Generic drug prescribing in central Saudi Arabia: Perceptions and attitudes of physicians

BACKGROUND AND OBJECTIVES: Physicians play a key role in generic drug prescribing, but their behavior is affected by many determinants. We examined physician practices and attitudes and other factors influencing the prescription of generic drugs. METHODS: A self-administered questionnaire was used to collect information from a random sample of physicians from different settings in central Saudi Arabia. Data were analyzed to describe all variables and test any significant difference between groups of physicians. RESULTS: The study included 772 physicians from different affiliations. The majority of physicians (n=741, 96%) reported that they knew enough about the therapeutic value of generic drugs. The majority (75%) reported that they knew the price differences, and this knowledge helped 72% of them to switch to generic prescription medication. Most physicians (79%) support generic substitution, but they indicated that there are certain clinical situations where they prefer to use brand name drugs. Physicians reported receiving visits and samples more frequently from representatives of brand name companies. Physicians did not report a significant difference in pressure from patients to prescribe either generic or brand drugs. Most physicians had a positive attitude towards the government role in assuring the quality of local drug products (80%) and in enforcing physicians to prescribe generic drugs (85%). CONCLUSION: Physicians face competing forces to prescribe either brand name or generic drugs. The majority support generic drug substitution. There are multiple factors that support prescription of generic drugs.

H ealth care costs have been on the rise globa a ally, and this trend is expected to continue. 1 Expenditures on pharmaceuticals are consida a ered a major driving factor for rising health care costs. Spending on drug prescriptions has increased sharply in recent years with a growth rate faster than other major components of the health care system. 2 The drug market in Saudi Arabia in 2006 exceeded 6 billion Riyals (1.6 billion US dollars), which accounts for 10% of health care expenditures. 3 The growth rate of the drug mara a ket in Saudi Arabia exceeded 10% in the year 2006. 3 Many countries have adopted costacontrol strategies to slow drug spending growth such as drug utilization rea a view and encouraging the use of less expensive generic drugs. 4a6 The use of generic drugs can provide substantial savings in health care cost without affecting the quala a ity or the therapeutic effect of the prescribed medicine. A generic drug is identical, or bioequivalent, to a brand name drug in dosage form, safety, strength, route of ada a ministration, quality, performance characteristics and intended use. 7 The adoption of generic drugs in medical practices is a complex phenomenon and many determinants can affect it. Physicians play a key role in controlling this phenomenon and their decision in prescribing generic drugs is likely to be affected by many factors. Although there is increasing local and international encouragea a ment for physicians to prescribe generic products, some physicians are not in favor of prescribing generic drugs. Therefore, many studies have tried to find determinants of this practice. 8a11 In Saudi Arabia, generic drug prescribing has bea a come a common practice; however, this trend has not been assessed. The purpose of this study is multifaceted. The study aimed to investigate physician perception and attitudes regarding substituting generic medications for brand name drugs and to examine factors that affect this pattern of prescription. Lastly, the study explored varia a ous types of potential pressures from patients and drug companies that might affect physician decisionamaking to prescribe generics.

METHODS
Preliminary interviews were conducted with a sample of 12 physicians and 4 pharmacists to assess the significant dimensions of generic drug practices. Based on this initial response and a review of the literature, a questionnaire was designed and constructed. The questionnaire was refined after preatesting it on a sample of physicians.
This study was conducted in central Saudi Arabia. All selected individuals were practicing physicians. Sampled physicians included primary health care, hospital, as well as private practitioners. The sample size was estimated to assess the perceptions and attitudes of physicians toa a wards generic drug prescribing, with a prevalence rate of 15% and an absolute precision of 3% on both sides of this anticipated prevalence and a confidence level of 95%. The required sample size was 544 physicians. The sample was multiplied by 1.5 to accommodate for the design effect since sample selection was based on a stratified sampling method. The required sample after considering the design effect was 816 physicians. The sample size was increased to 900 to compensate for nona response. To obtain this sample, physicians were selected from primary health care centers, governmental hospia a tals and private sectors.
