Comparison of prescribing practices for older adults treated by female versus male physicians: A retrospective cohort study

Associations of clinical personnel characteristics and controlled substance prescribing practices

CONTEXT

Over 68,000 deaths were attributed to opioid-related overdose in 2020. Evaluative studies have shown that states that utilized Prescription Drug Monitoring Program (PDMP) systems have decreased opioid-related deaths. With the growing use of PDMPs and an ongoing opioid epidemic, determining the demographics of physicians at risk of overprescribing can elucidate prescribing practices and inform recommendations to change prescribing behaviors.

OBJECTIVES

This study aims to assess prescribing behaviors by physicians in 2021 based on four demographics utilizing the National Electronic Health Record System (NEHRS): physician's age, sex, specialty, and degree (MD or Doctor of Osteopathic Medicine [DO]).

METHODS

We performed a cross-sectional study of the 2021 NEHRS to determine the relationship between physician characteristics and PDMP use on opioid-prescribing behaviors. Differences between groups were measured via design-based chi-square tests. We constructed multivariable logistic regression models to assess the relationships, via adjusted odds ratios (AOR), between physician characteristics and alternate prescribing patterns.

RESULTS

Compared to female physicians, male physicians were more likely to alter their original prescription to reduce morphine milligram equivalents (MMWs) prescribed for a patient (AOR: 1.60; CI: 1.06-2.39; p=0.02), to change to a nonopioid/nonpharmacologic option (AOR: 1.91; 95 % CI: 1.28-2.86; p=0.002), to prescribe naloxone (AOR=2.06; p=0.039), or to refer for additional treatment (AOR=2.07; CI: 1.36-3.16; p<0.001). Compared to younger physicians, those over the age of 50 were less likely to change their prescription to a nonopioid/nonpharmacologic option (AOR=0.63; CI: 0.44-0.90; p=0.01) or prescribe naloxone (AOR=0.56, CI: 0.33-0.92; p=0.02).

CONCLUSIONS

Our results showed a statistically significant difference between specialty category and frequency of prescribing controlled substances. After checking the PDMP, male physicians were more likely to alter their original prescription to include harm-reduction strategies. Optimizing the use of PDMP systems may serve to improve prescribing among US physicians.

Exploring physician gender bias in the initiation of prescribing cascades for older men and women: a qualitative clinical vignette study protocol

INTRODUCTION

A prescribing cascade occurs when a drug is prescribed to manage the often unrecognised side effect of another drug; these cascades are of particular concern for older adults who are at heightened risk for drug-related harm. It is unknown whether, and to what extent, gender bias influences physician decision-making in the context of prescribing cascades. The aim of this transnational study is to explore the potential impact of physician implicit gender biases on prescribing decisions that may lead to the initiation of prescribing cascades in older men and women in two countries, namely: Canada and Italy.

METHODS AND ANALYSIS

Male and female primary care physicians at each site will be randomised 1:1 to a case vignette that features either a male or female older patient who presents with concerns consistent with the side effect of a medication they are taking. During individual interviews, while masked to the true purpose of the study, participants will read the vignette and use the think-aloud method to describe their ongoing thought processes as they consider the patient's concerns and determine a course of action. Interviews will be recorded, transcribed verbatim and thematic analysis will be conducted to highlight differences in decisions in the interviews/transcripts, using a common analytical framework across the sites.

ETHICS AND DISSEMINATION

This study has received ethics approval at each study site. Verbal informed consent will be received from participants prior to data collection and all data will be deidentified and stored on password-protected servers. Results of this study will be disseminated through peer-reviewed journal articles and presented at relevant national and international conferences.

Emergency physician gender is associated with early pregnancy loss management: a multisite retrospective cohort study

BACKGROUND

Patients experiencing early pregnancy loss often first present to the emergency department (ED) where they can be managed non-operatively through expectant or medical management, or surgically by the obstetrical team. Studies have reported that physician gender can influence clinical decision making, but there is limited research on this phenomenon in the ED. The objective of this study was to determine whether emergency physician gender is associated with early pregnancy loss management.

METHODS

Data were retrospectively collected from patients who presented to Calgary EDs with a non-viable pregnancy from 2014 to 2019. Pregnancies >12 weeks gestational age were excluded. The emergency physicians included saw at least 15 cases of pregnancy loss over the study period. The primary outcome was obstetrical consult rates by male versus female emergency physicians. Secondary outcomes included rates of initial surgical evacuation via dilation and curettage (D&C) procedures, ED returns, returns to care for D&Cs and total D&C rates. Data were analysed using χ², Fisher's exact and Mann-Whitney U tests, as appropriate. Multivariable logistic regression models accounted for physician age, years of practice, training programme and type of pregnancy loss.

