Pressures on the general practitioner and decisions to prescribe

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

Background

How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made.

Method

The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors.

Results

Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades.

Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing.

Conclusion

Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01574-x.

Determinants of Medical Practice Variation Among Primary Care Physicians: Protocol for a Three Phase Study

BACKGROUND

One of the greatest challenges of modern health systems is the choice and use of resources needed to diagnose and treat patients. Medical practice variation (MPV) is a broad term which entails the differences between health care providers inclusive of both the overuse and underuse. In this paper, we describe a 3-phase research protocol examining MPV in primary care.

OBJECTIVE

We aim to identify the potential targets for behavioral modification interventions to reduce the variation in practice patterns and thus improve health care, decrease costs, and prevent disparities in care.

METHODS

The first phase will delineate the variation in primary care practice over a wide range of services and long follow-up period (2003-2017), the second will examine the 3 determinants of variation (ie, patient, physician, and clinic characteristics), and attempt to derive the unexplained variance. In the third phase, we will assess a novel component that might contribute to the previously unexplained variance - the physicians' personal behavioral characteristics (such as risk aversion, fear of malpractice, stress from uncertainty, empathy, and burnout).

RESULTS

This work was supported by the research grant from Israel National Institute for Health Policy Research (Grant No. 2014/134). Soroka University Medical Center Institutional Ethics Committee has approved the updated version of the study protocol (SOR-14-0063) in February 2019. All relevant data for phases 1 and 2, including patient, physician, and clinic, were collected from the Clalit Health Services data set in 2019 and are currently being analyzed. The evaluation of the individual physician characteristics (eg, risk aversion) by the face-to-face questionnaires was started on 2018 and remains in progress. We intend to publish the results during 2020-2021.

CONCLUSIONS

Based on the results of our study, we aim to propose a list of potential targets for focused behavioral intervention. Identifying new targets for such an intervention can potentially lead to a decrease in the unwarranted variation in the medical practice. We suggest that such an intervention will result in optimization of the health system, improvement of health outcomes, reduction of disparities in care and savings in cost.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18673.

Knowledge, attitudes and practice preference regarding drug prescriptions of resident dental doctors: A quantitative study

BACKGROUND

There has been an increasing need to examine undergraduate dental education in prescribing to confirm whether it is establishing the goal of producing safe and rational prescribers. Prescribing by dental doctors after graduation is influenced by a variety of factors: the different teaching approaches of the professors at the clinics and in the pharmacology course, fellow colleagues and even the information provided by the pharmaceutical industry.

OBJECTIVE

The aim of this study was to assess the prescription knowledge, attitude, preference and common errors made by junior resident dental doctors in the dental department of two medical colleges and hospitals in India.

METHODS

Dental graduates (n = 70) who served as junior resident doctors at dental departments and graduated from various dental colleges in India, participated in the study. A survey was conducted among 70 junior resident dental doctors in the dental department, applying a previously validated questionnaire consisting of open-ended questions. The knowledge, attitude and practice preference of resident doctors regarding drug prescription and common errors made by them were analyzed and reviewed.

RESULTS

The most frequent response to each question was considered the most significant. The most common reason for prescribing medication was infection (n = 33, 47.14%) and the most widely prescribed antibiotic was amoxicillin (n = 29, 41.42%). The most frequent error reported by resident doctors was lack of knowledge about drug posology (n = 31, 44.28%). Maximum number of junior doctors acquired the information for prescribing drugs from their faculty (n = 33, 47.14%). Around 45.71% dental doctors had no knowledge about the WHO Guide to Good Prescribing. About 50- 60% doctors had knowledge about the dose, frequency, duration and route of administration of the drug prescribed. While prescribing drugs to the patient, 25.71% doctors explain the disease and treatment properly to the patient; 24.28% doctors do not criticize other doctors, and 10% doctors address the patient by name.

CONCLUSION

The results of this study indicate that resident dental doctors' knowledge, attitudes and behavior about the drug prescription need to be improved. More studies are needed to determine whether this issue affects the quality of patient care and the effectiveness and safety of treatments.

