Do physicians' beliefs about genetic engineering influence their likelihood of prescribing a biopharmaceutical? An empirical investigation

Biopharmaceuticals present one of the fastest growing segments of the pharmaceutical industry. Biopharmaceuticals are produced through genetic engineering, a technology that some believe is unethical and can have unforeseen consequences to individual health and the environment (Bredhal, 1999; Gaskell et al., 1999; Hallman et al., 2002). In this study, we investigate whether physicians' beliefs about genetic engineering have any influence on their likelihood of prescribing a biopharmaceutical. A sample of 175 physicians practicing in one state in the mid-south region of the U.S. was selected and their beliefs, importance of genetic modification as a drug attribute and the likelihood of prescribing a biopharmaceutical, were measured. Results showed that the physicians' beliefs about genetic engineering related to their likelihood of prescribing this class of drugs. In addition, the study also found that the importance of genetic modification as a drug attribute moderated the relationship between beliefs and likelihood in the decision making process. The implications of these findings are also discussed.

Factors influencing prescribing: an intern's perspective

OBJECTIVES

To examine the self-reported influences on intern prescribing practice.

DESIGN

Qualitative interviews with a cross-sectional cohort.

PARTICIPANTS AND SETTING

Ten interns practising in two urban teaching hospitals in New South Wales, Australia.

RESULTS

The interns identified a number of factors that improve their confidence and perceived competence and allow them to extend their existing skills. These were approachable, available and up-to-date teachers (most often registrars and subspecialty nurses and pharmacists); timely, relevant and practical teaching (such as interactive bedside teaching); concise and widely accepted resources (such as prescribing pocket guides); and a constructive manner on the part of senior staff for dealing with prescribing errors. Interns also identified influences that are detrimental to confidence, conflict with their perceptions of appropriate prescribing and inhibit learning and skills acquisition. These were unapproachable, physically and mentally remote teachers (most often consultants); theoretical, inconsistent and irrelevant teaching (such as grand rounds or didactic education sessions); inconsistent and inaccessible resources; and a confrontational and accusatory way of dealing with prescribing errors. The added pressures of time, hospital hierarchies and the indirect influence of drug company promotion also impeded acquisition of good prescribing habits.

CONCLUSIONS

At a critical time in skills development, interns encounter many forces that can potentially impact on prescribing practices in both positive and negative ways. Our data contribute to the understanding of the multifaceted learning environment of interns and may be useful in providing a foundation for prescriber education programmes tailored to the specific needs of junior doctors.

Drug samples and family practice residents

OBJECTIVE

To describe residents' knowledge, attitudes, and behaviors regarding sample medications and to determine the education provided in residency training regarding sample use.

METHODS

A 6-item survey was sent to directors of US family practice residency programs. Residents of a sample of these programs were sent an anonymous, self-administered, 21-item questionnaire assessing knowledge, attitudes, and practices relating to sample use. Both surveys consisted of initial and follow-up mailings.

RESULTS

The residency directors' survey was returned by 232 of the 436 residency directors (53%). Although 66% of the programs had a policy regarding samples, only 15% of the policies completely incorporated recommendations of the Society of Teachers of Family Medicine. After two mailings, 248 resident responses were received from 43 of 47 residencies (92%). Only 21% of respondents thought that they received adequate training about sample use in medical school; this number increased to 49% for residency training. Agreement with the adequate training statement was highest among respondents from residencies that had both a sample distribution policy and a pharmacist (p = 0.044). Fifty-five percent thought that samples influenced their prescribing and 70% thought that samples helped them to learn more about the sampled medication.

CONCLUSIONS

Family practice residents value and use samples, although they are often unaware of the rules governing the labeling of samples. While reported distribution of samples by residents often is appropriate, education about effective sample use could be improved. Drug samples play a significant role in residency training.

Retrospective drug utilization review and the behavior of Medicaid prescribers: an empirical marginal analysis

The objectives of this study were to evaluate the effectiveness of drug utilization review (DUR) letter intervention on reducing the cost of medications under Medicaid. The target drugs in this study were six antiulcer agents prescribed for Alabama Medicaid recipients. The study group consisted of 100 prescribers who received DUR intervention. A total of 3776 prescribers who did not receive DUR intervention served as the comparison group. Using an interrupted time series design, these 3876 prescribers were studied before and after the implementation of the DUR program. The study found that prescribers' behavior changed after the DUR letter were sent out, resulting in a reduction in the average marginal days of drug therapy and drug reimbursement per recipient. For the target drugs, there was an average savings of $112.73 per prescriber per month and a total of $136,370.82 savings per month for the Alabama Medicaid program.

