International Non-proprietary Name Prescribing Research Articles

Assessment of medicine use among outpatients at healthcare facilities in Ethiopia using the WHO's prescribing indicators with a focus on antibiotics: a systematic review and meta-analysis.

To summarize studies on prescribing medicine to general outpatients through the WHO/International Network for Rational Use of Drugs (INRUD) prescribing indicators with a focus on antibiotic prescription. A systematic review and random-effects meta-analysis of studies on the WHO prescribing indicators with a focus on the percentage of encounters with antibiotics prescribed (PEAP) was performed. The databases PubMed, Web of Science, EMBASE and Global Index Medicus were searched. Twenty-six studies with a total of over 34 000 prescription encounters were included in the systematic review, showing a mean of two medicines per encounter. In each meta-analysis, a range of 19 to 25 studies was included. The percentages of medicines prescribed with an international non-proprietary name (INN) and from the essential medicines list (EML) were 91% and 96% of the total number of medicines, respectively, while 19% of encounters contained injections. Studies with over 25 000 prescription encounters reported an average PEAP of 58% and PEAP showed an increasing trend over the years included in this review. Multivariable meta-regression showed that PEAP increased with the average number of medicines per encounter (estimate = 0.83, P value = 0.0005). The number of medicines, study design and year of prescription explained over 40% of the variation in PEAP across studies. Patterns of medicine use within and close to the WHO reference values were reported for the number of medicines, INN prescribing, prescription of injections and compliance with the EML, on average. Prescription of antibiotics requires attention as amounts much higher than the reference values were prescribed, which were even higher with polypharmacy and increasing over the years included in this review.

Prescribers’ and dispensers' views about generic medicines and international non-proprietary name prescribing – a mixed methods study in Portugal

PurposeThis study aims to explore the views of pharmacy professionals (PPs) in Portugal about generic medicines and international non-proprietary name (INN) prescribing and compare them with the views of general practitioners (GPs).Design/methodology/approachA self-administered questionnaire was used to collect data from a sample of 185 community PPs and 85 GPs. Their perceptions were examined using a five-point Likert scale applied to statements focusing on five main topics of interest: motivation, safety, users’ perceptions and knowledge, advantages and disadvantages of generic medicines and INN prescribing. Daily experiences and suggestions for decreasing health and pharmaceutical expenses were explored through open-ended questions. Nonparametric tests were used to compare attitudes between both groups and to explore associations between the level of agreement and respondents’ demographic characteristics. Content analysis was used to categorize the answers to the open-ended questions.FindingsGenerally, GPs expressed more negative opinions toward generics and INN prescribing than PPs. GPs perceived generics as less effective, less safe, inferior in quality, more likely to cause side effects and believed that users do not trust them. Both groups believed that patients remain very confused and ill-informed about generics, only adhering to them because of their low cost and expressed concerns about the existence of an excessive number of generic medicines and the lack of patients’ responsibility toward medicines costs.Originality/valueTo the best of the authors’ knowledge, this study represents the first attempt to elicit and compare Portuguese GPs and PPs opinions concerning INN prescribing.

Ongoing activities to influence the prescribing of proton pump inhibitors within the Scottish National Health Service: their effect and implications

Introduction: There has been a considerable increase in the use of proton pump inhibitors (PPIs) in recent years due to their effectiveness versus H2 antagonists. This includes reducing GI bleeds in patients at risk. However, there are concerns with their long term use and potential costs. Costs can be reduced with increased prescribing of low cost generic PPIs. Aims: To analyse the influence of multiple demand-side measures in Scotland in recent years to increase the prescribing of low cost generic PPIs as well as encourage the prescribing of lower strength PPIs. Methods: Documenting utilization (mainly items dispensed) and expenditure in Scotland from 2001 to 2017 using health authority databases combined with documenting the multiple initiatives and measures both nationally and regionally. Results: The multiple measures in Scotland ensured high International non-proprietary name prescribing (up to 100% for some PPIs) as well as the prescribing of generic versus patented PPIs, with costs of generic PPIs as low as 8.5% of their pre-patent loss prices. Overall, total expenditure on PPIs in Scotland was 66.7% lower in 2017 at GB£18.83million compared to 2001 levels. This was despite a 3.06-fold increase in PPI utilization during this period. The savings were driven by the increasing use of generic omeprazole and lansoprazole versus patent protected PPIs. There was also a reduction in the prescribing of high strength PPIs during this period. Conclusion: Multiple initiatives in Scotland in recent years have reduced expenditure on PPIs despite appreciably increased utilisation. Multiple initiatives have also helped to reduce the prescribing of higher strength PPIs. This is an exemplar to other countries seeking to enhance their prescribing efficiency

