Doctors won’t prescribe generics

Patients are less likely to fill prescriptions when their doctors specify that generics can't be substituted for brand name drugs, according to a new study.

Along with leaving patients untreated, that practice could be costing the health system almost $8 billion (about R54 billion) a year, the researchers say in their paper, published in the American Journal of Medicine.

Despite evidence that generic drugs work just as well and are just as safe as brand name drugs, "there's a small population of doctors that still express concern about generics," said Dr William Shrank, the lead author of the study from Harvard Medical School in Boston.

He added, "it's really hard for either patients or doctors to anticipate the cost of the medication when the patient goes to the pharmacy."

The study

In the study, Dr Shrank and his colleagues analyzed all prescriptions that were filled by CVS Caremark at CVS stores and its online site over the course of 1 month. In total, there were 5.6 million prescriptions filled by 2 million patients. CVS Caremark funded the study. They also analyzed rates of "reversals" –that is, how many prescriptions were ordered and then cancelled after patients changed their minds.

Almost 3% of prescriptions were labelled "dispense as written" by doctors, and another 2% were marked by patients who wanted brand name drugs.

But even when patients were the ones who had requested a brand name drug, they were less likely to fill the prescription when they couldn't substitute generics.

When there was no "dispense as written" label on a new prescription for a chronic condition, about 8% were "reversed." That compared to close to 12% when patients said they didn't want a generic, and 16% when doctors ruled out the generic.

Older patients and older doctors were both more likely to require that a prescription be filled with brand name drugs. In addition, specialists were 78% more likely than generalists to indicate "dispense as written."

No more “dispense as written”

When the authors scaled the results to the 3.6 billion prescriptions that are filled annually in the US, they estimated that patients could save $1.2 billion (about R8.16 billion) if doctors did away with "dispense as written" –and the health system could save $7.7 billion (about R52.3 billion).

They said prescriptions for thyroid medications, anticoagulants, and anticonvulsants were far more likely to be accompanied by a dispense as written requests. "There has been substantial debate in the scientific literature as to the equivalency of these products; although the literature may not corroborate these clinical concerns, it is likely that patients and physicians have a clinical rationale for these requests," the authors wrote.

On the other hand, they were surprised at the high rates of dispense as written requests for hypnotics, ulcer agents, and migraine drugs –which they suspect might be due to "effective marketing campaigns to patients and physicians."

The findings

In general, the findings show "it's important that physicians think very carefully about whether or not the patient needs that particular brand of medication," Dr Alex Federman, of the Mount Sinai School of Medicine in New York City, said.

"And, they've got to keep working that message about generics as being a perfectly cost-effective substitute for brand name medications," said Dr Federman, who has studied how people use generics but was not involved in the current report.

Dr Shrank said that while some doctors and patients may like the idea of prescribing and taking brand name drugs, patients might not realize how much extra those drugs will cost them. He and his colleagues found that patients in the study paid an average of about $18 (about R122) for a generic prescription and $44.50 (about R302) for brand name drugs that had a generic alternative.

Knowing that beforehand might help both doctors and patients make more educated decisions, Dr Shrank said.

"There has to be more open discussion between doctors and patients about medication costs (because) cost ends up being an important barrier for many patients," he said.

(Reuters Health, March 2011)

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