Friday, December 25, 2009

Evidence based marketing

I got the above image from here.

Today the world-over including in urban and rural India, it is well established that there is a nexus between pharma companies and doctors; between doctors and neighourhood pharmacy(ies), and doctors and diagnostic labs. There is a kickback culture at all these link points. Today, it is not whether a doctor takes a cut from such entities or not - it is about how much the doctor takes! Many doctors reason that there is nothing wrong about these commercial understandings as long as patients are not exploited. And doctors do argue: why should we prescribe pharma brands 'for free' - after all, pharma companies are making profits from the sales. Pharma companies are not charitable organizations - goes their argument. Well, each viewpoint has its merits. One cannot cast a Nelson's eye or turn a deaf ear to the logic in each viewpoint.

So where is the truth for pharma marketers?

In the face of such a market picture, pharma marketers are forced to invest in commercial inputs for doctors and chemist-retailers (both clinical and personal) to ensure sales continue. However, the fears are that in a very commercial environment patient interests inevitably get sacrificed, medical profession loses its noble status. The need for a code for promotion has hence been highlighted in the editorial of Chronicle Pharmabiz issue dated17.12.2009. Another hilarious report in Times of India has also lampooned doctor behavior at the national cardiological conference held at Kochi. In such a complex picture of the medical and pharmaceutical profession where is the marketing truth for pharma marketers?

Pragmatic pharma marketers cannot adopt a holier than thou attitude and lose sales due to lack of commercial activity. Yet, the whole truth is that doctors will not prescribe medicines or brands only due to commercial activity. There is a certain truth in pharma marketing from which pharma marketers should never deviate.

Consider a doctor in need of a medication...

Imagine a doctor wants an anticold tablet or an antibiotic for his personal use or for his children! In such a context, which brand will the doctor opt for?! In all probabilties, the doctor will go in for a 'standard' brand. A pharma brand that he trusts - a brand that the doctor finds reliable. A brand from a company the doctor has a good image of, IRRESPECTIVE OF ANY COMMERCIAL ACTIVITY. In fact, in all probabilities, the doctor will choose the brand despite the fact that the company has not done any commercial activity for him. The doctor will not compromise when it comes for self-use or for use by his children.

How did the brand become the doctor's choice brand?

The answer to above question lies in the core truth of pharma marketing ... evidence based marketing. Evidence based medicine (EBM) is the most important method of medical decision making today. EBM is a big science. Pharma marketing that rides on the principles of EBM will strike a chord with doctors. There is a great chance of becoming the doctor's choice brand when pharma marketing does not sacrifice evidence based marketing on the altar of commercial activity. Today, it is unfortunate that many an Indian company believes only in commercial marketing activity. And this is an Achilles heel of marketing attitude. Mere commercial activity will not yield desired marketing outcomes.

EBM (Evidence Based Medicine)

EBM is a paradigm in healthcare. It involves using current evidence in medical literature to provide the best possible care to patients. In the EBM based attitude of the physician, there is a conscentious, explicit, and judicious use of the best evidence in making decisions about the care of individual patients. So the brand of pharma marketing that helps provide the best inputs for practice of EBM will obviously be a fast favorite of physicians. The logic is simple. Better the patient care from a doctor, better will be his practice. Better his practice, better his bargaining power with pharma companies, diagnostic labs and neighbourhood medical shops. So EBM based pharma marketing will help develop strong pharma brands. The impact of evidence based pharma marketing will be better than short-cut commercial activity (which also needs to be done moderately by pharma marketers).

Educational prescriptions

Educational prescriptions refers to prescriptions generated by physicians through the practice of EBM. To generate EBM based educational prescriptions, physicians follow a particular routine. The first standard approach is called the PICO model. PICO stands for Patient, Intervention, Comparison, and Outcome in the process of EBM.

PICO model

In PICO, p that stands for patient refers to the individual or population to whom the information is applied. The pharma marketer ought to position the marketed brand clearly for a specific patient population. For eg., paracetamol 650 mg in the management of viral fevers in adults, for optimal response.

