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Personal selling and its effectiveness in generating sales: an assessment of: ‘promotional’, ‘non-promotional’ personal selling and ‘non-personal’ selling as part of the Promotiona... Research · October 2015 DOI: 10.13140/RG.2.1.4043.5920

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Personal selling and its effectiveness in generating sales: an assessment of: ‘promotional’, ‘non-‐promotional’ personal selling and ‘non-‐personal’ selling as part of the Promotional Mix in the Pharmaceutical Industry. Author: Ravi Jandhyala MSc MBBS MRCS MFPM LLM MBA1,2 Affiliation: 1. University of Sunderland, UK 2. Medialis Limited, UK Corresponding author: Ravi Jandhyala, Medialis Limited, 13 Horse Fair, Banbury, Oxfordshire, OX16 0AH, UK. Email: [email protected] Article type: Original research

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Abstract Purpose: To assess any differences in the influence of personal or non-‐personal selling activities on prescribing customers when making treatment decisions. Methodology: All United Kingdom prescribers working in the highly specialised therapy area of pulmonary arterial hypertension (PAH) were asked to rate what influence various personal and non-‐personal selling activities, such as promotional face-‐to-‐face meetings or non-‐promotional medical literature, had on their decision to prescribe two drugs approved for use in PAH, ambrisentan and epoprostenol. Findings: Overall, there was a good response rate of 27.9% (34/122). Personal selling is influential in generating sales, but non-‐promotional personal activities, such as scientific meetings or 1:1 visit from industry physician, may be more influential than promotional personal activities, i.e. call from a sales representative or a congress promotional stand. Furthermore, non-‐personal selling activities, including medical literature and study reports, national guidelines and recommendation from colleagues may be more influential in generating sales of a product than either non-‐promotional or promotional personal selling activities. Research limitations: Although the n-‐value is small, the respondents represent over one-‐ quarter of prescribers working in PAH in the United Kingdom. Originality/value: Personal selling in the pharmaceutical industry is an integral part of the ‘promotional mix’; however, non-‐personal selling activities, such as medical literature publications may be more influential for generating sales. Article Type: Research paper Keywords Personal selling, non-‐personal selling, advertising, direct marketing, sales promotion, public relations; sales representatives; medical marketing

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Introduction The assessment of personal selling has evolved from a more basic definition of ‘interactive, personal, paid, promotional approach between buyer and seller’ (Tanner Jr and Raymond, 2010) to a broader definition now captures the multivariate engagement process, involving more functions and newer technologies (Dixon and Tanner, 2012). The effectiveness of personal selling appears to have taken a further step upwards in complexity. The selling process, now is less ‘episodic’ and more ‘continuous’ meaning that with the advent of the Internet, information transfer is less focussed around sales calls (Rhoton, 2011). It is important to the balance of impact between personal and non-‐personal selling components of the promotional mix as may be the case that, with the advent of Internet journals, email campaigns and YouTube that the face-‐to-‐face interaction is a relic of a bygone era of promotion. The pharmaceutical industry has actively questioned the effectiveness of a sales force (Kremer et al., 2008, Leeflang and Wieringa, 2010, Singh, 2009, Harris, 2009, Griffiths, 2008, Janakiraman et al., 2008, Caudill et al., 1996, Puneet Manchanda et al., 2004). Furthermore, personal selling from the sales force may be seen as a liability as physicians, their target customers, sometimes react to them with suspicion (Jackson, 2001) and certain institutions have taken the extreme measure of asking for them to be banned from visiting them (Harris, 2009). Personal selling has been scrutinised in this industry with a number of tools including modelling metaanalyses (Oldani, 2004, Lim et al., 2008, Narayanan et al., 2004, Puneet Manchanda et al., 2004, Joseph and Mantrala, 2009) and e-‐detailing (Gonul and Carter, 2010). Within the pharmaceutical industry, activities that can be utilised in the promotion of a product consist of five elements: personal selling; advertising; direct marketing; sales promotion and public relations (Table 1). Here, these are further grouped into personal and non-‐personal selling, where personal selling is split into promotional and non-‐promotional selling. This will help to understand the differences in effectiveness of the broad functional categories described as well as between the tradition sales function and a new type of function within the personal selling category.

