Special challenges for drug adherence following generic substitution in Pakistani immigrants living in Norway

Use and perception of risk: traditional medicines of Pakistani immigrants in Norway

BACKGROUND

Pakistani immigrants are the largest non-Western ethnic minority group in Norway. Traditional medicines (TM) are extensively used in Pakistan, and studies show that ethnic minorities also use them to recover from illness after migration to the Western world. This study aims to explore Pakistani immigrants' experiences and perceptions of risk regarding the use of TM to treat illnesses.

METHODS

A qualitative study was conducted through in-depth interviews (n = 24) with Pakistani immigrants in Norway from February to March 2023. Participants were recruited through purposive and snowball sampling methods. The data was analyzed using Braun & Clarke's reflexive thematic analysis (RTA) using Nvivo.

RESULTS

RTA revealed three main themes and six sub-themes. The main themes were: (a) House of knowledge, (b) Choosing the best possible approach for health restoration, and (c) Adverse effects of TM used. A total of 96 different TM were identified, including herbs, food items, animal products, minerals, herbal products, and ritual remedies. All participants used TM to restore health in acute and chronic diseases, and many used TM along with conventional medicines. The participants' mothers were the primary source of knowledge about TM, and they passed it on to the next generation. They also frequently used religious knowledge to recover from illness. Although TM is considered safe because of its natural origin, some participants experienced adverse effects of TM, but none of them reported it to the health authorities.

CONCLUSION

The study helps to understand the experiences and perceptions of risk of Pakistani immigrants in Norway regarding traditional practices for treating health complaints. Public health policies to improve the health of these immigrants should consider the importance of TM in their lives. Further research is necessary to explore the safety and toxicity of those TM that are common in Pakistani households in Norway.

Continuities and discontinuities in pharmaceutical treatment and medication use among older chronically ill patients of Turkish descent in Germany: a qualitative structuring content analysis

Background

Polypharmacy occurs frequently among older adults and is associated with an increased risk of falls and medication-related adverse events. In particular, people with a history of migration may receive inappropriate medication due to language barriers or discrimination in healthcare. This study aims to assess the continuities, discontinuities and barriers to drug therapy in older migrants of Turkish descent in Berlin, Germany.

Methods

Eleven problem-centered qualitative interviews with chronically ill older persons of Turkish descent and family caregivers were conducted and analyzed qualitatively by means of structuring content analysis.

Results

The chronically ill participants of Turkish descent predominantly take more than 5 types of medication per day and aim to take them regularly. Discontinuities emerge when medication is forgotten or intentionally omitted due to side effects. Frequent changes in medication and physicians' lack of time are relevant barriers to drug treatment plans. To avoid language barriers and disinterest on the part of professionals, respondents prefer Turkish-speaking physicians.

Living with polypharmacy: a narrative interview study with older Pakistanis in East London

BACKGROUND

Polypharmacy is a growing and major public health issue. It can be burdensome and risky for patients and costly to healthcare systems. Older adults and those from ethnic minority backgrounds are disproportionately affected by polypharmacy. This study focuses on medication practices among Urdu-speaking Pakistani patients, a significant ethnic group in the UK. Most existing research on medication practices within South-Asian communities centres on adherence, leaving the social and moral dimensions of polypharmacy unpacked. Understanding how British Pakistani patients understand and manage polypharmacy in the context of their daily lives is crucial to avoiding harmful polypharmacy.

METHODS

In-depth narrative interviews were conducted with 15 first-generation Pakistani patients using the Biographical Narrative Interview Method. Participants were recruited from GP practices in East London. All participants were prescribed ten or more regular medications (a pragmatic marker of 'higher risk' polypharmacy) and were aged over 50. Interviews were conducted with a bilingual researcher at home and were designed to elicit narratives of patients' experiences of polypharmacy in the context of their biographies and daily lives.

RESULTS

Polypharmacy is enacted through networks of interpersonal and socio-material relationships. The doctor-patient relationship and the family network held particular significance to study participants. In addition, participants described emotional bonds between themselves and their medicines, identifying them as 'forces for good'-substances which allowed them to maintain their health through the intercession of God. Meanings attributed to medicines and enacted through these social, emotional, and spiritual relationships contributed to emerging and sustaining polypharmacy.

CONCLUSIONS

Patients make sense of and manage treatments in culturally specific ways. Developing an understanding of how medication practices in different communities are enacted is important for informing meaningful and effective conversations with patients about their medicines. Our findings contribute to enabling the integration of culturally sensitive approaches to prescribing.

Barriers and facilitators experienced by migrants and refugees when accessing pharmaceutical care: A scoping review

BACKGROUND

Pharmacists in the community are often among the first health professionals encountered by new arrivals. Their accessibility and the longevity of the relationship gives pharmacy staff unique opportunities to work with migrants and refugees to meet their health needs. While the language, cultural and health literacy barriers that cause poorer health outcomes are well documented in medical literature, there is a need to validate the barriers to accessing pharmaceutical care and to identify facilitators for efficient care in the migrant/refugee patient-pharmacy staff interaction.

OBJECTIVE

The purpose of this scoping review was to investigate the barriers and facilitators that migrant and refugee populations experience when accessing pharmaceutical care in host countries.

METHODS

A comprehensive search of Medline, Emcare on Ovid, CINAHL and SCOPUS databases, guided by the PRISMA-ScR statement, was undertaken to identify the original research published in English between 1990 and December 2021. The studies were screened based on inclusion and exclusion criteria.

RESULTS

A total of 52 articles from around the world were included in this review. The studies revealed that the barriers to migrants and refugees accessing pharmaceutical care are well documented and include language, health literacy, unfamiliarity with health systems, and cultural beliefs and practises. Empirical evidence was less robust for facilitators, but suggested strategies included improvement of communication, medication review, community education and relationship building.

CONCLUSIONS

While barriers experienced are known, there is a lack of evidence for facilitators for provision of pharmaceutical care to refugees and migrants and poor uptake of available tools and resources. There is a need for further research to identify facilitators that are effective in improving access to pharmaceutical care and practical for implementation by pharmacies..

Factors facilitating and hindering counselling about generic substitution and a reference price system in community pharmacies - a survey among Finnish dispensers

Background

Pharmacies play the key role in implementing generic substitution (GS) and counselling customers about it. This study aimed to explore dispensers’ perceptions of the factors that facilitate or hinder counselling customers on GS and the reference price system (RPS) in community pharmacies. It also studied dispensers’ opinions about the benefits and problems of these systems and discusses them from the counselling point of view.

