Study results: Underutilization of generics by U.S. Ophthalmologists

One of the highest healthcare costs for patients in the United States is prescription drug spending. Each year prescription drug spending reaches around $300 billion of the total national healthcare expenditure, this number keeps on rising every year.

Generic medications are approved by the FDA and have similar effectiveness and quality as brand-name medications. They also contain the same chemical substance as the drug that was originally protected by chemical patents. They are also allowed for sale after the patent on the original drug expires. Furthermore, generic drugs cost less than other branded drugs. The use of it will help poor people get their needed medication and prevent the rising cost of medicine in the US healthcare system.

So, if they cost less and are also effective, why aren’t they popular?

According to a nationwide survey of chronically ill older adults, 66% of participants report underuse of generic drugs “due to cost concerns, never informed their clinician that they did not intend to adhere to the medication regimen, and 35% never discussed the issue of cost concern at all”.

This is very true in the field of ophthalmology where many conditions are managed through preventive treatments and pharmacotherapy. According to a 2018 published analysis of Medicare Part D, this field forms the largest percentage of brand name medications and the lack of generic alternatives is one of its biggest issues.

Overview of the Study
92 board-certified ophthalmologists in the US were surveyed regarding their opinions on generic and brand name medications. The study aims to find out different factors that might be influencing their prescribing habits. The study also hypothesized that there are reasons as to why this is happening. One of these may be ophthalmologists’ negative opinions of generic medications. The study aims to identify negative perceptions of generic drugs and the characteristics of ophthalmologists who have these perceptions. Findings can help educate people into creating drug policies that will result in a better cost of health care.

Methods
A standardized cross-sectional survey with an IRB approved consent letter was given to currently practicing board-certified ophthalmologists located in the Midwest region of the United States (Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, South Dakota, Ohio, and Wisconsin)

All participants were provided informed consent and were protected by their anonymity. Chosen physicians also weren’t given incentives or benefits for participating in the study. The responders gave self-reported information, all answers were assumed honest and accurate. It was approved by the University of Nebraska Medical Center Institutional Review Board and was distributed and collected through Google Forms in this timeframe: July 2018 – April 2019.

Ophthalmologists who took the survey were reached through email, online office contact forms, or via individual state ophthalmology societies. There was a total of over 700 ophthalmologists via state societies, and 374 independent ophthalmologists practicing at academic institutions.

The survey included questions that were overall related to ophthalmologists’ views and knowledge about brand-name and generic drugs. It included questions about the cost, quality, and safety of the drug, patient feedback, and their own prescribing choices.
Study Results

● 56.5% of ophthalmologists in our survey perceived that patients preferred generic drugs
● 38% were unsure whether patients preferred generics
● 55% of participants report they have no reservations about prescribing generic drugs over brand-name drugs.
● 44.6% had at least one reservation. First, switching of generics based on pharmacy contracts and the variation between generics, and second, the additives in generics that can vary based on production lots and manufacturers.
● 44.6% of ophthalmologists said that they would increase generic prescriptions if they knew their patients would stay on only one generic rather than getting switched based on pharmacy contract and/or supply.
● 40% of participants say they were extremely knowledgeable about the available options of generic drugs
● 22.9% of ophthalmologists reported 3 or lower on the Likert scale for knowledge
about the availability of generic options
● 31% of office visits of glaucoma patients included discussion about cost
● 29% of participants say that drug representatives didn’t visit their clinic

The high cost of drugs and medication is one of the leading reasons why many people aren’t able to get proper treatment. If patients can’t afford brand-name drugs and medication, doctors must recommend generic drugs. They should strive to help their patients get the best treatment options that they can afford.

Lack of Generic Alternatives
Another reason why doctors often prescribed brand-name drugs is the lack of generic alternatives. For example, commonly prescribed medications such as cyclosporine don’t have generic counterparts.

Lack of Knowledge About Costs
The study found three variables that correlate with switching patients to generic drugs: generic options, price difference, and patient preference. It’s important to educate ophthalmologists about generic options and the price difference between generic and brand-name drugs as their understanding and opinion can greatly affect that of their patients.

Patients Hesitant on Using Generic Drugs
There are also cases when it is the patient themselves who are hesitant to use generic drugs because of efficacy concerns. This wrong notion can be extremely crippling especially for patients in greater financial need. For these cases, it’s important that patients are educated to increase generic drug utilization.

Ophthalmologists Preference Bias
The study also found four variables that affect ophthalmologists’ willingness to switch to generic drugs: 1) increased disease severity, 2) anecdotal feeling and 3) personal preference for taking the brand name.

● The severity of the disease. Out of the 92 respondents, 20 said that if the eye disease is more severe, they were more likely to prescribe a brand-name drug.
● Anecdotal feelings that outcome is affected by the choice of the brand name.
● Personal preference – When asked about a hypothetical scenario where they could pick between both free generic and brand-name drugs, 40 out of 92 said that they prefer brand-name drugs due to personal preference.
Study Limitations
● The study does not fully represent all board-certified ophthalmologists in the US as participants were all from the Midwest region.
● Practice setting can also influence prescribing habits. Those who work in academic and private practice settings may have different ways. The majority of participants are those from academic settings.
● Survey answers are always subject to reporting bias.
Conclusion
Based on the outcomes of the study, the researchers have a few suggestions for the healthcare and drug industry.

1. Perform randomized clinical trials that compare brand-name medications and generics to see how both drugs perform. This can help destroy the notion that brand name drugs are more effective than generic drugs.
2. Physicians should prescribe generic drugs more to reduce healthcare costs and improve health among patients.
3. Ophthalmologists should be knowledgeable of generic options and should include price difference information when prescribing medications to patients. They should also correct and educate patients who may have wrong notions about generic drugs.

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