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Personal selling activities Activities that the pharmaceutical company has direct control over, in terms of personal selling activities, have also been included. Within pharmaceutical companies there are sales representatives and non-‐sales people. Sales representatives are recruited and trained to perform a personal selling function. There are inevitably other functions within any organisation that are not from a sales background or employed to ‘sell’. This does not mean however they are not able to ‘sell’. The medical department are defined as ‘non-‐promotional’ in the eyes of the Association of British Pharmaceutical Industry; they are physicians by training and are not ‘bonused’ on sales of products. Their activities are intended to further the development and commercialisation of medicine and to obtain feedback on how to improve development for the future. They are also able to engage in peer-‐to-‐peer discussions with customers by virtue of their identical training. Promotional personal selling The activities included in this section are the ‘true blue’ promotional personal selling activities engaged by the sales force to promote their products. Non-‐promotional personal selling These activities are those routinely carried out by the medical department within the pharmaceutical company they also routinely do not involve the presence or involvement of the sales force in order to meet the criteria set out by the Association of the British Pharmaceutical Industry (ABPI) for non-‐promotional activities. The activities carried out can mirror those executed by the sales force differing only in the background of the individual carrying out the activity. Non-‐personal selling activities These include all activities that an organisation may not have direct control over but would still influence the target customers’ decision to prescribe the medicines selected. Influence of activities The healthcare professionals as customers for the pharmaceutical industry were chosen as targets this study for the following reasons: The marketing of medicines in the UK is a highly

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specialised industry involving detailed training for the sales force, incurring an inevitable expense. Information on sales force effectiveness or lack of it would have a high likelihood of delivering impact through adoption. The evidence reviewed for the pharmaceutical industry has shown some authors directly questioning the value of a pharmaceutical sales representative in influencing their decision to prescribe. These reports are anecdotal and there is no evidence in a larger population that this is true beyond the author. Currently there is little objective evidence showing which activities influences sales of a pharmaceutical product. As such, very little is known about the effectiveness of the sales force. The targets, i.e. the customers, have not been questioned about the influence of the activities carried out by the sales force or other activities that may influence sales. The purpose of this study is to assess the relative influence of personal and non-‐personal selling activities as self-‐assessed by pulmonary arterial hypertension (PAH) healthcare specialists to help demonstrate alternative strategies to traditional personal selling component of the promotional mix and to identify possible inefficiencies in using the personal selling approach. Methods This study investigated activities that may influence healthcare professional (HCP) prescribers (doctors, nurses and pharmacists) using an internet-‐based questionnaire. The activities that may influence sales of a particular drug were classified into three groups: 1. Promotional personal selling; 2. Non-‐promotional personal selling; and 3. Non-‐personal selling. Participants In order to survey all the HCP prescribers in one therapy area, all the HCP prescribers who work in a highly specialised therapy area of pulmonary arterial hypertension (PAH) in the United Kingdom (UK) were contacted and asked to complete the questionnaire. In the UK, physicians, and some nurses and pharmacists are all allowed to prescribe drugs so no distinction was made between the types of prescriber because all UK prescribers have high levels of training and have proven competence in their therapy of expertise. Respondents were offered a small remuneration of £20 as an incentive to complete the questionnaire.