RESULTS

98 emergency physicians and 2630 patients from 4 ED sites were included. 76.5% of the physicians were male accounting for 80.4% of pregnancy loss patients. Patients seen by female physicians were more likely to receive an obstetrical consultation (adjusted OR (aOR) 1.50, 95% CI 1.22 to 1.83) and initial surgical management (aOR 1.35, 95% CI 1.08 to 1.69). ED return rates and total D&C rates were not associated with physician gender.

CONCLUSION

Patients seen by female emergency physicians had higher rates of obstetrical consultation and initial operative management compared with those seen by male emergency physicians, but outcomes were similar. Additional research is required to determine why these gender differences exist and how these discrepancies may impact the care of early pregnancy loss patients.

A comparison of family physician and dermatologist topical corticosteroid prescriptions: A population-based cross-sectional study

BACKGROUND

Topical corticosteroids (TCS) are commonly prescribed to treat inflammatory skin diseases, and appropriate prescription is necessary for treatment success.

OBJECTIVE

To quantify differences between TCS prescribed by dermatologists at consultation and family physicians for patients treated for any skin condition.

METHODS

Using administrative health data in Ontario, we included all Ontario Drug Benefit recipients who filled at least one TCS prescription from a dermatologist at consultation and a family physician in the year prior between January 2014 and December 2019. We estimated mean differences and 95% confidence intervals in amount (in grams) and potency between the index dermatologist prescription and the highest and most recent family physician prescription amounts and potencies in the preceding year using linear mixed-effect models.

RESULTS

A total of 69,335 persons were included. The mean dermatologist amount was 34% larger than the highest amount and 54% larger than the most recent amount prescribed by family physicians. There were small but statistically significant differences in potency using established 7-category and 4-category potency classification systems.

CONCLUSIONS

Compared to family physicians, dermatologists prescribed substantially larger amounts and similarly potent TCS at consultation. Further research is needed to determine the effect of these differences on clinical outcomes.

Prescribing decision making by medical residents on night shifts: A qualitative study

INTRODUCTION

Prescribing of medications with well-known adverse effects, like antipsychotics or benzodiazepines, during hospitalisation is extremely common despite guideline recommendations against their use. Barriers to optimal prescribing, including perceived pressure from allied health professionals and fatigue, may be particularly pronounced for less experienced medical residents, especially during night shifts when these medications are often prescribed. Under these circumstances, physicians may be more likely to use 'quick', often referred to as System 1 choices, rather than 'considered' System 2 strategies for decisions. Understanding how medical residents use, these different cognitive approaches could help develop interventions to improve prescribing.

METHODS

To understand decision-making and contextual contributors that influence suboptimal prescribing during night coverage by medical residents, we conducted semi-structured qualitative interviews with residents in general medicine inpatient settings. The interviews elicited perspectives on shift routines, stressful situations, factors influencing prescribing decision making and hypothetical measures that could improve prescribing. Interviews were audio-recorded and transcribed. Data were analysed using codes developed by the team to generate themes using immersion/crystallisation approaches.

RESULTS

We conducted interviews with 21 medical residents; 47% were female, 43% were White, and 43% were Asian. We identified five key themes: (i) time pressures affecting prescribing decisions, (ii) fears of judgement by senior physicians and peers and being responsible for patient outcomes, (iii) perceived pressure from nursing staff, amplified by nurses' greater experience, (iv) clinical acuity as a key factor influencing prescribing, and (v) strategies to improve communication between members of the care team, like ensuring adequate hand-off by day teams.

CONCLUSION

Medical residents highlighted numerous contextual factors that promote quick thinking rather than slower thinking when prescribing on night shifts, particularly time constraints, perceived pressure and patient clinical acuity. Interventions aimed at reducing prescribing should address how to manage stress and perceived pressure in decision making.

Latent Class Analysis of Prescribing Behavior of Primary Care Physicians in the Veterans Health Administration

BACKGROUND

Benzodiazepines, opioids, proton-pump inhibitors (PPIs), and antibiotics are frequently prescribed inappropriately by primary care physicians (PCPs), without sufficient consideration of alternative options or adverse effects. We hypothesized that distinct groups of PCPs could be identified based on their propensity to prescribe these medications.

