title: The consequences of requesting "dispense as written".
abstract: BACKGROUND
  All US states have adopted generic substitution laws to reduce medication costs. However, physicians may override these regulations by prescribing branded drugs and requesting that they are dispensed as written. Patients also can make these requests. Little is known about the frequency and correlates of dispense as written requests or their association with medication filling.
  
  
  METHODS
  We identified beneficiaries of a large pharmacy benefits manager who submitted a prescription claim from any pharmacy in January 2009. We categorized claims as a physician-assigned dispense as written, patient-assigned dispense as written, or no dispense as written. We described rates of these requests and used generalized estimating equations to evaluate physician, patient, treatment, and pharmacy characteristics associated with dispense as written requests. We also used generalized estimating equations to assess the relationship between dispense as written designation and rates prescriptions are not filled by patients.
  
  
  RESULTS
  Our sample included 5.6 million prescriptions for more than 2 million patients. More than 2.7% were designated as dispense as written by physicians, and 2.0% were designated as dispense as written by patients. Substantial variation in dispense as written requests were seen by medication class, patient and physician age, and geographic region. The odds of requesting dispense as written was 78.5% greater for specialists than generalists (P<;.001). When chronic prescriptions were initiated, physician dispense as written (odds ratio 1.50, P<;.001) and patient dispense as written (odds ratio 1.60, P<;.001) were associated with greater odds that patients did not fill the prescription.
  
  
  CONCLUSIONS
  Dispense as written requests were common and associated with decreased rates of prescription filling. Options to reduce rates of dispense as written requests may reduce costs and improve medication adherence.
authors: Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA. wshrank@partners.org
authors: William H
authors: WH
authors: Shrank
authors: Joshua N
authors: JN
authors: Liberman
authors: Michael A
authors: MA
authors: Fischer
authors: Jerry
authors: J
authors: Avorn
authors: Elaine
authors: E
authors: Kilabuk
authors: Andrew
authors: A
authors: Chang
authors: Aaron S
authors: AS
authors: Kesselheim
authors: Troyen A
authors: TA
authors: Brennan
authors: Niteesh K
authors: NK
authors: Choudhry
mesh_terms: D057915:Drug Substitution; D006801:Humans; D007880:Legislation, Drug; D010349:Patient Compliance; D010818:Practice Patterns, Physicians'; D055553:Prescription Drugs / Q000191:economics*; D014481:United States
chemical_list: D055553:Prescription Drugs