The questionnaire was designed to elicit the percepa a tion, attitude and behavior in relation to generic prea a scribing. To standardize the definition of generic drugs among study participants, a clear definition was included at the beginning of the questionnaire. The questionnaire collected information on: (1) personal, background and demographic data of the sampled physicians including their affiliation, specialty, years of experience and age; (2) the perception of physicians of price differences between generics and brand names and the sources of their infora a mation; (3) physician attitudes and beliefs regarding gea a neric drug quality, therapeutic efficacy, the impact of use of generics on drug research, and the perception that the use of drugs has potential cost savings; (4) prescribing beliefs of physicians; and (5) the role of patients, drug company representatives, and health care administration policy in influencing the physician decisions on prescriba a ing.
The questionnaire was selfaadministered and disa a tributed by ordinary and electronic mail and by pera a sonal contact. The sample was a stratified sample to ensure representation of physicians from different seta a tings and affiliations. Analysis of data was done using the Statistical Package for Social Sciences (SPSS 11.0). Frequency distributions of all variables were produced.
All P values were based on 2asided tests, and the cutoff value for statistical significance was set at .05. Chiasquare analysis was used to test differences in proportions and an independent t test was used for analysis of quantitaa a tive data. For testing differences between proportions, the sample size was calculated to estimate a difference of 0.03 between proportions with a 5% level of significance and a power of 90% in a twoasided test. The estimated sample size was equal to more than 668 so the larger sample size (900) was used.

RESULTS
Data were collected between May and September 2007. The response rate to the questionnaire was 85.8% (772 of 900) ( Table 1). Primary care physicians were more likely to see more than 100 patients in a typical week compared with hospital and private physicians (92%, 45%, 25%, respectively, P<.05). Furthermore, they were more likely to report seeing patients of all ages than hospital and private physicians (67%, 23%, 10%, respeca a tively, P<.05). The number of prescriptions written by primary care physicians per week was also higher than that written by hospital and private physicians (median of 146, 74 and 92, respectively, P<.05).
The majority of physicians (n=741, 96%) reported that they knew enough about the therapeutic value of generic drugs they prescribe. There was no difference between primary care, hospital, and private physicians in their perception of knowledge about the therapeutic value of generic drugs (98.5%, 94.2% and 95%, respeca a tively P>.05). Younger physicians (75% of those 30a40 years of age) were less likely than older physicians (93% of those 40a50 years and 89% of those ≥50 years of age) to report that they knew enough about the therapeutic value of generics to prescribe them and to illustrate this value to patients and peers (P<.05).
The majority of physicians (75%) reported that they knew "some" about the price differences between brand name and generic drugs. On the other hand, 13% india a cated that they knew "a lot" about the price differences. The rest of physicians either knew "very little" (7%) or knew "nothing at all" (5%). Also, the majority of physia a cians (72%) strongly agreed that the price difference helped them to switch to a generic prescription. Based on physician knowledge about the price difference, pria a mary care physicians were significantly more likely to switch to generic prescription than hospital and private physicians (47%, 31% and 22%, respectively, P<.05). The main source of information about generic drugs were drug manufacturer representatives followed by pharmacists and medical journals ( Figure 1). The drug formulary was the least source of information.
The majority of physicians (79%) supported generic substitution in "most" cases, and reported that there are certain situations where brand drugs are preferred ( Figure 2). Only 16% of the physicians supported using generics in "all" clinical situations if generic drugs were available. On the other hand, only 5% did not support generic substitution at all. The preference of generic substitution in "most" cases was more common among primary care physicians than hospital and private phya a sicians (55%, 28%, 17%, respectively, P<.05). On the other hand, hospital physicians were more likely than primary care and private physicians (37%, 33%, 30%, rea a spectively, P>.05) to support generic substitution in "all" cases where a generic drug is available. However these differences were not significant.
