A stated preference survey to explore patient preferences for novel preventive migraine treatments.

OBJECTIVE: The objective of this study was to explore patient preference for attributes of calcitonin gene-related peptide (CGRP) inhibitors for the preventive treatment of migraine and to describe differences in treatment preferences between patients. BACKGROUND: CGRP inhibitors are a novel class of migraine drugs specifically developed for the preventive treatment of migraine. Clinicians should understand patient preferences for CGRP inhibitors to inform and support prescribing choices. METHODS: Patients with migraine in the US and Germany were recruited to participate in an online discrete choice experiment (DCE) survey, which presented hypothetical treatment choices using five attributes: mode of administration, side effects, migraine frequency, migraine severity, and consistency of treatment effectiveness. Attribute selection was informed by a literature review and semi-structured patient interviews (n = 35), and evaluated using patient cognitive debriefing interviews (n = 5). RESULTS: Of 680 who consented to participate, 506 participants completed the survey and were included in the study (US = 257; Germany = 249). Overall, participants placed highest importance (preference weight, beta = 1.65, p < 0.001) on the treatment's ability to reduce the severity of migraine (mild vs. unchanged severity), followed by consistent treatment effectiveness (beta = 1.13, p < 0.001), and higher chance of reduced migraine frequency (beta = 1.00, p < 0.001). Participants preferred an oral tablet every other day (beta = 1.00, p < 0.001) over quarterly infusion, quarterly injections (p = 0.019), or monthly injection (p < 0.001). Preference for all treatment attributes were heterogeneous, and the subgroup analyses found that participants naïve to CGRP monoclonal antibody treatments had a stronger preference for oral therapy compared to those with such experience (p = 0.006). CONCLUSION: In this DCE assessing CGRP inhibitors attributes, the main driver of patient choice was treatment effectiveness, specifically reduced migraine severity, and consistent treatment effectiveness. Further, patients exhibited an overall preference for an oral tablet every other day over injectables. Patients' experience with previous treatments informs the value they place on treatment characteristics.

Nitroglycerin for treatment of retained placenta: A randomised, placebo-controlled, multicentre, double-blind trial in the UK.

BACKGROUND: Retained placenta following vaginal delivery is a major cause of postpartum haemorrhage. Currently, the only effective treatments for a retained placenta are the surgical procedures of manual removal of placenta (MROP) and uterine curettage, which are not universally available, particularly in low- and middle-income countries. The objective of the trial was to determine whether sublingual nitroglycerin spray was clinically effective and cost-effective for medical treatment of retained placenta following vaginal delivery. METHODS AND FINDINGS: A randomised, placebo-controlled, double-blind trial was undertaken between October 2014 and July 2017 at 29 delivery units in the UK (Edinburgh, Glasgow, Manchester, Newcastle, Preston, Warrington, Chesterfield, Crewe, Durham, West Middlesex, Aylesbury, Furness, Southampton, Bolton, Sunderland, Oxford, Nottingham [2 units], Burnley, Chertsey, Stockton-on-Tees, Middlesborough, Chester, Darlington, York, Reading, Milton Keynes, Telford, Frimley). In total, 1,107 women with retained placenta following vaginal delivery were recruited. The intervention was self-administered 2 puffs of sublingual nitroglycerin (800 µg; intervention, N = 543) or placebo spray (control, N = 564). The primary clinical outcome was the need for MROP, assessed at 15 minutes following administration of the intervention. Analysis was based on the intention-to-treat principle. The primary safety outcome was measured blood loss between study drug administration and transfer to the postnatal ward or other clinical area. The primary patient-sided outcomes were satisfaction with treatment and side-effect profile, assessed by questionnaires pre-discharge and 6 weeks post-delivery. Secondary clinical outcomes were measured at 5 and 15 minutes after study drug administration and prior to hospital discharge. There was no statistically significant or clinically meaningful difference in need for MROP by 15 minutes (primary clinical outcome, 505 [93.3%] for nitroglycerin versus 518 [92.0%] for placebo, odds ratio [OR] 1.01 [95% CI 0.98-1.04], p = 0.393) or blood loss (<500 ml: nitroglycerin, 238 [44.3%], versus placebo, 249 [44.5%]; 500 ml-1,000 ml: nitroglycerin, 180 [33.5%], versus placebo, 224 [40.0%]; >1,000 ml: nitroglycerin, 119 [22.2%], versus placebo, 87 [15.5%]; ordinal OR 1.14 [95% CI 0.88-1.48], p = 0.314) or satisfaction with treatment (nitroglycerin, 288 [75.4%], versus placebo, 303 [78.1%]; OR 0.87 [95% CI 0.62-1.22], p = 0.411) or health service costs (mean difference [£] 55.3 [95% CI -199.20 to 309.79]). Palpitations following drug administration were reported more often in the nitroglycerin group (36 [9.8%] versus 15 [4.0%], OR 2.60 [95% CI 1.40-4.84], p = 0.003). There were 52 serious adverse events during the trial, with no statistically significant difference in likelihood between groups (nitroglycerin, 27 [5.0%], versus placebo, 26 [4.6%]; OR 1.13 [95% CI 0.54-2.38], p = 0.747). The main limitation of our study was the low return rate for the 6-week postnatal questionnaire. There were, however, no differences in questionnaire return rates between study groups or between women who did and did not have MROP, with the patient-reported use of outpatient and primary care services at 6 weeks accounting for only a small proportion (approximately 5%) of overall health service costs. CONCLUSIONS: In this study, we found that nitroglycerin is neither clinically effective nor cost-effective as a medical treatment for retained placenta, and has increased side effects, suggesting it should not be used. Further research is required to identify an effective medical treatment for retained placenta to reduce the morbidity caused by this condition, particularly in low- and middle-income countries where surgical management is not available. TRIAL REGISTRATION: ISRCTN.com ISRCTN88609453 ClinicalTrials.gov NCT02085213.