OBJECTIVE

To identify PCP groups based on their propensity to prescribe benzodiazepines, opioids, PPIs, and antibiotics, and patient and PCP characteristics associated with identified prescribing patterns.

DESIGN

Retrospective cohort study using VA data and latent class regression analyses to identify prescribing patterns among PCPs and examine the association of patient and PCP characteristics with class membership.

PARTICIPANTS

A total of 2524 full-time PCPs and their patient panels (n = 2,939,636 patients), from January 1, 2017, to December 31, 2018.

MAIN MEASURES

We categorized PCPs based on prescribing volume quartiles for the four drug classes, based on total days' supply dispensed of each medication by the PCP to their patients (expressed as days' supply per 1000 panel patient-days). We used latent class analysis to group PCPs based on prescribing and used multinomial logistic regression to examine patient and PCP characteristics associated with latent class membership.

KEY RESULTS

PCPs were categorized into four groups (latent classes): low intensity (23% of cohort), medium-intensity overall/high-intensity PPI (36%), medium-intensity overall/high-intensity opioid (20%), and high intensity (21%). PCPs in the high-intensity group were predominantly in the highest quartile of prescribers for all four drugs (68% in the highest quartile for benzodiazepine, 86% opioids, 64% PPIs, 62% antibiotics). High-intensity PCPs (vs. low intensity) were substantially less likely to be female (OR: 0.30, 95% CI: 0.21-0.42) or practice in the northeast versus other census regions (OR: 0.10, 95% CI: 0.06-0.17).

CONCLUSIONS

VA PCPs can be classified into four clearly differentiated groups based on their prescribing of benzodiazepines, opioids, PPIs, and antibiotics, suggesting an underlying typology of prescribing. High-intensity PCPs were more likely to be male.

Physician Gender and Its Association With Patient Satisfaction and Visit Length: An Observational Study in Telemedicine

Introduction

Female physicians conduct longer visits than male physicians, with negative implications for their compensation. Yet patients often report higher satisfaction with female physicians. It is unknown whether satisfaction scores for female physicians are associated with their visit lengths. Our objective was to characterize the role of the physician and patient gender with respect to visit length and patient satisfaction.

Methods

We conducted an observational cohort study with patients and physicians of a nationwide telemedicine service between 2016 and 2018. Visit length was measured by the telemedicine system. Patients rated physicians on scales of one to five stars, with five considered “top box” satisfaction. We used logistic regression to estimate differences in patient satisfaction and linear regression to estimate differences in visit length by the physician and patient gender. We tested interactions between physician and patient gender and accounted for clustering by the physician.

Results

Among 102,664 visits with 405 physicians, the mean visit length was 5.8 minutes. Visits with male physicians were 1.11 minutes shorter than those with female physicians (95% CI:-1.58, -0.65). Controlling for visit length, male physicians were less likely than female physicians to receive top-box satisfaction scores (OR: 0.72; 95% CI: 0.61, 0.85). Visits between female physicians and male patients were the longest and visits between male physicians and female patients were the shortest. Female physicians had longer visits than male physicians but this did not explain their higher satisfaction scores.

Conclusions

To reduce inequity in compensation resulting from differences in visit length, female physicians could shorten their visits without negative consequences for their satisfaction ratings.

Evaluation of Factors Associated With Appropriate Drug Prescription and Effectiveness of Informative and Educational Interventions—The EDU.RE.DRUG Project

Background: EDU.RE.DRUG study is a prospective, multicentre, open-label, parallel-arm, controlled, pragmatic trial directed to general practitioners (GPs) and their patients.

Methods: The study data were retrieved from health-related administrative databases of four local health units (LHUs) of Lombardy and four LHUs in Campania. According to the LHUs, the GPs/patients were assigned to (A) intervention on both GPs (feedback reports about appropriate prescribing among their patients and online courses) and patients (flyers and posters on proper drug use), (B) intervention on GPs, (C) intervention on patients, and (D) no intervention (control arm). A set of appropriate prescribing indicators (potential drug–drug interactions [pDDIs], potential and unnecessary therapeutic duplicates [pTDs], and inappropriate prescriptions in the elderly [ERD-list]) were measured at baseline and after the intervention phase. The effectiveness of the intervention was evaluated estimating the absolute difference in percentages of selected indicators carrying out linear random-intercept mixed-effect models.

