Attitudes of Slovene General Practitioners Towards Prescribing Generic Drugs
Attitudes of Slovene General Practitioners Towards Prescribing Generic Drugs
Prescribing Generic Drugs
Associated Professor Janko Kersnik, MD, PhD, MSc
Medical Faculty, Department of Family Medicine
University of Ljubljana
Poljanski nasip 58
1000 Ljubljana, Slovenia
Jure Peklar, Mr Pharm
National Insurance Institute
Miklosiceva 24
1000 Ljubljana, Slovenia
Corresponding author:
Janko Kersnik
Koroska 13
SI-4280 Kranjska Gora, Slovenia
Phone: +386 4 58 84 601
Fax: +386 4 58 84 610
e-mail: janko.kersnik@s5.net
Word count – abstract: 299
Word count – text: 2.409
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Prescribing Generic Drugs
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Attitudes of Slovene General Practitioners Towards Prescribing Generic Drugs
Background
There is a steady 7.4% yearly increase in prescribing costs in Slovenia and contributed to 17% of the total
national health care budget. Substitution to generic products can offer savings. General practitioners (GPs) are
usually concerned with the quality of generic products on the market and possible legal liabilities associated with
their use.
Objective
We wanted to examine the attitudes towards generic prescribing among GPs in Slovenia.
Methods
We conducted a postal survey of a random sample of 200 out of 800 GPs in Slovenia in April 2002 from the
National insurance institute database. We asked them 21 questions regarding their knowledge on generic drugs,
awareness of prescribing costs, relative price of generic drugs in face of brand name drugs and attitude towards
use of generic drugs.
Results
We received 117 (58.5%) questionnaires which represents 15% of the whole GPs in Slovenia. For 66.1% of GPs
rising costs presented a serious problem for the health care budget. Over 50% of GPs experienced demands from
patients for specific drugs on a weekly basis, majority of GPs usually followed patient demands or the advice
from hospital consultants. 38.3% of GPs did not take price in the consideration when prescribing drugs. The
majority of GPs (88.9%) perceived the generics as drugs with the same effectiveness. One quarter of GP would
prescribe more generics in the case of additional clinical trials, 37.3% would follow academic detailing and
30.3% expect the generics should be even cheaper than they are at the present. Independent detailing is highly
desired as 63.8% GPs stated, that pharma industries have big influence on the prescribing habits and additional
15.5% stated tremendous impact on the prescribing patterns.
Conclusion
Slovene GPs are aware of the prescribing costs. They are willing to accept independent academic detailing
support to improve prescribing patterns.
Key words: pharmaceutical economics, drug costs, cost control, family practice, primary care, Eastern Europe
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Background
Health care expenditures for the drugs are rising in all health care systems in the world. There is a steady 7.4%
yearly increase in prescribing costs in Slovenia, too (1). In 2001 the National insurance institute, which is
responsible for basic mandatory health care coverage, paid 23.248 sit, i.e. 103 euro on average for each citizen
for the drugs. These costs contributed to 17% of the total national health care budget.
Different factors contribute to increases in per capita prescription drug costs. Morgan found that changes in drug
prices, the pattern of patient exposure to drugs across therapeutic categories, and the mix of drugs used within
therapeutic categories all caused spending per capita to increase (2, 3). Only a small part of variation in the costs
can be explained by observable characteristics of individual patients (4). It is generally believed that heavy
marketing pressure of pharmaceutical industry leads to an increase in prescribing (5). Another important factor
that appears to lead to an increase in market share is being the first drug introduced into the defined market (6).
Brand name drugs appear first. They are first drugs used and their names leave an important subconscious trace
in the memory of the prescribing doctors, who connect the effectiveness of the substance, which they experience
during the first trials and the brand name of the particular substance. By the omission of the generic name from
their every day decision processes they are reluctant to use the same generic compound offered to them by other
manufacturers under different trade names.
