Resistance to in-office dispensing of generic antibiotic samples.

Abstract

In this issue of JMCP, Conklin, Culley, and O’Donnell describe the results of an initiative to foster greater use of generic antimicrobial medications through the use of an in-office automated generic medication samples kiosk.1 A similar report describing the result of this initiative on overall rates of generic product use and cost was previously published in the June 2007 issue of JMCP.2 In the current study examining the impact of the kiosk program on prescribing of antimicrobial drugs specifically, the authors found that rates of “first-line” (generic) antimicrobial use, measured as a proportion of all antimicrobial prescriptions, were similar among network prescribers with versus without access to the medication kiosks (42.0% vs. 41.4%, respectively; P = 0.028) in 2006, the most recent year measured. For the same year, the authors report a lower average cost per antimicrobial claim among prescribers with kiosk access ($28.44) than among those without access ($32.40; P < 0.001). The authors also compared mean cost per antibiotic claim and rates of use of “first-line” (generic) antibiotics between the 2 groups using a difference-in-difference analysis that measured change from the pre-intervention year (2003) to the post-intervention year (2005). They found that rates of use of “first-line” (generic) antibiotics declined among both groups during this 2-year period, from 49.1% to 47.0% (-2.1%) among prescribers having access to the samples kiosks and from 46.0% to 42.6% among the other network providers (-3.4%). The between-group difference in the magnitude of this reduction was not found to be statistically significant. Average cost per claim was also less in 2005 as compared with 2003 for both groups (changes from $33.56 to $29.42 for the kiosk users versus $38.26 to $34.91 for the other network providers), yet the between-group difference in magnitude of the reduction in antibiotic drug cost was also found to be statistically insignificant. The premise of this intervention is a logical one. In many instances, lower-cost generic medications are a cost-effective substitute for higher-priced brand name products, particularly in generic substitution, and also when it is within the boundaries of evidence-based care to utilize a generic drug from a different therapeutic class in place of a branded product that does not have a generic substitute (i.e., therapeutic selection). Increasing access to generic antimicrobials via the use of in-office medication kiosks represents a novel approach in attempting to reduce the over-prescribing of broad spectrum higher-cost antibiotics. Yet this method of facilitating access to generic antibiotics raises a range of important issues, including what constitutes appropriate antimicrobial drug use from the perspective of the health plan, the implications of drug dispensing in the absence of pharmacist involvement, and overall, the role of drug sampling programs within our health care system. Moreover, this study provides another example of the drug product being parsed from the service, with technology having a fundamental role in reshaping the order fulfillment process. Specifically, pharmacists are increasingly providing patient education and counseling without having a direct role in the order-fulfillment function because newer dispensing technologies are enabling order fulfillment with diminishing pharmacist involvement. Yet, order fulfillment in the absence of pharmacist counseling raises substantial concerns with respect to patient safety and promoting appropriate medication use. Thus, we believe that it is imperative that the health professions, regulators and health plans consider the broader implications of newer technologies, such as the medication sampling kiosk initiative described in this study.