Doctors perception and use of generic names for prescribing medicines: Exploring reasons and policy options

Sir,

Prescribing generic (non-proprietary) medicines have been an issue of controversy with prescribers all over the world. Notwithstanding, the economic gains offered by prescribing non-proprietary medicines, resistance to the use of generic medicines has been seen with both prescribers and patients in health-care settings.^[1] Governments faced with budgetary constraints and the difficult task of improving access to essential medicines for their populations is adopting policies where use of generic medicines is recommended. The same has been the policy of Government of NCT of Delhi (India) for its public health facilities since 1994.^[2]

We conducted a prescription audit among 500 out-patients and in-patients each, to assess the extent of prescribing by generic names, in a tertiary care, public, teaching hospital located in NCT of Delhi, India. In addition, a survey of resident doctors working in the same hospital, regarding their knowledge, perception of generic medicines, and reasons for their prescribing choice was also conducted.

We found that in 66% cases (Inpatients 72%, and Outpatients 61%) the medicines were prescribed in brand names. Over three-fourth (79.5%) of medicines were prescribed from the hospital essential medicine list (EML), of which 64% were also prescribed in brand names. These findings are similar to the previous reports which have found that prescriptions are predominantly written by doctors using brand names.^[3] Doctors prescribe brand medicines even when bioequivalent generic alternatives were available, resulting in an estimated $ 8.8 billion expenditure per year in USA.^[4] Cost of treatment is unaffordable for most of the patients attending a public health facility and prescribing brand medicines (Named Generics) despite availability of free generic medicines is not justified.

Fixed drug combinations (FDCs) formed nearly one-tenth (343) of medicines prescribed and all were prescribed in brand names. Use of brand names for FDCs may be justified as it is difficult to write names of individual constituents with their amounts. A large proportion of FDCs were of vitamins and minerals which were available as individual medicines in the EML. A closer look at the constituents of the FDCs indicates that many were irrational combinations and many of these are on the list of medicines, the Drug Regulatory Authorities in India are trying to ban.

A look at why prescribing of brand medicines is so widely prevalent was seen in the doctor survey (N=57). It was found that the majority of prescribers (76%) did not have adequate knowledge regarding nomenclature of medicines. This is not surprising since many of these are facts to which a doctor is not exposed to in the formal medical education. While many of these would not affect general management of patients, awareness of what generic medicines are and when they become available in market would help a doctor in making better informed decisions while prescribing medicines. This awareness was found to be much less (17.54%) than reported by a similar study (57.5%) conducted in a tertiary care hospital in South India.^[5]

Majority of the doctors (71.9%) surveyed acknowledged the cost saving benefits of prescribing generic medicines but expressed major concerns regarding their quality and only one-third doctors would recommend to use them for self or their family. The poor quality (66.7%) and non-availability (43.9%) of generic medicines were cited as major reasons for prescribing brand medicines.^[6]

The familiarity with brand names was another important reason cited by doctors for preferring brand names (59.65%). The major sources of drug information in this survey were colleagues (33%) and pharmaceutical representatives (21%). Perhaps, the lexicons learned from colleagues and advertising by pharmaceutical companies ensured that brand names are remembered more often than the generic names.^[6]

Many of the residents (47.6%) also stated that higher costs of brand medicine do not ensure better quality but still banded medicines from over 90 different pharmaceutical companies were prescribed in the same hospital. This suggests that doctors are prescribing brand names more out of habit which is reinforced by medical representatives and colleagues, than any other reason.

The major advantage of using generic medicines is their potential to provide considerable savings in health-care costs and reducing the out-of-pocket expenditure on medicines. This is of immense relevance in a country like India, where 60% patients lack access to essential medicines. However, expecting a dramatic change in the prescribing behavior of doctors without addressing their concerns regarding generic medicines will be futile. Confidence building measures are required as regard quality assurance of generic medicines with dissemination of facts in a scientific, evidence-based manner. It is time that Drug Regulatory Authorities in India work toward this goal, to help optimize the use of non-proprietary generic medicines for the masses. An imperative step to meet the public health needs in India.