Physicians are thus an important agent in determining whether patients receive either brand name or generic
drugs (4). Other authors found that only 16.5% of variation in prescribing costs between individual doctors can
be explained by the family doctor demographic characteristics, leaving majority of the prescribing costs variation
unexplained (7).
Many health insurance providers have changed benefits packages to encourage use of fewer or less expensive
drugs. Adding an additional level of co-payment, increasing existing co-payments or coinsurance rates, and
requiring mandatory generic substitution all reduced plan payments and overall drug spending (8). By
encouraging the use of generic drug products and/or cost-effective brand name products within therapeutic
categories we can slow down the increase in drug costs (2). Similar effects can be achieved by allowing generic
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substitution at the pharmacist level (9). Usually only health plans benefit from the use of generic substitutes. In
some health care systems sometimes also practices can benefit from savings (5).
Another way to reduce drug costs is to involve prescribing physicians to change their behaviour. Almost all
physicians prescribe both types of drugs to their patients. Some physicians are more likely to prescribe generic
drugs while other physicians are more likely to prescribe brand name drugs (4, 10). Even in the absence of sound
clinical research evidence physicians usually follow marketing pressure from the pharmaceutical industry (5).
The doctors are following the same marketing actions as other people are. Without very strict corporate or
personal policy on this issue, the doctors will prescribe drugs with huge variation.
Few interventions have successfully encouraged physicians to alter prescribing patterns (3, 11). Generic
prescribing in the most frequently monitored prescribing indicator in primary care groups in Great Britain (12).
Fundholding as one of the organisational attempts did not exercise any considerable cut down in prescribing
costs (5). Multifaceted intervention including pharmaceutical adviser, practice comparison feedback, and peer
review meetings showed lower increases in costs and higher increases in percentage of generic items with no
deterioration of quality indicators (13). Individual contact of trustful out reach personal with prescribers as
modelled on the successful activities of drug company representatives has potential to influence prescribing (14).
The most popular way to diminish expenditures is use of various contracting techniques to standardise generic
drugs in their schemes (15). Health plans cut their costs also by policies that incorporate evidence-based
formulary algorithms which can result in substantial cost savings (15). Some health plans encourage physicians
to prescribe generic drugs by paying them financial incentives to increase generic prescribing (16). Such type of
interventions is difficult to measure as there might be other influences for the shift in prescribing practices (11).
One of the key issues regarding incentives is sustainability of the effect (11). Peer pressure and adult learning
cycle is another type of improvement prescribing patterns which can be used to reduce costs. Quality circles
increased the proportion of generic drugs and reduced the mean prescription costs per patient (17).
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Objective
GPs are usually concerned with the quality of generic products on the market and possible legal liabilities
associated with their use (10, 18), we wanted to examine the attitudes towards generic prescribing among family
physicians in Slovenia. Knowing the attitudes towards generic prescribing among family physicians will enable
us to draw sound strategies in changing physician practice behaviour (19).
Method
Participants
A random sample of 200 out of 800 practising GPs in Slovenia in April 2002 from the National insurance
institute database was chosen.
Methods
We conducted a postal cross-sectional survey in sample of Slovene GPs in spring 2002. We mailed them
questionnaires alongside with the explanation of the study and with a prepaid envelope for a return mail. We
asked them 21 questions regarding their knowledge on generic drugs, awareness of prescribing costs, relative
price of generic drugs in face of brand name drugs and attitude towards use of generic drugs. We tested the
questions and the time necessary to fill in the questionnaire in a pilot. On average 15 minutes were required to
complete the questionnaire.
Analysis
Data were entered in the Excel sheet and in a statistical programme SPSS 8.0 for Windows. Percentages and
means were calculated. Hi-square or t-test was used for group comparison. Significance level lower than 0.05
was used.
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Prescribing Generic Drugs
Results
We received questionnaires from 117 (58.5%) GPs. This present 15% of the whole GP population in Slovenia.
Mean age of the respondents was 47.5 years (SD = 8.1 years). There were 61 (52.1%) female GPs in the sample.
