Physicians’ perceptions towards brand medicine and its effect on prescribing: A narrative review

Abstract

Objective

The purpose of this paper is to examine existing literature on physicians’ perceptions towards brand medicines, to examine the extent to which brands influence drug prescription and whether pharmaceutical industry influences the prescription of brands, as well as to examine the loyalty of physicians to a brand when prescribing drugs or willingness to switch to generic drugs.

Methods

Related articles published in different online databases from 2000 to 2017 were surveyed; 38 scientific articles indexed in Google Scholar, Science Direct, and PubMed were selected for review. Articles focused on physicians’ perceptions towards brand drugs and its effect on prescribing were extracted. The experimental design and quantitative and qualitative methods used in the studies were analyzed. The deductions made in each study were examined in tandem with the objective of the review.

Findings

The studies showed that physicians from high-income countries are inclined to prescribe generic drugs more than brand, whereas those from low-income countries heavily prescribe the brand drugs. The studies also revealed that brand influences the prescribing behavior of physicians. Five studies reported that marketing endeavors encourage the physicians to prescribe brand medicines, while three studies stated that physicians have a high loyalty toward brand medicines irrespective of country’s income. Other studies provided evidence that physicians are disposed to switching from brand to generic medicines under certain conditions. Marked differences in the prescribing generic drugs use by physicians among different age were observed. General physicians and pediatrics were more likely to suggest switching from the brand to generic drugs. The majority of physicians were familiar with biosimilars drugs.

Conclusion

Generally, the studies showed that physicians tend to have mixed views regarding prescribing brand medicines. The perceptions of physicians towards the brand drugs were found to differ in relation to the nature of healthcare system and level of development.

Keywords

Brand brand drug physician prescribing generic biosimilars

Introduction

Brand medicines are typically the original products that are discovered and developed by the pharmaceutical company.¹ In fact, the brand drug manufacturers must first gain approval from the Food and Drug Administration (FDA) to sell and market their medicines. Moreover, drug patents are usually valid for 20 years after the drug is invented. The patent, in fact, protects the innovator manufacturer and does not allow any other firms to make and market the drug. After the patent of the original brand is expired, other pharmaceutical companies can start to make and sell the same medicine “branded generic” to the pharmaceutical market under a different brand name.

A branded generic is an off-patented medicine that is re-issued into the market with a different brand name. Inventor’s companies create their own generic because they want to continue to profit on their customers who perceive their drug has come off patent and that there are generic drugs available. These branded generics are usually given a brand name, but the trend is that the generic name is primarily focused on a brand name. Generic medicines which may be produced by manufacturers other than the original firm are usually unbranded products with chemically identical active ingredients.¹ Theoretically, generic drugs are equivalent and might, in fact, be excess in developed countries. Actually, they are typically sold as a brand or under a proprietary name as “branded generics.” In developing countries, very few medications are patent-protected and almost all drugs are “branded generic” as per international standard.

The brand and generic medicines are differentiated based on inefficient ingredients (such as flavors and preservatives), shape, packaging, and color.² Because of these differences, the generic drug manufacturers are required to submit additional paperwork to the FDA to prove that their product is manufactured in accordance with good manufacturing practices and is as pure and stable as the brand name product. Brand drugs are generally more expensive compared to their generic equivalents because of its more research and development costs; hence, it is a challenge to keep it economically competitive. Brand drugs are more expensive than its generic equivalents because of its perceived higher quality and customers strongly prefer brand drugs.³ Despite the relatively high pricing of brand medicine compared with the generic products, the branded drugs still maintained high market shares.

The majority of the big pharmaceutical firms prefer to market their drugs under brand names, which allows them to position and promote enough to fulfill the regulatory standards and product stability.⁴ In fact, these companies invest heavily in marketing in order to develop strong worldwide recognition of their brand names as well as create a brand image among physicians and consumers.⁵ Several theories consider the brand to be a significant factor that maximizes company’s profits and enable communication between the pharmaceutical firms and physicians.⁶ Marketing managers to consider strong brands to be the cornerstone of physicians’ loyalty⁷ and an influential factor in maintaining a competitive advantage for their companies. Physicians, in turn, tend to select a drug based on their preferred brand or firm in a case where no other factors such as price influence their judgment.⁸ Physicians may prefer a specific brand because of its higher quality, which is promoted by advertising activities.

Studies on the prescribing behavior of physicians suggest that new brand drugs increase the interest of physicians, and thus, they are inclined to use drugs endorsed by their colleagues.⁹ This implies that when given the choice between two similar products, the physicians often select the recognized brand, particularly when less qualitative information is available. This decision making can have a significant influence on the prescribing behavior when that brand name is linked with efficiency.¹⁰ Furthermore, cognizance of one of the brands in a category will result in the repeated selection of that brand by the physician even when the generic option is available but offers quantitatively established lower quality.¹¹ In this line, it can be argued that several physicians opt for these brands and decline the use of substitutes (e.g., generic drugs) even though offered at relatively lower prices.¹² Therefore, related literature posits a consensus on the presence of drug brands in the prescription.

However, given the peculiar and distinct nature of brand medicine category, further studies are needed.⁶ Contextually, existing reviews are narrowly focused and only partly present the perceptions of physicians towards generic drugs. For instance, Hassali et al.¹³ reviewed 16 studies related to physicians’ perceptions and attitudes towards generic medicines in low- and medium-income countries. Toverud et al.¹⁴ concluded that physicians and pharmacists are cognizant of the role played by generic drugs in improving worldwide availability of drugs. Thus, it can be deduced there is no detailed review of physicians’ perceptions towards brand drugs. To fill this gap, this study conducted a semi-systemic review that uses predefined criteria to identify studies in order to re-examine the physicians’ perceptions towards brand drugs as well as the effects of the the brand on physicians’ prescribing decisions.

What are brand drugs?

In marketing, the brand is defined as a “name, term, sign, symbol, design, or a combination of these elements, used to identify the products or services of one seller or group of sellers and to differentiate them from those of competitors.”¹⁵ In a different study, Kapferer¹⁶ defined a brand as the combination of name, symbol, design, and packaging by which the product differs from its competitions. Based on a consumer viewpoint, Ambler et al.¹⁷ took an advanced approach to defining a brand as the assurance of bundles of attributes that motivate and provide satisfaction to the customer. These attributes of the brand may be physical, emotional or rational, tangible or intangible.

In the pharmaceutical field, branding is an approach to differentiating products. Drug branding is often considered as giving an attention-grabbing name to a product or drug.¹⁸ Kumar et al.¹⁹ defined drug branding as giving a name or a symbol to a drug in order to differentiate it from other substitutes as well as to imprint the drug in the minds of physicians as medicine with tangible (rational) and intangible (irrational or emotional) benefits. The difference based on branding is often used as an instrument for differentiation since it is easy to identify additional elements in a product, whether tangible (rational) or intangible (emotional).⁸ Therefore, branding of drugs is usually perceived as an important aspect of pharmaceutical marketing, possibly due to the official designation and labeling in the drug’s profile, and the ban on direct advertising of ethical drugs to patients, and short life cycles of products.¹⁸ Given the trust and confidence of physicians and patients in the brand drug, brands add a greater value to the medicine.¹⁸ Prescribers are encouraged to prescribe drugs by their brand name. This is because that brand medicines have guaranteed efficiency and confidence when used by physicians for treatment.

Physicians generally have their personal list of drugs they prescribe, which are compiled based on drugs they are aware of, respective brand names, and new drugs in the market. Moreover, brand names generate awareness among several physicians and allow them to develop an opinion of the brand and its image, in terms of safety and efficacy, which are being communicated through medical representatives (MRs) of drug firms. In addition, drug branding can have a positive effect on the prescribing judgment of physicians.⁹ In the context of prescription behavior, continual prescription of the same brand drug (brand loyalty) is a very important phenomenon in the pharmaceutical industry.¹¹ Nonetheless, while some physicians have a preference for brands manufactured by certain companies due to their loyalty, other physicians prescribe the same brand due to its efficacy confirmed by the success of previous treatments and experience as well as the impact of marketing efforts.⁷

However, despite the positive effect of prescribing drug branding, the brand can be harmful to patients which pose a challenge to its success in the market. For instance, when physicians become cognizant of the side effects of one brand, they are more expected to prescribe its alternatives and thus the life cycle of the brand will become very short. Moreover, the increased focus on generic drugs as cost-effective alternatives to the expensive brand name drugs are perhaps other barriers to the use of brand medicines by physicians. Therefore, the dilemma generally still remains regarding the actual perceptions of a physician towards brand drugs and effects on prescribing.

To resolve the aforementioned dilemma, this paper extracted the perceptions of physicians towards brand drugs from the published articles for the following seven perspectives: perception of physician towards brand medicines; effects of the brand on prescribing; physician loyalty to brand medicines; physicians’ disposition to switch from brand to generic drugs or substituting a branded medication with its generic equivalent; physicians’ age and experience and their attitude towards prescribing generic drugs; switching from brand to generic among specialists especially in areas such as pediatrics and epilepsy; and physicians’ attitudes towards prescribing of generic biosimilar. Furthermore, it is pertinent to obtain a better understanding of the effects of pharmaceutical industry promotions on the prescription of brand drugs.

