Physician Prescribing Decisions Research Articles

Treatment Preferences of Patients with Chronic Obstructive Pulmonary Disease: Results from Qualitative Interviews and Focus Groups in the United Kingdom, United States, and Germany.

A wide range of therapeutic regimens, including single-inhaler triple therapies (SITTs), are now available for the maintenance treatment of chronic obstructive pulmonary disease (COPD). Thus, an improved understanding of patient preferences may be valuable to inform physician prescribing decisions. This study was performed to assess the factors considered by patients when making decisions about their COPD treatments using qualitative techniques. In the United Kingdom, United States and Germany, individual qualitative interviews (n=10 per country) and focus groups (1 per country; [United Kingdom, n=4; United States, n=6; Germany, n=6 participants]) were conducted. Interviews and focus groups were semi‑structured, lasting approximately 60 minutes, and focused on treatment preferences. Data were analyzed according to emerging themes identified from the interviews; qualitative thematic analysis of the data was performed using specialist software. In interviews and focus groups, efficacy, ease of use, and lower frequency of use were favored attributes for current treatment, while side effects, medication taste, and more complex administration techniques were key dislikes. In interviews, most participants would consider a switch in medication, mainly for improved efficacy, but also to reduce medication frequency or following physician advice. Overall, efficacy and ease of use were the 2 most important attributes reported in interviews in all 3 countries. Patients with COPD have preferences for certain attributes of medication, highlighting the multi-faceted nature of treatment effectiveness and the importance of the delivery device.These results were subsequently used to inform the design of a discrete choice experiment.

Impact of Pharmaceutical Companies??? Promotional Tools on Physicians??? Prescription Pattern

Purpose: The role of pharmaceutical companies’ promotional tools in the prescribing decision of physicians comprises five commonly-used promotional tools: sales promotions; advertising; public relations; direct marketing; and personal selling. The purpose of this paper was to examine the existing literature on promotional tools and then explore which medical practitioners’ demographic factors influence the relationship between the various promotional tools and physicians’ prescription behaviour. Design/methodology/approach: A survey of the literature was carried out across online databases from 2008 to 2018, and 41 reviewed articles were identified. The influence of promotional tools on physician prescribing decisions was identified in the articles. Findings: There have been numerous studies on the effect of promotional tools on physician prescription decision. They demonstrated that promotional tools strongly influence physicians’ prescribing decision, but a few others found only minor or no relation. To resolve this ambiguity, there is a need to precisely understand how promotional tools affect prescribing decisions of physicians, under different contexts and conditions. Research limitations/implications: The study recommends further studies on the influence of each factor on physician prescribing behaviour and an evaluation of the proposed model and moderating variables. Originality/value: This paper provides a significant step towards recognizing the relationship between promotional tools and prescribing behaviour. This research contributes to the debate on the ways prescribing behaviour can be affected.

Development and validation of an instrument designed to measure factors influencing physician prescribing decisions.

Background:Previous attempts to develop an instrument to measure factors that influence prescribing decisions among physicians were relatively insufficient and lacked validation scale.Objective:We present a new tool that attempts to address this shortcoming. Hence, this study aims to develop and validate a self-administrated instrument to explain factors that influence the prescribing decisions of physicians.Methods:The questionnaire was developed based on literature and then subjected to an exhaustive assessment by a board of professionals and a pilot examination before being administered to 705 physicians. Three pre-tests were carried out to evaluate the quality of the survey items. In pre-test 1, after items are generated and the validity of their content is assessed by academics and physicians. In pre-test 2, the scale is carried out with a small sample of 20 respondents of physicians. In pre-test 3, fifty drop-off questionnaires were piloted amongst physicians to test the reliability.Results:On the basis of partial least squares structural equation modelling (PLS-SEM) analyses using SmartPLS 3, the content and convergent validity of the instrument were confirmed with 44 items grouped into four categories, namely, marketing efforts, patient characteristics, pharmacist variables, and contextual factors with 13 reflective constructs.Conclusions:The study outcomes prove that the scale is more valid and reliable for measuring factors that influence the decision of the physician to prescribe the drug. The development and presentation of a scale of thirteen factors related to physicians prescribing decisions help to ensure valid findings and facilitates comparisons of studies and research settings.