Most physicians (82%) reported visits by represena a tatives of brand name drug companies on a monthly basis ( Figure 3). On the other hand, representatives of generic drug companies were less likely to visit physia a cians. Seventyafive percent of physicians claimed that they had never been visited by representative of generic drug companies. Ninetyaseven percent of physicians who had been visited by brand name drug company representatives reported receiving samples while only 22% of received samples from generic drug companies (P<.05). There was no significant difference between primary care, hospital and private physicians in receiving visits and samples from representatives of generic drugs. However, private physicians were more likely than hosa a pital and primary care physicians to have visits and sama a ples from brand name company representatives.
An equal proportion of physicians "sometimes" felt pressured by patients to prescribe either brand drugs or generic drugs ( Figure 4) (41% vs. 40%, respectively, P>.05). However, physicians were more likely to report that they "frequently" felt pressured to prescribe genera a ics (25%) rather than brand name drugs (9%, P<.05). Physicians reported that 23% of patients asked about the cost of the prescribed drug, 16% asked about effeca a tiveness, and only 8% talked about their past experience with generic drugs. Overall, the proportion of physicians who expected the pharmacist to dispense brand name as written without substitution was 47%. However, hospital physicians (23%) were significantly less likely than primary care (35%) and private physicians (54%) to report that pharmacists would dispense brand drugs without substitutions (P<.05). Only 25% of physicians in governmental institutions (and centers) reported that the prescription form they use included a statement that allowed the pharmacist to substitute generic drugs when  brand drugs were not available. None of the private phya a sicians reported that the prescription forms they use included such a statement. Seventyafour percent of phya a sicians expressed acceptance that the pharmacist could substitute a prescribed brand drug by a generic one while 21% accepted that the pharmacist could substitute a brand drug for a generic drug. Most physicians had a positive attitude towards the government role in controlling the drug industry (82%), assuring the quality of drug products (80%), and enforca a ing physicians to prescribe generic drugs (85%). Most physicians (65%) believed that generic drugs produce the intended therapeutic effects, while 67% reported that the efficacy of generic drugs was equal to that of brand drugs ( Table 2).
Seventyatwo percent of physicians believed that price differences between brand and generic drugs helped them to switch to generics. The majority of physia a cians (84%) believed that using generics helps in saving health costs. A proportion of private physicians (24%) used generic drugs to help them keep their patients. Additionally, 61% of physicians believed that wider use of generic drugs would not affect the research and devela a opment of new drugs.

DISCUSSION
The response rate of physicians to the questionnaire (85.8%) was satisfactory and comparable to other studa a ies, 8a10 but the characteristics of nonrespondents are unknown. Most physicians in this study were in their late forties in age. They were mainly practicing clinicians for an average period of experience that exceeded 20 years and saw more than 60 patients every week in all age groups. Characteristics of physicians regarding their demographic, personal and practice information were comparable with the data at the national level. 12 Primary care physicians were more likely than hosa a pital and private physicians to see more patients in a typical week, see patients of all ages, and write more prea a scriptions in a week. This observation is in parallel with the job requirements and policy planning for primary health care in Saudi Arabia; thus, primary care physia a cians constitute the majority of practicing physicians in Saudi Arabia. 12,13 Therefore, their contribution in cost savings would be substantial if they switch to generic prescriptions.
The majority of physicians supported generic substia a tution in "most" cases. Other studies showed the same findings and supported generic substitution. 11,14a16 In this study, "certain situations" where they prefered to use brand name drugs were not identified and it is difficult to know in which situations physicians will not support  Figure 4. proportions of physicians who feel pressured by patients to prescribe generic or brand drugs. Table 2. proportion of physicians who strongly or somewhat agree with the items related to government drug regulations.

