Prevalence of and Risk Factors for Prescription Opioid Misuse, Abuse, Diversion and Doctor Shopping in Japan: A Survey Study

INTRODUCTION

Opioid use disorder is a global problem. Although opioid analgesics are prescribed less frequently in Japan than in many other countries, the rate of aberrant prescription opioid-taking behaviors in Japan is unknown.

METHODS

An internet survey was conducted to estimate the prevalence of and risk factors for prescription opioid misuse, abuse, diversion and doctor shopping in Japanese subjects with chronic pain who had been prescribed opioid analgesics.

RESULTS

The proportion of respondents (n = 387) who reported opioid misuse was 45.5% (95% confidence interval [CI]: 40.4-50.6); rates were: 24.6% (95% CI: 20.3-29.2) for abuse; 15.0% (95% CI: 11.6-19.0) for diversion; and 10.6% (95% CI: 7.7-14.1) for doctor shopping. Aberrant prescription opioid-taking behaviors were higher in participants with chronic post-cancer treatment pain (misuse, 64.2%; abuse, 52.2%) or chronic cancer pain (misuse, 57.4%; abuse, 26.2%) than in those with chronic noncancer pain (misuse, 37.8%; abuse, 17.0%). Younger age, male sex, smoking, habitual drinking, diagnosis of psychiatric disease, use of opioids other than tramadol, and use of opioids for chronic post-cancer treatment pain and chronic cancer pain were identified as risk factors for aberrant prescription opioid-taking behaviors.

CONCLUSION

Even in Japan, which has not experienced the surge in opioid consumption documented in other countries, aberrant prescription opioid-taking behaviors were observed. When prescribing opioid analgesics, universal precautions should always be taken for both cancer and non-cancer patients.

TRIAL REGISTRATION

UMIN000041788.

Desire for Alternative Treatment Options in Patients with Atopic Dermatitis in Japan: Results of a Web-Based Cross-Sectional Study (AD-JOIN Study)

INTRODUCTION

Treatment satisfaction in patients with atopic dermatitis (AD) has been investigated in several studies, but the desire for alternative treatment options is unclear and has not been previously evaluated. We conducted a cross-sectional, web-based survey aimed at evaluating the desire for alternative treatment options in adults with AD from a patient registry in Japan.

METHODS

Main eligibility criteria were adults aged ≥ 18 years with AD who were receiving treatment with topical corticosteroids (TCS) and not systemic therapy. Questionnaires included the Patient Oriented Eczema Measure (POEM) and pruritus Numeral Rating Scale. The proportion of patients with a desire for an alternative treatment option was assessed, overall (Overall Desire) and by specific type of alternative treatment option (Specific Desire), including change in medication, hospital transfer, and complementary and alternative medicine (CAM) use. Patient background factors associated with desire were evaluated using multivariate logistic regression.

RESULTS

Of the 1500 patients included in the analysis, 91.5% (n = 1372) had an Overall Desire, with the most common Specific Desire being a change in medication (n = 1213, 80.9%), followed by CAM (n = 593, 39.5%) and hospital transfer (n = 429, 28.6%). Dissatisfaction with current treatment was significantly (p < 0.05) associated with Overall Desire and Specific Desire (p < 0.001 each). Severe disease according to POEM was significantly associated with Overall Desire and a change in medication (p < 0.001 each).

CONCLUSIONS

A high proportion of Japanese patients with AD being treated with TCS had a desire for alternative treatment options. The desire was greatly affected by patients' satisfaction with their current treatment and perception of disease severity. These findings highlight the importance of assessing patients' satisfaction or perception of disease severity, and facilitating early discussions between patient and doctor on their available treatment options, including new treatment options.

"Fear of stopping" vs "wanting to get off the medication": exploring women's experiences of using domperidone as a galactagogue - a qualitative study

Background

Domperidone is the most frequently prescribed medicine used to increase breast milk supply. There is considerable controversy surrounding the use of domperidone in lactation, due to limited evidence about efficacy and concerns about rare but life-threatening side-effects. Despite this, in many high-income settings such as Australia, use of domperidone among breastfeeding mothers appears to be increasing. The aim of this paper was to explore women’s experiences of using domperidone during breastfeeding.

Methods

Semi-structured interviews were conducted in 2019 with 15 women in Australia who reported using domperidone as a galactagogue during breastfeeding. Interviews were recorded, transcribed and analysed thematically.

