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Florida Board Of Veterinary Medicine

Abstract

Prescribers practicing in metropolitan Atlanta were surveyed to examine their attitudes about compounding pharmacy, their perceived uses and indicated needs for compounding services, and their interest in learning more about compounding pharmacy. A questionnaire was mailed to random samples of 100 prescribers in each of the following specialties: veterinary, internal medicine, obstetrics and gynecology, and dermatology, with 25% responding. Attitudes toward compounding pharmacy were measured using 21 items and a five-point response scale (1 = strongly disagree). Overall, the prescribers felt favorably toward compounding pharmacy, with a mean attitude of 3.94. The majority indicated that they had needs for compounding pharmacy related to medication strength, size, dosage form, removal of dyes or preservatives, and commercial availability. Potential areas for detailing compounding services were identified within specialties, where prescribers were not aware of some beneficial uses of compounding pharmacy. The majority of prescribers were interested in learning more about compounding pharmacy. The desired educational methods in order of preference were written information (96%), attendance at a seminar (40%), and an office detail conducted by a compounding pharmacist (31%).

Introduction

Modern compounding is very different from its historical predecessor. Because the contemporary version of this ancient art continues to offer unique treatment solutions unavailable through commercial medications, modern compounders are acutely aware of the need to invest time in marketing their services to physicians.

Pharmacists who specialize in compounding spend much of their marketing efforts educating physicians about: the services they offer and introducing the innovative dispensing devices, dosage forms and preparations they can create. However, truly successful marketing begins with knowing the prospective buyer's motivations and intentions. By addressing the specific concerns of prescribers considering compounded medications, pharmacists who market such services could tailor their presentations and make more efficient use of their time. Unfortunately, very little literature is available to compounders that identifies exactly what these concerns are.

Numerous studies1-4 have identified physicians' attitudes towards aspects of pharmacy other than compounding. Some of those aspects include:

1. Clinical pharmacy services,

2. Pharmacist-provided drug information,

3. Clinical pharmacy encounters in family practice and

4. Physicians' overall views of the pharmacist.

However, very few published studies specifically reveal prescribers' views of contemporary compounding.

Prescribers who have historically used compounded prescriptions may realize that these services are useful, but they have trouble locating a pharmacist who is willing to provide these products. In a 1984 study, Smith et al5 surveyed 169 dermatologists who represented 20 different metropolitan areas. Eighty-one percent of those respondents indicated that they had encountered pharmacists who were unwilling or unable to fill a compounded prescription, and 40% of those respondents indicated that this had occurred more than twice a month. Nearly 80% of the respondents in the study by Smith et al5 indicated that they had advised their patients to take their compounded prescriptions to a specific pharmacy. The top four reasons these dermatologists referred their patients to a particular pharmacy were cited as follows:

* The pharmacy had shown a proven ability to compound preparations.

* They were confident that the prescription would be accurate and reliable.

* The pharmacy offered a variety of available ingredients.

* The pharmacists had shown a definite interest in compounding.

In the same study, responding dermatologists indicated that, while compounding was central to their practice, some doubted the pharmacists' ability to compound and preferred to do it themselves.6

In a 1986 study, which analyzed the relationship between dermatologists and pharmacists, Aranjo et al7 surveyed 465 dermatologists. The reasons the responding dermatologists did not write prescriptions for compounded medications were identified as follows:

* 30%-The pharmacist was unwilling or unable to compound.

* 20%-The pharmacy inventory was inadequate.

* 15%-The pharmacist did not have time to compound.

Poor compounding skills and inadequate knowledge of dermatological problems were cited by the dermatologists as additional impediments to the pharmacist's ability to compound.

In 1998, Ling8 outlined the reasons dermatologists compound.

* Compounding connects them to their roots.

* Compounding provides niche products to fill gaps in commercially manufactured medications.

* Compounding allows dermatologists to treat unusual diseases or to target specific symptoms individually.

Ling also presented drawbacks to extemporaneous pharmaceutical compounding. Although most of the issues addressed arc not specifically directed at pharmacists, mention was made that individual pharmacists may not have the knowledge, equipment or motivation to produce compounded products to the same level of safety required of commercial products that arc regulated by the US Food and Drug Administration. Regarding compounding in general, Ling cited problems with bioavailability, kinetics, stability and sterility of medications not manufactured by commercial drug companies.8

A 1994 article by Plumb9 addressed whether or not veterinarians, who have also held a historic role in the use of compounded medications, have the training and equipment to compound drugs. The author noted that there are many instances in veterinary medicine when a compounded medication is necessary, because it would be virtually impossible for the commercial veterinary drug industry to financially justify the production of every possible strength and dosage form to accommodate the multitudes of sixes and species of animals treated by veterinarians. Plumb, a pharmacist who published this article in a journal for veterinary medicine, acknowledged that veterinarians do indeed have the training and equipment necessary to compound many medications; but noted that, when complex preparations are needed, veterinarians may not have the resources available to compound the prescription required to adequately treat the animal.

