Pharmacists' Satisfaction with Drug Product Selection Legislation

REVIEWED RESEARCH

Pharmacists' Satisfaction with Drug Product Selection Legislation By Nawarut Charupatanapong and Karen L. Rascati, PhD Summary

Introduction

The potential for savings from drug product selection is not being fully realized. To determine Texas pharmacists' opinions about various aspects of the Texas Drug Product Selection Legislation of 1981 and to identify barriers to drug product selection, a sample of 1,500 pharmacists were surveyed. Of 959 respondents, 80.7% indicated they were satisfied or somewhat satisfied with the law. The most common reasons for satisfaction were that pharmacists are allowed to use their professional judgment, and the law helps save patients money. The pharmacists rated the physicians' use of the "Dispense as Written" line as the greatest barrier to drug product selection. Those who did not practice drug product selection cited uncertainty about effectiveness or quality of generics, and patients' preference for brand name products. Public education and increased information on generic drug quality are recommended as techniques for achieving the law's intent.

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Nawarut Charupatanapong is a doctoral student and Karen L. Rascati, PhD, is assistant professor at the College ofPharmacy, the University of Texas at Austin, Pharmacy Administration Division, Austin, TX. This article was written while Charupatanapong was a master's degree candidate. Recei ved December 1987; accepted May 1988.

he implementation of Section 40 of House Bill 1628 (Texas Pharmacy Act, 1981) in January 1982 made it legal for pharmacists in the state of Texas to select less expensive generic drug products in dispensing prescription medications rather than brand name drug products. Texas mandates a double signature line prescription form that allows the prescriber to sign on either the "dispense as written" or "product substitution permitted" line.

Background wo years after the adoption of this legislation, a study was conducted to evaluate the extent of drug product selection being performed by Texas pharmacists. 1 Although a 40% savings was reported when the pharmacist dispensed a generically equivalent drug, the generic selection rate in terms of percentage of total audited dispensed prescriptions was only 3%. This was lower than the national average of about 5%. 2 That study concluded that one

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possible reason for this low rate of drug product selection was that in 65% of the prescription orders surveyed, the physician had signed on the "dispense as written" (DAW) line, thus giving the pharmacist no option for generic selection. It also was found that pharmacists simply chose not to select the generic product even when allowed. The 1983 National Substitution Audit found that in states with double signature line prescription forms, the overall rate of dispensing generic products for new prescriptions was 3.9%, whereas in states without this provision (for example, when the prescriber must write "dispense as written" or check a box indicating no substitution), the rate was 5.5%.2 This reflects the finding that in states with double signature line prescription order forms, prescribers prohibited drug product selection 60% to 70% of the time (vs 3% to 5% in other states). 2 The double-line prescription order form is one barrier to drug product selection, but it is not the only barrier. Results of the Texas study indicated that of the prescription orders written for a brand name and where generic selection was allowed by the physician, drug product selection still occurred only 12.5% of the time.! This low percentage raises many questions that need to be studied. Why are Texas pharmacists reluctant to select generic drug products? Does stocking both the generic and brand name products increase in-

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I ventory

chain pharmacists. A pretest was given to 156 community pharmacists in the Austin area. In February 1987, some 1,500 survey packets containing the questionnaire, a request-for-results postcard, the first cover letter, and a preaddressed postage-paid return envelope were mailed. Two weeks after the mailing, 1,500 reminder/thank you postPurpose of This Study cards were sent to all those surveyed. A second cover letter plus a he intent of the law is to save replacement questionnaire were consumers money. The potential mailed to nonrespondents a month is there, but it is not being fully later. realized. As the previous study has The questionnaire asked pharmashown, there are barriers. This study evaluated Texas pharmacists' cists to indicate their satisfaction satisfaction with the Texas Drug with the Texas Drug Product SelecProduct Selection Legislation. It tion Legislation. Satisfaction was examined what barriers to drug measured using a five-point scale product selection exist, and what ranging from satisfied (1) to discan be done to remove these barriers satisfied (5). An open-ended quesso that Texas consumers can receive tion was provided to determine the the full benefits of the drug product reason(s) for each respondent's satisselection legislation. faction or dissatisfaction. Respondents also were asked to rank a list of eight criteria used in a pharmacist's selection of generic drug products. To determine the pharmacist's IThe intent of the law agreement or disagreement about is to save consumers potential barriers to generic selection, a five-point Likert scale was money. The potential used, ranging from strongly disis there, but it is not agree (1) to strongly agree (5). being fully realized.' The final section consisted of three questions that surveyed the respondent's opinion regarding the Texas Drug Product Selection After the repeal of antisubstituLegislation. The three questions tion laws in many states, attempts were: were made to focus on people's atti• Overall, do you believe the law tudes toward drug product selechas improved the public's image of tion. Several studies concerning a pharmacist, lessened it, or had no these attitudes have been coneffect? ducted, and various perceptions • When you choose not to practice from different groups of people have drug product selection, what are the been discussed. 1-15 Pharmacists, reasons? physicians, and consumers were • Do you believe anything should three groups surveyed by most rebe done to encourage more drug searchers. This study focusses only product selection in Texas? on pharmacists' opinions about variThree statistical methods ous aspects of drug product selecSpearman rank order correlation, tion. Wilcoxon rank sum, and KruskalWallis test - were used in our Methods analyses with p
cost too much? Are the pharmacists concerned about increased liability? Are bioequivalence data not readily available? Do consumers prefer brand name drug products? Do pharmacists increase their profits by not selecting generics?