Methods

A postal survey was conducted among Finnish community pharmacy dispensers in spring 2018. The research questions were studied through open-ended questions and analyzed both qualitatively and quantitatively. The questions were analyzed first with inductive content analysis by two researchers independently. The responses were encoded and categorized according to the analytical framework, which was inductively developed alongside the analysis. The categorized responses were further analyzed using frequencies and percentages.

Results

The response rate was 50.8% (n = 498). Of the respondents, 75.9% reported factors that facilitated counselling about GS and RPS. The most commonly mentioned factors included customers’ characteristics (36.5%), the information systems used in the pharmacy (28.3%), and the features of interchangeable medicines (21.7%). Of the respondents, 89.0% reported factors that hindered counselling, of which customers’ characteristics (45.8%), the unavailability of medicines and other availability issues (32.5%), the features of interchangeable medicines (22.6%) and time pressure in the pharmacy (22.1%) were the most commonly reported. The benefits of the systems focused on cost savings for customers and society (74.4%). The most commonly reported problems concerned medicine availability (31.9%), changes in medicine prices and in reference price band (28.9%), as well as how GS is time-consuming and increases workload (24.2%).

Conclusions

Finnish dispensers reported more hindering than facilitating factors in GS and RPS counselling. Customers’ characteristics were the most often mentioned in both cases. Customers’ knowledge could be increased by providing information and education. However, developing simpler regulations for GS and RPS, intelligent assisting software, and solutions for secured medicine availability would facilitate implementation of GS. Simplified price counselling would also guarantee the time needed and focus on instructions on the correct and safe use of medicines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08477-2.

A nationwide survey exploring physicians’ and pharmacists’ knowledge, awareness and perceptions regarding generic medicines in China

Background

Generic medicines substitution is an important means to control rapid growth of pharmaceutical expenditures for the healthcare system in China. Acceptance and utilization of generic medicines is highly influenced by healthcare providers’ perceptions. This study aimed to compare the knowledge, awareness and perceptions of generic medicines between physicians and pharmacists in China.

Methods

We used an online, cross-sectional survey across China. The questionnaire explored four sections: demographic characteristics, assessment of the participants’ knowledge and awareness of generic medicines, perceptions of generic medicines and generic substitution practices. Chi-square or Mann–Whitney-U tests were applied to compare differences between physicians and pharmacists. P-values < 0.05 were considered significant.

Results

A total of 1644 physicians and 4187 pharmacists participated. Most physicians (82.8%, n = 1362) and pharmacists (89.8%, n = 3760) correctly identified the definition of generic medicines. A similar percentage of physicians and pharmacists agreed that approved generic medicines are as effective (64.1% vs 68.2%) or safe (63.8% vs 69.1%) as brand-name medicines. Most physicians and pharmacists (67.6% vs 71.0%) supported the policy of generic substitution. In practice, 79.4% (n = 1305) of physicians reported that they had prescribed generic medicines. More than 78% of respondents reported an obvious increase in the number of generic medicines prescribed in their medical institutions. The majority of physicians and pharmacists identified lack of trust regarding efficacy and safety of generic medicines and the difficulty of changing patients’ preference as top challenges in generic substitution.

Conclusions

Both physicians and pharmacists surveyed had adequate knowledge of generic medicines, and hold positive attitude towards generics and generic substitution. Efficacy and safety are key factors related to prescribing or dispensing generic medicines. Various policies and regulations should be taken to encourage successful generic substitution.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08438-9.

Perspectives of patients and consumers on the use of generic medicines

INTRODUCTION Access to medicines constitutes a public health challenge worldwide. Promoting utilization of generic medicines is one of the strategies that has been proposed to optimize pharmaceutical spending and thus allow greater coverage. However, its use is not yet widespread enough. This study seeks to explore the perspectives and acceptability to the use of generic medicines from patients and consumers. METHODS We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a evidence synthesis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS We identified four systematic reviews that together include 47 primary studies, of which one corresponds to a randomized trial. A low rate of patients or consumers has a negative perception regarding generic medicines, including dimensions such as risk, quality, safety, risk of adverse effects, among others.

Comparison of adherence, persistence, and clinical outcome of generic and brand-name statin users: A retrospective cohort study using the Japanese claims database

BACKGROUND

Non-adherence to statin treatment results in an increased risk of cardiovascular events and all-cause mortality. This study compared adherence, persistence, and clinical outcomes of patients who initiated brand-name and generic statins in the Japanese population.

METHODS

The retrospective cohort study included adult patients who initiated statins between 2014 and 2016. Primary adherence was measured as the proportion of days covered (PDC) within 1 year. Persistence was assessed using the proportion of non-persistent users. Any major adverse cardiac and cerebrovascular event (MACCE) was assessed as a clinical outcome. Propensity score matching was performed to adjust for confounding factors.

RESULTS

Among 47,770 patients who met inclusion criteria in the study, 32,130 (67.3%) initiated generic statins. The median age of the patients was 53 (interquartile range: 46-59) years and 60.2% were male. A higher proportion of patients with PDC ≥80% [60.2% vs. 57.1%; odds ratio, 1.14; 95% confidence interval (CI), 1.09-1.19; p<0.001] and a higher PDC value (median, 90.2% vs. 87.9%; difference, 2.3%; p<0.001) were observed in the generic group. Similarly, fewer patients discontinued statins in the generic group [24.2% vs. 27.7%; hazard ratio (HR), 0.91; 95% CI, 0.87-0.95; p<0.001]. Differences in MACCE occurrence were not significant between the groups (4.3% vs. 4.2%; HR, 1.04; 95% CI, 0.93-1.17; p=0.99).

CONCLUSIONS

Adherence and persistence were higher among generic statin recipients; nevertheless, no significant differences in clinical outcomes were noted between the two groups, suggesting that generic medication did not impair treatment benefits and may improve patient adherence.

Generic versus brand-name over-the-counter analgesics: knowledge and attitudes among Swedish pharmacy customers

Background

Due to a liberalisation reform in 2009, the availability of over-the-counter (OTC) analgesics has increased significantly in the Swedish market over the past decade. With the increasing number of generic products available on the market and the possibility of buying OTC drugs from non-pharmacy outlets, a key to safe drug use is that consumers possess the necessary knowledge to differentiate between the different brands and choose the appropriate drug for their ailments. The aim of this study was to investigate Swedish consumers' knowledge of and attitudes towards generic OTC analgesics.

Methods

A sample of 209 Swedish adults (66% women; mean age 43.1 years) who bought OTC analgesics at a community pharmacy in one of the country's three largest cities responded to a structured questionnaire. The questions related to knowledge of active substances, the use and choice of OTC analgesics (generic or original brand), attitudes towards generic OTC analgesics, information received about OTC analgesics and experience with generic substitution of prescription drugs.

