Review of literature on the factors affecting drug prescribing

Key factors influencing the prescribing of statins: a qualitative study among physicians working in primary healthcare facilities in Indonesia

OBJECTIVES

To elicit key factors influencing physicians' decision to prescribe statins.

DESIGN

A qualitative study using a phenomenological approach within a pragmatism interpretive framework. A combination of purposive and snowball sampling was used to recruit physicians. Data were collected through face-to-face, semistructured interviews with physicians working in primary healthcare facilities in a capital of a province in Indonesia. We recorded and verbatim transcribed the interviews. Coding was done independently by two researchers and data were analysed using phenomenological data analyses. Key factors influencing physicians' decision to prescribe statins were classified into factors at the microlevels, mesolevels and macrolevels according to the structural model by Scoggins et al. PARTICIPANTS AND SETTING: Physicians working in primary healthcare facilities in a capital of a province in Indonesia.

RESULTS

Ten physicians were included in the study. Key factors at the microlevel were that physicians knew guidelines in general, but there was uncertainty how to take into account the level of total cholesterol in combination with other cardiovascular risk factors such as diabetes and hypertension. At the macrolevel, the new National Health Insurance System (NHIS) that appeared to facilitate the prescription of statins though more clinical information should be integrated in the system's platform to support appropriate prescribing.

CONCLUSIONS

The findings indicate lack of awareness of specific details in current guideline recommendations. Appropriate prescribing of statins should be enhanced using the new NHIS.

Social and Behavioral Theories and Physician’s Prescription Behavior

The efficacy, safety, and cost of medication are the major concerns for a patient; thus, this research addresses factors that influence the physician’s prescription behavior. The objective of the undertaken study is the empirical testing of a novel conceptual model that was newly developed by the previous literature, which is based on behavioral and social theories. The considered model explains the association between marketing efforts, pharmacist factors, patient characteristics, and the physician’s decision to prescribe a drug. This unique model also includes the influence of cost and benefit ratio, drug characteristics, physician’s persistence, and trustworthiness as moderating variables. This model is useful for analyzing the prospects of marketing. We have collected 984 physicians’ responses from the urban centers of Pakistan through a structured questionnaire. We have used Structural equation modelling (SEM) based multivariate techniques such as exploratory and confirmatory factor analysis, and conditional process modelling to explore the direct and indirect relationship amongst the exogenous, moderating, and endogenous variables. The findings of the study demonstrated that marketing efforts, patient’s characteristics, and pharmacist factors have a positive and significant influence on the physician’s decision to prescribe medicines. The moderation analysis exhibited the significant effect of drug characteristics, cost–benefit ratio, physician’s persistence, and trustworthiness in a relationship between exogenous and endogenous variables. The results of the undertaken study are helpful for the marketers of the pharmaceutical industry to save wasteful marketing expenditures for the product portfolios, and measured variables may help to make meaningful marketing strategies for the physician’s prescription that provide optimum Returns on Investment (ROI) of their investments.

Two decades of off-label prescribing in children: a literature review

BACKGROUND

In the past two decades, many legislative and regulatory initiatives were taken globally to improve drug use in children. However, children are still found to be prescribed with off-label drugs. This study was conducted to provide an overview of the worldwide trend in off-label prescribing in children from the year 1996 to 2016.

DATA SOURCES

The articles published in PubMed, MEDLINE and Google Scholar were searched using text words: off-label, unlicensed, paediatric and children. Additional articles were identified by reviewing the bibliography of the retrieved articles. Full-text articles published in English which reported on the prevalence of off-label prescribing in children between January 1996 and December 2016 were included.

RESULTS

A total of 101 studies met the inclusion criteria. Off-label prescribing definition included four main categories: age, indication, dose and route of administration. The three most common reference sources used in the studies were summary of product characteristics, national formularies and package inserts. Overall, the off-label prescribing rates in children ranged from 1.2 to 99.7%. The most common category of off-label prescribing in children was dose and age.

CONCLUSIONS

This review highlighted that off-label prescribing in children was found to be highly prevalent throughout the past two decades, persistently in the neonatal intensive care units. This suggests that besides legislative and regulatory initiatives, behavioural, knowledge aspects and efforts to integrate evidence into practice related to off-label prescribing also need to be evaluated and consolidated as part of the concerted efforts to narrow the gaps in prescribing for children.

Physicians’ relationship with the pharmaceutical industry and its reflection in introduction of a new drug

Purpose

This study aims to examine the attitudes of physicians towards the pharmaceutical industry and investigates how these are reflected when a new drug is introduced.

Design/methodology/approach

The qualitative theme-interview study adopts the innovation diffusion perspective and is conducted with 22 general practitioners and specialists.

Findings

Physicians’ positive relationship orientation and active interaction can result in early adoption of new drugs with product advantage. In comparison, negatively oriented and passively interacting physicians will adopt a new drug later based on research evidence- and experience-based reasoning and opinions of their colleagues.

Research limitations/implications

The objective was to obtain a deeper understanding of the research themes. Further qualitative studies in different countries and health care environments with a larger sample size would improve generalizability of results.

Practical implications

It’s necessary to find an optimal win – win situation that fulfils both parties’ needs, while decreasing unnecessary and time-consuming marketing activities and avoiding waste of limited resources and allowing physicians to participate in activities that better serve their primary needs. Managers in pharmaceutical companies should ensure their sales representatives act in appropriate and professional ways, interact openly and reciprocally and provide accurate and objective information.

Originality/value

The study demonstrates that the physician–pharmaceutical industry relationship has developed from being ethically precarious and having non-professional related personal benefits, towards becoming a more sustainable collaboration. The mutually beneficial collaboration supports physicians’ professional development, enabling better patient care and relieving strain on limited resources.

