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

Risk of opioid misuse in people with cancer and pain and related clinical considerations: a qualitative study of the perspectives of Australian general practitioners

OBJECTIVE

To explore the perspectives of general practitioners (GPs) concerning the risk of opioid misuse in people with cancer and pain and related clinical considerations.

DESIGN

A qualitative approach using semistructured telephone interviews. Analysis used an integrative approach.

SETTING

Primary care.

PARTICIPANTS

Australian GPs with experience of prescribing opioids for people with cancer and pain.

RESULTS

Twenty-two GPs participated, and three themes emerged. Theme 1 (Misuse is not the main problem) contextualised misuse as a relatively minor concern compared with pain control and toxicity, and highlighted underlying systemic factors, including limitations in continuity of care and doctor expertise. Theme 2 ('A different mindset' for cancer pain) captured participants' relative comfort in prescribing opioids for pain in cancer versus non-cancer contexts, and acknowledgement that compassion and greater perceived community acceptance were driving factors, in addition to scientific support for mechanisms and clinical efficacy. Participant attitudes towards prescribing for people with cancer versus non-cancer pain differed most when cancer was in the palliative phase, when they were unconcerned by misuse. Participants were equivocal about the risk-benefit ratio of long-term opioid therapy in the chronic phase of cancer, and were reluctant to prescribe for disease-free survivors. Theme 3 ('The question is always, 'how lazy have you been?') captured participants' acknowledgement that they sometimes prescribed opioids for cancer pain as a default, easier option compared with more holistic pain management.

CONCLUSIONS

Findings highlight the role of specific clinical considerations in distinguishing risk of opioid misuse in the cancer versus non-cancer population, rather than diagnosis per se. Further efforts are needed to ensure continuity of care where opioid prescribing is shared. Greater evidence is needed to guide opioid prescribing in disease-free survivors and the chronic phase of cancer, especially in the context of new treatments for metastatic disease.

Psychiatrist and Psychiatric Pharmacists Beliefs and Preferences for Atypical Antipsychotic Treatments in Patients With Schizophrenia and Bipolar Disorders

BACKGROUND

Selection of schizophrenia or bipolar disorder treatments is complicated by treatment-effect heterogeneity.

OBJECTIVES

This study assessed how clinicians' beliefs and health system/ insurace policies impact choice of atypical antipsychotic agent in schizophrenia and bipolar disorder.

METHODS

A cross-sectional survey was conducted of members of the American College of Clinical Pharmacy and College of Psychiatric & Neurologic Pharmacists. Beliefs regarding atypical antipsychotic effectiveness and safety, impact of comorbidity on drug selection, and factors influencing atypical antipsychotic therapy selection were assessed.

RESULTS

Twenty-four psychiatric pharmacists and 18 psychiatrists participated. Mean age was 39.6 years, 57.1% were female. Most clinicians (64.3%) believed medication effectiveness and safety equally important, while 26.2% believed safety and 9.4% believed effectiveness more important. The most important medication properties for schizophrenia were reducing positive symptoms (92.7%) and hospitalizations (87.8%) and for bipolar disorder were reducing manic episodes (87.8%), episode relapse (53.7%), and hospitalizations (53.7%). Agranulocytosis (78.1%), arrhythmias (70.7%), and extrapyramidal side effects (68.3%) were most concerning. Restrictions affected antipsychotic choice at 80.5% of sites and were believed to affect medication adherence (55.0%) and outcomes (53.4%).

CONCLUSION

Efficacy and safety were considered equally important when choosing atypical antipsychotics. Formulary restrictions were perceived as impacting treatment choice and outcomes.

How is medication prescribing ceased? A systematic review

BACKGROUND

Medication prescribing is a complex process where the focus tends to be on starting new medication, changing a drug regimen, and continuing a drug regimen. On occasion, a prudent approach to prescribing may necessitate ending an ongoing course of medication, either because it should not have been started in the first place; because its continued use would cause harm; or because the medication is no longer effective.

OBJECTIVE

To identify effective strategies for stopping pre-existing prescribing in situations where continued prescribing may no longer be clinically warranted.

RESEARCH DESIGN

Systematic searches for English-language reports of experimental and quasi-experimental research were conducted in PubMed (1951-November 2009), EMBASE (1966-September 2008), and International Pharmaceutical Abstract b (1970-September 2008). A manual search for relevant review articles and a keyword search of a local database produced by a previous systematic search for prescribing influence and intervention research were also conducted.

