Would Pharmacy Students Advocate Green Pharmacy Given Their Preference for Medicines With Environmental Impact?

OBJECTIVE: To investigate the preferences among university students in Gothenburg, Sweden for medicines that have a different environmental impact with respect to effect and explore to what extent having received information about pharmaceuticals' potential harm to the environment is associated with the stated preferences. METHODS: A survey was conducted among students in different study programs at the University of Gothenburg, Sweden. In all, 704 students received oral and written information about the study at the end of a lecture and were invited to take part (response rate: 83.5%). The questionnaire contained items about medicinal environmental information and 2 scenarios with fictious medicines as options for the treatment or symptom relief of minor ailments in humans. RESULTS: Overall, 53.3% of the students (pharmacy students: 57.8%) had received information about the environmental impact of medicines, and 79.6% (pharmacy students: 80.6%) reported that they had concerns about the consequences. Twenty percent (pharmacy students: 9.0%) named the university as an information source. The students were most satisfied overall with the least effective and most environmentally friendly medicines. Consistently, pharmacy students gave higher scores to the most environmentally harmful medicines, especially compared with medical and health care students. Pharmacy students, who, to the same extent as medical and health care students had received information about medicines' environmental impact, were less likely to state environmentally friendly options with an inferior effect as their preferred choice. CONCLUSION: Pharmacy students generally rated the medicines higher than other student groups, despite being aware of the harmful effects on the environment.

Intra-Individual Variability in Self-Reported Use of Non-Steroidal Anti-Inflammatory and Analgesic Medicines Depending on Mode of Data Collection - Observations from the Population Study of Women in Gothenburg, Sweden.

BACKGROUND: Self-report by questionnaire is one of the main methods to collect data on drug utilization. There are several modes of data collection by questionnaire, differing in the way of delivering the questionnaire to respondents and in the administration of the questions, both influencing the recall and participation rates. The aim of this study was to compare different modes of data collection for self-reported use of non-steroidal anti-inflammatory (NSAIDs) and analgesic medicines. METHODS: Data on 573 women (38 or 50 years) were retrieved from the Population Study of Women in Gothenburg. Data on medicine use were collected using two different modes: (1) a self-administered questionnaire with closed-ended medicine-specific questions; and (2) an interviewer-administered questionnaire with open-ended questions. Cohen's kappa statistics were applied to assess the agreement of the two modes. RESULTS: The proportion of participants that reported use of NSAIDs and analgesics was higher with the self-administered questionnaire compared with the interviewer-administered questionnaire (69.3% vs 58.5%, p <0.001). The overall agreement between the two modes of data collection was fair (Ⱪ=0.27), ranging from none for antimigraine preparations to fair (Ⱪ=0.36) for NSAIDs. A higher proportion of the participants aged 38 years reported use of NSAIDs and analgesics compared with the 50-year olds. In the regression model using data from the self-administered questionnaire, all four categories of bodily pain were significant predictors for use of NSAIDs and analgesics. The most severe reported bodily pain was the only significant predictor in the model using data from the interviewer-administered questionnaire. CONCLUSION: This study showed that use of a self-administered questionnaire with closed-ended medicine-specific questions identified more users of NSAIDs and analgesic medicines compared with an interviewer-administered questionnaire with open-ended questions. Reported use according to the self-administered questionnaire was also more strongly associated with experienced pain.

Generic versus brand-name over-the-counter analgesics: knowledge and attitudes among Swedish pharmacy customers.