Models and theories of prescribing decisions: A review and suggested a new model

To date, research on the prescribing decisions of physician lacks sound theoretical foundations. In fact, drug prescribing by doctors is a complex phenomenon influenced by various factors. Most of the existing studies in the area of drug prescription explain the process of decision-making by physicians via the exploratory approach rather than theoretical. Therefore, this review is an attempt to suggest a value conceptual model that explains the theoretical linkages existing between marketing efforts, patient and pharmacist and physician decision to prescribe the drugs. The paper follows an inclusive review approach and applies the previous theoretical models of prescribing behaviour to identify the relational factors. More specifically, the report identifies and uses several valuable perspectives such as the ‘persuasion theory - elaboration likelihood model’, the stimuli–response marketing model’, the ‘agency theory’, the theory of planned behaviour,’ and ‘social power theory,’ in developing an innovative conceptual paradigm. Based on the combination of existing methods and previous models, this paper suggests a new conceptual model of the physician decision-making process. This unique model has the potential for use in further research.

Improving Use of Medicines

In 1994 the Government of Delhi (India) implemented an essential medicines policy in public health facilities (HF) to improve the availability and rational use of medicines (RUM). An essential medicines list (EML) was made. Training programmes in RUM were initiated. After 13 years the outcome of the policy on RUM within public HF was evaluated.

 Policy implementation improved the availability of medicines to 91.4 per cent. Prescribing of medicines from EML increased (94.6 per cent) and antimicrobials declined (51.7 per cent). The number of patients with complete knowledge of how to take prescribed medicines improved (53.4 per cent). However, the use of generic medicines declined (18.1 per cent) and prescriptions were mostly incomplete (79.6 percent).

 Majority of prescribers lacked awareness about the Drug Policy, including not having undergone training sessions on RUM. There were no Drugs and Therapeutic Committees within HF, and only a few doctors had information about medicines available within the HF. The most common sources of information for medicines were commercial published sources and medical representatives of pharmaceutical companies.

 The regulatory intervention of enforcing an EML in public HF has been successful in increasing the use of medicines from the EML and improving some prescribing indicators. However, educational interventions have been inadequate and need to be combined and strengthened to improve the policy outcomes in RUM.

Socioeconomic factors influencing antipsychotic prescription for schizophrenia inpatients in China: a cross-sectional study

Medication is critical in schizophrenia therapy, and prescription patterns have changed considerably over the past 20 years in China. This study attempts to evaluate the prescription patterns of antipsychotics for inpatients with schizophrenia in China and to identify factors influencing these patterns. Claims data of inpatients diagnosed with schizophrenia in 2010 were derived from the reimbursement database of Wuhan and Wuxi. A total of 5251 inpatients received antipsychotic medications, of whom 29.0% received second-generation antipsychotics apart from clozapine (SGAs#), 13.7% received clozapine (CLO), 13.5% received first-generation antipsychotics (FGAs), 43.8% received at least both drug classes, and 5.1% used FGAs, CLO as well as SGAs#. Multinomial logistic regression for 2904 identified inpatients showed that factors of drug reimbursement policy, duration of hospitalization, age group, and municipality were statistically significant in antipsychotic medication. Drug list B and the 25-45 age group presented a significant relationship with SGAs# prescription (FGAs vs. SGAs#). Furthermore, the 12-30-day duration of hospitalization and the 25-45 age group showed a significant relationship with SGAs# prescription (CLO vs. SGAs#). Socioeconomic factors such as health insurance policies, especially reimbursement policy of drugs and payment system, as well as mental health resource distribution are important in antipsychotic prescription in China.

Factors associated with physicians' prescribing behavior for treatment of influenza in the USA

Purpose

– The aim of this paper is to identify factors (i.e. age, gender, ethnicity, type of medical facility, geographical location, etc.) associated with physicians' prescribing behavior when treating influenza in the USA. The study aims to examine why the number of antiviral prescriptions remains substandard.

Design/methodology/approach

– Data were obtained from the National Ambulatory Medical Care Survey for each influenza season between the years of 2005-2008. Bivariate analyses and two models of multivariate logistic regression analyses (one with no fixed effect and the other including year as a fixed effect) were used to analyze the data.

Findings

– The results from this study revealed that among family practice physicians, 40.5 percent prescribed antiviral medications to patients presenting with influenza while 59.5 percent prescribed another form of medication. Antibiotics comprised 41.3 percent of the prescriptions for treatment of influenza. Multivariable logistic regression analyses revealed that race (White; p=0.023), type of health setting (private solo/group practice; p=0.041), employment status (owner; p=0.046), and metropolitan location (metropolitan statistical area; p=0.032) were all significantly associated with prescribing antivirals. Patients' expected source of payment (private insurance) and geographical location (Midwest) of health facility were marginally associated with prescribing antivirals.

Originality/value

– By identifying factors associated with physicians' prescribing practices of antiviral medications, a more timely diagnosis and treatment of influenza can occur. Efforts should be targeted to improve physician education and awareness of the illness. Interventions may be implemented to improve the prescribing of antiviral medications and potentially inappropriate prescribing.

Does managed care affect the diffusion of psychotropic medications?

Newer technologies to treat many mental illnesses have shown substantial heterogeneity in diffusion rates across states. In this paper, I investigate whether variation in the level of managed care penetration is associated with changes in state-level diffusion of three newer classes of psychotropic medications in fee-for-service Medicaid programs from 1991 to 2005. Three different types of managed care programs are examined: capitated managed care, any type of managed care and behavioral health carve-outs. A fourth-order polynomial fixed effect regression model is used to model the diffusion path of newer antidepressant and antipsychotic medications controlling for time-varying state characteristics. Substantial differences are found in the diffusion paths by the degree of managed care use in each state Medicaid program. The largest effect is seen through spillover effects of capitated managed care programs; states with greater capitated managed care have greater initial shares of newer psychotropic medications. The influence of carve-outs and of all types of managed care combined on the diffusion path was modest.

