Family Practice Vol. 17, No. 1, 36-41
© Oxford University Press 2000
A study of factors associated with cost and variation in prescribing among GPs
Research and Development Support Unit, Salisbury Healthcare NHS Trust, Salisbury District Hospital, Salisbury, Wiltshire SP2 8BJ,
a Department of Epidemiology and Public Health, University of East Anglia,
b Department of Education, University of Bristol and
c Backwell and Nailsea Medical Group, UK.
Carthy P, Harvey I, Brawn R and Watkins C. A study of factors associated with cost and variation in prescribing among GPs. Family Practice 2000; 17: 36–41.
Received 29 March 1999; Revised 26 July 1999; Accepted 6 September 1999.
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Abstract |
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Background. Inappropriate prescribing has the potential to harm both the individual and society. Previous research has identified doctor or demographic characteristics that influence prescribing variation but which were not amenable to change.
Objectives. To identify modifiable factors associated with GP prescribing variance and cost.
Method. Qualitative research methods were used in semi-structured taped interviews with 17 GPs in Avon, South West NHS Region, UK.
Results. GPs considered themselves cautious and conservative prescribers. Prescribing decisions often were justified by the prescriber, despite conflicting clinical or cost arguments. A personally developed drug formulary was used to reduce dilemmas potentially associated with prescribing uncertainty. Willingness to reflect upon, and measure, prescribing habits against set professional standards varied considerably. The absence of monitoring mechanisms of prescribing decisions, coupled with under utilization of the community pharmacist, resulted in uncertain prescribing outcomes. Some GPs found it difficult to keep up to date professionally due to perceived time constraints. Excessive patient demand was considered to influence their prescribing, but GPs stated that they were not unduly influenced by the drug representative.
Conclusions. Prescribing makes a considerable impact on health and budgets and yet remains a contentious issue. Improved partnerships between patient, doctor and pharmacist must be established. Better prescribing decision monitoring and support through policy development and educational intervention is needed to reduce prescribing uncertainty. Newly established Primary Care Groups may need to reflect upon the difficulties facing prescribers, particularly when prescribing within cash-limited budgets, to avoid discord between prescribing behaviour and local policy development.
Keywords. Costs, decision making, prescribing variation, support..
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Introduction |
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Drugs prescribed by the GP account for ~10% of NHS expenditure and half of the total cost of family health services.1 It is argued that new technological advances, particularly those involving expensive medications, increased public expectation and an ageing population are largely responsible for a soaring national drugs bill.2
There is also concern for suboptimal, or indeed harmful prescribing which fails to meet the highest professional standards of care. This is particularly so for vulnerable groups such as the elderly who receive nearly half of all prescription items.3
Critics argue that weak regulation of the pharmaceutical industry allows dubious drug marketing practices to flourish that fuel drug costs and encourage inappropriate prescribing.4
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Aims |
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Despite a wealth of literature, there remains a lack of real understanding of factors that influence prescribing decisions. Here we describe the qualitative phase of a project that aims to identify modifiable factors associated with prescribing cost and variation. Findings from a subsequent quantitative phase of the study will be reported separately.
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Method |
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Semi-structured taped interviews were conducted with 17 Avon GPs to obtain views about their prescribing habits. The GPs were identified from practice Prescribing Analyses and Cost (PACT) data.
Recruitment of interviewees
Following a pilot exercise with two GP members from the Department of Social Medicine, 15 GPs were selected randomly from a sampling frame of 30 GPs. A letter was sent to selected GPs inviting them to participate in the study. GPs who agreed to take part in the study subsequently were interviewed by an experienced researcher (P.C.).
Interview proforma
Key headings of the interview proforma included: the determinants of prescribing; decisions on whether or not to prescribe; the choice of drug; and desired decision-making support.
