Practices of dispensing doctors - drug use and health economics
Trap, B
Zimbabwe Essential Drugs Action Programme,
Ministry of Health & Child Welfare
Problem Statement:
Doctors dispense drugs for many reasons, such as insufficient pharmacy coverage, to
increased drug accessibility and availability, and for economic reasons. For policies and
strategies to be developed, information regarding the rationality of having drugs prescribed
and dispensed by one and the same person need to be reviewed and evaluated.
Objectives:
To review and evaluate the appropriateness and validity of available information pertaining to
the practice of dispensing doctors related to the aims of national drug policies in ensuring
rational drug use and affordability.
Designing and Setting:
The review was prepared based on available literature and information obtained at national
and international levels. A critical evaluation of the existing literature was carried out and
areas for further investigation identified. More than 50 references were reviewed and the
various issues were discussed and presented in a coherent way.
Outcome Measure(s) and Results:
There is little solid information available to develop national policies on the practices of
dispensing doctors. Very few valid studies have been undertaken to evaluate the rationality of
this practice, and where studies have been done, there is no concurrence through repeated or
comparable studies. In addition most of these studies, which examine aspects such as
procurement, prescribing and dispensing behaviours, and compliance and costs, have been
done in developed countries. The conclusions that have been drawn, in comparison to nondispensing doctors, are that dispensing doctors prescribe more drugs, fewer generic drugs, and
have a greater income. Other aspects of dispensing prescribers that have been reported on are
the influence of drug company sales representatives, the use of free samples, storage practices
and the conflict of interest that receiving payment for prescribed medications poses. The
benefits of a second check by a pharmacist / dispenser - such as reducing adverse drug
reactions and improving compliance - could not be proven. Ensuring standards in dispensing
and control of pharmaceuticals, and rational drug use aspects like adherence to accepted
treatment protocols, were not critically evaluated in the studies.
Conclusion:
Almost all of these studies were undertaken in developed countries, and only the finding of
increased drug use has been confirmed in more than one study. In view of the increasing drug
costs experienced in most countries, the need for strengthening national policies and rational
drug use, and for undertaking cost evaluations in both the public and private sector, is evident.
More information on the practice of dispensing doctors is required if optimal policies are to be
developed in this area. Studies in this regard should therefore be encouraged.
Summary
This article reviews literature concerning the practice of dispensing doctors in comparison to
non-dispensing doctors and pharmacists. Dispensing is an important step in ensuring drug
accessibility, affordability, safety and rational use. To ensure optimal utilization of limited
funds, dispensing must be regulated by appropriate policies and laws. To provide politicians
with information enabling them to prioritize and legislate, this review was prepared.
The various legal aspects regulating dispensing by doctors have been listed. The spectrum of
what is legal is very wide. Many laws focus on regulating dispensing when carried out by
pharmacists, whereas dispensing by doctors in several countries is not clearly defined. South
Africa, Zimbabwe and some states in the USA have recently started giving priority to enforce
and regulate dispensing by doctors.
Prior to the 11th century all drug dispensing was carried out by doctors. Thereafter,
pharmacists became recognized and started taking over dispensing. This development
continued in most countries where doctors were paid a consultation fee. In other countries
where a doctor's livelihood depends on the sale of drugs, dispensing by doctors has carried on,
i.e. in India, Japan and Pakistan, where about 80% of doctors dispense. In other countries,
dispensing doctors only constitute a minority of 5-10 %. However, the number of dispensing
doctors is increasing.
Actual studies on dispensing doctors are very limited and much of the available information is
related to emotions, belief and personal opinions, rather than sound scientific evaluations. The
following findings have been based on studies carried out mainly in UK, USA and from an
inspection in South Africa.
In comparison to doctors who do not dispense, those who do were found to prescribe more
drugs annually per patient, prescribe fewer generic drugs, issue more prescriptions (but in
lower quantities), have older patients, and have less years in practice. The average number of
visits per patient per year was found higher for dispensing doctors' patients. In an inspection
of dispensing doctors' practices in South Africa, 46% were found to have inappropriate
storage facilities for drugs, 52% were staffed by untrained dispensers, 61% did not provide
suitable containers and 27% were unsatisfactorily labelled. The benefits of a second check by
a pharmacist, in regard to minimising adverse drug reactions or compliance, could not be
proven in a study on elderly admissions to hospital.
Only few of the findings have reoccurred in more than one study, and several of them are
based on very small sample sizes. There is a need to obtain more information on this practice
and to repeat previous findings in other countries, including developing countries, in order to
ensure the achievement of an optimal health care system catering to the majority of the
population.
Introduction
Doctors dispense drugs for many reasons, such as insufficient pharmacy coverage, to increase
drug accessibility and availability, and for economic reasons. For politicians to make policies
and strategies to regulate the practice of dispensing by doctors, information regarding the
rationality of having drugs prescribed and dispensed by the same person needs to be reviewed
and evaluated (33).
A definition of a dispensing doctor was offered by SA Axon at the FIP conference in 1993: a
dispensing doctor is a medical practitioner who is permitted to provide a dispensing service to
some or all of his patients either as an exception to the general legislation governing the
provision of pharmaceutical services or as part of the overall provision of medical services
(37).
