Doctors perceptions of the influences on their prescribing: a comparison of general practitioners based in rural and urban Australia

Investigating general medication prescription by general practitioners during a 12-month randomized controlled weight loss trial

Much healthcare expenditure is on pharmaceutical drugs. Expenditure on medications has increased both in absolute terms, and as a proportion of total health expenditure. No previous studies have investigated the prescribing costs by general practitioners when managing patients during a weight loss intervention. This study evaluated the medication costs by individual class during a 1-year study in which 268 participants were randomized to one of two weight loss programmes, either standard care (SC) as defined by national guidelines, or a commercial provider (Weight Watchers) (CP). The baseline body mass index of participants (mean ± standard deviation) was 32.0 ± 2.5 kg m^-2 , their body weight was 87.5 ± 11.8 kg, and age 47.4 ± 11.7 years. Weight loss for the SC and CP groups was -2.6 and -6.1 kg, respectively (between group difference; P < 0.0001). The greater weight loss in the CP group compared to SC was accompanied by larger reductions in waist circumference and fat mass. The CP group also had significantly greater improvements than SC in high-density lipoprotein cholesterol. Despite SC participants being prescribed and spending more on medications than the CP group with no better weight or metabolic outcomes, this was not of statistical significance. For both groups the highest proportion of prescriptions (≥30% of medications) was for control of risk factors for cardiovascular disease. In conclusion, this study indicates that obesity treatment via a shared care approach with a CP results in greater weight loss and some better clinical outcomes, but despite lower medication costs overall, this was not significant when compared to SC treatment.

Urban-rural differences in the uptake of new oral bisphosphonate formulations

We identified significantly slower uptake, and consistently lower proportions of new oral bisphosphonate formulations dispensed in rural regions compared to urban regions of Ontario. Further research examining regional differences in outcomes may provide insight as to whether urban-rural differences in prescribing translate into health disparities between regions.

PURPOSE

The aim of this study was to examine urban-rural differences in the uptake of new oral bisphosphonate formulations available on the Ontario drug formulary: alendronate + vitamin D3 (January 2007), monthly risedronate (June 2009), and risedronate delayed-release (February 2012).

METHODS

We plotted the monthly proportion of new formulation claims of all claims with the same drug molecule, from their formulary listing date until March 2014. Results were stratified by major urban, nonmajor urban, and rural regions as defined by the Rurality Index of Ontario. We compared the rate of uptake over the first year of formulary availability using linear regression, and compared proportions dispensed between regions using chi-squared tests.

RESULTS

We identified a regional gradient in uptake for alendronate + vitamin D3 and monthly risedronate; major urban regions had the fastest uptake, followed by nonmajor urban regions, and rural regions had the slowest uptake. Rural regions also had the slowest uptake of risedronate delayed-release; however, uptake in major urban and nonmajor urban regions were similar. Rural regions dispensed the lowest proportions for all new formulations 1 year after formulary availability: alendronate + vitamin D3 (32% major urban, 23% nonmajor urban, 12% rural), monthly risedronate (26% major urban, 21% nonmajor urban, 16% rural), and risedronate delayed-release (21% major urban, 22 % nonmajor urban, 13% rural). This pattern persisted throughout our study.

CONCLUSION

We identified significantly slower uptake and lower proportions of new formulations dispensed in rural regions compared to urban regions. Further research examining regional differences in outcomes may demonstrate whether urban-rural differences in prescribing translate into health disparities between regions.

Why is the use of clopidogrel increasing rapidly in Australia? An exploration of geographical location, age, sex and cardiac stenting rates as possible influences on clopidogrel use

PURPOSE

To explore clopidogrel use within Australia, investigating geography, age, sex and cardiac stenting rates.

METHODS

Data for clopidogrel supply (Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS)) and cardiac stenting procedures (State Health Departments) were obtained for four different geographic regions (very remote/remote and major city in two Australian states). General linear modelling and correlation analyses were used to test for associations and chi2 analyses for proportions.

RESULTS

Clopidogrel supply increased rapidly in Australia since introduction, from 1.2 to 9.0 Defined Daily Doses (DDD)/1000 population/day. Among concessional and veteran populations use was much higher. Analysis of geographical area data confirmed an association between clopidogrel supply rates and cardiac stenting rates (r = 0.8-0.9 Spearman's rho, p < 0.01). Sex, age and geographical location were associated with both rates when considered together and when considered independently. Further modelling indicated that between 30 and 73% of clopidogrel supply could be accounted for by people receiving cardiac stents.