STUDY SELECTION AND DATA EXTRACTION

Following initial title screening for relevance 2 reviewers, using formal assessment and data extraction tools, independently assessed abstracts for relevance and full studies for quality before extracting data from studies selected for inclusion.

RESULTS

Of 1306 articles reviewed, 12 were assessed to be of relevant, high-quality research. A variety of drugs were examined in the included studies with benzodiazepines the most common. Studies included in the review tested 9 different types of interventions. Effective interventions included patient-mediated interventions, manual reminders to prescribers, educational materials given to patients, a face-to-face intervention with prescribers, and a case of regulatory intervention. Partially effective interventions included audit and feedback, electronic reminders, educational materials alone sent to prescribers, and distance communication combined with educational materials sent to prescribers.

CONCLUSIONS

It appears possible to stop the prescribing of a variety of medications with a range of interventions. A common theme in effective interventions is the involvement of patients in the stopping process. However, prescribing at the level of individual patients was rarely reported, with data often aggregated to number of doses or number of drugs per unit population, attributing any reduction to cessation. Such studies are not measuring the actual required outcome (stopping prescribing), and this may reflect the broader ambiguity about when or why it might be important to end a prescription. Much more research is required into the process of stopping pre-existing prescribing, paying particular attention to improving the outcomes that are measured.

Systematic Review of Interventions to Improve Prescribing

Objective:

To update 2 comprehensive reviews of systematic reviews on prescribing interventions and identify the latest evidence about the effectiveness of the interventions.

Data Sources:

Systematic searches for English-language reports of experimental and quasi-experimental research were conducted in PubMed(1951–May 2007). EMBASE (1974–March 2008), International Pharmaceutical Abstracts (1970–March 2008), and 11 other bibliographic databases of medical, social science, and business research. Following an initial title screening process and after selecting 6 specific intervention categories (identified from the previous reviews) in community settings, 2 reviewers independently assessed abstracts and then full studies for relevance and quality and extracted relevant data using formal assessment and data extraction tools. Results were then methodically incorporated into the findings of the 2 earlier reviews of systematic reviews.

Data Selection And Synthesis:

Twenty-nine of 26,314 articles reviewed were assessed to be of relevant, high-quality research. Audit and feedback, together with educational outreach visits, were the focus of the majority of recent, high-quality research into prescribing interventions. These interventions were also the most effective in improving prescribing practice. A smaller number of studies included a patient-mediated intervention; this intervention was not consistently effective. There is insufficient recent research into manual reminders to confidently update earlier reviews and there remains insufficient evidence to draw conclusions regarding the effectiveness of local consensus processes or multidisciplinary teams.

Conclusions:

Educational outreach as well as audit and feedback continue to dominate research into prescribing interventions. These 2 prescribing interventions also most consistently show positive results. Much less research is conducted into other types of interventions and there is still very little effort to systematically test why interventions do or do not work.

Antibiotic prescribing for children with nasopharyngitis (common colds), upper respiratory infections, and bronchitis who have health-professional parents

OBJECTIVE

Antibiotic resistance might be reduced if patients could be better informed regarding the lack of benefits of antibiotics for children with viral infections and avoid antibiotic prescriptions in these circumstances. This study investigated whether children having health professionals as parents, a group whose parents are expected to have more medical knowledge and expertise, are less likely than other children to receive antibiotics for nasopharyngitis (common colds), upper respiratory tract infections (URIs), and acute bronchitis.

METHODS

Retrospective analyses were conducted by using National Health Insurance data for children of physicians, nurses, pharmacists, and non-health personnel, who had visited hospital outpatient departments or physician clinics for common colds, URIs, and acute bronchitis in Taiwan in 2000. A total of 53733 episodes of care for common colds, URIs, and acute bronchitis in a nationally representative sample of children (aged < or =18 years) living in nonremote areas were analyzed.

RESULTS

The study found that, after adjusting for characteristics of the children (demographic, socioeconomic, and health status) and the treating physicians (demographic, practice style, and setting), children with a physician (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.36-0.68) or a pharmacist (OR: 0.69; 95% CI: 0.52-0.91) as a parent were significantly less likely than other children to receive antibiotic prescriptions. The likelihood of receiving an antibiotic for the children of nurses (OR: 0.91; 95% CI: 0.77-1.09) was similar to that for children in the comparison group.