Results

Almost one in five reported weekly use of OTC analgesics, and 32% assigned minimum three out of four active substances to the correct brand(s) of OTC analgesics. Among the 50 participants (24%) who assigned all four active substances correctly, it was predominantly women and participants with higher education. Four out of five participants were positive towards the cheaper brands, and 69% reportedly chose cheaper generic brands over more expensive brands. Knowledge about the active substances of different brands was associated with positive attitudes towards generic products.

Conclusion

Swedish pharmacy customers have to a varying extent the knowledge to differentiate between different brands of commonly used OTC analgesics in terms of active substances. There is a predominantly positive attitude towards generic OTC analgesics, although some consider generic drugs to be inferior and stay loyal to the original brands.

The Use of Generic Medications for Glaucoma

The use of generic medicines has grown considerably in recent years providing considerable cost savings. In England, generic items represented 11.7% of prescriptions for glaucoma and ocular hypertension in 2009, increasing to 55.2% of prescriptions in 2018. Generics can be brought to the market quickly and at low cost as manufacturers are not required to repeat animal or clinical research on active ingredients already approved for safety and efficacy. Although there is no regulatory requirement for studies comparing branded and generic eye drops, several randomised crossover studies have been performed comparing branded and generic prostaglandin analogues. While most have shown similar intraocular pressure lowering, studies are of short duration and have not evaluated visual field endpoints. Furthermore, differences in inactive ingredients, pH, viscosity, levels of particulate matter, and degradation over time have been reported. Other potential problems with generic eye drops include differences in bottle design affecting adherence, problems with supply, and the possibility that reduced revenue for innovator companies will lead to reduced investment in new drug development. This article reviews the potential advantages and disadvantages of generic antiglaucoma medications.

Reasons for allowing and refusing generic substitution and factors determining the choice of an interchangeable prescription medicine: a survey among pharmacy customers in Finland

Background

Generic substitution (GS) was introduced in Finland in 2003 and supplemented with a reference price system (RPS) in 2009. Patients play a vital role in the acceptance of GS and the use of less expensive generic medicines. The objective of this study was to explore Finnish pharmacy customers’ experience with allowing and refusing GS. Specific aims were to investigate the reasons for (1) allowing and (2) refusing GS and (3) to determine the prescription medicine-related factors influencing the customer’s choice of an interchangeable prescription medicine.

Methods

A questionnaire survey was conducted in February 2018. Questionnaires were handed out from 18 community pharmacies across Finland to customers ≥18 years who purchased for themselves a prescription medicine included in the RPS. A descriptive approach was used in the analysis using frequencies, the Chi-square test and Fisher’s exact test.

Results

The final study material consisted of 1043 questionnaires (response rate 40.0%). Of the customers, 47.9% had both allowed and refused GS, 41.2% had only allowed GS and 6.0% had only refused GS. Customers had allowed GS because they wanted to lower their medicine expenses (75.5%), or because the prescribed medicine (30.8%) or medicine they had used before (27.4%) was unavailable at the pharmacy. The main reasons for refusing GS were an insignificant price difference between interchangeable medicines (63.3%) and satisfaction with the medicine used before (60.2%). The main factors influencing customers’ choice of an interchangeable prescription medicine were price (81.1%), familiarity (38.4%) and availability (32.8%). Customers who had allowed GS chose the medicine based on price. Customers who had only refused GS appreciated familiarity more than the price of the medicine.

Conclusions

GS is a common practice in Finnish community pharmacies. The price of the medicine was the most important factor affecting customers’ decision to allow or refuse GS and the choice of an interchangeable prescription medicine. Thus, customers should receive information about medicine prices at the pharmacy in order to help them make their decision. However, individual needs should also be taken into account in counselling because customers regard several factors as important in their choice of an interchangeable medicine.

The content of patient counseling about interchangeable medicines and generic substitution in Finnish community pharmacies - a survey of dispensers

Background

Generic substitution aims to increase the use of more affordable generic preparations and restrain the growth of medicine expenditures. Pharmaceutical staff plays an important role in generic substitution by implementing substitution and counseling customers. The aim of this study was to explore how Finnish dispensers inform pharmacy customers about interchangeable medicines and generic substitution and what customers ask dispensers about generic substitution and the reference price system.

Methods

A questionnaire was sent to a random sample of dispensers (n = 1054) working in community pharmacies in spring 2018. The data was analyzed using frequencies, percentages and the Chi-square test and Fisher’s exact test. The open-ended questions were analyzed first using inductive content analysis and later with the quantitative methods mentioned above.

Results

The final study material consisted of 498 questionnaires (response rate 51%). The main topics dispensers always informed customers about were the physician’s record in the prescription not to substitute the medicine (69%) and that the prescribed or purchased interchangeable medicine did not belong in the reference price band (59%). Topics mentioned often by dispensers dealt with customer’s chance to choose their medicine from among several alternative products (68%) and the manufacturer of the interchangeable medicines (66%). Differences in appearance (33%) or in composition (28%) of interchangeable products were the most common topics mentioned only when the customer asked about them. Of the respondents 17.6% always and 51.4% often informed the customer about the least expensive interchangeable product at the point of dispensing. Customers’ questions about the generic substitution and reference price system most commonly (82.4%) concerned the similarity of interchangeable medicines.

Conclusions

Finnish dispensers provide customers with a wide range of information about different subjects when dispensing interchangeable medicines. Patient counseling generally meets the legislative requirements, except for price counseling. In future, information about generic substitution and interchangeable medicines should continuously be provided to customers both at pharmacies and elsewhere, e.g. through educational campaigns.

Experiences of Kurdish immigrants with the management of type 2 diabetes: a qualitative study from Norway

Objective: To explore the experiences of immigrant Kurdish patients in Oslo, Norway, related to the management of type 2 diabetes mellitus (T2DM). Design: A qualitative study with focus group interviews. Setting: Participants were recruited at meeting places in Oslo through Kurdish networks. Subjects: Eighteen Kurdish immigrants (9 females and 9 males) living in Oslo, aged 40 to 64 years, diagnosed with T2DM participated in a total of five focus groups. Participants had to be proficient in the Norwegian language to be eligible. Main outcome measures: Immigrant Kurdish patients' experiences with being diagnosed with T2DM, their disease management, and need for medical information. Results: Participants stressed that living with T2DM was emotionally challenging, mainly because they were afraid of possible complications of the disease. They claimed to adhere satisfactorily to their medicines and blood glucose measurements. The majority of participants shared that they had made changes to their diet, even though it was difficult. To the contrary, physical activity received only minimal attention. The participants' main source of information was general practitioners and the majority of them were satisfied with the information that they had received about their disease and its management. Conclusion: Kurdish T2DM patients in the present study from Norway reported that they adhered to the medical treatment, even if they were stressed about living with the disease. However, they were more occupied with changing their diet than to be physically active. Therefore, healthcare personnel should try to be aware of lifestyle challenges among their patients. KEY POINTS Eighteen Kurdish patients in Oslo with Type 2 diabetes claimed to be adherent to medication treatment and blood glucose measurement. The participants shared that they had made changes to their diet, even though it was hard. There was generally little attention given to the need for physical activity in their daily lives. The participants were in need of more information and support in making healthy lifestyle changes.