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Questionnaire design The participants self-‐reported the influence of the three categories of activities on prescribing two drugs approved for use in PAH, ambrisentan (Volibris®; Glaxo Group Ltd, Brentford, United Kingdom) and epoprostenol 0.5 mg (Flolan®; Glaxo Group Ltd, Brentford, United Kingdom). Ambrisentan, an oral tablet used to treat the milder cases of PAH, was approved by the European Medicines Agency (EMA) for the treatment of PAH in 2008. Epoprostenol, approved for use in 1995 by the United States Food and Drugs Administration, and in 2001 by the EMA for the treatment of more severe PAH, has to be administered using an intravenous infusion.(Rubin et al., 1990, Barst et al., 1996) Respondents were asked to rate what influence various personal (either promotional or non-‐promotional) and non-‐ personal activities had on their prescribing habits for these two drugs using a scale of 0−10, where 0 = ‘no impact at all on prescribing of the product’ and 10 = ‘the most important factor in influencing prescribing of the product’. Table 2 describes each type of activity in detail that were selected for inclusion in the questionnaire. Table 3 lists all the questions in the questionnaire. The responses for the two products were captured in two parallel columns to allow them to post answers in relation to each other. Questionnaire implementation and data collection The targets were identified from a list of physicians, nurses and pharmacists held by GlaxoSmithKline, the manufacturer of both of the products included for reference in the questionnaire. The respondents were given a period of 2 weeks to complete the questionnaire. Two weeks after the questionnaire was distributed, the database was locked and the date sent for statistical review. The database was monitored by Kyeesha Ltd, Banbury and a blinded excel spread sheet was forwarded to the principle investigator and then for statistical review. Statistical analysis The confidence level and margin of error for the number of respondents was calculated. The mean scores of influence of each type of selling activity were also calculated for the individual types of activity and for the three categories of activities (promotional personal selling; non-‐promotional personal selling and non-‐personal selling activities). Promotional personal selling, non-‐promotional personal selling and non-‐personal selling activities were compared using the student’s paired t-‐test and Tukey’s studentized range honest

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significance test, a single-‐step multiple comparison and significance test, to find the mean values that are significantly different from each other by identifying any difference between two means that is greater than the expected standard error. Results Survey respondents Of the 122-‐targeted healthcare professionals who received the questionnaire, 34 (27.9%) responded within the 2-‐week time limit. The findings of the survey have a confidence level of 90% and margin of error of 12% given that 34 out of 122 people responded (Penwarden, 2014). Different types of activities influencing sales of products Personal versus non-‐personal selling activities The combined total mean influence scores for the personal selling activities were significantly lower than the combined total influence mean score for non-‐personal selling activities (3.6 vs 7.7; p<0.001 [student’s t-‐test]). Promotional versus non-‐promotional personal selling The combined total mean scores for the influence of promotional selling activities was lower than the combined total mean score for the influence of non-‐promotional selling activities (2.85 vs 4.45; p<0.001 [student’s t-‐test]). Comparison between the three activity categories The combined total mean scores for the influence of each of the three types of selling activities were significantly different from each for all comparisons (p<0.05 for all [Tukey’s studentized range test]). Relative influence of individual activities All types of activities were scored by the respondents as having some influence on sales, i.e. the mean influence scores for each activity were greater than zero. Figure 1 shows the combined mean influence scores for each category of activities as rated by the respondents. For the combined analysis of both ambrisentan and epoprostenol, ‘Medical Literature and Studies’ and ‘NSC Guidelines’ were significantly more influential than all other activities with mean scores of 8.38 and 8.00, respectively, whereas ‘Call from Sales Representative’ were

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least influential with a mean score of 2.35 (Figure 1A). There were differences in how respondents rated the influence of activities depending on which drug the activity was being referred to. Overall, all activities were rated to have greater influence on the newer drug, ambrisentan, with a large overlap in groupings for promotional and non-‐promotional personal selling activities (Figure 1B) compared with epoprostenol, which had no overlap in groupings for promotional and non-‐promotional personal selling activities (Figure 1C). In considering both products together and the impact of the various individual activities side by side, there was very little to differentiate the two products other than the Tukey groupings. The only significant difference noted between the two products was with the preceptorship activity. This is a non-‐promotional visit organised by the manufacturer for a team from a centre in one country to visit a centre in another country. The impact of this activity was statistically greater with ambrisentan than epoprostenol. This may be attributable to the fact that ambrisentan is a new product requires a little more guidance than for the older product epoprostenol. The opportunity for physicians to visit another hospital using the new product and gaining peer-‐to-‐peer advice in this setting may account for the difference with epoprostenol, which is a product they already have had more than a decade of experience with. Discussion This study investigated the influence of personal and non-‐personal selling activities as rated by HCP prescribers (physicians, nurses and pharmacists) who work within the therapy area of PAH in the UK and responded to an Internet-‐based questionnaire survey. The results of this survey demonstrate that there is some benefit in maintaining a sales force, as the influence on prescriptions was not rated as zero by the respondents. The effectiveness of the sales force therefore can be said to have been proven against a baseline of zero impact. These results have been obtained directly from prescribers based in the UK and their view on how much each activity influences their prescribing (a surrogate marker for purchase and sales) of the product. Other research has in the past suggested that changes in detailing or pharmaceutical advertising expenditures may have zero effect (Mackowiak and Gagnon, 1985). The next study question was whether personal selling can be performed by another function within the organisation? Within the pharmaceutical industry there two departments within