Pharmacist-physician co-operation at a regional level

In the Dutch region of "Betuwe" the hospital pharmacists and community pharmacists together provide short drug letters about new drugs, which are sent bimonthly to all the practising general practitioners (n = 83) and medical specialists (n = 50) in this region. A survey was conducted among these physicians in order to investigate their opinion about and reported use of the drug letters in comparison with other drug-information sources. The majority of the responding physicians (response rate 68%) was found to read the drug letter frequently and evaluated the drug letter as a useful source of information about drugs, especially its section about the advantages and disadvantages of the new drug compared to other drugs. With respect to the different stages of the drug-adoption process, the drug letter was found to be the most frequently used information source at the decision stage. At the introduction stage the pharmaceutical industry representative seems to be the most frequently used source of information, while at the information stage it is the "Geneesmiddelenbulletin" (Drug Bulletin). The majority of the responding general practitioners reported to participate in local group meetings with pharmacists. However, in only 20% of these group meetings attention is given to the drug letter. Since it is known that written information has only a limited influence on the physician's behaviour, the influence of the "Betuwe Circulaire" may increase when attention is paid to it in the local contacts between pharmacists and physicians.

Problems in distribution of scientific knowledge: intrauterine contraceptive devices and drug catalogs

Intrauterine contraceptive devices (IUDs) are a popular method of contraception worldwide. However, some serious problems have been associated with them. Finland has developed and now manufactures and exports IUDs. Therefore, drug control and the quality of drug information existing in Finland are significant for other countries, as well. This study analyzes the information in the Finnish commercial drug catalog on copper-releasing IUDs and compares it with the scientific literature, the instructions from the licensing authority, and material in its U.S. counterpart, during the last two decades. The results indicate that the distribution of scientific knowledge to the drug catalogs has often been slow. In the early 1980s Finnish manufacturers did not give any practical information on their products, and then and later the Finnish catalog was less comprehensive than the U.S. catalog. The variations in the control system in different nations were reflected in the contents of the Finnish catalog. For practitioners, drug catalogs are important sources of medical information. The results of this study demonstrate (1) that more attention should be paid to the contents of these catalogs, and (2) the continuous need for up-to-date, unbiased drug information.

Therapeutic decision making of physicians

In this review the therapeutic decision-making process of physicians is described. This process is divided into two steps: the generation of a limited set of possible options (the 'evoked set') and the selection from this evoked set of a treatment for a specific patient. Factors that are important in both steps are reviewed. Behavioural and decision-making theories in general and decision-making analysis of physicians in particular are discussed to identify possible shortcomings in their decision-making process. Based on this information a model of the drug choice process is presented. With reference to this model possible ways of influencing drug choices of physicians are discussed.

Choosing between apples and apples: physicians' choices of prescription drugs that have similar side effects and efficacies

OBJECTIVE

To examine physician choices of commonly used medications having similar side effects and efficacies, and to evaluate factors that may affect these choices.

DESIGN/SETTING

Cross-sectional survey conducted in winter 1989-1990.

PARTICIPANTS

263 physicians at a university teaching hospital (response rate = 71%).

MEASUREMENTS AND MAIN RESULTS

Physicians rated patient compliance, cost to patient, and patient preference as the three most influential factors in their selection of a particular agent from a class of similar drugs. Housestaff were less likely than faculty to consider cost to patient as a "very important" factor (33% vs. 60%; p less than 0.05), and only 11% of all physicians felt that cost to third-party payer was very important. Physicians reported that their choices of particular nonsteroidal anti-inflammatory drugs (NSAIDs), histamine-2 (H2) blockers, and inhaled beta-agonists were mainly determined by which drugs enhanced compliance or were used by others (the "traditional choice"); cost to patient was a less important influence in these instances. All physician subgroups were inaccurate in predicting the approximate prices of their first- and second-choice agents. For example, only 28% of those selecting naproxen as their preferred NSAID were within $10 of the range of the prices of a one-month supply, and 14% were within $10 for cimetidine.

CONCLUSION

Although this group of physicians reported considering drug costs to be important when choosing between similar drugs, they acknowledged that cost was relatively unimportant in several specific instances studied and their knowledge of the absolute and relative prices of drugs they commonly prescribed was deficient.