The articles and studies mentioned above were published in journals targeting prescribers in the fields of dermatology and veterinary medicine. Articles in journals directed at compounding pharmacists present compounding from a different perspective. For instance, an article by Davis10 recommended marketing to veterinarians based on her experience in the held, as well as interviews with veterinarians and fellow compounders. One veterinarian who was interviewed advised that prescribers in his field who are unfamiliar with compounding arc more receptive to compounding pharmacy than physicians, because using novel solutions to solve patient problems is a major part of their practice.

This study examined how prescribers in metropolitan Atlanta felt about compounding pharmacy. Specific objectives of this study were to measure the

* Attitudes of prescribers toward compounding pharmncy;

* Indicated needs and perceived uses of prescribers for compounding pharmacy services; and

* Level of interest of prescribers in learning more about compounding pharmacy.

Methods

The universe for this study consisted of veterinarians and physicians from the metropolitan Atlanta area who were board certified in obstetrics/gynecology (ob/gyn), internal medicine and dermatology. After we eliminated those with second specialties, the study population totaled 1726, which included 395 veterinarians, 827 internists, 384 ob/gyns and 120 dermatologists. A random sample of 400, 100 from each specialty, was chosen. Two weeks after the initial mailing, the names of those for whom surveys were undeliverable were replaced with new names; and a replacement survey and reminder letter were mailed to all practitioners. Six surveys were returned undeliverable after the second mailing and were not replaced. This resulted in a total survey of 100 veterinarians, 99 internists, 98 ob/gyns and 97 dermatology specialists.

A questionnaire was constructed. Attitude toward compounding pharmacy was measured using 21 items that presented favorable and unfavorable statements and a five-point response scale where 1 = strongly disagree. Attitudes were compared according to specialty. Needs for compounding pharmacy were measured using 14 items and a yes/no response choice. Content domain was addressed by a review of the literature to ensure that the attitudinal items included those mentioned in the literature as possibly important in affecting specialists' attitudes toward compounding. Items were then reviewed for clarity and completeness by seven practitioners representing pharmacy, education and some of the specialties surveyed. Demographic characteristics measured included sex, age, years in current practice, type of practice and percentage of compounded prescriptions they write.

Analyses were conducted using the STATISTIX (Analytical Software, Tallahassee, Florida) program and included simple descriptive statistics, t-tests and an analysis of variance. Significance was reported at P

Results

Demographics

A total of 99 completed, usable questionnaires were analyzed, for a response rate of 25.1%. The sample comprised 60.4% men and 39.6% women. Mean age was 47.8 (standard deviation [SD] = 14). There was considerable variability among the prescribers with respect to practice experience. Respondents had been practicing in their specialty a mean of 18.3 years (SD = 11.9). The composition of respondents by specialty included 43.2% in veterinary medicine, 29.5% in dermatology, 15.8% in ob/gyn and 11.6% in internal medicine.

Preservers' Attitudes Toward Compounding Pharmacy

Responses to the attitudinal items were first analyzed to assess reliability of the attitude scale. The results of the t-tests revealed that each attitudinal item was discriminating between the upper and lower 25% of responses. Corrected item-total correlations met the criteria of being significant at F

Table 1 contains the mean response of the prescribes for each attitudinal item. Overall attitude toward compounding pharmacy was computed for the prescribers using the Method of Summated Rating.12 This method involved reversing the scoring for negatively worded items so that a high score would consistently reflect positive attitudes toward the variable being measured. Total scores were then determined by adding together individual item scores, and averages were calculated. The mean attitude of respondents was 3.94, with an SD of 0.46. Therefore, overall, the responding prescribers felt favorably toward compounding pharmacy.

Some individual attitudinal items elicited strong responses. Mean responses > or = 4.0 indicated that prescribers agreed with the following statements:

* "Pharmacy education should include instruction in compounding."

* "Compounded medications can help me solve medication problems."

* "Customizing medication to individual patients' needs improves therapeutic results."

* "Prescribers would value the opinion of a compounding pharmacist to help solve medication problems."

Mean responses

* "Prescription compounding is no longer necessary with a wide variety of commercial medications available."

* "I hesitate to prescribe compounded medications for my patients due to negative media attention on the subject."

* "Pharmacy-compounded medications are not safe for my patients."

* "Compounding pharmacy is a form of alternative medicine and is not a reliable treatment option."

* "Pharmacists should not be allowed to compound medications."

The majority (61.2%) of prescribers strongly disagreed with the latter statement.

