Phth3501_116-144

Comparison of Internet and Community Pharmacies
Mary L Wagner, Janette Alonso, and Allana J Mehlhorn of drug information11 with Internet pharmacies. Landis12
Ann Pharmacother 2001;35:116-9.
briefly discussed many issues related to Internet pharma-cies, including regulation, insurance coverage, and effect Surfing the Internet for information and services is be- on pharmacy practice. We intend to expand on these dis- coming a way of life. Healthcare professionals need to cussions by comparing the costs and services of Internet become aware of the advantages and disadvantages of fill- ing prescriptions via the Internet. They should know whyInternet pharmacies are growing as well as how patients Procedure to Obtain Medications via the Internet
can obtain prescriptions and drug information via the Inter-net.
The patient must first connect to the Web site, select the The prescription drug market is estimated to be $103 option for obtaining a prescription, and then set up an ac- billion in the US.1 Pharmacists dispensed nearly 2.8 billion
count. This involves the transmission of personal informa- prescriptions in 1998 and are expected to dispense about 4 tion, including name, address, E-mail address, birth date, billion prescriptions a year by 2005. In addition, staff phone number, gender, allergies, medical conditions, cur- members from Consumer Reports interviewed more than rent medications, and insurance information. It is difficult 15 000 readers and found that four out of 10 paid for part to ascertain in advance whether the patient’s insurance is or all of their prescriptions and one out of four were upset accepted, but Internet pharmacies E-mail the consumer if about the long wait at a community drugstore to have a there is a problem with the insurance or if it is not accepted prescription filled. This increased demand and large mar- at that site. Each patient chooses a private password to ac- ket value creates great potential for alternative prescription cess this information. All information is transmitted via a outlets, such as Internet pharmacies.
secure connection to maintain confidentiality. Once the The Internet is becoming a common way that people first order has been placed, this information is kept on file purchase many goods, including prescription medications.
so it does not have to be reentered when additional orders Patients may be using Internet pharmacies because of the are placed. To obtain medication subsequent to a new pre- greater selection of brands, the ease of comparing costs, scription, the patient can mail the original prescription or and the anonymity or convenience associated with receiv- have the physician contact the Web site via phone, FAX, or ing medications and advice via the Internet. Over the next mail. A technician or pharmacist at the Web site can also five to 10 years, transactions via Internet pharmacies are contact the physician for a prescription. Refills can be or- expected to reach $10 billion with the benefit of reducing dered online or transferred from any pharmacy where the costs, decreasing medication error rates, and improving pa- prescription is currently active. Internet pharmacies cur- tient care.2
rently choose not to dispense Schedule C-II controlled sub- Several articles have discussed cost issues,3 legal issues,4-8
stances (e.g., fentanyl, hydromorphone). Prior to comple- safety concerns,3,6,9,10 guidelines for patients,10 and quality
tion of the online transaction, the patient is asked to specifythe shipping address and shipping method, and to provide Author information provided at the end of the text.