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the same organisation that interact with the same customer group: one is the sales department and the other the medical department. Maintaining these departments in parallel is expensive and the natural question was which one is better at personal selling? In specific scenarios, such at the 1:1 visits the industry physician was rated by the customers as more influential than the sales person’s call. This can be attributed to the physician having a common background with the customer; both are physicians, and as such, the messages being delivered can be considered trustworthy. In comparison, sales calls or visits from the sales force were the least effective in generating sales. Overall, when considering all non-‐promotional and promotional personal selling activities, there may be a significantly greater influence in generating sales when personal selling is carried out by the medical department than the sales force. This supports the argument that the medical department can be effective in personal selling through its interaction with the customer and may negate the need for a formal sales force in some settings. The peer-‐to-‐ peer interaction may account for the greater mean total influence score for non-‐ promotional personal selling compared with a lower score for promotional personal selling activities. These data suggest that if resources were scarce within the organisation, the medical department should be preserved over the sales force as the ability to personally sell is not limited to the sales force and selective recruitment along with sales force training still does not increase influence to the level of influence that the medical department has within the pharmaceutical industry. Furthermore, peer-‐to-‐peer interactions, and interactions between an industry physician and a prescriber are more likely to aim to improve patient health rather than simply increase sales, thereby increasing the trust between the pharmaceutical company and it’s customers. Timely and clear messaging to the prescribers is particularly important when there is new clinical data to support changes in prescribing habits (Calfee, 2002). In addition, there are non-‐personal selling activities (the remaining members of the promotional mix) affecting promoted products that can have an influence on prescribers. Non-‐personal selling activities had a significantly greater influence on the respondents compared with both non-‐promotional and promotional personal selling activities. Organisations should be aware of these external factors that may further improve uptake and sales of their products.

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An assessment was carried out relating to whether the non-‐personal, promotional personal or non-‐promotional personal selling activities were more or less effective when considering two distinct products with differing profiles. The question here was whether the product makes a difference to the effectiveness of activities influencing sales. The overall finding was that there was no appreciable difference between the ways sales were expected to be influenced. Overall, the results of this questionnaire showed that non-‐personal selling activities were thought to be more influential than personal selling activities. Moreover, non-‐promotional personal activities were thought to be more influential than promotional personal activities. Respondents rated each activity as influencing their decision to prescribe either ambrisentan or epoprostenol (i.e. no activity was given a score of zero). Nonetheless, the mean influence score differs for each of the activities. The three most influential activities were non-‐ personal selling activities, such as medical literature and studies, national guidelines and recommendation from colleagues. Of the non-‐promotional personal selling activities, scientific meetings were the most influential at generating sales followed by a 1:1 visit from an industry physician. There was a significant difference between the influences on sales generation between a visit from the industry physician compared with a sales representative. The traditional sales call from the sales representative is the least influential at generating sales from all of the activities assessed. All activities were generally rated as more influential for the newer agent, ambrisentan, compared with epoprostenol, which highlights that for new drugs to market, any personal or non-‐personal activities, promotional or non-‐promotional, have a greater influence on prescribers, with little difference between the types of activity (i.e. there is large overlap between the groups). Interestingly, there is no overlap between non-‐personal selling activities and personal selling activities for epoprostenol. As epoprostenol is an older product, prescribers may be less susceptible to promotional activities as they have greater experience of using the drug in clinical practice and their own experiences will have greater influence than other people’s opinions. Here, the scientific meeting is more impactful than its promotional counterpart the face-‐to-‐face promotional meeting. A possible explanation for this may lie in the experience the customers already have with the product negating the need for promotional messaging from the manufacturer and a greater need to air more ‘peripheral and scientific’ views on the products use. This may include new applications for