The role of computerized decision support in reducing errors in selecting medicines for prescription: narrative review

This narrative review includes a summary of research examining prescribing errors, prescription decision making and the role computerized decision support plays in this decision-making process. A reduction in medication prescribing errors, specifically a reduction in the selection of inappropriate medications, is expected to result from the implementation of an effective computerized decision support system. Previous research has investigated the impact of the implementation of electronic systems on medication errors more broadly. This review examines the specific characteristics of decision support systems that may contribute to fewer knowledge-based mistakes in prescribing, and critically appraises the large volume of information available on the decision-making process of selecting medicines for prescription. The results highlight a need for work investigating what decision strategies are used by doctors with different levels of expertise in the prescribing of medications. The nature of the relationship between decision support and decision performance is not well understood and future research is needed to determine the mechanisms by which computerized decision support influences medication selection.

A national cross-sectional study on socio-behavioural factors that influence physicians' decisions to begin antimicrobial therapy

PURPOSE

Current efforts to prevent antimicrobial resistance include limiting antimicrobial use, providing education about appropriate use, and developing better point-of-care tests, but what do physicians actually think of rational prescribing and potential interventions? We tried to ascertain which factors can influence a physician's decision to start antimicrobial therapy on a patient, and their opinions on measures to promote rational prescribing.

METHODS

We conducted a nationwide, cross-sectional survey of 10,600 physicians from medical registries of all known board-certified physicians in Germany.

RESULTS

Among respondents (n = 3,492; 33%; detailed non-response bias analysis included), 90% indicated that they decide to start antimicrobial therapy on a patient at least weekly, and 66% reported that they decide daily. We identified correlates for deciding to start antimicrobial therapy on a patient. Predictors were status as a hospital physician (odds ratio (OR) 1.29 (95% confidence interval (CI) 1.00-1.68)), male physician (OR 1.81 (95% CI 1.42-2.31)), being age 50-59 (OR 1.56 (95% CI 1.10-2.21)), and practising in states in the former East Germany (OR 1.60 (95% CI 1.15-2.21)). Each specialist was significantly less likely to decide to start a course of antimicrobial therapy than ENTs and urologists. Other predictors were agreeing to prescribe to be on the safe side (OR 1.34 (95% CI 1.03-1.76)), believing that the quality of prescribing practice improves after receiving continuing education from pharmaceutical companies (OR 1.43 (95% CI 1.11-1.84)), and having experience with failed therapy for resistant pathogens (OR 2.42 (95% CI 1.83-3.19)).

CONCLUSIONS

Physicians in our sample decide to start antimicrobial therapy on a patient, and they value intervention to support prudent use, for example continuing education, practice guidelines and implementation of surveillance measures. Socio-behavioural factors, regional variation, gender, and age merit further research to promote rational antimicrobial prescribing and explore related influencing factors.

General medical practitioners' perceived use of drug information sources with special reference to drug information centres

This study reports the current perceived use of available sources of drug information for general medical practitioners. The sample frame, of 463 GPs practising in Derbyshire, England, on January 1, 1990, provided a 74 per cent response rate to a pre-piloted questionnaire. Two printed sources, the Monthly Index of Medical Specialities and the British National Formulary (BNF) plus one personal service, fellow colleagues, were by far the most frequently used. The estimated average minimum number of days per year on which personal information services were consulted was 28.51 days compared with 63.83 days for non-personal, printed sources. Thus, if GPs are to be guided by independent sources then the BNF must be considered a prime vehicle. Drug information centres (DICs) were ranked last with 56 per cent of GPs having consulted such a source within the previous year. Use of DICs could not be predicted from GPs' characteristics or demographic data. Interviews with 101 of 106 randomly selected GPs generally confirmed questionnaire findings. However, only 41 per cent perceived themselves as users of DICs. Collation of queries from two local centres showed 25 per cent were known to be users. From interviews, discrepancies were seen to arise from accessing DICs outside the sample frame boundary plus confusion of DICs with poisons centres and hospital pharmacy departments. Thus, for use of DICs, questionnaire techniques may be unreliable unless source definition is considered. If using DICs, GPs very significantly had lower concurrent use of community pharmacists, GP colleagues and hospital consultants for general drug information

Biases in medication prescribing: the case of second-generation antipsychotics

The shift from first-generation antipsychotic medications to second-generation antipsychotic medications initially caused a wave of excitement about the potential for improved and broader efficacy of these medications concurrent with an improved side-effect profile. Recent data from high-quality research analyses have subsequently raised significant questions about these claims. This research evidence has, however, not altered prescribing behavior in a way that would be expected from fully rational evaluation of the evidence. Prescribing decisions represent poorly understood, complex behaviors influenced by a number of external and internal forces, some of which may be elucidated by advances in social and cognitive psychology. In this article, the decision to prescribe first- versus second-generation antipsychotic medications is examined, and specific social psychological biases and individual cognitive biases are hypothesized to be significant influences on clinicians. These biases may perpetuate disparity between research evidence and clinical practice.

Variations in anxiolytic and hypnotic prescribing by GPs: a cross-sectional analysis using data from the UK Quality and Outcomes Framework

BACKGROUND

Wide variations in anxiolytic and hypnotic prescribing by GPs in England have been described, but are largely unexplained.

AIM

To examine the relationships between the volume of anxiolytics and hypnotics prescribed by GPs and their practice characteristics, population demography, and performance indicators.

DESIGN OF STUDY

Cross-sectional study.

SETTING

All general practices in England.