Results

Women reported a wide variety of practices concerning the timing of initiation of domperidone use, including prophylactic use, as well as the dose and duration of use. Prolonged periods of use and unsupervised dosing were commonly reported, these practices were sometimes associated with a fear of the consequences of stopping, insufficient provision of information about the drug or feeling dismissed by health professionals. Some women indicated that when doctors refused to prescribe domperidone they responded by doctor shopping and seeking anecdotal information about benefits and risks online, leading to unsupervised practices. Women often reported high expectations surrounding the effectiveness of domperidone, and most used the medication in conjunction with food/herbal galactagogues and non-galactagogue support. Positive outcomes following domperidone use included having greater confidence in breastfeeding and pride at achieving breastfeeding goals.

Conclusions

This study identified a variety of practices concerning domperidone use, including potentially unsafe practices, linked in some cases to inconsistent advice from health professionals and a reliance on online, anecdotal information sources. These findings emphasise the urgent need for development of clinical practice guidelines and a greater focus on translating existing evidence concerning domperidone into clinical practice, including clinical support that is tailored to women’s needs.

Doctor shopping among chronic noncancer pain patients treated with opioids in the province of Quebec (Canada): incidence, risk factors, and association with the occurrence of opioid overdoses

Opioid doctor shopping was a rare phenomenon among people living with chronic noncancer pain but was associated with the occurrence of opioid overdoses.

Introduction:

Prescription opioids continue to be involved in the opioid crisis, and a better understanding of factors associated with problematic opioid use is needed.

Objectives:

The aim of this study was to assess the incidence of opioid doctor shopping, a proxy for problematic opioid use, to identify associated risk factors, and to assess its association with the occurrence of opioid overdoses.

Methods:

This was a retrospective cohort study of people living with chronic noncancer pain (CNCP) and treated with opioids for at least 6 months between 2006 and 2017 in the province of Quebec (Canada). Data were drawn from the Quebec health administrative databases. Doctor shopping was defined as overlapping prescriptions written by ≥ 2 prescribers and filled in ≥3 pharmacies.

Results:

A total of 8,398 persons with CNCP were included. The median age was 68.0 (Q1: 54; Q3: 82) years, and 37.1% were male. The 1-year incidence of opioid doctor shopping was 7.8%, 95% confidence interval (CI): 7.2–8.5. Doctor shopping was associated with younger age (hazard ratio [HR] 18–44 vs ≥65 years: 2.22, 95% CI: 1.77–2.79; HR 45–64 vs ≥65 years: 1.34, 95% CI: 1.11–1.63), male sex (HR = 1.20, 95% CI: 1.01–1.43), history of substance use disorder (HR = 1.32, 95% CI: 1.01–1.72), and anxiety (HR = 1.41, 95% CI: 1.13–1.77). People who exhibited doctor shopping were 5 times more likely to experience opioid overdoses (HR = 5.25, 95% CI: 1.44–19.13).

Conclusion:

Opioid doctor shopping is a marginal phenomenon among people with CNCP, but which is associated with the occurrence of opioid overdoses. Better monitoring of persons at high risk to develop doctor shopping could help prevent opioid overdoses.

Assessing the impact of Indiana legislation on opioid-based doctor shopping among Medicaid-enrolled pregnant women: a regression analysis

Background

States have passed various legislative acts in an attempt to reduce opioid prescribing and corresponding doctor shopping, including prescription drug monitoring programs. This study seeks to determine the association between two state-based interventions enacted in Indiana and the level of doctor shopping among Medicaid-enrolled pregnant women.

Methods

Indiana Medicaid claims data over the period of January 2014 to March 2019 were used in a regression model to determine the longitudinal change in percentage of pregnant women engaged in doctor shopping based on passage of Indiana Administrative Code Title 884 in 2014 and Public Law 194 in 2018. The primary reasons for prescribing were also identified.

Results

There were 37,451 women that had both pregnancy and prescription opioid claims over the time horizon. Of these, 2130 women met the criteria for doctor shopping. Doctor shopping continued to increase over the time between the passage of the two interventions but decreased after passage of Public Law 194.

Conclusion

The decrease in doctor shopping among Medicaid-enrolled pregnant women after passage of Public Law 194 points to the importance of addressing this issue across a broad set of healthcare professionals including nurse practitioners and physician assistants. It is also possible that the potential punitive component in the Law for non-compliance played a role.