I stands for intervention, and refers to the therapy, exposure or diagnostic test that the doctor is interested in applying to the patient. For a pharma marketer, it is important to market the linkage between product and the patient profile. For eg., positioning of atenolol 25 mg for the management of isolated systolic borderline hypertension is a good strategy.

C stands for comparison. A comparison of the planned intervention is done against the standard intervention. The comparison of planned intervention with placebo is now an outdated thinking. So pharma marketers who compare thier product with a placebo will obviously not be well rated. The marketed products should be compared against a prominent approach and the benefit reiterated for better physician acceptance. Hence, in this vein, a pharma marketer can well subtly imply in his promotional message that his brand of paracetamol 650 mg is better than using two NSAIDs as gastric irritation is lesser.

O stands for outcomes. The doctor is interested in a set of desired patient outcomes. These outcomes should not be surrogate outcomes but ought to actually decrease morbidity and mortality of the patient. In the management of post-tonsillectomy pain, no matter what, a doctor will always prefer an anti-inflammatory agent to paracetamol (which is only an analgesic and antipyretic, without anti-inflammatory property). So in the initial phase of treatment, a doctor is likely to write a NSAID that offers anti-inflammatory property in addition to analgesic and antipyretic properties. Or he will combine it with paracetamol for better patient outcomes.

Technology based EBM

An environment for the practice of EBM is fast being facilitated by new tech devices. For eg., smartphones, PDAs, laptops connected to internet, and other such gadgets are being used by doctors to search medical literature bases for working out the best approach to manage patient outcomes.

Mobile phones with internet search ability and PDAs are being used by doctors for accessing an "evidence cart" for providing best possible bedside interventions. Savvy pharma marketers are providing 'loaded PDAs' with subtle brand marketing, and helping doctors practice EBM to simultaneously gain enhanced Rx share.

DOE versus POEM

In the practice of EBM, many acronyms are used, DOE stands for Disease Oriented Evidence and POEM stands for Patient-Oriented Evidence that Matters. Another important abbreviation in EBM is CAT ie., Critically Appraised Topic.

Let us say a doctor thinks of doing a PSA (prostate specific antigen) test on a patient. While ordering for this test, there is a possibility that the intervention will/may provide DOE to the doctor. However, a positive PSA test may not influence the course of treatment, and the morbidity or mortality of the patient. In other words, this PSA test intervention may not provide good Patient-Oriented Evidence that Matters (POEM). So the doctor might as well postpone this intervention. This is an example of how doctors can take decisions based on EBM searches of medical databases.

Internet helps the process of EBM

With greater role of the internet in society, EBM is receiving a fillip. There are a number of medical sites dedicated to practice of EBM. is one such. is another popular EBM site. EBM practitioners go to this website too: This link provides various EBM web links: The Cochrane library is considered as the "gold standard" of the EBM websites. is an interesting EBM site.

Pharma marketers and EBM

Pharma marketers should now learn to operate and become a part of the EBM environment. This means pharma marketers should look beyond the MR based product promotion. It is about becoming a part of the EBM environment on the net. For eg., creating a EBM website while subtly promoting a brand is one such approach. Getting studies done and ensuring that the results are in to the EBM environment is another approach.

Today, Bangalore is living up to its reputation as an innovation hub. Biocon is making public statements that its oral insulin is in the final lap of clinical tests. However, to taste real success, taking IN-105 oral insulin to the EBM environment will be inevitably required in this contemporary world. When doctors using the EBM approach, relate to IN-105 through PICO, and find IN-105 the best option, then the physician's acceptance of this novel drug will be better.

There were the days of experts. These expert innovator doctors would be experienced and well-qualified physicians. Pharma companies would influence them to adopt the new drug, and this would ensure that the new drug would take-off. These expert doctors would also have a following of doctors who would also adopt the new drug. In India, to an extent this is true. However, the international trend and the overall picture is towards EBM. The internet will also provide a definite fillip to EBM.

Convergence tech is the in-thing. Doctors will be able to access a lot of medical literature through convergence tech. This will help doctors provide cutting edge patient care. The modern approach to pharma marketing is to combine commercial inputs with messaging based on clinical evidence (clinical trials, clinical case studies, case series, and clinical opinions/experiences).

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