Drug prescriptions in Danish out-of-hours primary care: a 1-yearpopulation-based study

OBJECTIVE

General practitioners are the first point of contact in Danish out-of-hours (OOH) primary care. The large number of contacts implies that prescribing behaviour may have considerable impact on health-care expenditures and quality of care. The aim of this study was to examine the prevailing practices for medication prescription in Danish OOH with a particular focus on patient characteristics and contact type.

DESIGN AND SETTING

A one-year population-based retrospective observational study was performed of all contacts to OOH primary care in the Central Denmark Region using registry data.

MAIN OUTCOME MEASURES

Prescriptions were categorised according to Anatomical Therapeutic Chemical Classification (ATC) codes and stratified for patient age, gender and contact type (telephone consultation, clinic consultation or home visit). Prescription rates were calculated as number of prescriptions per 100 contacts.

RESULTS

Of 644,777 contacts, 154,668 (24.0%) involved medication prescriptions; 21.9% of telephone consultations, 32.9% of clinic consultations and 14.3% of home visits. Around 53% of all drug prescriptions were made in telephone consultations. Anti-infective medications for systemic use accounted for 45.5% of all prescriptions and were the most frequently prescribed drug group for all contact types, although accounting for less than 1/3 of telephone prescriptions. Other frequently prescribed drugs were ophthalmological anti-infectives (10.5%), NSAIDs (6.4%), opioids (3.9%), adrenergic inhalants (3.0%) and antihistamines (2.3%).

CONCLUSION

About 25% of all OOH contacts involved one or more medication prescriptions. The highest prescription rate was found for clinic consultations, but more than half of all prescriptions were made by telephone. KEY POINTS As the out-of-hours (OOH) primary care services cover more than 75% of all hours during a normal week, insight into the extent and type of OOH drug prescription is important. General practitioners (GPs) are responsible for more than 80% of all drug prescriptions in Denmark. Of all contacts 24.0% involved medication prescriptions; 21.9% of telephone consultations, 32.9% of clinic consultations and 14.3% of home visits. Of all prescriptions, 53% were made in telephone consultations. Anti-infective medications for systemic use accounted for 45.5% of all prescriptions, thereby being the most frequently prescribed drug group for all three contact types.

Drug prescription by telephone consultation in Danish out-of-hours primary care: a population-based study of frequency and associations with clinical severity and diagnosis

Background

Danish general practitioners (GPs) answer all calls to the out-of-hours primary care service. About 60% of the calls are terminated on the telephone through provision of medical advice and prescription of medication. Nevertheless, little is known about the prescription patterns of telephone consultations, such as prescription frequency and indications for drug use. Our aim was to examine the characteristics of patients and GPs in telephone consultations resulting in drug prescription.

Methods

The study was based on a 12-month survey on reasons for encounter in the Danish out-of-hours primary care service. A total of 385 GPs (55.5% of all GPs from Central Denmark Region on duty during a year) participated in answering electronic pop-up questionnaires integrated in the electronic patient administration system. The questionnaires contained items on reasons for encounter (e.g. existing chronic disease or new health problem), diagnoses, and GP-assessed severity of the health problem. Data on time of contact, patient gender and age, and prescribed medication (Anatomic Therapeutic Chemical classifications) for telephone consultations were obtained from the patient administration system. Differences in characteristics of patients, general practitioners, and contacts were examined, and associations with prescribed medication were analysed using a multivariate analysis with prevalence ratios.

Results

Medication was prescribed in 19.9% of the included 4,173 telephone consultations; antibiotics and analgesics were prescribed most frequently (10.8% and 2.5%, respectively). GPs tended to assess contacts resulting in antibiotic prescription as more severe than other contacts. For high-severity contacts, there was a lower likelihood for prescription (prevalence ratio = 0.28 (0.16-0.47)). Children aged 0-4 years had lower probability of receiving a prescription compared with patients aged 18-40 years. The prescription rate was highest during the first four hours of the opening hours of the out-of-hours primary care service.