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Results total of 1,115 pharmacists responded. Of these, 130 were not currently practicing pharmacy and 26 did not complete usable questionnaires. The other 959 completed surveys were used for further analyses. Of those, 466 respondents were independent community pharmacists and 457 were chain pharmacists; the remainder included those who worked in a franchise pharmacy, clinic pharmacy, home heal th care center, HMO, or as a relief (part-time) pharmacist. A total of 80.7% of the respondents indicated that they were satisfied or somewhat satisfied with the Drug Product Selection Legislation; 4.1 % had no opinion; and 15.2% were somewhat dissatisfied or dissatisfied with the law. The overall mean rating (X = 1.96) indicated that on average, Texas pharmacists were somewhat satisfied with the law (1 = satisfiedl5 = dissatisfied). Similar findings existed when respondents were analyzed separately for independent community (X = 2.00) and chain pharmacy (X = 1.92) groups. A Wilcoxon rank sum test showed no statistically significant difference between independent community and chain pharmacy responses. The next analysis compared respondents' satisfaction with the law with the following variables: respondents' current positions (owner

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or part owner vs pharmacy and/or store manager vs staff pharmacist); status of employment (full-time vs part-time); n umber of years licensed; sex; pharmacy school (Texas vs non-Texas); pharmacy location (urban vs rural); and the average number of prescription medications

dispensed per day (upper quartile vs lower quartile). Using Wilcoxon rank sum and Kruskal-Wallis tests, respondents' satisfaction was compared with these demographic variables and no significant differences were found in any of these comparisons.

Table 1. Reasons Texas Pharmacists WerelWere Not Satisfied with Texas Drug Product Selection Legislation Reason

Frequency*

Percentt

Reasons Pharmacists Were Satisfied/Somewhat Satisfied:t: The law helps patients save money

84

15.3

Pharmacists are allowed to use their judgment as professionals

78

14.2

Physicians are not aware of the double-line signature No problem, everything seems fine

52

9.5

44

8.0

Pharmacists do not trust some generic products, question bioequivalency

38

6.9

Reasons Pharmacists Were Dissatisfied/Somewhat Oissatisfied** Pharmacists do not trust generic products 25

18.1

Pharmacists cannot make their own selection because of physicians, patients, and state board

16

11.6

Physicians write" Dispense as written" and do not allow pharmacists to select generics instead of brand name products

13

9.4

10

7.2

9

6.5

Third party programs require generic selection Drug product selection should be patient's choice

Respondents also were asked to state why they indicated the responses given. Those who were satisfied with the law most often cited the fact that it saved their patients money, and it allowed them to use their judgment as professionals. The top five reasons from those who were satisfied and somewhat satisfied and the top five reasons from those who were somewhat dissatisfied and dissatisfied are shown in Table 1.

Most important criteria to use when selecting generic drug products were quality, company reputation, and cost. Next, respondents were given eight criteria to use when selecting generic drug products and asked to rank them according to their importance. They ranked quality, reputation of the company, and cost as the most important. The average ranking of importance is in Table 2. Using the mean rating scores, a Spearman's rank-difference coefficient of correlation (rp) indicated a high degree of correlation between the two rankings from independent and chain pharmacy respondents

* Based on the total number of responses because respondents could give more than one reason. t Calculation based on t he total number of respondents (N = 549 or N = 138). t N = 549, those satisfied/somewhat satisfied who indicated a reason . * * N = 138, those dissatisfied/somewhat dissatisfied who indicated a reason .