Living with Diabetes: Personal Interviews with Pakistani Women in Norway

The prevalence of Type 2 diabetes (T2D) among Pakistani women in Norway is remarkably high. This study aims to assess how they live with the disease and their response to lifestyle and medical information. 120 Pakistani women living in Norway (mean age: 55.7 years) were personally interviewed about their T2D using a structured questionnaire (response rate: 95%). The participants were first-generation immigrants (mean residence time: 28.7 years) of whom 27% were illiterates. Poor health was reported by one-third, and 71% had developed macrovascular comorbidities. A majority reported physical inactivity and an unhealthy diet included religious fasting. One-third was not able to self-measure their blood glucose. There was a great variation in antidiabetic drug regimens and one-fourth had to use insulin in addition to tablets. Pakistani women in Norway showed suboptimal control of their T2D in terms of lifestyle habits, comorbidities and drug use. Low literacy and cultural factors seem to challenge adherence to lifestyle and medical information.

Utilisation of Healthcare Services and Medicines by Pakistani Migrants Residing in High Income Countries: A Systematic Review and Thematic Synthesis

Migration, as a global phenomenon, gives rise to many challenges for healthcare professionals providing care to migrant populations. Migrants originating from diverse cultural backgrounds have unique beliefs and healthcare needs, and their utilisation of healthcare services and medicines is influenced by a number of factors. This review aims to assess the factors influencing the utilisation of healthcare services and medicines among Pakistani migrants residing in high income countries. The databases searched included PubMed/Medline, Scopus, EMBASE, Web of Science, CINAHL, and IPA. Of the 2566 publications initially obtained, 37 met the inclusion criteria. They included eight countries-the United Kingdom, United States of America, Canada, Denmark, Norway, Australia, United Arab Emirates and Cyprus. Eight descriptive themes emerged and two analytical constructs were established, as a result of thematic synthesis of included publications. The profile of utilisation of healthcare services and medicines among Pakistani migrants was multifaceted and influenced by their individual circumstances (socioeconomic characteristics; personal beliefs, preferences, and experiences; individual culture and religion; family and friends; and language and communication), and host country characteristics (work environment; healthcare organisation, access and affordability; and health professionals' education, practices, and preferences). Awareness of population-specific characteristics of migrant communities is important to promote and implement culturally appropriate healthcare practices and service provision.

Perceptions of pharmacists and physicians on generic substitution in a financial crisis context in Northwestern Spain: A qualitative study

In Spain, the use of generics has considerably evolved in a short period of time through different anti-crisis legislation changes. Before the financial crisis the proposal of generics was an option for patients. Nowadays its use is actively enforced by Health authorities.

OBJECTIVE

To explore the perceptions of pharmacists and physicians regarding the generic substitution driven by new Spanish drugs policies as well as their adaptive strategies intended to lessen the impact of changes to their patients' treatment.

METHODS

Pharmacists (16) and physicians (13) from Ferrol and A Coruña participated in a qualitative study using semi-structured in-depth interviews.

RESULTS

Qualitative analysis allowed identification of nine key components in the substitution process: Enabling factors: 'Adequate information to patients', 'Acute treatments', 'Bioappearance', 'Prescription by Estate Official Denomination followed by laboratory name', 'Personalized dosage systems'. Obstructing factors: 'Generics/Authorities distrust', 'Lack of time', 'Patient characteristics', 'Pharmacy financial management'.

CONCLUSIONS

Pharmacists and physicians in our economic crisis context perceive different barriers resulting in difficulties in the generic substitution process. They have implemented strategies to capitalize on the enablers and overcome the additional budget-cut barriers imposed by the Administration that had prevented them from maintaining their patient's treatment preferences. Spanish health authorities could improve current legislation either by reducing the number of new laboratories of authorized generic manufacturers or by extending the pharmacist capability for equivalent drugs substitution.

Potential Clinical and Economic Impact of Switching Branded Medications to Generics

Switching branded to generic medications has become a common cost-containment measure. Although this is an important objective for health care systems worldwide, the impact of this practice on patient outcomes needs to be carefully considered. We reviewed the literature summarizing the potential clinical and economic consequences of switching from branded to generic medications on patient outcomes. A literature search of peer-reviewed articles published 2003-2013 using key words of "generic switching" or "substitution" was conducted using PubMed, OvidSP, and ScienceDirect. Of 30 articles identified and reviewed, most were related to the diseases of the central nervous system, especially epilepsy. Based on our review, potential impacts of switching fell into 3 broad categories: patient attitudes and adherence, clinical and safety outcomes, and cost and resource utilization. Although in many cases generics may represent an appropriate alternative to branded products, this may not always be the case. Specifically, several studies suggested that switching may negatively impact medication adherence, whereas other studies found that generic switching was associated with poorer clinical outcomes and more adverse events. In some instances, switching accomplished cost savings but did so at increased total cost of care because of increased physician visits or hospitalizations. Although in many cases generics may represent an appropriate alternative, mandatory generic switching may lead to unintended consequences, especially in certain therapeutic areas. Although further study is warranted, based on our review, it may be medically justifiable for physicians and patients to retain the right to request the branded product in certain cases.

Development and validation of a tool to assess knowledge and attitudes towards generic medicines among students in Greece: The ATtitude TOwards GENerics (ATTOGEN) questionnaire

INTRODUCTION

The use of generic medicines is a cost-effective policy, often dictated by fiscal restraints. To our knowledge, no fully validated tool exploring the students' knowledge and attitudes towards generic medicines exists. The aim of our study was to develop and validate a questionnaire exploring the knowledge and attitudes of M.Sc. in Health Care Management students and recent alumni's towards generic drugs in Greece.