CONCLUSIONS

This finding supports our hypothesis that better parental education does help to reduce the frequency of injudicious antibiotic prescribing. Medical knowledge alone, however, may not fully reduce the overuse of antibiotics. Physician-parents, the expected medically savvy parents, can serve as a benchmark for the improvement potentially achievable in Taiwan through a combination of educational, regulatory, communication, and policy efforts targeted at more appropriate antibiotic prescribing in ambulatory settings.

Factors that influence prescribing decisions

BACKGROUND

Strategies to control the quality and cost of medication use are largely dependent on the ability to alter selection of medications. Previous models of prescribing behavior have focused on physicians. In the hospital setting, clinical pharmacists and formulary committee members are also key players in drug therapy decision-making. Differences between physicians, formulary committee members, and clinical pharmacists have not been compared. Knowledge of these differences could have importance in predicting the effectiveness of strategies designed to influence drug use in this setting.

OBJECTIVE

To describe and compare the opinions of physicians, clinical pharmacists, and formulary committee members with respect to key factors that influence medication prescribing in community hospitals.

METHODS

Physicians, clinical pharmacists, and formulary committee members were solicited to participate. A trained interviewer administered a standardized questionnaire designed to elicit opinions of participants regarding the importance of factors thought to influence drug prescribing. Responses were described using descriptive statistics, and differences between the groups were determined by post hoc analysis.

RESULTS

A total of 150 individuals participated in the study. Safety, effectiveness, formulary status, and restrictions on prescribing were considered highly influential by all participants. Physicians rated the availability of drug samples and personal experience higher (more influential on prescribing) than clinical pharmacists and formulary committee members. Clinical pharmacists and formulary committee members rated the influence of recommendations by clinical pharmacists, prescribing guidelines, and cost or cost comparisons higher than physicians. Factors that were drug-related or that involved policy-related programs tended to be more influential than indirect factors.

CONCLUSIONS

Those who seek to implement programs to alter medication use should recognize and employ factors that are most influential in the decision-making process. Further, it may be important to consider differences that exist between key participants in the medication use process.

Prescribing of psychotropics in the elderly: why is it so often inappropriate?

Psychotropic medications are an important treatment approach to mental health disorders; such disorders are common in the elderly population. Elderly patients are more likely to experience adverse effects from these agents than their younger counterparts due to age-related changes in pharmacodynamic and pharmacokinetic parameters. Because of these factors, inappropriate use of psychotropic medications in elderly patients has become a focus of concern. In general an agent is considered inappropriate if the risk associated with its use exceeds its benefit. Implicit and explicit criteria for inappropriate use of medications in the elderly have been created and include psychotropic agents. These criteria vary in their make-up but the explicit criteria tend to agree that amitriptyline, doxepin, and benzodiazepines that have long half-lives are not appropriate. Although explicit inappropriate medication criteria have been in existence since 1991, elderly patients continue to receive inappropriate psychotropic medications. A wide array of factors may be responsible for this practice. Provider-related causes include deficits in knowledge, confusion due to the lack of a consensus on the inappropriate psychotropic criteria, difficulties in addressing an inappropriate medication started by a previous provider, multiple prescribers and pharmacies involved in the care of a patient, negative perceptions regarding aging, and cost issues. Patients may contribute to the problem by demanding an inappropriate medication. Finally, the healthcare setting may inadvertently contribute to inappropriate prescribing by such policies as restrictive formularies or lack of reimbursement for pharmacists' clinical services. Successful approaches to optimising prescribing have been either educational or administrative. Educational approaches (e.g. one-on-one sessions, academic detailing) seek to influence decision making, while administrative approaches attempt to enforce policies to curtail the undesired practice. The US Omnibus Budget Reconciliation Act of 1987, which improved psychotropic medication use in long-term care, is an excellent example of administrative intervention. More research specifically focused on the causes of inappropriate psychotropic medication use and methods to avoid this practice is needed before targeted recommendations can be made.