METHODS

A dataset was constructed for 8469 (98.8%) general practices including: standardised prescribing volume data for anxiolytics and hypnotics (average daily quantities per 1000 STAR-PUs [Specific Therapeutic group Age-sex weightings Related Prescribing Units]), practice descriptors, Index of Multiple Deprivation 2004, ethnicity data (2001 UK Census), and Quality and Outcomes Framework (QOF) data.

RESULTS

The standardised volume of anxiolytics and hypnotics prescribed varied eightfold between practices on the 5th and 95th centiles. A regression model was constructed which explained 20.5% of the variation. Higher prescribing practices were located in more deprived areas (standardised beta 0.31), but also in areas with a lower proportion of ethnic minorities (black or black British = -0.22; Asian or Asian British = -0.12). Higher volumes were also prescribed by practices with lower QOF scores ('Clinical Care' domain = -0.12; 'Organisational' domain = -0.08). Other significant but weaker predictors were: lower proportions of female GPs, higher recorded prevalence of serious mental illness and non-training status. The proportion of GPs trained outside UK was not a predictor.

CONCLUSION

Demographic factors were more powerful determinants of prescribing than characteristics of the practice itself. Nevertheless, the findings provide some support for the notion that high prescribing practices were less well developed, in that their QOF scores were lower and they were less likely to be training practices.

The importance of context in malaria diagnosis and treatment decisions - a quantitative analysis of observed clinical encounters in Tanzania

OBJECTIVE

To gain a better understanding of the decision-making context in the diagnosis of malaria in order to inform behaviour change strategies, using quantitative methods.

METHODS

We observed hospital outpatient and inpatient consultations in northeast Tanzania where malaria testing was routinely available, recording potential influences on testing and prescribing decisions. We analysed the effects of variables at patient, clinical context and clinician levels on three key decisions in malaria diagnosis and treatment: decision to test for malaria, presumptive treatment and treatment of test-negative patients with antimalarials.

RESULTS

Observation of 2082 consultations took place during 120 clinics (different shifts on different days and in different departments) with 34 clinicians. Malaria tests were requested for 16.9% of patients. This decision was driven primarily by clinical symptoms. Of patients not tested for malaria, 36.0% were prescribed antimalarials, this decision being associated with both clinical and non-clinical factors. In outpatients fever was a strong predictor of presumptive treatment [adjusted odds ratio (AOR): 45.9, 95% CI: 30-73], in inpatients this was less so (AOR: 2.7, 95% CI: 0.98-7.7). Outpatient clinicians who were working alone or who had attended <2 in-service training sessions in the past year were more likely to prescribe antimalarials presumptively. The decision to prescribe antimalarials without also prescribing antibiotic treatment to 22.8% patients who tested negative for malaria was not driven by clinical symptoms but was associated with age over 5 years, lower patient load and male sex of clinician.

CONCLUSIONS

Non-clinical factors are important in the overdiagnosis of malaria. Strategies to target antimalarials and antibiotics better need to use methods that address the context of clinical decision making in addition to the dissemination of conventional clinical algorithms.

Development of a rational antibiotic usage course for dentists

AIM

The aims of this report are to describe the development process of this rational antibiotic usage course and to evaluate the short-term efficiency of the course in terms of the level of improvement in knowledge and feedbacks of the participants.

MATERIALS AND METHODS

A needs assessment survey was carried out on the curriculum development process in order to determine the patterns of drug usage and level of knowledge on antibiotics of potential participants. A total of 162 dentists from two dental hospitals in Izmir were interviewed using standard questionnaires. The course content and educational strategies were determined according to the needs assessment results. Fifty-eight dentists applied to the first three courses conducted between 2002 and 2004. Pre/post-test design was performed for level of improvement in knowledge and a questionnaire form, scored by Likert Scale with 5 point, was used for participants' feedback.

RESULTS

The mean score, which was 9.74 +/- 2.71 in pre-test, increased to 18.16 +/- 1.58 in post-test and the difference was significant (t = -28.805; P = 0.000). The knowledge and approach of the trainers was appreciated most of all. Participants enjoyed the course very much, and reported a high level of satisfaction regarding the content, trainers, educational techniques and teaching material. The suggestions for future courses included increasing the course length (21.2%). Results from the needs assessment survey revealed that the study population over-used antibiotics, relied on incorrect sources of information, was unaware of the results of irrational antibiotic usage and did not check sufficiently with patients before prescribing.

CONCLUSIONS

These findings supported the need for regular courses in the application of antibiotics in dental practice and continuous refreshment of knowledge.

Potentially inappropriate prescribing among Australian veterans and war widows/widowers

This study examined the extent of potentially inappropriate medicine, as defined by explicit criteria, dispensed to Australian veterans using the Repatriation Pharmaceutical Benefits Scheme Pharmacy Claims database. Twenty-one per cent of the 192,363 veterans aged 70 years, with an eligible gold card, were dispensed at least one potentially inappropriate medicine in the first 6 months of 2005. Long-acting benzodiazepines, amitriptyline, amiodarone, oxybutynin and doxepin were the medicines most commonly implicated. Strategies to support quality prescribing of medicines to the elderly must include a focus on these medicines.

The role of etiquette and experimentation in explaining how doctors change behaviour: a qualitative study

Despite increasing interest over the last 30 years in individual variations in clinical practice, various research studies have thrown only limited light on either understanding or changing doctors' behaviour. This qualitative study explored a sample of British general practitioners' accounts of the influences on their prescribing, and identified the locus of the problem in their defence of professional identity through clinical autonomy, a tactic that precluded use of more customary change agents such as line management and economic incentives. The study identified two mechanisms, clinical etiquette and clinical experimentation, however, that enabled change to occur within the constraints imposed by the commitment to clinical autonomy.

