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Healthy Skepticism Library item: 19427

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.


Publication type: Journal Article

Shrank WH, Liberman JN, Fischer MA, Avorn J, Kilabuk E, Chang A, Kesselheim AS, Brennan TA, Choudhry NK
The consequences of requesting 'dispense as written'.
Am J Med 2011 Apr; 124:(4):309-17


BACKGROUND: All US states have
adopted generic substitution laws to
reduce medication costs. However,
physicians may override these
regulations by prescribing branded
drugs and requesting that they are
dispensed as written. Patients also
can make these requests. Little is
known about the frequency and
correlates of dispense as written
requests or their association with
medication filling.

METHODS: We identified beneficiaries
of a large pharmacy benefits manager
who submitted a prescription claim
from any pharmacy in January 2009.
We categorized claims as a
physician-assigned dispense as
written, patient-assigned dispense
as written, or no dispense as
written. We described rates of these
requests and used generalized
estimating equations to evaluate
physician, patient, treatment, and
pharmacy characteristics associated
with dispense as written requests.
We also used generalized estimating
equations to assess the relationship
between dispense as written
designation and rates prescriptions
are not filled by patients.

RESULTS: Our sample included 5.6
million prescriptions for more than
2 million patients. More than 2.7%
were designated as dispense as
written by physicians, and 2.0% were
designated as dispense as written by
patients. Substantial variation in
dispense as written requests were
seen by medication class, patient
and physician age, and geographic
region. The odds of requesting
dispense as written was 78.5%
greater for specialists than
generalists (P<;.001). When chronic
prescriptions were initiated,
physician dispense as written (odds
ratio 1.50, P<;.001) and patient
dispense as written (odds ratio
1.60, P<;.001) were associated with
greater odds that patients did not
fill the prescription.

CONCLUSION: Dispense as written
requests were common and associated
with decreased rates of prescription
filling. Options to reduce rates of
dispense as written requests may
reduce costs and improve medication


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Far too large a section of the treatment of disease is to-day controlled by the big manufacturing pharmacists, who have enslaved us in a plausible pseudo-science...
The blind faith which some men have in medicines illustrates too often the greatest of all human capacities - the capacity for self deception...
Some one will say, Is this all your science has to tell us? Is this the outcome of decades of good clinical work, of patient study of the disease, of anxious trial in such good faith of so many drugs? Give us back the childlike trust of the fathers in antimony and in the lancet rather than this cold nihilism. Not at all! Let us accept the truth, however unpleasant it may be, and with the death rate staring us in the face, let us not be deceived with vain fancies...
we need a stern, iconoclastic spirit which leads, not to nihilism, but to an active skepticism - not the passive skepticism, born of despair, but the active skepticism born of a knowledge that recognizes its limitations and knows full well that only in this attitude of mind can true progress be made.
- William Osler 1909