Methodology for the review

A systematic search was conducted for English-based scientific articles indexed in several electronic databases such as Google Scholar, Science Direct, and PubMed. To ensure the review is consistent with the current practice, this research was restricted to studies published between 2000 and 2017. The search approach combined terms for “brand,” “brand drugs,” “brand medicines,” “physician prescribing,” “factors influence prescribing,” and used free text words and medical topic heading such as branded vs. generic. The references listed in the reviewed articles were also examined and checked for additional relevant studies on brand drugs.

Once the searches had been run, articles were downloaded and entered into reference manager software (Mendeley). Articles were subsequently vetted for their eligibility to be included in the list of reviewed articles. The initial search of the electronic search of databases resulted in 529 titles and abstracts. However, 494 titles were unrelated to physicians’ perceptions towards branded medicine and effects on prescribing behavior. The remaining 52 articles were set aside for evaluation. Additional scrutiny showed that 14 of studies from 52 (per Figure 1) were excluded, while the remaining 38 were selected for review which categorically examined physicians’ perceptions towards branded medicine, but focused mainly on generic medicines, hence they were excluded from further analysis. The flow chart for the reviewed studies is shown in Figure 1.

Figure 1.

The study flow chart of articles included in the review. *All met the inclusion criteria.

Criteria for selecting the studies

The studies selected for review were analyzed with quantitative (survey study), experimental (panel data of physicians or industry experts), and qualitative methods (interviews and focus group). Articles such as reviews, commentaries, letters to editors, and small essays were excluded. Non-English-based published articles were excluded. Articles that evaluate the physicians’ perceptions towards generic drugs, as well as the effect of generic drugs on prescribing behavior, were excluded from this review, except studies involving the switch from a brand name to a generic drug among specialists. Studies focused on physicians’ attitudes towards prescribing of generic biosimilar drugs were also included, because their results involved brand drugs. Also excluded were studies that focused on brand drug prescription by non-physicians, such as patients, nurses, pharmacists, and pharmaceutical industry. Furthermore, perceptions of a physician towards brand companies were not taken into consideration.

Methodological quality

Each article was concisely reviewed to ensure quality. The study type and characteristics comprising the author, journal, and country of origin, the number of respondents, study design, objectives, findings, and limitations were reported. Afterward, five outcomes were extracted from the articles, which include physician’s perception towards brand medicines, physician prescribing practice, physicians’ disposition to switch from brand to generic drugs, the effect of the brand on prescribing behavior, and the effects of pharmaceutical industry marketing on the decision to prescribe the brand.

However, limitations were not reported for 22 studies.^{11,20–30,42,44–53} One study suffered low response rate²⁶ while another study³¹ was affected by small sample size. Twelve studies employed random sampling.^{10,21–23,27,28,32,38,40–43} Four studies used convenience sampling^9,39,48,50, another study used purposive sampling³³, while the study by Shamim–ul–haq et al.³⁰ used cluster sampling and nine studies not reported.^{42–47,49–52}

General characteristics of the reviewed studies

Fifty-five studies were initially selected but only 38 studies were finally included in the study as they fulfill the selection criteria, as shown in Table 1. The 38 studies were conducted in different countries, with the majority from United States (US; n = 7), India (n = 3), Pakistan (n = 3) , Malaysia (n = 2), Greece (n = 2), Yemen (n = 2), Germany (n = 2), and one study each from Denmark, Brazil, Bangladesh, Thailand, Slovenia, Poland, France, Switzerland, Italy, Lebanon, Canada, Jamaica, Saudi Arabia, Ghana, Iraq, Jordan, and one study was jointly conducted in Greece and Cyprus. A list of countries involved in this review and gross national income (GNI) per capita for each to allow comparison between findings are showed in Table 2. The majority of the studies (30) employed the cross-sectional survey design,^{9,10,21,23,26–29,30–34,38–54} seven studies used experimental methods,^{11,20,24,25,35–37} while just 1 study²² used the qualitative method.

Table 1.