Conclusion

One in five of all telephone consultations involved drug prescription; antibiotics constituted half of these prescriptions. Drug prescription by telephone was less likely to be offered in cases involving ‘severe’ reason for encounter or children. This study calls for further studies of drug prescriptions issued via out-of-hours primary care telephone consultations.

The discomfort caused by patient pressure on the prescribing decisions of hospital prescribers

BACKGROUND

The influence of patient expectations and demands on the decisions of prescribers in general practice has been associated with irrational prescribing and lack of evidence-based practice. However, to our knowledge, no one has investigated patient pressure to prescribe in secondary care.

OBJECTIVES

To investigate the influences on hospital prescribers' decisions by exploring what they found uncomfortable when prescribing.

METHODS

Qualitative interviews with 48 prescribers of varying seniority from 4 hospitals were conducted. Interviews were based on the critical incident technique, and prescribers were asked, before an interview, to remember any uncomfortable prescribing decisions that they had made; these were then discussed in detail during an interview. This approach allowed the interviewer to explore the more general influences on the decision to prescribe. Interviews were tape recorded and transcribed verbatim. A grounded theory approach to data analysis was taken.

RESULTS

Prescribers discussed various factors that could provoke feelings of discomfort when prescribing. Pressure on the prescribing decision from patients, relatives, or carers was a major theme, and more than half of interviewees discussed discomfort caused by such perceived pressure on the prescribing decision. How prescribers dealt with this pressure varied with seniority and the type of relationship that they had fostered with the patient. Nearly half of all incidents of patient pressure resulted in the patient being prescribed the medication they requested. Yet, many of these requests were deemed inappropriate by the prescriber. Their reasons for capitulation varied but included maintaining a good prescriber-patient relationship and avoiding conflict in the wider health care team.

CONCLUSIONS

Pressure from patients, relatives, or carers was an uncomfortable influence on these hospital prescribers' prescribing decisions. Increasingly consumer-driven health care will intensify these issues in the future. We advocate further research, focusing on managing patient demands and improving prescribers' coping strategies.

Influence exerted on drug prescribing by patients' attitudes and expectations and by doctors' perception of such expectations: a cohort and nested case-control study

RATIONALE, AIMS AND OBJECTIVES

Although demand for medication is regarded as one of the most important factors in pharmaceutical expenditure, little is known about patients' influence on drug prescribing. This study assesses the influence exerted on drug prescribing by patients' attitudes and expectations, and by doctors' perception of such expectations.

METHOD

We conducted a population-based cohort study covering 937 subjects attending a health centre in the northwest of Spain. Prescription-drug advertising directly targeted at patients is banned in Spain. We conducted home-based interviews at the start of follow-up to assess patients' attitudes, and monthly telephone interviews during the 1-year follow-up period to assess consumption of medical drugs and medical visits. Using nested case-control study covering 127 of the cohort subjects who attended the health centre, we assessed patients' pre-consultation expectations for prescriptions, doctors' perception of such patients' expectations, and the drugs actually prescribed.

RESULTS

Of the total sample, 69.3% answered the home-based questionnaire, 77.6% completed 11 or more months of follow-up, and 100% of cohort subjects who attended the health centre responded to the pre-consultation survey conducted in the waiting room. Patients' attitudes, though not associated with prescription (P > 0.1), were, however, associated with demand for medical consultation (P < 0.01), self-medication (P < 0.01) and prescription expectations (P < 0.01). Although doctors' perception of patients' expectations did indeed show an association with drug prescribing (P = 0.001), there was no association between patients' expectations and doctors' perception of such expectations (P > 0.1), as these tended to be overestimated by doctors.

CONCLUSION

We conclude that, although doctors prescribe in accordance with what they believe their patients expect, in practice patients exert no influence on drug prescribing because their prescription expectations are misconstrued by doctors, who overestimate them.