"Doctor and pharmacy shopping": A fading signal for prescription opioid use monitoring?

BACKGROUND

The term "doctor and pharmacy shopping" colloquially describes patients with high multiple provider episodes (MPEs)-a threshold count of distinct prescribers and/or pharmacies involved in prescription fulfillment. Opioid-related MPEs are implicated in the global opioid crisis and heavily monitored by government databases such as U.S. state prescription drug monitoring programs (PDMPs). We applied a widely-used MPE definition to examine U.S. trends from a large, commercially-insured population from 2010 to 2017. Further, we examined the proportion of enrollees identified as "doctor shoppers" with evidence of a cancer diagnosis to examine the risk of false positives.

METHODS

Using a large, commercially-insured population, we identified patients with opioid-related MPEs: opioid prescriptions (Schedule II-V, no buprenorphine) filled from ≥5 prescribers AND ≥ 5 pharmacies within the past 90 days ("5x5x90d"). Quarterly rates per 100,000 enrollees (two specifications) were calculated between 2010 and 2017. We examined the trend in a recently published all-payer, 7 state cohort from the U.S. Centers for Disease Control and Prevention for comparison. Cancer-related ICD-9/10-CM codes were used.

RESULTS

Quarterly MPE rates declined by approximately 73 % from 18.2-4.9 per 100,000 enrollee population with controlled substance prescriptions. In 2017, nearly one fifth of these commercially-insured enrollees identified by the 5x5x90d algorithm were diagnosed with cancer. Approximately 8% of this sample included patients with ≥ 1 buprenorphine prescriptions.

CONCLUSIONS

Opioid "shopping" flags are a long-standing but rapidly fading PDMP signal. To avoid unintended consequences, such as identifying legitimate medical encounters requiring high healthcare utilization or opioid treatment, while maintaining vigilance, more nuanced and sophisticated approaches are needed.

Multiple opioid prescribers: A genuine quest for treatment rather than aberrant behaviour. A two-decade population-based study

BACKGROUND

Accessing multiple prescribers for opioid prescription, referred to as doctor-shopping, is associated with an increased risk of opioid overdose and fatalities.

AIM

The primary aim of this study was to assess the probability of accessing multiple prescribers among patients dispensed prescription opioids.

METHOD

A retrospective population-based study using the Monitoring of Drugs of Dependence system of the Medicines Monitoring Unit (MMU) of Queensland Health, Australia. We assessed the odds of accessing multiple prescribers across both -short-term (≤1 month, 2-3 months) and longer-term (4-6 months and ≥7 months). We examined the relationship between multiple doctor visits, the dispensed dose of opioid and patient's residential socioeconomic status (SES).

RESULT

Compared to those dispensed opioid prescriptions for ≥7-12 months, those dispensed opioids for ≤1 month were more likely to have visited ≥3 prescribers (adjusted odds ratio (aOR)) 4.06, 95% CI 4.01, 4.10, while for 2-3 months and 4-6 months the odds were aOR 2.36, 95% CI 2.33, 2.39 and aOR 1.79, 95% CI 1.74, 1.79 respectively. Patients dispensed opioid doses of ≥100 oral morphine milligram equivalent per day (MME/day) were more likely to obtain prescriptions from ≥3 prescribers compare to those receiving a dose of <20MME/day (aOR 1.90; 95% CI 1.87, 1.94). The probability of obtaining opioid prescriptions from multiple prescribers increased as the socioeconomic status decreased: aOR 1.41; 95% CI 1.38, 1.44 for lowest SES compared to the highest SES.

CONCLUSION

Patients were more than four time likely to be dispensed opioid prescriptions from multiple prescribers within the first 30 days of initiating opioid treatment, possibly as part of multidisciplinary referral post-hospital discharge. High dose opioid and low SES was associated with higher probability of accessing multiple prescribers.

Somatic symptom disorder should be suspected in children with alleged chronic Lyme disease

We report a case series of seven children admitted to a tertiary level pediatric ward for long-lasting physical symptoms with a previous diagnosis of chronic Lyme disease. In these children, medical history and clinical features were strongly suggestive of a psychopathological disorder, mainly a somatic symptom disorder. What is Known: • There is an increasing number of diagnoses of chronic Lyme disease both in North America and in Europe. Adults receive this diagnosis to explain chronic physical complaints often with negative history and serology. What is New: • Somatic symptom disorder should be suspected in children and adolescents with non-specific symptoms diagnosed with chronic Lyme disease.