Characteristics of the included studies in systematic review

Author, country, and journal	Study description	Objective	Outcomes	Main limitations
Skipper and Vejlin³⁵ Denmark (high income) Soc Sci Med	Methods: experiment including prescriptions for seven blockbuster drugs	To investigate if demand for branded medications in post-patent markets is patient or physician is driven	Effect of the pharmaceutical industry on prescribing of brand medicines: Results revealed that physicians do not seem to push brand drugs and suggest that removing promotion incentives for physicians to prescribe brand drugs is important if one wishes to increase generic drug use.	The estimators are not consistent.
Ladeira et al.⁹ Brazil (upper middle income) IJ PHM	Sample size: 232 Response rate: not Sampling: convenience sampling Methods: survey Target group: physicians Source of sample: office located physicians Pilot study: 10 physicians	To analyze the functional relationships between factors related to the prescription of medical drugs in Brazil	Effect of brand on physicians’ prescribing drugs: This study determined that the brand drug has the strongest effect on physician prescription.	The sampling technique is not probabilistic (convenience) and small sample size. And the location is restricted to doctors practicing in Brazil.
Tajdar et al.²³ Pakistan (lower middle income) Rev Integr Bus Econ	Sample size:100 Response rate: not Sampling: random sampling Methods: survey Target group: hospital physicians Source of sample: five hospitals of Peshawar Pilot study: not	To explore factors influencing doctor’s prescription decision	Effect of brand on physicians’ prescribing drugs: This study found that the brand name is a highly important factor influencing doctor’s prescription decision.	Not reported.
Janakiraman et al¹¹ USA (high income) MS	Methods: experiment – panel data examining 9672 prescriptions written for depression by 108 physicians	To understand whether physicians exhibit structural persistence in drug choice	Physicians’ loyalty to brand medicines: The study proved that persistent physicians to prescribe a specific brand are available even a cheaper generic. This might imply that physicians may not be making the most cost-effective decision while keeping therapeutic effectiveness.	Not reported.
Parihar³² India (lower middle income) Asia-Pacific Market Rev	Sample size: 150 Response rate: not Sampling: random sampling Methods: survey Target group: Physicians Source of sample: practicing physicians	To identify the marketing activities which are really influence prescription behavior	Effect of brand on physicians’ prescribing drugs: Results revealed that physicians are more concerned about the brand name of the drug.	Small sample size and may not representative of the entire medical fraternity population.
Bamoriya³³ India (lower middle income) J Econ Business Res	Sample size: 879 Response rate: 69.5% Sampling: purposive sampling Methods: survey Target group: Physicians Source of sample: not reported	To examining the factors that influence prescribing	Effect of the brand on physicians’ prescribing drugs: The study suggested that availability of a brand is the most marketing factors influencing physician prescription.	The study was used use self-survey to collect data from physicians and thus may lead to the common method variance.
Lieb and Scheurich ²⁶ Germany (high income) PLoS ONE	Sample size: 1 388 Response rate: 11.5% Sampling: not Methods: survey Target group: physicians Source of sample: not report	To investigate the influence of pharmaceutical sales representatives (MRs) on prescribing	Effect of the pharmaceutical industry on prescribing of brand medicines: The physicians who never took part in sponsored events from MRs had a lower number of prescriptions of on-patent branded drugs, a lower proportion of on-patent-branded drugs, a higher proportion of generics and a lower expenditure on off-patent branded drugs per patient.	The response rate of the study is low; thus, the generalizability of the results is limited.
Shamim–ul–haq et al. ³⁰ Pakistan (lower middle income) Pharma Innov	Sample size: 260 Response rate: not Sampling: cluster sampling Methods: survey Target group: GPs and specialties Source of sample: government and private hospitals physicians	To examine the factors influencing the prescription behavior of physicians	Effects of the brand on physicians’ prescribing drugs: The brand prescription is less effective on the prescription behavior of physician because of the cost of branded drugs are expensive than local products.	Not reported
Plianbangchang et al.²⁰ Thailand (upper middle income) JPP	Methods: experimental –panel data examining 14,500 prescription	To explore physicians’ generic prescription patterns in district hospitals.	Perception of a physician towards brand medicines: The minority of prescriptions was written by brand names. Brand name prescribing was found to be concentrated on off-patented medications.	Not reported
Joyce et al.³⁷ USA (high income) Am J Manag Care	Sample size: not Response rate: not Sampling: not Methods: experimental – examining prescribers with at least five prescriptions within a class from 2005 to 2007 Target group: not Source of sample: not	To examine the factors affecting prescribing choices, and its impact on patient-level outcomes	Perception of a physician towards brand medicines: In 8 of 10 therapeutic classes, the median physician prescribes at least three different drugs and less than one in six physicians prescribes the only brand drug.	The sample of prescriptions was small and inconsistent effects.
Bashrahil ²⁵ Yemen (Lower middle income) East Mediterr Health J	Methods: experiment examining 550 prescriptions from 20 health facilities	To investigate the availability of essential drugs and local information source	Perception of physician towards brand medicines: Most of the prescription drugs (60.8%) were prescribed by brand name Effect of the pharmaceutical industry on prescribing of brand medicines: The study reported that here is a strong influence of the pharmaceutical industry on prescribers to prescribe the brand	Not reported
Hossain et al.²⁷ Bangladesh (lower middle income) IRJP	Sample size: 500 Response rate: not Sampling: stratified random sampling Methods: survey Target group: physicians specialties Source of sample: not given	To explore the factors influence the prescription practices of doctors	Perceptions of physicians towards brand medicines: Most of the physicians (66 %) reported they like to prescribe drugs in brand names and 33 % answered that they like to write generic names of drugs in prescription.	Not reported
Al-Shami et al.²⁴ Yemen (lower middle income) J Clin Diagn Res	Methods: experiment examining hospitals equal to 1200 prescriptions	To investigate the prescribing of antibiotics	Perceptions of physicians towards brand medicines: The majority (76.8%) of the antibiotics prescriptions was prescribed by using a brand name.	Not reported
Theodorou et al.³⁴ Greece and Cyprus (high income) BMC Health Serv Res	Sample size: 1463 physicians in Greece and 240 physicians in Cyprus Response rate: not Sampling: not Methods: survey Target group: physicians Source of sample: not Pilot study: 217 physicians in Cyprus	To investigate the attitudes and the factors that influence physician prescribing decisions	Perceptions of physicians towards brand medicines: The majority of physicians in both countries agreed that the effectiveness, safety, and efficacy of generic medicines may not be excellent but they are acceptable compared to brand.	The study was used postal where questionnaires are used as a tool to extract data.
Afriyie et al.³⁶ Ghana (lower middle income) J Infect Dev Countries	Methods: experiment examining prescribing trends from 3127 patient cards	To assess the prescribing trend of anti-malarial drugs	Perceptions of physicians towards brand medicines: About 39.5% prescriptions were prescribed by brand names. Effect of pharmaceutical industry on prescribing of brand medicines The study reported that brand medicine prescribing could be a result of the pharmaceutical promotion.	The effect of drug promotion on prescribing was not assessed
Kersnik et al.²¹ Slovenia (high income) J Clin Pharm Ther	Sample size: 200 Response rate: 58.5 % Sampling: random sampling Methods: survey Target group: GPs Source of sample: National database	To examine the attitudes of GPs in Slovenia towards generic drug prescribing	Attitudes towards switching to generic drugs: The majority of the physicians (96.3%) were willing to switch the brand to cheaper generic versions (if prices were lower by 25–35% than brand innovator medicines).	Not reported
Narendran and Narendranathan ²⁹ India (lower middle income) JIMA	Sample size: 50 Response rate: not Sampling: stratified random sampling Methods: survey Target group: GPs Source of sample: National database	To explore the influence of pharmaceutical marketing on the prescription practices of doctors	Effects of the brand on physicians’ prescribing drugs: Results revealed that the brand name has a significant influence prescription behavior. Effect of the pharmaceutical industry on prescribing of brand medicines: This study found that the physician influenced by detailing and the gifts or samples given by the MRs and this puts the doctor under some obligation to prescribe the brands that are promoted.	Not reported
Mikhael and Alhilali ³¹ Iraq (upper middle income) Pharmacol Pharm	Sample size: 35 Response rate: 63%. Sampling: stratified random sampling Methods: survey Target group: GPs Source of sample: National database Physicians specialists (n=35)	To evaluate the interaction between MRs and specialist physicians through the acceptance of MRs gifts and the effect of such acceptance on prescribing	Attitudes towards switching to generic drugs: This study showed that physicians significantly shift prescribing generic drugs and also from brand to generic drugs. Effect of the pharmaceutical industry on prescribing of brand medicines: The study also reported that the prescribing behavior of physicians is always influenced by MRs activities.	The sample size was small and may not be representative of GPs in the country.
El-dahiyat et al.²⁸ Jordan (upper middle income) J Pharm Policy Pract	Sample size: 500 Response rate: 75. 2 % (376). Sampling: stratified random sampling Methods: self-survey Target group: GPs Source of sample: not Pilot tested with 10 physicians	To examine factors that affect physicians’ prescribing generic drugs	Physician loyalty to brand medicines: About 50–80% private physicians were more likely to oppose substitution the brand to generic drugs, as they might have stronger brand name loyalty.	Not reported
Karayanni ¹⁰ Greece (high income) IJCRMM	Sample size: 100 Response rate: 69% – 69. Sampling: random sampling Methods: self-survey Target group: general practitioners and specialists Source of sample: physicians’ registrar of the city of Patras Pilot test: not	To examine the associations between physicians personal values with physicians prescribing criteria and preferred marketing communications	Physician loyalty to brand medicines: Results revealed that brand medicines to be less important compared to the brand loyalty to prescribing Effect of the pharmaceutical industry on prescribing of brand medicines: The prescription criterion of brand image was related to publicity and detailing, indicating that physicians who would rather prescribe a branded medicine, than an alternative generic	This is an exploratory study and the results cannot be generalized too far.
Wong et al.²² Malaysia (upper middle income) J Generic Med	Sample size: 25 Response rate: not Sampling: not Methods: face–to–face interviews Target group: physicians Pilot test: not	To explore physicians’ knowledge, perceptions and views about generic medicines	Effects of the brand on physicians’ prescribing drugs: Although the authors gained a little insight into the impact of the brand on prescribing, they found that specialists might be influenced more by original brand more than generic.	Not reported
Shrank et al.³⁸ USA (high income) Ann Pharmacother	Sample size: 2764 Response rate: 30.4% (n = 839) Sampling: stratified random sampling Methods: web survey Target group: physicians	To evaluate perceptions of a physician about generic medications	Physician’s age and experience on prescribing generics drugs (1) The age of respondents was reported to be associated with physicians’ perception of generic medicine (2) older physicians showing more negative perceptions towards	Limited by the sample surveyed, a large group of physicians (120,000) selected from a national sample.
Chua et al.³⁹ Malaysia (upper middle income) Health Policy	Sample size: 325 Response rate: 26.8% (n = 87) Sampling: convenience sampling Methods: postal survey Target group: GPs Source of sample: private medical centers	To investigate knowledge, perceptions and behavior of physicians regarding generic medicines	Physician’s age and experience on prescribing generics drugs (1) Physicians’ age and years of practicing were found to be significantly associated with prescribing of generic medicines. (2) GPs older than 60 years and those who have been in practice for more than 30 years were significantly less likely to prescribe generics than those who were younger and have practiced for less than 30 years.	Surveys were postal questionnaires and used as a tool to extract data. Respondents feature not fully evaluated.
Lewek et al.⁴⁰ Poland (high income) Bosn J Basic Med Sci	Sample size: 183 Response rate: 92.8% (n = 170) Sampling: random sampling Methods: Self - survey Target group: primary care physicians	To survey the opinions of primary care doctors on generics, and determine the factors which may affect prescribing generic.	Physician’s age and experience on prescribing generics drugs (1) No correlation was found between physician age and opinion on the efficacy of generics, or physician age and preference for generics.	Survey was conducted among primary care physicians in the Lodzkie province
Tsiantou et al.⁴¹ Greek (high income) J Clin Pharm	Sample size: 1463 Response rate: 82.3% (n = 1204) Sampling: stratified sampling Method: postal survey Target group: physicians	To investigate the profile of physicians and the factors that influence their decision on generics prescribing	Physician’s age and experience on prescribing generics drugs (1) Physicians had positive views on the safety, efficacy and quality of generic medicines. (2) Participants’ age and their opinion of generic medicines were two factors influencing generic medicines prescribing. (3) Older physicians have a higher probability of prescribing generics than younger ones.	The study applies to postal surveys; the high rate of missing values in questions mostly related to the quality of generics efficacy – may bias the results.
Alghasham ⁴² Saudi Arabia (upper middle income) Ann Saudi Med	Sample size: 772 Response rate: 96% (n = 741) Sampling: random Methods: self- survey Target group: primary care physicians Pilot tested with 12 physicians and 4 pharmacists	To evaluate attitudes and other factors influencing the prescription of generic drugs.	Physician’s age and experience on prescribing generics drugs (1) 75% Younger physicians (30–40 years) were less likely than older physicians to report that they knew enough about the therapeutic value of generics to prescribe them and to illustrate this value to patients and peers. (2) There was the difference between primary care, hospital, and private physicians in their prescrbing generic drugs.	Not reported
Jamshed et al.⁴³ Pakistan (lower middle income) South Med Rev	Sample size: 289 Response rate: 71.3% (n=206) Sampling: random Methods: self-survey Target group: GPs Source of sample: Karachi, Pakistan	To explore the knowledge, perception, and attitude of general practitioners towards generic medicines	Physician’s age and experience on prescribing generics drug (1) Physicians who aged between 41 and 50 and have been in private practice for 16–20 years showed greater significant association with the affordability of generic medicines. (2) Older GPs expressed a greater sense of discomfort to prescribe all local generics drugs when compared to their younger and middle age counterparts.	The study was performed in one city of Pakistan. Therefore, the findings cannot be generalized to physicians practicing in other cities of Pakistan
Fabiano et al.⁴⁴ Italy (high income) Health Policy	Sample size: 303 Response rate: not reported Sampling: no reported Method: postal survey Target group: pediatricians	To evaluate the knowledge of generic medicines and prescribing habits of family pediatricians	Switching from brand to generic drugs among specialists (1) GPs and family pediatricians were less confident in prescribing generics equivalents instead of branded drugs. (2) 13.5% of them declared that more than a half of their patients were treated with generic medicine. (3) Nearly half proposed to patients the substitution of a branded with a generic medicine.	Not reported
Gossell-Williams⁴⁵ Jamaica (upper middle income) West Indian Med J	Sample size: 101 Response rate: 60% (n = 60) Sampling: No reported Method: telephone survey Target group: physicians of varying specialties	To examine the attitudes of physicians towards the use of generic substitutes	Switching from brand to generic drugs among specialists (1) 49% of physicians were mostly prescribing generic brands willingly. (2) 33% of the physicians were able to identify at least one case in the past year of clinical problems with generic substitutes	Not reported
Berg et al.⁴⁶ USA (high income) Epilepsy Behav	Sample size: 606 Response rate: not reported Sampling: no reported Method: postal survey Target group: physicians who treat the patients’ epilepsy	To understand perceptions about generic of branded antiepileptic drugs (AED) substitution and how these guide prescribing	Switching from brand to generic drugs among specialists (1) 88% of physicians were concerned about an increase in breakthrough seizures in patients switched from a brand AED to a generic. (2) 75% physicians were concerned about efficacy. (3) About half of physicians were extremely/very likely to request that brand AEDs not be substituted with a generic.	Not reported
Haskins et al.⁴⁷ USA (high income) Epilepsy Behav	Sample size: 435 Response rate: not reported Sampling: not reported Method: telephone surveys Target group: physicians Source of sample: physicians in Canada, the UK, France, Germany, and Spain	To provide a broad perspective of generic AED substitution in five countries.	Switching from brand to generic drugs among specialists (1) 65% of AED prescriptions were for brand name drugs. (2) 55% of physicians were opposed to generic substitution without physician consent. (3) 27% physicians, 18% of GPs, and 38% of neurologists, believed that they had a patient who experienced a breakthrough seizure likely caused by switching from a branded to a generic AED. (4) 89% believed substitution should not be allowed in certain indications. (5) 76% of physicians felt pharmacies should be allowed to substitute a generic AED only with their consent.	Not reported
Grabowski et al.⁴⁸ Canada (high income) Clin Rheumatol	Sample size: 369 Response rate: 22.8% (n = 81) Sampling: convenience Methods: postal survey Target group: GPs	To identify gaps in knowledge and attitudes towards biosimilars among Canadian rheumatologists	Physicians attitudes to generic prescribing of biosimilar (1) 31 % of physicians were familiar with biosimilars. (2) Physicians with more than 20 years of practice were significantly more likely to be familiar with biosimilars compared to respondents with less than 10 years or 10–20 years of experience.	Not reported
Molinari et al. ⁴⁹ USA (high income) J Clin Oncol	Sample size: 376 in the US, 399 in Latin America, and 470 in Europe. Sampling: not reported Methods: online survey Target group: physicians from various practice settings in the US, Latin America and Europe	To examine the physician's attitudes toward biologics and biosimilars.	Physicians attitudes to generic prescribing of biosimilar (1) The majority of physicians in the U.S., Latin America, and Europe are familiar with biologics and biosimilars and want to be notified of substitutions. (2) Physicians in the US lack technical knowledge and understanding about the effects of biologics and biosimilars sharing the same non-proprietary name.	Not reported
Farhat et al.⁵⁰ Lebanon (upper middle income) SpringerPlus	Sample size: 117 Response rate: 22.8% (n = 81) Sampling: convenience Methods: A regional survey Target group: professional healthcare from the Arab countries, Iran, Belgium and Italy	To understand the impact of different parameters on the acceptance and future prescription of biosimilars	Physicians attitudes to generic prescribing of biosimilar (1) 63.2 % in the Arab and Middle Eastern agreed that biosimilars are already marketed. (2) 48% physicians are aware of biosimilars presence in the market and do prescribe them in Lebanon and the Arab region. (3) 41% confirmed that they prescribe biosimilars drugs	Not reported
Hallersten et al.⁵¹ Switzerland (high income) Regul Toxicol Pharmacol	Sample size: 250–800 physicians per country Response rate: 22.8% (n = 81) Sampling: not reported sampling Methods: online survey Target group: physicians from seven European countries.	To understand physicians’ preferences on type and detail of information in the biosimilar label and their use of information sources when prescribing biosimilars	Physicians attitudes to generic prescribing of biosimilar generics generics (1) Physicians prefer more product-specific information in the biosimilar label. (2) 68.8% of physicians who prescribe biosimilars, the main prescription driver were the drug’s approval by the FDA. (3) 60.7% of respondents considered that the main advantage of biosimilars is their lower price	No reported
Beck et al.⁵² France (high income) BioDrug	Sample size: 116 Response rate: not reported Sampling: not reported sampling Methods: self-survey Target group: physicians rheumatologists	To assess the knowledge, experience and opinions of rheumatologists with biosimilar medicines	Physicians attitudes to generic prescribing of biosimilar generics drugs (1) Many physicians reported having little knowledge and a lack of available information about biosimilar drugs. (2) 98.3% of the respondents had at least one question about biosimilars. (3) Only eight rheumatologists had already prescribed biosimilars drugs. (4) A majority of physicians expressed a negative opinion about substitution by the pharmacist.	Not reported
Bokemeyer et al.⁵³ Germany (high income) Z Gastroenterol	Sample size: 449 Response rate: not reported Sampling: not reported Methods: a nationwide online survey Target group: German gastroenterologists	To evaluate gastroenterologists experiences and opinions on biosimilars	Physicians attitudes to generic prescribing of biosimilar generics (1) 61 % of the participants had already prescribed Infliximab biosimilars. (2) 15 % considered themselves to be very experienced with biosimilars. (3) 71 % reported that the lower price in comparison to the originator is the most important advantage of biosimilars. (4) 68 % requested specific gastroenterological trials and registries to increase the data available on biosimilars drugs.	Not reported
Cohen et al.⁵⁴ USA (high income) Adv Ther	Sample size: 1201 Response rate: not reported Sampling: not reported sampling Methods: survey Target group: physicians across specialties	To assess physicians’ awareness, knowledge, and perceptions of biosimilars drugs in US	Physicians attitudes to generic prescribing of biosimilar generics drugs (1) The majority of physicians have heard about biosimilars, (2) The actual knowledge of the fundamentals of biosimilars was low. (3) Physicians across specialties have generally positive attitudes toward biosimilars, dermatologists and rheumatologists appear to be less enthusiastic about biosimilars, particularly due to safety concerns. (4) Physician groups require more information from trusted sources to address their current concerns.	The time of the survey limited, only one biosimilar was approved and marketed in the US