Excessive and disproportionate advertising in peer-reviewed journals

The International Committee of Medical Journal Editors (ICMJE) has outlined ethical guidelines concerning the advertising practices of peer-reviewed journals that briefly discuss issues of excessive and disproportionate advertising. The authors evaluated these guidelines using quantitative data, assessing the types and frequencies of advertising in 2001 print issues of NEJM and JAMA, two principal members of ICMJE. Advertising ratios (ratio of advertisements to editorial content) were near unity in NEJM and 0.30 in JAMA, compared with reported ratios of 0.15 among low-circulation specialty science journals and 0.80 among high-circulation consumer magazines. In both journals, five corporations placed more than 50% of all display advertisements. The findings suggest a dissonance between the ethical guidelines and the de facto advertising practices of arguably the two most important member journals of the ICMJE. There is a need to define and apply standards for excessive and disproportionate advertising.

Gifts to physicians from the pharmaceutical industry: an ethical analysis

Gifts to physicians by the pharmaceutical industry pose numerous ethical questions. Although individual patients and physicians may benefit financially and educationally from certain gifts, the risk of bias resulting from such gifts makes them ethically challenging. After a brief description of the nature and scope of the practice of gift giving, this article examines major arguments for and against this practice. We then review the development of guidelines by professional societies, trade organizations, and government agencies. We conclude with a list of summary recommendations designed to help individual physicians, educators, and administrators engage in careful reflection and analysis and make sound ethical decisions about acceptance of gifts.

Antibiotic use following a Korean national policy to prohibit medication dispensing by physicians

This study investigated whether a Korean national policy prohibiting doctors from dispensing drugs as of 2000 selectively reduced inappropriate antibiotic prescribing in viral illness compared with bacterial illness. We assessed the proportions of episodes prescribed an antibiotic and the number of different antibiotics prescribed for patients with viral and bacterial illness episodes before and after the policy. The nationally representative sample consisted of 50,999 episodes (18,656 viral and 7758 bacterial pre-policy, 16,736 viral and 7849 bacterial post-policy) from 1372 primary care clinics. We used generalized estimating equations to investigate changes in antibiotic prescribing after the policy, and multiple linear regression to determine provider factors associated with reductions in inappropriate antibiotic prescribing for viral illness. After the dispensing restriction, antibiotic prescribing declined substantially for patients with viral illness (from 80.8 to 72.8%, relative risk (RR) = 0.89, [95% confidence interval: 0.86, 0.91], p<0.001), and only minimally for patients with bacterial illness (from 91.6 to 89.7%, RR = 0.98, [0.97, 0.99], p = 0.017). Reductions in antibiotic prescribing were significantly larger (RR = 0.90, [0.87, 0.93], p<0.001) for patients with viral illness. The number of different antibiotics prescribed per episode also decreased significantly after the policy, but there were no significant differences in these reductions between viral and bacterial illness. The dispensing restriction also reduced prescribing of non-antibiotic drugs, with no difference by diagnosis. Provider factors found to be associated with reduced inappropriate antibiotic prescribing were younger age and practice location in an urban area. Prohibiting doctors from dispensing drugs reduced prescribing overall, both of antibiotics and other drugs, and selectively reduced inappropriate antibiotic prescribing in viral illness.

Exploring unexplained twofold differences in sales of cardiovascular drugs between two neighbouring Swedish municipalities

PURPOSE

To analyse sales data for cardiovascular drugs and to explore the long-standing unexplained inter-municipality differences in out-patient sales, especially for ACE inhibitors/angiotensin II antagonists (ATC-group C09) and statins (C10AA) between two Swedish neighbouring municipalities.

METHODS

Crude and age-standardised data regarding drug sales on prescription from the National Corporation of Swedish Pharmacies, was analysed. In subsequent qualitative interviews, the sales data were presented to a number of purposefully chosen key persons exploring their explanations of the long-standing large differences in the sales between the two neighbouring municipalities.

RESULTS

The study confirms previous analyses that large inter-municipality differences in out-patient sales of cardiovascular drugs exist between the municipalities, differences that remained when data were standardised. In the year 2002, for example, the age-standardised out-patient sales of drugs in ATC-group C09 was 64.4 defined daily dose (DDD)/1000 inhabitants/day in one municipality compared to 112.1 in the other. For ATC-group C10AA, the corresponding figures were 41.7 and 80.9 respectively. All interviewees considered so called treatment traditions as the most important reason for the observed differences. Taking part in clinical trials was also believed to be of great importance. Activities of the Drug and Therapeutic Committees (DTC), the presence of a hospital in the municipality, marketing activities by pharmaceutical companies or differences in morbidity were not considered of major importance in explaining the differences.

CONCLUSIONS

Large differences in sales data between the two municipalities remained despite age and sex standardisation. Key informants shared the view that differences in the so called 'treatment traditions' were most important for the differences.

Delivering generics without regulatory incentives? Empirical evidence from French general practitioners about willingness to prescribe international non-proprietary names

France presents a unique situation in which the take-off of a generic drug market depends, out of regulatory incentives, on whether physicians choose a prescription method (international non-proprietary names, INN) that can lead to the delivery of these drugs and on whether patients accept them. This paper is aimed at pointing out factors explaining general practitioners' (GPs') willingness to prescribe in INN through data collected from a South-Eastern France representative sample of 600 GPs in March 2002. The main results shed light on the key-role played by GPs' information about drugs and the source which they take it from, by GPs' volume of services and caseloads, and slightly by socio-economic characteristics of patients.

Price elasticity and pharmaceutical selection: the influence of managed care

State Medicaid programs are turning increasingly to managed care to control expenditures, although the types of managed care programs in use have changed dramatically. Little is known about the influence of the shifting Medicaid managed care arena on treatment decisions. This paper investigates factors affecting the selection of treatments for depression by providers participating in either of two Medicaid managed care programs. Of particular interest is the influence of medication price on the choice of treatment, since one vehicle through which managed care organizations can reduce total expenditures is by increasing the price sensitivity of participating providers. We take a new approach by phrasing the problem as a discrete choice, using a nested multinomial logit model for the analyses. Contrary to earlier literature, we find some evidence that physicians in both programs do take price into consideration when selecting among treatment options. HMO providers in particular demonstrate increased price sensitivity in the two most commonly prescribed categories of antidepressants.