The effects of communication skills training on pediatricians' and parents' communication during "sick child" visits

This article reports the development and evaluation of a physician-parent communication skills training program designed to improve communication regarding antibiotic prescribing for children. Four pediatricians and 81 parents participated in the study, which involved audiotaping "sick child" office visits and then coding transcripts for evidence of program influence on information seeking, giving, and verifying, as well as relational communication. Parents who received training were more likely to verify information, t(79) = 1.82, p = .04, and more likely to express concerns, t(79) = 1.79, p = .04, than were parents who did not receive training; there was a nonsignificant trend for trained parents to be more likely to give information, t(79) = 1.7, p = .051. In terms of physician behavior, there were nonsignificant trends for physicians to spend more time creating a partnership with parents after training than before training, t(3) = 2.29, p = .053, and to encourage more questions from parents after training than before, t(3) = 2.15, p = .06. In addition, once one outlier parent in the control condition was removed from the analysis, the results showed that physicians spent more time addressing treatment options after training than before, t(3) = 2.9, p = .03. The results of this study are considered promising, with effects shown for various important elements of physician-parent communication. Implications of results and directions for future research are discussed.

Prevalence of the use of cancer related self-tests by members of the public: a community survey

BACKGROUND

Self-tests are those where an individual can obtain a result without recourse to a health professional, by getting a result immediately or by sending a sample to a laboratory that returns the result directly. Self-tests can be diagnostic, for disease monitoring, or both. There are currently tests for more than 20 different conditions available to the UK public, and self-testing is marketed as a way of alerting people to serious health problems so they can seek medical help. Almost nothing is known about the extent to which people self-test for cancer or why they do this. Self-tests for cancer could alter perceptions of risk and health behaviour, cause psychological morbidity and have a significant impact on the demand for healthcare. This study aims to gain an understanding of the frequency of self-testing for cancer and characteristics of users.

METHODS

Cross-sectional survey. Adults registered in participating general practices in the West Midlands Region, will be asked to complete a questionnaire that will collect socio-demographic information and basic data regarding previous and potential future use of self-test kits. The only exclusions will be people who the GP feels it would be inappropriate to send a questionnaire, for example because they are unable to give informed consent. Freepost envelopes will be included and non-responders will receive one reminder. Standardised prevalence rates will be estimated.

DISCUSSION

Cancer related self-tests, currently available from pharmacies or over the Internet, include faecal occult blood tests (related to bowel cancer), prostate specific antigen tests (related to prostate cancer), breast cancer kits (self examination guide) and haematuria tests (related to urinary tract cancers). The effect of an increase in self-testing for cancer is unknown but may be considerable: it may affect the delivery of population based screening programmes; empower patients or cause unnecessary anxiety; reduce costs on existing healthcare services or increase demand to investigate patients with positive test results. It is important that more is known about the characteristics of those who are using self-tests if we are to determine the potential impact on health services and the public.

Prevalence and determinants of the use of self-tests by members of the public: a mixed methods study

Background

Self-tests can be used by members of the public to diagnose conditions without involving a doctor, nurse or other health professional. As technologies to design and manufacture diagnostic tests have developed, a range of self-tests have become available to the public to buy over-the-counter and via the Internet. This study aims to describe how many people have used self-tests and identify factors associated with their use.

Methods

A postal questionnaire will elicit basic information, including sociodemographic characteristics, and whether the person has used or would use specified self-tests. Consent will be sought to recontact people who want to participate further in the study, and interviews and focus groups will be used to develop hypotheses about factors associated with self-test use. These hypotheses will be tested in a case-control study. An in-depth questionnaire will be developed incorporating the identified factors. This will be sent to: people who have used a self-test (cases); people who have not used a self-test but would use one in the future (controls); and people who have not used and would not use a self-test (controls). Logistic regression analysis will be used to establish which factors are associated with self-test use.

Discussion

Self-tests do have potential benefits, for example privacy and convenience, but also potential harms, for example delay seeking treatment after a true negative result when the symptoms are actually due to another condition. It is anticipated that the outcomes from this study will include recommendations about how to improve the appropriate use of self-tests and existing health services, as well as information to prepare health professionals for patients who have used self-tests.