Table 2.

List of countries and GNI per capita.⁵⁶

No.	Country	GNI per capita (US$-2015)	Income group
1	Switzerland	84,630	High income
2	Denmark	58,590	High income
3	US	54,960	High income
4	Canada	47,540	High income
5	Germany	45,940	High income
6	France	40,540	High income
7	Italy	32,810	High income
8	Cyprus	25,930	High income
9	Saudi Arabia	23,550	High income
10	Slovenia	22,610	High income
11	Greece	20,290	High income
12	Poland	13,340	High income
13	Malaysia	10,570	Upper middle income
14	Brazil	9,850	Upper middle income
15	Lebanon	7,710	Upper middle income
16	Thailand	5,620	Upper middle income
17	Iraq	5,550	Upper middle income
18	Jamaica	5,050	Upper middle income
19	Jordan	4,680	Upper middle income
20	India	1,590	Lower middle income
21	Ghana	1,480	Lower middle income
22	Pakistan	1,440	Lower middle income
23	Yemen	1,300	Lower middle income
24	Bangladesh	1,190	Lower middle income

The objectives of the studies were diverse (Table 3). Eight studies directly related the factors that influence physician prescribing behavior. Three studies investigated the attitude and perception of physicians towards generic medicines. Three of the articles studied the prescribing practice of antibiotics. Five studies analyzed the interaction of marketing endeavors and its effect on prescribing behavior. One study examined the routine persistence of physicians in prescribing for brand drugs, while another assessed the demands of brand medicine. Six studies examined the association between physician age and experience and prescribing generic drugs. Four studies investigated the switching from brand to generic among specialists. Seven studies examined the attitudes of physicians towards prescribing generic biosimilar drugs.

Table 3.

Summaries of the variables that were investigated in the studies

References	Perception of a physician towards brand medicines	Effects of brand on physicians’ prescribing drugs	Effect of pharmaceutical industry on prescribing of brand medicines	Physician loyalty to brand medicines	Attitudes towards switching to generic drugs	Doctors ages and experience	physicians attitudes to generic prescribing of biosimilar
Skipper and Vejlin³⁵			√
Ladeira et al.⁹		√
Tajdar et al.²³		√
Janakiraman et al¹¹				√
Parihar³²		√
Bamoriya³³		√
Lieb and Scheurich²⁶			√
Shamim–ul–haq et al.³⁰		√	√
Plianbangchang et al.²⁰	√
Joyce et al.³⁷	√
Bashrahil²⁵	√		√
Hossain et al.²⁷	√
Al-Shami et al.²⁵	√
Theodorou et al.³⁴	√
Afriyie et al.³⁶	√		√		√
Kersnik et al.²¹
Narendran and Narendranathan²⁹		√	√
Mikhael and Alhilali et al.³¹			√		√
El-dahiyat et al.²⁸				√
Karayanni¹⁰				√
Wong et al.²²		√
Shrank et al.³⁸						√
Chua et al.³⁹						√
Lewek et al.⁴⁰						√
Tsiantou et al.⁴¹						√
Alghasham⁴²						√
Jamshed et al.⁴³						√
Fabiano et al.⁴⁴					√
Gossell-Williams⁴⁵					√
Berg et al.⁴⁶					√
Haskins et al.⁴⁷					√		√
Grabowski et al.⁴⁸							√
Molinari et al^.49							√
Farhat et al.⁵⁰							√
Hallerstena et al.⁵¹							√
Beck et al.⁵²							√
Bokemeyer et al.⁵³							√
Cohen et al.⁵⁴							√

Results

Table 1 shows the key results of the reviewed studies. A detailed and concise review of the content of each research article reveals the perceptions of physicians towards brand drugs. The findings are grouped into the following eight sections.