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

OBJECTIVES

To compare and contrast the influences on prescribing perceived by general practitioners in an urban area of Queensland, Australia, to those perceived by general practitioners in rural Queensland.

METHOD

An investigation was undertaken with a group of general practitioners in urban and rural locations of Australia. A self-administered questionnaire requested the doctors' demographic details and their opinions on statements about prescribing. They also reported their prescribing of six recently marketed drugs.

RESULTS

One hundred and forty-two general practitioners from rural areas of Queensland (55% of the eligible population of these doctors) and one hundred and thirty-seven from the urban area (54% response) returned the surveys. The urban group were older and had more experience as general practitioners. Similarities and differences were detected between the two groups. The urban group considered that continuing medical education had a lesser influence on their prescribing than the rural group. The rural general practitioners were more likely than the urban doctors to agree that their information needs on prescribing were not being met in their practice, that their practice location had an effect on their prescribing (and also an effect on their prescribing of new drugs) as well as the remoteness of the patient's address having an effect. The rural doctors agreed more than the urban doctors that they try to avoid drugs requiring a significant amount of monitoring, reinforced by their agreement that they would be more likely to prescribe a newly marketed drug requiring less monitoring. When relating to whether the doctors in the two groups had reported initiating a supply of specific newly marketed drugs, independent of a specialist, rural general practitioners had initiated fewer of these selected new medicines.

CONCLUSION

This study has highlighted some of the differences in perceptions of doctors on the influences on prescribing in rural relative to urban areas of Australia. An understanding of these perceptions will allow targeting and development of location-relevant prescribing interventions and messages.

Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care

CONTEXT

Broad-spectrum antibiotics are commonly prescribed, but little is known about the physicians who prescribe and the patients who take these agents.

OBJECTIVE

To identify factors associated with prescribing of broad-spectrum antibiotics by physicians caring for patients with nonpneumonic acute respiratory tract infections (ARTIs).

DESIGN, SETTING, AND PATIENTS

Cross-sectional study using data from the National Ambulatory Medical Care Survey between 1997 and 1999. Information was collected on a national sample of 1981 adults seen by physicians for the common cold and nonspecific upper respiratory tract infections (URTIs) (24%), acute sinusitis (24%), acute bronchitis (23%), otitis media (5%), pharyngitis, laryngitis, and tracheitis (11%), or more than 1 of the above diagnoses (13%).

MAIN OUTCOME MEASURE

Prescription of broad-spectrum antibiotics, defined for this study as quinolones, amoxicillin/clavulanate, second- and third-generation cephalosporins, and azithromycin and clarithromycin.

RESULTS

Antibiotics were prescribed to 63% of patients with an ARTI, ranging from 46% of patients with the common cold or nonspecific URTIs to 69% of patients with acute sinusitis. Broad-spectrum agents were chosen in 54% of patients prescribed an antibiotic, including 51% of patients with the common cold and nonspecific URTIs, 53% with acute sinusitis, 62% with acute bronchitis, and 65% with otitis media. Multivariable analysis identified several clinical and nonclinical factors associated with choice of a broad-spectrum agent. After adjusting for diagnosis and chronic comorbid illnesses, the strongest independent predictors of broad-spectrum antibiotic prescribing were physician specialty (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.5 for internal medicine physicians compared with general and family physicians) and geographic region (OR, 2.6; 95% CI, 1.4-4.8 for Northeast and OR, 2.4; 95% CI, 1.4-4.2 for South [both compared with West]). Other independent predictors of choosing a broad-spectrum agent included black race, lack of health insurance, and health maintenance organization membership, each of which was associated with lower rates of broad-spectrum prescribing. Patient age, sex, and urban vs rural location were not significantly associated with prescribing choice.

CONCLUSIONS

Broad-spectrum antibiotics are commonly prescribed for the treatment of ARTIs, especially by internists and physicians in the Northeast and South. These high rates of prescribing, wide variations in practice patterns, and the strong association of nonclinical factors with antibiotic choice suggest opportunities to improve prescribing patterns.

Factors associated with the consumption of psychotropic drugs in a cohort of men and women aged 50 and over

OBJECTIVES

The use of psychotropic drugs has increased continuously over recent years in industrialized countries. In Europe, France has the highest consumption of such drugs. The aim of this study was to identify the sociodemographic and medical factors associated with the use of psychotropic agents.

METHODS

Data, collected as part of the SUVIMAX (SUpplementation en VItamines et sels Mineraux AntioXydants) prevention trial, from a self- administered questionnaire involving 7299 subjects aged 45-60 years, were subjected to logistic regression analysis.

RESULTS

A total of 467 subjects used psychotropic drugs (8.4% of the women, 4.6% of the men). Use of psychotropic drugs increased in subjects of both sexes with past history of depression, perception of poor health and use of other drug treatments. Widowhood in men [odds ratio (OR) = 3.4; 95% CI = 1.6-7.3] and divorce in women (OR = 2; 95% CI = 1.2-3.2) were also associated with an increased use of psychotropic drugs. Interaction was demonstrated between educational level and occupational satisfaction in men (OR = 2.9; 95% CI = 1.5-5.8) and between perception of health status and use of other types of medication in women (OR = 6.5; 95% CI = 4.6-9.5).

CONCLUSION

The results of our study are consistent with those of others in demonstrating that specific socio-occupational factors in men and specific medical factors in women influence extent of use of psychotropic drugs.

