Influencing factors of physicians' prescription behavior in selecting essential medicines: a cross-sectional survey in Chinese county hospitals

Short- and long-term impacts of the National Essential Medicines Policy on drug availability, price, and usage in a deprived rural county in southwestern China: an interrupted time series analysis across 8 years

Background

China's National Essential Medicines Policy (NEMP) has been implemented for over 15 years; yet empirical evidence on its long-term impacts is lacking, particularly in remote and rural regions. This study aims to assess the short-and long-term effects of NEMP on the drug availability, price, and usage in a deprived rural county in southwestern China.

Methods

A quasi-experimental design was employed, featuring a single-group pre-and-post comparison. We gathered 74,436 procurement records spanning from 2009 to 2016 from the drug warehouses of local medical institutions. Pharmaceutical data were analyzed quarterly, considering various policy and therapeutic attributes. Fisher's Drug Price Index (DPI-F) was calibrated for the retail and wholesale prices of a consistent collection of 405 medications. We conducted interrupted time-series analysis to examine the immediate and enduring impacts of NEMP's initial (commencing in January 2011) and second (starting from December 2015) stages.

Results

After initiation of NEMP, the number of available essential medicines surged by 115 but subsequently faced a steady quarterly decline (-9.1) in township healthcare centers (THCs, primary care). Conversely, county hospitals (secondary care) initially saw a reduction of 40 in drug availability but later exhibited a steady increase (+4.2 per quarter) up to the second-stage NEMP. Regarding price, THCs encountered abrupt (-26.1%/-15.9% in retail/wholesale price) and sustained (-0.2%/-0.3% per quarter) price drops after NEMP. The immediate price change after NEMP in county hospitals were milder but significant in non-essential medicines, and long-term declines were also observed in all drugs. As for total sales, a significant long-term disparity emerged between THCs (+0.9% per quarter) and county hospitals (+3.3% per quarter). Following the second-stage NEMP, retail prices in county hospitals further decreased, although wholesale prices did not; however, following price upward trends were observed in both THCs and county hospitals. Lastly, the influences of NEMP varied across different therapeutical categories of medicines.

Conclusion

NEMP has successfully regulated drug prices in primary and secondary healthcare facilities in remote and rural areas, both short-term and long-term. However, a remarkable disparity in medicine availability and utilization was observed between different levels of facilities over time. Continuous monitoring is essential, with increased attention needed on the uneven impacts of the policy on diverse drugs, facilities, regions, and demographics.

Influencing Factors of Generic Prescribing Behavior of Physicians: A Structural Equation Model Based on the Theory of Planned Behavior

Background

Although affordable generics could probably contribute to the solution of rapidly increasing pharmaceutical expenditure, those drugs are prescribed at a lower rate in China. Physicians' perception and knowledge of generics have a great influence on their prescribing behavior.

Objective

This study aimed to identify factors that affect physicians' generic prescribing behavior based on the theory of planned behaviors (TPB).

Methods

Data were collected by both electronic and paper-based surveys from 1297 Chinese physicians, and 1047 surveys were retained. The structural equation model (SEM) was employed to investigate the relationship between four behavioral constructs, namely, attitudes, subjective norms, perceived control of behaviors, and intentions.

Results

About 50% of Chinese physicians had a positive attitude towards generic drugs that had passed the "Consistency Evaluation of Quality and Efficacy of Generic Drugs" (high-quality generic drugs), but their knowledge of generic drugs was relatively inadequate. The path coefficients for the effect of attitudes, subjective norms, and perceived behavioral control on behavioral intention were 0.285, 0.366, and 0.322 respectively. The path coefficients for the effect of behavioral intention and perceived behavioral control on prescribing behavior were 0.009 and 0.410 respectively.

Conclusion

Physicians' attitudes, subjective norms, and perceived behavioral control were significant positive correlation predictors of behavioral intention. Subjective norms and perceived behavior control had a greater impact than attitude on physicians' prescribing intention. However, the generic prescribing behavior is not under the volitional control of Chinese physicians. Physicians' prescribing practice is likely affected by perceived strong control over prescribing generic drugs.

A quasi-experimental study of the volume-based procurement (VBP) effect on antiviral medications of hepatitis B virus in China