MATERIALS AND METHODS

The development of the questionnaire was a result of literature review and pilot-testing of its preliminary versions to researchers and students. The final version of the questionnaire contains 18 items measuring the respondents' knowledge and attitude towards generic medicines on a 5-point Likert scale. Given the ordinal nature of the data, ordinal alpha and polychoric correlations were computed. The sample was randomly split into two halves. Exploratory factor analysis, performed in the first sample, was used for the creation of multi-item scales. Confirmatory factor analysis and Generalized Linear Latent and Mixed Model analysis (GLLAMM) with the use of the rating scale model were used in the second sample to assess goodness of fit. An assessment of internal consistency reliability, test-retest reliability, and construct validity was also performed.

RESULTS

Among 1402 persons contacted, 986 persons completed our questionnaire (response rate = 70.3%). Overall Cronbach's alpha was 0.871. The conjoint use of exploratory and confirmatory factor analysis resulted in a six-scale model, which seemed to fit the data well. Five of the six scales, namely trust, drug quality, state audit, fiscal impact and drug substitution were found to be valid and reliable, while the knowledge scale suffered only from low inter-scale correlations and a ceiling effect. However, the subsequent confirmatory factor and GLLAMM analyses indicated a good fit of the model to the data.

CONCLUSIONS

The ATTOGEN instrument proved to be a reliable and valid tool, suitable for assessing students' knowledge and attitudes towards generic medicines.

Choice of mandatory prescribed drugs in Portugal: a consumers’ perspective

Purpose

This paper aims to contribute to the understanding of what influences consumers’ choice of mandatory prescribed drugs, by looking with more detail to the substitution of branded drugs by generics. Specifically, this research looks at three factors that can influence this decision, namely, participative decision-making, perceived risk and price consciousness, within the recent changes introduced in the Portuguese pharmaceutical market by new legislation.

Design/methodology/approach

A cross-sectional study was conducted, using a self-administered questionnaire, to survey a sample of consumers/patients that visited a doctor and were prescribed some kind of drug. Data were treated using factor analysis for dimensionality reduction purposes and regression analysis to test the main hypothesis.

Findings

The results show that participative decision-making has no impact on purchase decision of generics, while perceived risk and price consciousness show a predictive power regarding purchase intention of generic drugs.

Research limitations/implications

Although the results are only applicable to the Portuguese context, it draws important conclusions regarding consumers’ behaviour when choosing between branded and generic drugs.

Practical implications

Knowing what influences consumers’ choices of generic drugs contributes to tune marketing strategies and actions. For public institutions, this paper offers insights on how to adapt public policies.

Originality/value

This paper is valuable because it is the first to look at the Portuguese pharmaceutical market from a consumer behaviour perspective since new legislation was set up.

Package Design Affects Accuracy Recognition for Medications

OBJECTIVE

Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors.

BACKGROUND

An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors.

METHOD

In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated.

RESULTS

The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications.

CONCLUSION

Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications.

APPLICATION

A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose.

Therapy discontinuation or substitution in patients with cardiovascular disease, switching among different products of the same off-patent active substance: a 'real-world' retrospective cohort study

OBJECTIVE

The present study investigated the effects of switching to different products of the same off-patent active substance (brand name or generic) on therapy discontinuation or substitution with another molecule of the same class, in patients with cardiovascular disease treated with statins and antihypertensives in a 'real-world' setting.

DESIGN

A retrospective cohort study in a 'real-world' setting.

SETTING

Analysis of data performed by integrating administrative databases that included approximately two million individuals who are assisted by the National Health System from three Local Health Units located in three different regions of Italy.

PARTICIPANTS

All patients aged ≥18 years with at least one prescription of simvastatin, ramipril or amlodipine in the period 1 January to 31 December 2010 were included and followed up for 2 years.

MAIN OUTCOME MEASURES

Prescription refills occurring during follow-up were evaluated. Frequency of discontinuation of therapy or substitution with another molecule of the same class (eg, from simvastatin to a different statin) during follow-up was identified.

RESULTS

During follow-up, therapy discontinuation or substitution was found to be more frequent in patients switching to a different product of the same active substance compared with non-switching patients (11.5% vs 10.8% and 22.2% vs 20.8% (p=0.002), respectively, in the simvastatin group; 4.0% vs 3.5% and 24.6% vs 22.7% (p<0.001), respectively, in the amlodipine group). In the ramipril group, 8% of patients undertook a therapy substitution to another molecule; no trend towards a lower percentage of substitution was observed in the non-switching group, while 18% of patients discontinued treatment, with a significant difference in favour of patients not switching. These findings were partially confirmed by multivariate analysis.

CONCLUSIONS

Switches among products of the same active substance are quite common in patients with cardiovascular disease. Our study suggests that switching may expose patients to a higher risk of therapy discontinuation or substitution.

The influence of generic substitution on the content of patient–pharmacist communication in Swedish community pharmacies

Objectives

The objective was to study the relationship between the length and content of patient–pharmacist communication in community pharmacies, and generic substitution.

Methods

The study was conducted in six community pharmacies in Sweden. Non-participant observations with audio recordings and short structured interviews were conducted. Out of 32 pharmacists 29 agreed to participate (90.6%), as did 282 out of 407 patients (69.3%). Logistic regression analysis was applied to calculate odds ratio for occurrence of generic substitution. Linear regression (β-coefficients) was applied to test for differences in time spent on different categories.

Key findings

In encounters where generic substitution occurred more time (19.2 s) was spent on non-medical (for instance administrative or economical) issues (P = 0.01, 95% confidence interval 4.8–33.6). However, the total time of the encounter was not significantly longer. The amount of time spent on non-medical issues increased with age of patient (age 60+: β, 33 s, P &gt; 0.001). The results indicate that more time was spent on medical issues with patients who have a higher education (high school: β, 10.8 s, P = 0.07, university: β, 10.2 s, P = 0.11) relative to those with only elementary school education.

Conclusions

Occurrence of generic substitution was correlated with more time spent on communicating on non-medical, but not on medical, issues. No extra time was spent on medical information for the groups normally overrepresented among those with low health literacy. This study suggests that pharmacists need to further embrace their role in promoting rational use of medicines, not least when generic substitution occurs.

Refill Adherence in Relation to Substitution and the Use of Multiple Medications: A Nationwide Population Based Study on New ACE-Inhibitor Users

Objective

Generic substitution has contributed to economic savings but switching products may affect patient adherence, particularly among those using multiple medications. The aim was to analyse if use of multiple medications influenced the association between switching products and refill adherence to angiotensin-converting-enzyme (ACE) inhibitors in Sweden.

Study Design and Setting

New users of ACE-inhibitors, starting between 1 July 2006 and 30 June 2007, were identified in the Swedish Prescribed Drug Register. Refill adherence was assessed using the continuous measure of medication acquisition (CMA) and analysed with linear regression and analysis of covariance.