Impact of pharmaceutical sales representatives on physician antibiotic prescribing

This study revealed a significant impact on physician prescribing practices by PSRs, based on the results of evaluations of each agent's average number of new prescriptions per month, number of grams dispensed per month, and dollar values of those prescriptions. Comparisons of these data to regional, national, and world trends revealed no correlation.

Pharmaceutical representatives in academic medical centers: interaction with faculty and housestaff

OBJECTIVE

To determine the nature, frequency and effects of internal medicine housestaff and faculty contacts with pharmaceutical representatives (PRs).

DESIGN AND SETTING

The authors surveyed internal medicine faculty at seven midwest teaching hospitals and housestaff from two of the teaching programs. The survey asked about type and frequency of contacts with PRs and behavior that might be related to these contacts. T-tests and logistic regression were used to estimate the relationship between reported physician contacts and behavioral changes.

PARTICIPANTS

Two hundred forty faculty (78%) and 131 house officers (75%) responded to the survey.

RESULTS

Faculty and housestaff averaged 1.5 brief contacts per month with PRs. Housestaff averaged more than one meal/month at pharmaceutical company expense. Twenty-five percent of faculty and 32% of residents reported changing their practices at least once based on PR contact. Independent predictors of faculty change in practice were brief or extended conversations and free meals. Predictors of faculty requests for formulary addition were brief conversations and receipt of honoraria or research support. Only brief conversations independently predicted housestaff changes in practice.

CONCLUSION

Academic housestaff and faculty have frequent PR contact; such contact is related to changes in behavior. The potential for influence of PRs in academic medical centers should be recognized, and their activities should be evaluated accordingly.

A model of methods for influencing prescribing: Part I. A review of prescribing models, persuasion theories, and administrative and educational methods

The purpose of this literature review is to develop a model of methods to be used to influence prescribing. Four bodies of literature were identified as being important for developing the model: (1) Theoretical prescribing models furnish information concerning factors that affect prescribing and how prescribing decisions are made. (2) Theories of persuasion provide insight into important components of educational communications. (3) Research articles of programs to improve prescribing identify types of programs that have been found to be successful. (4) Theories of human inference describe how judgments are formulated and identify errors in judgment that can play a role in prescribing. This review is presented in two parts. This article reviews prescribing models, theories of persuasion, studies of administrative programs to control prescribing, and sub-optimally designed studies of educational efforts to influence drug prescribing.

'Codes' and practice: information in drug advertisements--an example from Sri Lanka

The amount of scientific information that should appear in an advertisement for a drug has been discussed for over 20 years. The information should promote the rational use of the drug. There is a lack of data from developing countries. We analysed all drug advertisements in the Ceylon Medical Journal (CMJ) 1985-1986. Conformity with the existing WHO guidelines and IFPMA code was also assessed. The 111 advertisements constituted 42% of the pages in the CMJ. Thirty-one of 34 companies were from the industrialized nations. Twenty-one per cent of the advertisements did not have the generic name; 94% had information on indications, whereas only 23 and 22% had information on adverse effects and contraindications. Only 16% provided information on generic name, indications, dosage, adverse effects and contraindications. Despite this 68% satisfied the criteria of the WHO guidelines and IFPMA code mainly under an ill defined 'reminder advertisement' clause. The existing guidelines are insufficient to ensure the minimum scientific information in drug advertisements.

Doctors and detailers: therapeutic education or pharmaceutical promotion?

Pharmaceutical companies in industrialized countries generally view detailers as the most crucial element in the promotion of their products, with the result that over 50 percent of expenditures on promotion are devoted to detailers. Publicly the companies make claims for the scientific knowledge of detailers and for their role in passing on information to physicians, but the main purpose of detailers is to sell their company's products. This emphasis on sales is evident from statements of detailers themselves, from advertisements for detailers, from company documents, and by looking at the groups of physicians that companies specially target for visits by detailers. A variety of explanations are offered as to why physicians see detailers, but on examination none of the reasons is justifiable. Studies from a number of industrialized countries have shown that over 90 percent of physicians see detailers and a substantial percentage rely heavily on detailers as sources of information about therapeutics. Detailers are highly successful in altering physicians' prescribing habits, but almost all the literature available shows that the more reliant doctors are on commercial sources of information, the less appropriate they are as prescribers. Widespread use of DES (diethylstilbestrol) and the Dalkon Shield was encouraged by detailers. Although detailers have received the endorsement of both physicians' groups and government bodies, seeing detailers is detrimental to the practice of good medicine, and the best interests of doctors and their patients would be served if physicians had nothing further to do with detailers.