Ongoing activities to optimize the quality and efficiency of lipid-lowering agents in the Scottish national health service: influence and implications

ABSTRACTBackground: Prescribing of lipid-lowering agents (LLAs) has increased worldwide including in Scotland with increasing prevalence of coronary heart disease, and higher dose statins have been advocated in recent years. There have also been initiatives to encourage prescribing of generic versus patented statins to save costs without compromising care. There is a need to document these initiatives and outcomes to provide future direction.Method: Assessment of utilization (items dispensed) and expenditure of key LLAs (mainly statins) between 2001 and 2015 in Scotland alongside initiatives.Results: Multiple interventions over the years have increased international nonproprietary name prescribing (99% for statins) and preferential prescribing of generic versus patented statins, and reduced inappropriate prescribing of ezetimibe. This resulted in a 50% reduction in expenditure of LLAs between 2001 and 2015 despite a 412% increase in utilization, increased prescribing of higher dose statins (71% in 2015) especially atorvastatin following generic availability, and reduced prescribing of ezetimibe (reduced by 72% between 2010 and 2015). As a result, the quality of prescribing has improved.Conclusion: Generic availability coupled with multiple measures has resulted in appreciable shifts in statin prescribing behavior and reduced ezetimibe prescribing, resulting in improvements in both the quality and efficiency of prescribing.

Medical specialists' knowledge, perceptions and views about generic medicines in Malaysia: Findings from a qualitative study and the implications

Background and objective Medical specialists have an essential role in promotion of generic medicines. However, misconceptions and negative perceptions about generic medicines among them could be a barrier to utilization of generic medicines. Therefore, the aim of this study was to explore their knowledge, perceptions and views about generic medicines. Methods A qualitative methodology was adopted in this study. A qualitative descriptive study with phenomenology overtones was the research strategy. Face-to-face semi-structured interviews were conducted with a purposive sample of medical specialists until saturation of data was achieved. The interviews were audio taped and transcribed verbatim. Then, the subsequent transcripts were analysed using thematic analysis. The themes were generated using both deductive (theoretical) and inductive coding. To ensure reliability of data analysis, peer review and independent analysis of the data were done. Results Five major themes were identified: (1) factors affecting specialists' prescribing practice with regard to generic medicines and original brand medicines, (2) specialists' perceptions of efficacy, safety and quality of generic medicines, (3) specialists' knowledge and confidence with Malaysian generic regulatory approval system, (4) drug information sources used by the specialists and (5) international non-proprietary name prescribing. Conclusion The study findings showed that several factors influenced prescribing decision with regard to the brands of the medicines including familiarity and experience with generic medicines, clinical condition of the patient, availability of the medicine brand in the hospital and department financial allocations. Moreover, misconceptions about quality, safety, efficacy and bioequivalence of generic medicines were prevalent among some participants. Furthermore, many participants were not familiar with the Malaysian generic medicines approval system. Therefore, medical specialists' concerns need to be addressed. Some recommendations and suggestions were made to improve generic medicines utilization in the country.