The definition relates to the legal restriction of the practice. Depending on the national laws, it
allows doctors, in general, to dispense, or it only permits dispensing injections, free samples,
in emergencies or in remote rural areas where pharmacy services are unavailable to ensure
accessibility (11, 73, 55).
The evaluation of dispensing by doctors is far more complex than a simple spirited
competition between two or more dispensing alternatives. Drugs cannot be viewed as ordinary
commodities of commerce as they are not like most other commodities (72). Drugs are not
chosen directly by the buyer (the patient), the buyer is not always the responsible payer, the
buyer often has no background or the necessary information to evaluate or make a choice
which can have hazardous or even deadly consequences for the patient. Normally market
economics have to be modified when applied to drugs as assumptions are not easily fulfilled
(77). This has been recognized in regard to pricing, demand and sale of drugs where special
models have been developed (77, DK articles). Studies in the UK found that reducing the
price of drugs did not markedly affect their use (71).
Policy makers must find the best way to achieve the aims of their national health or drug
policies and decide on necessary regulation. Part of this is to pass laws on dispensing by
doctors.
The main objective of the Zimbabwe National Drug Policy is to ensure the availability and
accessibility of safe, efficacious, cost-effective, and affordable pharmaceutical products of
good quality to the entire population of the country, and furthermore to promote the rational
use of drugs through improved information, prescription and compliance (75).
Legal aspects
Back in 1271 in France, doctors and pharmacists were reported to have feuded over
dispensing. This discussion has continued to this day in many countries, developed as well as
developing (11, 54, 46, 14, 77). In 1240 the German Emperor Frederick II initiated the
separation of the occupations performed by doctors and pharmacists. Doctors became the
diagnostic and prescribing experts and pharmacists experts in drug dispensing and drug
management. This development became possible due to urbanization whereby markets had
become large enough to allow for specialization (11, 38, 39, 59). Doctors could generate an
income from diagnosing and prescribing. Likewise, pharmacists were not prescribing but
could sustain a living through the sale and dispensing of drugs. The fact that doctors could
generate an income from diagnosing and prescribing, and pharmacists from dispensing alone,
was fundamental to the separation of the two practices.
These principles were accepted by Parliament in the UK in 1912 and by the national health
insurance in 1964 (13). Paying for a consultation is, however, not accepted in all cultures. In
India and Pakistan patients do not generally accept paying a consultation fee, and the common
way doctors generate an income is by dispensing (selling) drugs (13, 62, 63). This is also the
practice in Japan, Mexico and South Africa. In 1991, over 80 % of all doctors in these
countries dispensed medicines (39b,59, 37). In Japan the law allows dispensing by doctors if
"medically necessary". Drug expenses in Japan in 1993 were found to be 30% of the total
health care bill, compared to other developed countries which spend about 5% on drugs (37).
In 1990 in South Africa, 80 % of drug expenditure was spent in the private sector, although
60-70% of the total volume of pharmaceuticals was consumed in the public sector (74).
In countries such as Scandinavia and Germany, the two professions continue to be separate.
For example, in Denmark the law does not allow a person to practice medicine and pharmacy
at the same time. Doctors dispense injections and drugs only in special circumstances, such as
emergencies.
Most countries have regulated dispensing by doctors. In the USA 45 of the 50 states have
some type of regulation (10). However, the interpretation and implementation of these
regulations have met with difficulties due to a lack of resources, ability or authority to inspect
dispensing doctors; a lack of clarity on who is responsible for enforcement; and the imprecise
wording of the laws (11,10, 65). A US survey in 1989 found that 20 states had strengthened
their regulations in the last 2-3 years. However, as mentioned above, the enforcement was
hampered because of limited resources, and only a few states conducted inspections of
dispensing doctors’ offices (10). A survey undertaken from 1986-1987 found that 20 to 31 US
states permitted physician dispensing with no specific or minimal regulations (11).
The basic aim in most laws is covered by the following principles:
* Rurality: permits physicians to dispense in rural areas where there are no pharmacies. The
laws, e.g. in England, Netherlands and Zimbabwe, allow dispensing by doctors if no
pharmacy is available with in a mile or 5 km from either the patient's home or, in some laws,
from the doctor's practice (37, 73, 56).
* Dispensing rights - renewal: once a doctor undertakes dispensing, this right can either be
reviewed annually or continues even when a pharmacy is established within the one mile or 5
km limit (73). Compensation for a decrease in income has been much debated in the UK (56).
* Emergencies: permit physicians to dispense in emergencies. The laws in 5 US states
allow dispensing only in limited situations, such as medical emergencies (10, 59). In Denmark
this occurs during an after hours visit to a patient where treatment might be required.
* 72 hour supply: in USA the Federal Trade Commission requires that no more than 72
hours' worth of medicine be dispensed by doctors (11, 30). In Germany, since 1993, the law
allows doctors to provide treatment at home before and after a stay at hospital in order to
shorten an expensive stay at hospital (37, 38).
* Not for profit or cost/price regulation: limits the amount physicians may charge for
medication they dispense. In Australia, which only has 69 dispensing doctors, passed laws
that forbid dispensing doctors from making a profit (37). In 1989 the US congress considered
a bill to prohibit practitioners to dispense drugs for profit (10).
* Procedural requirements: limit dispensing to physicians' own patients and require
dispensing to follow the same regulations mandated for pharmacists, e.g. labeling, record
keeping, package requirements and storage. Labeling and record keeping requirements are
applied in at least 23 of the 45 states in USA that permit physician dispensing, and in South
Africa (10, 11, 59, 65).
