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Direct-to-consumer pharmaceutical services in dermatology: Ethical implications

2021; Elsevier BV; Volume: 85; Issue: 4 Linguagem: Inglês

10.1016/j.jaad.2021.02.059

1097-6787

Abraham M. Korman, Stephanie K. Fabbro,

Biomedical Ethics and Regulation

Dear Dermatoethicist: A patient presented with androgenetic alopecia after taking finasteride from an online, direct-to-consumer company. He suffered from erectile dysfunction and was not screened prior to receiving finasteride. Should the use of these direct-to-consumer services be ethically supported?—Dermatologist Dear Dermatoethicist: A patient presented with androgenetic alopecia after taking finasteride from an online, direct-to-consumer company. He suffered from erectile dysfunction and was not screened prior to receiving finasteride. Should the use of these direct-to-consumer services be ethically supported? —Dermatologist Dear Dermatologist: Direct-to-consumer (DTC) teledermatology companies that facilitate electronic consultations between physicians and patients are expanding. DTC companies advertise on social media, promoting dermatologic treatments such as finasteride, spironolactone, and oral contraceptives. Many problems exist, such as issues with confirming patient identity, ascertaining the medical history of patients, prescription of non-evidence-based therapies, and providing inadequate counseling on the adverse effects of medications.1Resneck J.S. Abrouk M. Steuer M. et al.Choice, transparency, coordination, and quality among direct-to-consumer telemedicine websites and apps treating skin disease.JAMA Dermatol. 2016; 152: 768-775Crossref PubMed Scopus (72) Google Scholar Patients are often not free to choose prescribers and may receive care from nondermatologists or mid-level providers, who may not be licensed to practice in the United States despite licensure being required.1Resneck J.S. Abrouk M. Steuer M. et al.Choice, transparency, coordination, and quality among direct-to-consumer telemedicine websites and apps treating skin disease.JAMA Dermatol. 2016; 152: 768-775Crossref PubMed Scopus (72) Google Scholar Visits often accrue out-of-pocket expenses between $35 and $95 or require monthly subscription fees.1Resneck J.S. Abrouk M. Steuer M. et al.Choice, transparency, coordination, and quality among direct-to-consumer telemedicine websites and apps treating skin disease.JAMA Dermatol. 2016; 152: 768-775Crossref PubMed Scopus (72) Google Scholar There is a potential for drug-drug interactions to develop and medications can be used that could exacerbate pre-existing conditions because of the lack of knowledge of comorbidities.2Bollmeier S.G. Stevenson E. Finnegan P. Griggs S.K. Direct to consumer telemedicine: is healthcare from home best?.Mo Med. 2020; 117: 303-309PubMed Google Scholar There is a lack of communication with other physicians (eg, primary care physicians) involved in the patient's care and a lack of integration with health care systems and other specialists. Conflicts of interest for prescribers exist, as a defining feature is that in addition to patient fees, these companies profit when they distribute medications that they sell. Therefore, these companies would not profit if physicians do not prescribe medications.3Curtis H. Milner J. Ethical concerns with online direct-to-consumer pharmaceutical companies.J Med Ethics. 2020; 46: 168-171Crossref PubMed Scopus (3) Google Scholar Although most DTC companies do not compensate prescribers per prescription, an inherent incentive to prescribe medications exists and this creates ethical conflicts.3Curtis H. Milner J. Ethical concerns with online direct-to-consumer pharmaceutical companies.J Med Ethics. 2020; 46: 168-171Crossref PubMed Scopus (3) Google Scholar Some dermatology offices sell in-house products, but their revenue does not rely principally on the sale of such products; thus, there are less conflicts of interest compared with that of DTC companies. There are positive elements associated with the use of DTCs from the patient perspective. DTC teledermatology companies may increase access for underserved populations, invoking the principle of justice. However, evidence suggests that most users are not from traditionally medically underserved populations.4Jain T. Mehrotra A. Comparison of direct-to-consumer telemedicine visits with primary care visits.JAMA Netw Open. 2020; 3: e2028392Crossref PubMed Scopus (30) Google Scholar Some of these companies may treat disconcerting conditions, such as hair loss, invoking the principle of beneficence. They may provide an opportunity for care with a sense of anonymity (patients receive medications without having to interact face-to-face with health care professionals, eg, the intake nurse or prescriber), which promotes patient autonomy. The cost of services can favorably compare with high-deductible health insurance plans. In addition, some patients hesitate to receive nonurgent dermatologic services during the pandemic. We suggest that dermatologists follow the American Academy of Dermatology's position statement on teledermatology, which states that dermatologists using DTC services should "have an existing physician-patient relationship […], create a physician-patient relationship through the use of a live-interactive face-to face consultation", or "be a part of an integrated health delivery system where the patient already receives care."5Position Statement on Teledermatology. 2020https://server.aad.org/Forms/Policies/Uploads/PS/PS-Teledermatology.pdfGoogle Scholar Dermatologists must abide by state regulations, ensuring that there are proper mechanisms to facilitate continuity of care and should have the capacity to provide referrals for urgent services. DTC services allow patients to seek discrete care for conditions for which prompt treatment could be beneficial. Every effort should be made for prescriptions to be rendered only after taking an adequate history and examination, as well as having a prior patient-physician relationship, without prioritizing profit. None disclosed. Direct-to-consumer teledermatology platforms may have inherent conflicts of interestJournal of the American Academy of DermatologyVol. 85Issue 4PreviewTo the Editor: We read with interest Korman and Fabbro's research letter describing ethical concerns regarding direct-to-consumer (DTC) teledermatology companies identifying a financial conflict of interest that may exist for dermatologists working with these platforms.1 It is important to examine and characterize DTC teledermatology companies' structures to fully understand any potential conflicts. Full-Text PDF Accessibility of direct-to-consumer teledermatology to underserved populationsJournal of the American Academy of DermatologyVol. 86Issue 3PreviewTo the Editor: We read with interest the letters by Korman and Fabbro1 and Ranpariya and Lipoff2 outlining issues related to the expansion of direct-to-consumer (DTC) teledermatology. DTC applications advertise readily accessible dermatologic care via the internet that bypasses the need for a pre-existing physician-patient relationship. As discussed, significant concerns exist, including conflict of interest, treatment by nondermatologists, and prescription of medication absent a thorough history. Full-Text PDF