BACKGROUND: Due to a liberalisation reform in 2009, the availability of over-the-counter (OTC) analgesics has increased significantly in the Swedish market over the past decade. With the increasing number of generic products available on the market and the possibility of buying OTC drugs from non-pharmacy outlets, a key to safe drug use is that consumers possess the necessary knowledge to differentiate between the different brands and choose the appropriate drug for their ailments. The aim of this study was to investigate Swedish consumers' knowledge of and attitudes towards generic OTC analgesics. METHODS: A sample of 209 Swedish adults (66% women; mean age 43.1 years) who bought OTC analgesics at a community pharmacy in one of the country's three largest cities responded to a structured questionnaire. The questions related to knowledge of active substances, the use and choice of OTC analgesics (generic or original brand), attitudes towards generic OTC analgesics, information received about OTC analgesics and experience with generic substitution of prescription drugs. RESULTS: Almost one in five reported weekly use of OTC analgesics, and 32% assigned minimum three out of four active substances to the correct brand(s) of OTC analgesics. Among the 50 participants (24%) who assigned all four active substances correctly, it was predominantly women and participants with higher education. Four out of five participants were positive towards the cheaper brands, and 69% reportedly chose cheaper generic brands over more expensive brands. Knowledge about the active substances of different brands was associated with positive attitudes towards generic products. CONCLUSION: Swedish pharmacy customers have to a varying extent the knowledge to differentiate between different brands of commonly used OTC analgesics in terms of active substances. There is a predominantly positive attitude towards generic OTC analgesics, although some consider generic drugs to be inferior and stay loyal to the original brands.

"I did not know it was so important to take it the whole time" - self-reported barriers to medical treatment among individuals with asthma.

BACKGROUND: Asthma is an extensive public health problem and inadequate disease control is not uncommon. Individuals' self-perceived barriers to medical treatment for the entire treatment chain (from seeking care for symptoms to using a medicine) have seldom been studied for chronic diseases such as asthma. The aim of this study was to explore self-perceived barriers to medical treatment among individuals with asthma within the framework of AAAQ (availability, accessibility, acceptability and quality). METHODS: Individuals with asthma visiting the asthma nurse at a primary health care centre, and who currently had a prescription for anti-asthmatic medicines, were informed about the study. The nurse asked the persons for their consent to be contacted by an interviewer. The interview guide was constructed from the elements of AAAQ exploring self-perceived barriers to asthma treatment. Interviews were conducted in Swedish, English, Arabic and Persian. They were transcribed verbatim and a manifest content analysis was conducted. RESULTS: Fourteen interviews were conducted. There was a large variation in both age and reported number of years with asthma. Self-perceived barriers to asthma treatment were experienced throughout the whole treatment chain. Barriers that emerged were health care accessibility, perceived quality of care, beliefs about medicines, life circumstances, knowledge gap about asthma and medicines, practical obstacles to using medicines, and experiences with treatment. The self-perceived barriers cover all four elements of AAAQ, but there are also some barriers that go beyond those elements (life circumstances and practical obstacles to using medicines). CONCLUSIONS: Self-perceived barriers among individuals with asthma cover the whole treatment chain. We want to highlight the inadequate information/education of patients leading to knowledge gaps about both disease and the effect of medicines, and also the perceived unsatisfactory treatment at the PHCC, which could partly be counteracted if patients know what to expect from health care visits.

Experiences of Kurdish immigrants with the management of type 2 diabetes: a qualitative study from Norway.

Objective: To explore the experiences of immigrant Kurdish patients in Oslo, Norway, related to the management of type 2 diabetes mellitus (T2DM). Design: A qualitative study with focus group interviews. Setting: Participants were recruited at meeting places in Oslo through Kurdish networks. Subjects: Eighteen Kurdish immigrants (9 females and 9 males) living in Oslo, aged 40 to 64 years, diagnosed with T2DM participated in a total of five focus groups. Participants had to be proficient in the Norwegian language to be eligible. Main outcome measures: Immigrant Kurdish patients' experiences with being diagnosed with T2DM, their disease management, and need for medical information. Results: Participants stressed that living with T2DM was emotionally challenging, mainly because they were afraid of possible complications of the disease. They claimed to adhere satisfactorily to their medicines and blood glucose measurements. The majority of participants shared that they had made changes to their diet, even though it was difficult. To the contrary, physical activity received only minimal attention. The participants' main source of information was general practitioners and the majority of them were satisfied with the information that they had received about their disease and its management. Conclusion: Kurdish T2DM patients in the present study from Norway reported that they adhered to the medical treatment, even if they were stressed about living with the disease. However, they were more occupied with changing their diet than to be physically active. Therefore, healthcare personnel should try to be aware of lifestyle challenges among their patients. KEY POINTS Eighteen Kurdish patients in Oslo with Type 2 diabetes claimed to be adherent to medication treatment and blood glucose measurement. The participants shared that they had made changes to their diet, even though it was hard. There was generally little attention given to the need for physical activity in their daily lives. The participants were in need of more information and support in making healthy lifestyle changes.