CONCLUSIONS

The supply of clopidogrel increases with age, male sex and living in a major city. These same demographic variables were important for cardiac stenting, an indication which is currently not approved for subsidy by the Australian government, but which modelling indicated could account for between one-third and three quarters of clopidogrel use. A review may be required to ensure subsidised indications reflect current evidence and cost-effective use.

Hospital doctors' views of factors influencing their prescribing

RATIONALE, AIM AND OBJECTIVE

Factors influencing doctors in prescribing of drugs have mostly been studied in primary care. Studies performed in hospital care have primarily focused on new drugs, not prescribing in general. An in-depth understanding of the prescribing process in the more specialized secondary care is not only important for secondary care itself, but because it also influences prescribing in primary care. The aim of this study is therefore to identify factors that secondary care doctors believe influence them in prescribing drugs, using a qualitative approach.

METHOD

Semi-structured interviews were conducted with 15 hospital doctors in different medical specialities and the interviews were analysed from an interpretivist perspective. The information gathered was on how prescribing decisions were made in general and how the doctors chose a specific drug therapy, including information sources used.

RESULTS

According to our interviews, the hospital doctors took patient-specific factors and cost into consideration when prescribing, informed by different written information sources and commercial verbal information. Personal practice, colleagues and therapeutic tradition at the hospital or clinic, were influential in the prescribing of drugs. The themes identified should not to be seen as individual influences; many of them probably act in combination.

CONCLUSIONS

If changes in prescribing behaviour are desired, factors warranting more attention include understanding how to influence therapeutic traditions and the doctor's personal habits for prescribing. The importance of clinical experience and information exchange with colleagues should not be underestimated in providing information about drugs to hospital doctors.

Respiratory symptoms/diseases, impaired lung function, and drug use in two Italian general population samples

BACKGROUND

Research and practice indicate that a sizeable amount of prescribed drugs is never used.

AIM

To assess the habitual up-take of medicines in subjects with respiratory symptoms/diseases or impaired lung function in general population samples.

METHODS

Data regard 4010 subjects (8-88 years) from the rural area of Po River Delta (North Italy) and the urban area of Pisa (North-Central Italy). Analyses concern the habitual use of any or specific medicines (broncho-pulmonary, anti-allergic, cardio-vascular, diuretic) in subjects with asthma, chronic bronchitis/emphysema (COPD), COPD or chronic cough/phlegm (COPDsx), and airways obstruction (AO, FEV(1)/FVC<70%).

RESULTS

Asthma, COPD, COPDsx, and AO were present in 6%, 5%, 21%, and 13% of cases, respectively. Only 37% and 21% of subjects with respiratory symptoms/diseases used any or specific medicines, respectively. The subjects with COPD exhibited the highest prevalence of assumption (59% for any drug, 38% for specific medicines), followed by asthmatics (42% and 30%), and subjects with AO (40% and 25%). After accounting for sex, age, residence area, smoking habit, education, and presence of comorbidity, the conditions significantly related to any medicine up-take were COPD (OR 1.65, 95% CI 1.08-2.53) and asthma (OR 1.47, 95% CI 1.01-2.12). Only asthma resulted significantly associated with the use of specific drugs (OR 3.11, 95% CI 1.94-4.97). Drug use was higher in the urban than in the rural area.

CONCLUSION

The results indicate that most people in the general population do not use drugs, in spite of reported respiratory disorders. The underuse of medicines seems lower in the urban area.

Motivations and perceived influences on rural and urban general practitioners when prescribing conventional non-steroidal anti-inflammatory drugs or COX-2 inhibitors

BACKGROUND AND OBJECTIVE

Prescribers in rural and remote locations perceive that there are different influences on their prescribing compared with those experienced by urban prescribers. The aim of this study was to compare the motivations and perceived influences on general practitioners (GPs) when prescribing COX-2 inhibitors rather than conventional non-steroidal anti-inflammatory drugs (NSAIDs) between rural and urban-based GPs in Queensland, Australia.

METHODS

A questionnaire was administered to two geographically distinct groups of GPs, one urban (n=67) and one rural (n=67), investigating the reasons that the GP would prescribe a COX-2 inhibitor rather than a conventional NSAID or vice versa and also focusing on patients requesting a prescription for a COX-2 inhibitor.

RESULTS AND DISCUSSION

A 51% response rate (n=68) was achieved. The difference between the rural and the urban GPs was that the urban GPs were more likely to perceive that they were influenced to prescribe COX-2 inhibitors by their patients' knowledge of these new (at the time) drugs. GPs in both the rural and urban areas perceived the COX-2 selective inhibitors to be safer than conventional NSAIDs, and that there was little difference in terms of efficacy between the two drug classes. However, GPs from both of the study areas stated that conventional NSAIDs were preferred over COX-2 selective inhibitors, primarily due to their expense, if their patients were not at risk for developing a GI bleed.