* Delegation of dispensing: permits dispensing to be undertaken only by trained or
employed staff related to the physician's practice. Conflicting laws also exist which require
dispensing to be done by the physician personally (37,40).
* Patient choice: this principle protects the freedom of choice for patients when deciding
whether to purchase prescription drugs from their physician or the pharmacy (8).
* Duty at factories: permits physicians to dispense drugs in small amounts to employees
during factory visits. This is practiced in Germany (38).
* Registration: the laws in Zimbabwe and in 13 states in the US require dispensing doctors
to be registered (10, 73).
Most laws regulate dispensing to protect public health, safety and welfare. However,
interpretation and enforcement often aim to regulate dispensing when carried out by
pharmacists, not physicians. However, more countries have started addressing this issue, and
drug policies began prioritizing the regulation surrounding dispensing undertaken by
practitioners. In 1996 the new National Drug Policy of South Africa stated that dispensing
doctors can only be permitted where separate pharmaceutical services are not available. In
these cases, the dispensing doctors or dispensing nurses must be registered and annually
renew the registration, be trained in dispensing, be inspected, practice good dispensing and
show transparency in the pricing structure (74).
Development
The number of dispensing doctors has recently increased in several countries. In the UK about
12.5% of general practitioners were found to dispense in 1966/67(56). This increased slightly
to 14% in 1989-90 and to 15% in 1993(28, 77): dispensing doctors account for about 7% of
all primary care prescriptions (28). In the USA, about 40% of all physicians dispensed drugs
in 1923; this decreased to 25% in 1947, 8.7-10% in 1967, and about 5%-8.5% in 1990-91 (11,
12, 59). A survey in Louisiana in 1992 based on questionnaires found that only 4 % of
physicians dispensed; but the same survey found that 10.5 % stated that they intended to
dispense within the next 2 years (30).
Other authors also believed that the number of dispensing doctors will continue to increase.
The reasons given are to benefit patients and society, and because dispensing offers a
possibility to increase or sustain physicians' incomes, which have been declining over the past
years. Also, dispensing has been facilitated by the introduction of prepackaged drugs. The
decline in physicians' incomes in the USA has been related to increased competition resulting
in a fall-off in patient load (59). In South Africa the number of retail pharmacies have
remained almost constant from 1985 to 1995, whereas the number of registered dispensing
doctors has doubled from about 4000 to almost 9000 in the same 10 years (65). In 1996, new
policies were introduced in South Africa aiming at strengthening regulation of dispensing
doctors. Similar developments are called for in USA, Zimbabwe and Japan (10, 76, FIP). In
countries such as India and Pakistan, dispensing by doctors is the common way for general
practitioners to earn a living as this is closely linked to cultural changes which are expected to
occur as a result of consumer education (13, 63).
Drug dispensing by doctors
Doctors dispense for many reasons and the debate has been lively on the pros and cons. Often
discussions are related to economics from the pharmacist's or doctor's point of view, giving
less priority to the patient and to the aim of the national policies. Pros and cons are difficult to
evaluate as very few actual studies have been undertaken regarding dispensing doctors; the
discussions have thus been very theoretical and controversial.
The heated debate on the practice of dispensing doctors is being waged over a complex
variety of ethical, economic, public health and patient care issues (8, 72, 39, 10, 36, 59, 12,
37, 29, 11, 18, 67). To provide information for further studies, the discussion is summarized
below as questions related to the outcome of dispensing.
Ethics:
1. Is it a conflict of interest for physicians to sell the prescription drugs they prescribe?
2. Is it important that the consumer has the freedom to choose from where to obtain drugs?
3. If doctors are viewed as authorities, do patients feel compelled to buy drugs from them,
or will they be able to obtain the drugs from a pharmacy? Would this result in a closed
market?
4. Is dispensing by doctors an exploitation of the patient - physician relationship?
5. Will professional ethics and peer pressure protect patients from abuse?
Availability:
6. Can availability of drugs be satisfactorily achieved by dispensing doctors?
7. Do dispensing doctors ensure appropriate procurement and distribution from a health
economics perspective?
Accessibility:
8. Obtaining a prescription and drugs at the same place is convenient and increases
accessibility for the patient. Does it outweigh the advantages of dispensing by pharmacists?
9. What is the best system to ensure national accessibility of drugs?
Safety:
10. Is dispensing by pharmacists a safety net? Will prescriptions with errors, drug
interactions or excessive drug use be prevented or minimized significantly by having the
prescription pass through two qualified trained health professionals?
11. How does the use of prepackaged drugs compare to pharmacy dispensing bags with
regard to safety, cross contamination, labeling, etc.?
12. How can quality be ensured for drugs dispensed by dispensing doctors versus
pharmacist dispensed drugs?
13. Are the laws on dispensing (by doctors or pharmacists) sufficiently structured and
implemented to safeguard patients?
Affordability:
14. Are drugs distributed through dispensing doctors cheaper or more expensive for the
patient and for society?
15. Do dispensing doctors offer the best combination of price and quality of service?
16. Will dispensing by doctors enhance competition and reduce prices?
17. Is a price control structure in place or is affordability based on competition?
18. Must governments ensure the professional status, and provide the necessary background
for doctors to maintain an acceptable income?
