Cost-conscious medications-prescribing behavior among physicians working in Saudi Arabia

Background: Pharmaceutical costs are the fastest-growing healthcare expense in most countries, meaning that physicians are required to adopt cost-conscious behavior in their medication prescribing practice. This study aimed to assess the levels of cost-consciousness and the familiarity with cost concepts among physicians working in Saudi Arabia.  Methods: This was a cross-sectional, questionnaire-based study conducted in the period from May to October 2019. It included physicians employed in Saudi Arabia in different workplaces and settings.  Results: A total of 239 physicians responded to the survey, about 85% of whom had never received any formal education or training in health economics or pharmacoeconomics. Almost all of them (94%) agreed that physicians need to take a more prominent role in limiting the use of unnecessary medications and three-quarters (75.3%) of them agreed that trying to contain medications cost is the responsibility of every physician. The factors that were found to affect cost-consciousness behavior were gender, as well as knowledge of and familiarity with cost-effectiveness as one of the economic evaluation concepts. Higher cost-consciousness was observed among those who were knowledgeable about the terms cost-containment (p=0.039) and cost-effectiveness (p=0.002) and who were familiar with the concept of cost-effectiveness (p<0.001). Conclusion: The physicians agreed that costs should be borne in mind when prescribing medicines. However, it also appears that physicians are not overly confident about their knowledge of healthcare costs. Factors such as medical ethics and patient demand and satisfaction were perceived as the most common barriers for considering cost in physicians’ therapeutic decision-making in their daily practice.

1. Atia A. Physician Trends of Drug Prescription in Libya: A Pharmacoepidemiological Study. Pharmacophores. Pharmacophores. 2019;10(3):33-8.
2. Gronde TV, Uyl-de Groot CA, Pieters T. Addressing the challenge of high-priced prescription drugs in the era of precision medicine: A systematic review of drug life cycles, therapeutic drug markets, and regulatory frameworks. PLoS One. 2017; 12: e0182613.
3. Fitch Solutions Group Limited. Saudi Arabia pharmaceuticals & healthcare report - q2 2019.  BMI Country Industry Reports. London, UK: Fitch Solutions Group Limited, 2019:1-58.
4. Al-Omar HA, Attuwaijri AA, Aljuffali IA. What local experts expect from a health technology assessment (HTA) entity in Saudi Arabia: Workshop conclusions. Expert Rev Pharmacoecon Outcomes Res. 2019: 1-6.
5. Gellad WF, Donohue JM, Zhao X, et al. The financial burden from prescription drugs has declined recently for the nonelderly, although it is still high for many. Health Aff (Millwood). 2012; 31: 408-16.
6. Lubloy A. Factors affecting the uptake of new medicines: A systematic literature review. BMC Health Serv Res. 2014; 14: 469.
7. Mousnad MA, Shafie AA, Ibrahim MI. Systematic review of factors affecting pharmaceutical expenditures. Health Policy. 2014; 116: 137-46.
8. Mantel J. A defense of physicians' gatekeeping role: Balancing patients' needs with society's interests. Pepp L Rev. 2014; 42: 633-63.
9. Skirbekk H, Hem MH, Nortvedt P. Prioritising patient care: The different views of clinicians and managers. Nurs Ethics. 2018; 25: 746-5
10. Alshammari E. Prescription evaluation practice by final year pharmacy students. J. Adv. Pharm. Edu Res. 2019;9(3):76-9.
11. Godin G, Belanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals' intentions and behaviors: A systematic review of studies based on social cognitive theories. Implement Sci. 2008; 3: 36.
12. van der Geer LA, Kangis P. The influence of cost on medical prescriptions: A comparison of the theory of planned behavior and the composite attitude-behavior model. Journal of Medical Marketing. 2002; 2: 311-27.
13. Harris A, Carney K, Volpicelli FM. Value in hospital medicine. Hospital Medicine Clinics. 2017; 6: 131-45.
14. Goold SD, Hofer T, Zimmerman M, Hayward RA. Measuring physician attitudes toward cost, uncertainty, malpractice, and utilization review. J Gen Intern Med. 1994; 9: 544-9.
15. Jamal AA, Al-Furaih IM, Binsufayan SA, Jamalaldeen MR, Abunohaiah IS, Alhuzaymi AM, Alduhaim AA, Alfaris E. Factors Determining the Choice of Medical Specialty and Work Environment Among Saudi Physicians: Results from A National Cross-Sectional Survey. Int. J. Pharm. Res. Allied Sci. 2018;7(2):58-66.
16. Allan GM, Innes G. Family practice residents' awareness of medical care costs in British columbia. Fam Med. 2002; 34: 104-9.
17. Allan GM, Lexchin J, Wiebe N. Physician awareness of drug cost: A systematic review. PLoS Med. 2007; 4: e283.
18. Hernu R, Cour M, de la Salle S, et al. Cost awareness of physicians in intensive care units: A multicentric national study. Intensive Care Med. 2015; 41: 1402-10.
19. McGuire C, King S, Roche-Nagle G, Barry MC. Doctors' attitudes about prescribing and knowledge of the costs of common medications. Ir J Med Sci. 2009; 178: 277-80.
20. Reichert S, Simon T, Halm EA. Physicians' attitudes about prescribing and knowledge of the costs of common medications. Arch Intern Med. 2000; 160: 2799-803.
21. Safavi KT, Hayward RA. Choosing between apples and apples: Physicians' choices of prescription drugs that have similar side effects and efficacies. J Gen Intern Med. 1992; 7: 32-7.
