Background
Method
Study setting
Study design
Selection of study participants
Interview schema development
Data collection
Data analysis
Results
Characteristics of participants
Characteristics of healthcare professionals | Characteristics of patients | |||
---|---|---|---|---|
Physicians (n = 13) | Pharmacists (n = 12) | n = 10 | ||
Gender | Gender | |||
Male | 9 | 6 | Male | 6 |
Female | 4 | 6 | Female | 4 |
Experience (years) | Educational level | |||
Average | 7.9 | 3.8 | Secondary | 5 |
Range | 3–15 | 1–15 | Intermediate | 1 |
Interview duration (minutes) | Graduate | 2 | ||
Average (SD) | 24 (3.2) | 28 (3.7) | Postgraduate | 1 |
Range | 20–32 | 22–43 | Masters | 1 |
Interview duration (minutes) | ||||
Average (SD) | 22 (3.4) | |||
Range | 18–30 |
Overlapping theme
Theme 1: impact of medicines shortages on patients
Themes | Subthemes | Categories | Supporting quotations |
---|---|---|---|
Impact of medicines shortages on patients | Clinical impact | Compromised treatment • Delayed treatment • Disease proliferation and complications • Treatment failure | “Obviously, when patient fails to take medicine according to prescribed regimen, his disease proliferates and it could be difficult to control again. This is very evident in case of infectious diseases and cancer treatment. When good efficacy antibiotic brand is not available, recovering the patient becomes difficult.” (Physician 4) “Sometimes efficacy of alternative generic as compared to international brand is less and that is unable to properly treat a disease.” (Pharmacist 1) “It has huge impact on the patient. Patient suffers more than anyone else. I have experienced this in my skin allergy and the brand was not available due to shortage. Even cream and soap were not available. I was very worried because I wanted to recover quickly. Although, alternative brands were available, but I just wanted that specific brand. Because there was an ingredient in that brand, which was more effective for my skin.” (Patient 5) |
Medication safety issues due to • Wrong therapeutic alternative • Medication error • Adverse drug reactions • Other risk associated with substandard and counterfeit medicines | “When any brand is short, we have to change it or sometimes, new brand has different strength or dosage form. As a result, the treatment regimen changes, but our patients are used to follow previous regimen and mostly have limited literacy level. In such case, risk of medication error increases and very often patient return and complain that they are having side effects.” (Physician 8) “There are also few antihuman elements and when prescribed brand is not available, they take benefit from it and start selling substandard and counterfeit medicines. This happens especially with branded medicines because few brands have high demand. These counterfeit medicines are harmful and cause adverse drug reactions…” (Pharmacist 5) “Alternative brands are mostly available but then there can be strength issues and it impacts patient a lot. I have blood pressure issue and I use Byscard 2.5 mg. Few days back, I don’t know it was short or dispenser was careless but he gave me 5 mg and he didn’t guide me to take half tablet. Due to which my blood pressure got very low, which was not good impact. I could have died.” (Patient 4) | ||
Risk of mortality | “In hospitals, there are many patients who cannot afford a single penny over medicines, so ultimately, when they cannot get medicines from hospitals, their condition gets worsen and worsen or some may lead to death as well.” (Physician 4) “If any generic gets short then obviously all those patients who are taking that generic, for example asthma patients have to take inhalers, TB patients have to be on ATT so their whole treatment will be disturbed, even this could be fatal…” (Pharmacist 6) “Sometimes, it turns into a matter of life and death. My father is heart patient and you know anti-angina medicine is very much important for such patients. But it was critically short in the market. I am pharmaceutical distributor but it was difficult even for me to find it. You can understand the consequences if such important medicines are short...” (Patient 7) | ||
Humanistic impact | • Confusion • Wastage of time | “Comparable efficacy brands are available in markets, but as most of the people are illiterate, they are not aware of it. If the physician prescribes him a brand which is not available in the market, he will be confused and faced with a problem in search of that brand. Patients waste time and ask for same medicine brand again and again, because they want that specific medicine brand.” (Physician 11) “Patient experiences a lot of confusion when prescribed brand is not available in the market. If a pharmacist advises patient on some alternative brand, he usually hesitates to take his advice and proceed to search for the particular brand.” (Pharmacist 5) “If there is a shortage of branded medicine then we have to visit other pharmacies. It takes a lot of time. In case alternative is available, we have the satisfaction issue that whether the alternative will be good or not, we will recover or not. We feel the need to visit the physician again to confirm.” (Patient 8) | |
