The study cost $130,000,000 and included 42,000 patients. It compared the effectiveness of four types of blood pressure drugs: a calcium channel blocker, an alpha blocker, an ACE inhibitor, and a simple diuretic. The diuretic performed best. It was the sort of finding worthy of celebration. Health costs are too high, and rising too quick. Our flabby society gets bad readings when it straps on the blood pressure cuff, and soon enough we'll all be on these drugs. And here were study results saying that the diuretic, a generic drug which sells for pennies, outperformed its pricey, patented competitors. So what happened? Not a whole lot. The Times tells the story, and even includes a graph:
Diuretics sales jumped, but only by a few percentage points. "[They] should have more than doubled," says Curt Furberg, who chaired the study. And in a world where doctors prescribe medications based on a simple reading of the latest evidence, maybe they would have doubled. But we don't live in that world. We live in a world where pharmaceutical companies have big budgets and sophisticated public relations teams. Pfizer, for instance, put up $40 million to ensure that their Cardura, their alpha blocker, was included in the study. That proved a mistake. Patients on Cardura were more than twice as likely to require hospitalization for heart failure.So what did Pfizer do? Spin! "Rather than warn doctors that Cardura might not be suited for hypertension," reports The New York Times, "Pfizer circulated a memo to its sales representatives suggesting scripted responses they could use to reassure doctors that Cardura was safe, according to documents released from a patients’ lawsuit against the company." Another e-mail from the same document dump shows Pfizer's PR people congratulating each other over diverting a group of European physicians away from a cardiology conference and onto a sightseeing trip on the day when these results were being presented. Then came the methodological challenges, some cynical, some legitimate. The pharmaceutical companies pounced eagerly atop these arguments. At a shareholder meeting, Pfizer's chief executive called the results "extremely positive." In what can only be described as wry understatement, he said, "it will be our job to explain that to the medical community.” Pfizer began taking out full-page ads in medical journals touting their performance in the mega-study. The ads didn't mention the superiority of the diuretics, nor the increase in heart failure when using the other drugs. And on, and on. The basic reality was this: The pharmaceutical companies had a skilled team and a lot of money promoting their drugs. No one was promoting the generic diuretics. Folks looking to things like comparative effectiveness review to save the health care system should take the story seriously. Evidence is only effective if physicians use it. And right now, they have no real reason to use it. Even in a system this expensive, there's no internal incentives to aggressively cut costs. Maybe it's time there were. If doctors were paid by capitation -- if they got a fixed amount of money per patient, and they kept whatever they didn't use, as happens in England -- it's hard to imagine they wouldn't have been more interested in these study results.
Diuretics sales jumped, but only by a few percentage points. "[They] should have more than doubled," says Curt Furberg, who chaired the study. And in a world where doctors prescribe medications based on a simple reading of the latest evidence, maybe they would have doubled. But we don't live in that world. We live in a world where pharmaceutical companies have big budgets and sophisticated public relations teams. Pfizer, for instance, put up $40 million to ensure that their Cardura, their alpha blocker, was included in the study. That proved a mistake. Patients on Cardura were more than twice as likely to require hospitalization for heart failure.So what did Pfizer do? Spin! "Rather than warn doctors that Cardura might not be suited for hypertension," reports The New York Times, "Pfizer circulated a memo to its sales representatives suggesting scripted responses they could use to reassure doctors that Cardura was safe, according to documents released from a patients’ lawsuit against the company." Another e-mail from the same document dump shows Pfizer's PR people congratulating each other over diverting a group of European physicians away from a cardiology conference and onto a sightseeing trip on the day when these results were being presented. Then came the methodological challenges, some cynical, some legitimate. The pharmaceutical companies pounced eagerly atop these arguments. At a shareholder meeting, Pfizer's chief executive called the results "extremely positive." In what can only be described as wry understatement, he said, "it will be our job to explain that to the medical community.” Pfizer began taking out full-page ads in medical journals touting their performance in the mega-study. The ads didn't mention the superiority of the diuretics, nor the increase in heart failure when using the other drugs. And on, and on. The basic reality was this: The pharmaceutical companies had a skilled team and a lot of money promoting their drugs. No one was promoting the generic diuretics. Folks looking to things like comparative effectiveness review to save the health care system should take the story seriously. Evidence is only effective if physicians use it. And right now, they have no real reason to use it. Even in a system this expensive, there's no internal incentives to aggressively cut costs. Maybe it's time there were. If doctors were paid by capitation -- if they got a fixed amount of money per patient, and they kept whatever they didn't use, as happens in England -- it's hard to imagine they wouldn't have been more interested in these study results. 