Determination of Cost-Effectiveness Threshold for Health Care Interventions in Malaysia.

BACKGROUND: One major challenge in prioritizing health care using cost-effectiveness (CE) information is when alternatives are more expensive but more effective than existing technology. In such a situation, an external criterion in the form of a CE threshold that reflects the willingness to pay (WTP) per quality-adjusted life-year is necessary. OBJECTIVES: To determine a CE threshold for health care interventions in Malaysia. METHODS: A cross-sectional, contingent valuation study was conducted using a stratified multistage cluster random sampling technique in four states in Malaysia. One thousand thirteen respondents were interviewed in person for their socioeconomic background, quality of life, and WTP for a hypothetical scenario. RESULTS: The CE thresholds established using the nonparametric Turnbull method ranged from MYR12,810 to MYR22,840 (~US $4,000-US $7,000), whereas those estimated with the parametric interval regression model were between MYR19,929 and MYR28,470 (~US $6,200-US $8,900). Key factors that affected the CE thresholds were education level, estimated monthly household income, and the description of health state scenarios. CONCLUSIONS: These findings suggest that there is no single WTP value for a quality-adjusted life-year. The CE threshold estimated for Malaysia was found to be lower than the threshold value recommended by the World Health Organization.

Will the Public Engage with New Pharmacy Roles? Assessing Future Uptake of a Community Pharmacy Health Check Using a Discrete Choice Experiment.

BACKGROUND: Pharmacists are increasingly providing more clinically orientated services that focus on enhancing patient care and health promotion. However, little is known about how acceptable this is to the public. This study explored public preferences for a community pharmacy-based health check for cardiovascular disease (CVD). METHODS: A convenience sample of 423 individuals was recruited (from a community pharmacy, a dental practice, a shopping centre, a university campus and a sports centre) to complete a discrete choice experiment (DCE) survey administered face to face on a tablet. The DCE included six attributes: day of the week (weekday or weekends); way of accessing the service (walk-in and wait or by appointment); provider of health check (trainee pharmacist, pharmacist or nurse); duration of health check (30 or 45 min); follow-up phone call (no, yes and within 3 months); and cost (included to estimate the monetary value of health checks). Experimental design methods were used to create 12 choice tasks describing different health check services. Mixed logit (MXL) was used to analyse response data. RESULTS: Respondents had a preference for a community pharmacy-based CVD health check over no health check. They preferred a service provided (i) at the weekend; (ii) by appointment; (iii) by a nurse; (iv) for 30 min and (v) with follow-up after 3 months. Respondents were willing to pay £50 for this health check. CONCLUSION: Findings affirm the public's acceptance and value of a pharmacy-led CVD health check. The findings can inform pharmacy-based screening services before they are introduced, guide new service design and support resource allocation decisions.

