IMPROVING ECONOMIC PRESCRIBING

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• IMPROVING ECONOMIC PRESCRIBING
• IN A TEACHING HOSPITAL
• THROUGH AN EDUCATIONAL STRATEGY TO PROMOTE
  GENERIC PRESCRIBING
• Premjit Suttipoom
• Wimon Anansakunwatt
• Thienchai Ngamthipwatthana Anita Wagner
• Dennis Ross-Degnan

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Background

• Siriraj Hospital Mahidol University
• 4,426 outpatients per day
• 2,324 beds in 172 wards
• 786 physicians
• 2500 items of hospital formulary
• Hospital formulary
• Brand or original medications ( Brands )
• Brand only
• Brand with generic substitute
• Multi-source lower-priced pharmaceutical
  equivalent medications ( Generics )
• Generic only
• Generic with brand substitute

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Factors influence prescribing patterns

• Believe that Brands are more effective
• Prescribe Brands for a long time
• Learn from senior prescribers
• Lack of information about price and quality
• of Brands and Generics
• Prescribe Brands if patients can pay or can
• reimburse
• Hospital policy not authorize pharmacist to
• substitute Brands with Generics

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Estimation

• Generics prescribing of only 6 popular expensive
  brands could save 35 million Bahts ( 875,000 USD
  )
• ( 5 of pharmaceutical expenditure )
• ( Wimon et al 1997 )

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Objective

• To assess
• the impact on generic prescribing and drug cost
• of a multi-method educational intervention
• for physicians by hospital pharmacist
• about medication quality and cost

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Study Questions

• Will an educational intervention
• lead to increase in generic prescribing ?
• transfer the effect to another drug class ?

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Interventions

• A multi-method educational intervention
• Group discussion (with opinion leaders )
• Providing drug price information
• Providing quality assurance information of
  generic substitution products using printed
  materials
• posters , pocket cards and booklets

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Interventions

• Targeted only antibiotic prescribing
• Antihistamine prescribing was studied to assess
  learning effect
• ( comparison series)

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Duration

• 9 months before, 4 months during and
• 6 months after intervention
• (December 1999 June 2001)

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Study Population

• Staff physicians and residents from
• Ear-Nose-Throat (ENT) Department
• 21 staff
• 17 residents
• 2 fellowship trainees

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A multi-method educational intervention
Academic Detailing
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A multi-method educational intervention
Face to Face Communication
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A multi-method educational intervention
Pocket Cards
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A multi-method educational intervention
Booklets inform price of antibiotics
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A multi-method educational intervention
Invitation letters for group discussion
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A multi-method educational intervention
Poster inform about drug quality
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A multi-method educational intervention
Group Discussion
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Methods

• Design
• Interrupted time series of prescribing patterns
  and drug costs
• Sampling 50 of antibiotic and antihistamine
  prescriptions per month
• Outcome Measures
• Generic prescribing of antibiotic and
  antihistamine
• Brand prescribing of antibiotic and
  antihistamine
• Cost of antibiotic and antihistamine per
  prescription

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Results

• Effects of the intervention on
• Generic prescribing of
• All antibiotics
• Top 3 antibiotics
• Prescriber status
• Generic prescribing of
• All antihistamines
• (Learning Effect)
• Cost

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Results

• For all antibiotics Generic prescribing did not
  increase significantly

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Results

• Amoxycillin
• Generic prescribing did not increase significantly

Generic unit price 3.00 Bahts Brand unit
price 6.50 Bahts
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Results

• Co-amoxiclav
• Generic prescribing increased from 52.09 to
  64.20
• (p 0.048)

Generic unit price 19.80 Bahts Brand unit
price 33.50 Bahts
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Results

• RoxithromycinGeneric prescribing increased from
  19.4 to 37.7 (p 0.00004)

Generic unit price 5.00 BahtsBrand unit
price 14.00 Bahts
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Market Share and Price of Top 3 Antibiotic
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Results

• Effects on prescriber status
• For Staff physicians
• Generic prescribing did not increase significantly

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Result

• Effects on prescriber status
• For Non-Staff physicians
• Generic prescribing did not increase significantly

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Results

• Effects on prescriber status
• For Staff physicians
• Roxithromycin generic prescribing increased
  significantly (p 0.0005)

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Results

• Effects on prescriber status
• For Residents (Non staff)
• Roxithromycin generic prescribing did not
  increase significantly

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Learning Effect

• For all antihistamine
• Generic prescribing increased significantly
• (p 0.00)

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Learning Effect (con)

• Cetirizine
• Generic prescribing increased from 17.4 to 66.5
  (p 0.00000008)

Generic unit price 1.00 BahtsBrand unit
price 9.00 Bahts
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Market Share and Price of Top 3 Antihistamine
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Effects on Cost

• Drug cost per prescription
• decreased 4.5 Bahts per month
• Total cost saving of 676,440.72 Bahts
• (16,911 USD) per year

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Conclusion

• A multi-method educational intervention
• can improve economic prescribing of high price
  difference antibiotics
• but not in all targeted antibiotics
• The information of generic prescribing can be
  transferred to a non-targeted drug class

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Implementations

• Hospital policy change Since October 2001
  prescriptions of Brands have been automatically
  substituted with Generics if prescribers do not
  emphasize Brands by the symbol

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Implementations

• Pharmacists role increase
• for rational drug use- educational intervention
  by
• newsletter (Siriraj Pharmletter)
• drug information center in the hospital -
  encourage the pharmaceutical and therapeutic
  committee to bring more generic drugs into
  hospital formulary or select only 1 brand for 1
  chemical

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Acknowledgement

• International Network for Rational Use of Drugs
• Department of Essential Drugs and Medicine
  Policy, WHO
• Center for International Health, Boston
  University School of Public Health
• Department of Ambulatory Care Prevention,
  Harvard Medical School
• RPM Plus and SEAM Programs, Management Sciences
  for Health
• Thai Network for Rational Use of Drugs
• U.S. Agency for International Development
• Dr. Dennis Ross-Degnan
• Dr. Anita Wagner
• Dr. Sauwakon Ratanawijitrasin

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Thank you