Background: The Pilot Plan of National Centralized Volume-Based Procurement (NCVBP) was adopted to cope with the rapid increase in drug expenditures. This research aimed to quantitatively evaluate the impact of the NCVBP on antiviral medications for the hepatitis B virus. Methods: Data on nucleoside analogs (NAs) medications of hepatitis B virus monthly procurement records in the pilot cities from January 2018 to December 2019 were extracted from the China Drug Supply Information Platform (CDSIP). The impacts of the NCVBP on purchased volumes, expenditures, and pre-defined daily dose costs were evaluated by interrupted time-series (ITS) analysis using Stata 16.0. We constructed two segments with one interruptive point (March 2019). Results: Compared to the same period between pre-and post-intervention, the purchased volume of NAs medications were increased by 92.85%, and selected medications were increased by 119.09%. Analysis of changes in the level of NAs medication followed a decrease in purchased expenditure (coefficient: 5364.88, p < 0.001), meanwhile, the purchased volume was increased with statistical significance (coefficient:605.49, p < 0.001). The Defined Daily Dose cost (DDDc) of NAs medication followed a decrease (coefficient: 8.90, p < 0.001). The NCVBP reform was followed by an increase of 618.41 ten thousand Defined Daily Dose (DDD) (p < 0.001) in purchased volume and a reduction of 5273.84 ten thousand Chinese Yuan (CNY) (p < 0.001) in the purchased expenditure of selected medications in the level. The DDDc of selected medications decreased in the level (coefficient: 9.87, p < 0.001), while the DDDc of alternative medications increased in the slope (coefficient:0.07, p = 0.030). The purchased volume and expenditure of bid-winning products increased by 964.08 ten thousand DDD and 637.36 ten thousand CNY in the level (p < 0.001). An increase of 633.46 ten thousand DDD (p < 0.001) in purchased volume and a reduction of 4285.32 ten thousand CNY (p < 0.001) in the purchased expenditure of generic drugs in the level was observed. Conclusion: The NCVBP reduced the DDDc of NAs medication, improved the utilization of the selected medications, and promoted the usage of generic products.

The impact of China's zero markup drug policy on drug costs for managing Parkinson's disease and its complications: an interrupted time series analysis

Background

In April 2009, the Chinese government launched Zero Markup Drug Policy (ZMDP) to adjust medical institutions' revenue and expenditure structures.

Objective

This study evaluated the impact of implementing ZMDP (as an intervention) on the drug costs for managing Parkinson's disease (PD) and its complications from the healthcare providers' perspective.

Methods

The drug costs for managing PD and its complications per outpatient visit or inpatient stay were estimated using electronic health data from a tertiary hospital in China from January 2016 to August 2018. An interrupted time series analysis was conducted to evaluate the immediate change following the intervention (step change, β₁) and the change in slope, comparing post-intervention with the pre-intervention period (trend change, β₂). Subgroup analyses were conducted in outpatients within the strata of age, patients with or without health insurance, and whether drugs were listed in the national Essential Medicine List (EML).

Results

Overall, 18,158 outpatient visits and 366 inpatient stays were included. Outpatient (β₁ = -201.7, 95%CI: -285.4, -117.9) and inpatient (β₁ = -372.1, 95% CI: -643.6, -100.6) drug costs for managing PD significantly decreased when implementing ZMDP. However, for outpatients without health insurance, the trend change in drug costs for managing PD (β₂ = 16.8, 95% CI: 8.0, 25.6) or PD complications (β₂ = 12.6, 95% CI: 5.5, 19.7) significantly increased. Trend changes in outpatient drug costs for managing PD differed when stratifying drugs listed in EML (β₂ = -1.4, 95% CI: -2.6, -0.2) or not (β₂ = 6.3, 95%CI: 2.0, 10.7). Trend changes of outpatient drug costs for managing PD complications significantly increased in drugs listed in EML (β₂ = 14.7, 95% CI 9.2, 20.3), patients without health insurance (β₂ = 12.6, 95% CI 5.5, 19.7), and age under 65 (β₂ = 24.3, 95% CI 17.3, 31.4).

Conclusions

Drug costs for managing PD and its complications significantly decreased when implementing ZMDP. However, the trend in drug costs increased significantly in several subgroups, which may offset the decrease at the implementation.

The Effects of Cost Containment and Price Policies on Pharmaceutical Expenditure in South Korea

BACKGROUND

Policy-makers have proposed and implemented various cost-containment policies for drug prices and quantities to regulate rising pharmaceutical spending. Our study focused on a major change in pricing policy and several incentive schemes for curbing pharmaceutical expenditure growth during the 2010s in Korea.

METHODS

We constructed the longitudinal dataset from 2008-2017 for 12 904 clinics to track the prescriber behavior before and after the implemented policies. Applying an interrupted time series model, we analyzed changes in trends in overall monthly drug expenditure and antibiotic drug expenditure per prescription for outpatient claims diagnosed with three major diseases before and after the policies' implementation.

RESULTS

Significant price reductions and incentives for more efficient drug prescriptions resulted in an immediate decrease in monthly drug expenditures in clinics. However, we found attenuated effects over the long run. The top-spending clinics showed the highest rate of increase in drug costs.

CONCLUSION

Future policy interventions can maximize their effects by targeting high-spending providers.

Factors influencing the prescription pattern of essential medicines from the perspectives of general practitioners and patients: a qualitative study in China

OBJECTIVES

This qualitative study aimed to explore the factors influencing the prescription patterns of essential medicines (EMs) from the perspectives of general practitioners (GPs) and patients in Beijing, China.

DESIGN

The qualitative study was conducted using individual in-depth interviews.

SETTING

This study was conducted from January to August 2020, in community health service centres (CHSCs) across six urban districts of Beijing, China.

