Effect of doctors' ethnicity and country of qualification on prescribing patterns in single handed general practices: linkage of information collected by questionnaire and from routine data

Native and foreign healthcare workers' knowledge of appropriate use of antibiotics: a prospective pre-post study in Danish nursing homes

Aim:

The aim was to determine the association between healthcare workers’ (HCWs) country of birth and their knowledge of appropriate use of antibiotics, and whether the association changed after an educational intervention.

Background:

Older residents in nursing homes have been recognized to receive excessively antibiotic treatments. HCWs often represent an important link between the older resident and the general practitioner prescribing the antibiotics, thus their knowledge of appropriate use of antibiotics is important.

Methods:

This study was conducted as a prospective pre-post study. Totally, 312 HCWs from 7 nursing homes in Denmark were included. For statistical analyses, χ² test and a linear mixed regression model were applied.

Findings:

Native HCWs were more likely to have a higher percentage of correct responses to single statements related to knowledge of appropriate use of antibiotics. Native HCWs had a significantly higher knowledge-of-antibiotic score compared to foreign HCWs (−7.53, P < 0.01). This association remained significant after adjusting for relevant covariates (−5.64, P < 0.01). Native HCWs’ mean change in knowledge-of-antibiotic score after the intervention did not differ from the foreign HCWs’ mean change in knowledge-of-antibiotic score.

Conclusion:

Our findings indicate that HCWs born outside Denmark reveal a lower knowledge-of-antibiotic score than HCWs born in Denmark despite comparable educational backgrounds. All participants increased their knowledge from baseline to follow-up. Our findings also indicate that an educational seminar cannot equalize the difference in knowledge between native and foreign HCWs. Studies with larger sample size and a more detailed measurement of cultural identity should investigate this association further.

Family doctors' views of pharmaceutical sales representatives: assessment scale development

BACKGROUND

The prescribing patterns depend on the physicians' attitudes and their subjective norms towards prescribing a particular drug, as well as on their personal experience with a particular drug. The physicians are affected by their interactions with pharmaceutical industry.

OBJECTIVE

The objectives were to develop a scale for assessment of pharmaceutical sales representatives (PSRs) by the family doctors (FDs) and to determine factors for their evaluation.

METHOD

Cross-sectional anonymous postal study. We included a random sample of 250 Slovenian FDs. Settings. Slovenian FDs' surgeries.

MAIN OUTCOME MEASURE

The score of various items regarding FDs' assessment of PSRs on a 7-point Likert scale.

RESULTS

We got 163 responses (65.2% response rate). The most important characteristic of PSRs, as rated by respondents on the scale from 1 to 7, was the fact that they did not mislead when presenting products' information. The second most important characteristic was the ability to provide objective information about the product. The first three most important characteristics, as rated by the respondents by themselves, were 'Shows good knowledge on the promoted subject', 'Provides objective product information' and 'Makes brief and exact visits'. Cronbach's alpha of the composite scale was 0.844. Factor analysis revealed three PSRs' factors: selling skills, communicating skills and sense of trustworthiness.

CONCLUSION

FDs evaluate PSRs mainly by their managerial skills and trustworthiness. The scale proved to be a reliable tool for assessing PSRs by FDs.

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

BACKGROUND

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

AIM

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

DESIGN OF STUDY

Cross-sectional study.

SETTING

All general practices in England.

METHODS

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

RESULTS

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

CONCLUSION

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

Factors influencing variation in prescribing of antidepressants by general practices in Scotland

BACKGROUND

The prescribing of antidepressants has been rising dramatically in developed countries.

AIM

As part of an investigation into the reasons for the rise and variation in the prescribing of antidepressants, this study aimed to describe, and account for, the variation in an age-sex standardised rate of antidepressant prescribing between general practices.

DESIGN OF STUDY

Cross-sectional study involving analyses of routinely available data.

SETTING

A total of 983 Scottish general practices.

METHOD

Age-sex standardised prescribing rates were calculated for each practice. Univariate and multivariate regression analyses were undertaken to examine how the variation in prescribing was related to population, GP, and practice characteristics at individual practice level.

RESULTS

There was a 4.6-fold difference between the first and ninth deciles of antidepressant prescribing, standardised for registered patients' age and sex composition. The multivariate model explained 49.4% of the variation. Significantly higher prescribing than expected was associated with more limiting long-term illness (highly correlated with deprivation and the single most influential factor), urban location, and a greater proportion of female GPs in the practices. Significantly lower prescribing than expected was associated with single-handed practices, a higher than average list size, a greater proportion of GP partners born outside the UK, remote rural areas, a higher proportion of patients from minority ethnic groups, a higher mean GP age, and availability of psychology services. None of the quality-of-care indicators investigated was associated with prescribing levels.