Results

The study population included 42735 individuals whereof 51.2% were exposed to switching ACE-inhibitor and 39.6% used multiple medications. Refill adherence was higher among those exposed to switching products than those not, but did not vary depending on the use of multiple medications or among those not. Refill adherence varied with age, educational level, household income, country of birth, previous hospitalisation and previous cardiovascular diagnosis.

Conclusion

The results indicate a positive association between refill adherence and switching products, mainly due to generic substitution, among new users of ACE-inhibitors in Sweden. This association was independent of use of multiple medications.

A Systematic Review of Physicians' and Pharmacists' Perspectives on Generic Drug Use: What are the Global Challenges?

BACKGROUND AND OBJECTIVES

Generic substitution has been introduced in most countries in order to reduce costs and improve access to drugs. However, regulations and the generic drugs available vary between countries. It is the prescriber or dispenser of the drug who is the final decision maker. Nevertheless, physicians' and pharmacists' perceptions of generic drug use are not well documented to date. This study presents a systematic review of physicians' and pharmacists' perspectives on generic drug use worldwide.

METHODS

A systematic literature search was performed to retrieve all articles published between 2002 and 2012 regarding physicians' and/or pharmacists' experiences with generic drugs and generic substitution.

RESULTS

Of 1322 publications initially identified, 24 were eligible for inclusion. Overall, the studies revealed that physicians and pharmacists were aware of the cost-saving function of generic drugs and their role in improving global access to drugs. Nevertheless, marked differences were observed between countries when studying physicians' and pharmacists' perceptions of the available generic drugs. In less mature healthcare systems, large variations regarding, for example, control routines, bioequivalence requirements, and manufacturer standards were reported. A lack of reliable information and mistrust in the efficacy and quality were also mentioned by these participants. In the most developed healthcare systems, the participants trusted the quality of the generic drugs and did not hesitate to offer them to all patients regardless of socioeconomic status. In general, pharmacists seemed to have better knowledge of the concept of bioequivalence and generic drug aspects than physicians.

CONCLUSIONS

The present study indicates that physicians and pharmacists are aware of the role of generic drugs in the improvement of global access to drugs. However, there are marked differences regarding how these health professionals view the quality of generic drugs depending on the maturity of their country's healthcare system. This can be attributed to the fact that developed healthcare systems have more reliable public control routines for drugs in general as well as better bioequivalence requirements concerning generics in particular.

What do people really think of generic medicines? A systematic review and critical appraisal of literature on stakeholder perceptions of generic drugs

BACKGROUND

Considerable emphasis is presently being placed on usage of generic medicines by governments focussed on the potential economic benefits associated with their use. Concurrently, there is increasing discussion in the lay media of perceived doubts regarding the quality and equivalence of generic medicines. The objective of this paper is to report the outcomes of a systematic search for peer-reviewed, published studies that focus on physician, pharmacist and patient/consumer perspectives of generic medicines.

METHODS

Literature published between January 2003 and November 2014, which is indexed in PubMed and Scopus, on the topic of opinions of physicians, pharmacists and patients with respect to generic medicines was searched, and articles within the scope of this review were appraised. Search keywords used included perception, opinion, attitude and view, along with keywords specific to each cohort.

RESULTS

Following review of titles and abstracts to identify publications relevant to the scope, 16 papers on physician opinions, 11 papers on pharmacist opinions and 31 papers on patient/consumer opinions were included in this review. Quantitative studies (n = 37) were the most common approach adopted by researchers, generally in the form of self-administered questionnaires/surveys. Qualitative methodologies (n = 15) were also reported, albeit in fewer cases. In all three cohorts, opinions of generic medicines have improved but some mistrust remains, most particularly in the patient group where there appears to be a strongly held belief that less expensive equals lower quality. Acceptance of generics appears to be higher in consumers with higher levels of education while patients from lower socioeconomic demographic groups, hence generally having lower levels of education, tend to have greater mistrust of generics.

CONCLUSIONS

A key factor in improving confidence in generic products is the provision of information and education, particularly in the areas of equivalency, regulation and dispelling myths about generic medicines (such as the belief that they are counterfeits). Further, as patient trust in their physician often overrules their personal mistrust of generic medicines, enhancing the opinions of physicians regarding generics may have particular importance in strategies to promote usage and acceptance of generic medicines in the future.

Norwegian elderly patients' need for drug information and attitudes towards medication use reviews in community pharmacies

OBJECTIVES

Medication use review (MUR) is a community pharmacy service in several countries. Knowledge about what patients want from such a service is limited. The aim of this study was therefore to investigate Norwegian elderly patients' need for drug information and their attitudes towards MURs.

METHODS

In Norway's two largest cities, 162 patients (72% women; mean age: 78.9 years) who used at least one prescription drug were recruited from 18 senior centres. They were interviewed personally with a structured questionnaire (29 closed and 4 open-ended questions).

KEY FINDINGS

The average number of prescription drugs used was 4.4. Seventy per cent also used over-the-counter drugs. The main source of drug information was the general practitioner (GP) followed by package inserts and pharmacy staff. For drug-related problems, 62% would contact the GP compared with 24% who preferred the pharmacist. Fifty per cent remembered no information when collecting prescriptions. However, 56% wanted to know more about their medication and 55% were interested in a MUR. The main topics they wished to address were effect/side effects and interactions. Lack of privacy was reported to be a major obstacle in the current situation.

CONCLUSIONS

This study shows that community pharmacies in Norway play a minor role regarding drug information to elderly polypharmacy patients. The GP is both their main information source and whom they contact for drug-related problems. However, half of the patients would like to know more about their medication. More than half were positive towards taking part in a MUR.

Need for multicriteria evaluation of generic drug policies

Policymakers tend to focus on improving patented drug policies because they are under pressure from patients, physicians, and manufacturers to increase access to novel therapies. The success of pharmaceutical innovation over the last few decades has led to the availability of many off-patent drugs to treat disease areas with the greatest public health need. Therefore, the success of public health programs in improving the health status of the total population is highly dependent on the efficiency of generic drug policies. The objective of this article was to explore factors influencing the true efficiency of generic prescription drug policies in supporting public health initiatives in the developed world. Health care decision makers often assess the efficiency of generic drug policies by the level of price erosion and market share of generics. Drug quality, bioequivalence, in some cases drug formulations, supply reliability, medical adherence and persistence, health outcomes, and nondrug costs, however, are also attributes of success for generic drug policies. Further methodological research is needed to measure and improve the efficiency of generic drug policies. This also requires extension of the evidence base of the impact of generic drugs, partly based on real-world evidence. Multicriteria decision analysis may assist policymakers and researchers to evaluate the true value of generic drugs.