Doctor shopping of opioid analgesics relative to benzodiazepines: A pharmacoepidemiological study among 11.7 million inhabitants in the French countries

BACKGROUND

The abuse of prescription opioids and its subsequent consequences is an important public concern particularly in the USA. The literature on opioid analgesic abuse is scarce.

OBJECTIVE

We assess the extent and risk of opioid analgesics abuse relative to benzodiazepines (BZD) using the doctor shopping method, taken into account the pharmacological characteristics (dosage, route of administration, extended or immediate release).

METHODS

We used SNIIRAM database covering 11.7 million inhabitants. All individuals with at least one reimbursement for non-injectable opioid analgesic or BZD in 2013 were included. Opioids for mild to moderate pain and for moderately severe to severe pain were studied. The Doctor Shopping Quantity (DSQ) is the quantity obtained by overlapping prescriptions from several prescribers. The Doctor Shopping Indicator (DSI) is the DSQ divided by the total dispensed quantity.

RESULTS

The strong opioid analgesics have the highest DSI (2.79%) versus 2.06% for BZD hypnotics. Flunitrazepam ranked first according to its DSI (13.2%), followed by morphine (4%), and zolpidem (2.2%). The three-strong opioids having the highest DSI were morphine, oxycodone and fentanyl (respectively 4%, 1.7% and 1.5%). The highest DSI was observed for the highest dosages of morphine (DSI = 8.4% for 200 mg) and oxycodone (DSI = 2.8% for 80 mg). The highest DSI for fentanyl was described with nasal and transmucosal forms (4.1% and 3.3% respectively). The highest DSI for morphine was described for extended-release (4.1%).

CONCLUSION

There is a need to reinforce surveillance systems to track opioid misuse and to increase awareness of healthcare professionals.

Doctor Shopping Behavior and the Diversion of Prescription Opioids

OBJECTIVES

"Doctor shopping" as a means of prescription opioid diversion is examined. The number and percentage of prescriptions and morphine-equivalent milligrams diverted in this manner are estimated by state and molecule for the period 2008-2012.

METHODS

Eleven billion prescriptions with unique patient, doctor, and pharmacy identifiers were used to construct diversion "events" that involved between 1 and 6 unique doctors and between 1 and 6 unique pharmacies. Diversion thresholds were established based on the probability of each contingency.

RESULTS

A geographically widespread decline occurred between 2008 and 2012. The number of prescriptions diverted fell from approximately 4.30 million (1.75% of all prescriptions) in 2008 to approximately 3.37 million (1.27% of all prescriptions) in 2012, and the number of morphine-equivalent milligrams fell from approximately 6.55 metric tons (2.95% of total metric tons) in 2008 to approximately 4.87 metric tons (2.19% of total metric tons) in 2012.

CONCLUSIONS

Diversion control efforts have likely been effective. But given increases in opioid-related deaths, opioid-related drug treatment admissions, and the more specific resurgence of heroin-related events, it is clear that additional public health measures are required.

Exploring the latent trait of opioid use disorder criteria among frequent nonmedical prescription opioid users

BACKGROUND

There is a need to explore the dimensional and categorical phenotypes of criteria of opioid use disorder among frequent nonmedical users of prescription opioids (NMUPO) users.

METHODS

We used pooled data of 2011-2012 National Survey on Drug Use and Health to examine reliability and phenotypic variability in the diagnosis of OUD secondary to NMUPO in a nationally-representative sample of 18+ years-old frequent past-year NMUPO users (120+ days, n = 806). Through exploratory factor analysis (EFA) and latent class analysis (LCA), we examined 10 past-year OUD criteria. We examined associations between the latent classes and sociodemographic/psychiatric/NMUPO correlates.

RESULTS

OUD criteria were unidimensional, and a three-class model was the overall best fitting solution for characterizing individuals into phenotypes along this unidimensional continuum: a "non-symptomatic class" (40.7%), "Tolerance-Time spent class" (29.0%) with high probability of endorsing Tolerance/Time Spent criteria, and a "High-moderate symptomatic class" (30.1%). The last class was significantly associated with being male, having insurance and obtaining prescription opioids (PO) nonmedically via "doctor shopping" as compared to the non-symptomatic class. "Tolerance-Time spent class" was significantly associated with being younger (18-25 years) and obtaining PO nonmedically from family/friends as compared to the non-symptomatic class.