19. Is there a need for and political interest in having pharmacies in the future?
20. Do dispensing doctors prescribe more brand-name drugs or generic drugs compared to
non-dispensing doctors?
Rational use:
21. Will dispensing by doctors lead to over prescribing?
22. Will dispensing by doctors narrow the therapeutic options by mainly limiting the drugs
prescribed to those in stock?
23. Are dispensing doctors' prescribing habits different from those of non-dispensing
doctors, e.g. injections, quantities, frequency, generic prescription and other rational drug use
aspects?
24. Do dispensing doctors adhere to good dispensing practices?
25. What is the effect of the physician-patient relationship with regard to rational drug use?
26. How can quality assurance for prescribing best be ensured in the private sector?
27. Can non-health staff be sufficiently trained in dispensing to it take over?
28. Dispensing doctors know what medicine patients are getting when they dispense
themselves, and pharmacists cannot change it by generic substitution.
Information:
29. Is provided patient information adequate when provided by one health professional
instead of two? And is the information unbiased?
30. Is patient knowledge increased or decreased by dispensing doctors?
Compliance:
31. Will dispensing by dispensing doctors increase compliance?
32. Can dispensing doctors better ensure prescription refills?
Several of these questions can be answered based on scientific evaluations or studies.
However only a few of such studies have been undertaken, and many of the above questions
still remain unanswered.
Factors influencing prescribing by dispensing doctors
Good prescribing habits are essential to ensure effective and safe treatment, the shortest
duration of illness, less distress and harm to the patient, and lower cost. Bad habits make
prescribers vulnerable to influences which can cause irrational prescribing, such as patient
pressure, copying bad prescribing habits of colleagues, and pressure from peers and salesmen.
The steps in the prescribing process are: defining the patient's problem, specifying the
therapeutic objectives, verifying if a drug is to be used, selecting a specific drug (checking
effectiveness and safety), choosing dosage and regimen, providing information, writing the
prescription or start and monitor treatment. (78, 20).
Various factors have been found to influence the prescribing process and determine whether
the prescribing is rational. These factors include:
Education, diagnostic and therapeutic skills, pharmacological knowledge, advice from
colleagues, habits of the "copied prescribers", use of formularies or standard treatment
guidelines, years of practice/education, personal clinical experience, patients' demands,
prescribers' personalities, marketing activities from drug industry, consultation time,
importance of maintaining patient load, quality assurance, control and regulatory measures,
information and knowledge on drug costs (71, 62, 69, 20, 78, 29).
It is difficult to separate the effect of the individual factors, (71) and only little information is
available on the actual effect of the factors. Only very few studies have evaluated dispensing
practice carried out by doctors in relation to these factors.
Findings
Findings from studies comparing variables of dispensing doctors and non-dispensing doctors
or pharmacists were given. Not all references had given a detailed method or study
description, but only listed results. Where a method was described, it was summarized and
commented on when giving the results.
Background factors
A study examining the differences in the prescribing practices of 59 dispensing and 49 nondispensing doctors from 1989-90 in the UK found a higher proportion of dispensing doctors'
patients to be over 65 years old, compared to non-dispensing doctors' patients 0.195 versus
0.176 (28).
Distance to pharmacy (km) and rurality have been found to be significantly higher for
dispensing doctors than non-dispensing doctors. On average the distance to a pharmacy in the
UK was 4.36 km for dispensing doctors compared to 1.0 km for non-dispensing doctors.
Rurality (also measured in km), was 2.43 versus 1.25 (28). This is confirmed by a study from
California which found a higher percentage of dispensing doctors in rural areas, 12.9% versus
9.9% (11). In Louisiana, where not for profit dispensing is allowed to a maximum of a 72
hours supply, no difference could be found in regard to location between dispensing doctors
and non-dispensing doctors (30).
In 1992, to evaluate differences between dispensing doctors and non-dispensing doctors, a
questionnaire was sent to doctors in Louisiana. Of the 361 who returned the questionnaire,
only 13 were dispensing doctors. The survey found no difference between dispensing and
non-dispensing doctors with regard to type of practice, organization membership and number
of patients seen per week (30).
Dispensing doctors in the USA were found to have fewer years in practice compared to nondispensing doctors. 61% of doctors presently dispensing or with intention to dispense had less
than 15 years in practice, compared to 39% of non-dispensing doctors (30). The same study
also found that dispensing doctors or doctors with intention to dispense were associated with a
less positive attitude towards pharmacists.
Consultation time was measured in a study on the treatment of childhood diarrhoea in
Pakistan, comparing 62 general practitioners who dispensed drugs with 28 non-dispensing
pediatricians who were paid a consultation fee. The study included 996 patient encounters and
was based on observations of prescribers and patients 3-4 hours daily for 5-6 days. The
general practitioners who dispensed drugs spent on average 3 +/- 2 minutes per consultation.
48% of the encounters were less than 2 minutes, compared to non-dispensing pediatricians
who spent 9 +/- 4 minutes per patient (63). This difference, however, could also be attributed
to the difference in their education.
Rational drug use
The number of items prescribed annually per patient was found to be 15% higher for
dispensing doctors compared to non-dispensing doctors: 9.55 versus 8.32 (28). This might,
however, be a result of dispensing doctors prescribing smaller quantities more frequently.