Review of ongoing initiatives to improve prescribing efficiency in China; angiotensin receptor blockers as a case history

Introduction: Pharmaceutical expenditure is rising by 16% per annum in China and is now 46% of total expenditure. Initiatives to moderate growth include drug pricing regulations and encouraging international non-proprietary name prescribing. However, there is no monitoring of physician prescribing quality and perverse incentives. Objectives: Assess changes in angiotensin receptor blocker (ARB) utilization and expenditure as more generics become available; compare findings to Europe. Methodology: Observational retrospective study of ARB utilization and expenditure between 2006 and 2012 in the largest hospital in Chongqing district. Results: Variable and low use of generics versus originators with a maximum of 31% among single ARBs. Similar for fixed dose combinations. Prices typically reduced over time, greatest for generic telmisartan (−54%), mirroring price reductions in some European countries. However, no preferential increase in prescribing of lower cost generics. Accumulated savings of 33 million CNY for this large provider if they adopted European practices. Conclusion: Considerable opportunities to improve prescribing efficiency in China.

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.

What hinders general practitioners to prescribe cheaper? The use of International Non-proprietary Name (INN) in Belgium

Background Pharmaceutical expenses keep exerting pressure on health expenditures across Europe. A common strategy to stimulate the use of cheaper medicines is generic substitution and the use of the International Non-proprietary Name (INN) in medicine prescribing. Since 2006, Belgian physicians have to reach a minimum of ‘cheap’ prescriptions per year (including INN prescriptions). INN prescribing can result in considerable savings for patient and health insurance in Belgium. Since …

Physicians’ perception of generic and electronic prescribing: A descriptive study from Jordan

ObjectivesThe aim of this study was to investigate Jordanian physicians’ perception and attitudes toward generic medicines and generic substitution. It also aimed to examine factors that affect physicians’ pattern of prescribing, and to evaluate their opinion regarding future introduction of Electronic Prescribing (EP) in Jordan.MethodsA cross-sectional descriptive study involving Jordanian physicians working in both public and private sectors was undertaken, using a self-administrated anonymous questionnaire. Frequency tables, cross-tabulation and chi square tests were used for data analysis. The response rate was 75.2% (n = 376/500).ResultsCost was claimed to be an important factor in the prescribing decision for 69.1% of the Jordanian physicians. The majority of physicians (77.4%) claimed that they often prescribe generic medicines. Jordanian physicians predominantly welcomed the implementation of an EP and International Nonproprietary Name (INN) prescribing systems with 92%, and 80.1% respectively. More than two thirds of the physicians (69.4%) accepted generic substitution by pharmacists, with a significant association with their employment sector; physicians who work in the private sector tended to oppose generic substitution compared with physicians who work in the public sector. Physicians mostly (72.1%) opposed that generic substitution should only be allowed upon patient request.ConclusionsJordanian physicians have a positive attitude towards generic medications and high willingness and acceptance of strategies that encourage generic utilisation such as EP, INN prescribing and generic substitution. All these strategies would help reduce the high expenditure on medicines in Jordan. These findings would provide baseline data to policy makers to develop a robust generic policy to achieve greater clinical effectiveness and economic efficiency from medicines prescribing.

Does educational intervention improve doctors' knowledge and perceptions of generic medicines and their generic prescribing rate? A study from Malaysia.

Objectives:To investigate the impact of an educational intervention on doctors’ knowledge and perceptions towards generic medicines and their generic (international non-proprietary name) prescribing practice.Methods:This is a single-cohort pre-/post-intervention pilot study. The study was conducted in a tertiary care hospital in Perak, Malaysia. All doctors from the internal medicine department were invited to participate in the educational intervention. The intervention consisted of an interactive lecture, an educational booklet and a drug list. Doctors’ knowledge and perceptions were assessed by using a validated questionnaire, while the international non-proprietary name prescribing practice was assessed by screening the prescription before and after the intervention.Results:The intervention was effective in improving doctors’ knowledge towards bioequivalence, similarity of generic medicines and safety standards required for generic medicine registration (p = 0.034, p = 0.034 and p = 0.022, respectively). In terms of perceptions towards generic medicines, no significant changes were noted (p > 0.05). Similarly, no impact on international non-proprietary name prescribing practice was observed after the intervention (p > 0.05).Conclusion:Doctors had inadequate knowledge and misconceptions about generic medicines before the intervention. Moreover, international non-proprietary name prescribing was not a common practice. However, the educational intervention was only effective in improving doctors’ knowledge of generic medicines.