Data analysis
Interviews were audio taped, coded and transcribed. Qualitative research principles5 were used to identify, log and list emerging themes, that were considered to influence prescriber decisions, by the lead researcher (P.C.). Themes were identified, grouped and cross-referenced by the research team in a series of meetings. Issues included: managerial or prescribing policy; doctor– patient relationship; professional knowledge; and educational support. Additional subgroups were established, compared and analysed, using criteria to discard factors that were not measurable or were potentially modifiable through an educational intervention.
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Results |
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Interviewees
Between August 1995 and April 1996, 17 GPs (15 randomly selected and two from a pilot exercise) were interviewed, one of whom was female. GPs were aged between 37 and 56 years with an average age of 43 years. Five city, six urban and six rural practices were represented, five of which were fundholding and two single-handed. Seven GPs were from ‘high prescribing cost’ practices, four from ‘medium cost’ practices and the remaining six from ‘low cost’ practices (as defined by overall prescribing cost PACT data). The length of interview ranged from 45 minutes to 1 hour and 20 minutes, with an average of 1 hour duration.
Key influences upon prescribing
Prescribing uncertainty and GP knowledge..
Prescribers used a personal ‘head-held’ drug formulary; a unique, if somewhat idiosyncratic individual index, to decide whether and what to prescribe. The formulary was established during medical training and shaped by colleagues, patients, policy and own experience in general practice. Prescribing doubts usually were associated with adverse drug effects: whether the decision to prescribe a particular drug had a potentially detrimental effect; uncertain or ill-defined diagnoses; or treatments for children or the elderly.
Drugs adopted during early training were often retained, and still perceived to meet the needs of patients and working practices:
"... you are influenced by other colleagues and superiors when you're going through training and I think gradually as time goes on, you become, you know, it's natural that you become more set in your ways. I think it's harder and harder for pharmaceutical companies and FHSA advisors to influence you because ... as time goes on you actually tend to use the drugs more and more and you become familiar with, you become familiar with the doses and so you ... you tend to write the same drugs over and over again. So perhaps we become more conservative as we get older as well."
Asked to describe his prescribing:
"I would say a conservative prescriber really, I never really prescribe a drug that's fresh onto the market, because that's just my nature. I always go for a tried and tested drug ... em ... I think it's easy to be caught out by a new drug that comes onto the market and finally after it has been used for a while, problems start to ensue and you then realise there could be other problems involved ... It's very unusual for a new drug to break into my own personal formulary!" (mq6–6 code)
This cautious watchful, wait and see policy was stated by many:
"I don't think that changes that were introduced post 1990 (new national GP contract) have had much effect ... or an impact on my prescribing habits. As I see it, the situation as far as prescribing and treatment is concerned, on a one to one basis, I haven't changed my views, irrespective of prescribing figures and so on. I see a patient who has a need ... and I address that need and I try to provide as constructively ... as comprehensively for that need and that's the issue that presents to me whenever a patient sits on that chair." (mq2–96 code)
Generally, GPs expressed a desire to keep up-to-date professionally, particularly with regard to prescribing. Some described difficulties experienced during patient consultations, when they were required to access relevant drug information. The immediacy required to make a speedy judgement about the best possible course of action for particular patients was perceived as difficult.
GPs expressed concern about competing demands on their time (viewed as a potential threat to the quality of prescribing decisions). Time constraints were cited as reasons for not translating good intentions into meaningful action. Others described a feeling of unease, on reflection, about the action they had taken. A balance appears to have been struck, in terms of desirable continuing professional development, between what was preferred, feasible and attainable, in a demand-led service. Some GPs found it was simply a case of not knowing what, if any, educational input was needed.
When asked to describe factors contributing to perceived prescribing uncertainty or lack of knowledge, many GPs were unable to describe specific problems. Some suggested that it was a combination of factors; accessing information, but with insufficient time in which to keep professionally up-to-date; due to increasing workload; the changing culture of general practice; with patients apparently more aware of health issues and generally more questioning and challenging. However, when asked about suitable support for their prescribing decisions, many were unable to give a precise answer. Most wanted more available time in which to take stock.