Perceptions of physicians towards brand medicines

Seven of the 21 studies explored the physicians’ prescribing practice of brand medicines.^{20,25,27,30,34,36,37} In other words, the studies simply investigated whether a physician prescribes brand drugs, rather than the influence of branding on prescribing behavior. The study carried out in Thailand by Plianbangchang et al.²⁰ reported that few prescriptions were written by brand name. The study found that prescribing based on brand name is focused on off-patented brand medications. In a different study carried out in the US, Joyce et al.³⁷ investigated the factors that affect prescribing choices and reported that physicians prescribe an average of at least three different drugs while one in six physicians prescribe the only brand drug in 8 of 10 therapeutic cases. A cross-sectional survey carried out by Theodorou et al.³⁴ in both Greece and Cyprus examined the attitudes and factors that influence physician prescribing decisions. The majority of the physicians surveyed in the study agreed that though the efficacy and safety of generic medicines may not be outstanding factors, they are preferred over the brand of the drugs.

Furthermore, Hossain et al.²⁷ carried out a cross-sectional survey in Bangladesh, which found that about 66% of physicians prefer to prescribe drugs with brand names while the other 33% are inclined to prescribe to generic drugs. Al-Shami et al.²⁴ and Bashrahil²⁵ examined physicians’ prescribing practice and the use of essential drugs in Yemen. The findings of these studies are close, with Bashrahil,²⁵ reporting 60.8% of prescription drugs were brand drugs, while Al-Shami et al.²⁴ found that 76.8% of prescribed antibiotics were brand drugs. In another study, a postal survey in Ghana conducted by Afriyie et al.³⁶ discovered that only 39.5% of prescriptions were brand drugs.

Effects of brand on physician prescribing behavior

Six out of the 21 reviewed studies^{9,23,29,30,32,33} examined the effects of the brand on the prescribing behavior of physicians. Quantitative studies carried out by Ladeira et al.⁹ and Narendran and Narendranathan²⁹ using a self-administered questionnaire found that brand has a strong effect on prescribing behavior of physicians. Cross-sectional studies by Bamoriya³³ and Tajdar et al.²³ discussed the factors that influence drug prescribing in India and Pakistan and found that brand is an important factor capable of influencing prescribing behavior. A cross-sectional study in India³² reported that physicians are more interested in brand names of drugs. In contrast, Shamim–ul–haq et al.³⁰ found that brand plays an insignificant role in influencing drug prescribing in Pakistan. Wong et al.²² examined the physicians’ perceptions about generic medicine in Malaysia using interview data. Although the study reported a little detail into the effect of the brand on prescribing, they discovered that professionals might be inclined to prescribe original brands over generic drugs.

Effect of pharmaceutical industry on prescribing of brand medicines

Six of the reviewed studies explored the effect of different pharmaceutical promotions on physicians’ decision to prescribe brand drugs. In Greece, Karayanni¹⁰ discovered that the brand prescription was influenced by advertising and detailing, indicative of physicians’ preference for branded drugs over generic drugs. Narendran and Narendranathan²⁹ reported that physicians in India were influenced by the largesse or samples provided by sales persons, which makes the physicians biased towards prescribing the specific brand being promoted. An overwhelming tendency for prescribing drugs by brand names (99%) by the physicians was observed in India.⁵⁶ Mikhael and Alhilali³¹ performed a survey of specialists in Iraq and found that physicians are influenced by MRs’ promotional literature when they prescribe the brand drugs. Similarly, a survey study carried out by Lieb and Scheurich ²⁶ in Germany suggested that physicians who never participated in funded events had a lower number of on-patent branded drug prescriptions, a lower proportion of branded drugs, a higher proportion of generic drugs, and a lower expenditure on off-patent branded drugs per patient. An experimental study³⁵ carried out in Denmark revealed that physicians do not appear to prescribe brand drugs and thus recommended the removal of promotion inducements for physicians to prescribe brand drugs in order to increase the use of generic drugs.

Physicians’ loyalty to brand medicines

Three studies^10,11,28 evaluated the replacement of generic prescribing, brand persistence, and brand as a marketing tool. An experiment study by Janakiraman et al.¹¹ reported that physicians in the US persistently prescribe branded drugs (under patent protection) even when a cheaper generic drug is obtainable, implying that physicians may not be making the most economical decision, but rather take therapeutic effectiveness into consideration. Similarly, a cross-sectional study carried out in Greece by Karayanni¹⁰ reported that branded medicines are less important than prescription loyalty to a particular brand. El-dahiyat et al.²⁸ showed that 50–80% of physicians in Jordan working in the private sector were more likely to oppose replacement of branded with generic drugs, possibly because of their strong loyalty to the brand name.

Physicians’ willingness to switch from brand to generic drugs

A cross-sectional survey conducted in Slovenia by Kersnik et al.²¹ examined attitudes of general practitioners (GPs) towards prescribing the generic drug. The study found that 96.3% of physicians were disposed to switching from brand drugs to relatively cheaper generic drugs if the price was lower by 25–35%. Similarly, a recent survey in Iraq carried out by Mikhael and Alhilali³¹ showed that the prescription disposition of physicians significantly shifts from brand to generic drugs because of marketing efforts such as gifts.

Physician’s age and experience on prescribing generics drugs

Shrank et al.³⁸ evaluated the physicians’ perceptions towards generic medicines in the US. The age of respondents was associated with physicians’ perception of generic medicine. Older physicians (than of age of 55 years old) were more than three times as negative to generics drugs as younger physicians. The youngest physicians aged below 35 years were negative towards the quality of generic medicines. They further reported a personal preference for generics drugs or to suggest them to their family.

An additional study in the US found that older doctor, as well as those who work in small practices, were more likely to be persistent with a branded drug when a cheaper generic is available.¹¹ A study which surveyed GPs in Malaysia revealed that respondents’ age and years of practicing were significantly associated with prescribing of generic drugs. GPs older than 60 years and those who have more than 30 years of medical practice were considerably less likely to prescribe generics drugs than those who were younger and have practiced for less than 30 years.³⁹

In Poland, Lewek et al.⁴⁰ carried out a survey to examine the opinions of primary care physicians on generics drugs and to determine the factors which may affect prescribing generic. While this study confirmed that generic and brand name drugs are equally effective, no correlation was found between physician age and opinion on the efficacy of generics, or physician age and preference for generics. In Greece, Tsiantou et al.⁴¹ investigated the profile of doctors and other factors that influence prescribing generics decision. The study suggested that older physicians were more likely to prescribe generics drugs than younger ones. Others factors such as specialty and work of experience were not significant. Although physicians seemed to be positive about generics drugs, they were preferred to prescribe the brand medicines.

A study in Saudi Arabia examined doctors’ perceptions and their attitudes towards generic prescribing. The study found that 75% of younger physicians aged between 30 and 40 years were less likely than older physicians (93%) aged between 40 and 50 years and 89% of those above 50 years to report that they knew enough about the therapeutic value of generics drugs to prescribe them and to show this value to patients and peers. Also, the results suggested that primary care physicians were significantly more likely to prescribe generic drugs than hospital and private physicians.⁴²

Another study in Pakistan suggested that GPs who have more than 10 years of medical experience expressed their doubts towards the prescribing of low-cost brands. Physicians who aged 41–50 years and have practice more than 16–20 years showed higher positive perception towards the safety and affordability of generic medicines. In contrast, senior general practitioners expressed a greater sense of discomfort to prescribe all local generic drugs when compared to their younger and middle-age counterparts. Highly experienced and senior general practitioners expressed their concern about the quality check of locally manufactured generic medicines.⁴³ Furthermore, El-dahiyat et al.²⁸ examined factors that affect physicians’ prescribing of generic drugs in Jorden. The study found that doctors working in public tended to accept generic substitution more compared with physicians working in private sector.

Specialists’ attitude towards switching from brand to generic drugs

Using a public web survey in Italy, Fabiano et al.⁴⁴ found that GPs and family pediatricians were less confident in prescribing generics equivalents instead of branded drugs, and therefore, the prescribing of generic medicines were low. Only 14% of physicians reported that more than half of their patients have treated with generics drugs. Nearly half of them usually proposed to patients the substitution of a “branded” with a generic medicine and the majority declared to explain to their patients the characteristics of generic drugs regularly. In addition, 54.4% believed that reason for limited prescription of generics was a still too diffuse skepticism about them. In contrast, 20.4% believed that knowledge about generic drugs was still insufficient. Further key issues related to preventing generic prescribing are the safety of switching from brand drugs to generic equivalents. The study concluded that more information about generic medicines is required to increase the prescribing of the generic medicines among Italian family pediatricians.