The pharmaceutical industry and mental health nursing

Mental health nurses (MHNs) have a long and varied relationship with the pharmaceutical industry, including the attendance of educational seminars and the acceptance of promotional material. This article presents evidence that suggests MHNs may need to review this relationship regardless of their beliefs about the role of pharmacological interventions in the treatment of mental illness. It also explores the influence of advertising within professional journals and calls for greater debate on this issue.

[Externally induced prescriptions, degree of agreement and ... possibility of change in primary care?]

OBJECTIVE

To find whether externally induced prescriptions (EIP) condition attendance through their prevalence, quality, the degree of agreement of the PC doctor and his/her capacity to alter them.

DESIGN

Cross-sectional study of use of indication-prescription type medicines.

SETTING

Health district.

PARTICIPANTS

2656 prescriptions for 678 patients interviewed.

MEASUREMENTS

Each interview recorded: type of visit, age, sex, work situation, existence or otherwise of social problems and/or psychiatric pathology; doctor-patient relationship, pharmaceutical preparations (PP) prescribed and those which the patient remembers he/she is taking, indication, origin, duration, speciality of the prescribing person, agreement of the PC doctor issuing the prescription and the possibility of his/her changing it. For each prescription the following was analysed: therapeutic group, intrinsic value, time it lasts, cost and whether it is a recently marketed PP.

MAIN RESULTS

90% of visits to the doctor end in prescription. 58% of patients remember taking one or more EIP. 72% of the prescriptions analysed were externally caused. They came mostly from the public health system (66%), private medicine (20%) and self-medication (11%). There was no PC agreement with almost half these EIPs, but only 13% could be changed. The EIPs without agreement and without possibility of change were greater in: women, the elderly, people on a pension, psychiatric pathologies and in cases of bad doctor-patient relationship. The EIPs originated in health insurance companies, pharmacies, self-medication, former GPs and private doctors. They were associated with ill-defined signs and symptoms, circulatory diseases and locomotive disease. We found no significant differences in expenditure or use of PP recently put onto the market between self-medication and EIP, though there were in quality.

CONCLUSIONS

The current model of prescribing medication causes consultations to be greatly "medicinised" at the expense of EIP. Doctors only alter a small part of the EIPs they don't agree with. Longitudinal studies are needed to monitor patients to find the evolution of EIPs (withdrawal, replacement, dragging on or new external prescription).

Concordance between use of proton pump inhibitors and prescribing guidelines

OBJECTIVE

To determine (i) the relationship between prescriptions for proton pump inhibitors (PPIs) and upper gastrointestinal conditions, and (ii) compliance with Pharmaceutical Benefits Scheme (PBS) prescribing guidelines for PPIs.

DESIGN

Drug utilisation evaluation.

SETTING

800-bed metropolitan teaching hospital.

PARTICIPANTS

253 patients dispensed PPIs from the hospital pharmacy over five consecutive weeks (11 January to 15 February 1999).

MAIN OUTCOME MEASURES

Recorded gastrointestinal conditions; previous trial of H2-antagonist therapy; compliance with PBS criteria for prescribing PPIs.

RESULTS

Seventy patients (27.7%) had no appropriate upper gastrointestinal tract investigations, and 62 patients (24%) did not receive an adequate trial of H2-antagonist therapy before the commencement of a PPI. The major indications for use of PPIs in investigated patients were gastro-oesophageal reflux in 99 (54%) and peptic ulcer disease in 30 (16.4%). In only 57 patients (22.5%) did PPI prescriptions comply with PBS prescribing guidelines. Clinical indications that failed to meet prescribing criteria included milder forms of gastro-oesophageal reflux, gastritis/duodenitis, and non-specific dyspepsia with normal endoscopy results.

CONCLUSION

Drug utilisation data indicate widespread use of PPIs outside current prescribing guidelines. Many patients have not had relevant investigations and/or an adequate trial of H2-antagonist therapy. These findings explain the considerable hospital expenditure on PPIs.

The association of some practice characteristics with antibiotic prescribing

BACKGROUND

Antibiotic prescribing in general practice is often considered inappropriate, and its volume excessive. Considerable variation in antibiotic prescribing volume and costs exists among practices.

OBJECTIVE

To investigate some factors behind the variation in antibiotic prescribing among general practices, by examining the contribution to this variation of the level of deprivation in the practice population, training status, partnership status, and fundholding status.

METHOD

Analysis of prescribing data (PACT) from 351 practices in the Mersey region for the year ending March 1991 and the year ending March 1994; prescribing data standardized for variation in practice population demography. Use of multiple linear regressions to investigate the variation among practices in standardized prescribing volume and standardized prescribing costs, in both years.

RESULTS

Level of deprivation, training status and partnership status contributed to the models explaining variation in prescribing volume. The same variables contributed to the model explaining variation in prescribing costs in the year ending March 1991. For the year ending March 1994, level of deprivation, training status, and fundholding status contributed to all models.

CONCLUSION

Higher levels of antibiotic prescribing occur in practices serving more deprived communities, in single-handed practices, and in non-training practices. These higher levels of prescribing may be due to higher levels of morbidity, but may also reflect the organization and attitudes of these practices.

Information contents of drug advertisements: an Indian experience

OBJECTIVE

To critically analyze the drug information contained in Indian pharmaceutical advertisements.

DESIGN

Analysis of pharmaceutical advertisements supplied by drug representatives (DRs) to prescribers from July 1, 1995, to June 30, 1996.

SETTING

A university-affiliated urban teaching hospital in India.

PARTICIPANTS

585 pharmaceutical ad pamphlets.

MAIN OUTCOME MEASURES

The ads supplied by DRs to physicians in different clinical departments of the hospital were collected. These were distributed to different systems/categories and a special reference to fixed-dose drug combinations was given. The drug information contained in these ads was evaluated by using a checklist, framed by incorporating the World Health Organization ethical guidelines for medicinal drug promotion and some relevant items from other studies.