PARTICIPANTS

A total of 17 GPs from 17 CHSCs in 6 urban districts and 22 patients with non-communicable diseases from three CHSCs in the three urban districts of Beijing were recruited using the purposive sampling method and a three-stage sampling strategy, respectively.

RESULTS

Five major themes were identified among factors influencing the prescription pattern of EMs: (1) efficacy and safety of medicines, (2) prescription recommendations from physicians in tertiary or secondary hospitals, (3) patients' medication preference, (4) financial status of patients and (5) minimum requirement for the prescription of EMs.

CONCLUSION

The findings of this study contribute to our understanding of the factors influencing the prescription patterns and utilisation of EMs from the perspectives of GPs and patients, respectively. Policymakers should implement policies and measures to promote the National Essential Medicines System in China.

Lowering drug prices and enhancing pharmaceutical affordability: an analysis of the national volume-based procurement (NVBP) effect in China

To cope with the increasing healthcare costs brought about by the universal health insurance programme, national volume-based procurement (NVBP) was implemented in China to reduce drug prices. However, the impact of NVBP remains unknown. We reported the effects of the NVBP pilot programme on medication affordability and discussed the challenges and recommendations for further reforms. A total of 25 molecules won the bidding in the NVBP pilot programme, and price cuts ranged from 25% to 96%. Medication affordability was measured as the number of days' wages needed to pay for a course of treatment, and the medication was identified as affordable if the cost of a treatment course was less than the average daily wage. After the NVBP, the proportion of affordable drugs increased from 33% to 67%, and the mean affordability improved from 8.2 days' wages to 2.8 days' wages. Specifically, for rural residents, the proportion of affordable drugs increased from 13% to 58%, and the mean affordability improved from 15.7 days' wages to 5.3 days' wages. For urban residents, the proportion of affordable drugs increased from 54% to 71%, and the mean affordability improved from 5.9 days' wages to 2.0 days' wages. Implementing the NVBP substantially improved medication affordability. In future reforms, a multifaceted approach addressing all issues in the health system is needed to enhance medicine access.

Determinants associated with doctors' prescribing behaviors in public hospitals in China

Doctors' prescribing behaviors impact both medical expenses and health resources. This study aims to identify the significant determinants of prescribing behaviors of doctors, which could potentially provide theoretical evidence on how to improve prescribing decisions. A multistage, stratified, cluster, random sampling method was employed in this survey. Data were collected from Jiangsu and Shanxi provinces in China in 2018. A total of 444 doctors in public hospitals completed the self-administered questionnaires. A structural equation model based on the theory of planned behavior (TPB) was adopted for analysis. On the basis of the TPB, we constructed a model of doctors' prescribing behaviors, which explained the subjective and objective reasons for irrational prescribing behavior. Behavioral attitude, subjective norms, and perceived behavioral control could positively influence the actual behaviors, of which subjective norms impact prescribing behaviors the most. Employing the TPB helped in identifying determinants of prescribing behaviors from a new perspective. More significant policy changes and government support are required to help improve appropriate prescribing behaviors and ultimately make better prescribing decisions. This study provided a deeper understanding of this complex issue and will inform the development of a theory and evidence-based intervention for future research.

Factors Influencing Physicians' Clinical Decision-making at Upazila Health Complexes in Bangladesh

Introduction

Selecting the most appropriate treatment for each patient is the key activity in patient-physician encounters and providing healthcare services. Achieving desirable clinical goals mostly depends on making the right decision at the right time in any healthcare setting. But little is known about physicians' clinical decision-making in the primary care setting in Bangladesh. Therefore, this study explored the factors that influence decisions about prescribing medications, ordering pathologic tests, counseling patients, average length of patient visits in a consultation session, and referral of patients to other physicians or hospitals by physicians at Upazila Health Complexes (UHCs) in the country. It also explored the structure of physicians' social networks and their association with the decision-making process.

Methods

This was a cross-sectional descriptive study that used primary data collected from 85 physicians. The respondents, who work at UHCs in the Rajshahi Division, were selected purposively. The collected data were analyzed with descriptive statistics including frequency, percentage, one-way analysis of variance, and linear regression to understand relationships among the variables.

Results

The results of the study reveal that multiple factors influence physicians' decisions about prescribing medications, ordering pathologic tests, length of visits, counseling patients, and referring patients to other physicians or hospitals at the UHCs. Most physicians prescribe drugs to their patients, keeping in mind their purchasing capacity. Risk of violence by patients' relatives and better management are the two key factors that influence physicians' referral decisions. The physicians' professional and personal social networks also play an influential role in the decision-making process. It was found that physicians dedicate on average 16.17 minutes to a patient in a consultation session. The length of visits is influenced by various factors including the distance between the physicians' residence and their workplace, their level of education, and the number of colleagues with whom they have regular contact and from whom they can seek help.

Conclusion

The results of the study have yielded some novel insights about the complexity of physicians' everyday tasks at the UHCs in Bangladesh. The results would be of interest to public health researchers and policy makers.