Net clinical benefit of antiplatelet therapy was affected by patient preferences: A personalized benefit-risk assessment.

OBJECTIVES: To assess the effect of patient preferences on the net clinical benefit (NCB) of an antiplatelet therapy for the secondary prevention of cardiovascular complications. STUDY DESIGN AND SETTING: Risk equations were developed to estimate the individual predicted risk of key outcomes of antiplatelet treatment in patients with a prior myocardial infarction using the Clinical Practice Research Datalink linked to the Hospital Episode Statistics and UK Office of National Statistics databases. Patient preferences for outcomes of antiplatelet therapies were elicited in a separate discrete choice experiment survey. Trial hazard ratios, relative to placebo, were used to calculate the per-patient NCB using equal or preference weighting of outcomes. RESULTS: Risk equations were estimated using 31,941 adults in the Clinical Practice Research Datalink population, of which 22,125 were included in the benefit-risk assessment. The mean NCB was lower in the preference-weighted than in the equal-weighted analysis (0.040 vs. 0.057; P < 0.0001), but the direction of effect was unchanged by the weighting. In analyses stratified by the presence of bleeding risk factors, including preference weighting altered the ranking of subgroups by NCB. CONCLUSION: Patient preference weighting may have a significant effect on NCB and should be included in personalized benefit-risk assessments.

Comparing Patient Preferences for Antithrombotic Treatment During the Acute and Chronic Phases of Myocardial Infarction: A Discrete-Choice Experiment.

BACKGROUND: Antithrombotic drugs are used as preventive treatment in patients with a prior myocardial infarction (MI) in both the acute and chronic phases of the disease. To support patient-centered benefit-risk assessment, it is important to understand the influence of disease stage on patient preferences. OBJECTIVE: The aim of this study was to examine patient preferences for antithrombotic treatments and whether they differ by MI disease phase. METHODS: A discrete-choice experiment was used to elicit preferences of adults in the acute (≤ 365 days before enrolment) or chronic phase (> 365 days before enrolment) of MI for key ischemic events (risk of cardiovascular [CV] death, non-fatal MI, and non-fatal ischemic stroke) and bleeding events (risk of non-fatal intracranial hemorrhage and non-fatal other severe bleeding). Preference data were analyzed using the multinomial logit model. Trade-offs between attributes were calculated as the maximum acceptable increase in the risk of CV death for a decrease in the risk of the other outcomes. To assess the potential effect of sociodemographic and clinical characteristics on patient preferences, subgroups were introduced as interaction terms in logit models. RESULTS: The evaluable population included 155 patients with MI in the acute phase of disease and 180 in the chronic phase. The overall population was 82% male, mean age was 64.2 ± 9.6 years, and 93% had not experienced bleeding events or key ischemic events other than MI. Patients valued reduction in the risk of non-fatal intracranial hemorrhage more than CV death (p < 0.01) and CV death more than non-fatal ischemic events (p < 0.01). Preferences were similar in the acute and chronic populations (p = 0.17). However, older patients valued reduction in risk of MI more than younger patients (p = 0.04), and patients with bleeding risk factors valued reduction in the risk of CV death (p = 0.01) and MI (p = 0.01) less than patients without bleeding risk factors. Also, patients who were at high risk of future ischemic events valued reduction of the risk of CV death less than those at low risk (p = 0.01). CONCLUSION: Patient preferences for antithrombotic treatments were unaffected by disease stage but varied by bleeding risk and other factors. This heterogeneity in preferences is an important consideration because it can affect the benefit-risk balance and the acceptability of antithrombotic treatments to patients.