Female GPs were with 49.1 years (SD = 9.5 years) older than male GPs (45.9 years, SD = 6.2 years; p = 0,038).
The respondents were in 73 (62.4%) cases from rural-urban, 28 (23.9%) from urban and 16 (13.7%) from rural
practices, 86 (73.5) were from non-for-profit institutions and 31 (26.5%) from private contracting institutions. In
92 (78.6%) cases they worked in the same building with other GPs. They worked from 6 to 41 years in the
practice, mean 21.3 (SD = 7.6) years. On average they kept 1876 (SD = 585) patients on the list. Female GPs
kept more patients on the list (mean = 1997 patients, SD = 543 patients), than male GPs (mean = 1762 patients,
SD = 607 patients; p = 0.034). Also private contractors kept longer lists (mean = 2096 patients, SD = 379
patients, vs. mean = 1791 patients, SD = 630 patients; p = 0,003).
Awareness of prescribing costs and different demands for drugs in Slovene GPs is high. 76 out of 115 replies
(66.1 %) of doctors agreed, that rising costs of prescribed drugs presented a serious problem for the health care
budget. Table 1 shows how often the patients have demanded defined drug by a brand name and table 2 shows
how often have doctors followed patients demanded for defined drug.
Table 1. How often have patients demanded defined drug by its brand name in the previous week.
No.
%
Never
20
17.1
Up to 5 times
59
50.4
5 – 10 times
21
17.9
> 10 times
17
14.6
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Table 2. How often have doctors followed patients demanded for the defined drug.
No.
%
2
1.7
Seldom
50
42.7
Usually
46
39.3
Always
3
2.6
Missing
16
13.7
Never
One fifth (25; 21.4%) of the GPs would always follow the advice of a consultant and the majority of them would
follow it very often (90; 76.9%).
GPs’ opinions regarding the source of patients’ information on the drugs is shown in table 3.
Table 3. Where do patients get the information over the drugs?
No.
%
Friends
68
58.1
Consultants
60
51.3
Media
28
23.9
Waiting room
12
10.3
6
5.1
Other GPs
Percentages are not additive, as the patients reported several sources of information.
Not surprisingly GPs would follow academic detailing in shaping their generic drugs prescribing practices
(Table 4).
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Table 4. Under which condition the GPs would prefer prescribing generic drugs to the originals.
No.
%
More academic detailing
71
60.7
If generic drugs cheaper
58
49.6
More clinical trials
46
39.3
Better marketing
17
14.5
Percentages are not additive, as the patients reported several sources of information.
97 (82.9%) were willing to accept an expert drug consultant sent out by the insurance company. As the GPs
expressed low interest in scientific support to their decision to choose a generic drug, it is very important that
they took both types of drugs as the same or with not essential differences (Table 5.)
Table 5. How do you evaluate the difference between brand name drugs and generic drugs?
No.
%
Same medicine with the same compound
61
52.1
Similar drugs, the difference is not essential
55
47.0
Similar drugs with essential differences
0
0
Completely different drugs
1
0.9
Majority of GPs agreed, that both pharm industries exert considerable pressure towards prescribing doctors
(Table 6). GPs from urban areas reported higher pressure of pharm industries (p = 0.29).
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Attitudes of Slovene General Practitioners Towards Prescribing Generic Drugs
Table 6. Experienced pressure of pharm industries to prescribing doctors (116 responses).
No.
%
5
4.3
Small pressure
20
17.2
Considerable pressure
73
62.9
Enormous pressure
18
15.5
No pressure at all
The experience of GPs was, that both industries exert great pressure on them (Table 7), where brand name
companies were found more aggressive. The majority of GPs disbelieved the data provided by the pharm reps
(Table 7). They also believed, that both pharm industries had high profits (Table 7). GPs working in public nonfor-profit health care organisations were more inclined to the opinion, that both industries gained high profits (p
= 0.02).