Attitudes towards sales and use of over-the-counter drugs in Sweden in a reregulated pharmacy market: a population-based study.

OBJECTIVES: To analyse attitudes towards sales and use of over-the-counter (OTC) drugs in the Swedish adult population. METHODS: Data were collected through the web-based Citizen Panel comprising 21 000 Swedes. A stratified sample of 4058 participants was emailed a survey invitation. Questions concerned use of OTC drugs, and attitudes towards sales and use of OTC drugs. Correlations between the attitudinal statements were assessed using Spearman's rank correlation. Associations between attitudes and participant characteristics were analysed using multinomial logistic regression. KEY FINDINGS: Participation rate was 64%. Altogether 87% reported use of OTC drugs in the last 6 months. Approximately 10% of participants stated that they used OTC drugs at the first sign of illness, and 9% stated that they used more OTC drugs compared with previously, due to increased availability. The statement on use of OTC drugs at first sign of illness correlated with the statement about using more OTC drugs with increased availability. Socio-demographic factors (age, sex and education) and frequent use of OTC drugs were associated with attitudes to sales and use of OTC drugs. CONCLUSIONS: Increased use due to greater availability, in combination with OTC drug use at first sign of illness illustrates the need for continuous education of the population about self-care with OTC drugs. Increased awareness of the incautious views on OTC drugs in part of the population is important. Swedish policy-makers may use such knowledge in their continuous evaluation of the 2009 pharmacy reform to review the impact of sales of OTC drugs in retail outlets on patient safety and public health. Pharmacy and healthcare staff could be more proactive in asking customers and patients about their use of OTC drugs and offering them advice.

Multiple challenges of antibiotic use in a large hospital in Ethiopia - a ward-specific study showing high rates of hospital-acquired infections and ineffective prophylaxis.

BACKGROUND: This project aims to study the use of antibiotics in three clinical wards in the largest tertiary teaching hospital in Ethiopia for a period of 1 year. The specific aims were to assess the prevalence of patients on antibiotics, quantify the antibiotic consumption and identify the main indications of use. METHOD: The material was all the medical charts (n = 2231) retrieved from three clinical wards (internal medicine, gynecology/obstetrics and surgery) in Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa between September 2013 and September 2014. Data collection was performed manually by four pharmacists. RESULTS: Each medical chart represented one patient. About 60% of the patients were admitted to internal medicine, 20% to each of the other two wards. The number of bed days (BD) was on average 16.5. Antibiotics for systemic use were prescribed to 73.7% of the patients (on average: 2.1 antibiotics/patient) of whom 86.6% got a third or fourth generation cephalosporin (mainly ceftriaxone). The average consumption of antibiotics was 81.6 DDD/100BD, varying from 91.8 in internal medicine and 71.6 in surgery to 47.6 in gynecology/obstetrics. The five most frequently occurring infections were pneumonia (26.6%), surgical site infections (21.5%), neutropenic fever (6.9%), sepsis (6.4%) and urinary tract infections (4.7%). About one fourth of the prescriptions were for prophylactic purposes. Hospital acquired infections occurred in 23.5% of the patients (353 cases of surgical site infection). The prescribing was based on empirical treatment and sensitivity testing was reported in only 3.8% of the cases. CONCLUSIONS: In the present study from three wards in the largest tertiary teaching hospital in Ethiopia, three out of four patients were prescribed antibiotics, primarily empirically. The mean antibiotic consumption was 81.6 DDD/100BD. Surgical site infections constituted a large burden of the infections treated in the hospital, despite extensive prescribing of prophylaxis. The findings show the need to implement antibiotic stewardship programs in Ethiopian hospitals with focus on rational prescribing, increased sensitivity testing and better procedures to prevent hospital acquired infections.

Challenges in the management of Type 2 Diabetes among native women in the United Arab Emirates.