Special Contribution
Pilot Comparison Study
SURVEY RESULTS
Results of our survey found that the cost of purchasing a medication for Parkinson’s disease from Internet pharma- Our objective was to compare Internet pharmacies with community cies could range from 7% to 58% less for brand-name and pharmacies in terms of cost and services. To minimize covariates, surveydata were collected from three Internet pharmacy Web sites that were as- 31% to 76% less for generic medications purchased from sociated with retail chain pharmacies (www.drugstore.com, www.e- the associated community pharmacy (not taking into ac- pharmacy.com, www.soma.com), their associated retail store counter- count delivery fees or senior citizen discounts). Most Inter- parts (Rite Aid, Eckerd, CVS, respectively), one independent Internet net pharmacies, including those we studied, currently do pharmacy Web site (www.planetrx.com), and a randomly chosen inde-pendent retail pharmacy in New Jersey. We collected information about not offer senior citizen discounts, while many retail phar- each pharmacy by logging onto their Web sites, E-mailing, and calling macies offer 10% discounts for senior citizens. Comparing the registered pharmacist. Survey questions included the following: cer- www.soma.com with the CVS pharmacies, using Eldepryl tification, delivery time, shipping costs, senior citizen discount, the cost 5 mg as an example, the store was $0.07 cheaper than the of eight different Parkinson’s disease drugs, hours of operation, pharma-cist availability, online physician availability, availability of over-the- Web site when the 10% discount was applied. The Web counter products, and two drug information questions (Can Eldepryl be site drug prices are generally similar to each other. The dif- taken together with Prozac, and Should Sinemet be taken together with ference in Parkinson’s disease medication costs for the pharmacy Web sites and stores were greatest for Rite Aid, We chose to compare the cost of Parkinson’s disease medications for two reasons. Patients affected by this illness are frequently disabled, with the median Web site prices being 28% lower than re- have difficulty driving, and receive long-term medications that require extensive monitoring. Spouses who have assumed major care responsi- Prescriptions could be ordered over the Internet 24 hours bilities may not like transporting a late-stage Parkinson’s patient to get a day, seven days a week, and mailed directly to the pa- medications as it is very difficult to move disabled patients. Second, un-like popular medications such as Viagra, the cost of drugs for Parkin- tient’s home via standard or special mail. Although not all son’s disease is not likely to be affected by popular market demand.
retail stores may be open 24 hours a day and deliver medi- Table 1. Comparison of Internet Pharmacy Web Sites
Independent
Web Sitea
Web Siteb
Web Sitec
Web Sited
Delivery timee and cost
Median Web site:store drug cost ratiof
Quality of drug informationg
NA = not applicable; OTC = over-the-counter; VIPPS = Verified Internet Pharmacy Practice Sites.
awww.drugstore.com (accessed 11/1/99 and 6/1/00).
bwww.e-pharmacy.com (accessed 11/1/99 and 6/1/00).
cwww.soma.com (accessed 11/1/99 and 6/1/00).
dwww.planetrx.com (accessed 11/1/99 and 6/1/00).
eThis includes prescription processing time. Holidays, mailing of prescriptions, or problems with billing may substantially increase shipping time.
fThe median ratio of drug cost from Internet to community pharmacy. The difference between Web site and store for eight different drugs for Parkin-
son’s disease.
gTotal score out of four points; two questions at two points apiece, with 4 being the best score.
ML Wagner et al.
cations, only the independent pharmacy we interviewed Medications ordered through an Internet pharmacy actual- could receive a telephone prescription from a physician ly take longer to reach patients and are not always cheaper.
and deliver the medication to the patient’s home with no Consumer Reports1 also reported that prescription medica-
delivery charge. The Internet pharmacy services surveyed tion services for Internet pharmacies were up to 29% less required one to two days to process a prescription and mail expensive than community pharmacies for five commonly the medication via standard shipping (2–14 d) at no addi- prescribed drugs, but Bloom and Iannacone3 reported that
tional charge. If it would be necessary for the Internet the average cost of sildenafil and finasteride were 10% pharmacy to contact the physician or pharmacy, a three- to greater at 37 Internet sites than community stores in the five-day waiting period was required. Prescriptions could Philadelphia area. When patients have insurance, however, be shipped and received within two days for an additional the cost of medication will be the same between Internet charge of up to $7.95 per shipment or received overnight and retail pharmacies because of predetermined co-pay.
