am concerned Pharmac’s agenda is purely cost cutting.”

Satisfaction score 3

Nil

Satisfaction score 4

“I cannot approve Healthy Scepticism because its funded by PHARMAC. Even if no bias intended – it’s going to be impossible to separate CONFLICT OF INTERESTS.” (original emphasis).

“It is always good to read the other side! If feel both are extremes though maybe your article being overcritical and drug companies being under critical. Is the truth not somewhere in between. Doesn’t help to quote a few pertinent lines out of selected articles.”

Satisfaction score 5

“Useful synopsis of issues.”

I would like to see more of HS – it is a good review – well done.”

“Please continue.”

“Keep it up.”

“Happy to receive this kind of info.”

“Keep them coming. I don’t read many ads, but appreciate your investigation into their claims.”

“Having feedback on an A4 size to me is much easier (with a fax number reply) Just stuff it in FAX machine (no envelope, stamp, box box!)

Satisfaction score 6

“Great”

“I’m sorry that I missed your visit. It is nice to have my own scepticism about antibiotics + drug company ploys reinforced. Thank you.”

“Content is biased, but unashamedly so. A more balanced viewpoint might give more credibility. Is it appropriate to use Australian guidelines in NZ? The impression given is that they will be applicable here – are they?”

“Enjoyed recent seminar in Wgtn by Peter.”

“Perhaps slightly negative. After all I do need to use some drugs which are advertised. Overall: informative and useful.”

“All issues have been a very interesting and a welcome addition to my ‘in tray’. Further issues would be read & appreciated.”

“A lot of useful information + arguments to help put the issues in persective.”

“Excellent viewpoints + analysis.”

“Enlightening.”

“A booster to one’s anti “Maddison Avenue bull”.

“Keep up the good work but don’t get too evangelical.”

“A fresh approach to use of medicines and their promotion by co’s.”

“Very useful to have a source of balanced information to counter the information received from drug reps.”

“Nice to get an alternative viewpoint.”

“This is great!!! We need more! I’m sorry I missed your talk in ChCh – please come back! I think I don’t overuse ab’s – trouble is we probably all think that!”

“My practice with antibiotics is probably ok but the issue on antihypertensives was really useful for reinforcing what has been acceptably proven and what has not been.”

Satisfaction score 7

“It is so helpful to have the balancing opinion to weigh against the advertising. Thank you. Please continue to publish this”.

“More please!!”

“Helpful to have an independent viewpoint.”

“Its excellent. Long overdue.”

“Very helpful and interesting.”

“Would strongly support continuation of this excellent publication.”

“Good ideas and reports.”

“Great. Short, simple, to the point and well researched. Easy tool to improve habits and confirm good judgement. Certainly hope we’ll get more issues.”

“I would like to see this journal continue provided editorial independence can be guaranteed.”

“I would be very keen for further episodes of Healthy Scepticism.”

“Excellent publication – please continue.”

“Excellent & appropriate newsletter- aims @ right level & is right length for those engaged in the paper war. Let’s hope for more of the same.”

“Please keep going.”

Some very satisfied respondents had specific suggestions for improvements that would increase impact:

“I am all for it. I can’t stand advertising. However I wonder if you might be better to start “counter advertising”- ads which clearly and succinctly state what you are saying in Healthy Scepticism.”

“I feel that last time [calcium channel blockers] you made many self-evident or trivial points; this time they seemed less obvious and more worth making; I hope Healthy Scepticism wil be able to continue. But most GPs probably won’t take the TIME to read it - ? make it simpler to take in the info quickly.”

Encouraging best practice in prescribing and Obtaining better health outcomes through cost effective prescribing
Intention to change prescribing after reading HS NZ V2N2 Antimicrobials
1=Not at all
7=Significantly
U=Unspecified

Many respondents indicated that that they did not intend to change their prescribing significantly after reading HS only because it reinforced what they believed they were already doing. Some indicated that it reinforced a change that they had recently made eg in response to education from their IPA.

Here are some examples:

“I largely follow these recommendations already”, “But this is because our IPA peer GP mtgs have looked at these issues recently otherwise I might be more affected by your paper” and “I don’t mean to boast but it tends to conform with what I already try to do.” Supporting optimal prescribing so that it does not change in response to other forces may be more achievable and as important as changing suboptimal prescribing.

“Thought provoking. Good to review optimal Rx options eg Helicobacter ulcers. This is the most useful aspect for me in helping change my prescribing habits.”

“Antibiotics are difficult. Firstly trying to not prescribe them, which I am strong on, + secondly choosing the correct one to treat the problem appropriately while not increasing resistance. This article helped.”

“Thank you. It certainly makes one look at the prescribing, which becomes, a habit with certain drugs, probably driven initially by advertising. I’d be sorry to see it [HS NZ] lapse…

I’ve used this drug [Ceclor] extensively as first line especially for children + I’ll review this…

I’ve been using it [Noroxin] as first line. I will revise that and use trimethoprim.”

 

 

HS Int News index

 

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Far too large a section of the treatment of disease is to-day controlled by the big manufacturing pharmacists, who have enslaved us in a plausible pseudo-science...
The blind faith which some men have in medicines illustrates too often the greatest of all human capacities - the capacity for self deception...
Some one will say, Is this all your science has to tell us? Is this the outcome of decades of good clinical work, of patient study of the disease, of anxious trial in such good faith of so many drugs? Give us back the childlike trust of the fathers in antimony and in the lancet rather than this cold nihilism. Not at all! Let us accept the truth, however unpleasant it may be, and with the death rate staring us in the face, let us not be deceived with vain fancies...
we need a stern, iconoclastic spirit which leads, not to nihilism, but to an active skepticism - not the passive skepticism, born of despair, but the active skepticism born of a knowledge that recognizes its limitations and knows full well that only in this attitude of mind can true progress be made.
- William Osler 1909