Operational rules for the implementation of INN prescribing

PurposeThe aim is to describe the process, principles and results of the International Nonproprietary Name (INN) prescribing project in Belgium. The purpose of this project was to operationalize electronic INN prescribing for outpatient care in daily medical practice and to develop a factual database which can be used in electronic INN prescribing applications. MethodsThe operationalization process consisted of three phases: (1) expert consultation, (2) review by regulatory authorities and (3) test phase with stakeholders and end-users. ResultsThe INN prescribing project resulted into (1) operational rules for electronic INN prescribing and (2) a reference database to be implemented in commercial medical software. The operational rules for electronic INN prescribing define valid INN groups as sets of equivalent medicinal products, described by three elements: the therapeutic moiety (the active part of the therapeutic ingredient) or combination of therapeutic moieties, the strength (with standardized denominators), and the method of administration (with simplified but standardized options). The operational rules also define two categories of exemptions for INN prescribing: INN groups where the first choice of treatment should be continued throughout the therapy period (NO SWITCH) and medicinal product groups not suitable for INN prescribing (NO INN). The reference database is the result of the virtual classification of the Belgian therapeutic arsenal into INN groups, according to the operational rules. ConclusionsDefining the operational rules for INN prescribing for and with different stakeholders was a difficult yet feasible assignment. The INN prescribing project resulted into explicit operational rules and a reference database. The Belgian experience may provide important information for other countries planning to operationalize or refine electronic INN prescribing. It can also be used for a thorough evaluation of the impact of the new concept of INN prescribing on daily practice and on medical education.

주요국의 제네릭 의약품 활성화 정책 고찰과 시사점

Backgrounds: Escalating pharmaceutical expenditure has threatened the sustainability of National Health Insurance system in Korea. Generic medicines allow patients to access safe, effective, high-quality medicines at low cost, thus insurers could achieve significant financial savings by promotion of generics, if they are priced much lower than the originator. The purpose of this study was to review generic pricing as well as promotion policies in other countries and assess the implication of those policies. Methods: We reviewed the main measures adopted by the developed countries such as Austria, Belgium, Denmark, Finland, France, Germany, Italy, Japan, Netherlands, Norway, Sweden, United Kingdom, especially in countries where governments are the largest third-party payers or insurance finance resource is the national health insurance. Results: The foreign countries’s experience with generic medicine policy shows that demand-side policies such as physician budgets, international nonproprietary name prescribing, generics substitution, patients co-payment as well as supply-side policies relating to pricing and reimbursement seems to play a critical role in developing the generic medicines market.Conclusion: Various strategy should be implemented to promote generic drug use.Keywords: Generic drugs; Drug policy; Costs and cost analysis; Generic use

Reforms and initiatives in Scotland in recent years to encourage the prescribing of generic drugs, their influence and implications for other countries

Scotland has introduced a number of initiatives to enhance the prescribing of low-cost generic drugs versus originators and patent products in a class where these are seen as similar. The objective of this review is to appraise the influence of the various measures on subsequent utilization patterns and expenditure in high-volume classes to provide guidance. This review is principally a narrative review of published studies. The authors’ found supply-side measures resulted in generic prices as low as 3% of pre-patent loss prices. Multiple demand-side measures resulted in high international non-proprietary name prescribing, and a considerable increase in prescribing efficiency for the proton pump inhibitors, statins, renin–angiotensin inhibitor drugs and selective serotonin reuptake inhibitors. There were no specific activities encouraging the prescription of losartan versus other angiotensin receptor blockers or risperidone versus other atypical antipsychotic drugs following generics and no change in their utilization patterns post generics. The authors can conclude multiple measures are needed to change physician prescribing habits. Authorities cannot rely on any ‘spillover’ effects to affect future prescribing, even in closely related classes.

