1. A LONGITUDINAL POLICY ANALYSIS OF THE IMPACT ON PRESCRIBING PATTERNS AND MEDICATION COST OF A GENERIC DISPENSING POLICY IN A TEACHING HOSPITAL IN THAILAND

2. A LONGITUDINAL POLICY ANALYSIS OF THE IMPACT ON PRESCRIBING PATTERNS AND MEDICATION COST OF A GENERIC DISPENSING POLICY IN A TEACHING HOSPITAL IN THAILAND
Anansakunwatt W*, Suttipoom P*,Wagner A**, Ross-Degnan D**, Wongtanasuporn Y*
* Siriraj Hospital, Mahidol University, Thailand; ** Harvard Medical School, Boston, USA
Problem Statement: At Siriraj Hospital, as in many other hospitals, preferential prescribing of brand name products contributes to large and increasing drug expenditures.
Objectives: To estimate the impact of a hospital-wide generic dispensing policy on prescribing patterns and cost of medication and to explore healthcare professionals’ and patients’ perceptions of the policy.
Design: Retrospective, interrupted time series study of monthly computerized inventory data and in-patient and out-patient dispensing records, from one year before to one year after the policy. Cross-sectional assessment of health care professionals’ and patients’ perceptions of the policy using standardized questionnaires. Segmented linear regression, with adjustment for autocorrelation, was used to analyze time series data.
Setting and Population: Siriraj hospital, a 2,324 bed tertiary care teaching hospital, where more than 3,000 outpatient prescriptions per day are filled.
Intervention: In October 2001, the hospital administration implemented a generic dispensing regulation to lower medication expenditures by authorizing pharmacists to automatically dispense a generic product unless the prescriber specifically requests dispensing of the brand name product.
Outcome Measures: Post-policy change in % of drugs dispensed as generic, average drug cost per prescription, total cost of drugs dispensed from pharmacy, compared to before the policy and accounting for pre-policy levels and trends in these measures; policy perception among professionals and patients.
Results: Generic substitution policy caused % of drugs dispensed as generic increased and drug cost decreased in a substitutable group (p=0.00) and saved million USD per year. The cost of products that are available as brand-only (non-substitutable) drugs increased but not influenced by the policy. Average drug cost per prescription did not change. Most physicians’, nurses’ and pharmacists’ perceptions of the generic dispensing policy are concern about generic drug quality and they understand the rationale of this policy implementation. Most patients (89.23 %) were satisfied by this policy.
Conclusions: The policy saved drug cost and both personnel and patients were not unsatisfied by the policy implementation .
Funding Source: United States Agency for International Development.

3. Background
Siriraj Hospital, 2,324 bed university hospital in Thailand has more than 2,000 items of drug.
In October 2001, the hospital administration implemented a generic dispensing regulation to lower medication expenditures by authorizing pharmacists to automatically dispense a generic product unless the prescriber specifically requests dispensing of the brand name product by adding the symbol ® after the original brand name.

4. Research Questions
How did hospital medication use and expenditures change?
How did the rate of generic dispensing of selected medications change?
How did the use of selected medications that are available as brand-only change?
How did average prescription cost change?
What are physicians’, nurses’ pharmacists’ and patients’ perceptions of the generic dispensing policy?

5. Methods
(1) an analysis of medication consumption data based on pharmacy stock records in the year before and the year after implementation of the generic dispensing policy
(2) a longitudinal study of prescribing and dispensing patterns between October 1, 2000 and September 30, 2002
(3) a cross-sectional qualitative study of physicians’, nurses’, pharmacists’ and patients’ perceptions of the generic dispensing policy.

6. Result 1: Dispensing of substitutable original brands decreased and generic products increased significantly by the policy (p=0.00).
Substitutable Generic product
Policy start
Generic only
Brand only
Substitutable Original brand

7. Result 2: Cost of substitutable original brands decreased and generics increased by the policy (p=0.00) and saved million USD per year but the cost of unique brands increased by month influence (p=0.003)
Brand only
Policy start
Substitutable Original brand
Substitutable Generic product
Generic only
Picture of OPD Drug Cost

8. Result 2: Cost of substitutable original brands decreased and generics increased by the policy (p=0.00) and saved million USD per year but the cost of unique brands increased by month influence (p=0.003)
Policy start
Brand only
Substitutable Original brand
Substitutable Generic product
Generic only
Picture of IPD Drug Cost

9. Result 3 : Cost per prescription did not change significantly.
Policy start

10. Result 4: Generic dispensing of selected popular drugs increased significantly
Policy start
Generic Omeprazole cap.
Original Losec MUPs
Generic Furosemide inj.
Policy start
Original Lasix inj.
Generic Glipizide
Policy start
Original Minidiab

11. Survey Results
DISTRIBUTED
RETURNED %
PRESCRIBER
452
219
48.45
PHARMACIST 40 26
65.00
NURSE
486
439
90.33
PATIENT
496
100.00

12. Summary
Generic substitution policy caused drug cost decreased in a substitutable group (p=0.00) and saved Million USD per year.
The cost of products that are available as brand-only (non-substitutable) drugs increased and caused total drug cost of this subgroup rising but was not influenced by the policy.
The cost per prescription did not change.
89.23% of patients were satisfied by the generic drug substitution policy.
Physicians’, nurses’ and pharmacists’ perceptions of the generic dispensing policy
Concern about generic drug quality
Understand why this policy was implemented

13. Recommendations
The hospital administrators should implement new policies to
Assure the quality of drugs accepted in the hospital formulary.
Control the use of new original brands that are high cost items.
Review drug use pattern regularly and feedback to prescribers.