22. Schutte T, Tichelaar J, Nanayakkara P, et al. Students and doctors are unaware of the cost of drugs they frequently prescribe. Basic Clin Pharmacol Toxicol. 2017; 120: 278-83.
23. Wei D, Osman C, Dukhovny D, et al. Cost consciousness among physicians in the neonatal intensive care unit. J Perinatol. 2016; 36: 1014-20.
24. Shrank WH, Joseph GJ, Choudhry NK, et al. Physicians' perceptions of relevant prescription drug costs: Do costs to the individual patient or to the population matter most? Am J Manag Care. 2006; 12: 545-51.
25. Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: A systematic review. JAMA. 2015; 314: 2384-400.
26. Colgan S, Faasse K, Martin LR, et al. Perceptions of generic medication in the general population, doctors, and pharmacists: A systematic review. BMJ Open. 2015; 5: e008915.
27. Wilf-Miron R, Uziel L, Aviram A, et al. Adoption of cost-consciousness: Attitudes, practices, and knowledge among Israeli physicians. Int J Technol Assess Health Care. 2008; 24: 45-51.
28. Lin KY. Physicians' perceptions of autonomy across practice types: Is autonomy in solo practice a myth? Soc Sci Med. 2014; 100: 21-9.
29. Bovier PA, Martin DP, Perneger TV. Cost-consciousness among Swiss doctors: A cross-sectional survey. BMC Health Serv Res. 2005; 5: 72.
30. Ginsburg ME, Kravitz RL, Sandberg WA. A survey of physician attitudes and practices concerning cost-effectiveness inpatient care. West J Med. 2000; 173: 390-4.
31. Polinski JM, Maclure M, Marshall B, et al. Does knowledge of medication prices predict physicians' support for cost-effective prescribing policies. Can J Clin Pharmacol. 2008; 15: e286-94.
32. Fraeyman J, Symons L, De Loof H, et al. Medicine price awareness in chronic patients in Belgium. Health Policy. 2015; 119: 217-23.
33. Strech D, Danis M. How can bedside rationing be justified despite coexisting inefficiency? The need for 'benchmarks of efficiency'. J Med Ethics. 2014; 40: 89-93.
34. Voigt K. Rationing, inefficiency and the role of clinicians. J Med Ethics. 2014; 40: 94-6.
35. Khullar D, Chokshi DA, Kocher R, et al. Behavioral economics and physician compensation--promise and challenges. N Engl J Med. 2015; 372: 2281-3.
36. Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA. 2013; 310: 380-8.
37. Furrow BR. The ethics of cost-containment: Bureaucratic medicine and the doctor as patient–advocate. Notre Dame J Law Ethics & Public Policy. 1988; 3: 187–225.
38. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012; 172: 405-11.
39. Strech D, Persad G, Marckmann G, Danis M. Are physicians willing to ration health care? Conflicting findings in a systematic review of survey research. Health Policy. 2009; 90: 113-24.
40. Sabbatini AK, Tilburt JC, Campbell EG, et al. Controlling health costs: Physician responses to patient expectations for medical care. J Gen Intern Med. 2014; 29: 1234-41.
41. Arao RK, O'Connor MY, Barrett T, et al. Strengthening value-based medication management in a free clinic for the uninsured: Quality interventions aimed at reducing costs and enhancing adherence. BMJ Open Qual. 2017; 6: e000069.
42. Stammen L, Slootweg I, Stalmeijer R, et al. The struggle is real: How residents learn to provide high-value, cost-conscious care. Teach Learn Med. 2019; 31: 402-11.
43. Eriksen, II, Melberg HO, Bringedal B. Norwegian physicians' knowledge of the prices of pharmaceuticals: A survey. PLoS One. 2013; 8: e75218.
44. De Vito C, Carmelo Nobile G, Furnari G, et al. The role of education in improving physicians' professional use of economic evaluations of health interventions: Some evidence from a cross-sectional survey in Italy. Eval Health Prof. 2009; 32: 249-63.
45. Qureshi NA, Neyaz Y, Khoja T, et al. Effectiveness of three interventions on primary care physicians' medication prescribing in Riyadh city, Saudi Arabia. East Mediterr Health J. 2011; 17: 172-9.
46. Andrews L, Susla G, Ng V, et al. Cost-effective medication use in critical care: Capital health system's experience in vha's music program. Journal of Clinical Outcomes Management. 2006; 13: 615-22.
47. de Leon N, Sharpton S, Burg C, et al. The development and implementation of a bundled quality improvement initiative to reduce inappropriate stress ulcer prophylaxis. ICU Director. 2013; 4: 322-25.
48. Ijo I, Feyerharm J. Pharmacy intervention on antimicrobial management of critically ill patients. Pharm Pract (Granada). 2011; 9: 106-9.
49. Niquille A, Ruggli M, Buchmann M, et al. The nine-year sustained cost-containment impact of Swiss pilot physicians-pharmacists quality circles. Ann Pharmacother. 2010; 44: 650-7.
50. Prada SI, Loaiza JS. Comparing the Medicaid prospective drug utilization review program cost-savings methods used by state agencies in 2015 and 2016. Am Health Drug Benefits. 2019; 12: 7-12.
51. Roth EJ, Plastaras CT, Mullin MS, et al. A simple institutional educational intervention to decrease use of selected expensive medications. Arch Phys Med Rehabil. 2001; 82: 633-6.