Comparing defined daily doses (18) or using the INRUD indicators (79), measuring the
number of drugs per encounter is perhaps a more appropriate measurement. A recent study in
South Africa in 1996 confirmed that dispensing doctors tend to prescribe more items more
frequently. The number of items per script was 2.38 for dispensing doctors compared to 1.67
for non-dispensing doctors (65b). A UK study found the same number of items being
prescribed by both dispensing doctors and non-dispensing doctors, namely 2.59 (18). The
average number of visits per year was found to be higher for dispensing doctors compared
with non-dispensing doctors (3.34 versus 2.48) (65b).
The use of injections has been evaluated in Pakistan in relation to childhood diarrhoea,
comparing general practitioners who dispense drugs with non-dispensing pediatricians.
Doctors' use of injections for dispensing doctors was double that of non-dispensing doctors.
32% and 18% prescribed/dispensed injections in 15% and 8% of their encounters respectively
(63).
Rational prescribing in regard to dispensing by doctors has been evaluated. The Pakistan
study found ORS to be prescribed by 53% of the dispensing doctors compared to 61% of the
non-dispensing pediatricians. However, in about 50% of the encounters in both practices,
patients were given ORS. Significant differences were found in the use of antibacterials as
well as antidiarrhoeals. More dispensing doctors were found to prescribe these types of drugs
as compared to the non-dispensing pediatricians: 66% of dispensing doctors prescribed
antibacterials compared to 50% of non-dispensing pediatricians; and 60% versus 29% for
antidiarrhoeals. Moreover, 89% of the dispensing doctors, in 77% of encounters, dispensed
drug formulations of unknown composition and mixtures made in their own drug dispensing
areas. History taking was found to be more elaborate for non-dispensing doctors compared to
dispensing doctors: 73 versus 63% measured by using four indicator questions. An
explanation of these differences could be the dispensing variable, but it should be mentioned
that the non-dispensing doctors were specialists and the dispensing doctors were general
practitioners (63).
Generic prescribing was found to be lower for dispensing doctors in comparison to nondispensing doctors. In the UK, 26.5 % of drugs prescribed by dispensing doctors were
generic, compared to 42% for non-dispensing doctors (28). Dispensing doctors in practices
that introduced fundholding in 1991 prescribed 27% generics in 1991, increasing to 39% in
1994. This compared to non-dispensing doctors who in 1991 prescribed 44.5 % generics,
which increased to 58% in 1994. This increase in generic prescribing in both practices is
related to fundholding being an incentive to save on drug expenditures. In 1991, dispensing
doctors prescribed cotrimoxazole instead of septrin/bactrim 5% of the time, which increased
to 62% in 1994; for non-dispensing doctors the figures are 58% and 97% respectively. The
same figures for naproxen versus naprosyn for dispensing doctors were 13.5 % increasing to
66 % in 1994; for non-dispensing doctors, 64.4% increasing to 91% (18, 23).
The role of pharmacists to detect errors and interactions is well known (50b). One study
showed that 1.6 % of all prescriptions contained errors which were detected by pharmacists.
Of these 0.2 % were life threatening (11). Dispensing errors by pharmacy staff have also been
surveyed. Based on a 12 day peer-review, errors were detected in 12.4 % of the prescriptions
with 1.5% being serious. Drug interactions in other studies were 9.5-22 % (11). It has been
argued that pharmacist dispensing only increases the risk of introducing more errors.
However, in view of detecting systematic repeated errors, safety increases if two qualified
persons are involved in providing drugs to the patient compared to only one (double check).
A study compared 905 admissions from dispensing doctors with 3449 admissions from
community pharmacists by assessing drug problems in the elderly admitted to hospital. This
study however found no significant difference with regard to adverse events (8.4 versus
9.4%), non-compliance (1.8 v 1.3%) and miscompliance for three selected drugs. The authors
question the sensitivity of the design in the study (67).
Compliance was not evaluated in the specific studies related to dispensing by doctors.
However, it was argued that doctors, in comparison to pharmacists, are better at administering
eye/ear drops and giving children medicines. The importance of giving an initial dose of
treatment and medicine similar to the last received was also highlighted in order to improve
compliance (12,15, 38). Furthermore, it is argued that dispensing doctors can ensure better
compliance, compared to pharmacists, when refilling prescriptions (11,12,59). Other authors
argue that compliance can be better ensured by having the medicines dispensed by
pharmacists, where doctors and pharmacist work as a team (11).
Dispensing and storage
No state in the USA allows a licensed pharmacist to delegate the dispensing function to a nonpharmacist, unless the pharmacist personally supervises the activity. However many laws are
ambiguous regarding physicians' authority to delegate dispensing (11). To improve dispensing
by dispensing doctors or their assistants, training courses were implemented (40).
Based on inspections carried out in South Africa, it was found that in 52% of dispensing
doctors' practices, medicines were dispensed by inappropriately trained persons, e.g.
receptionists (65). Drug dispensing at pharmacies in Zimbabwe was carried out by pharmacy
personnel with only in-service training in dispensing (80).
In the same South African evaluation, storage conditions were found to be inappropriate in
39% of dispensing doctors' practices (65). A further survey which included 1103 dispensing
doctors' practices in South Africa found unsatisfactory storage conditions for medicine in 46%
of practices (64). An expiry date monitoring system was only found in 30% of the practices,
and 20% of the medicines were not clearly labeled (64).