Gossell-Williams⁴⁵ examined the attitudes of physicians from various specialties (mostly general/family practice physicians) towards generic substitution in Jamaica; 49% of the physicians were mostly prescribed generic brands willingly when the cost of generic substitutes was a significant factor. Furthermore, half of the physicians felt that the bioequivalent of generics drugs were therapeutically equivalent to those branded drugs. However, 33% mentioned that they could identify at least one case related to the clinical problem of generic medicines in previous years and also indicated that this did not happen with the brand medications.

Berg et al.⁴⁶ evaluated the perceptions of physicians and patients on generic of branded antiepileptic drugs (AED) substitution. Of the physicians surveyed, 88% of respondents were worried about a rise in breakthrough seizures in patients who switched from a brand AED to a generic. Further, nearly two-thirds of respondents have linked breakthrough seizures to generic AED substitution, but at the same time, 75% were concerned about efficacy. Only half of respondents were very likely to request that brand AEDs not be substituted with a generic. Nevertheless, the physicians’ perceptions do not align with the FDA position that generic AEDs have the same effectiveness and safety profile as branded AEDs.

Haskins et al.⁴⁷ conducted a telephone survey in five developed countries such as France, Spain, Germany Canada, and the United Kingdom (UK). Overall, the study revealed that 65% of AED prescriptions were for brand name drugs. The greatest proportion of prescriptions for branded AED was written in France (98%) and Spain (91%) and the least in Canada (53%) and the UK (54%). However, 55% of physicians were opposed to generic substitution without physician consent. The greatest proportion of opposition was among physicians in Germany (70%) with the least opposition in France (15%). Furthermore, 27% of doctors, 18% of GPs, and 38% of neurologists believed that they had a patient who experienced a breakthrough seizure likely caused by switching from a branded to a generic AED. Nevertheless, 89% believed substitution should not be allowed in certain indications, and 76% felt pharmacies should be allowed to substitute a generic AED only with their consent, and nearly 47% believed the pharmacy should have patient consent.

Physicians’ attitudes towards generic prescribing of biosimilar generics drugs

Physicians’ attitudes towards generic prescribing of biosimilar should not be neglected. Seven articles in this review investigated the attitude of doctors towards generic biosimilar drugs.^48–54

In Canada, Grabowski et al.⁴⁸ carried out a survey to evaluate attitudes towards biosimilars drugs among rheumatologists. Only 31% of physicians were familiar with biosimilars. Doctors who had more than 20 years of practice were significantly more likely to be very with biosimilars than the respondents with less than 10 years or 10–20 years of experience. Furthermore, 32% agreed or strongly agreed that they would be comfortable with indication extrapolation. Finally, 88% were highly concerned if a pharmacist had the ability to substitute a biologic drug for a biosimilar without the physician’s approval.

Based on the online survey, Molinari et al.⁴⁹ examined physicians’ attitudes from various specialties toward biosimilars medicinal products in the US, Latin America (Colombia, Mexico, Brazil, and Argentina) and Europe countries (Italy, France, Germany, UK, and Spain). Overall, the study revealed that the majority of respondents were familiar with biosimilars and wanted to be notified of substitutions. US physicians were 20% and 3% more likely to be familiar or very familiar with biosimilars drugs than Latin American and European doctors, respectively. And 80% of physicians from the US, 87% from Latin America, and 77% of Europeans believe that receive notification when the biosimilar is replaced is critical. Moreover, physicians in the US lack technical knowledge about the effects of biosimilars drugs sharing the same non-proprietary name.

Farhat et al.⁵⁰ surveyed professional healthcare in the Arab countries, Iran, Belgium, and Italy to understand the impact of various factors on the acceptance and future prescription of biosimilars drugs. Overall, 65.8% out of respondents had knowledge about biosimilars, and 63.2% agreed that biosimilars in these countries were already marketed. Only 41% confirmed that they prescribe biosimilars while 32.5% do not prescribe them. The main driver for prescribing biosimilars drugs was the drug’s approval by the FDA, the European Medicines Agency (EMA) (68.8%), a lower price (64.6%), bioefficacy (47.9%), safety (41.7%), and reputation of the manufacturer company (31.3%).

Hallersten et al.⁵¹ evaluated physicians’ preferences from seven specialties on the type, detail, and sources of information of the biosimilar label when prescribing biologics drugs including biosimilars in seven European countries namely the UK, France, Germany, Spain, Italy, Poland, and Sweden. Overall, physicians prefer more product-specific information in the biosimilar label. The label for biosimilars drugs is the main source of information used by doctors. For 68.8% of doctors who prescribe biosimilars, the main prescription driver was the drug’s approval by the FDA followed by the lower price (60.7%).

Beck et al.⁵² evaluated the knowledge, experience, and opinions of rheumatologists with biosimilar medicines in France. Overall, the majority of physicians reported that they had little knowledge and a lack of available information about biosimilar drugs. Only eight rheumatologists reported that they prescribed biosimilars drugs. However, 98.3% had at least one issue related to these medicines. Seven out 10 of physicians mentioned problems related to substitution, iatrogenic effects, or cost savings that might be achievable. Finally, the majority of the respondents were expressed a negative opinion about generic substitution by the pharmacist.

Bokemeyer et al.⁵³ evaluated gastroenterologists’ experiences and their views on biosimilars drugs in Germany. Only 61 % of the respondents reported that they prescribed Infliximab biosimilars drugs. However, 15 % considered themselves to be very experienced with biosimilars. Furthermore, 71 % indicated that the lower price is the most significant advantage of biosimilars comparison to the originator. Nevertheless, 68 % requested specific gastroenterological trials and registries to increase the data available on biosimilars drugs.

In an additional study in the US, Cohen et al.⁵⁴ assessed physicians’ awareness, knowledge, and perceptions of biosimilars medicines in the US. Overall, the majority of doctors have heard about biosimilars drugs but, at the same time, appeared to have a low knowledge of the fundamentals of biosimilars. Although physicians across specialties have positive attitudes toward biosimilars, some of them such as dermatologists and rheumatologists showed to be less enthusiastic and still had concerns regarding the safety of biosimilars. The authors concluded that more information regarding biosimilars drugs was required to address current concerns.

Discussion

This study identified 21 studies that examined the perceptions and attitudes of physicians towards brand drugs worldwide. The findings revealed that physicians are inclined to have mixed views as regards prescribing brand medicines. Related studies conducted in developed countries such as the US,³⁷ high-income countries, for example, Greece and Cyprus³⁴, and medium-income country such as Thailand²⁰ indicate that physicians have a tendency to prescribe generic medicines over brand medicine due to the positive perception of generic medicines among physicians in these countries. This positive perception may be attributable to the fact that these countries observe a strict bioequivalence acceptability criteria for generic medicines, which are set by their relevant drug organizations. Moreover, these countries have more dependable public control procedures for producing and dispensing generic drugs to ensure better bioequivalence requirements for generic medicines. This deduction is consistent with a recent review by Toverud et al.,¹⁴ who found that medical professionals in European countries possess a high level of trust in the bioequivalence of generic drug with the branded analog regarding active element, dosage, and therapeutic effects.

In contrast, physicians in low-income countries such as Yemen, Bangladesh, and Ghana are inclined to heavily prescribe brand drugs.^24,25,2736 This tendency has been attributed to the perceived safety and efficiency of branded drugs as well as the uncertainty over the quality of the generic drugs in these countries. Also, there is the perception that generic medicines are easily counterfeited, which may harm patients. Then again, marketing efforts provided by pharmaceutical companies to a physician may be a more plausible reason for brand prescribing in developing countries. The wide use of brand drugs results in increased cost of drug and healthcare expenses. Thus, the disparity in perception and attitude of physicians towards drug prescribing stems from considerable differences in the healthcare system, drug policies, the level of advertising by pharmaceutical firms, and drug information sources between developed and developing countries.

Based on the evidence presented, this review deduced that brand has an influence on physician prescribing decision. One plausible reason is that brand can create justifiable points for distinguishing competing drugs and thus influence physician decision to prescribe the drug. However, there is no unanimity in the literature supporting the notion that brand is a significant factor influencing the prescription decision. This may be attributable to the drawback of previous studies on physician prescribing behavior, where aspects of the brand were measured rather than the actual brand of the drug. Hence, it is difficult to confidently attach weight to the brand variable.

Furthermore, this review found that the promotions constantly advertised in the pharmaceutical industry play the key role in encouraging physicians to prescribe brand medicines. This is confirmed by the fact that physicians who never participated in sponsored events had a relatively lower number of branded drug prescriptions compared to those who did.²⁶ Moreover, this review points out that the effect of MRs in altering the prescription of brand medicines by physicians should not be ignored in low-income countries. For instance, studies have shown that the gifts or samples given by MRs put physicians under a certain level of commitment to prescribe the promoted brands.^29,31 Other studies revealed that marketing endeavors of the pharmaceutical industry had an influence on prescribing patterns of branded drugs.^25,36

This paper reviewed three studies that assessed the perceptions of physicians towards brand medicine in high-income countries^11,10 and low-income country.²⁸ As a whole, the studies reported that physicians have a tendency to be loyal to brand medicine because of their therapeutic efficacy and safety and creating barriers to prescribing a new drug. It was also inferred that physicians find it difficult to change their perceptions towards certain brands.¹¹ This shows the influence of brand loyalty created by persistent and persuasive pharmaceutical marketing. Therefore, the effect of marketing efforts of pharmaceutical companies on brand loyalty is an area that needs to be further explored. Another plausible reason for brand loyalty is proven efficacy based on the experience of physicians with the drug. Thus, the brand is continually prescribed by physicians to ensure full recovery of their patients.

