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Open in a separate window Patient and physician demographic characteristics Patient and physician demographic characteristics were introduced as control variables.
The role of patient age and Biaxin Remboursement in the use of a brand versus a generic drug within the context of the reference price system is not straightforward.
The association between patient age and gender and the probability of using a generic drug was found to be rather heterogeneous over the ten molecules. While for five active ingredients diltiazem, clarithromycin, piroxicam, citalopram and acetylcysteine men had a higher probability than women of receiving Biaxin Remboursement generic drug, for lansoprazole the opposite result held.
For the other molecules, gender did not play a role in using a generic drug. These results are in line with previous studies where patient characteristics such as Biaxin Remboursement, age and ethnicity have little or no association with the use of generic drugs [ 3839 ].
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The age of the patient even had a less pronounced association with the probability of using a generic drug. Biaxin Remboursement the combination of bisoprolol and thiazides, younger patients had a smaller probability of using a generic alternative, Biaxin Remboursement. The same conclusion holds for the association between physician age and gender and the probability of using a generic drug.
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Physician gender played a role in prescribing behavior in six groups. Male doctors prescribed more generics for lansoprazole, Biaxin Remboursement, furosemide, bisoprolol and thiazides, and piroxicam, and less for citalopram and acetylcysteine. Although physician age was also associated with prescribing behavior, no clear pattern was identified for the ten molecules.
Patient health status Although the separate analysis for the ten molecules increased the homogeneity of patient health status within each group, differences remain. No direct health status information was Biaxin Remboursement in the databases, Biaxin Remboursement.
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However, entitlement to a lump sum for chronic illness can be interpreted as an indirect measure of health status. The variable was included as a Biaxin Remboursement variable. Compared to more healthy individuals, patients receiving a lump sum for being Biaxin Remboursement ill were less likely to use a generic alternative for diltiazem, tramadol and acetylcysteine.
The opposite held for bisoprolol and thiazides.
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Patient socioeconomic characteristics Patient socioeconomic background was proxied by three variables available at the individual level and one at the level of the Biaxin Remboursement sector. For the individual characteristics—work status, having a guaranteed income and being entitled to increased reimbursement—some patterns can be observed, Biaxin Remboursement.
Having a guaranteed income was associated with a higher probability of using a generic version for bisoprolol and thiazides, clarithromycin and citalopram, and a lower probability for diltiazem. This last result is rather striking, since diltiazem has the highest reference supplement see Fig. Higher use of a generic alternative of furosemide, Biaxin Remboursement, piroxicam, acetylcysteine and citalopram was also associated with patients being entitled to increased reimbursement.
Work status was associated with the use of a generic drug for five active ingredients Biaxin Remboursement, bisoprolol and thiazides, claritromycin, tramadol and acetylcysteine but with opposite results. Compared to pensioners, which is our reference category, the probability of using a generic version of furosemide was higher for the other work status categories. On the contrary, for bisoprolol and thiazides, pensioners were more likely to use its generic version than all other groups.
For clarithromicyn, tramadol and acetylcysteine, invalids and handicapped patients were less likely to use a generic alternative than pensioners. Patients living in small areas with Biaxin Remboursement education levels were more likely to use a generic alternative for six types of drugs: Only for acetylcysteine the opposite result was found: Patients enrolled in a primary care center Biaxin Remboursement more likely to receive generic alternatives in six groups: A possible explanation for the higher generic drug use in primary care centers could be that generic prescribing is an essential part of their policy [ 40 ].
Moreover, there is some evidence that the type of practice may influence prescription behavior of physicians [ 39 ]. A possible explanation for the larger probability of generic drug use for patients with a global medical record might be that, since having a medical record is possible only if patients ask their preferred GP to keep one, these patients have a better knowledge of the health system, including the existence of the reference supplement and how to avoid it, Biaxin Remboursement.
Another Biaxin Remboursement is that patients and physicians using such a tool might be better suited to discuss prescription choices and thus use the less expensive alternatives.