Adherence to good dispensing practices by dispensing doctors was evaluated. Following an
inspection of dispensing doctors' practices in South Africa, 33% were found to count tablets
and capsules by hand, 61% did not have suitable containers for dispensing and 27% of
practices did not label the dispensed medicine(s) appropriately. The labels did not state expiry
date, batch number or name of dispenser (65). Batch numbers for the recall of medicines were
not recorded in 61% of practices. In a 1995 study on labeling undertaken by 31 pharmacies in
Zimbabwe, labeling was found to be correct in 86% of the cases. The lowest scores were for
including the doctor's name on the label (79% correct) and for including the manufacturers
name (19% correct) (80).
The South African survey also found that patients were given antibiotic powder which they
were expected to make up at home (65).
The South African study concluded that patient information was unsatisfactory. Patients were
not sufficiently informed on how to use medicines, on cheaper generic alternatives or about
the unwanted effects of the medicines, what the medicine is expected to do, etc. (65).
Information related to the diagnosis was evaluated in the study from Pakistan. Non-dispensing
doctors were found to communicate the diagnosis in 37 % versus 11% for dispensing doctors
(63).
Health economics factors
In a study comparing costs per patient in UK using data from the Prescription Pricing
Authority, the annual net ingredient cost per patient was found to be 10.3 - 13% higher for
dispensing doctors compared to non-dispensing doctors, i.e. GBP 48.47 for non-dispensing
doctors compared to GBP 54.78 for dispensing doctors (37, 28). Annual net ingredient cost
per item was found to be slightly lower per dispensing doctor patient: 5.74 versus 5.83 (28).
To analyze these differences further, 10 indicator drugs were used for comparison purposes,
and it was found that dispensing doctors prescribed significantly lower quantities (28). It was
discussed whether 10 indicator drugs are enough to draw these conclusions (26). Other UK
figures indicate that dispensing doctors issue 12.9% more prescriptions than non-dispensing
doctors (37).
Similar findings on costs can be found in studies from the USA and South Africa. A study by
the Pharmaceutical Assistance Contact for the Elderly found that the average prescription cost
paid to physicians was more than one US$ higher then that paid when dispensed from a
pharmacy (11). The South African study found that the average cost per script for dispensing
doctors to be 120.35 Rand compared to 140.26 Rand for non-dispensing doctors which makes
a difference of 3-4 US$ (65b).
A UK study evaluated the effect of fundholding in 3 dispensing doctors' practices compared
to 5 non-dispensing doctors' practices. All practices were fundholders in the study period from
1990 to 1994. Dispensing doctors were initially found to spend GBP 15.51 per unit (
prescription) versus GBP 15.23 for non-dispensing doctors. By 1994 this increased to GBP
20.48 for dispensing doctors compared to GBP 21.34 for non-dispensing doctors. This
development was explained by dispensing doctors being better informed on prescribing costs.
Moreover, it could be seen that the savings achieved from fundholding was much smaller than
the increase in drug prices, which took place in the study period (18). Also in this study the
sample size is very low. Another study on the annual cost of items dispensed by doctors and
pharmacists from 1985 to 1991 found a savings in the UK of 23 pence per item when
dispensed by dispensing doctors (33). Discussions on this study argue that greater savings
would have been found in pharmacies had other factors been included, e.g. discounts,
remuneration and fees for containers (32 a, 32b).
The cost of prepackaged drugs, in some studies, was found to be higher than pharmacy retail
prices. A USA study conducted by the National Association of Chain Drug Stores comparing
prices of 50 prescription drugs between the chain drug stores and dispensing doctors, showed
that dispensing doctors' prices were on average 13.2% higher (11). Another study compared
20 prescription drugs of given dosage and quantity sold by prepackagers and retail
pharmacies. It found in 30% of pharmacy retail prices were lower than the prepackers' prices
to the dispensing doctors. When comparing estimated drug costs to be paid by the patient, it
was evaluated that 80% of the time, dispensing doctors' prices would be higher than pharmacy
prices (59). The American Pharmaceutical Association hired a consulting firm to conduct an
economic and policy analysis including a study involving 7600 prescriptions. The use of
drugs and costs were compared for physicians with and without ownership interests in
repackaging firms. Patients of dispensing doctors with ownership were found to pay 1/3 more
for their medication (mean daily medication cost). Prescriptions per patient were higher and
own brands were more prescribed. Penicillin was prescribed 8 times more frequently for the
owner group. The two groups were compared before ownership and no significant differences
in prescribing behavior could be discerned (59).
Other studies have found dispensing doctors' prices to be lower. A study by the National
Association for Ambulatory Care found that the centers charged on average US$ 4.00 per
prescription compared to the pharmacy charge of US$ 13.00 (11). Newsweek conducted a
survey on the cost of ampicillin and found it to be obtainable from dispensing doctors for US$
5, whereas the pharmacy price was from US$ 11.30 to US$ 14.05 (12).
In countries where big scale procurement is practiced by chain pharmacies, one would expect
pharmacies to be able to obtain more favorable prices, when compared to dispensing doctors,
as they can benefit from mass purchasing power. In other countries where competition among
pharmacies is intense and patients can shop around one can also expect low pharmacy prices.