Nonetheless, a few studies in this review reported that physicians were more willing to switch from brand to generic medicines under certain conditions such as price and marketing efforts. This further confirms the notion that physician prescribing is always influenced by marketing efforts and price.

Physician’s age and experience on prescribing generics drugs were variable and occasionally contradictory. Studies suggest that younger doctors in the US, Pakistan and Malaysia with fewer years of practice were more likely to prescribe generic drugs than older physicians. In contrast, older physicians in Saudi Arabia and Greece were more likely to prescribe generic drugs more than younger, and in Poland, the age was not associated with the perception the physicians to prescribe or preference generic drugs. This might reflect differences in how the healthcare systems work or in differences in the consistency of medical instruction content about generic and brand name drugs over time.

Furthermore, these differences may be due to differences in the lack of doctors’ knowledge of generic medicines during their education and clinical practice as well as the inadequate regulatory framework of the generic market in the country.⁴¹ The review also found that there were differences in the opinions of physicians on prescribing generic medicines in public and those of physicians on the private sector. Doctors in the public sector are likely to accept the substitute of the generic drugs more than those who were working in the private’s sector. Overall, the review suggests that there were significant differences in the prescribing generic drugs use by physicians among different age, years of practice, or different practice settings.

From the present review, four studies from high-income and middle-income countries indicate that knowledge on switching from a branded to a generic among specialists of family physicians, epilepsy and pediatrics and others. Although general/family physicians and pediatrics were more likely than physicians who treat patients with epilepsy to suggest switching from the brand to generic drugs to their patients, they expressed greater concern about the safety of switching to generic equivalents. In contrast, the physicians opposed generic substitution of antiepileptic drugs without physician’s approval. The reason for these results could be that the physicians were worried about the therapeutic equivalency of interchangeable medicines, breakthrough seizures after switching, and pharmacists’ ability to substitute safely.^46,47 Generic substitution of antiepileptic drugs is still a matter of controversy and concern among physicians.

From the current review, there were seven articles, six from high-income countries and one from the middle-income country was accessed in which knowledge of prescribing biosimilar drugs. Overall, all studies reported that the majority of physicians were familiar with biosimilars drugs although that they had a low level of knowledge of the basis of these drugs across countries in worldwide. Thus, the biosimilar generic prescribing drugs were low. Another interesting result was that physicians, regardless of the lower price of biosimilar drugs, expressed concerns over the effects and safety of prescribing biosimilar drugs. There was some evidence about the negative views of physicians towards biosimilars drugs. The physicians appeared to be worried about substitution by the pharmacist or switching between different generics should not be recommended medicines.

As mentioned above, physicians in the US^49,54 had a low level of knowledge regarding the effects and fundamentals of generic biosimilar drugs compared to their counterparts in European countries and an early-stage healthcare system like Arabic countries. This may be attributed to the fact that views of physicians in the US who most likely did not yet have any practical experience in the prescribing biosimilars drugs since no biosimilar was authorized in this country before March 2015. On the contrary, doctors in the Europe countries have more practical experience with the biosimilar drugs, because, for several years, the European Union countries has been the first and only jurisdiction in the world to adopt a regulatory framework for the authorization of biosimilars drugs.⁵¹ Overall, this review concludes that there is a lack of confidence among physicians towards biosimilars generics, and knowledge is one of the most factors to be improved for higher prescribing of biosimilars generics drugs. Therefore, the review of the literature in this area highlights a significant need for more information and education about biosimilars medicines for physicians across countries.

Strength and limitations of the review

This study provides a comprehensive review of the perceptions of physicians towards brand medicine and the effects of the brand on drug prescription. This study is considered novel, given that there is no similar review conducted on this particular topic. Although a recently published systematic review by Hassali et al.¹³ focused on perceptions of physicians towards drug prescription in low- and middle-income countries, the study only focused on generic medicines. In addition, Toverud et al.¹⁴ reviewed the perspectives of physicians and pharmacists on the use of generic drugs. However, the review found little evidence on the perception of physicians towards brand medicines as well as the effect of drug brands on prescribing decisions. Therefore, this current review has expanded the results of preceding reviews regarding perceptions of physicians towards brand drugs, the effects of the brand on prescribing decisions, the influence of marketing efforts on the prescription of brand drugs, physician’s age and their experience on prescribing generic drugs, switching from branded to generic equivalents among specialists, and attitudes of physicians towards biosimilar generic drug prescribing.

Despite the use of established methodologies by this review, several limitations arose. First, this review only considered recent studies from the year 2000 and onwards; however, this is justified by the higher relevance of current findings compared older studies. Second, most of the reviewed articles are survey papers, which have design limitations such as small sample size, some non-validated questionnaires, and pilot tests, in addition to the difficulty of directly measuring the brand. Other limitations relate to brand medicine, where only results from studies regarding the perception of physicians and effects on prescribing were extracted. This review excluded the results about perceptions towards generic medicines, although numerous studies have been conducted on generic medicines. Hence, the perceptions of physicians for towards brand and generic medicines in different countries should be compared in future studies.

Furthermore, because the current review was focused on the opinions of specific physicians’ populations, the patients or the general public were not examined in the area of switch brand to generic among specialists such as epilepsy and pediatrics. Research on this subject was limited and fragmented, and most studies investigated public opinions, patients, pharmacists, the pharmaceutical industry, and using different populations in distinct settings.

Implications for policy makers and practice

Research on perceptions of physicians towards brand medicines has implications for drug control policies and practices. Based on this review, marketers and health decision-makers can have an insight into physicians’ perceptions of brand drugs compared to perceptions of generic drugs. This will help them to determine alternative marketing strategies in order to increase brand trust and boost the effects of branding on the prescribing decision as well as to improve overall brand perception and image especially in developing countries. On the other hand, examining the brand loyalty and the switching of the brand to generics is a key to understanding the generics paradox for generics manufacturers and policy makers. This review also provides critical information that will be valuable to researchers evaluating the effects of brand drugs on physicians’ prescription behaviors.

The review found evidence of the lack of an inadequate knowledge on biosimilar drugs needs more information to address the effects and safety of these drugs. To develop such a policy, more information on biosimilar generics to physicians during their education and clinical practice should be implemented. Also, promotional efforts for the pharmaceutical industry should be conducted to promote the bioequivalence for biosimilar generic medicines to doctors.

Conclusion

This paper is a novel study on physicians’ perceptions towards brand drugs and its effect on the prescription decision. The perceptions of physicians towards the brand drugs were found to differ in relation to the nature of healthcare system and level of development. The physicians prescribed more generic drugs than brand drugs in countries with reliable public control routines for drugs as well as better bioequivalence requirements concerning generics. The review showed that drug brand can influence the prescribing decision of physicians. The majority of physicians acknowledged that their prescribing decisions could be influenced by marketing efforts of pharmaceutical industry, while some physicians showed loyalty to a specific brand. Some physicians asserted that they are willing to switch from brand to generic drugs, due to the notion that their prescribing decisions may be affected by promotional efforts or prices of the drugs.

The review suggests that there were significant differences in the prescribing generic drugs use by physicians among different age, years of practice, or different practice settings. The studies reviewed indicate that general/family doctors and pediatricians were more likely than physicians who treat patients with epilepsy to suggest switching from the brand to generic drugs to their patients. Physicians regardless of specialty expressed greater concern about the safety of switching from brand to generic. All studies reported that the majority of physicians were familiar with biosimilars drugs although that they had a low level of knowledge of the basis of these drugs across countries in worldwide. It appeared that, although the physicians were prescribing biosimilars generics, they still had concerns about the effects and safety of prescribing biosimilar drugs. Therefore, biosimilar generic prescribing drugs were low. This highlights a significant need for more information and education about biosimilars medicines for physicians across countries.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biographies

Mohsen Ali Murshid is a PhD Candidate in the Graduate School of Business (GSB), Universiti Sains Malaysia – Malaysia. His current research interests include factors influencing physician prescribing behavior.

Zurina Mohaidin is a Marketing Lecturer in Graduate School of Business (GSB), Universiti Sains Malaysia – Malaysia. Her main research interests include looking at the patterns of brand and product selection by consumers and relating it to the philosophy of economic psychology, specifically the explanation of consumer choice.

References

Stros

Lee

. Marketing dimensions in the prescription pharmaceutical industry: a systematic literature review. J Strat Market 2015; 23: 318–336.

US Food and Drug Administration (FDA). FDA Center for Drug Evaluation and Research. Office of Generic Drugs. Orange book: approved drug products with therapeutic equivalence evaluations, http://www.fda.gov/downloads/Drugs/DevelopmentApprovalProcess/UCM071436.pdf_ (2014, accessed 10 January 2013).

Iacocca

Sawhill

Zhao

. Why brand drugs priced higher than generic equivalents. Int J Prognost Health Manage 201; 9: 3–19.

Ahmed

. Pharmaceutical marketing mix strategy and physician’ s prescription behavior. J Pharm Innov 2014; 3: 8–12.

Joseph

Spake

Godwin

. Aging consumers and drug marketing: senior citizens’ views on DTC advertising, the Medicare prescription drug programmers and pharmaceutical retailing. J Med Microbiol 2008; 8: 221–228.