Preferences of patients for benefits and risks of insomnia medications using data elicited during two phase III clinical trials.

STUDY OBJECTIVES: To elicit the trade-offs patients are willing to make between benefits and risks of medications for chronic insomnia, with the purpose of allowing a patient-centric interpretation of clinical trial data. METHODS: A discrete choice experiment (DCE) was included in the two placebo-controlled phase III trials that evaluated the efficacy and safety of daridorexant. The DCE design was informed by a two-phase qualitative study, followed by qualitative and quantitative pilot testing before fielding. Relative attribute importance (RAI) and acceptable trade-offs between benefits and risks were obtained using a mixed logit model. RESULTS: Preferences were elicited from 602 trial participants (68.1% female, aged 58.6 ± 14.5 years). Preferences were most affected by daytime functioning (RAI = 33.7%) as a treatment benefit and withdrawal symptoms (RAI = 27.5%) as a risk. Patients also valued shorter sleep onset (RAI = 6.4%), longer sleep maintenance (RAI = 5.4%), reduced likelihood of abnormal thoughts and behavioral changes (RAI = 11.3%), reduced likelihood of dizziness/grogginess (RAI = 9.2%), and reduced likelihood of falls at night (RAI = 6.5%). Patients were willing to make trade-offs between these attributes. For example, they would accept an additional 18.8% risk of abnormal thoughts and behavioral changes to improve their daytime functioning from difficult to restricted and an additional 8.1% risk of abnormal thoughts and behavioral changes to avoid moderate withdrawal effects. CONCLUSIONS: Patients with insomnia were willing to make trade-offs between multiple benefits and risks of pharmacological treatments. Because patients valued daytime functioning more than sleep latency and duration, we recommend that functional outcomes and sleep quality be considered in treatment development and evaluation.

Colorectal cancer screening preferences among physicians and individuals at average risk: A discrete choice experiment.

BACKGROUND: Guidelines include several options for average-risk colorectal cancer (CRC) screening that vary in aspects such as invasiveness, recommended frequency, and precision. Thus, patient and provider preferences can help identify an appropriate screening strategy. This study elicited CRC screening preferences of physicians and individuals at average risk for CRC (IAR). METHODS: IAR aged 45-75 years and licensed physicians (primary care or gastroenterology) completed an online discrete choice experiment (DCE). Participants were recruited from representative access panels in the US. Within the DCE, participants traded off preferences between screening type, screening frequency, true-positive, true-negative, and adenoma true positive (physicians only). A mixed logit model was used to obtain predicted choice probabilities for colonoscopy, multi-target stool DNA (mt-sDNA), fecal immunochemical test (FIT), and methylated septin 9 (mSEPT9) blood test. RESULTS: Preferences of IAR and physicians were affected by screening precision and screening type. IAR also valued more regular screening. Physicians preferred colonoscopy (96.8%) over mt-sDNA (2.8%; p < 0.001), FIT (0.3%; p < 0.001) and mSEPT9 blood test (0.1%; p < 0.01). IAR preferred mt-sDNA (38.8%) over colonoscopy (32.5%; p < 0.001), FIT (19.2%; p < 0.001), and mSEPT9 blood test (9.4%; p < 0.001). IAR naïve to screening preferred non-invasive screening (p < 0.001), while the opposite was found for those who previously underwent colonoscopy or sigmoidoscopy. CONCLUSIONS: While physicians overwhelmingly preferred colonoscopy, preferences of IAR were heterogenous, with mt-sDNA being most frequently preferred on average. Offering choices in addition to colonoscopy could improve CRC screening uptake among IAR. This study used a discrete choice experiment in the US to elicit preferences of physicians and individuals at average risk for colorectal cancer screening modalities and their characteristics.

Patient and Physician Preferences for Regimen Attributes for the Treatment of HIV in the United States and Canada.