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the product where the manufacture is limited to promoting only approved, licensed indications This study has a number of limitations. The sample population was not chosen at random, and as such, there may be inherent bias meaning that the sample is unlikely to be representative of the whole population being studied. This has the limitation in that it undermines the ability to make generalisations. The benefits however, lie in its ease of implementation and low cost. The response rate, although not high, was in line with an expected response rate of approximately 25% (Penwarden, 2014, Yun and Trumbo, 2006). Nonetheless, higher response rates for comparative surveys that collated responses over longer time periods are often statistically indistinguishable from the responses collated over a shorter time period and that have a lower response rate overall (Visser et al., 1996, Keeter et al., 2006). Furthermore, it is preferable to get a better response rate from a small sample population (Evans, 1991). Furthermore, as there were relatively few participants, it was not statistically meaningful to assess the impact of each of the activities by subgroups of customers (i.e. physician, nurse, pharmacist), which would have provided valuable information. Repeating the survey with an initial larger target population would have some merit. Follow-‐up requests for the selected HCP prescribers to participants were not performed as repeated reminders to complete the survey may have been viewed in an unfavourable light by the recipients. The list of activities provided for rating is an exhaustive list personal and non-‐personal activities and satisfies the validity of the content of the questionnaire. The central question relates to an inherently abstract, subjective assessment on the part of the subject, this not an easily validated. Nonetheless, influence on decision-‐making is important when considering product sales. In addition, personal selling is a multifactorial phenomenon. This means it is almost impossible to model exhaustively. Responsiveness to personal selling can vary from person to person, country to country, industry to industry, product to product even phase to phase of the salesperson’s own lifecycle. To summarise, personal selling is effective in generating sales, but non-‐promotional personal activities within an organisation may be more influential than promotional personal activities. Nevertheless, non-‐personal selling activities may be more influential in generating sales of a product than either non-‐promotional or promotional personal selling activities.

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Further research is required to determine the relative influence of pharmaceutical-‐funded publications compared with publications funded by other sources. Acknowledgements The author would like to thank Adrian Mills for his guidance during this project and Lovemore Gakava for his support in the statistical analysis. This project was part of a MBA thesis written by the author (RJ). Database management was performed by Kyeesha Ltd, Banbury, UK and funded by GlaxoSmithKline. Editorial and medical writing support for manuscript preparation was provided by Celia J Parkyn, PhD, and funded by Medialis Limited. Funding acknowledgement The research received an educational grant from GlaxoSmithKline. Conflict of interest statement The author has previously worked as a pharmaceutical physician in the PAH therapy area at GlaxoSmithkline. References Barst, R. J., Rubin, L. J., Long, W. A., Mcgoon, M. D., Rich, S., Badesch, D. B., Groves, B. M., Tapson, V. F., Bourge, R. C., Brundage, B. H., Koerner, S. K., Langleben, D., Keller, C. A., Murali, S., Uretsky, B. F., Clayton, L. M., Jobsis, M. M., Blackburn, S. D., Shortino, D., Crow, J. W. & Primary Pulmonary Hypertension Study, G. 1996. A comparison of continuous intravenous epoprostenol (prostacyclin) with conventional therapy for primary pulmonary hypertension. N Engl J Med, 334, 296-‐301. Calfee, J. E. 2002. The role of marketing in pharmaceutical research and development. Pharmacoeconomics, 20 Suppl 3, 77-‐85. Caudill, T. S., Johnson, M. S., Rich, E. C. & Mckinney, W. P. 1996. Physicians, pharmaceutical sales representatives, and the cost of prescribing. Arch Fam Med, 5, 201-‐6. Dixon, A. L. & Tanner, J. F. 2012. Transforming Selling: Why It Is Time to Think Differently About Sales Research. Journal of Personal Selling & Sales Management, 32, 9-‐13. Evans, S. J. 1991. Good surveys guide. BMJ, 302, 302-‐3. Gonul, F. F. & Carter, F. J. 2010. Impact of e-‐detailing on the number of new prescriptions. Health Care Manag Sci, 13, 101-‐11.

