Disease Prevalence and Treatment Reticence

A staggering number of preventable and manageable serious disease states remain undiagnosed and untreated, although widespread access to physicians and information sources from the Internet to direct-to-consumer (DTC) advertising have expanded consumer awareness. The social and economic costs of these "lost" patients--people with undiagnosed and/or untreated ailments--are increasing as the population ages, despite significant advances in the development and availability of effective prescription (Rx) medications.

The National Heart, Lung, and Blood Institute, for example, estimates that nearly one in three Americans has high blood pressure, and that one-third of Americans with hypertension are unaware of their condition, a leading cause of heart failure and stroke. High blood pressure is listed as the primary or contributing cause of over 10% of all deaths in the United States; with nearly half a million hospitalizations a year due to hypertension, high blood pressure and its complications cost the U.S. economy more than $100 billion each year. Identifying the size of the problem and means to improve treatment is an opportunity that no one can afford to ignore.

Gauging Potential for Rx Medications

Market Estimator is Ipsos Insight Health's approach to gauging the potential for Rx medications among consumers. In research and development for Market Estimator, Ipsos Insight Health's conducted research to comprehensively assess the potential for prescription medications among consumers by analyzing five Ps: disease Prevalence, habits and Practices, attitudes and Perceptions, Prospects for concepts and segmentation, and Projections. Our analysis is based on a custom survey administered among Ipsos' longitudinal PharmTrends consumer panel, yielding a sample of 6,288 American adults aged eighteen and older.

Ipsos Insight Health's research modeled the linkage between more than 100 attitudinal and behavioral variables to explore critical issues such as consultation and diagnosis rates, use of Rx therapy, and persistence and compliance. It incorporates such attributes as patient attitudes toward medication (safety, trust, acceptance, affordability), physicians (including comfort level with doctors, perceived need to visit doctors, level of empowerment, and involvement with treatment choices), and medical information (for example, whether they are information-seekers, the types of information sought, and channels). By combining an understanding of disease prevalence with knowledge of current practices and perceptions, the study offers insight into the opportunities and challenges for Rx medications.

Prevalence

The first step in a Market Estimator study is to determine the prevalence of conditions among the population to assess the total treatable base. In our R&D study, we measured self-reported diagnosis. The numbers in themselves are not surprising--innumerable studies and statistics on disease rates exist--but prevalence figures become dynamic when viewed in the context of patient perceptions and practices. The chart below shows the number of patients who have not consulted their doctor in the past twelve months about their condition, combined with the prevalence of the condition. It reveals that insomnia and chronic allergies, for example, are conditions where there is a great deal of opportunity to increase the size of the Rx market, as the conditions are prevalent and percent of sufferers treating with Rx medication few. In addition, while there are relatively fewer migraine, overactive bladder, and erectile dysfunction sufferers, only about half have turned to Rx solutions for their health problem, indicating significant opportunity for both more optimal treatment and market expansion.

Practices

The habits and practices module of the study recorded self-reported behavior, focusing on use of physicians, medication, and information seeking. Most Americans have a family doctor (83%), and people who have a chronic condition see their doctor an average of four times a year. This indicates regular contact and continuity of care for most people. However, is it enough contact--given problems with persistence and disease control?

The disparity between the number of people suffering from a condition and those that have successfully managed or controlled their illness is a significant issue. Survey results measuring self-perception of disease control revealed that very few patients feel their conditions are well controlled, indicating suboptimal treatment, poor disease control, and the need to improve satisfaction with Rx medications. High levels of dissatisfaction among patients suffering from asymptomatic conditions such as hypertension and elevated lipid levels are particularly concerning, and corroborate epidemiological studies show alarmingly high levels of under-treatment.

With chronic diseases, frequency of consultation has particularly significant effects on persistence and compliance. Persistence is a measure of how long a patient stayed on the medication prescribed by their physicians. In order to maintain persistence, doctors need to be writing lengthy prescriptions to ensure sufferers have consistent drug coverage; the average prescription length is far less than the 90 days' coverage a patient would require if he or she were only seeing a doctor an average of four times a year.

While seeking information on conditions and medications is increasingly common, it is still the activity of a minority of Americans, with just one in three having sought out information on prescription drugs in the past year. The Internet is the leading source, accounting for more than half of all inquiries, whether people were searching for information on a disease or medical condition, brand of prescription medication, or alternative medicine or therapy. Surprisingly, despite the proliferation of DTC advertising for prescription medication, dedicated health and wellness channels and shows, and news programs with health segments, few respondents actively look to television for health information.

Patients' information-seeking behaviors have implications for their consultation rates and persistence. There is both cause and effect here; people who seek information are more engaged in managing their health, but what they learn has an effect on their perceptions of doctors and medications and how they engage with the health care system.

Perceptions

Patient perception is key to understanding why some seek medical help while others do not, why some people persist while others give up, and why some follow through after being exposed to DTC advertising. We measured patient's perceptions using over 50 attitudinal items. For simplicity of reporting, we distilled these items down into eight key themes or factors and created summated rating scales that provide reliable measures of each theme. .

We modeled how these items predict:

• how frequently patients see a physician (a necessary precursor to diagnosis);
• treatment rates (% of conditions treated with an Rx medication);
• the number of health information sources consulted (a measure of activism, engagement and how reachable they are); and
• responsiveness to DTC (number of actions taken after exposure).