A long-acting injectable (LAI) antiretroviral therapy (ART) regimen is now available as a treatment option for virologically suppressed adults with HIV-1. This study assessed preference for a LAI regimen using an online survey of virally suppressed people living with HIV (PLWH) and physicians treating HIV in the US and Canada. Preference was elicited in a discrete choice experiment (DCE) with three choice options (switch to a LAI regimen, switch to another daily oral ART regimen, or stay on their current daily oral ART regimen) and four treatment attributes. A total of 553 PLWH and 450 physicians completed the survey. From the DCE results, 59% of PLWH were predicted to prefer a LAI over an alternative oral ART or staying on their current oral treatment, and 55-66% of physicians were predicted to recommend LAI for PLWH, depending on the treatment challenge scenario presented. PLWH indicated LAI would remove daily reminders of HIV (75%) and reduce feelings of being stigmatized (68%). A majority of PLWH and physicians preferred a LAI over oral ART to overcome treatment challenges such as daily pill burden and adherence. These benefits of LAI ART along with preferences of PLWH and physicians can help to inform ART choice.

Glyceryl trinitrate to reduce the need for manual removal of retained placenta following vaginal delivery: the GOT-IT RCT.

BACKGROUND: Retained placenta is associated with postpartum haemorrhage and can lead to significant maternal morbidity if untreated. The only effective treatment is the surgical procedure of manual removal of placenta, which is costly, requires skilled staff, requires an operative environment and is unpleasant for women. Small studies suggest that glyceryl trinitrate may be an effective medical alternative. OBJECTIVE: To determine the clinical effectiveness and cost-effectiveness of sublingual glyceryl trinitrate spray compared with placebo in reducing the need for manual removal of placenta in women with retained placenta after vaginal delivery following the failure of current management. DESIGN: A group-sequential randomised double-blind placebo-controlled trial with a cost-effectiveness analysis. SETTING: There were 29 obstetric units in the UK involved in the study. PARTICIPANTS: There were 1107 women (glyceryl trinitrate group, n = 543; placebo group, n = 564) randomised between October 2014 and July 2017. INTERVENTIONS: Glyceryl trinitrate spray was administered to 541 women in the intervention group, and a placebo was administered to 563 women in the control group. MAIN OUTCOME MEASURES: Four primary outcomes were defined: (1) clinical - the need for manual removal of placenta, (2) safety - measured blood loss, (3) patient sided - satisfaction with treatment and side effects and (4) economic - cost-effectiveness of both treatments using the UK NHS perspective. Secondary clinical outcomes included a > 15% decrease in haemoglobin level, time from randomisation to delivery of placenta in theatre, the need for earlier manual removal of placenta than planned, increase in heart rate or decrease in blood pressure, requirement for blood transfusion, requirement for general anaesthesia, maternal pyrexia, and sustained uterine relaxation requiring additional uterotonics. RESULTS: No difference was observed between the glyceryl trinitrate group and the control group for the placenta remaining undelivered within 15 minutes of study treatment (93.3% vs. 92%; odds ratio 1.01, 95% confidence interval 0.98 to 1.04; p = 0.393). There was no difference in blood loss of > 1000 ml between the glyceryl trinitrate group and the control group (22.2% vs. 15.5%; odds ratio 1.14, 95% confidence interval 0.88 to 1.48; p = 0.314). Palpitations were more common in the glyceryl trinitrate group than in the control group after taking the study drug (9.8% vs. 4.0%; odds ratio 2.60, 95% confidence interval 1.40 to 4.84; p = 0.003). There was no difference in any other measures of patient satisfaction between the groups. There was no difference in costs to the health service between groups (mean difference £55.30, 95% confidence interval -£199.20 to £309.79). Secondary outcomes revealed that a fall in systolic or diastolic blood pressure, or an increase in heart rate, was more common in the glyceryl trinitrate group than in the control group (odds ratio 4.9, 95% confidence interval 3.7 to 6.4; p < 0.001). The need for a blood transfusion was also more common in the glyceryl trinitrate group than in the control group (odds ratio 1.53, 95% confidence interval 1.04 to 2.25; p = 0.033). CONCLUSIONS: Glyceryl trinitrate spray did not increase the delivery of retained placenta within 15 minutes of administration when compared with the placebo, and was not cost-effective for medical management of retained placenta. More participants reported palpitations and required a blood transfusion in the glyceryl trinitrate group. Further research into alternative methods of medical management of retained placenta is required. TRIAL REGISTRATION: Current Controlled Trials ISRCTN88609453. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 70. See the NIHR Journals Library website for further project information.