CONCLUSION

Almost half of the variation in the prescription of antidepressants can be explained using population, GP, and practice characteristics. Initiatives to reduce the prescribing of antidepressants should consider these factors to avoid denying appropriate treatment to patients in some practices.

Prescribing patterns in high-need Health Authority populations: how does an ethnically mixed composition affect volume and cost?

BACKGROUND

Prescribing is the most common therapeutic intervention in primary care, and there is substantial variation in prescribing practice across England. We investigate broad patterns of prescribing across Health Authorities in England, concentrating on ethnically diverse populations.

METHODS

Initially we examined the association between a number of prescribing indicators from the Prescribing Support Unit Prescribing Toolkit and 'Needs Profiles'. We then considered whether the observed patterns of prescribing were appropriate, that is, could be largely explained by variations in the prevalence of a medical condition for which the corresponding group of drugs would be prescribed.

RESULTS

The volume and cost of prescribing was generally lower in more ethnically diverse Health Authority populations when compared with more elderly or deprived populations. There was a significant negative association between ethnic composition and net-ingredient-cost per patient of cardiovascular drugs, but this disappeared upon adjusting for mortality from coronary heart disease.

CONCLUSIONS

The volume and cost of prescribing was generally lower in more ethnically diverse Health Authority populations relative to other high-need population profiles. Further work on this subject matter is merited, particularly if individual level data is available.

Determinants of physicians' attitude towards prescribing

OBJECTIVE

To identify the primary care physicians' (PCP) characteristics that are associated with their prescribing attitude.

METHODS

A validated questionnaire was sent to randomly selected PCPs stratified in three groups according to any higher qualification in family medicine.

RESULT

The best predictor for orientation of quality of care in prescribing was the country of qualification. Duration after qualification was negatively associated with PCP's belief in the use of drugs. Physicians who were female, with higher qualification, sooner after qualification, and working in group practice were less likely to perceive pressure from patients to prescribe, with group practice being the most significant determinant.

CONCLUSION

Different physician factors affect different aspects of PCPs' prescribing attitude. As duration after qualification was an important but negative attribute, quality use of medication should be emphasized in continuing medical education.

Determinants of prescribing costs amongst single-handed general practitioners

OBJECTIVE

To investigate the contribution of patient and doctor characteristics in explaining observed variations in prescribing costs between individual doctors.

METHOD

Secondary analysis of data collected from general practitioners, Family Health Services Authorities, 1991 Census data set and the Prescription Pricing Authority.

RESULTS

A multiple regression model with four variables (social class, training status, generic prescribing and length of time in general practice) explained only 16.5% of the variation in costs/ASTRO-PU.

CONCLUSION

This study highlights that very little of the variation in prescribing costs can readily be explained. Further research is needed to document contributing factors.

A healthy disposition? The use and limitations of the characteristics approach to general practice research

A range of easily identifiable characteristics is often used by researchers and general practitioners to categorise primary care practices. In the United Kingdom, for example, practices can be defined as dispensing, single-handed or training. The availability of routinely collected data has led to a growing research literature that links practice characteristics to their workload, performance and costs. This paper examines the use and limitations of this 'characteristics approach' and argues that this type of research is often undertaken because it is easy to perform rather than because it is the most appropriate way to study primary care. Using this approach may lead to failure to do the following: to account for the environmental factors that determine the effects particular characteristics manifest; to identify the true relationships between the observed characteristics; to control for changes in the effects of characteristics over time; to differentiate between the behaviour of individual members of a group with the same characteristic and that of the group as a whole; to assign the correct causality to relationships between practice characteristics, workloads, performance, and costs. The characteristics approach should be used with great caution by general practice researchers.

Antibiotic prescribing by single handed general practitioners: secondary analysis of data

AIM

To determine the contribution of various doctor and patient factors on the frequency of antibiotic prescribing.

METHODS

Secondary analyses of data on 155 single handed general practitioners.

RESULTS

Three variables explained 25% of variation in antibiotic prescribing. Doctors qualified from the Indian subcontinent issued more antibiotics than U.K.-qualified doctors. Patients from the non-manual social class were issued fewer antibiotics than those from the manual class and the most deprived patients received significantly more antibiotics.