AIM: To investigate Type 2 Diabetes mellitus (T2DM) management in native female patients in the United Arab Emirates (UAE). METHODS: Ninety women from the outpatient diabetes clinic at Tawam Hospital, UAE, were interviewed face-to-face about how they manage their disease, using a structured questionnaire. Clinical values of the patients were extracted from medical records. RESULTS: The mean age of the women was 57.5 (SD: 12.7) years and half of them were illiterates. Two-third of the participants had hypertension and/or high cholesterol. A majority reported to have received information about lifestyle modification but admitted low physical activity and unhealthy diet. Mean weight and BMI were 80.0 (SD: 17.2) kg and 33.5 (SD: 6.3) kg/m2, respectively. Although the majority were taught how to measure blood glucose, 46% considered self-measurement difficult. Oral antihyperglycemic drugs were used by 96% of participants, and 31% were also taking injections. Forty-nine percent had HbA1c values below 7% and the average was 7.7% (range: 4.9-14.1). Two-third had systolic blood pressure (SBP) and low-density lipoprotein (LDL) values within the target range. CONCLUSION: Despite major challenges in T2DM management among native female patients in UAE, this study shows that one in two patients had an overall glycemic control that was acceptable.

Living with Diabetes: Personal Interviews with Pakistani Women in Norway.

The prevalence of Type 2 diabetes (T2D) among Pakistani women in Norway is remarkably high. This study aims to assess how they live with the disease and their response to lifestyle and medical information. 120 Pakistani women living in Norway (mean age: 55.7 years) were personally interviewed about their T2D using a structured questionnaire (response rate: 95%). The participants were first-generation immigrants (mean residence time: 28.7 years) of whom 27% were illiterates. Poor health was reported by one-third, and 71% had developed macrovascular comorbidities. A majority reported physical inactivity and an unhealthy diet included religious fasting. One-third was not able to self-measure their blood glucose. There was a great variation in antidiabetic drug regimens and one-fourth had to use insulin in addition to tablets. Pakistani women in Norway showed suboptimal control of their T2D in terms of lifestyle habits, comorbidities and drug use. Low literacy and cultural factors seem to challenge adherence to lifestyle and medical information.

Consumer preferences for over-the-counter drug retailers in the reregulated Swedish pharmacy market.

Following a large regulatory reform in 2009, which ended the state's pharmacy monopoly, non-pharmacy retailers in Sweden today sell certain over-the-counter (OTC) drugs. The aim of this study was to investigate consumer preferences regarding OTC drug retailers and the reasons for choosing a pharmacy versus non-pharmacy retailer. We conducted a web survey aimed at Swedish adults. Out of a stratified sample of 4058 persons, 2594 agreed to take part (48% women; mean age: 50.3 years). Questions related to OTC drug use, retailer choice and factors affecting the participants' preferences for OTC drug retailers. Logistic regression was conducted to analyse OTC drug use and reasons for retailer choice in relation to sex, age and education. Nine in ten participants reported OTC drug use in the 6 months prior to the study. For their last OTC purchase, 76% had gone to a pharmacy, 20% to a grocery shop and 4% to a convenience store, gas station or online. Geographic proximity, opening hours and product range were reported as the most important factors in retailer choice. Counselling by trained staff was important to 57% of participants. The end of the state's pharmacy monopoly and the increase in number of pharmacies seem to have impacted more on Swedish consumers' purchase behaviours compared with the deregulation of OTC drug sales.

A Systematic Review of Physicians' and Pharmacists' Perspectives on Generic Drug Use: What are the Global Challenges?

BACKGROUND AND OBJECTIVES: Generic substitution has been introduced in most countries in order to reduce costs and improve access to drugs. However, regulations and the generic drugs available vary between countries. It is the prescriber or dispenser of the drug who is the final decision maker. Nevertheless, physicians' and pharmacists' perceptions of generic drug use are not well documented to date. This study presents a systematic review of physicians' and pharmacists' perspectives on generic drug use worldwide. METHODS: A systematic literature search was performed to retrieve all articles published between 2002 and 2012 regarding physicians' and/or pharmacists' experiences with generic drugs and generic substitution. RESULTS: Of 1322 publications initially identified, 24 were eligible for inclusion. Overall, the studies revealed that physicians and pharmacists were aware of the cost-saving function of generic drugs and their role in improving global access to drugs. Nevertheless, marked differences were observed between countries when studying physicians' and pharmacists' perceptions of the available generic drugs. In less mature healthcare systems, large variations regarding, for example, control routines, bioequivalence requirements, and manufacturer standards were reported. A lack of reliable information and mistrust in the efficacy and quality were also mentioned by these participants. In the most developed healthcare systems, the participants trusted the quality of the generic drugs and did not hesitate to offer them to all patients regardless of socioeconomic status. In general, pharmacists seemed to have better knowledge of the concept of bioequivalence and generic drug aspects than physicians. CONCLUSIONS: The present study indicates that physicians and pharmacists are aware of the role of generic drugs in the improvement of global access to drugs. However, there are marked differences regarding how these health professionals view the quality of generic drugs depending on the maturity of their country's healthcare system. This can be attributed to the fact that developed healthcare systems have more reliable public control routines for drugs in general as well as better bioequivalence requirements concerning generics in particular.