Societal value of generic medicines beyond cost-saving through reduced prices

OBJECTIVE

This paper aims to provide an overview of the added societal value of generic medicines beyond their cost-saving potential through reduced prices. In addition, an observational case study will document the impact of generic entry on access to pharmacotherapy in The Netherlands and an illustrative exercise was carried out to highlight the budget impact of generic entry.

METHODS

A narrative literature review was carried out to explore the impact of generic medicines on access to pharmacotherapy, innovation and medication adherence. Data from the Medicines and Medical Devices Information Project database in The Netherlands were used for the case study in which the impact of generic medicine entrance on the budget and the number of users was calculated as an illustrative exercise.

RESULTS

Generic medicines have an additional societal value beyond their cost-saving potential through reduced prices. Generic medicines increase access to pharmacotherapy, provide a stimulus for innovation by both originator companies and generic companies and, under the right circumstances, have a positive impact on medication adherence.

CONCLUSION

Generic medicines offer more to society than just their cost-saving potential through reduced prices. As such, governments must not focus only on the prices of generic medicines as this will threaten their long-term sustainability. Governments must therefore act appropriately and implement a coherent set of policies to increase the use of generic medicines.

Attitudes of physicians and pharmacists towards International Non-proprietary Name prescribing in Belgium

International Non-proprietary Name (INN) prescribing is the use of the name of the active ingredient(s) instead of the brand name for prescribing. In Belgium, INN prescribing began in 2005 and a major policy change occurred in 2012. The aim was to explore the opinions of Dutch-speaking general practitioners (GPs) and pharmacists. An electronic questionnaire with 39 five-point Likert scale statements and one open question was administered in 2013. Multivariate analysis was performed with multiple linear regression on a sum score for benefit statements and for drawback statements. Answers to the open question were qualitatively analysed. We received 745 valid responses with a representable sample for both subgroups. Participants perceived the motives to introduce INN prescribing as purely economic (to reduce pharmaceutical expenditures for the government and the patient). Participants accepted the concept of INN prescribing, but 88% stressed the importance of guaranteed treatment continuity, especially in older, chronic patients, to prevent patient confusion, medication non-adherence and erroneous drug use. In conclusion, the current way in which INN prescribing is applied in Belgium leads to many concerns among primary health professionals about patient confusion and medication adherence. Slightly adapting the current concept of INN prescribing to these concerns can turn INN prescribing into one of the major policies in Belgium to reduce pharmaceutical expenditures and to stimulate rational drug prescribing.

Cultural barriers encountered by Norwegian community pharmacists in providing service to non-Western immigrant patients

BACKGROUND

Western societies' need for knowledge about how to meet the challenges in health care following increased immigration has emerged as studies have showed that non-Western immigrants tend to experience more obstacles to drug use and poorer communication with health professionals.

OBJECTIVES

To identify the cultural barriers encountered by Norwegian community pharmacists in providing service to non-Western immigrant patients and to outline how they are being addressed.

SETTING

Community pharmacies in Oslo, Norway.

METHODS

A qualitative study consisting of four focus groups was conducted. In total 19 ethnic Norwegian pharmacists (17 female and 2 male; mean age: 40.6 years) participated. They were recruited from 13 pharmacies situated in areas of Oslo densely populated by non-Western immigrants. The audio-records of the focus group discussions were transcribed verbatim. A thematic content analysis was conducted. Main outcome measure Cultural barriers identified by Norwegian community pharmacists in the encounter with non-Western immigrants.

RESULTS

All the pharmacists were in contact with non-Western immigrant patients on a daily basis. They said that they found it challenging to provide adequate service to these patients, and that the presence of language as well as other cultural barriers not only affected what the patients got out of the available information, but also to a great extent what kind of and how much information was provided. Although the pharmacists felt that immigrant patients were in great need of drug counselling, there were large disparities in how much effort was exerted in order to provide this service. They were all uncomfortable with situations where family or friends acted as interpreters, especially children. Otherwise, cultural barriers were related to differences in body language and clothing which they thought distracted the communication. All the pharmacists stated that they had patients asking about the content of pork gelatin in medicines, but few said that they habitually notified the patients of this unless they were asked directly. Ramadan fasting was not identified as a subject during drug counselling.

CONCLUSION

This focus group study shows that language and other cultural barriers, including differences in body language, non-Western gender roles, and all-covering garments, are of great concern for ethnic Norwegian community pharmacists in the encounter with non-Western immigrant patients. Although the pharmacists recognise their role as drug information providers for immigrant patients, large disparities were detected with respect to kind of and amount of information provided to these patients.

Patient perceptions of generic medicines: a mixed-methods study

INTRODUCTION

In an attempt to benefit from the cost-savings associated with use of generic medicines, in June 2013 Ireland introduced generic substitution and reference pricing for the first time. However, perceptions of Irish patients towards generic medicines have not been published previously. Therefore, the objective of this study was to assess how generic medicines were perceived amongst patients in the time leading up to the enactment of the new legislation.

METHODOLOGY

A total of 42 patients were recruited from general practices affiliated with the Graduate Entry Medical School at the University of Limerick and from community pharmacies. Interviews were semi-structured and included quantitative assessments of opinions using 15 structured questions and a five-point Likert scale response system. Interview transcripts were coded and thematically analysed using NVivo (version 9), for qualitative data. Quantitative data were analysed using SPSS (version 20).

RESULTS

Nearly one-third (31 %) of patients had no knowledge of generic medicines and 39 % of those exhibited confusion between the words 'generic' and 'genetic'. Almost one-quarter (24 %) held the view that generics were of poorer quality than originators, while 18 % expressed the opinion that generics do not work as well as originator products. Approximately one-third (30 %) of patients believed that generics were manufactured to a poorer quality, with 29 % holding the view that generics are less expensive due to being of inferior quality. Nearly 90 % of patients stated they would take a generic medicine if it were prescribed by their GP; however, 24 % of patients stated a preference, if offered a choice, for the originator medication. Additionally, a majority of patients (86 %) were in favour of reference pricing and generic substitution. Of the patients interviewed, 50 % stated that a leaflet, or similar, with appropriate, understandable, and accessible information regarding generic medicines would be of use to them.

CONCLUSION

This is the first study of patients' attitudes towards generic medicines in Ireland. Conducted in the time period leading up to the implementation of legislation promoting the use of generic medicines, it highlights variable knowledge about generic medicines among this key stakeholder group. Although patients are supportive of their more widespread use, concerns regarding safety, clinical effectiveness, and manufacturing quality of generic medicines were identified.

