per cent of all new prescriptions issued in Florida were potentially ... of Pharmacy Administration, College of Pharmacy, University of Tennessee,. 874 Union ...
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REFERENCES
1. Copley DP, Mantle JA, Rogers WJ, et al: Improved outcome for prehospital cardiopulmonary collapse with resuscitation by bystanders. Circulation 1977: 56:901-905. 2. Lund I, Skulberg A: Cardiopulmonary resuscitation by lay people. Lancet 1976; 2:702-705. 3. Thompson RG, Hallstrom AP, Cobb LA: Bystander initiated cardiopulmonary resuscitation in the management of ventricular fibrillation. Ann Intern Med 1979; 90:737-740. 4. Guzy PM, Pearce ML, Greenfield S: The survival benefit of bystander cardiopulmonary resuscitation in a paramedic served metropolitan area. Am J Public Health 1983; 73:766-769. 5. Cobb LA, Hallstrom AP, Thompson RG, et al: Community cardiopulmonary resuscitation. Ann Rev Med 1980; 31:453-462. 6. Eisenberg MS, Bergner L, Hallstrom A: Cardiac resuscitation in the community: importance of rapid provision and implications for program planning. JAMA 1979: 241:1905-1907. 7. Eisenberg MS, Copass MK, Hallstrom AP, et al: Treatment of out-ofhospital cardiac arrest with rapid defibrillation by emergency medical technicians. N Engl J Med 1980; 302:1379-1383. 8. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1974; 227(Suppl):833-868. 9. McElroy CR: Citizen CPR: the role of the lay person in prehospital care. Topics Emerg Med 1980; 1:37-46. 10. Goldberg RJ, Gore JM, Love DG, et al: Layperson CPR-are we training the right people? Ann Emerg Med 1984; 13:701-704. 11. St. Louis P, Carter WB, Eisenberg MS: Prescribing CPR: a survey of physicians. Am J Public Health 1982; 72:1158-1160. 12. World Health Organization: Prevention of Coronary Heart DiseaseReport of a WHO Expert Committee. WHO Technical Report Series. Geneva: WHO, 1982.
13. Wenger NK, Hellerstein HK, Blackburn H, et al: Physician practice in the management of patients with uncomplicated myocardial infarctionchanges in the past decade. Circulation 1982; 65:421-427. 14. Wechsler H, Levine S, Idelson RK, et al: The physicians's role in health promotion-a survey of primary care practitioners. N EngI J Med 1983; 308:97-100. 15. Dismuke SE, Miller ST: Why not share the secrets of good health?: the physician's role in health promotion. JAMA 1983; 249:3181-3183. 16. Relman AS: Encouraging the practice of preventive medicine and health promotion. Public Health Rep 1982; 97:216-219. 17. Talley RC: Effects of continuing medical education on practice patterns. J Med Educ 1978; 53:602-603. 18. Inui TS, Yourtee EL, Williamson JW: Improved outcomes in hypertension after physician tutorials: a controlled trial. Ann Intern Med 1976; 84:646-651. 19. Thompson RS, Kirz HL, Gold RA: Changes in physician behavior and cost savings associated with organizational recommendations on the Ie of routine chest x-rays and multichannel blood tests. Prev Med 19 12:385-396. 20. Kottke TE, Foels JK, Hill C, et al: Perceived palatability of the prudent diet: results of a dietary demonstration for physicians. Prev Med 1983; 12:588-593. 21. Dalen JE, Howe JP, Membrino GE, et al: CPR training for physicians. N Engl J Med 1980; 303:455-457.
ACKNOWLEDGMENTS This study was made possible by the interest and cooperation of physicians in the Worcester and Springfield, Massachusetts metropolitan areas. William Regonini, Karen Deignan, and Mark Aggar assisted in data collection and analysis.
Drug Product Selection: The Florida Experience Revisited EDWARD H. CLOUSE, PHD, WILLIAM C. MCCORMICK, PHD, RICHARD A. ANGORN, RPH, JD, CAROLE L. KIMBERLIN, PHD, AND DOUGLAS D. BRADHAM, DRPH pharmacists, physicians, and consumers to adapt their behaviors to conform to the intent and specific provisions of Abstract: The comparison of drug product selection rates the new law. determined approximately one year and four years after passage of The purpose of the present study was to assess the longFlorida's Drug Product Selection (DPS) Law indicates very little term effects of Florida's Drug Product Selection Law on change in the product selection and brand interchange behaviors of product selection and brand interchange. In assessing these Florida pharmacists. Lack of adequate guidelines from the state and effects it should be noted that, although the patient has the the liability concerns of pharmacists appeared to limit an expected opportunity to prohibit DPS, pharmacists are not required increase in the state DPS rate. (Am J Public Health 1985; 75:283under the terms of the Florida law to make any notation 284.) when patient refusal occurs. Introduction In the 1977 survey on drug product selection (DPS) in the state of Florida,' the researcher found that, while 36.3 per cent of all new prescriptions issued in Florida were potentially eligible for product interchange, only 6.2 per cent of the eligible prescriptions were actually interchanged. Since the survey was conducted approximately one year after the enactment of Florida's Drug Product Selection Law,2 the low rate of product interchange may have been due in part to a need for a longer period of time for Address reprint requests to Edward H. Clouse, PhD, Assistant Professor of Pharmacy Administration, College of Pharmacy, University of Tennessee, 874 Union Avenue, Memphis, TN 38163. Co-authors McCormick (chairman), Angorn (associate professor), Kimberlin (associate professor) and Bradham (assistant professor) are with the Department of Pharmacy Health Care Administration, University of Florida, Gainesville. This paper, submitted to the Journal June 13, 1984, was revised and accepted for publication October 15, 1984. © 1985 American Journal of Public Health 0090-0036/85 $1.50
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Methods In the 1977 survey, a stratified random sample of 60 Florida community pharmacies (3 per cent of total) were selected from a list of all community pharmacies obtained from the Department of Professional and Occupational Regulation. Resurvey approval was obtained from 52 (85 per cent) of these original pharmacies, hence the comparisons across studies could be somewhat biased by the fact that all of the original 60 pharmacies were not resurveyed. The data collection process used in 1977 was repeated. Every effort was made to obtain the actual acquisition costs of both the products prescribed and the products dispensed. This was usually accomplished by looking at vouchers dated closest to the prescription filling date. In addition, the sampling frame was expanded from four months to a year to determine if there were any seasonal differences in the DPS rates. No such differences were found, however.