Norwegian elderly patients' need for drug information and attitudes towards medication use reviews in community pharmacies.

OBJECTIVES: Medication use review (MUR) is a community pharmacy service in several countries. Knowledge about what patients want from such a service is limited. The aim of this study was therefore to investigate Norwegian elderly patients' need for drug information and their attitudes towards MURs. METHODS: In Norway's two largest cities, 162 patients (72% women; mean age: 78.9 years) who used at least one prescription drug were recruited from 18 senior centres. They were interviewed personally with a structured questionnaire (29 closed and 4 open-ended questions). KEY FINDINGS: The average number of prescription drugs used was 4.4. Seventy per cent also used over-the-counter drugs. The main source of drug information was the general practitioner (GP) followed by package inserts and pharmacy staff. For drug-related problems, 62% would contact the GP compared with 24% who preferred the pharmacist. Fifty per cent remembered no information when collecting prescriptions. However, 56% wanted to know more about their medication and 55% were interested in a MUR. The main topics they wished to address were effect/side effects and interactions. Lack of privacy was reported to be a major obstacle in the current situation. CONCLUSIONS: This study shows that community pharmacies in Norway play a minor role regarding drug information to elderly polypharmacy patients. The GP is both their main information source and whom they contact for drug-related problems. However, half of the patients would like to know more about their medication. More than half were positive towards taking part in a MUR.

'Because of the circumstances, we cannot develop our role': Norwegian community pharmacists' perceived responsibility in role development.

OBJECTIVE: The development of more patient-centred care is not always visible in community pharmacies. The aim of this study was to explore Norwegian pharmacists' motivation and perceived responsibility regarding role development and involvement in patient-centred care. METHODS: A semi-structured interview guide was developed. Four focus group interviews were conducted with a heterogeneous sample of 21 community pharmacists and transcribed verbatim. An inductive analysis was performed, supplemented with an agent perspective. KEY FINDINGS: Two main categories and nine subcategories were identified, with the main categories being 'reality vs. vision' and the overall 'agent' category. A gap was found between what the pharmacists said they were doing in their day-to-day work and what they expressed as their ideal tasks in the pharmacy. The pharmacists seem to transfer the need for their role as active medicine experts in patient-centred care to other agents such as authorities and pharmacy chains. CONCLUSIONS: There is a gap between what the Norwegian community pharmacists express as their vision and current practice. The identified agent relationships appear to hamper the pharmacists' perceived ability to be active and take full responsibility in their role development and further implementation of patient-centred care. Adopting a fairly inactive position when it comes to increasing patient-centred care might be a result of a traditional product-focused pharmacy culture.

Cultural barriers encountered by Norwegian community pharmacists in providing service to non-Western immigrant patients.