Prescribing intention and the relative importance of drug attributes: a comparative study of HMO and fee-for-service physicians

This study utilized the Fishbein Behavioral Intention Model as a conceptual framework to compare health maintenance organization (HMO) and fee-for-service (FFS) physicians. A mail questionnaire was used to obtain data and information from random samples of HMO (n = 73; 50% response) and FFS (n = 49; 33% response) physicians in the Phoenix and Tucson metropolitan areas. No differences were found between the two groups of physicians regarding the Fishbein variables: prescribing intention, importance of attributes, attribute beliefs, and subjective norms. The Fishbein Model was found to explain a significant portion of the variance in prescribing intentions of the HMO and FFS physicians.

Out-patient use of beta-blocking agents--prescribing preferences of physicians in training

Beta-blocking agents are among the most frequently prescribed medications. To investigate the factors that influence their use we analysed the practices of 25 medical residents who provided longitudinal care in the out-patient clinics of a teaching hospital. A computer-based audit identified the 349 patients treated with one of four beta-blocking agents during a 4-month period. The most frequently prescribed was atenolol (48%), followed by metoprolol (28%), propranolol (20%), and nadolol (4%). Ease of use and compliance and continuation of a beta-blocker prescribed by a previous physician emerged as the most influential factors. In contrast, cost of drugs, manufacturers' promotions and advertisements had no significant influence on beta-blocker selection.

Physicians' knowledge of prescribing for the elderly. A study of primary care physicians in Pennsylvania

The 143 physicians who returned to Temple University Medical School a questionnaire on knowledge of prescribing for the elderly constituted 25% of a stratified random sample of general practitioners (GPs), family practitioners (FPs), and practitioners in internal medicine (IMs) reimbursed under Medicare in Pennsylvania in 1979. The mean score on the 23-item drug questionnaire was significantly lower (P less than .05) than the score deemed adequate by a panel of six experts in the field. Five variables, identified by survey questions, were positively associated with physicians' test scores: importance of professional meetings, perception of need for continuing medical education, board eligibility/certification, group practice, and a practice in which the elderly constitute 25 to 49% of all patients. Two variables were negatively associated: number of years since date of licensure and the importance of drug advertisements. Respondents and nonrespondents were compared on nine variables for which American Medical Association (AMA), American Osteopathic Association (AOA), or Blue Shield data were available. Pennsylvania graduates were significantly overrepresented in the respondent group. The only other significant difference found was in field of practice, where findings differed by source of information. There was no significant difference in mean scores of early and late respondents. The research findings support those of three previous studies, not limited to the elderly, which found prescribing knowledge inadequate. They suggest the need for examining/improving the opportunities for medical students and physicians to increase their knowledge of geriatric pharmacology.

Decision to adopt new medical technology: a case study of thrombolytic therapy

New medical technologies are adopted by practising physicians at varying rates. Thrombolytic therapy is an example of a technological advance that many physicians have seemed reluctant to employ. A random sample of board certified internists was surveyed by mail to study factors that influence decisions to use thrombolytic agents. Variables important in predicting use were identified by discriminant analysis. In general users and non-users had similar assumptions about the risks and benefits of this technology. Among the important predictor variables were a perception of having patients suitable for treatment, availability of the agents and self-rating of knowledge about this therapy. Among questions related to type of practice and education, only subspecialization and textbook reading were important discriminators. These results suggest that decisions to adopt new technologies do not follow simply from risk-benefit assessments.