Analysis of variance followed by Scheffe's multiple comparison test revealed a significant difference in attitude toward compounding pharmacy according to the prescribers' practice specialties (Table 2). Dermatologists reported a mean attitude of 4.21 (SD = 0.31), and veterinarians reported a mean attitude of 4.05 (SD = 0.34). These two specialties had a more positive attitude toward compounding pharmacy than prescribers in ob/gyn, who had a mean attitude of 3.54 (SD = 0.50), and prescribers in internal medicine, who had a mean attitude of 3.53 (SD = 0.43). Attitudes toward compounding pharmacy did not vary based on the other demographic characteristics, including gender, age, years in practice and percentage of compounded prescriptions written.

Indicated Need for Compounding Services

Table 3 illustrates that the prescribers answered affirmatively to questions designed to measure the need for compounding services. Some items did not reflect a significant difference among the specialties but were significant for the group as a whole. More than 90% of respondents indicated that at one time they had wished that a medication came in a different strength or size or that it was available without dye or preservatives. A similar percentage of respondents indicated that their patients have had problems with noncompliancc of medication because of cost. When asked, "Have your patients had problems with medication noncompliance because of dosage form?" the majority of the respondents (80.6%) indicated that they have. A large percentage (91.8%) of the total group answered positively to the question, "Have you ever wanted to prescribe a medicine that is no longer commercially available?" The vast majority (86%) of the prescribcrs, including 87.5% of veterinarians and 77.8% of dermatologists, indicated that they were not familiar with the laws regulating compounding pharmacy.

Some items that evaluated need were significant by specialty. Nearly all responding specialists in internal medicine (90.9%) admitted that they had problems with medication noncompliance because of taste, cost and patient allergies. The majority of prescribers in this specialty (63.6%) were not aware of a pharmacist who compounded and did not know how to locate one. Furthermore, only 20% of these specialists felt knowledgeable about the types of preparations that could be made by a compounding pharmacy. all (100%) responding dermatologists indicated that at some point they had wanted to prescribe a medication that was no longer commercially available.

Level of Interest in Learning More About Compounding Pharmacy

Table 4 presents the prescribers' level of interest in learning more about compounding pharmacy. The majority of prescribers (96.3%) indicated that they would be willing to read printed information about compounding pharmacy sent to their office, while only 14.6% indicated that they would be willing to meet with a iionpharmacist representative from a compounding pharmacy. More than 40% of the prescribers indicated a willingness to attend a seminar on compounding pharmacy, and 30.5% indicated they would be willing to meet in their office with a compounding pharmacist.

When responses were evaluated by specialty, the trend in the level of interest was very similar to that of the total group. More prescribers (16.7%) expressed a willingness to meet in their office with a nonpharmacist representative from a compounding pharmacy than those (in their specialty) who would be willing to visit a compounding pharmacy (8.3%).

Perceived Uses for Compounding Pharmacy

Table 5 presents the perceived uses for compounding pharmacy as indicated by the group of responding prescribers as a whole. The top three uses for this group, for which more than 65% of the respondents indicated a use for compounding, were topical medications, capsules and Savored medications. The three least likely uses, for which

These results changed when they were examined according to the respondents' practice specialty. Veterinarians' two most frequent uses for compounding pharmacy were flavored medications (95.1%) and suspensions (90.2%). However, the majority of veterinarians reported uses for compounding services for sterile ophthalmic drops or ointments (65.9%), drugs that are on backorder (65.9%), topical medications (61.0%) and capsules (61.0%).

The majority of dermatologists mentioned topical medications (96.4%) and suspensions (60.1%) as uses for compounding pharmacy. No respondents in this specialty mentioned enemas or intrathccal medications as uses.

The ob/gyns who responded said that the most frequent uses for compounding pharmacy included natural hormones (83.3%), topical medications (58.3%) and suppositories (50%). No prescribcrs in this group perceived the following as uses for compounding pharmacy: the preparation of IV or subcutaneous injectables, sterile opthalmics, commercial drugs that arc too expensive or drugs that are still under patent.

Specialists in internal medicine most frequently mentioned topical medications (77.8%) and suspensions (66.7%) as uses for compounding pharmacy; flavored medications and suppositories were both mentioned by 55.6% of this group. No specialists in internal medicine mentioned sterile ophthalmic drops or ointments, drugs that arc still under patent or intrathecal medications as uses for compounding pharmacy.

Discussion

More responses were received from specialists who have historically been more frequent prescribers of compounded medications. Agreement with the statements, "Pharmacy education should include instruction in compounding," and "I would value the opinion of a compounding pharmacist to help solve medication problems," together with disagreement with the statement that "Pharmacists should not be allowed to compound medications," suggests that prescribers expect that pharmacists have the ability to compound and the knowledge to participate in prescribing decisions, as well as the right to compound.