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Griffiths, S. 2008. Pharmaceutical branding:' To brand or not to brand'. Journal of Medical Marketing 8, 113-‐118. Harris, G. 2009. Pharmaceutical representatives do influence physician behaviour. Fam Pract, 26, 169-‐70. Jackson, T. 2001. Are you being duped? 322, 1312. Janakiraman, R., Dutta, S., Sismeiro, C. & Stern, P. 2008. Physicians' persistence and its implications for their response to promotion of prescription drugs. Management Science, 54, 1080-‐1093. Joseph, K. & Mantrala, M. 2009. A model of the role of free drug samples in physicians’ prescription decisions. Marketing Letters, 20, 15-‐29. Keeter, S., Kennedy, C., Dimock, M., Best, J. & Craighill, P. 2006. Gauging the Impact of Growing Nonresponse on Estimates from a National RDD Telephone Survey. Public Opinion Quarterly, 70, 759–779. Kremer, S. T. M., Bijmolt, T. H. A., Leeflang, P. S. H. & Wieringa, J. E. 2008. Generalizations on the effectiveness of pharmaceutical promotional expenditures. International Journal of Research in Marketing, 25, 234-‐246. Leeflang, P. S. H. & Wieringa, J. E. 2010. Modeling the effects of pharmaceutical marketing. Market Letters, 21, 121-‐133. Lim, C. W., Kirikoshi, T. & Okano, K. 2008. Modeling the effects of physician-‐directed promotion using genetic algorithm-‐partial least squares. International Journal of Pharmaceutical and Healthcare Marketing, 2, 195-‐215. Mackowiak, J. I. & Gagnon, J. P. 1985. Effects of promotion on pharmaceutical demand. Soc Sci Med, 20, 1191-‐7. Narayanan, S., Desiraju, R. & Chintagunta, P. 2004. Return on Investment Implications for Pharmaceutical Promotional Expenditures:The Role of Marketing-‐Mix Interactions. Journal of Marketing, 68, 90-‐105. Oldani, M. J. 2004. Thick prescriptions: toward an interpretation of pharmaceutical sales practices. Med Anthropol Q, 18, 325-‐56. Penwarden, R. 2014. Response rate statistics for online surveys -‐ what numbers should you be aiming for? Available at http://fluidsurveys.com/university/response-‐rate-‐ statistics-‐online-‐surveys-‐aiming/. Accessed June 24, 2015. [Online]. [Accessed 24 June 2015]. Puneet Manchanda, Peter E. Rossi & Chintagunta, P. K. 2004. Response Modeling with Nonrandom Marketing-‐Mix Variables. Journal of Marketing Research, 41, 467-‐478.

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Rhoton, D. 2011. The Future of Learning. MIT World, April 29. Available from: http://mitworld.mit.edu/video/923/). Accessed April 20, 2015. Rubin, L. J., Mendoza, J., Hood, M., Mcgoon, M., Barst, R., Williams, W. B., Diehl, J. H., Crow, J. & Long, W. 1990. Treatment of primary pulmonary hypertension with continuous intravenous prostacyclin (epoprostenol). Results of a randomized trial. Ann Intern Med, 112, 485-‐91. Singh, R. 2009. Network connectedness of pharmaceutical sales rep (FLE)-‐physician dyad and physician prescription behaviour: A conceptual model. Journal of Medical Marketing, 8, 257-‐268. Tanner Jr, J. & Raymond, M. 2010. Principles of Marketing, v.1.0. Available from http://catalog.flatworldknowledge.com/bookhub/reader/2030?e= -‐ fwk-‐133234-‐ chab. Accessed April 20, 2015. Flat World Knowledge, Washington, DC. Visser, P., Krosnick, J. & Curtin, M. 1996. Mail surveys for election forecasting? An Evaluation of the Colombia Dispatch Poll. Public Opinion Quarterly 60, 181-‐227. Yun, G. & Trumbo, C. 2006. Comparative response to a survey executed by post, e-‐mail, & web form. J Compu-‐Mediated Com, 6, Available online at: http://jcmc.indiana.edu/vol6/issue1/yun.html Accessed June 25, 2015.