Results: A cohort of 3,586 GPs (2,567 in intervention groups and 1,019 in the control group) was evaluated. In Campania, the mean pre-intervention percentage of patients with at least one pDDI was always greater than 20% and always lower than 15% in Lombardy. The pre–post difference was quite heterogeneous among the LHUs, ranging from 1.9 to −1.4 percentage points. The mean pre-intervention percentage of patients with pTDs ranged from 0.59 to 2.1%, with slightly higher values characterizing Campania LHUs. The magnitude of the pre–post difference was very low, ranging from −0.11 to 0.20. In Campania, the mean pre-intervention percentage of patients with at least one ERD criterium was considerably higher than in Lombardy (approximately 30% in Lombardy and 50% in Campania). The pre–post difference was again quite heterogeneous. The results from the models accounting for GP geographical belonging suggested that none of the interventions resulted in a statistically significant effect, for all the three indicators considered.

Conclusion: The proposed strategy was shown to be not effective in influencing the voluntary changes in GP prescription performance. However, the use of a set of explicit indicators proved to be useful in quantifying the inappropriateness. Further efforts are needed to find more efficient strategies and design more tailored interventions.

Association of clinical competence, specialty and physician country of origin with opioid prescribing for chronic pain: a cohort study

Background

Although little is known about why opioid prescribing practices differ between physicians, clinical competence, specialty training and country of origin may play a role. We hypothesised that physicians with stronger clinical competence and communication skills are less likely to prescribe opioids and prescribe lower doses, as do medical specialists and physicians from Asia.

Methods

Opioid prescribing practices were examined among international medical graduates (IMGs) licensed to practise in the USA who evaluated Medicare patients for chronic pain problems in 2014–2015. Clinical competence was assessed by the Educational Commission for Foreign Medical Graduates (ECFMG) Clinical Skills Assessment. Physicians in the ECFMG database were linked to the American Medical Association Masterfile. Patients evaluated for chronic pain were obtained by linkage to Medicare outpatient and prescription files. Opioid prescribing was measured within 90 days of evaluation visits. Prescribed dose was measured using morphine milligram equivalents (MMEs). Generalised estimating equation logistic and linear regression estimated the association of clinical competence, specialty, and country of origin with opioid prescribing and dose.

Results

7373 IMGs evaluated 65 012 patients for chronic pain; 15.2% received an opioid prescription. Increased clinical competence was associated with reduced opioid prescribing, but only among female physicians. For every 10% increase in the clinical competence score, the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94) but not male physicians (OR 0.99, 95% CI 0.92 to 1.07). Country of origin was associated with prescribed opioid dose; US and Canadian citizens prescribed higher doses (adjusted MME difference +3.56). Primary care physicians were more likely to prescribe opioids, but surgical and hospital-based specialists prescribed higher doses.

Conclusions

Clinical competence at entry into US graduate training, physician gender, specialty and country of origin play a role in opioid prescribing practices.

Sex- and Gender-Based Pharmacological Response to Drugs

In humans, the combination of all sex-specific genetic, epigenetic, and hormonal influences of biologic sex produces different in vivo environments for male and female cells. We dissect how these influences of sex modify the pharmacokinetics and pharmacodynamics of multiple drugs and provide examples for common drugs acting on specific organ systems. We also discuss how gender of physicians and patients may influence the therapeutic response to drugs. We aim to highlight sex as a genetic modifier of the pharmacological response to drugs, which should be considered as a necessary step toward precision medicine that will benefit men and women. SIGNIFICANCE STATEMENT: This study discusses the influences of biologic sex on the pharmacokinetics and pharmacodynamics of drugs and provides examples for common drugs acting on specific organ systems. This study also discusses how gender of physicians and patients influence the therapeutic response to drugs.

Resident-Level Predictors of Dementia Pharmacotherapy at Long-Term Care Admission: The Impact of Different Drug Reimbursement Policies in Ontario and Saskatchewan: Prédicteurs de la pharmacothérapie de la démence au niveau des résidents lors de l'hospitalisation dans des soins de longue durée : l'impact de différentes politiques de remboursement des médicaments en Ontario et en Saskatchewan

OBJECTIVES

Cholinesterase inhibitors (ChEIs) and memantine are approved for Alzheimer disease in Canada. Regional drug reimbursement policies are associated with cross-provincial variation in ChEI use, but it is unclear how these policies influence predictors of use. Using standardized data from two provinces with differing policies, we compared resident-level characteristics associated with dementia pharmacotherapy at long-term care (LTC) admission.