BACKGROUND: Western societies' need for knowledge about how to meet the challenges in health care following increased immigration has emerged as studies have showed that non-Western immigrants tend to experience more obstacles to drug use and poorer communication with health professionals. OBJECTIVES: To identify the cultural barriers encountered by Norwegian community pharmacists in providing service to non-Western immigrant patients and to outline how they are being addressed. SETTING: Community pharmacies in Oslo, Norway. METHODS: A qualitative study consisting of four focus groups was conducted. In total 19 ethnic Norwegian pharmacists (17 female and 2 male; mean age: 40.6 years) participated. They were recruited from 13 pharmacies situated in areas of Oslo densely populated by non-Western immigrants. The audio-records of the focus group discussions were transcribed verbatim. A thematic content analysis was conducted. Main outcome measure Cultural barriers identified by Norwegian community pharmacists in the encounter with non-Western immigrants. RESULTS: All the pharmacists were in contact with non-Western immigrant patients on a daily basis. They said that they found it challenging to provide adequate service to these patients, and that the presence of language as well as other cultural barriers not only affected what the patients got out of the available information, but also to a great extent what kind of and how much information was provided. Although the pharmacists felt that immigrant patients were in great need of drug counselling, there were large disparities in how much effort was exerted in order to provide this service. They were all uncomfortable with situations where family or friends acted as interpreters, especially children. Otherwise, cultural barriers were related to differences in body language and clothing which they thought distracted the communication. All the pharmacists stated that they had patients asking about the content of pork gelatin in medicines, but few said that they habitually notified the patients of this unless they were asked directly. Ramadan fasting was not identified as a subject during drug counselling. CONCLUSION: This focus group study shows that language and other cultural barriers, including differences in body language, non-Western gender roles, and all-covering garments, are of great concern for ethnic Norwegian community pharmacists in the encounter with non-Western immigrant patients. Although the pharmacists recognise their role as drug information providers for immigrant patients, large disparities were detected with respect to kind of and amount of information provided to these patients.

Cultural influences on medicine use among first-generation Pakistani immigrants in Norway.

PURPOSE: The aim of this study was to explore medicine use among first-generation immigrants from Pakistan who had been residing in Norway 10 years or more, with emphasis on cultural influences, language proficiency, and sociodemographic variables. METHODS: Personal interviews with 82 first-generation Pakistani immigrants (40-80 years) were conducted primarily in the participant's home using a semistructured questionnaire. The participants were users of antihypertensives, and/or antidiabetics, and/or cholesterol-lowering drugs. RESULTS: All participants had a family doctor in Norway. They used on average 6.7 (range: 1-28) prescription drugs, and 48% used nonprescription drugs (primarily analgesics) as well. Fifteen percent were occasionally using drugs acquired from Pakistan. Two thirds reported various disease symptoms despite being on medication. Fifty-one percent lacked essential knowledge of their drug therapy, but 93% were of the opinion that it was important to take drugs every day. Nearly half of the participants altered their drug taking during Ramadan. Women were overrepresented when it came to reporting symptoms, fasting, frequent physician visits, and communicational challenges in the pharmacies. Women and/or those with low educational levels were most likely to send someone else to collect their drugs from the pharmacy or bring family members along to act as translators. CONCLUSION: This study shows that cultural influences may affect medicine use among first-generation immigrants from Pakistan after having lived 10 years or more in Norway. Although access to drugs and basic health care services seems to be problem free, language proficiency is a considerable problem that obstructs access to information and is detrimental to the level of communication with health professionals.

Special challenges for drug adherence following generic substitution in Pakistani immigrants living in Norway.

PURPOSE: This study aims to explore how long-term drug users with a Pakistani background living in Oslo (Norway) perceive generic substitution and how generic substitution influences drug adherence in this population. METHODS: Personal interviews using a semi-structured questionnaire were carried out with 83 Pakistani immigrants (aged 40-80 years) who were using antihypertensives, antidiabetics, and/or cholesterol-lowering drugs. RESULTS: In all, 73% of the participants were using generic drugs at the time of the interview. Of these, 10% were erroneously using two equivalent generics at the same time. One quarter of the participants were of the opinion that cheaper generic drugs were counterfeit drugs. Two thirds had accepted generic substitution in the pharmacy whereas the remaining participants had either opposed or were unaware of the substitution. Of those who had accepted substitution, 27% claimed that the effect of the new drug was poorer and 20% reported more side-effects. Generic substitution had resulted in concerns about the therapy in 41% of the patients, and 26% thought it had become more demanding to keep track of their medication. Poor adherence tended to be most common among patients who were not fluent in Norwegian, patients who had concerns about medicine use, and patients who had accepted generic substitution in the pharmacy. CONCLUSION: This study shows that generic substitution may have a negative effect on drug adherence in Pakistani immigrants in Oslo (Norway) because of concerns and misconceptions, including confusion with regard to counterfeit drugs. Problems result primarily from inadequate information caused by language barriers but also from culturally conditioned views on encounters with the health care system.

Generic substitution: a potential risk factor for medication errors in hospitals.