Other countries have pricing policies and drug prices are controlled, fixed and regulated based
on accounts from pharmacies or other parameters.
A study from USA comparing 13 dispensing doctors and 38 doctors with intent to dispense
with 310 non-dispensing doctors found that doctors positive to dispensing had a lower annual
income compared to non-dispensing doctors, 35% versus 20%, earning less than US$ 70,000
per year (30). Figures from UK find that dispensing doctors have a 25.2 % higher annual
income compared to non-dispensing doctors (37). Prepacker companies advertise that by
dispensing 10 prescriptions a day, dispensing doctors can increase their annual income by US
$20,000-61,000 (11,14).
The number of prepackaging companies increased from 1987 to 1989 from 3 to 23 (11),
indicating an increase in requests for prepackaged drugs and in dispensing practice by doctors
in the USA. A Newsweek article estimated dispensing by doctors to account for 0.1% of the
total prescribed amount of about US$ 20 billion (11). Furthermore, some authors would argue
that the use of prepackaged drugs in safety-sealed containers, packed under GMP, are much
safer than drugs taken from larger containers and packed by pharmacists (12).
Cost in relation to society was evaluated in South Africa. The average number of visits for
dispensing doctors' patients was found to be 35% higher than for non-dispensing doctors. The
additional number of visits for medical aid patients has been estimated at 112 million
annually. Moreover, an additional 72 million items have been prescribed (65b). Dispensing
doctors in the UK prescribed 15% more drugs annually than non-dispensing doctors (28).
A deduction scale exists in the UK whereby 9% of the drug bill is returned from the
pharmacies to the government. This has been compared with 6% recovery from dispensing
doctors. However, the author points out that it must be considered that dispensing doctors
negotiate better and obtain lower prices from companies due to the fact they prescribe the
medicines (37).
All drugs prescribed must, however, be available at all times, and any system must ensure this
overall aim. Moreover the drugs must be affordable. Any system which allows dispensing
doctors to practice must ensure the availability of the high selling drugs as well as low turn
over, low profit drugs at an affordable cost.
A pharmacy, in order to be viable and make up the lost revenue from the doctor-dispensed
drugs, must charge higher prices on the other drugs it dispenses. This might result in an
overall increase in drug costs to the consumer (15). A pharmacy that has lost profits from high
turn over drugs will have difficulties in staying viable, leading to reduced accessibility.
The increase in dispensing by doctors in the UK has been accompanied by an increase in the
number of over-the-counter drugs. This may be a way whereby pharmacies can increase their
profit and still be viable in spite of their loss related to increased dispensing by doctors. The
benefits of this development have still to be evaluated (74).
Conclusion
Based on the reviewed literature, it can be concluded that actual studies comparing the
practices of dispensing doctors and non-dispensing doctors is very limited. Studies comparing
dispensing practices of doctors compared to pharmacists is also very limited and often related
to emotions, beliefs and personal opinions. The large number of questions raised by various
authors which remain unanswered indicates the importance of this subject.
Based on the study findings some conclusions can be drawn. However these findings need to
be reevaluated in view of the method applied, e.g. the low number of dispensing doctors
included for comparison, or national differences or development of the country. The findings
are all closely linked to the laws regulating dispensing by doctors. This must be considered in
evaluating the results. Furthermore, most of the studies and discussion have taken place in
English speaking countries, especially the UK and the USA, and in developing counties such
as South Africa and Pakistan.
Comparing non-dispensing doctors to dispensing doctors or their practices, in view of these
reservations, the following can be concluded.
1. Background factors:
dispensing doctors' patients are normally older, with a higher proportion of them being over
65 years old;
dispensing doctors have less years in practice;
dispensing doctors have a less positive attitude to pharmacists;
when the law allows dispensing by doctors in relation to rurality, more dispensing doctors will
be situated in rural areas compared to non-dispensing doctors; if the laws do not relate
dispensing doctors to rurality, this difference could not be found;
consultation time was found to be 1/3 for dispensing doctors in comparison to non-dispensing
doctors. Also history taking was found to be less elaborate for dispensing doctors. Only 11%
of dispensing doctors provided information to patients on their diagnosis, compared to 37%
for non-dispensing doctors. In this study the dispensing doctors were paid through the sale of
drugs, whereas non-dispensing doctors were pediatricians who were paid a consultation fee.
2. Rational drug use:
the number of drugs prescribed per patient annually and per encounter were found to be
higher for dispensing doctors in two studies and the same in another;
use of injections by dispensing doctors per encounter was found to be higher for dispensing
doctors than for non-dispensing pediatricians;
dispensing doctors were found to prescribe more antibacterials, anti-diarrhoeals, and home
made mixtures of unknown composition than ND-pediatricians;
fewer dispensing doctors prescribe ORS compared to non-dispensing pediatricians;
generic prescribing in two studies was found to be lower for dispensing doctors; in spite of
financial incentives (fundholding) it did not reach the level of non-dispensing doctors;
in two studies, the average number of visits per patient per year was found to be higher for
dispensing doctors' patients, who were also issued 13% more prescriptions.
3. Economics:
annual cost per patient from dispensing doctors practices was, in several studies, found to be
higher (10 -13%) than for non-dispensing doctors;
dispensing doctors were found to prescribe lower quantities per encounter;
dispensing doctors may be better informed on drug prices than non-dispensing doctors;
one study found dispensing doctors to have a lower income than non-dispensing doctors and
another found dispensing doctors to have a higher income.