Results The prescribing behaviors of Florida physicians during 283
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the two study periods are compared in Table 1. Multisource drug products were prescribed to a greater extent in the state of Florida than in other states.3 This high rate of multisource drug prescribing, coupled with a relatively low rate of both prescribing from the negative formulary and prohibiting product selection by physicians, should have allowed pharmacists the opportunity to product select more frequently than ever before. However, the additional opportunities did not appreciably alter the brand interchange behaviors of Florida pharmacists. While 52.6 per cent of all new prescriptions issued in Florida were potentially eligible for product interchange, only 6.8 per cent of the eligible prescriptions (3.9 per cent of total) were actually interchanged, an unimportant increase over the 1977 rate of 6.2 per cent. Table 2 displays the comparisons for mean price of products prescribed, mean price of products dispensed, and mean reduction in retail price. The consumer did save an average of $2.40 per prescription when product selection took place, but this increase over the average savings determined in 1977 also was not significant. The savings passed on to the consumer represented over 90 per cent of the reduction in acquisition costs of the dispensing pharmacies. Some caution must be used in interpreting savings based on acquisition costs as invoices could not always be verified. Also, acquisition costs obtained at the individual pharmacy level could be higher than those actually paid by the small and large chain pharmacies. With the above cautions in mind, it was estimated that prescription purchasers statewide saved approximately $3,800,000 during the 1979-80 study through drug product selection. This figure was determined by applying the DPS rate and the reduction in retail price determined in the sample pharmacies to all new prescriptions dispensed in the state during the study period. The actual savings may have TABLE 1-Comparison of New Prescription Characteristics (1977 Versus 1979-80), Per Cent of New Prescriptions by Study Period
Characteristics
Single Source Multi-Source Written by Brand Multi-Source Written Generically Negative Formulary Products Written by Brand Written Generically "Medically Necessary" Written Multi-Source Single Source Other than "Medically Necessary" Written to Prohibit Drug Product Selection Multi-Source Single-Source
1977 (N = 11,982)
1979-80 (N = 10,468)
46.5 43.2 10.2 6.6 6.3 0.4 1.4 1.0 0.4
33.3 56.3 10.4 4.9 3.0 1.9 1.0 0.7 0.3
2.3 1.2 1.0
0.8 0.7 0.2
Some entries may not total due to rounding. Absolute values of paired difference z were computed to test the differences between the means.
284
TABLE 2-Comparison of Reduction in Retail Price between Prescribed and Dispensed Products (1977 versus 1979-80)
Category
1977 (N = 2,001)
1979-80 (N = 2,871)
Mean Price of Product Prescribed Mean Price of Product Dispensed Mean Reduction in Retail Price
$5.92 $3.99 $1.92
$7.29 $4.88 $2.40
Some entries may not total due to rounding.
been considerably larger as no attempt was made to estimate savings from renewal prescriptions. Discussion Drug product selection (DPS) in the state of Florida, although occurring with greater frequency than in the 1977 study, was still occurring at a minimal rate approximately four years after enactment of a Florida law entitled "Substitution of Drugs." Although consumers did save money on those prescriptions for which DPS occurred, it appears that prescribers and pharmacists are still not in full compliance with the specific provisions of the Florida law. Notations other than the words "medically necessary" were used in about 50 per cent of the instances in which prescribers sought to prohibit drug product selection. Furthermore, 30 per cent of those prescriptions with the appropriate restrictive wording prohibiting brand interchange were for drug products having only one source of supply. Pharmacists, on the other hand, appeared to be reluctant to engage in brand interchange without explicit permission from the prescriber. Even though the Florida law is considered mandatory, and each pharmacy is responsible for compiling its own positive formulary, no sanctions for noncompliance were included in the law at the time of this study. A recent study indicated that states with positive formularies had higher substitution rates than those without them; and formularies that were state generated were more effective in encouraging substitution than the Food and Drug Administration's formulary.4 REFERENCES 1. Vuturo GJ, McCormick WC, Krischer JP: Drug product selection: the Florida experience. Am J Public Health 1980; 70:479-484. 2. Florida Statutes, 465.025. 3. Goldberg T, DeVito C: The impact of state generic drug substitution laws. Drug Therapy 1981; 11(12):75-81. 4. Zeich RC: One-line Rx forms boost drug substitution. Drug Topics 1984; 128(2):37-38.
ACKNOWLEDGMENTS
This paper was presented before the Academy of Pharmaceutical Sciences Economic, Social and Administrative Sciences Section, American Pharmaceutical Association Annual Meeting, May 9, 1984. Montreal. Canada.
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