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Table 1. Promotional activities within the pharmaceutical industry Activity

Definition

Personal selling

One-‐to-‐one communication between seller and purchaser. It generates direct contact with prospects and customers; it is arguably one the most expensive forms of promotion

Advertising

Non-‐personal promotion where the organisation invests in ways to promote ideas, goods, or services in a variety of media outlets. This is therefore a one-‐way communication e.g.: magazines, newspapers, television and websites

Direct marketing

This is advertising directly to a targeted prospect and customers rather than a mass audience. Examples here are: hardcopy mailings or mass emailing. The goals here are to generate sales or leads for sales representatives to pursue. Direct marketing allows a business to engage in one-‐way communication, etc.

Sales promotion

Encompasses all marketing activities other than personal selling, advertising and public relations. Sales promotions are designed to stimulate purchasing and sales. Examples are: coupons, product samples and point-‐of-‐sale purchase displays

Public relations

These activities enable an organisation to influence a target audience. In many cases, campaigns are developed on behalf of the organisation in relation to a particular theme or promotion. Essentially, this term relates to the notion of ‘publicity’ i.e. bringing newsworthy information to the public

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Table 2. Descriptions of activities that may influence sales Activity Description Promotional personal selling activities Face-‐to-‐face These meetings are where the salesperson delivers a presentation to a group of customers promotional in the same room. meetings Online promotional In this situation the same material is delivered over the Internet via ‘web meeting’ the meetings speaker and audience are at different locations. Meetings where This will have come about through the personal selling and advocacy development carried respondent is paid out by the sales person. to present data on behalf of the company to a group of their peers Calls from the sales This is the traditional ‘sales call’ there will not be a formal presentation simply a short representative meeting to maintain the relationship between the sales representative and the customer to explore how the product is performing if it has been adopted or if it hasn’t been adopted, to understand obstacles in its way Presentations from In this scenario the salesperson delivers a pre-‐approved presentation to a single customer the sales on a 1:1 basis. representatives Sponsorship to From time to time the sales person will select customers to attend international meetings. attend congresses The sponsorship will involve the salesperson using his budget to pay for travel, registration and board at the congress. This activity will involve personal engagement and relationship management to gain agreement to attend. This activity has been used regularly by the sale person to gain favour and ultimately influence the prescriber. Industry symposia Many industries engage with customers at trade shows. Often trade shows will contain a and promotional large promotional stand where sales people are present to detail their products. The stands at company may also pay for time at the congress to deliver a symposium on its products of congresses subjects related to its products. The sales function is involved in both these activities intimately whether related to the case study or not. The influence of these on the hard endpoint of sales of the medicine are critical in considering the vast sums of money required to execute them. Non-‐promotional personal selling 1:1 visits from the These are intended to mirror the calls from the sales force. Their content may differ in the industry physician material used. The scope available to an industry physician to discuss medical matters is far wider than that available to the sales person and the peer-‐to-‐peer angle is also open to leverage. Personal selling though not correct terminology within regulatory framework of the pharmaceutical industry is perfectly with context in the business theory sense. This comparison may provide insight into whether the sales background is of any added value over and above selecting a function as close as possible in background to the customer. Meetings where Once more, the question here is whether or not the background of the function delivering the industry the information, engaging in ‘personal selling’ has an influence on the outcome of sales. physician presents This type of presentation should only differ in the function of the person delivering it. The data content would be identical to when a sales person delivers the content. Advisory board They are usually convened to answer a specific, non-‐promotional question. However, the meetings are engagement and invitation arises solely from the medical function and the relationship specific type of deliberately excludes the sales person to preserve its non-‐promotional nature. meeting where customers are paid to attend Scientific meetings The main difference, once again lies in the fact that the regulatory authorities preclude are the non-‐ involvement of the sales forcing in any non-‐promotional meetings of this sort. In other promotional regards these meetings do not carry the branding elements and logos of the medicines or equivalent of the the brand name of the product, only the non-‐promotional, generic name. Again the industry symposia meetings are run exclusively through the medical department and relationships are at congresses leveraged through the physician-‐to-‐physician peer-‐to-‐peer route. Preceptorships These have no equivalent in the promotional portfolio of activities and have been included for completeness to ascertain their relative effectiveness in general. They are visits organised by the medical department for a team of healthcare professionals from one hospital to another in another part of the world working in the same therapy area.