CONCLUSION

This study revealed the different characteristics and routes of access to PO of different classes of frequent NMUPO users. It is possible that these groups may respond to different interventions, however such conclusions would require a clinical study.

A survey of Physicians' Perspectives on the New York State Mandatory Prescription Monitoring Program (ISTOP)

BACKGROUND

Prescription drug monitoring programs (PDMPs) have emerged as one tool to combat prescription drug misuse and diversion. New York State mandates that prescribers use its PDMP (called ISTOP) before prescribing controlled substances. We surveyed physicians to assess their experiences with mandatory PDMP use.

METHODS

Electronic survey of attending physicians, from multiple clinical specialties, at one large urban academic medical center.

RESULTS

Of 207 responding physicians, 89.4% had heard of ISTOP, and of those, 91.1% were registered users. 45.7% of respondents used the system once per week or more. There was significant negative feedback, with 40.4% of respondents describing ISTOP as "rarely" or "never helpful," and 39.4% describing it as "difficult" or "very difficult" to use. Physicians expressed frustration with the login process, the complexity of querying patients, and the lack of integration with electronic medical records. Only 83.1% knew that ISTOP use is mandated in almost all situations. A minority agreed with this mandate (44.2%); surgeons, males, and those who prescribe controlled substances at least once per week had significantly lower rates of agreement (22.6%, 36.2%, and 33.0%, respectively). The most common reasons for disagreement were: time burden, concerns about helpfulness, potential for under-treatment, and erosion of physician autonomy. Emergency physicians, who are largely exempt from the mandate, were the most likely to believe that ISTOP was helpful, yet the least likely to be registered users. 48.4% of non-emergency physicians reported perfect compliance with the mandate; surgeons and males reported significantly lower rates of perfect compliance (18.2% and 36.8%, respectively).

CONCLUSIONS

This study offers a unique window into how one academic medical faculty has experienced New York's mandatory PDMP. Many respondents believe that ISTOP is cumbersome and generally unhelpful. Furthermore, many disagree with, and don't comply with, its mandatory use.

Incidence of high dosage buprenorphine and methadone shopping behavior in a retrospective cohort of opioid-maintained patients in France

BACKGROUND

Opioid Substitution Treatment (OST) misuse and diversion have significantly increased worldwide. Obtaining OST prescriptions from multiple prescribers, known as doctor shopping, is a way in which opioids may be diverted.

OBJECTIVES

The aim of this study was to assess the incidence of OST (high dosage buprenorphine (HDB) and methadone (MTD)) shopping behavior and identify associated risk factors, and its impact on mortality.

METHODS

A retrospective cohort of patients treated by OST between April 1, 2004 and December 31, 2012 from a sample of the French Health Insurance database was established. Doctor shopping was defined as ≥1 day of overlapping prescriptions written by ≥2 different prescribers and filled in ≥3 different pharmacies.

RESULTS

A total of 2043 patients were enrolled, 1450HDB and 593 MTD. The one-year incidence of shopping behavior was 8.4% (95% CI: 7.0-10.1) in HDB group and 0% in MTD group, compared to 0.2% (95% CI: 0.1-0.2) for diuretics. On multivariate analysis, factors associated with HDB shopping behavior were: male gender HR: 1.74 (95% CI: 1.20-2.54); low-income status HR: 2.95 (95% CI: 2.07-4.44); mental health disorders HR: 1.43 (95% CI: 1.06-1.94); concurrent hypnotics use HR: 1.90 (95% CI: 1.39-2.61); concurrent use of weak opioids HR: 1.48 (95% CI: 1.09-1.99) and morphine HR: 1.69 (95% CI: 1.02-2.80). HDB shoppers had a higher, yet non-significant risk of death (HR: 1.56 (95% CI: 0.64-3.81)) than non HDB shoppers.

CONCLUSION

Shopping behavior was only found in high dosage buprenorphine patients and concerned almost one out ten patients.