The favorable attitude of respondents possibly reflects receptiveness to marketing efforts. This is consistent with the findings that evaluate the prescribers' levels of interest in learning more about compounding pharmacy. Based on this study, mailed literature would be the most well-received method for reaching prescribers. It is interesting that a significant number of respondents indicate a willingness to attend a seminar about compounding pharmacy, yet it is rare that compounders host such an event. Given that few respondents expressed a willingness to meet with nonpharmacist representatives, more efforts should be made to train pharmacists to perform direct-to-physician marketing rather than to expend resources to train ancillary personnel for this task. A recent series of articles by Letendre and Jackson13-15 provides further information on marketing compounding services.

Individual attitudinal items reveal that prescribers accept the idea that customizing medication to patients' needs can improve therapeutic outcomes and that compounded medications can help prescribers solve medication-related problems; therefore, most specialists do not need to be convinced of these benefits. Instead, this information may provide a usable approach when initiating marketing efforts. It may be beneficial to open a discussion of compounding services by simply testing the prescribers' agreement with these benefits before introducing new concepts in compounding. For example, start with the question, "Would you agree that customizing medication to patients' needs can improve therapeutic outcomes?" If the prescriber answers affirmatively, it will be easier to discuss specific services of a compounding pharmacy.

Items designed to identify need for compounding services reveal that all specialties included in this survey need many of the common uses. Surprisingly, many dermatologists and veterinarians, specialists who have historically shared the practice of compounding with pharmacists, are unfamiliar with the laws that regulate compounding. Lack of knowledge in this area by all the specialties could possibly be an obstacle in generating new business. Bridging this gap by keeping current on the most recent regulations on compounding, along with discussing this with potential clients, could make the specialists more likely to prescribe compounded medications. It is interesting that a strong majority of specialists of internal medicine reports difficulties with medication therapy due to taste and palatability, yet this group poorly recognizes the use for compounding pharmacy in the area of flavoring. Concentration of marketing efforts and education in this area may prove to be beneficial. Although this study reveals that specialists in internal medicine do not have as favorable an attitude toward compounding pharmacy as the other specialists surveyed, it is possible that this is due to their lack of knowledge of the available services and. their inability to find a compounding pharmacist to help them when they encounter a medication problem that may be solvable by compounding services. This need for compounding services, coupled with an inability to find a compounding pharmacist, clearly indicates potential business to be generated from specialists in internal medicine.

Veterinarians and dermatologists have a more favorable attitude toward compounding pharmacy, perhaps because they perceive more uses for it, as evidenced in this study. Veterinarians' uses for compounded medications are well understood; therefore, marketing to these practitioners may only require introduction of the presence of compounding pharmacy rather than education about specific products. Dermatologists perceive uses for compounding services that are traditionally outside their practice area; therefore, when marketing to dermatologists, it may be productive to request referrals to specialists outside their practice area.

It is disappointing that ob/gyns do not perceive the use of compounding pharmacy for injectables, considering the potential use for compounding in this dosage form. Marketing efforts should incorporate education in these areas, while reinforcing education in the use of natural hormones. The perceived use of compounding pharmacy for capsules, flavored medications, natural hormones and injectables is not recognized by specialists in internal medicine. As there arc potential opportunities for these specialists to use these products, marketing efforts should include education on the ways these products can be used to customize patient therapy.

Readers are cautioned about generalizing the positive attitudes reported. The specialists sampled were from metropolitan Atlanta; thus, the attitudes reported may be regional. Recause response to the questionnaire was voluntary, those with more favorable attitudes may have chosen to respond.

Conclusion

This study involves a small sampling of specialists targeted for promotion of compounding services. Clearly, all possible attitudes were not measured. Further research needs to be conducted to measure the attitudes of specialists in other fields and to gather their opinions about additional aspects of contemporary compounding so that marketing efforts will lead to increased use of compounding pharmacy and, ultimately, improved patient outcomes.

Acknowledgment

This research was funded by a grant from the International Academy of Compounding Pharmacists, Sugar Land, TX.

References

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12. Edwards AL. Techniques of Attitude Scale Construction. New York: Appleton-Century-Crofts; 1957:30.

13. Letendre W, Jackson R. Marketing your prescription compounding practice-Part 1. IJPC 2000;4:36-38.

14. Letendre W, Jackson R. Marketing your prescription compounding practice-Part 2. IJPC 2000;4:115-117.

15. Letendre W, Jackson R. Marketing your prescription compounding practice-Parts. 3. IJPC 2000;4:199-202.

Aimee R. Greenberg, PharmD

Candace W. Barnett, PhD

Mercer University

Southern School of Pharmacy

Atlanta, Georgia

Address correspondence to: Candace W. Barnett, PhD, Mercer University, Southern School of Pharmacy, 3001 Mercer University Drive, Atlanta, GA 30341-4155. E-mail: Barnett_C@mercer.edu

Copyright International Journal of Pharmaceutical Compounding Jan/Feb 2004
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