METHODS

Using linked clinical and administrative databases, we examined characteristics associated with dementia pharmacotherapy use among residents with dementia and/or significant cognitive impairment admitted to LTC facilities in Saskatchewan (more restrictive reimbursement policies; n = 10,599) and Ontario (less restrictive; n = 93,331) between April 1, 2009, and March 31, 2015. Multivariable logistic regression models were utilized to assess resident demographic, functional, and clinical characteristics associated with dementia pharmacotherapy.

RESULTS

On admission, 8.1% of Saskatchewan residents were receiving dementia pharmacotherapy compared to 33.2% in Ontario. In both provinces, residents with severe cognitive impairment, aggressive behaviors, and recent antipsychotic use were more likely to receive dementia pharmacotherapy; while those who were unmarried, admitted in later years, had a greater degree of frailty, and recent hospitalizations were less likely. The direction of the association for older age, rural residency, medication number, and anticholinergic therapy differed between provinces.

CONCLUSIONS

While more restrictive criteria for dementia pharmacotherapy coverage in Saskatchewan resulted in fewer residents entering LTC on dementia pharmacotherapy, there were relatively few differences in the factors associated with use across provinces. Longitudinal studies are needed to assess how differences in prevalence and characteristics associated with use impact patient outcomes.

Influence of Physician Sex and Gender on Prescribing Practices Among Older Adults

Although prescribing is the most common intervention provided by physicians, limited research has examined the role of physician sex and gender on prescribing practices. In this article, we briefly summarize research relating to differences in prescribing behaviors based on physician sex and gender. To identify articles, PubMed was searched for studies from the last 20 years reporting on prescribing differences by physician sex or gender for the general population and specifically for older adults. We describe major themes emerging from the studies, illustrate findings from key studies, and note the major gaps in the literature, notably the lack of evidence on prescribing for older adults. Given the paucity of research in this area, we also explore evidence on the impact of physician sex and gender on other aspects of healthcare delivery, such as communication within the patient-physician relationship, and consider how these findings may also apply to prescribing behaviors. In general, we note that female physicians have been observed to engage in more careful and conservative healthcare provision including prescribing. A careful and conservative approach to prescribing may reduce the incidence of adverse drug events in older adults and be linked to a more patient-centered approach to care. To what extent these differences in prescribing are important for patient health outcomes is unknown, and further research is required to identify optimal prescribing practices that minimize harms.

The Effect of Expert Feedback on Antibiotic Prescribing in Pediatrics: Experimental Evidence

Background. Inappropriate prescribing of antibiotics, which is common in pediatric care, is a key driver of antimicrobial resistance. To mitigate the development of resistance, antibiotic stewardship programs often suggest the inclusion of feedback targeted at individual providers. Empirically, however, it is not well understood how feedback affects individual physicians’ antibiotic prescribing decisions. Also, the question of how physicians’ characteristics, such as clinical experience, relate to antibiotic prescribing decisions and to responses to feedback is largely unexplored. Objective. To analyze the causal effect of descriptive expert feedback (and individual characteristics) on physicians’ antibiotic prescribing decisions in pediatrics. Design. We employed a randomized, controlled framed field experiment, in which German pediatricians (n=73) decided on the length of first-line antibiotic treatment for routine pediatric cases. In the intervention group (n=39), pediatricians received descriptive feedback in form of an expert benchmark, which allowed them to compare their own prescribing decisions with expert recommendations. The recommendations were elicited in a survey of pediatric department directors (n=20), who stated the length of antibiotic therapies they would choose for the routine cases. Pediatricians’ characteristics were elicited in a comprehensive questionnaire. Results. Providing pediatricians with expert feedback significantly reduced the length of antibiotic therapies by 10% on average. Also, the deviation of pediatricians’ decisions from experts’ recommendations significantly decreased. Antibiotic therapy decisions were significantly related to pediatricians’ clinical experience, risk attitudes, and personality traits. The effect of feedback was significantly associated with physicians’ experience. Conclusion. Our results indicate that descriptive expert feedback can be an effective means to guide pediatricians, especially those who are inexperienced, toward more appropriate antibiotic prescribing. Therefore, it seems to be suitable for inclusion in antibiotic stewardship programs.