Financial burden | • Increased treatment costs • Patient out-of-pocket costs | “If we give alternative and that alternate is costly then it effects on the pocket of the patient.” (Pharmacist 13) “In case of shortage, patients buy medicines from drug retail outlets. But usually, patients who visit government hospitals are not rich and they only come in search of free medication. When any medicine is not available in the hospital, we ask them to buy it from outside and this increases burden on patients.” (Physician 9) “It takes a considerable amount of time and money. Sometimes, we have to purchase high price alternative brand or the same brand at high price from black marketers.” (Patient 8) |
Patients’ specific theme
Theme 2: patients’ practices in response to medicine shortages
Themes | Subthemes | Categories | Supporting quotations |
---|---|---|---|
Patients’ practices in response to medicine shortages | Preference for type of healthcare professional to seek advice when medicine is not available | • Few preferred physicians • Very few preferred pharmacists • Majority preferred non-pharmacist pharmacy worker | “I ask physician because he is a person authorized to do so. So, I take medicine that he prescribes. Because best practice is, medicine should be prescribed by the person who has diagnosed the disease.” (Patient 5) “If there is a pharmacist in the pharmacy, then I usually ask him for the alternative brand. At big pharmacies, pharmacist is very cooperative and they guide me about my medicine and help me understand how to take it” (Patient 6) “I seek advice from dispenser. Dispensers know everything about medicines, their brands and prices and they are better than pharmacists and physicians. They even know where that medicine will be available in the market...” (Patient 2) |
Other approaches | Self-decision | “Or if there is general fever or pain medicine shortage then I take any available brand because I know all such medicine work the same” (Patient 9) | |
Ask family or friends | “… If any family member has same illness or is in the medical field then I ask them…” (Patient 7) | ||
Forgo treatment | “When dispenser tells me about the shortage of the brand I asked for, then I know it will be not available at other pharmacies in the vicinity as well. I don’t travel to any other store and try to treat myself with home remedies.” (Patient 4) | ||
Explore using internet | “I Google to match the ingredients between the prescribed brand and dispensed brand. If there is no difference, I consume the medicine fearlessly.” (Patient 3) |
Healthcare professionals’ specific themes
Theme 3: influence of shortages on medical practice and pharmaceutical business
Theme 4: barriers to solutions of medicines shortages issue
Theme 5: suggestions to assuage the impact of medicine shortages
Themes | Subthemes | Categories | Supporting quotations |
---|---|---|---|
Negative influence of shortage on practice and pharmaceutical business | Impact on physicians | • Patient dissatisfaction • Personal dissatisfaction | “Its effects physician’s credibility. If physician prescribes a short brand to patient, patient thinks that physician is taking incentives for this brand that’s why he is prescribing this despite shortage.” (Physician 12) “Physician faces problem, as he loses confidence. When he usually prescribes some trustworthy brands but if he has to switch to other brands or local brands due to shortage, then he remains uncertain that whether it has same efficacy and gives same results or not, my patient will be satisfied or not…” (Physician 5) |
Impact on business | • Credibility loss • Financial loss | “Impact on the pharmacy business depends on brands whose shortages occur because some pharmaceutical companies provide more margins to pharmacies for specific brands. So if those well-known brands get into shortage, then there will be profit loss.” (Pharmacist 5) “Financial losses are obvious and then there are credibility losses. One of the major losses is that your customers are dependent on your drug. So your relations with them are disturbed. So both financial and credibility losses happen.”(Pharmacist 4) | |
Healthcare professional level barriers to solutions of medicines shortages issue | • Excessive advertisement and promotional campaigns of short brands | “Incentives play a key role here, if pharmaceutical companies provide incentives to create demand of their product. They do good marketing and continually approach physicians. As a result, physician will prescribe more of their short brand and patient suffers.” (Physician 7) “According to medical representatives, customer is not patient but a physician. They directly convince the physician that if they prescribe short brand then they will get reward or incentives in return. In such cases, patient continues to experience due to unavailability of medicines. If physicians easily switch to alternative, they can manage the shortages very easily.” (Pharmacist 7) | |