CONCLUSION

The motivations and perceived influences to prescribe a COX-2 inhibitor in rural and in urban areas of Queensland, Australia were very similar. Almost all surveyed GPs in rural and urban areas had patients request a prescription, or enquire about the COX-2 inhibitors. Urban GPs were more likely to feel pressured to prescribe a COX-2 inhibitor than their rural counterparts, agreeing with other research which found that patient pressure to prescribe appears to be greater in urban general practice.

Changes in prevalence of and prescribing for Ischaemic heart disease in Ireland 1990–2002

BACKGROUND

Secondary prevention therapies, such as angiotension converting enzyme (ACE) inhibitors, beta-blockers and statins, are known to reduce cardiovascular morbidity and mortality.

OBJECTIVE

The aim of the study was to examine the prevalence of coronary heart disease (CHD) and the prescribing of secondary preventive therapies in the period 1990-2002.

METHODS

The General Medical Services prescription database was used to identify the study cohort, those with CHD, in each year 1990-2002. CHD was defined in two ways: prescription of any nitrate, and co-prescription of nitrate and aspirin. In addition, co-prescription of secondary preventive agents including statins, ACE inhibitors and beta blockers were examined.

RESULTS

We found a significant increasing prevalence of CHD from 1990 to 2002 in both men and women. There was a significant increase (p < 0.0001) in the prescribing rate for beta blockers, ACE inhibitors, and for statins, buta significant decrease (p < 0.0001) for calcium channel blockers.

CONCLUSION

These trends reflect the growing evidence base on the effectiveness of secondary preventive therapies, and the implementation of the National Cardiovascular Health Strategy.

Original Article. Do rural consumers expect a prescription from their GP visit? Investigation of patients' expectations for a prescription and doctors' prescribing decisions in rural Australia

OBJECTIVE

To assess patients' expectation for receiving a prescription and GPs' perceptions of patient expectation for a prescription.

DESIGN

Matched questionnaire study completed by patients and GPs.

SETTING

Seven general practices in rural Queensland, Australia.

SUBJECTS

The subjects were 481 patients consulting 17 GPs.

MAIN OUTCOME MEASURES

Patients' expectation for receiving a prescription and GPs' perceptions of patients' expectation.

RESULTS

Ideal expectation (hope) for a prescription was expressed by 57% (274/481) of patients. Sixty-six per cent (313/481) thought it was likely that the doctor would actually give them a prescription. Doctors accurately predicted hope or lack of hope for a prescription in 65% (314/481) of consultations, but were inaccurate in 19% (93/481). A prescription was written in 55% of consultations. No increase in patients' expectation, doctors' perceptions of expectation, or decision to prescribe were detected for patients living a greater distance from the doctors.

CONCLUSIONS

Rural patients demonstrated similar rates of hope for a prescription to those found in previous urban studies. Rural doctors seem to be similarly 'accurate' and 'inaccurate' in determining patients' expectations. Rates of prescribing were comparable to urban rates. Distance was not found to increase the level of patient expectation, affect the doctors' perception or to influence the decision to prescribe.

Uptake of new drugs in rural and urban areas of Queensland, Australia: the example of COX-2 inhibitors

OBJECTIVE

This study compared the changes over time in the volume of prescriptions of COX-2 selective inhibitors between rural and urban Queensland to reveal any difference in the uptake of the prescribing of these new drugs between two geographically distinct areas.

METHODS

This study used data from an administrative claims database. Dispensing data were obtained for celecoxib and rofecoxib in two areas, one rural and one urban, defined by postcodes. The numbers of consumers in these areas were similar and they were served by similar numbers of general practitioners. The number of defined daily doses (DDDs) of celecoxib and rofecoxib dispensed at specific times was calculated.

RESULTS

Statistical analysis revealed no significant difference between the total numbers of DDDs of COX-2-selective non-steroidal anti-inflammatory drugs dispensed in the rural and urban groups over the period August 2000 to December 2002 (P=0.81). The rate of uptake of usage was also clearly similar between the urban and the rural groups. Total usage peaked in August 2000 in both groups (urban 39 DDD/1,000 people per day; rural 37 DDD/1,000 people per day), coinciding with the pharmaceutical benefits scheme (subsidized) listing of celecoxib. The number of DDDs declined dramatically in the following month, and then peaked again in May 2002 (urban 34, rural 36). The number of DDDs then steadily decreased in both areas after October 2002.

CONCLUSION

The results suggest that the marketing of the new COX-2 inhibitors and the patients' anticipation of a safe and effective treatment have overcome the geographical boundaries of Queensland. Both areas had very high rates of uptake of the prescribing of these new drugs.