(rp = 0.98).

Table 2. Average Ranking of Importance of Criteria Used to Select Generic Drug Products Independent Criteria

Rank*

Mean

All Respondents

Chain SO

Rank*

Mean

SO

Rank*

Mean

SD 1.20

Quality

1

2.10

1.28

1

1.86

1.10

1

1.98

Reputation of Company

2

2 .72

1.53

2

2.85

1.47

2

2.79

1.51

3.14

1.37

Cost

3

3.18

1.36

3

3.15

1.38

3

Availability of Bioequivalence Information

4

3.88

2.26

4

3.42

2.01

4

3.68

2.17

1.64

5

5.19

1.56

5

4.99

1.60 1.50

Delivery Time

5

4.83

Return Goods Policy

6

5.91

1.51

7

6.49

1.45

6

6.20

Packaging

7

6.44

1.35

6

6 .00

1.35

7

6.23

1.38

Availability of Company Representative

8

6.80

1.46

8

6.84

1.31

8

6.8 1

1.39

SD = Standard deviation .

* 1 = most important, 8 = least important

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Table 3. Comparison of Independent vs Chain Pharmacists' Agreement or Disagreement with Items Regarding Potential Barriers to Generic Selection Independent Mean*

Items

SD

Wilcoxon rank sum test (p< )

Chain Mean*

SD

Too often physicians sign the Dispense as written (DAW) line

3.45

1.25

3.50

1.21

0.626

Patients tend to prefer brand name products

2.84

1.09

2.61

1.02

0.001 t

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/I

Management tends to discourage pharmacists from practicing generic drug product selection

1.91

0.92

1.34

0.'66

0.001 t

I have less confidence in the quality of generic products Generics cause a significant increase in inventorycosts

2.79

1.29

2.49

1.13

0.001t

2.74

1.30

2.34

1.19

O.OOlt

My pharmacy does not stock an adequate inventoryof equivalent generics

1.88

0.91

1.79

0.84

0.227

Generics provide a low profit margin

1.87

0.97

1.62

0.79

0.001 t

It is too inconvenient for me to comply with the law I have no incentive to practice drug product sel ection

1.92

0.99

1.73

0.004t

1.90

0.96

1.95

0.88 1.07

0.970

* 1 = strongly disagree, 5 = strongly agree. t Difference in the two means was statistically significant.

Respondents were asked to indicate their extent of agreement on nine items representing potential barriers to generic selection. Results revealed that physicians' use of the DAW line was rated as the greatest barrier, whereas the others, on average, were not seen as barriers eX < = 3.00). Wilcoxon rank sum tests were used to determine if any statistically significant differences occurred between ratings of independent community and chain pharmacy respondents. Of the nine items provided (Table 3), six of them indicated statistically significant differences between settings. On all six items, chain pharmacy respondents indicated a higher level of disagreement than did independent community respondents. When asked how the law affected the public image of pharmacists, nearly half of the respondents (48.2%) indicated that the legislation had improved their public image; 41.3% indicated it had no effect; and 10.4% believed the public's image of a pharmacist had been lessened by this legislation. The top three reasons from those who believe the law had improved, lessened, or had no effect on their public image are in Table 4. When the respondents were asked why they chose not to practice 30

Table 4. Reasons Respondents Believe the Law Has Improved/Lessened/Had No Effect on Public Image Reason

Frequency*

Percentt

Pharmacists help patients save money

192

45.9

Pharmacists have chance to communicate with patients

145

34.7

54

12.9

The controversy between costs and charges for generics has hurt the pharmacists' image. Public no longer perceives pharmacy as a professional career but as a business

41

44.6

Public does not know or understand the law or generic products, does not realize the role of pharmacists in generic selection

10

10.9

Adverse rumors against the generics make patients feel generics are of poor quality

10

10.9

96

34.8

49 -36

17.8 13.0

Reasons Law Has Improved Image:t:

Public perceives pharmacists as knowledgeable Reasons Law Has Lessened Image**

Reasons Law Has Had No Effect on Imagett Public does not know or understand the law and generic products, does not realize the role of pharmacists in generic selection Patients trust pharmacists, believe pharmacists are on their side, so the image is still high in the eyes of the patients Respondents do not know or have no idea

* Based on the total number of responses; respondents could give more than one reason. t Calculation based on the number of total respondents. ::\: N = 418, those who believe the law has improved their image and indicated a reason for this belief. * * N = 92, those who believe the law has lessened their image and indicated a reason for th is belief. tt N = 276, those who believe the law has had no effect on their image and indicated a reason for this belief.