A retained placenta is diagnosed when, following the birth of a baby, the placenta is not delivered. When this situation occurs, women are at risk of bleeding heavily. The only way to treat a retained placenta is for a trained doctor to remove it by an operation in theatre. This procedure can be painful and upsetting. Furthermore, the timing of the operation can interrupt mother­baby bonding immediately after giving birth. The study tested if the use of glyceryl trinitrate spray, given as two puffs under the woman's tongue following the diagnosis of retained placenta, may help the placenta to deliver without an operation. The study also tested if glyceryl trinitrate was safe, assessed what women thought about the treatment and compared the costs of glyceryl trinitrate with those of current operative management. This study included 1107 women diagnosed with retained placenta following the birth of their baby. Half of the women were treated with glyceryl trinitrate spray and the other half were treated with a dummy spray, which looked identical but did not contain the active treatment. If the placenta delivered within 15 minutes of the study treatment being taken, this was considered a success. However, if the placenta did not deliver within 15 minutes and the woman had to have her placenta removed by an operation, then this was viewed as unsuccessful. Neither the woman nor the clinical staff knew if the treatment given was the glyceryl trinitrate spray or the dummy spray. The results indicate that, although women were happy to be involved in the trial and the treatment was safe, the use of glyceryl trinitrate spray did not reduce the need for the placenta to be manually removed by an operation in theatre. Furthermore, glyceryl trinitrate spray was not cost-effective.

Exploring the willingness to pay for a quality-adjusted life-year in the state of Penang, Malaysia.

INTRODUCTION: The incremental cost-effectiveness ratio (ICER) is typically compared with a reference value to support the cost-effectiveness of a decision. One method for estimating this value is to estimate the willingness-to-pay (WTP) for a quality-adjusted life-year (QALY). This study was conducted to explore the WTP for a QALY in the Malaysian population. METHODS: A cross-sectional, contingent valuation study was conducted in Penang, Malaysia. Respondents were selected from randomly chosen geographical grids of Penang. Respondents' sociodemographic information, qualities of life, and WTP for one additional QALY were collected using predesigned questionnaires in face-to-face interviews. WTP values were elicited using a double-bound dichotomous choice via a bidding game approach. The Heckman selection model was applied to the analysis of the mean WTP/QALY values, where the "protest zero" values, which may contribute to selection bias, were excluded. RESULTS: The mean value of WTP for an additional QALY gained was estimated to be MYR (Malaysian Ringgit) 29,080 (~USD 9,000). Key factors that affected the WTP include ethnicity and estimated monthly household income. CONCLUSION: The study findings suggested that the cost-effectiveness threshold value as studied in Penang, Malaysia was estimated to be MYR 29,080.

Job satisfaction, organisation commitment and retention in the public workforce: a survey among pharmacists in Malaysia.

OBJECTIVES: The aims of the study were to assess job satisfaction and organisational commitment among pharmacists working in the public sector and its influence on their likelihood to stay within the public workforce. METHODS: A cross-sectional survey was conducted among all fully registered pharmacists (FRPs) in the northern states of Malaysia in 2009 (n = 467). The questionnaire consisted of three sections to capture the demographic characteristics of the respondents, assess job satisfaction and organisational commitment of the respondents and their likelihood of staying in public service. KEY FINDINGS: A total of 247 FRPs (response rate 52.9%) in the northern region of Malaysia participated in this survey. Majority of the respondents were women (n = 205, 83.0%), of Chinese ethnicity (n = 155, 62.8%), graduates from public universities (n = 173, 70.0%), single (n = 172, 69.6%), with a median age of 27 years (interquartile range (IQR) 2.0) and had worked with the Ministry of Health for a median of 2.75 years (IQR 1.63). The mean job satisfaction and organisational commitment score were 58.09 (standard deviation (SD) 11.83) and 53.46 (SD 6.65) respectively out of a maximum possible score of 90. Majority of the respondents claimed that they were likely to stay in public service (n = 176, 71.3%). Their likelihood of staying in public service was affected by respondents' gender, ethnicity, job satisfaction and organisational commitment. CONCLUSIONS: The findings from this study provide stakeholders with evidence on factors and issues affecting pharmacists' job satisfaction and commitment in the public workforce as well as the likely turnover rate with an early cohort of pharmacists affected by the compulsory service.