Prevalence, prescribed quantities, and trajectory of multiple prescriber episodes for benzodiazepines: A 2-year cohort study

BACKGROUND

Little is known about the use of multiple prescribers for benzodiazepines, which might reflect fragmented patient care and increases the risk of hospital admission for drug dependence or poisoning. Therefore, we aimed to identify the prevalence, prescribed quantities, and trajectory of multiple prescriber episodes for benzodiazepines.

METHODS

We conducted a 2-year cohort study of 1178,361 recipients aged 0-74 years using a large health insurance claims database in Japan. We quantified multiple prescriber episodes for benzodiazepines occurring in ambulatory care settings in a baseline and subsequent year by (1) counting the number of unique providers within a 12-month period, (2) calculating the maximum number of unique providers within a single month, and (3) identifying consecutive overlapping prescriptions of over 30 days duration.

RESULTS

Among 58,314 patients with a benzodiazepine prescription during the baseline year, 282 (0.5%) filled prescriptions from four or more providers within a 12-month period, 439 (0.8%) filled prescriptions from three or more providers within a single month, and 757 (1.3%) filled consecutive overlapping prescriptions. The odds for multiple prescriber episodes were significantly higher among patients with multiple chronic conditions. Consecutive overlapping prescriptions had the best accuracy to detect patients with potentially questionable prescribed quantities as well as to predict those with multiple prescriber episodes in the subsequent year.

CONCLUSIONS

These results highlight the need for pharmacists to increase their involvement in prescription oversight and for health insurance agencies to implement a prescription monitoring program to screen for patients with multiple prescriber episodes for benzodiazepines.

Ethical dilemmas in pediatric and adolescent psychogenic nonepileptic seizures

To date, only a very narrow window of ethical dilemmas in psychogenic nonepileptic seizures (PNES) has been explored. Numerous distinct ethical dilemmas arise in diagnosing and treating pediatric and adolescent patients with PNESs. Important ethical values at stake include trust, transparency, confidentiality, professionalism, autonomy of all stakeholders, and justice. In order to further elucidate the ethical challenges in caring for this population, an ethical analysis of the special challenges faced in four specific domains is undertaken: (1) conducting and communicating a diagnosis of PNESs, (2) advising patients about full transparency and disclosure to community including patients' peers, (3) responding to requests to continue antiepileptic drugs, and (4) managing challenges arising from school policy and procedure. An analysis of these ethical issues is essential for the advancement of best care practices that promote the overall well-being of patients and their families.

Doctor shopping before and after a visit to a paediatric emergency department

BACKGROUND

Use of multiple care providers is known to be associated with poor continuity of care.

OBJECTIVES

To estimate the prevalence of and identify risk factors for doctor shopping by parents of children with common acute illnesses seen in the emergency department (ED) of a children's hospital.

SETTING

ED at the Montreal Children's Hospital (MCH), Montreal, Quebec.

METHODS

Doctor shopping was defined as visiting three or more different care sites (the MCH ED, other EDs, outpatient clinics or private offices) for a single illness episode, including all visits occurring within successive 72 h periods up to a maximum of 15 days before and after an ED visit from April 1995 to March 1996. Logistic regression was used to compare characteristics of illness episodes with doctor shopping versus those without.

RESULTS

Of the total 40,150 visits during the study period, doctor shopping was observed in 18% of the visits. The risk of doctor shopping was positively associated with an initial visit at other EDs (odds ratio [OR] 9.08, 95% CI 7.16 to 11.52), outpatient clinics (OR 4.47, 95% CI 3.71 to 5.37) or private offices (OR 1.71, 95% CI 1.48 to 1.96) versus those who visited the MCH ED first. The risk did not differ according to whether a paediatrician versus a general practitioner saw the child during the initial visit (OR 0.99, 95% CI 0.86 to 1.15). Some diagnoses (the reference category was upper respiratory infection), including urinary tract infection (OR 3.31, 95% CI 2.58 to 4.23) and gastroenteritis (OR 1.59, 95% CI 1.35 to 1.88), were associated with an increased risk of doctor shopping, while asthma was associated with a reduced risk (OR 0.71, 95% CI 0.60 to 0.86).

CONCLUSION

Doctor shopping is common among parents of children with acute illnesses. Parents of children who were seen in the MCH ED first were less likely to doctor shop, perhaps because the parents were more confident about the advice and treatment received. Further research should investigate the underlying reasons for doctor shopping, eg, services other than an ED were not available and parents' perceptions of the quality of health services.