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Supporting These two activities, though run from the medical department, have extremely care investigator stipulations around their use enforced by the ABPI. These transfers of monies should not initiated studies in constitute an ‘inducement to prescribe’ and therefore must be completely devoid of the respondent’s association with product use. However, it is conceivable that the support for activities of centre or the the customers’ own interest may well have a by-‐product of good will towards the respondents own company and, indirectly, increase sales. meetings with educational grants Non-‐personal selling activities Recommendations During informal communication information exchanges take place. These exchanges may from colleagues include whether or not one product for a particular disease is better in their opinion than another. Though it is difficult to identify the origin of the information prior to the exchange, the ultimate lever to prescribing to be investigated here is how much a personal recommendation from a peer-‐to-‐peer has on the decision to prescribe a product. National Guidelines As with other non-‐pharmaceutical selling environments, there may be formal bodies, set-‐ up independently of the selling organisation, an external stakeholder that has been charged with the responsibility of review different products and services and offer recommendation on which one should be used in preference to another. Usually, the criteria selected for the review is cost or cost-‐effectiveness but others will inevitably exist. With respect to National Institute for Health and Clinical Excellence (NICE), it actively reviews all new technologies and provides its recommendation on the available published evidence in conjunction with its own health economic modelling. NICE requests information on products from the manufacturer in a pre-‐defined format and these are provided to the agency through the non-‐personal selling route. These guidelines and technical appraisals considered as significant non-‐industry driven activities influencing the decision to prescribe. Published articles in The peer-‐review system is expected to act a strong filter to poor quality research. peer-‐reviewed Speciality medical journals exist to provide HCPs with the latest evidence supporting journals treatments in their specific field of expertise. Journal articles can be submitted by the pharmaceutical companies but their propagation through the journal is not guaranteed and there is no aspect of personal selling involved in the submission process, many journals accept submission through an online portal and blind the reviewers to the authors to preserve and objective review. Nonetheless, peer-‐reviewers are not blinded to sources of funding and acknowledgment of pharmaceutical company involvement.

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Table 3. Questionnaire assessing the influence of various ‘selling’ activities Please select the number which indicates the impact of the following activities have had on your prescribing of the following products, where 0=‘no impact at all’ and 10=‘the most important factor’. Participants were asked to complete the survey for both ambrisentan (Volibris®) and epoprostenol (Flolan®). Please select the number which indicates the impact of the following activities have had on your prescribing of the following products, where 0=‘no impact at all’ and 10=‘the most important factor’. Personal selling Promotional activities Promotional meetings: face-‐to-‐face Promotional meetings: online Promotional meetings: where you are paid to be present Calls from Sales Representatives Presentations from sales representatives Congresses: sponsorship for you to attend Congresses: industry symposia Congresses: promotional stand Non-‐promotional 1:1 visit from industry physician Meetings where industry physician presents data Advisory boards Scientific meetings Preceptorships Supporting investigator initiated studies in your centre Supporting your meetings with educational grants Non-‐personal selling Recommendations from colleagues National Screening Committee guidelines Medical literature and published studies

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Figure 1. Comparisons of mean influence scores for all selling activities Groups were determined using Tukey’s studentized range test. The mean influence score of each activity within a specific group were not significantly differently, but were significantly different for between group comparisons. A. Influence of activities for ambrisentan and epoprostenol combined (n=68)

B. Influence of activities for ambrisentan (n=34)

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C. Influence of activities for epoprostenol (n=34)

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