American Pharmacy, Vol. NS28, No. 10 October 1988/638

drug product selection, their most commoniy cited reasons were that they were not sure of the effectiveness or quality of some generics (n= 404), and that some patients prefer brand name drugs (n = 280). Other reasons given among the top five were: pharmacists did not dispense generics for some critical diseases, especially when the ailments were serious or life-threatening (n = 165); prescribers prohibit drug product selection by signing on the

Pharmacists chose not to practice drug product selection because they were not sure of the effectiveness or quality of some generics, and some patients prefer brand name drugs.

each state's drug product selection regulations. Nevertheless, this study sampled a large number of Texas pharmacists and a high response rate was obtained. Although the high response rate supports generalization to pharmacists practicing in Texas, the results should not be generalized to pharmacists practicing in other states. The probable primary reason no significant differences were found when comparing satisfaction of the law with other variables is that the majority of respondents (80.7%) indicated they were satisfied or somewhat satisfied with the law. Second, the five-point scale used to measure respondents' satisfaction did not allow for extremes (ie, very satisfied or very dissatisfied). Third, although some respondents reported they were satisfied or somewhat satisfied with the law, some of the reasons they gave were the same as those given by respondents who said they were dissatisfied or somewhat dissatisfied. In such cases, it was difficult to interpret whether or not those respondents were actu-

ally satisfied or dissatisfied with the law. Fourth, for those who reported they were dissatisfied, the law itself was not mentioned as the major problem; rather, the quality of some generic drugs was rated a major reason. The Spearman rank order correlation found no significant difference between independent community and chain pharmacy respondents in regard to factors that pharmacists use in selecting generic drug products. Findings in this study were similar to studies done in other states that looked at factors infl uencing pharmacists' decision making in product selection. Quality, reputation of the company, and cost were the three common factors found to be important in Florida, 3 Kentucky,4 and Drug Topics 5 generic drug surveys. Wilcoxon rank sum tests showed significant differences in six out of nine factors regarding potential barriers to generic drug product selection between independent community and chain pharmacy respondents. Contrary to what might

DAW line (n = 154); and the particular generic drugs are unavailable (n= 146).

Finally, respondents were asked whether anything should be done to encourage more drug product selection in Texas. Of 959 respondents, 442 believe that something should be done, 308 believe nothing should be done, and 209 chose not to answer the question. For those who believe something should be done, the prescriber's prohibition on the DAW line was the problem cited most frequently. For those who believe nothing should be done, the most common reason was that they Were satisfied with the present law. The top five reasons from respondents from both groups are listed in Table 5.

Discussion

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he results from this study are limiting because they are based on a sample from only one state. Although similar studies in other states were conducted, conclusions cannot be compared with those studies because of differences both in the study methods used and in

Table 5. Reasons Respondents Believe Something/Nothing Should Be Done to Encourage More Drug Product Selection in Texas Reason

Frequency*

Percentt

192

43.4

Reasons Something Should Be Done:!: DAW is the problem; physicians should be educated about the law and the quality of medications they prescribe Public should be educated about the law and the positive aspects of generic products

91

20.6

Prod uct selection shou Id be decided by pha rmacists Generics help patients save money on medications

81

18.3

74

16.7

Generic drugs' quality should be controlled

62

14.0

Reasons Nothing Should Be Done** Pharmacists are satisfied with the present law

96

31.2

Product selection should be decided by patients

47

15.3

Product selection should be decided by pharmacists

37

12.0

Generic drugs' quality should be controlled

33

10.7

Public should be educated about the law and the positive aspects of generic products

24

7 .8

* Based on the total number of responses; respondents could give more than one reason. t Calculation based on the total number of respondents. :t: N = 442, those who believe something should be done to encourage more drug product selection in Texas and indicated a reason for the belief. ** N = 308, those who believe nothing should be done to encourage more drug product selection in Texas and indicated a reason for the belief.