What lessons can be learned from the launch of generic clopidogrel?

Resource pressures will continue to grow. Consequently, health authorities and health insurance agencies need to take full advantage of the availability of generics in order to continue funding comprehensive health care particularly in Europe. Generic clopidogrel provides such an opportunity in view of appreciable worldwide sales of the originator. However, early formulations contained different salts and only limited indications. Consequently, there is a need to assess responses by the authorities to the early availability of generic clopidogrel including potential reasons preventing them from taking full advantage of the situation. In addition, it is necessary to determine the extent of initial price reductions obtained in practice to guide future activities. Feedback from health authorities and health insurance personnel involved with the reforms surrounding generic clopidogrel was principally used to assess authority responses as there is limited information in the public domain. Abu Dhabi has been included as a representative of the Middle East since it has introduced compulsory international non-proprietary name (INN) prescribing except for limited situations. Generic clopidogrel is not one of these – providing direction to other health authorities alongside, e.g. Lithuania. Australia has also been included in view of the high court ruling in favour of generic clopidogrel. Authorities from across Australia, Europe and the Middle East typically adopted a pragmatic approach to the availability of generic clopidogrel to enhance its prescribing and dispensing once approved by regulatory agencies such as EMA. This included guidance to enhance its utilisation such as academic publications, co-payment incentives and compulsory INN prescribing. However, this was not always possible with challenges to the availability of generics in some countries. Again, there was appreciable variation in the initial price reductions for generic clopidogrel versus the originator. Authorities can take full advantage of the early availability of generics despite different formulations and indications. Pharmaceutical companies need to accept this in order to help fund new premium price products as resource pressures grow.

Initiatives to enhance the quality and efficiency of statin and PPI prescribing in the UK: impact and implications

Aim: To assess the impact of a range of national and regional initiatives introduced in the North Lancashire Teaching Primary Care Trust (NLTPCT) since 2004 to enhance the quality and efficiency of prescribing proton pump inhibitors (PPIs), statins and ezetimibe. In addition, to suggest additional measures that could be introduced in NLTPCT to further enhance the quality and efficiency of prescribing based on initiatives in other European countries. Method: A before-and-after observational study was undertaken on the utilization and expenditure of prescriptions dispensed in ambulatory care in NLTPCT from 2004 to 2007. Utilization was assessed using ‘defined daily doses’ (DDDs) and ‘DDDs/1000 inhabitants per day’ and compared over the study period. Reimbursed expenditure was assessed in terms of overall expenditure, expenditure/DDD, as well as expenditure/1000 inhabitants per year. Results: The combination of measures and initiatives enhanced the utilization of generic PPIs. International Nonproprietary Name (INN) prescribing of omeprazole reached 98% of all omeprazole by 2007. The measures also resulted in limited utilization of esomeprazole and lowered reimbursed expenditure/DDD of generic omeprazole to GB£0.13 by 2007. This was 87% below 2004 originator prices, leading to a 41% fall in PPI expenditure during the study period despite increased utilization. Utilization of statins grew by over 130% during the study period enhanced by increased utilization of high doses of simvastatin and atorvastatin following the introduction of the quality and outcomes framework. Simvastatin dominated statin utilization by 2007, with generic simvastatin accounting for over 99.5% of total simvastatin. Reimbursed expenditure/DDD for generic simvastatin was £0.03 in 2007, 95% below 2004 originator prices, leading to a fall in overall expenditure on statins. It proved difficult to undertake an impact analysis as, typically, a range of measures were introduced sequentially and simultaneously during the study period. Conclusion: The findings are in line with expectations and do provide examples to other European countries. This includes a high rate of INN prescribing, low reimbursed prices for generic simvastatin and omeprazole and growing utilization of higher strength statins. The high rate of INN prescribing reduces the need for additional measures that have been instigated in other European countries to further enhance the prescribing and dispensing of generics to fully realize the resource benefits. Additional demand side measures are feasible and have already been instigated to conserve resources.