Leonard

Prevel Katsanis

. The dimensions of prescription drug brand personality as identified by consumers. J Consum Manage 2013; 30: 583–596.

Abdul Waheed

Jaleel

Laeequddin

. Prescription loyalty behavior of physicians: an empirical study in India. Int J Prognost Health Manage 2011; 5: 279–298.

Pinto

Ferreira

Alexandre

et al.

Determinant values in the medical act of prescribing in the Portuguese context. J Med Microbiol 2010; 10: 213–230.

Ladeira

Dalmoro

Eduardo Maehler et al.

Drug prescription practices in Brazil: a structural equation model. Int J Prognost Health Manage 2011; 5: 262–278.

10.

Karayanni

. A cluster analysis of physician’s values, prescribing behaviour and attitudes towards firms’ marketing communications. Int J Custom Relation Market Manage 2010; 1: 62–79.

11.

Janakiraman

Dutta

Sismeiro

et al.

Physicians’ persistence and its implications for their response to promotion of prescription drugs. Manage Sci 2008; 54: 1080–1093.

12.

AL-Tamimi

Hassali

Alrasheedy

. Challenges to generic medicines utilization in Yemeni healthcare system. GaBI J 2013; 2: 63–64.

13.

Hassalia

Wong

Alian

et al.

Perspectives of physicians practicing in low and middle-income countries towards generic medicines: a narrative review. Health Policy 2014; 117: 297–310.

14.

Toverud

Hartmann

Hakonsen

. A systematic review of physicians’ and pharmacists’ perspectives on generic drug use: what are the global challenges? Appl Health Econ Health Policy 2015; 13: S35–S45.

15.

Kotler

Armstrong

. Principles of marketing, 9th ed. London: Prentice Hall, 2001.

16.

Kapferer

. The new strategic brand management: Advanced insights and strategic thinking, 5th ed. London: Kogan Page, 2012.

17.

Ambler

Bhattacharya

Edell

et al.

Relating brand and customer perspectives on marketing management. J Serv Res 2002; 5: 13–25.

18.

Sanyal

Datta

Banerjee

. Conceptualisation of branding: strategy based on the Indian pharma sector. Int J Prognost Health Manage 2013; 7: 175–198.

19.

Kumar

Srivastava

. An exploratory study of product and brand positioning typologies with respect to pharmaceutical companies. Rev Integr Bus Econ Res 2013; 2: 638–654.

20.

Plianbangchang

Jetiyanon

Suttaloung

et al.

Physicians' generic drug prescribing behavior in district hospitals: A case of Phitsanulok, Thailand. Pharm Pract 2010, pp. 167–172.

21.

Kersnik

Klemenc-Ketis

Petek-Ster

et al.

Family doctors’ views of pharmaceutical sales representatives: assessment scale development. J Clin Pharm Ther 2011; 28: 456–460.

22.

Wong

Alrasheedy

Aljadhey

et al.

Medical specialists’ knowledge, perceptions and views about generic medicines in Malaysia: findings from a qualitative study and the implications. J Generic Med 2015; 3: 1–18.

23.

Tajdar

Ahmad

. Customers’ prescription of foreign versus local brands in the pharmaceutical industry of Peshawar (Pakistan). Rev Integr Bus Econ Res 2015; 4: 378–396.

24.

Al-Shami

Izham

Abdo-Rabbo

. Evaluation of the quality of prescriptions with antibiotics in the government hospitals of Yemen. J Clin Diagn Res 2011; 5: 808–812.

25.

Bashrahil

. Indicators of rational drug use and health services in Hadramout, Yemen. East Mediterr Health J 2010; 16: 151–155.

26.

Lieb

Scheurich

. Contact between doctors and the pharmaceutical industry, their perceptions, and the effects on prescribing habits. PLoS One 2014; 9: e110130–e110130.

27.

Hossain

Kawsar

Tanmy

et al.

Assessment of influencing factors on prescription practices of physicians in Bangladesh. Int Res J Pharm 2013; 8: 112–116.

28.

El-Dahiyat

Kayyali

Bidgood

. Physicians’ perception of generic and electronic prescribing: a descriptive study from Jordan. J Pharm Policy Pract 2014; 7: 1–8.

29.

Narendran

Narendranathan

. Influence of pharmaceutical marketing on prescription practices of physicians. J Indian Med Assoc 2013; 111: 47–50.

30.

Shamim-ul-haq

Ahmed

Ahmad

. Factors influencing prescription behavior of physicians. Pharma Innov 2014; 3: 30–35.

31.

Mikhael

Alhilali

. Gift acceptance and its effect on prescribing behavior among Iraqi specialist physicians. Pharmacol Pharm 2014; 5: 705–715.

32.

Parihar

. Influence of pharmaceutical marketing promotion on physicians prescription behaviour in Tier-III and Tier-IV. Asia-Pacific Market Rev 2012; 1: 45–49.

33.

Bamoriya

. Mystery written on prescription pads: exploring marketing factors influencing prescription behaviour using the AHP approach. J Econ Bus Res 2012; XVIII: 85–100.

34.

Theodorou

Tsiantou

Pavlakis

et al.

Factors influencing prescribing behaviour of physicians in Greece and Cyprus: results from a questionnaire-based survey. BMC Health Serv Res 2009; 9: 150–150.

35.

Skipper

Vejlin

. Determinants of generic vs. brand drug choice: evidence from population-wide Danish data. Soc Sci Med 2013; 130: 204–215.

36.

Afriyie

Amponsah

Antwi

et al.

The prescribing trend of antimalarial drugs at the Ghana Police Hospital. J Infect Dev Ctries 2015; 9: 409–415.

37.

Joyce

Carrera

Goldman

et al.

Physician prescribing behavior and its impact on patient-level outcomes. Am J Manag Care 2013; 17: e462–e471.

38.

Shrank

Liberman

Fischer

et al.

Physician perceptions about generic drugs. Ann Pharmacother 2011; 4: 31–8.

39.

Chua

Hassali

Shafie

et al.

A survey exploring knowledge and perceptions of general practitioners towards the use of generic medicines in the northen state of Malaysia. Health Policy 2010; 95: 229–235.

40.

Lewek

Smigielski

Kardas

. Factors affecting the opinions of family physicians regarding generic drugs – a questionnaire based study. Bosn J Basic Med Sci 2015; 15: 45–50.

41.

Tsiantou

Zavras

Kousoulakou

et al.

Generic medicines: Greek physicians’ perceptions and prescribing practices. J Clin Pharm Ther 2009; 34: 547–554.

42.

Alghasham

. Generic drug prescribing in central Saudi Arabia: perceptions and attitudes of physicians. Ann Saudi Med 2009; 29: 24–29.

43.

Jamshed

Ibrahim

Hassali

et al.

Perception and attitude of general practitioners regarding generic medicines in Karachi, Pakistan: a questionnaire based study. South Med Rev 2012; 5: 22–30.

44.

Fabiano

Mameli

Cattaneo

et al.

Perceptions and patterns of use of generic drugs among Italian family pediatricians: first round results of a web survey. Health Policy 2012; 104: 247–252.

45.

Gossell-Williams

. Generic substitutions: a 2005 survey of the acceptance and perceptions of physicians in Jamaica. West Indian Med J 2007; 56: 458–463.

46.

Berg

Gross

Haskins

et al.

Generic substitution in the treatment of epilepsy: patient and physician perceptions. Epilepsy Behav 2008; 13: 693–699.

47.

Haskins

Tomaszewski

Crawford

. Patient and physician reactions to generic antiepileptic substitution in the treatment of epilepsy. Epilepsy Behav 2005; 7: 98–105.

48.

Grabowski

Henderson

Lam

et al.

Attitudes towards subsequent entry biologics/biosimilars: A survey of Canadian rheumatologists. Clin Rheumatol 2015; 34: 1427–1433.

49.

Molinari

Gewanter

Loaiza-Bonilla

et al.

Global survey of physicians’ attitudes toward biologic and biosimilar therapies. J Clin Oncol 2016; 34.

50.

Farhat

Othman

el Karak

et al.

Review and results of a survey about biosimilars prescription and challenges in the Middle East and North Africa region. SpringerPlus 2016; 5: 2113–2113.

51.

Hallersten

Fürsta

Mezzasalmab

. Physicians prefer greater detail in the biosimilar label (SmPC) – results of a survey across seven European countries. Regul Toxicol Pharmacol 2016; 77: 275–281.

52.

Beck

Michel

Rybarczyk-Vigouret

et al.

Rheumatologists’ perceptions of biosimilar medicines prescription: findings from a French web-based survey. BioDrugs 2016; 30: 585–585.

53.

Bokemeyer

Dignass

Schreiber

. Inflammatory bowel disease (IBD): experiences and perceptions of German gastroenterologists. Z Gastroenterol 2017; 55: 369–374.

54.

Cohen

Beydoun

Chien

et al.

Awareness, knowledge, and perceptions of biosimilars among specialty physicians. Adv Ther 2017; 33: 2160–2172.

55.

Aqil

Bhadana

Alam

et al.

Medicine utilization review at a university teaching hospital in New Delhi. J Pharm Bioallied Sci 2012; 4: 202–206.

56.

The World Bank. GNI per capita, Atlas method (current US$). https://en.wikipedia.org/wiki/List_of_countries_by_GNI_(nominal,_Atlas_method)_per_capita (accessed 7 April 2015).