Prescribing was not viewed as a priority area for many, when compared with other aspects of work. The changing face of general practice, the demands of the NHS reforms and the diversity of general practice loomed far larger. Keeping pace with these competing demands resulted in insufficient time available to examine their day-to-day practice.
Prescribing support.. The British National Formulary (BNF) and Monthly Index of Medical Specialties (MIMS) were frequently cited as useful support materials. Decision support computer packages, such as PRODIGY (Prescribing Rationally with Decision support in General Practice), had been experimented with by some and found to be helpful, albeit with limited adaptability and flexibility when patients presented with multiple conditions.
The community pharmacists' role was both valued and dismissed by GPs. Where a professional partnership had been established, benefits for both were evident. GPs acknowledged their fail-safe role in identifying prescription error but, in general, the pharmacist's potential role, in terms of decision support, was rarely exploited.
Perceived pressure to ‘do something' in response to a difficult situation, rather than being viewed as incompetent or not having a ready solution, was highlighted by some. Difficulties also occurred when seemingly endless drug regimes were exhausted, repeated advice to patients went unheeded or where prescribing for ‘heartsink patients' proved particularly onerous.
GPs felt that they generally prescribed appropriately: prescribing decisions deemed inappropriate were described as "the human side of general practice". Most acknowledged that from time to time they "hadn't got it right". There seemed to be acceptance of a "decision allowance", a grey area of prescribing, clearly acceptable to the prescriber, in response to unusual individual circumstances:
"As an individual, I mean there are always exceptions ... the businessman who is flying off to the States, who's got a cold in the head and he's terrified he's going to get sinusitis. If you explain things a bit more, and if you point out to them, if you (the patient) think you are going to get better, then you certainly shouldn't be bothering with them." (mq4–96 code)
Prescriptions for antibiotics, with instructions "to wait and see if further symptoms appear, before redeeming the prescription", was common practice. Whether doctors resisted perceived patient demand depended largely on the amount of available time or their inclination to explain (or need to continually repeat) reasons for not prescribing. Competing work, sustaining effort or interest over time or a poorly established relationship with the patient exacerbated the problem.
Peer influences.. The hospital consultant was viewed as a valuable source of advice and support. This was especially true in the use of new drugs, as a direct result of secondary care patient treatment plans, or from attendance at a specialist-led GP seminar:
"I mean there are terrific numbers (antidepressants) and there's all these new SSRIs coming out and you know, you're thinking, well which one's better than the rest? And you end up sort of peeking through little summaries of them and you look to people you respect ... we met with the consultant psychiatrist ... because we wanted to learn more about his thinking about them." (mq4–96 code)
Others thought consultants were unaware of prescribing cost differences between primary and secondary care settings or advocated specific drug regimes without full patient histories:
"A patient with prostatitis, who had been prescribed Desmopressin by the hospital consultant presented (to the GP ) ... you think hang on a minute here, this chap who is hypertensive was on calcium antagonists and you look it up and sure enough, it's contraindicated in hypertension. What do you say? There's always hassle but I mean, it's easy to say to the patient ‘the consultant said yes ... here's your prescription'." (mq4–96 code)
Use of new drugs was considered to be cautious and conservative but could be influenced by failure of tried and tested therapies. Specific reports or articles in professional journals could also trigger use of new drugs, although research studies in professional journals were criticized for their user unfriendliness, dullness and length.
Few prescribers met with colleagues to compare their prescribing. Reluctance to compare prescribing was due to either confidence in prescribing ability or fear of criticism.
One GP described hearing a colleague being criticized, "for goodness sake, you're not still using XXXXXX (type of drug) are you!"
The presence of a locum or trainee or registration of a new patient (with different drug regimens) could also trigger prescribing change.