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to be considered when selecting a Substitution Permitted (PSP) line generic drug product were quality, or by specifically indicating when reputation of the company, and cost. they want a single-source product The most highly agreed upon potento be dispensed. ® tial barrier to drug product selection was that too often physicians References sign the DAW line. 1. M .D. Shepherd et al., An ExaminaNearly half of Texas pharmacists tion of Drug Product Substitution believe the legislation has improved in Texas Two Years After Enacttheir public image; about 40% indihave been expected, chain pharment of Legislation, J P harmaceut Marketing Management, 1, 97 cated it had no effect; and 10% bemacy respondents reported a higher (1986). lieve the public's image of a pharmalevel of disagreement than indepen2. R .C. Zeich, Substitution Audit cist has been lessened by this legisdent community respondents to two Cites Six-Year Gains, Drug Topics, lation. The major reason given for statements: 127, 72 (1983). an improved image was that phar• Management tends to discourage 3. G.J. Vuturo etal., AttitudesofPharpharmacists from practicing gemacists help patients save money. macists and Physicians Toward A major reason for lessened image neric substitution; Florida's Drug Product Selection was that the controversy between • Generics provide a low profit Law, ContempPharmPract, 3, 156 margin. costs and charges has hurt the phar(1980). On the other hand, there was no macists' image; the public no longer 4. H.A. Smith et al., Views of Kentucky Pharmacists on Drug Prodsignificant difference found be- percei ving pharmacy as a profesuct Selection Issues, Am J Pharm, tween the two groups on three po- sion, but rather as a business. 155, 77 (1983). tential barriers: The most commonly cited reason 5. Anon., How Today's Pharmacists • Too often physicians sign the pharmacists chose not to practice Feel About Generics, Drug Topics, DAW line; drug product selection was that 129, 32 (1985). • My pharmacy does not stock an they were not sure of the effective6. T Goldberg et al., Evaluation ofImadequate inventory of equivalent ness or quality of generics. About pact Drug Substitution Legislagenerics; half of the responding pharmacists tion, J Am Pharmaceut Assoc, • I have no incentive to practice thought something should be done NS16, 64 (1976). drug product selection. to encourage drug product selec7. Anon., How Pharmacists View Both groups commonly agree tion; most of these pharmacists comDrug Product Selection, Pharmacy with the first statement, but disTimes, 42, 53 (1976). mented that the DAW line is a prob8. Anon., What 1,000 Chain Pharmaagree with the last two statements. lem and that physicians and the cists Think, Chain Store Age, 47, public should be educated about the As indicated, most respondents 26 (1971). law. agreed that the physician's use of 9. Anon., RPh's Pass Up Most OpporSince this study identified the the DAW line was a major problem. tunities to Substitution, A .D. SurConcerning this issue, one interest- problems but did not focus on physivey Discloses, American Druggist, ing comment was that some physi- cians' prescribing habits, future 178, 12 (1978). studies are recommended to learn cians signed on the DAW line even 10. WC. McCormick and R.W. Hammore about prescribers' attitudes in though a generic drug was premel, Pharmacists' and Physicians' drug product selection. Many pharscribed. Respondents suggested Attitudes Toward Removal of the macists, when asked to make addiProhibition on Brand Substitution: that the reason this happens is that A Comparative Study, Med Markettional comments, indicated that the the DAW line is usually located on ing Media, 7, 27 (1972). the right-hand side of the prescrip- public's awareness of the law and 11. T.J. McCormick, Are Pharmacists i generic drug products also needs to tion form, where the signature line Beginning to Substitute More? has traditionally been for many be increased. Med Marketing Media, 19, 32 years, and thus many physicians (1984). sign on that line without the inten12. Anon., The Retail Druggist: A Recommendations tion of prohibiting drug product Growing Influence in Drug Selec- , selection. o achieve the intent of the Texas tion, Med Marketing Media, 18, 38 ! Drug Product Selection Legisla(1983). i tion, the results of this study indi- 13. Anon., Chain Pharmacists Are I Conclusions Found More Likely Than Indeps to I cate: Use Unbranded Generics, A mer- I n the average, Texas pharma• Information on generic drug ican Druggist, 186, 13 (1982). : quality should be more readily cists were found to be satisfied 14. R.H. Hunter, The Ohio Generic I with the Texas Drug Product Selecavailable; Product Selection Law: Influence i tion Law. The most common reasons • The public should be educated on Pharmacy Practice, M ed M ar- j for satisfaction with the law were about the law and generic drug keting Media, 14, 33 (1979). ! that pharmacists are allowed to use products; 15. M.J. Myers and J .L. Fink, Effective- : their ownjudgment as professionals • Prescribers need to increase their ness of Drug Product Selection and that the law helps patients save Legislation in Delaware, Contemp roles in drug product selection Pharm Pract, 1, 4 (1978). money. The most important items either by signing on the Product

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