• Inferior generics | “Secondly, in Pakistan the quality also matters, if there are multinationals then they are of good quality while the local are not of high quality sometimes.so there is an issue. Different brands have different quality; good brands show good effect like we have omeprazole of Esomepra, it is very much better as compared to any other company’s brand.” (Physician 6) “One issue is efficacy of alternatives. Local companies don’t conduct comparative bioequivalence studies and there is no data about its efficacy. Second many pharmaceutical companies use substandard excipients to manage the price of product. As a result, quality of generic products is poor as compared to branded medicines.” (Pharmacist 1) | ||
• Poor collaboration and communication between physicians and pharmacists | “Major issue is poor collaboration, which leads to poor demand prediction in hospitals. Demands are not based on actual needs of patients. Medicines having very low demand are purchased in large quantities and medicines having high demand are purchased in small quantities. We cannot blame administration for this. It is the duty of pharmacists and physicians to decide which medicine is needed in large quantities, but as you know physicians and pharmacists do not collaborate much in our hospitals.” (Pharmacist 5) | ||
• Patient psychological acceptance and rigid perception | “It’s not related to physicians but is based on patient satisfaction of its own. It is also based on patient psychology that if they are satisfied with a specific brand then they think they will be harmed by switching to generic. So, they resist changing brand, demand the same.” (Physician 7) “Patient trust physician so he sets his mind on brands prescribed by physician. He thinks physician is always right. For instance, there was a case when Calpol was prescribed by the physician and I dispensed Panadol to the patient due to shortage, but he refused to take that. Its patients’ psychological issue that they think physician has prescribed this brand, so we have to take this, otherwise we would not get treated.” (Pharmacist 10) | ||
Suggestions to effectively assuage the impact of medicine shortages | • Generic prescribing/ Prescribing by international nonproprietary name (INN) | “If government changes its policy and promotes generic prescription instead of brand, and compels companies to market medicines with the generic name only then branded shortage issue can be managed or entirely vanished.” (Physician 7) “There should be generic prescription, like in European countries. Even in Pakistan, there is only generic prescription in some high-level hospitals, such as Shaukat Khanum hospital and Agha khan hospital. But, there is brand prescription in government or some other hospitals due to incentives. Because incentives are only received on brands and not on generics. If they shift to generic, then all brand authority will shift to pharmacist. Pharmacist will be responsible for brand selection. When prescription comes with generic, pharmacist will provide patients with the best brand available.” (Pharmacist 9) | |
• Check and balance on pharmaceutical promotion to avoid incentives driven irrational prescription of short brand | “Physicians should not stick to one brand because of any agreement. Companies should be punished for luring physicians through incentives.” (Physician 1) “Again I would say that the government should keep an eye on promotional practices of pharmaceuticals. Also they should bound physicians not to make deals with the companies. If physicians are strictly punished for being biased towards a brand, this issue will vanish by itself…Physicians need to work ethically and prioritize patients rather than personal gains.” (Pharmacist 12) | ||
• Be aware of shortage and prescribe accordingly | “If a medicine is not available, physician should be aware of shortage. If he knows then he should shift his patients to alternate brand as soon as possible.” (Pharmacist 2) “Sometimes, physicians don’t have information about brand shortage. If medical representatives have not informed the physician, then he will continue to prescribe that brand.” (Physician 8) | ||
• Patient education about safety of generics | “If any patient is taking one brand of antihypertensive or anti-diabetic, then physician should educate him that other brands are also available. Whether patient is educated or not, educates him as much as you can; that this medicine is available under different brand names, but salt is same in each brand. This brand suits you but in case if shortage of that brand occurs then you can switch to another brand....” (Physician 1) “Patients should have knowledge of brands if one brand is short in market then there is always an alternative of that brand available. Based on the mind of our patients, it is the duty of physicians to spread awareness among patients about alternative brands” (Pharmacist 11) | ||
• Collaborative/mutual efforts of physicians and pharmacists to better procure, select cost effective alternative and optimize selected alternative therapy | “If we don’t know which alternative brand is better or at least equivalent in terms of efficacy then pharmacist should guide us. Also he should tell us all the possible side effects if they suggest any new salt because many times we resist switching just to avoid negative impact on patient.” (Physician 1) “The collaboration between physician and pharmacists should be promoted, because as I said before procurement of medicines in hospitals is heavily affected due to this issue and leads to shortage.” (Pharmacist 5) |