for an additional $10.95–12.00. The Internet pharmacies Consumers should make sure that the Internet pharmacy could ship to street and PO box addresses using all ship- ping methods. None of the Internet pharmacies shipped in- Patients must allow adequate time when ordering refills ternationally and only www.planetrx.com shipped to the or sending a new prescription so as not to be stranded US territories (Puerto Rico, the Pacific Islands, the Virgin without medication while the medication is prepared and Islands). The medication would be mailed after the phar- mailed. Samples from the physician, however, may be ade- macies received the prescription and payment information; quate during this time. One advantage of a retail communi- thus, the process would be delayed if the patient mailed the ty pharmacy is that the pharmacist can give the patient a prescription or had difficulty with payment. Thus, Internet 72-hour supply of a chronic maintenance medication if the pharmacies had a longer turnaround time to obtain a pre- prescription has no refills or has expired and the physician scription and could have a higher overall cost due to ship- Some patients may prefer asking questions anonymous- New prescriptions and refills ordered online could be ly, while others would rather have person-to-person con- obtained on the same day at the affiliated retail pharmacy tact with someone with whom they are familiar. Internet location of the customer’s choice (usually available for pharmacists may prepare better answers to questions than pickup within 2–5 h of order placement). All of the prices pharmacists in retail stores because their staff has more quoted online applied when the patient picked the medi- time dedicated to answering questions without the distrac- cine up at the retail pharmacy, except in the case of www.
tions that occur in the community stores. Gardner11 gave a
soma.com, which would not guarantee the same prices C grade for the quality of drug information obtained at an when prescriptions were picked up at CVS, the correspond- Internet site; however, this evaluation was made a short time after the site opened and it is possible that the quality We found that the quality of drug information was quite of the service has improved. All information on the Inter- variable between the Internet pharmacies, but was general- net should be reviewed rigorously for quality, and a partial ly more comprehensive than that received from the com- list of guidelines is available.13 It is unknown whether the
munity stores. For each of the two questions, there were lack of person-to-person counseling when using an Inter- two points that should be mentioned in each answer allow- net pharmacy will translate into poorer compliance with ing a total score of 4. None of the pharmacies received a medication. One advantage of Internet pharmacies is pro- perfect score. Patients were able to ask questions of their grams such as the eMedAlert, www.drugstore.com phar- Internet pharmacist, either online or over the telephone.
macies, which allows the pharmacy to distribute important They were not guaranteed to be able to write or speak to drug information (e.g., warning letters) to their clients more the same pharmacist each time they contacted the Web site; however, they could request to speak to the same per- A disturbing disadvantage of Internet pharmacies is that son. The response time was longer with the Internet phar- patients must be certain that they are not dealing with an il- legal Web site. An Internet pharmacy that is not regulatedby the Food and Drug Administration (FDA) may be po- Discussion
tentially sending medications from foreign countries thatdo not comply with US regulations for quality, purity, and The results of our pilot study are limited by the small potency of drug products. The FDA launched 134 Internet- number of sites surveyed, small number of drugs evaluat- related investigations into criminal activity that resulted in ed, and the speed at which Internet pharmacies are expand- 36 arrests and 17 convictions, and 49 sites have received ing their services. Although there are more than 600 Inter- regulatory action.4 The FDA maintains a list of products
net pharmacies, other common US Web sites associated sorted by country or product that do not meet FDA regula- with community stores for purchasing medications that tions in the US.14 Plans have been announced by the Clin-
were not in our survey include walgreens.com, wal-mart.
ton administration that all Internet pharmacy sites must be com, and www.drugemporium.com. The Internet pharma- approved by the FDA in order to operate.6
cies claim that they are cheaper and that the patient saves Another concern is that some online sites, such as www.
time by not having to wait for a prescription to be filled.
kwikmed.com, offer to have an online physician prescribe Special Contribution
popular drugs, such as Viagra, Propecia, and Xenical. It is References
very easy for the recipient to provide false information in 1. Consumer Union of U.S., Inc. Relief for the Rx blues. Consumer Rep an attempt to receive these drugs. Bloom and Iannacone3
reported finding 46 Web sites that sell prescription medica- 2. Posey M. Online pharmacies. PNN Pharmacotherapy Line 2000;7(73): tions to the public; 37 of these required a prescription and nine (not in the US) did not. This should be of great con- 3. Bloom B, Iannacone R. Internet availability of prescription pharmaceuti- cals to the public. Ann Intern Med 1999;131:830-3.
cern to healthcare practitioners, because although these 4. Lueck S. FDA seeks more power to regulate Net drugs. Available at: sites offer limited drugs at the moment, a shift in market URL: http://www.zdnet.com/zdnn/stories/news/0,4586,2471844,00.html.