Knowledge and beliefs of primary care physicians, pharmacists, and parents on antibiotic use for the pediatric common cold

The aim of this study is to investigate knowledge and beliefs of primary care physicians (e.g. family practitioners and pediatricians), pharmacists, and parents regarding the use of antibiotics for the pediatric common cold, using a self-administered questionnaire for physicians and pharmacists and a telephone interview for parents. This article suggests that parents' expectation for antibiotics is a minor factor, and health care providers' unfounded beliefs in the effectiveness of antibiotics and exaggeration of parents' demand for antibiotics may be the major contributing factor underlying antibiotic over-prescription for the pediatric common cold in Korea. Most physicians and pharmacists knew the correct cause of the pediatric common cold, but majorities of the physicians and pharmacists believed that antibiotics could treat and reduce its complications. On the other hand, 34% of the parents believed that antibiotics could prevent complications. Seventy three per cent of the physicians reported that they perceived expectations for antibiotics from parents, but only 2% of the parents reported asking their physicians for antibiotics. In summary, this study suggests that physicians' knowledge and faulty beliefs can be more important factors for inappropriate antibiotic prescription.

Médicament et vieillesse

Cet article emprunte une approche socioculturelle de la problématique de la vieillesse par rapport au médicament. Il appréhende avec un regard critique le phénomène « médicament » à travers trois énoncés de relations : le « médicament-obligation » comme qualificatif de la relation des personnes âgées au médicament ; le « médicament-concession » en tant que trame de fond de la relation thérapeutique entre médecin et patient âgé ; le « médicament-compassion », enfin, comme métaphore du rôle des médicaments psychotropes en lien avec le statut de la vieillesse dans nos sociétés occidentales avancées.

[A system, developed by prescribing doctors, of indicators of the quality of pharmaceutical prescription in primary care]

OBJECTIVE

To work out a system of indicators and standards, designed by means of a consensus group of general practitioners, that enables evaluation of the quality of Primary Care prescription to be improved. Design. Informal consensus method.

SETTING

A PC area in Asturias with 156 614 inhabitants and 9 health centres.Participants. Nine PC doctors accepted voluntarily to take part in the project.

METHOD

A consensus group of nine PC doctors was formed. At a first meeting they worked out some potential indicators of quality of prescription. After applying these indicators to the prescription data, a second meeting was held, at which the results of applying the indicators along with criteria of excellence were used to establish the definitive indicators and their numerical values of optimum compliance.

RESULTS

It was possible to agree by consensus 11 indicators of quality of prescription and their values of optimum compliance. Eight of the indicators referred to choice of a medicine within a pharmaco-therapeutic group; and three, to groups in which the volume of prescription may suggest improper usage.

CONCLUSIONS

It is feasible for PC doctors to reach a consensus on a group of criteria that is perceived as valid for measuring quality of prescription and which includes certain impalpable values for determining quality.

Current Management Issues Associated with Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is a significant cause of morbidity, mortality, and increased cost. Despite numerous managementguidelines, CAP continues to existas a challenge to the learned clinician. Due to a lack of sensitive diagnostic testing, causative pathogens are often not identified, making most therapy empiric. Increasing levels of bacterial resistance to available antimicrobials worldwide has been implicated in driving up the costs of treatment and adversely effecting clinical outcomes. Pharmacists can be part of the solution by encouraging appropriate antimicrobial selection based on resistance patterns in their communities and ensuring appropriate vaccines are employed to prevent CAP.