CONCLUSION

Very little of prescribing of antibiotics by doctors is explained by these doctor-patient factors. Prescribing is a complex process and the search for factors must continue in order to address the rising antibiotic resistance.

Prescribing rates for psychotropic medication amongst east London general practices: low rates where Asian populations are greatest

OBJECTIVES

The aim of this study was to examine the contribution of Asian ethnicity to the variation in rates of practice prescribing for antidepressant and anxiolytic medication, taking into account other population and practice organizational factors.

METHODS

A practice-based cross-sectional survey was carried out of the prescribing of antidepressants and anxiolytics (daily defined dosages) in 164 general practices. The study was set in East London and the City Health Authority, which includes the multiethnic inner London boroughs of Hackney, Tower Hamlets, Newham and the City of London. The main outcome measures were the annual prescribing rates for each group of drugs, calculated as the total annual daily defined dosages divided by the practice population, and the ratio of antidepressant/ anxiolytic annual prescribing rates.

RESULTS

Prescribing rates for antidepressants showed a 25-fold variation between practices; this was greater for anxiolytics. The median annual prescribing rate for all antidepressants combined was 4.13 (interquartile range 2.50-5.88). For all anxiolytics and hypnotics combined the median annual prescribing rate was 3.55 (interquartile range 1.71-6.36). Univariate analysis showed that Asian ethnicity alone accounted for 28% of the variation in antidepressant prescribing and 20.5% of the variation in the anxiolytic prescribing. A backwards multiple regression model using 10 explanatory practice and population variables accounted for 47.7% of the variance in antidepressant prescribing and 34% of the variance in the anxiolytic prescribing.

CONCLUSION

In practices where the proportion of Asian patients is high, both antidepressant and anxiolytic prescribing is low. This is important for understanding interpractice prescribing variation and for setting levels of drug budgets. This study confirms that the low rates of non-psychotic disorders presented by Asian populations is not a selective feature of access to secondary care, but is evident in the prescribing behaviour of GPs. Uncertainty remains as to how much this is due to a lower prevalence rate, "culture-bound syndromes" or practical difficulties in diagnosis and management within the general practice setting.

Do Asians with diabetes in Sandwell receive inferior primary care? A retrospective cohort study

Although diabetes is more prevalent among Asian people, Asians with diabetes are anecdotally believed to receive a lesser standard of care, compared with non-Asians. The aim of this study was to evaluate whether Asian patients with diabetes in Sandwell receive an inferior standard of care in primary care compared with non-Asians. Standards were based on tests carried out, in compliance with Sandwell's Diabetes Local Clinical Guideline. Data were collected from records of 774 patients with diabetes in 14 Sandwell practices. Proportions were recorded of Asian patients receiving specified tests, compared with non-Asians. No significant differences were observed between Asians and non-Asians for checks on feet, eyes, body mass index (BMI), smoking or blood pressure. Significantly fewer Asians received an HbA1c check. The mean HbA1c value was higher in Asians. More Asian patients received a urine test than non-Asians. Asian patients generally had lower BMI values. When stratified by practice however, no significant differences between Asians and non-Asians were observed for any single check. No significant differences were found between the overall proportions of checks carried out between Asians and non-Asians. A wide variation was observed in the proportion of patients who had individual checks done, between practices. There were no systematic differences in the standard of care given to Asian and non-Asian patients. Practices varied a great deal in the extent to which they carry out, and record, checks on patients with diabetes. A possible explanation for the reason that no summary result showed a significant difference was due to the confounding effect of the practice: that general practices tended to treat all their patients--Asian and non-Asian--similarly. Nevertheless, general practitioners should therefore take steps to ensure that all patients with diabetes have these checks at recommended intervals.

The effect of doctor ethnicity and country of qualification on prescribing patterns: an ecological study

OBJECTIVE

To assess the effect of doctor ethnicity and country of qualification on prescribing patterns.

DESIGN

Ecological study.

SETTING

90 Family Health Services Authorities in the U.K.

RESULTS

Being an Asian doctor and qualifying from the Indian subcontinent contributes to 5% of the observed variation seen in the frequency of prescribing, but not the cost. The major determinant of variation in prescribing is deprivation, which accounts for 14% of the cost and 32% of the frequency of prescribing.

CONCLUSIONS

Being an Asian doctor and qualifying from the Indian subcontinent contributes to the frequency, but not the cost of prescribing variation. As this study was at the FHSA level, 'ecological fallacy' exists and further research is advocated at the individual doctor level.