Table 7. Which pharm industry exerts greater pressure towards prescribing doctors (115 responses), which one
provides unbiased data and which one has higher profits (116 responses).
Pressure towards
Provision of
prescribing doctors
unbiased data
Higher profits
No.
%
No.
%
No.
%
No one
2
1,7
17
14,9
1
0.9
Generic drugs companies
4
3,5
23
20,2
14
12.1
39
33,9
12
10,5
12
10.3
70
60,9
62
54,4
89
76.7
Brand name drugs
companies
Both equally
67 (62.0%) of GPs would consider switching to generic drug if they were up to 25% cheaper as brand name
drugs, another 37 (34.3%), if they were 25 – 35% cheaper and 4 (3.7%), if they were over 35% cheaper. Table 8
shows opinions regarding the extend of help provided to GPs by different stake holders in the health care system.
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Prescribing Generic Drugs
Table 8. Contributions of different stake holders in health care to more cost effective prescribing. Number of
total responses is in brackets.
Ministry of
University (114)
Vocational
Medical
Medical
Centre for
Insurance
Health
training
chamber
association
disease
company
(114)
(114)
(112)
(113)
control
(113)
(114)
No.
Enough
%
No.
%
No.
%
No.
%
No.
%
No.
%
No.
%
7
6.1
10
8.8
19
16.7
10
8.9
16
14.2
7
6.1
36
31.9
15
13.2
20
17.5
7
6.1
31
27.7
37
32.7
22
19.3
4
3.5
92
80.7
84
73.7
88
77.2
71
63.4
60
53.1
85
74.6
73
64.6
Not
enough
Not its
task
Discussion
We achieved a good response rate, which is comparable to other surveys in this field (10) and allows us to
generalise the results to the whole population of GPs in the country. Age, gender, urban-rural, type of practice,
type of employment and number of patients on the list distribution of our sample is comparable to the national
data (1).
Slovene GPs are aware of the prescribing costs. They are willing to switch to cheaper generic drugs in the case
the prices are lower 25 or 35% as compared to brand name drugs. So called social referral system is on the top
on the list of driving forces for patients’ demands for drugs and plays an important role in driving the patterns of
prescribing habits in GPs, who were more or less willing to follow patients’ demands. GPs try to keep patients’
trust and build good relationship with their patients also by accepting patients’ desires for a defined drug.
GPs do not demand high scientific support for changing from brand named drugs to generics. Lower prices can
persuade only half of the GPs. Also different marketing strategies are low on their list. This is in line with the
Bloor and Freemantel, that providing information on its own will not lead to substantial changes in practice and
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that more active strategies should be used (11). On the contrary, academic detailing seems rather important to
them, which is in line with data from research on interventions in this field (13, 14). This is well known in
shaping GPs generic drugs prescribing practices to the research communities and used in pharma companies with
enormous success, but rather neglected in health insurance industry.
As GPs believe that generic drugs are more or less same as brand name drugs this leave an open window of
opportunity to health policy maker to put more emphasis on the use of academic detailing in order to promote
cheaper generic drugs. Prescribers need reassurance regarding legal and quality assurance aspects of generic
prescribing, if the level of generic drug use is to increase (18). We have to take into account of possible impact
of the change in prescribing habits on health outcomes (20).
GPs are aware of the pressure from the pharm industry and are cautious in accepting data from pharm industry’s
sources as they believe in high profits made by the industry. The expectations from GPs regarding several stake
holders are moderate except for Medical association, which is the only one institution regarded in high
percentage as responsible for providing criteria for cost-effective prescribing.
Conclusion
Generic drugs are known to GPs as equivalent substitute to brand name drugs. GPs are willing to use them if
they are substantially cheaper than brand name drugs. Besides lower prices academic detailing from an unbiased
source as medical associations might be an important push in changing prescribing patterns in GPs. This seems
also the only balance to the pressure exercised by pharm industry.
Acknowledgements
We would like to thank all the participating general practitioners. The survey was partly supported by the
research grant from Ministry of science.
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