Prescribers prefer people: The sources of information used by doctors for prescribing suggest that the medium is more important than the message

AIMS: The sources of prescribing information are legion but there is little knowledge about which are actually used in practice by doctors when prescribing. The aims of this study were to determine the sources of prescribing information considered important by doctors, establish which were used in practice, and investigate if hospital and primary care physicians differed in their use of the sources. METHODS: Two hundred general practitioners (GPs) and 230 hospital doctors were asked to rate information sources in terms of their importance for prescribing 'old' and 'new' drugs, and then to name the source from which information about the last new drug prescribed was actually derived. RESULTS: Among 108 GPs, the Drugs and Therapeutics Bulletin and medical journal articles were most frequently rated as important for information on both old and new drugs while pharmaceutical representatives and hospital/consultant recommendations were more important for information on new drugs, as opposed to old. In practice, information on the last new drug prescribed was derived from pharmaceutical representatives in 42% of cases and hospital/consultant recommendations in 36%, with other sources used infrequently. Among 118 hospital doctors, the British National Formulary (BNF) and senior colleagues were of greatest theoretical importance. In practice, information on the last new drug prescribed was derived from a broad range of sources: colleagues, 29%; pharmaceutical representatives, 18%; hospital clinical meetings, 15%; journal articles, 13%; lectures, 10%. GPs and hospital doctors differed significantly in their use of pharmaceutical representatives (42% vs 18%) and colleagues (7% vs 29%) as sources of prescribing information (P < 0.0001 for both). CONCLUSIONS: The sources most frequently rated important in theory were not those most used in practice, especially among GPs. Both groups under-estimated the importance of pharmaceutical representatives. Most importantly, the sources of greatest practical importance were those involving the transfer of information through the medium of personal contact.     

GP attitudes to managing drug- and alcohol-dependent patients: a reluctant role

The aim of this study was to determine the experience, confidence and views of GPs in South West Sydney towards managing drug and alcohol dependence and their interest in participating in shared care methadone prescribing. Five hundred and forty-eight GPs were mailed a self complete questionnaire. Non-responders were followed-up by telephone. Seventy-six per cent of GPs responded; 52% considered methadone maintenance to be effective. GPs were more confident managing smoking than alcohol and benzodiazepine dependence and least confident in illicit drug dependence. Fifty per cent reported having no patients on methadone and 40% between one and five patients. GPs in Fairfield and Liverpool reported having most patients; 25% were interested in prescribing methadone for patients in their own practice and 17% for patients referred to them. GPs who had more patients on methadone in their practice (especially those in Fairfield and Liverpool) considered methadone effective and were more likely to be interested in having patients referred to them. The most frequent reasons for not being interested were concerns about patients being demanding or aggressive or the impact on their practice. The most frequently requested support for shared care prescribing was for 24-hour back-up from specialist services, especially requested by those with less experience with patients on methadone. A shared-care approach to facilitating greater GP involvement in prescribing appears feasible, especially among GPs with some previous experience with patients on methadone.     

Comparison of prescribing habits of general practitioners in The Netherlands versus England and Wales

The alleged prescribing habits of 44 randomly chosen Dutch family doctors were compared with those of 59 family doctors from England and Wales by inference from their prescribing responses to 10 hypothetical patients presented in a mail survey. The response options were: (a) neither prescribing nor advising over-the-counter (OTC) medication; (b) advising OTC medication; or (c) prescribing medication. Although sample numbers were small, the sample appeared to be broadly representative of GPs in each country. There were significant differences in stated treatment habits between doctors of the 2 countries, especially with regard to treatment of sore throat, temporal arteritis, epigastric pain, travellers' diarrhoea and polyarthralgia. The results suggest substantial differences in management of common general practice problems exist between England/Wales and The Netherlands, despite their similar healthcare systems. These differences point to the need for rationalisation of management through improved education and audit.     

How do general practitioners manage alcohol-misusing patients? Results from a national survey of GPs in England and Wales

The appropriateness of the primary care setting to undertake health promotional activities has been emphasized, but little is known about the clinical work of GPs with patients misusing alcohol. This study examines how GPs managed alcohol-misusing patients. A 20% random sample of all general practitioners in England and Wales were surveyed using a postal questionnaire. A 44% response rate was achieved. GPs reported managing different levels of severity of drinking problems differently. Basic interventions, such as reporting the alcohol misuse diagnosis and the provision of advice and information, were routine. Health promotion leaflets were not used uniformly, even with the less severe problem drinkers. Detoxification, prescribing of drugs and the management of medical complications were undertaken mainly with dependent patients. Dependent drinkers were the most likely group to be referred to specialist services, while internal practice referrals occurred with all drinking status categories. Anti-depressants were the drugs most usually prescribed to alcohol-misusing patients. The data point to a need for basic guidelines, not only on how to manage and refer dependent drinkers, but also on how to detect and manage those who are not yet manifesting problems but are drinking above recommended guidelines. One of the most evident areas in which there appears to be a need for guidelines is that of prescribing within primary care.     