INTRODUCTION: Efforts to restrain pharmaceutical costs in the Norwegian hospital sector have focused on putting pharmaceuticals out to tender with resultant frequent changes in medicine inventories. Due to the extent of physicians failing to prescribe from the hospital drug list, the nurses have to perform generic substitution on the wards. The objective of the present study is to investigate the hospital nurses' experiences with generic substitution and to explore their views on this strategy as a risk factor for medication errors. METHODS: Personal interviews with 100 nurses who were employed in a large Norwegian hospital were conducted using a semistructured questionnaire. RESULTS: In all, 75% of nurses thought it was problematic that the hospital's drug inventory was subject to frequent changes, and 91% believed that the high number of generic products may contribute to erroneous dispensing. Nevertheless, three out of four admitted that they seldom or never verified the feasibility of the substitution with the physician, and that it was seldom documented in the medical charts. In total, 42% of the nurses had experienced mistakes that occurred as a result of substitution. They claimed that the medication errors relating to generic substitution derived from difficult drug names, frequent changes in the drug inventory, and the increasing number of generic drugs, as well as from heavy workload and insufficient training. CONCLUSIONS: The present study shows that generic substitution is often carried out by nurses on the wards. The nurses feel insecure about the situation and report that they do not have the necessary training for the task. They clearly believe that a high number of generic drugs and frequent generic substitutions are risk factors for medication errors. Hence, hospital managers should be aware that such strategies to reduce costs may interfere with patient safety.

Generic substitution: additional challenge for adherence in hypertensive patients?

OBJECTIVE: This study aims to investigate whether, and in what way, generic substitution affects drug adherence in hypertensive patients. METHODS: Personal interviews with 174 Norwegian patients (50-80 years) who had had their brand-name antihypertensive drug generically substituted were conducted using a semi-structured questionnaire. RESULTS: On average, 4.4 (1-14) prescription drugs were used by the participants. Of these, 2.0 (1-4) drugs were antihypertensives. More than 50% of the patients had been using antihypertensive drugs for more than 10 years. One in four found it difficult to remember to take their medication every day. One in three said generic substitution made keeping track of their medications more demanding. Twenty-nine percent were anxious when they started to use a generically substituted drug. Eight percent felt that the effect of the drug had changed, and 15% reported having new or more side-effects. A negative attitude towards generics was significantly associated with low educational attainment, increasing number of drugs, having general concerns about medicine use, and having received insufficient information regarding generic substitution. Five percent of the patients had been using more than one equivalent generic drug at the same time. These were among those who used several different drugs and also among those who got their medications from more than one pharmacy. Five percent is a too small number to draw general conclusions; however, there is no reason to suspect that these mistakes do not occur from time to time. CONCLUSIONS: This study shows that generic substitution can be an additional factor in poor drug adherence in hypertensive patients and contributes to concerns and confusion among the patients. Although generic substitution is an important measure of cost containment, health personnel should approach each patient individually. Clearly, many patients feel insecure about substituting their medication and demand more information.

Price control as a strategy for pharmaceutical cost containment - what has been achieved in Norway in the period 1994-2004?

OBJECTIVES: To describe and evaluate the different price control strategies implemented in Norway after its accession to the European Economic Area (1994-2004). METHODS: Interviews with ten key persons who had broad insight into the field in question were held. All the available literature was reviewed. RESULTS: Direct price control involving international reference pricing of prescription drugs, and the subsequent price revisions, that occurred from the year 2000 onwards, resulted in predictable and substantial price reductions. With respect to the indirect methods which targeted the off-patent market, the price reductions resulting from reference-based pricing (1993-2000) were only marginal and the achieved savings derived mainly from increased patients' charges. The introduction of generic substitution in 2001 led to increased market shares for non-branded products, but discounts from the manufacturers were not reflected in retail prices. An index price system (2003-2004) was therefore created; but as it entailed negative economical incentives for the pharmacy chains, the price changes did not meet the expectations. CONCLUSION: The direct pricing strategy, i.e. the international reference pricing, was considered to be the most successful method. In contrast, due to the unpredictability of the market situation, the resulting effects of the indirect methods, i.e. reference-based pricing, generic substitution, and index pricing, were more limited.