Effectiveness of educational interventions on the improvement of drug prescription in primary care: a critical literature review

This paper is a critical review of studies of educational programmes designed to improve prescription practices in ambulatory care. Scientific articles were selected from the following bibliographical indices: MEDLINE, IME, ICYT and ERIC. The searches covered the time period between 1988 and 1997. The search criteria included: primary-care, educat*, prescription* and other related keywords. The inclusion criteria were studies describing educational strategies aimed at general practitioners working in ambulatory settings. The study outcome was change in prescribing behaviour of physicians through prescribing indicators. The following data were extracted: study design, target drugs, type of intervention, follow-up period of the prescription trends, type of data analysis, type of statistical analysis and reported results. We found 3233 articles that met the search criteria. Of these, 51 met the inclusion criteria and 43 studied the efficacy/effectiveness of one or various interventions as compared to no intervention. Among seven studies evaluating active strategies, four reported positive results (57%), as opposed to three of the eight studies assessing passive strategies (38%). Among the 28 studies that tested reinforced active strategies, 16 reported positive results for all variables (57%). Eight studies were classified as a high degree of evidence (16%). We concluded that the results of our review suggest that the more personalized, the more effective the strategies are. We observe that combining active and passive strategies results in a decrease of the failure rate. Finally, better studies are still needed to enhance the efficacy and efficiency of prescribing practices.

Interactional group discussion: results of a controlled trial using a behavioral intervention to reduce the use of injections in public health facilities

Injections are commonly overused in Indonesia. More than 60% of patients attending public health facilities receive at least one injection, which increases clinical risk and has adverse economic impact. This study assesses the efficacy of an innovative behavioral intervention, the Interactional Group Discussion (IGD), for reducing the overuse of injections. This study was a controlled trial in a single district with 24 public health centers randomized to intervention and control groups. Prescribers in the intervention group were invited to one IGD, each of which consisted of 6 prescribers and 6 patients; a total of 24 IGDs were held in a 4-week period, and all invited prescribers participated. The groups, which lasted 90-120 minutes, were facilitated by a behavioral scientist and a clinician, who also served as a scientific resource person. The hypothesized mechanism of behavior change involved reality testing prescribers' assumptions about patient beliefs, imparting scientific information about injection efficacy, and establishing peer norms about correct behavior. Outcomes were measured by a retrospective prescribing survey covering the periods 3 months before and 3 months after the intervention, with samples of 100 prescriptions per center per month. Rates of injection and average number of drugs per prescription were computed separately for each center, and t-tests were used to compare pre-post changes in outcomes in both groups. Results showed a significant decrease in injection use from 69.5 to 42.3% in the intervention group, compared to a decrease from 75.6 to 67.1% among controls [-18.7.0% intervention vs control, 95% CI = (-31.1%, -6.4%), P < 0.025]. There was also a significant reduction in average number of drugs per prescription [-0.37 drugs prescribed per patient, 95% CI = (-0.04, -0.52), P < 0.05], indicating that injections were not substituted with other drugs. We conclude that the IGD significantly reduces the overuse of injections. It is suggested to try out other behavioral interventions to improve the rational use of drugs.

A strategy for promoting improved pharmaceutical use: the International Network for Rational Use of Drugs

Over the last decade, pharmaceutical selection, procurement, distribution, and financing have improved as a result of essential drugs programs. However, despite improved availability, pharmaceuticals are frequently used irrationally. The International Network for the Rational Use of Drugs (INRUD) has been established to help address this problem. The Network joins core groups of researchers from four African and three Asian countries with support groups in Boston, Sweden, WHO, and Australia. The activities of the Network are supported by multilateral, bilateral, foundation donors and by Management Sciences for Health. INRUD functions as a participatory organization in which members are involved in decision-making. The primary objective of the Network is to identify through a coordinated set of country-based research projects a set of effective interventions to recommend as policy options for the promotion of rational drug use. In developing these research projects, INRUD stresses the importance of a multi-disciplinary perspective for adequately understanding the reasons underlying inappropriate use of drugs. To better enable country groups to utilize strong research methodologies and to blend the strengths of multiple disciplines effectively, a major activity of the Network thus far has been the building of local research capacity.

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

OBJECTIVE

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

DESIGN/SETTING

Cross-sectional survey conducted in winter 1989-1990.

PARTICIPANTS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

A model of methods for influencing prescribing: Part II. A review of educational methods, theories of human inference, and delineation of the model

The purpose of this literature review is to develop a model of methods used to influence prescribing. This article reviews well-controlled studies of educational efforts, describes and relates theories of human inference to these studies, and delineates a model of methods for influencing prescribing. The model can be used to help explain the success or failure of various programs and as a framework for developing and testing methods to influence prescribing.