Influences of prescribing policy.. The concept of the practice-based formulary was well supported although implementation appeared problematic. When asked whether a practice formulary was used, most GPs stated, "we are going to develop one" or "we keep talking about introducing one". Prescribing advice from health authorities was well received by some and dismissed by others:
"I mean I get PACT data and you know, I think it does influence. I think my goodness, I'm ... you know ... there's this huge amount being spent on say one drug or em ... I think maybe I could influence that ... maybe there's an alternative drug which would be effective and yet cheaper ... I think a move to generic prescribing is for the better and I am very much in favour of that. Not wholesale change because there are circumstances when a brand drug is important to use ... just that (full scale) generic prescribing is often detrimental; it's not always to the benefit. So I think a lot of GPs are probably guilty of em, ... profligate spending, I mean, we've just got an open cheque book." (mq6– 96 code)
Less enthusiastic GPs referred to advice from the health authority as "political" or "managerial meddling" —"they just want to cut costs".
Interestingly, where changes had been made, from discussions of prescribing with health authority officials, it was the process of discussion or the external facilitation, rather than actual outcome, that was considered most useful.
Influences of the patient.. Prescribing for different socio-economic groups was subject to change. One GP described prescribing in a sister practice (situated in a poor district) and compared it with that of the main surgery (in an affluent middle class area) and acknowledged differences in prescribing between the surgeries. Reflecting upon the reasons for the disparity, he felt that "certain groups of patient were better at compliance or acted upon GPs' advice where circumstances offered better compliance."
Some GPs devised ways of saving money for poorer patients. These involved juggling prescriptions against costs of ‘over the counter drugs’, or involved prescriptions of greater volume, over time, to avoid multiple prescription payments.
Treating children accompanied by ‘difficult’ family members could trigger overly cautious ‘defensive’ reactions from the prescriber or inhibit medical examination of the child.
Another GP described prescribing for children of working mothers on a new housing estate:
"There was a need for their kids to be fit and well to be looked after by the childminder. This had a very definite impact upon the ease or the speed with which clinical presentation of minor illness takes place." The GP quoted the mother, "doctor fix the kid up because I've got to go to work and it's got a snotty nose and doesn't eat very well and I can't go to work if there's a problem to fix."(mq2–96 code)
Excessive and unrealistic demands from the patients frequently were cited. Media-prompted news could provoke huge responses from patients:
"I had somebody ... who had been reading about Prozac ... she hadn't got a relationship that was working out ... she thought Prozac would sort out her problems ... it was a difficult consultation because she didn't get the Prozac." (mq1–96 code)
‘The Patient's Charter’ was viewed as bothersome, and the phrase "a pill for every ill" was frequently quoted by interviewees.
Prescribing costs.. GPs appeared to support cost-reducing initiatives in principle, although some unease was acknowledged. Tensions were usually associated with perceived conflicts between professional boundaries and fiscal policy. All GPs bemoaned increased administrative chores and "excessive paper chasing", much of which was felt to be time wasting. Several non-fundholding GPs felt that their efforts to reduce prescribing costs had gone unrecognized or unrewarded. Some expressed regret about fundholding colleagues and their financial incentive schemes, when compared with their cost savings:
"But basically I'm a high cost prescriber ... but I'm not ... I don't feel uncomfortable about my prescribing, I feel comfortable about it. It's difficult when there are financial restrictions because I've seen that there (sic) are a little bit contrary to patients welfare but there are pressures for cheaper prescribing and not necessarily in the patients' best interests. For example, in the management of hypertension, I use a lot of calcium antagonists and ACE inhibitors, which I think are good drugs but I'm pressurised into using betablockers and thiazide diuretics which do have problems associated with them. If you're looking at patients' welfare, well-being, those things cause lethargy and precipitate asthma and thiazides precipitate diabetes and gout and there is dubious effect of betablockers on lipid profiles and so on ... I think it's quite difficult at times." (mq1–96 code)
GPs who used high amounts of generics but who still exceeded their drug budgets, had different views:
"In many respects our prescribing habits tend to be more modern prescribing, rather than old fashioned prescribing habits for cheap drugs ... hypertension as an example, cardiovascular drugs where we spend a lot, and the items tend to be expensive ... ACE inhibitors ... calcium blockers and things. Most of the people who we are prescribing for will have been reviewed and their medication will be changed and updated, and in the process of doing that, we tend to choose, lets say, newer, which tend to be more expensive products, rather than people ... who say ... have been on the same tablet for fifteen to twenty years still taking Propanalol or something which is six pence a bucket, and it may suit them well, but we wouldn't necessarily initiate very much prescribing of older drugs." (mq3–96 code)
Asked why their practice prescribed in this way, the GP continued:
"Well, in the case of hypertension, I mean there are many drugs which just aren't used any more, but there are still plenty of people out there still on them ... if you go to a practice which has been going for a long while with a stable population, you'll find lots of people on drugs like Methydopa. I haven't used Methydopa in many years ... sort of went out with the ark but are cheap prescribing with a significant effect on prescribing costs. I see myself as somebody who is not afraid to prescribe, and if it costs a lot of money, well that's just too bad ... if it's justifiable, but if the condition doesn't require drugs at all, and people respond to other interventions, or may be no intervention at all if it is self limiting, I'm not afraid to say no, it doesn't need anything." (mq3–96 code)
Apart from routine reviews of chronic conditions, prescribers rarely, if ever, monitored prescribing decisions, "the patient will always come back if it doesn't work." Monitoring of prescribing decisions was supported, but the process was deemed difficult to manage.
Influences of the pharmaceutical industry.. Most GPs felt that advice from drug representatives was selective or contained "half truths". Some technical data was valued, but GPs placed restrictions on access, or number and duration of visits. Drug company-sponsored study sessions proved popular, due to the perceived quality of invited expert speakers.
Most GPs appreciated that marketing techniques could influence their prescribing but generally expressed confidence in their ability to withstand commercial sales pressure:
"Well I think he (drug rep) has a very useful influence. I see drug reps as useful people ... in a sense that they bring to my attention the fact that they have a particular development and I hope they see my role as being educational, to some extent. I hope they see their role as being informative and not simply as peddlers of wares." (mq3–96 code)
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Discussion |
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TopAbstractIntroductionAimsMethodResultsDiscussionReferences |
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Despite some idiosyncratic prescribing, this group of GPs felt comfortable with their prescribing. However, use of the personal formulary has obvious drawbacks; it endorses self-belief in prescribing ability through habit and familiarity. Without scrutiny, the formulary may establish and perpetuate poor prescribing patterns.6
Some prescribing habits appeared to defy attempts from policy and managerial forces to change them, and prescribing decisions were justified, despite conflicting clinical or cost arguments.
GPs face numerous difficulties when prescribing within cash-limited budgets, some of which potentially influence prescribing behaviour. Newly established Primary Care Groups may need to reflect upon these difficulties in order to avoid further discord between actual prescribing activity and local policy development.
Policy and management forces need to develop locally appropriate and credible information, to enable prescribers to keep professionally updated. These measures should be underpinned by adequate support and training that is derived from individual needs assessment.
Use of a visiting pharmacist is known to improve GP prescribing, and yet support from pharmacists was generally patchy or absent.7 There is growing recognition of the need for better collaboration between GPs and pharmacists8 in order to enable the potential role of the community pharmacist to be fully developed for use in local training initiatives.
The development of new skills, such as computerized decision making, should be tailored to individual need to encourage all prescribers to engage in professional development. These initiatives must take account of varying perceptions of need that exist between older and younger age groups.
Behavioural change is notoriously difficult, and GPs differ and respond to different types of educational models. Supportive interventions of rational prescribing, therefore, need to be timed carefully and tailored to individual prescribing beliefs and attitudes.