RESULTS

The most frequently occurring ads were for antimicrobial agents. The ads on fixed-dose drug combinations constituted 37.9% of the total. More than 85% of the ads mentioned the generic name, brand name, contents, and pharmaceutical dosage forms, as well as the name and address of the company. The information concerning adverse effects, precautions, contraindications, warnings, major interactions, ingredients known to cause problems, pharmacology, drug overdose, references, drug storage, and cost was present in less than 40% of these ads.

CONCLUSIONS

There has been inadequate information in pharmaceutical ads supplied by DRs to the physicians in India. The current scenario could be improved by formulating some definite legislative guidelines for the minimum level of information to be included in pharmaceutical ads and adhering to that legislation.

Why are patients prescribed proton pump inhibitors? Retrospective analysis of link between morbidity and prescribing in the General Practice Research Database

OBJECTIVES

To establish the relation between new prescriptions for proton pump inhibitors and recorded upper gastrointestinal morbidity within a large computerised general practitioner database.

DESIGN

Retrospective survey of morbidity and prescribing data linked to new prescriptions for proton pump inhibitors and comparison with licensed indications between 1991 and 1995.

SETTING

General Practice Research Database and prescribing analysis and cost (PACT) data for the former West Midlands region.

SUBJECTS

Information for 612 700 patients in the General Practice Research Database. Anonymous PACT data for all general practitioners in West Midlands region.

MAIN OUTCOME MEASURES

Diagnostic codes linked to the first prescriptions issued for proton pump inhibitors; relation between new prescriptions and licensed indications; yearly change in ratio of new to repeat prescriptions and prescribing volumes measured as defined daily doses.

RESULTS

Oesophagitis was the commonest recorded indication in 1991, accounting for 31% of new prescriptions, but was third in 1995 (14%). During the study new prescriptions increased substantially, especially for duodenal disease (780%) and non-ulcer dyspepsia (690%). In 1995 non-specific morbidity accounted for 46% of new prescriptions. The total volume of prescribing rose 10-fold between 1991 and 1995, when repeat prescribing accounted for 77% of the total.

CONCLUSIONS

Changes in recorded morbidity associated with new prescriptions of proton pump inhibitors did not necessarily reflect changes in licensed indications. Although general practitioners seemed to respond to changes in licensing, particularly for duodenal and gastric disease, prescribing for unlicensed indications non-ulcer dyspepsia and non-specific abdominal pain increased.

Decision making: the context of nurse prescribing

From October 1994 qualified district nurses and health visitors from eight demonstration sites in England have been able to prescribe from a limited list of formulary items. Data collected from nurses formed only one part of the evaluation of nurse prescribing. These data highlighted a number of areas where prescribing nurses were faced with difficult decisions. A number of authors have considered how both doctors and nurses make decisions, and the factors which may influence the decision making process. With reference to the literature this paper focuses on the findings related to decision making in the context of nurse prescribing.

Factors associated with antibiotic prescribing in a managed care setting: an exploratory investigation

This multi-site, cross-sectional, observational study sought to identify attitudinal and social normative factors associated with the prescribing of oral antibiotics to ambulatory patients in a managed care setting. Participants were 25 physicians specializing in internal medicine, family practice or pediatrics from five ambulatory care clinics within a large, fully integrated health care system in a major midwestern U.S. city. The main outcome measure was number of prescriptions per physician written in the fourth quarter of 1994 for each of seven selected antibiotics. Correlational and multiple regression analyses revealed that behavioral intentions were significantly associated (P < 0.05) with both attitudes and subjective norms. However, physicians' attitudes, subjective norms and intentions were not predictive of actual antibiotic prescribing behavior. Prescribing behavior may have been a function of patient-specific rather than general beliefs about antibiotics. Methodological limitations related to the sample size and the sparseness of the utilization data may also have prevented a significant effect of intentions on behavior from being detected. Alternatively, in managed care settings, it is hypothesized that prescribing behavior may have been influenced more by non-psychological factors, such as management systems, formularies and therapeutic substitution programs, than they were by internal, psychological factors such as attitudes, subjective norms and intentions. Managed care is altering the role of the physician as an autonomous decision-maker. In response, models of prescribing must either incorporate variables such as perceived behavioral control to aid in the prediction of non-volitional behavior, model the decision-making of non-physician managers, or forego psychological models in favor of structural or system-level models of drug utilization.

Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice

OBJECTIVE

To test the hypotheses that patient expectations are a driving force in drug prescribing and that fulfilment of expectations is followed by higher satisfaction.

DESIGN

Pre- and post-consultation survey of patients; parallel doctor survey (matched pairs).

SETTING

Primary health care in Göttingen, a town of about 130,000 inhabitants in Germany.

SUBJECTS

Ten general practitioners and 185 randomly addressed patients.

MAIN OUTCOME MEASURES

Patient expectations with respect to the result of the consultation; doctor's perception of patient expectations; agreement between patient and doctor; patient satisfaction.

RESULTS

Nearly half of the patients (86/185) expected a drug prescription from their doctor; 68% (125/185) received a prescription. The doctors recognized the expectation of a prescription in only 40.7% of the patients. A high percentage (82.6%) of patients expecting a drug were issued a prescription. Nearly all the patients (45/48) who expected a drug according to their doctor's judgement left the surgery with a prescription, and 58.4% of the remaining patients were prescribed a drug. There was no difference in satisfaction scores between patients whose expectations were or were not fulfilled.

CONCLUSION

These results are in some contrast to the main hypotheses. As fulfilment of expectations was not associated with higher satisfaction, physicians need not necessarily worry that patients will change their doctor if he or she refuses a pharmacologically dubious prescription.