Table 3 Illustrative quotes from participants during the focus group discussions, along with the average second round ranking scores
Determinants of prescribing choices | Illustrative quotes | Average ranking (1–5) b |
|---|---|---|
Product-related factorsa | ||
Clinical data | “The newer insulins are insulins with a better action profile compared to traditional insulins. There are more clinical data showing that they are better, which is the main reason why physicians are prescribing newer insulins.” (FGD1_PHY3) “For many dermatologists, the lack of clinical trials for biosimilars is still a problem. The comparator trials between biosimilars and their originator are not there. Such trials are much more extensive in IBD and rheumatology.” (FGD3_PHY2) “In the beginning, there was a natural reluctance by most colleagues about biosimilars in terms of efficacy. Today, I think the concept of biosimilarity has become more and more known.” (FGD2_PHY4) | 3.6 |
Cost | “In dermatology, more expensive and newer biologicals are being prescribed much faster because of their clinical benefits. That certainly outweighs the higher societal cost for most physicians.” (FGD1_PHY5) “If we look at the evolution and uptake of the newer group of IL-17 or IL-23 inhibitors, which is very high in dermatology, then it seems to me that we don’t care much about societal cost.” (FGD3_PHY2) | 3.1 |
Administration | “The administration route is important for many physicians. I know that the uptake of JAK inhibitors within rheumatology is very high in Belgium. I suspect that has a lot to do with convenience for patients related to the oral administration.” (FGD3_PHY1) | 2.6 |
Novelty | “It is always nice to work with new molecules. If you have the luxury of working in a university hospital, you get involved in clinical trials and you receive the opportunity to work with new products. However, I do not think that weighs heavily in the choice of a product.” (FGD1_PHY4) | 2.2 |
Physicians’ personal factors | ||
Working environment | “Academic hospitals will switch to newer insulins somewhat more quickly because they are more likely to have gained earlier experience with these products in clinical studies compared to peripheral centers.” (FGD1_PHY3) “Working alone versus working in a hospital obviously influences your background knowledge regarding medicines. The working environment determines what kind of information you come in contact with. When you receive more information on a particular product, this definitely increases the chances you will prescribe it.” (FGD3_PHY3) | 3.9 |
Region | “We have the impression that the more southern in Belgium the smoother prescriptions are made toward new biologicals and more expensive therapies.” (FGD1_PHY1) “If you look at JAK inhibitors, one product is mostly prescribed in Flanders, and a different product in Wallonia. There is no way we can explain that difference, unless a certain pharmaceutical representative is more active in one region than in the other.” (FGD3_PHY1) | 3.5 |
Prescribing habits | “I would not overestimate the impact of prescribing habits. Only when it comes to biosimilars, it seems that we are reluctant to change. For new molecules, that does not seem to be the case.” (FGD4_PHY1) “It is in the pen of many physicians. In other words, many physicians will prescribe what one has experience with and be more conservative.” (FGD1_PHY1) “It often takes 10–15 years before you really see change in behavior because people are just very slow to change their habits, even if you are persuasive, even if you make guidelines.” (FGD2_PHY3) | 3.4 |
Age | “There is a younger generation of rheumatologists that have never experienced the scarcity in therapeutic options. They are more likely to prescribe more expensive and new medications.” (FGD1_PHY1) | 2.6 |
Healthcare system-related factors | ||
Preference of key opinion leaders (KOLs) | “If you get backup from colleagues or KOLs at the university centers, you are more likely going to follow their opinion as a physician. You become more at ease or confident to prescribe medicines KOLs are promoting.” (FGD4_PHY3) | 4.1 |
Clinical guidelines | “There is very little information on biosimilars in the European guidelines. That could be improved.” (FGD3_PHY2) “Clinical guidelines play a role in the discussion between products with different MOAs, but they do not play a role at the product level. Therefore, they do not matter when making the choice to prescribe a biosimilar or not.” (FGD4_PHY4) | 3.5 |
