IMPROVING ECONOMIC PRESCRIBING IN A TEACHING HOSPITAL THROUGH AN EDUCATIONAL STRATEGY TO PROMOTE GENERIC PRESCRIBING

Improving Economic Prescribing in a Teaching Hospital through an Educational Strategy to Promote Generic Prescribing Suttipoom P*, Anansakunwatt W*, Ngamthipwatthana T*, Wagner A**, Ross-Degnan D** * Siriraj Hospital, Mahidol University, Thailand; ** Harvard Medical School, Boston, USA Problem Statement: Medication costs are escalating when precious resources could be saved through more widespread use of lower-cost generic products rather than more expensive brand name medications. Objective: To assess the impact on generic prescribing and drug costs of a multi-method educational intervention for physicians by hospital pharmacists about medication quality and costs. Design: Interrupted time series with comparison series of prescribing patterns and drug costs. Fifty percent of antibiotic and antihistamine (comparison series) prescriptions per month were systematically sampled during 9 months before, 4 months during, and 6 months after the intervention (December 1999 – June 2001). Segmented linear regression, adjusting for autocorrelation, was used to analyze the data. Setting: Ear-Nose-and-Throat (ENT) department of a tertiary care teaching hospital with more than 4,000 outpatient visits per day. Study Population: All staff physicians(n=23)and residents(n=27) from the ENT department. Intervention: A multi-method educational intervention. Physicians discussed issues of generic prescribing in peer group meetings with a local opinion leader. They received feedback about their own prescribing patterns, and printed materials comparing generic and brand product prices and quality in the form of posters, pocket cards, booklets, and stickers. Interventions targeted only antibiotic prescribing. Antihistamine prescribing was studied to assess whether physicians transferred information about generic prescribing to another drug class. Outcome Measures: Percent of antibiotics and antihistamines prescribed as generics; cost of antibiotics per prescription. Results: Generic antibiotic prescribing for the whole ENT group did not statistically change after the intervention. But generic prescribing of the frequently prescribed antibiotics, roxithromycin, increased from 19.4% to 37.7% (p= ) and co-amoxiclav increased from 52.09% to 64.20% (p=0.048). Overall, drug costs decreased by 4.5 Bahts per prescription per month, for a total cost saving of 676, Bahts (16,911 USD) per year. Generic antihistamine prescribing also increased, from 17.4% to 66.5% (p= ) for the most frequently used antihistamine, cetirizine. Conclusions: A multi-method educational intervention did not result in increasing of generic prescribing of all targeted antibiotics but only roxithromycin and co-amoxiclav. The information of generic prescribing was transferred to a non-targeted drug class. Generic prescribing and dispensing should be encouraged through educational and other interventions Study Funding: United States Agency for International Development (USAID)

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

Background (con.) 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 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 )

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

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 Duration –9 months before, 4 months during and 6 months after intervention (December 1999 – June 2001) Study Population –Staff physicians and residents from Ear-Nose- Throat (ENT) Department

Interventions A multi-method educational intervention –Questionnaires –Providing drug price information –Providing information of quality assurance of generic substitution products using printed materials : posters, pocket cards and booklets –Group discussion (with opinion leaders )  Intervention targeted only antibiotic prescribing  Antihistamine prescribing was studied to assess learning effect ( comparison series)

Results Effects on prescribing pattern For all antibiotics : Generic prescribing did not increase significantly

Results Effects on prescribing pattern (con) For Roxithromycin : Generic prescribing increased from 19.4% to 37.7% (p = ) Generic unit price = 5 Bahts Brand unit price = 14 Bahts

Results Effects on prescriber status For Staff physicians : Roxithromycin generic prescribing increased significantly (p = ) For Residents (Non staff) : Roxithromycin generic prescribing did not increase significantly

Results Learning effect For all antihistamine : Generic prescribing increased significantly (p = 0.00)

Results Learning effect (con) For Cetirizine : Generic prescribing increased from 17.4% to 66.5% (p = ) Generic unit price = 1 Bahts Brand unit price = 9 Bahts Effects on cost Drug cost per prescription per month decreased 4.5 Bahts, total cost saving of 676, Bahts (16,911 USD) per year

Conclusion A multi-method educational intervention can not increase in generic prescribing of all targeted antibiotics except roxithromycin and co-amoxiclav. The information of generic prescribing can be transferred to a non-targeted drug class, antihistamines. Implementations 1.Hospital policy change Since October 2001 prescriptions of Brands have been automatically substituted with Generics if prescribers do not emphasize Brands by the symbol ® 2.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