Prescription drug advertising: trends and implications

Prescription drug advertisements which appeared in two leading American medical journals in 1972, 1977 and 1982 were analyzed to discover possible trends in advertising. The 5016 ads examined showed that ads for the diuretic-cardiovasculars, especially the beta-adrenergic blocking agents and the slow channel inhibitors, as well as the analgesics, had increased, while ads for the anti-infectives and tranquilizers had diminished. The average amount of space allocated for each ad had increased. On the average, most ads (69%) depicted neither male nor female patients in their graphics, and a trend of increased neutrality was observed. When the hormones were excluded, an average of 21% of the ads showed male patients and 10% showed females. Since a relationship was discerned between the leading drugs advertised and the leading prescriptions filled, it was concluded that advertising does have some effect on the prescribing behavior of practitioners. The findings suggest that great investment in advertising is necessary in order to achieve high levels of sales for such drugs as Valium (diazepam) which do not have a clear-cut ameliorative effect on a specific physiological condition. On the other hand, it was suggested that saturation advertising would not significantly enhance the sales of such drugs as Dyazide (triamterene and hydrochlorothiazide) because of its well established therapeutic value in the control of hypertension. Ten advertising companies, on the average, had purchased 67% of all advertising space and five had purchased almost half (47%). The same two pharmaceutical companies were among the top five advertisers and the same five were among the top ten for the three years studied.

Predictors of dentists' level of knowledge regarding the recommended prophylactic regimen for patients with rheumatic heart disease

Maintaining knowledge of clinical practices, conforming to the latest scientific information, is a major challenge for health professionals. The study aims were to measure clinicians' knowledge and to determine what social factors could best explain and predict those dental clinicians who are most knowledgeable about current expert recommendations for the use of appropriate antibiotic regimens for patients at risk for bacterial endocarditis. Telephone interviews were conducted with 322 New York State dentists, assigned to the study by a computer-generated randomization procedure from lists of oral surgeons, urban general practitioners and rural general practitioners. Data demonstrated extraordinary differences in level of knowledge between oral surgeons and general practitioners, while the level of knowledge between urban and rural general practice groups was quite similar. General Linear Model (GLM)-based analyses indicated that practice size, rationalization of practice, and practice setting and affiliations contributed to the explanation of knowledge level among general practitioners, when adjusted for age. R2s for each of those variables and age, ranged from a low of 0.132 to a high of 0.334. Age made a significant contribution to the explanation of knowledge level in all of the models presented, while the explanatory power of the practice structure variables varied according to respondent's locale (urban vs rural) and age (younger vs older). In order to assess the impact of these structural variables, they were dichotomized (high-low) and entered into a GLM program which accounted for age and locale. Differences in excess of 20 points (on a 0-100 knowledge scale) were sometimes noted.(ABSTRACT TRUNCATED AT 250 WORDS)

Drug information: an overview and prospect for the future

The need and demand for improved adverse drug reaction reporting; literature access, control and dissemination; and student-literature exposure has been evident for many years. Drug information attempts to manage these perplexities by performing specific functions (i.e., by the communication of information, designing improved retrieval systems and offering individualized services). The drug information specialist is clinically-oriented and endeavors to surmount long-existing barriers to information transmission (e.g., the "invisible college" or colleague consultation). As a documentalist he is concerned with bibliographic control and systems improvement and design. Both functions require specialized education which is obtainable in schools of graduate pharmacy and in schools of library and information science. The properties of such programs are presented.

Factors influencing drug prescribing--inquiry into research strategy

This review analyzes the approaches used in published studies into doctors' prescribing habits. Sixty-four studies in English, Scandinavian languages, and Finnish, mainly from the last 15 years, are included. Some factors affecting prescribing have not been studied and there were very few studies into two potentially important factors, education and control measures. Studies which measured the effect of drug firms tend to concentrate on the conventional forms of advertising. The general limitations of each of the approaches are listed and those which seem unlikely to yield much new information are pointed out. Some novel approaches are proposed.

covering the last 15 years were searched systematically, but journals in other fields were not covered so systematically. Some earlier studies were also included. Some studies of possible importance were unobtainable.

Only those studies were included in which the objective was to determine which factors affect, or to what extent they affect, drug prescribing. Studies designed to determine physicians' opinions on the different sources of drug information were. also included. The latter, in some studies, enlarged upon their initial objective. Articles which included descriptions of drug-firms were excluded if the authors had not connected them to drug prescribing. Studies which described prescribing as such were not included.

Only studies into “non-medical” factors were included. Studies into the effects of the results of medical research or the character of disease or the result of the treatment were ignored. So were studies into the “non-medical” properties of a drug, because the drug is here considered as the object of a doctor's decision making and not as an influencer.

Studies into the process of drug adaptation (the mechanism of a doctor's decision making) were largely disregarded. But studies into the effect of a physician's personal characteristics on his prescribing habits were included because these characteristics are an important modifier of the exterior influencers.

The studies were classified according to their most significant factor. The model for classification, described in a previous paper,4 was constructed for developed Western countries. It omits some factors, such as the