Survey of injectable methadone prescribing in general practice in England and Wales

Little is known about the extent and conduct of general practice prescribing of injectable methadone to opiate users in England and Wales. A postal questionnaire survey of general practitioners (GPs) was conducted in 1999 to ascertain how many GPs were prescribing injectable methadone, to describe their prescribing practices and to explore their perceptions of the service they provided. Four hundred and seven GP practices in 77 out of 105 health authorities were apparently prescribing injectable methadone. The difficulties in identifying, and obtaining a response from, GPs prescribing injectable methadone are discussed. Analysis of 93 usable returned questionnaires showed a range of GP characteristics and experience. The GPs were treating 211 patients with injectable methadone and a further 2003 patients with oral methadone. Prescribing practice and monitoring arrangements did not always follow national guidelines. A minority of GPs had received training in the management of drug dependency. They were most likely to decide to prescribe injectable treatment on the recommendation of a specialist drug agency, and to discontinue prescribing if there was a suspicion of diversion of prescribed ampoules. Although significant numbers of GPs felt unsure about their skills and the support available to them, most appeared to be managing their patients thoughtfully and with appropriate outcomes in mind. Recent policy documents from the Department of Health and the Home Office have questioned the place of injectable methadone in the treatment of opiate misuse, particularly in a general practice setting. A Home Office licence will shortly be required to prescribe injectable methadone. This survey suggests a minority of GPs would apply for such a licence. More research into the effectiveness of injectable methadone treatment in a range of settings is needed before conclusions can be drawn about the appropriateness of providing this treatment in general practice.     

The cost of medicines in the United Kingdom. A survey of general practitioners' opinions and knowledge

Prescribing costs in general practice continue to grow. Their importance is underlined by the amount of information concerned with costs that general practitioners (GPs) receive, and by the existence of target budgets. In 1986 and 1991, surveys showed that GPs agreed that cost should be borne in mind when choosing medicines, but that their knowledge of drug prices was often inaccurate. This study assessed the current knowledge and attitudes of GPs in the UK in respect of prescribing costs, and examined the influence of various developments in general practice since 1986 on the accuracy of drug price estimation. 1000 randomly selected GP principals (500 in Scotland and 125 in each of 4 English health regions) were sent a postal questionnaire. The GPs' level of agreement with 5 statements concerned with prescribing costs, and the accuracy of their estimates of the basic price of 31 drugs, were analysed. Most GPs (71%) agreed that prescribing costs should be taken into account when deciding on the best treatment for patients. Fundholders were more likely than non-fundholders: (i) to agree that prescribing costs could be reduced without affecting patient care; (ii) to agree that providing more information on costs would lower the cost of prescribing; and (iii) to comment that cost guidelines had changed their prescribing habits. Fundholders were less likely than non-fundholders to reject the principle of fixed limits on prescribing costs. Overall, one-third of the price estimates given were accurate (within 25% of the actual cost). For the most expensive drugs in the survey [those priced over 10 pounds sterling (Pound) per pack], half of the price estimates were accurate. There were significant differences between non-fundholders' and fundholders' estimates of the price of less expensive drugs (those priced at less than 10 pounds per pack). Use of a formulary or computer-displayed drug price information did not affect the accuracy of price estimates. It may be that GPs who were more knowledgeable and concerned about costs were more likely to become fundholders. It is also possible that the expansion of fundholding, or other mechanisms that give GPs responsibility for resource allocation, might improve accurate cost awareness in prescribing. Clinical and economic review of repeat prescribing is recommended.     

Effect of intervention promoting a reduction in antibiotic prescribing by improvement of diagnostic procedures: a prospective, before and after study in general practice

OBJECTIVE: To investigate if an intervention aimed at improving the quality of the diagnostic procedures in Spanish general practice could lower antibiotic prescribing in patients with respiratory tract infections (RTIs). METHODS: GPs in the intervention group (n=17) registered all patients with RTIs during a 3-week period before and after the intervention. The intervention was aimed at reducing prescribing of inappropriate antibiotics for RTIs by improving the diagnostic procedures and thereby helping the GPs to distinguish between bacterial and viral infections. It consisted of courses in management of RTI according to local clinical guidelines, and included implementation of two rapid diagnostic tests (StrepA and CRP measurement). Diagnoses and prescribing of antibiotics were assessed before and after the intervention, and compared to a control group not exposed to intervention (35 GPs). RESULTS: The intervention led to a significant reduction in antibiotic prescribing. Before the intervention 36% (29%-44%) of consultations were followed by antibiotic prescribing, after the intervention 24% (20%-29%). Antibiotic prescribing in the control group not exposed to intervention was 32% (27%-38%). The reduction was most pronounced in patients with sinusitis and lower RTIs. CONCLUSION: Quality improvement of diagnostic procedures may lead to a reduction of antibiotic prescribing in primary health care in Spain.     

Comparison of attitudes of general medical practitioners and community pharmacists to prescribing matters

In order to compare the attitudes of general medical practitioners (GPs) and community pharmacists to a broad range of issues concerning prescribing, a questionnaire was mailed in April, 1994, to all GPs and community pharmacists in contract with a local family health services authority (St Helens and Knowsley), an area covering 350,000 people. Replies were received from 60 per cent of the GPs and 84 per cent of the pharmacists. There was general agreement between the doctors and the pharmacists in their attitudes towards prescribing, and agreement that the quality of prescribing was a legitimate subject of concern for local health authorities. The role of community pharmacists was the main area of disagreement, with the GPs generally being more conservative while the pharmacists favoured a wider role. The professions shared a concern to improve the quality of prescribing, and about one third believed that a substantial amount of prescribing was of poor quality. A substantial minority of each profession had little contact with the opposite numbers from the other profession: 43 per cent of doctors had met a pharmacist fewer than four times in 1993. We present evidence of general agreement between the professions on a wide range of issues concerning the quality of prescribing in the community. However, if UK pharmacists are to achieve the wider role they and the government desire, the concerns of GPs need to be addressed.