Impact of generic substitution practice on care of diabetic patients

BACKGROUND

Patients with chronic diseases like type II diabetes mellitus often have their prescriptions substituted with generic medicines in the course of care to save costs of medicines and to improve access. There is need to assess impact of this practice on patient care.

OBJECTIVE

To assess patient's knowledge of generic substitution practice and its impact on patient care.

SETTING

An outpatient diabetic clinic of a tertiary hospital in Nigeria.

METHOD

The study is a cross sectional survey of patients attending a diabetic clinic. A structured questionnaire was used to interview willing patients. A total of 120 patients were enrolled for the study, but only 102 responded (85 % overall response rate).

MAIN OUTCOME MEASURES

Patients' knowledge of generic substitution practice, patients' report of abstaining from drug use, experiences of more side effects and patients' confusion.

RESULTS

Over half (57.8 %) of surveyed patients (n = 59) had noticed brand switches, out of which, 30.5 % experienced brand switches more than 3 times within a year. More than a third of the respondents (38.6 %) did not know when pharmacists actually substituted their medicines. About one in five (19.6 %) patients did not use their medicines after substitution because they were not sure of the brand supplied but 35.6 % have rejected substitution at one time and insisted on doctors' prescription. Respondents (14.9 %) agreed that brand substitution resulted in confusion while 24 % reported receiving brands that resulted in more side effects. More respondents (58.6 %) indicated that they never had a discussion with their pharmacists about the reasons for generic substitution and switches.

CONCLUSION

Generic substitution without adequate information resulted in confusion and subsequent lack of adherence. There is the vital need for appropriate policy and guidelines for generic substitution in Nigeria.

South Asians' cardiac medication adherence

AIM

This paper is a report of a narrative review examining the current state of knowledge regarding adherence with cardiac medication among South Asian cardiac patients.

BACKGROUND

South Asians experience higher rates of cardiovascular disease than any other ethnic group. South Asians may be less adherent with a cardiac medication regimen than Caucasians. The factors contributing to adherence are important to discover to assist South Asians to optimize their cardiac health.

DATA SOURCES

CINAHL, Medline (Ovid), PsychINFO, EMB Reviews-(Cochrane), and EMBASE were accessed using the key words: 'South Asian', 'Asia', 'East India', 'India', 'Pakistan', 'Bangladesh', 'Sri Lanka', 'medication compliance', 'medication noncompliance' and 'medication adherence'. English language papers published from January 1980 to January 2013 were eligible for inclusion.

REVIEW METHODS

Abstracts were reviewed for redundancy and eligibility by the primary author. Manuscripts were then retrieved and reviewed for eligibility and validity by the first and last authors. Content analysis strategies were used for the synthesis.

RESULTS

Thirteen papers were in the final data set; most were conducted in India and Pakistan. Medication side-effects, cost, forgetfulness and higher frequency of dosing contributed to non-adherence. South Asian immigrants also faced language barriers, which contributed to non-adherence. Knowledge regarding the medications prescribed was a factor that increased adherence.

CONCLUSION

South Asians' non-adherence to cardiac medications is multifaceted. How South Asians who newly immigrate to Western countries make decisions regarding their cardiac medication adherence ought to be explored in greater detail.

Price, familiarity, and availability determine the choice of drug - a population-based survey five years after generic substitution was introduced in Finland

Background

Mandatory generic substitution (GS) was introduced in Finland at the beginning of April 2003. However, individual patients or physicians may forbid the substitution. GS was a significant change for Finnish medicine users. It was thought it would confuse people when the names, colors, packages, etc., changed. The purpose of this study was to explore what medicine-related factors influence people's choice of prescription drugs five years after generic substitution was introduced in Finland.

Methods

A population survey was carried out during the autumn of 2008. A random sample was drawn from five mainland counties. A questionnaire was mailed to 3000 people at least 18 years old and living in Finland. The questionnaire consisted of both structured and open-ended questions. Factors that influenced the subjects' choice of medicines were asked with a structured question containing 11 propositions. Descriptive statistical analyses were performed.

Results

In total, 1844 questionnaires were returned (response rate, 62%). The percentage of female respondents was 55%. Price, availability, and familiarity were the three most important factors that influenced the choice of medicines. For the people who had refused GS, the familiarity of the medicine was the most important factor. For the subjects who had allowed GS and for those who had both refused and allowed GS, price was the most important factor.

Conclusions

The present study shows that price, familiarity, and availability were important factors in the choice of prescription medicines. The external characteristics of the medicines, for instance the color and shape of the tablet/capsule or the appearance of the package, were not significant characteristics for people.

Spectrum of antihypertensive therapy in South Asians at a tertiary care hospital in Pakistan

Background

Despite available guidelines on hypertension (HTN), use of antihypertensives is variable. This study was designed to ascertain frequency of patients on monotherapy and > 1 antihypertensive therapy and also to ascertain proportion of patients on diuretic therapy.

Methods

It was a crossectional study conducted on 1191 adults(age > 18 yrs)hypertensive patients selected by computerized International Classification of Diseases -9-coordination and maintenance (ICD-9-CM) presenting to a tertiary care hospital in Pakistan. Data on demographics, comorbids, type of antihypertensive drug, number of antihypertensive drug and mean duration of antihypertensive drug was recorded over 1.5 year period (2008-09). Blood pressure was recorded on admission. Primary outcome was use of combination therapy and secondary outcome was use of diuretic therapy.

Results

A total of 1191 participants were included. Mean age(SD) was 62.55(12.47) years, 45.3%(540) were males. Diabetes was the most common comorbid; 46.3%(551). Approximately 85% of patients had controlled hypertension. On categorization of anti hypertensive use into 3 categories;41.2%(491) were on monotherapy,32.2%(384) were on 2 drug therapy,26.5%(316) were on ≥3 drug therapy. Among those who were on monotherapy for HTN;34%(167) were on calcium channel blockers,30.10%(148) were on beta blockers, 22.80%(112) were on Angiotensin converting enzyme (ACE) inhibitors,12%(59) were on diuretics and 2.20%(11) were on Angiotensin receptor blockers(ARB). Use of combination antihypertensive therapy was significantly high in patients with ischemic heart disease(IHD)(p < 0.001). Use of diuretics was in 31% (369) patients. Use of diuretics was significantly less in patients with comorbids of diabetes (p 0.02), Chronic kidney disease(CKD)(p 0.003), IHD (p 0.001) respectively

Conclusion

Most patients presenting to our tertiary care center were on combination therapy. Calcium channel blocker is the most common anti hypertensive drug used as monotherapy and betablockers are used as the most common antihypertensive in combination. Only a third of patients were on diuretic as an antihypertensive therapy.