Rest and nursing home Biaxin Remboursement the elderly Residing in a rest or Biaxin Remboursement home for the elderly was associated with a higher use of generic alternatives for lansoprazole, furosemide, Biaxin Remboursement, clarythromicin and citalopram.
For acetylcysteine, the opposite result was found. Regional characteristics Compared with individuals living in Brussels, those living in Flanders and Wallonia were more likely to use generic alternatives in seven out of the ten groups that were analyzed glicazide, furosemide, diltiazem, clarithromycin, piroxicam, tramadol and citalopram. Discussion There are many different approaches to evaluate a reference price system.
A number of studies have tried to evaluate its effect on outcome measures such as drug use, changes in prices and cost for the third-party payer and Biaxin Remboursement patients. Only a few studies have directly assessed its impact Biaxin Remboursement financial accessibility [ 20 — 22 ], Biaxin Remboursement. However, a reference price system might impose a larger financial burden on more disadvantaged individuals if their knowledge of the existence and consequences of the system is not the same as that of more privileged individuals [ 41 ].
To our knowledge, this is the first article directly analyzing the possible unintended differential impact of a generic reference price system on individuals with a different socioeconomic background.
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Several results are worth mentioning. Patients enrolled in a primary care center do not pay any co-payments. Maybe these patients are more informed on how to reduce their health care expenditures. In addition to this, one peculiarity of the pharmaceutical market is that the demand Biaxin Remboursement pharmaceutical specialties is not determined solely by patients, but instead jointly by patients, Biaxin Remboursement, prescribers and pharmacists.
Having a medical record as well as being enrolled in a primary care center might also reflect how patients and physicians interact. Indeed, if those tools allow doctors to better internalize the health and financial cost for patients, they might result in a more efficient prescription behavior. There are a number of significant differences for individual drugs, and specific subgroups, but their clinical relevance can be questioned. Furthermore, Biaxin Remboursement, the characteristics of the drugs may also be important: However, except for diltiazem, Biaxin Remboursement, either a positive relationship, or none at all, between the use of a generic drug and a lower socioeconomic status was found.
In terms of financial accessibility, the generic price reference system in Belgium seems to work well. Although the results do not provide evidence that the RPS imposes an unbalanced financial burden on low-income patients, some patients are still bearing the cost of using brand drugs when a cheaper alternative is available.
How can it be explained that there are still prescriptions entailing a reference supplement? This question is particularly important in a system of generic reference pricing with narrowly defined clusters where potential differences in clinical effectiveness of generic and brand drugs can Biaxin Remboursement regarded as negligible.
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Some hypotheses can be put forward. First, no nationwide information campaign directed towards the general public was organized, Biaxin Remboursement. Second, generic substitution by pharmacists is not allowed. In Belgium, the pharmacist can dispense Biaxin Remboursement low-cost medication only when prescriptions are written using the International Non-proprietary Name. Third, for physicians the time investment necessary to Biaxin Remboursement a sound knowledge of the rapid changes in prices as well as their prescription habits may create a barrier for prescribing the less expensive alternatives [ 37 — 39 ].
Finally, the perception of generic drugs by GPs may play an important role. A number of surveys have been carried out in Belgium on this topic. Furthermore, patients show a high degree of confidence in their physician. Even though they are aware of the existence of generic drugs and overestimate the price differential, Biaxin Remboursement, they hesitate to ask their prescriber to change the prescription.
The extent to which a reference price system is able to attain both Biaxin Remboursement policy objective of controlling expenditures as well as being equitable essentially relies on the interaction among the physician, the patient and the pharmacist, Biaxin Remboursement. Measures in Belgium have mostly been directed toward patients and physicians. A step further may be to allow pharmacist generic substitution. Acknowledgments The authors wish to thank Maïté le Polain for her help on describing the Belgian reimbursement system and Erik Schokkaert for his comments on the first draft of this manuscript.
The authors also wish to thank both referees for their helpful comments. Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author s and the source are credited.