The results demonstrate the validity of the perception scales and hint at the complex web of factors that drive these behaviors--each critical to determining the size of the treatable market for a medication. The segmentation described in the following section shows how these themes come together to shed light on patients' information-seeking behavior and responsiveness to DTC.

We also modeled the key drivers of persistence and compliance, using select perception items, along with demographic and behavioral measures, for patients treating acid reflux, high cholesterol, and asthma. The most potent predictors of persistence--the number of days a patient stays on their medication--were DTC advertising and the patient's comfort level in seeing the doctor, though the magnitude of effect varied considerably between conditions. Patients who recalled seeing DTC advertising for their medication were more likely to take an active role in managing their healthcare, to have a positive relationship with their doctor, and were less likely to feel burdened by the cost of their medications. Patients who were comfortable with their physician were likely to remain persistent in taking their prescription medication, even when a non-prescription alternative is available, such as for treatment of gastrointestinal distress.

Compliance is a measure of how often a patient takes their medication as instructed. Research results showed that for some medications, such as proton pump inhibitor (PPI) treatment for acid reflux, compliance rates correlated with how the patient related to and trusts their doctor. This is because reflux sufferers who are not comfortable with a doctor can use OTC medications to relieve their symptoms instead of seeking Rx treatment. The key driver for compliance with asthma regimens was the burden of out-of-pocket costs, as treatment is often complex and requires multiple prescriptions. Asthma patients perceived drug costs as prohibitive to them pursuing treatment that would enable them to be at their healthiest. Compliance with lipid-lowering therapy was driven by conviction of the need to treat the asymptomatic condition.

Prospects

The prospects module of the research had two sub-components: concept evaluation and segmentation. The two are typically related, with perceptions that drive interest in the concept often being used as the basis for developing a segmentation.

The objective of the segmentation component is to identify types of patients with differing needs or who present unique opportunities. Segmentation is typically developed based on attitudes, demographics, and/or condition-specific markers of disease control and severity that drive consulting behavior and medication use. The result is segmentation with clear strategic and tactical implications.

In this study, we created a segmentation that provides strategic insight into the size and nature of consumer groups seeking out and responding to health information. It was created based on perceptions that drive information-seeking behavior and responsiveness to DTC advertising. A four-segment solution yielded the greatest insights and reliability. The segments are Confused Consumers (25%), Informed Patients (25%), Independent Researchers (30%), and the Unengaged (30%).

Confused Consumers

Confused consumers are very interested in health information--they just have a hard time understanding what they read and hear, and an even harder time knowing what information to trust. They rely on physicians to make the decisions they acknowledge they are ill informed to make, but they still worry that perhaps doctors are not coming clean on possible side effects.

Confused Consumers are responsive to DTC advertising and are quick to ask their doctor about an Rx they hear about. Confused Consumers are more likely to have to be poorer health, to have a lower income and to pay more out of pocket per month for medications.

Informed Patients

Informed Patients have a positive, trusting relationship with a family doctor, looking to them for information and guidance, but they take some responsibility into their own hands as well, seeking out information and trying to learn how to better manage their health.

Informed Patients spend more than average on out of pocket drug costs, but do not differ from the others in terms of income, age, or overall health.

Independent Researchers

Independent Researchers are skeptical of doctors and do not see them as a particularly useful source of health information. They take it upon themselves to research health topics. They seek out information from a greater number of sources than any of the other segments.

While Independent Researchers feel they understand what their research turns up, they are concerned about its accuracy. Unlike the other segments, they are as likely to look for information on alternative medicine as Rx therapy. Demographically they are unremarkable.

Unengaged

The Unengaged are relatively disinterested in health information and are not ashamed to admit it. They are least likely to respond to DTC, and are not terribly engaged in discussion with doctors, whom they seek less frequently than any of the other segments do. They do not differ demographically from the average.

Projections

Projections come into play when there is a need to measure the financial implications of a Market Estimator evaluation. Projection unites elements of the four other Market Estimator components: Prevalence quantifies the forecast population, Current Practices and Perceptions provide benchmarks for future behavior, and concept evaluations determine Prospects for the proposed initiative.

Validated multivariate statistical models are used to forecast the impact of market events. Specific marketing plan elements can be modeled (such as levels of detailing and DTC), macro-level category and competitive activity can be simulated, and segmentation insights can be used to hone marketing plan targeting.

Conclusion

Many Americans suffer needlessly or put themselves at serious risk through the undertreatment or nontreatment of their diagnosed conditions, but our Market Estimator analysis makes it clear that there are opportunities to rectify this dire situation. Most sufferers have contact with physicians and many are active in seeking information on their health. What is needed, for the majority who not optimally treated, is education--an increase in knowledge and a change of perception.

Patients' education needs vary from condition to condition, but some major themes are clear: there are opportunities to build rapport with physicians, increase comfort with prescription medication, convince people of the need to treat, and helping patients and prospective patients understand that control is an achievable and worthy goal.

Too many people don't know how to enter into a comfortable conversation with their physician about their condition and its management. There is great potential in equipping patients with the questions and conversation starters they need to have a discussion that actually educates them.

A lingering concern that also holds some consumers back is doubt that a doctor's recommendation to treat their condition with prescription medications is necessary. Add to that a widespread worry that side effects are worse than advertised, and the result is noncompliance. Clearly, there are opportunities to help people grasp the risks of nontreatment relative to the benefits and risks of prescription drug use.

While these conclusions are broadly true, specific education needs and opportunities vary from condition to condition, as does the potential for prescription medication to enhance sufferers' health and wellness.

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