Access to medicines: cost as an influence on the views and behaviour of patients

The present paper explores how charges for medicines incurred by patients influence their decisions for managing acute or chronic conditions, and whether prescription cost and affordability issues are discussed in the general practitioner (GP)-patient encounter. People suffering from dyspepsia, hay fever or hypertension, or those taking hormone replacement therapy, were recruited through three community pharmacies in the North-west of England. Six focus groups were conducted with a total of 31 participants, the majority of whom were non-exempt from prescription charges. The management behaviour of those participants who had to pay for their prescriptions, particularly those from less-affluent or deprived backgrounds, was influenced by cost. However, cost was not the overriding influence, with other factors, such as symptom or disease severity, effectiveness, or necessity of treatment, playing a more important part in participants' management decisions. Cost as an issue was reflected in the various strategies used by participants to reduce medication cost, such as not having some prescribed items dispensed, taking a smaller dose or buying a cheaper over-the-counter product. Despite the use of numerous strategies, participants did not talk to their GPs about issues of cost and affordability. Participants felt that paying for prescriptions was their problem. There was a belief that discussing cost issues could jeopardise the doctor-patient relationship. Although not the dominant factor, medication cost nevertheless influenced participants when deciding how to manage their condition. Awareness of the existence of prepayment certificates, which can be bought by patients who require regular medication, was low, and this should be addressed through improved information/dissemination. Despite the high level of prescription items exempt, the current level of the prescription charge is still a barrier to obtaining prescription medicines under the National Health Service to those on lower incomes.

The "supply hypothesis" and medical practice variation in primary care: testing economic and clinical models of inter-practitioner variation

Medical practice variation (MPV) is marked, apparently ubiquitous across the health sector, well documented, and continues to be a focus of professional and policy interest. MPV have stimulated two paths of investigation, one economic in emphasis and the other more-clinical in orientation; while health economists have stressed the potential role of income incentives in medical decision-making, health services research has tended to emphasise clinical ambiguity as a factor in practitioner decisions. Both sets of explanations converge in an implicit "supply hypothesis" that posits contextual practitioner and practice attributes as influential in clinical decisions. Data on inter-practitioner variation are taken from a large and representative regional survey of general practitioners in New Zealand, a country in which unsubsidised fee-for-service is the predominant mode of remuneration in primary care. The paper assesses the impact on three important areas of clinical decision-making prescribing, test ordering, request for follow-up -- of three key conceptual dimensions -- income incentives, physician agency, and clinical ambiguity (operationalised as local doctor density, practitioner encounter initiation, and diagnostic uncertainty respectively). Predictions are made about inter-practitioner variations in the rate of clinical activity in the three areas. The results of the analysis using multi-level statistical techniques are: 1. the extent of competition -- local doctor density -- seems to have no effect on the pattern of clinical decision-making; 2. doctor-initiated visits are, if anything, associated with lower rates of intervention; 3. diagnostic uncertainty is associated with higher rates of investigations and follow-up, both of which have clinical plausibility; 4. there is no significant interaction effect between density and uncertainty. It is concluded that, for the clinical activities studied and for the practitioner attributes as operationalised in this investigation, a clinical, rather than an economic, model of practitioner decision-making provides a more plausible interpretation of inter-practitioner variation in rates of clinical activity in general practice. The "supply hypothesis" requires further analytical refinement and empirical assessment before it can be applied as a generic explanatory framework for MPV.

Explaining variations in prescribing costs: results from a comparison of nursing home patients with matched pairs living in the community

OBJECTIVES

To examine and explain variations in prescribing costs associated with nursing home patients and patients matched by age and sex living in the community.

DESIGN

A 12-month case control study.

SUBJECTS

All nursing home residents over 65-years-old registered with nine general practices and patients matched with them for age and sex living in the community.

METHOD

Multivariate regression analysis of variations in monthly GP prescribing costs.

RESULTS

Multivariate regression models explaining cost variations in terms of the GP practice delivering care and patients' age and sex had little explanatory power (R(2)=0.07 for nursing home patients, R(2)=0.03 for matched pairs). A fuller model for nursing home patients only, incorporating the patient's Barthel score and initial diagnosis as additional explanatory variables, added little to the explanatory power of the model (R(2)=0.16).

CONCLUSION

The ability of the multivariate models used here to explain variations in prescribing costs among a group of elderly patients is poor. Adjusting weighted capitation formulae with respect to older patients to take account of such information or referring to it in negotiations on prescribing budgets would not appear to be warranted.