On evaluating good pharmacy practices by dispensing doctors and comparing their practices
with those of pharmacies, the following conclusions can be drawn, taking into consideration
the above mentioned reservations:
4. Interactions and compliance:
no significant differences were found between patients admitted to hospital by dispensing
doctors and by pharmacies in regard to adverse events, non-compliance and mis-compliance,
evaluating about 4500 admissions.
5. Dispensing and storage based on Ministry of Health inspections in South Africa:
52% of dispensing doctors practices dispensed medicines by inappropriately trained persons;
33% of dispensing doctors practices counted tablets by hand;
61% of dispensing doctors practices had unsuitable containers;
labeling was unsatisfactory in 27% of the dispensing doctors practices;
storage conditions were inappropriate in 46% of the dispensing doctors practices, with
unsatisfactory cool storage facilities in 39%, no expiry monitoring system in 30% and
medicines not clearly labeled in 20%.
6. Economic factors:
refunds for average prescription costs were found to be higher for dispensing doctors than for
pharmacies;
comparisons of drug sales or procurement prices for prepackagers and pharmacies, in most
studies, found that dispensing doctors' prices were more expensive for the majority of the
drugs evaluated than those sold by pharmacies.
Recommendations
Based on this review it is not possible to recommend one best solution for dispensing drugs
whereby the aims of a national drug policy can be ensured. Accessibility is important for
many patients in our often very busy society, but whether this should best be achieved by
having drugs dispensed by the prescribing doctor or by satellite pharmacies is not clear.
However it can be concluded that:
a. to safeguard the patient, dispensing must be regulated and the regulation implemented;
b. much more knowledge about the benefits and costs of various solutions must be addressed,
if appropriate policies and laws are to be found;
c. researchers should be urged to increase study on dispensing from the perspective of society
and how the aims of availability, accessibility, affordability, safety and rational drug use can
best be ensured.
Development
The number of dispensing doctors has recently been seen to increase in several countries.
In the UK about 12.5% of general practitioners dispensed drugs in 1966/67. This increased
slightly to 14 % in 1989-90 and to 15% in 1993. Dispensing doctors account for about 7% of
all primary care prescriptions.
In the USA about 40% of all physicians dispensed in 1923, which decreased to 25% in 1947;
8.7-10% in 1967; and about 5%-8.5% in 1990-91.
Other US authors believe that the number of dispensing doctors will continue to increase
mainly because of the increase in factories producing prepacked drugs. Other reasons given
are to benefit patients and society, and because dispensing offers the possibility to increase
physicians' declining income (due to a decrease in patient load).
In South Africa the number of retail pharmacies have remained almost constant from 1985 to
1995, whereas the number of registered dispensing doctors has doubled from about 4000 to
almost 9000 in the same 10 years.
Quality of Care
The heated debate on the practice of dispensing doctors is being waged over a complex
variety of ethical, economic, public- health and patient care issues:
conflict of interest
information
price control
freedom of choice
rational drug use
convenience
ethics
$
Actual studies on dispensing doctors are very limited and much of the available information is
anecdotal. Only a few of the studies have been repeated and several of the findings are based
on very small sample sizes.
Factors influencing prescribing of dispensing doctors
Various factors have been found to influence the prescribing process and determine its
rationale, which include:
education, diagnostic and therapeutic skills
pharmacological knowledge
advice from colleges
habits of the "copied prescribers"
use of formularies or standard treatment guidelines
years of practice/ education
personal clinical experience
demands by patients
prescribers personalities
marketing activities from the drug industry
consultation time
importance of maintaining patient load
quality assurance
control and regulatory measures
information and knowledge on drug costs.
It is difficult to distinguish between the effects of individual factors, and little information is
available on their actual effects.
Only very few studies have evaluated dispensing practice carried out by doctors in relation to
these factors.
Summary of rational drug use findings:
These findings indicate that dispensing doctors tend to prescribe irrationally with a inclination
towards polypharmacy, overuse of injections and brand name drugs, irrational choice of drugs
and poorer quality of service.
Findings - Dispensing and storage
Many laws are ambiguous regarding a dispensing doctor's authority to delegate dispensing.
Delegation by pharmacists is generally regulated, whereby pharmacists must personally
supervise the activity.
Dispensing Doctors
Dispensing
52% use inappropriately trained dispensers
20% of the medicines were not clearly labelled
patient information was unsatisfactory in general
11% of patients have had communication about their condition
33 % counted tablets by hand
61% did not have suitable containers
Storage
46% with unsatisfactory storage conditions
70% with no expiry date monitoring system
Health economic factors
When calculating costs in relation to dispensing by doctors, no model for comparison or
evaluation of affordability exists.
Procurement cost, sale cost, patient cost (with or without fees, subsidies, taxes etc), net costs,
health insurance schemes costs, or cost for the society applied annually or per encounter, have
all been applied in evaluating dispensing by doctors.
Findings confirmed in more than one study are:
Annual cost per patient 10-13% higher for dispensing doctors (SA,UK)
Dispensing doctors prescribe lower quantities per encounter and cost is found 5-17% less for
dispensing doctors (UK, SA)
Patients of dispensing doctors have, per year, 35% more visits and are prescribed 13 % more
prescriptions (SA,UK).