Patterns and predictors of non-prescription medicine use among Malaysian pharmacy patrons: a national cross sectional study.

OBJECTIVE: The study aims to evaluate the predictors of non-prescription medicine purchasing patterns among pharmacy patrons in Malaysia. METHODS: A cross-sectional nationwide study was undertaken in 2011 in sixty randomly selected community pharmacies across 14 Malaysian states. A pharmacy exit survey was conducted over a 6-month period across Malaysia. A one-stage random cluster sampling technique was employed as there was no national sampling framework available for conducting this survey. Face-to-face interviews using a validated and pre-tested questionnaire were conducted by trained data collectors. The non-prescription medicine purchasing pattern was explored and analysed descriptively. Chi-square/Fisher exact test was used to determine the association between study variables. Multinomial logistic regression analysis was used to determine the predictors of type of non-prescription medicine purchased. RESULTS: A total of 2729 pharmacy patrons agreed to participate in 60 selected pharmacy outlets. A total of 3462 non-prescription medicine were purchased during the study period with an average of 1.3 medicines per participant. Most of the non-prescription medicine purchased was meant for alimentary tract and metabolism (31.8%), followed by respiratory system (19.4%) and musculoskeletal system (15.8%) usage. Factors found to be associated with the choice of non-prescription medicine purchased were age group [χ2 = 170.75, (df = 57), p<0.01], locality [χ2 = 48.16, (df = 19), p<0.01], gender [χ2 = 32.93, (df = 13), p = 0.002], ethnic group [χ2 = 118.89, (df = 39), p<0.01] and type of occupation [χ2 = 222.434, (df = 117), p<0.01]. Non-prescription medicine purchased defined about 20% of the variance in the combination of predictors such as locality, gender, age, ethnicity, type of occupation and household income. CONCLUSION: The predictors for selection of non-prescription medicine were locality (urban or rural), gender, age, ethnicity, type of occupation and household income per month. Future studies need to explore the safety and effectiveness of using these non-prescription medicines.

A survey exploring knowledge and perceptions of general practitioners towards the use of generic medicines in the northern state of Malaysia.

OBJECTIVES: The objective of this study was to evaluate the general practitioners' (GPs') knowledge and perceptions towards generic medicines in a northern state of Malaysia. METHOD: A postal cross-sectional survey involving registered GPs in Penang, Malaysia was undertaken. A 23-item questionnaire was developed, validated and administered on the GPs. Eighty-seven GPs responded to the survey (response rate 26.8%). RESULTS: The majority of the respondents (85.1%) claimed that they actively prescribed generic medicines in their practice. On the other hand, only 4.6% of the respondents correctly identified the Malaysia's National Pharmaceutical Control Bureau's bioequivalence standard for generic products. There were misconceptions among the respondents about the concepts of "bioequivalence", "efficacy", "safety", and "manufacturing standards" of generic medicines. GPs in this survey believed that a standard guideline on brand substitution process, collaboration with pharmacists, patient education and information on safety and efficacy of generic medicines were necessary to ensure quality use of generics. Furthermore, advertisements and product bonuses offered by pharmaceutical companies, patient's socio-economic factors as well as credibility of manufacturers were factors reported to influence their choice of medicine. CONCLUSION: Although it appeared that GPs have largely accepted the use of generic medicines, they still have concerns regarding the reliability and quality of such products. GPs need to be educated and reassured about generic products approval system in Malaysia concerning bioequivalence, quality, and safety. The current findings have important implications in establishing generic medicines policy in Malaysia.