demand may encourage them to expand their business to 5. Landis NT. FTC zeros in on Internet health fraud. Am J Health Syst Patients and healthcare professionals should be aware of 6. Office of the Press Secretary. The Clinton administration unveils new the existence of Internet pharmacies and familiar with the initiative to protect consumers buying prescription drug products over process involved in obtaining a prescription. Advice about the Internet. Available at: URL: http://www.fda.gov/oc/buyonline/online-salespr.html. Accessed December 28, 1999.
buying online is available on the FDA’s Web page.15 Pa-
7. Green K. Marketing health care products on the Internet: a proposal for tients can verify that the Internet pharmacy they are using updated federal regulations. Am J Law Med 1998;24(2/3):365-86.
is VIPPS-certified (Verified Internet Pharmacy Practice 8. Henney J, Shuren JE, Nightingale SL, McGinnis TJ. Internet purchases of prescription drugs: buyer beware. Ann Intern Med 1999;131:861-2.
Sites).16 The National Association of Boards of Pharmacy
9. Ohliger PC. Online pharmacies — take heed! Drug Benefit Trends 2000; issues this seal of approval to Internet pharmacies consid- ered to be legitimate and compliant with the regulations 10. Foreman J. No one’s watching online druggists. Available at: URL: http:// that govern pharmacies. This is a voluntary program, how- www.boston.com/globe/search/stories/health/health sense/021599.htm.
Accessed February 15, 1999.
ever, not a regulatory program. In addition, the American 11. Gardner E. If this were a test, Drugstore.com would get a “C.” Available at: Pharmaceutical Association is working with Intel to create URL: http://www.iw/print/1999/04/12/news/19990412-drugstore.html.
a system that will indicate that pharmacists who work from the Internet have the appropriate credentials.17
12. Landis NT. Virtual pharmacies boast easy access, privacy safeguards.
“Ask your pharmacist — by E-mail”? Am J Health Syst Pharm 1999;56: Although purchasing medications from the Internet pro- vides many advantages, only people with Internet access 13. Ling CA. Guiding patients through the maze of drug information on the can benefit. The growing presence of Internet pharmacies Internet. Am J Health Syst Pharm 1999;56:212-3.
14. National Association of Boards of Pharmacy. VIPPS. Available at: URL: should motivate community pharmacists to foster more http://www.nabp.net/vipps/intro.asp. Accessed October 7, 1999.
personal relationships with patients by increasing educa- 15. US Food and Drug Administration. Buying medical products online.
tional programs, counseling, and disease state monitoring, Available at: URL: http://www.fda.gov/oc/buyonline. Accessed June 1, as patients will use the pharmacy that best fits their needs.
16. US Food and Drug Administration. Import detention reports for Oasis.
Available at: URL: http://www.fda.gov/ora/oasis/ora oasis det.html. Ac- Mary L Wagner MS PharmD, Associate Professor, Department of
Pharmacy Practice and Administration, College of Pharmacy, Rut- 17. Ukens C. Internet credentials coming for pharmacists. Drug Topics gers, The State University of New Jersey, Piscataway, NJ Janette Alonso PharmD, at time of writing, PharmD Student, Col-
lege of Pharmacy, Rutgers, The State University of New Jersey; now,
US Pharmacovigilance Specialist, Aventis Pharmaceuticals, Par-
sippany, NJ
Allana J Mehlhorn PharmD, at time of writing, PharmD Student,
College of Pharmacy, Rutgers, The State University of New Jersey;
now, Pharmacy Practice Resident, Mayo Clinic, Saint Mary’s Hos-
pital, Rochester, MN
Reprints: Mary L Wagner MS PharmD, College of Pharmacy, Rut-
gers, The State University of New Jersey, 160 Frelinghuysen Rd.,
Piscataway, NJ 08854-8020, FAX 732/445-2533, E-mail mwagner@
cop.rutgers.edu

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