Item %
• i feel secure in prescribing drugs approved by government 82 • government is capable of assuring high quality of local drug products 80 • requirements for approval of generics is less than that for brand names 63 • Health care administration is forcing physicians to prescribe generic drugs 85 • Therapeutic failure is a serious problem of some generic drugs 35 • generic drugs generally produces the indented therapeutic effects 65 • Most generic and brand names are equally effective 67 generic interchange. Interestingly, few physicians do not support substitution to generics at all. Reasons against supporting generic substitutions were not addressed in the study. This could be due to influence from the brand drug company' s "war against generics", lack of awareness about price differences, the belief that "genuine is better", or due to previous experience with generics. Although switching to generic drugs is widely practiced worldwide, there are still certain situations where interchangeability is controversial. When switching from brand to generic drugs with a narrow therapeutic index or critical dosing, bioequivalence may not be guaranteed and interchange is not advisable. 17 The majority of physicians also reported that they knew about the price difference between brand name and generic drugs. Also, they strongly agreed that the price difa a ference helped them to switch to a generic prescription; this is similar to findings in other studies. 10,11 It seems that whenever the knowledge is provided about generic drug prices, the required behavior can be ensured. 18a19 Proper education and training programs for medical stua a dents and for practicing clinicians are recommended to raise the level of physician knowledge of the benefits of generics.
Although physicians reported that representatives of generic drugs do not visit them frequently, they selected them as the first source of their information about genera a ics. Pharmacists were the second major source of infora a mation about generic drugs for physicians. Other valid and reliable sources such as medical journals, newsletters, the internet, and administration played a minor role. Therefore, the pharmacist contribution in providing valid information to physicians should be improved through training programs, workshops, and other active methods of education and learning. 20 Physicians should take their information about drugs from reliable sources. Probably the best source of information about marketed drugs in Saudi Arabia is the Saudi National Formulary (SNF). It is available onaline and provides information and pricing on registered and marketed drugs in the country.
Physicians reported that they felt pressured by paa a tients and the health care administration to prescribe generic drugs. Physicians also reported that patients wanted to talk about the side effects, the cost and the effectiveness of the prescribed drugs and their past exa a perience with generic drugs. It seems that generic drug prescription in the clinical practice is the result of mua a tual and active interaction between the physician and the patient. Therefore, both physicians and patients can be empowered by reliable information so that they both can place adequate pressure and influence on the other party to influence generic prescription. 21 Most physicians agreed that the pharmacist can suba a stitute a generic for a brand drug, but do not agree with a brand drug in place of a generic one. Also, they expected the pharmacist to switch to a generic drug instead of the written brand name without permission. A statement on the prescription form that gives the pharmacist the right to substitute generic instead of brand name drugs is not common and is more likely in the hospital setting. All these conflicting observations underscore the vital role of the pharmacist in generic drug dispensing. 22a24 Therefore, facilitating regulations, training programs and continua a ous monitoring of pharmacists should be an integral part of any cost saving program that encourages generic drug prescription. Efforts to educate physicians early in their career about the benefits and the value of generic drug prescribing should be encouraged. A viable role for other health care professionals should also be sought. Policy makers should continue to encourage generic prescribing when generic equivalent is available and suitable. Quality assurance of drugs, both brand and generics, should continue after approval through postamarketing surveila a lance.
The findings of this study indicate that physicians are faced by multiple and sometimes competing forces to prescribe either brand name or generic drugs. In this study, the majority of physicians support generic drug substitution. Supporting forces for generic prescription include physician knowledge about generic drug effeca a tiveness and price differences, a positive attitude among physicians towards generic drugs, the influence of paa a tients on prescribing generic drugs and the government role in supporting generic prescription. On the other hand, factors that work against generic prescription ina a clude the influence of the brand name drug companies and the use of drugs with a narrow therapeutic index. Further studies are needed to explore situations and faca a tors where switching from brand to generic drugs may not be advised.