Time pressure | “Time is often used as an excuse to hide the real reason why physicians are not switching to biosimilars. [...] However, if you have to explain to a patient who has been in remission for 10 years that they have to switch to a biosimilar, that leads to problems. So yes, that does take time to explain.” (FGD3_PHY1) “As a dermatologist, you have very busy consultations and little time per patient. If you have to go convince a patient to make a switch to a biosimilar, that is just not feasible in that short time span.” (FGD1_PHY5) | 3.4 |
Financial incentives | “I think incentives from the government do work. I hear that from colleagues as well. It is possibly because of the incentive that the click comes to prescribe biosimilars. Only then you are going to remove the barrier.” (FG1_PHY2) “The impact of the previous financial incentive in Belgium is very low. I would give 0 or 1 out of 5 on its impact. However, the impact of an appropriate incentive would be very high. There, I would give a 5.” (FGD4_PHY6) | 3.0 |
Patient-related factors | ||
Patient profile | “I think we, as physicians, are convinced that patient profile and clinical data drive us above all else. However, in reality, that will be less the case than we hope.” (FGD2_PHY3) “The benefits of newer insulins will certainly weigh more heavily for patients with type 1 diabetes than for patients with type 2 diabetes. [...] In the type 2 diabetes group, I think we are a bit more conservative and stick to the older insulins. Newer insulins are used mainly for type 1 diabetes.” (FGD1_PHY3) | 3.8 |
Patient preference | “It is remarkable that no patient has asked me so far whether they could switch a biosimilar? Not a single patient yet. They have already asked me to be prescribed the new IL-17 or − 23 inhibitor, though.” (FGD4_PHY3) “Patient preference is a difficult one, [...] most patients trust the physician or the practitioner. If you explain your choice well enough, patients will follow your decision. They are rarely going to come up with a suggestion of necessarily being treated with a specific product.” (FGD1_PHY4) | 3.2 |
Knowledge or perception of patients | “There are patients who are very skeptical about biosimilars. For these patients, it is best not to prescribe them a biosimilar. You will lose too much time on that anyway.” (FGD4_PHY5) “I think knowledge and perception only really matters in a minority of patients. Patients mainly rely on what physicians think is best for them, much less what they have read or heard before about a medicine.” (FGD2_PHY1) | 2.9 |
Factors related to the pharmaceutical company or brand | ||
Marketing and promotion of the pharmaceutical company | General “Physicians are reluctant to admit they are influenced by marketing and promotion. Physicians want to make a scientifically sound, patient-centered choice. You would rather not admit that you are influenced by marketing and promotion from the industry. Even though we all know that we are strongly influenced by it.” (FGD1_PHY1) Value-added services “We had a good agreement with the company that markets the originator biological about TDM. As a result, we could do dose optimization very quickly. These discussions with biosimilar companies were much more difficult, which has held back the uptake of biosimilars.” (FGD3_PHY3) Visits by pharmaceutical companies “Very often, it is the personal relationship with a pharmaceutical representative that makes prescribers stick with Humira.” (FGD4_PHY2) “The influence of pharmaceutical representatives in our field is not to be underestimated. Dermatologists are easily persuaded to take a certain therapeutic path.” (FGD3_PHY2) Sponsorships or grants “In many cases, pharmaceutical companies come up with an offer for a certain financial grant if you prescribe their product. This is in particular the case for biosimilar companies or the company marketing the originator. To be clear, companies are all doing this. They provide such things either as sponsorships or as a support for our hospital service.” (FGD3_PHY4) | 3.8 |
Reputation (or trust) in the company or brand | “The reputation of the company will especially play a role when choosing between biosimilars, since different biosimilar manufacturers exist and not all of them have the same experience with biological medicines. You want to know what the supply chain is like or whether there are chances for shortages?” (FGD1_PHY1) “Quite some physicians tend to prefer companies that also invest in research and development. Companies that merely do copying are not preferred.” (FGD3_PHY2) | 3.4 |