GPs who are more critical in their drug choice may have lower prescribing costs.9 Prescribers' knowledge, selection and use of drugs in this group varied considerably. Overly cautious use of new or expensive drugs may miss therapeutic opportunities, while high use of generic drugs reduces prescribing costs but may take scant account of individual circumstance.10
Critics argue that basic pharmacology, rather than problem solving and practical application or audit, is over emphasized during medical training, and largely responsible for establishing poor prescribing habits that subsequently prove difficult to change.11
There is cause for concern over professional literature that is deemed dull and uninspiring. Credible, updated drug information needs to be both interesting and easily accessible for doctors to act upon. Prescribers reported that they were not unduly influenced by the pharmaceutical industry, although this runs counter to the evidence.12
Excessive and unrealistic patient demand was cited frequently by this group. Critics argue that this professional viewpoint is often exaggerated and misdirected.13
Prescribing decisions require sufficient time—and a positive attitude—in which to access, critically appraise and synthesize information for the benefit of both patient and doctor. Lack of critical appraisal potentially provides a licence to prescribe haphazardly. The paucity of monitoring mechanisms makes it difficult to judge whether a prescribing decision is appropriate.
Conclusions
Prescribing decisions make a considerable impact on health and national budgets and require complex personal and professional judgements to be made about physical, psychosocial and cost dimensions of health. Is it feasible to expect clinical need to be determined, managerial and fiscal policy to be balanced and complex drug information accessed and assimilated, within the confines of an 8-minute consultation, in a demand-led service?
Professional experience, and the use of the personal formulary, may provide a suitable basis for change models. Time must be set aside for GPs to reflect upon their prescribing and compare it with clearly defined quality outcome indicators.
Without support and monitoring, and encouragement to forge better decision partnerships between doctor and patient, and doctor and pharmacist, some prescribing will, inevitably, remain suboptimal.
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Acknowledgments |
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With grateful thanks to all the doctors who participated in the study and Elizabeth Robinson, Medical Advisor, Avon Health, Bristol. The study was supported by funding from the Research and Development Directorate of the NHS Executive, South and West.
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References |
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1 Audit Commission. A Prescription for Improvement Towards More Rational Prescribing in General Practice. London: HMSO, 1995.
2 Pallot P. The cost of living. Health Service J 1996; 30 May: 11.
3 The Royal College of Physicians. RCP Medication for Older People. 2nd edn. London: The Royal College of Physicians, 1997: 10.
4 Collier J. The Health Conspiracy How Doctors, The Drug Industry and the Government Undermine our Health. London: Hutchinson Ltd, 1989.
5 Berg BL. Qualitative Research Methods. Boston: Allyn and Bacon, 1989.
6 McGavock H, Webb CH, Johnson GD, Milligan E. Market penetration of new drugs in one United Kingdom region: implications for general practitioners and administrators. Br Med J 1993; 307: 118–120.
7 Avorn J, Sourmerai S. Improving drug therapy decisions through educational outreach. N Engl J Med 1983; 308: 1457–1463.[Abstract]
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Yeo GT. Educational visiting and hypnosedative prescribing in general practice. Fam Pract 1994; 11: 57–61.
9 Van de Poel G. A way of achieving more rational drug prescribing. Int J Pharm Pract 1991; 1: 45–48.
10
Ayanian J, Hauptman PJ, Guadagnoli E, Antman EM, Paslos CL, McNeil BJ. Knowledge and practices of generalists and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med 1994; 331: 1136–1142.
11 Walley T. Rational prescribing in primary care—a new role for the clinical pharmacologist? Br Med J 1993; 36: 11–12.
12 Kingman S. Fisons investigations of excessive hospitality. Br Med J 1993; 307: 1301–1302.
13
Britten N. Patient demand for prescriptions; a view from the other side. Fam Pract 1994; 11: 62–66.
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