Active Learning to Promote Early and Effective Physician Interaction with Pharmaceutical Industry Marketing Practices

IntroductionThe challenge: There is not enough time in an overcrowded medical curriculum to prepare medical students to meet their professional ethical obligations before they first interact with the pharmaceutical representatives.The solution: A team of educators including a medical ethicist, pharmacist, MDs and MD student successfully pilot a required, engaging ethics intervention integrated into the first‐year pharmacology course.BackgroundInteractions with pharmaceutical companies influence physicians' prescribing behaviour.Medical students have extensive exposure to pharmaceutical industry marketing during early years of training. We integrated an ethics intervention in the first‐year medical students' required pharmacology course to address this.Methods120 students were divided into four equal‐sized groups for a one‐hour session. A short lecture described techniques used by reps to influence prescribing practices, including those developed for 8 physician types. Students watched two 5‐minute live dramatizations of a physician‐pharmaceutical representative interaction based on scripts developed by the team. Students identified examples of the techniques they could see being used on the physician‐actor according to one of the 8 types. Students debriefed with faculty, completed pre‐ and post‐session surveys, and a post‐course evaluation. 9 students did not complete either the pre‐ or post‐session surveys.Results45% of students had no prior experience with pharmaceutical representatives. 44% of students agreed or strongly agreed that pharmaceutical representatives provide educational value to medical students/physicians, both before and after the session. However, the number of students who agreed or strongly agreed that pharmaceutical representatives provide biased information increased from 82% to 98% after the session. The number of students who said pharmaceutical marketing and promotional activities have moderate or strong influence on physician prescribing decisions increased from to 63% to 80%. When asked to list all which would be acceptable for medical students to accept from a pharmaceutical representative, 25% of students said nothing would be acceptable before the session, compared to 61% afterwards. 90% of students believed that after the session, they could be able to individually find reliable information about a drug.ConclusionThe session altered how first year medical student viewed encounters with pharmaceutical representatives. Their perceptions of the information and interactions with pharmaceutical representatives changed during the session, and they learned methods to individually find reliable information about a drug. Further analysis and investigation into educating first year medical students on the pharmaceutical industry is recommended.Support or Funding InformationThis study was not supported by a grant and has been approved by FIU IRB.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Factors Influencing Prescribing Decisions Among Primary Health Care Physicians in Al-Buraimi Governorate, Oman

Prescribing plays a major role in the activities practiced by physicians. The vast majority of health care consultations occur in the primary health care (PHC) system, where medication errors are more likely and can even be potentially life threatening. The goal of this study is to explore the factors affecting prescribing decisions among physicians working in PHC institutions in Al-Buraimi Governorate, Oman using a cross-sectional survey. Of the 53 physicians who received the questionnaire, 41 (77.4%) completed it. The Cronbach's alpha of the instrument was 0.913. The main patient factors that influenced prescribing decisions were age group (78%), gender (75.6%), and medication preference or untruthful patients (70.7%). The main physician factors were the lack of treatment alternatives (70.7%), doctor–patient relationship (68.3%), strict policies and guidelines (65.9%) and avoiding problems of drug unavailability (65.9%). The pharmacist influenced prescribing decisions for 36.6% of physicians. The methods used for keeping physician s’ medical knowledge up to date were private reading and the Internet (87.8% and 80.5%, respectively). Sources of prescribing guidance were colleagues and evidenced-based medicine websites (78.0% and 70.7%, respectively). The current study sheds some light on the factors and behaviours that influence physician prescribing decisions in PHCs in Al-Buraimi Governorate, Oman. Additionally, this study could be used for developing policies to improve drug selections and to increase clinical and economic effectiveness and efficiency.

Impact of Pharmaceutical Companies’ Promotional Tools on Physicians’ Prescription Patterns: A Systematic Review

Purpose: The role of pharmaceutical companies’ promotional tools in the prescribing decision of physicians comprises five commonly-used promotional tools: sales promotions; advertising; public relations; direct marketing; and personal selling. The purpose of this paper was to examine the existing literature on promotional tools and then explore which medical practitioners’ demographic factors influence the relationship between the various promotional tools and physicians’ prescription behaviour. Design/methodology/approach: A survey of the literature was carried out across online databases from 2008 to 2018, and 41 reviewed articles were identified. The influence of promotional tools on physician prescribing decisions was identified in the articles. Findings: There have been numerous studies on the effect of promotional tools on physician prescription decision. They demonstrated that promotional tools strongly influence physicians’ prescribing decision, but a few others found only minor or no relation. To resolve this ambiguity, there is a need to precisely understand how promotional tools affect prescribing decisions of physicians, under different contexts and conditions. Research limitations/implications: The study recommends further studies on the influence of each factor on physician prescribing behaviour and an evaluation of the proposed model and moderating variables. Originality/value: This paper provides a significant step towards recognizing the relationship between promotional tools and prescribing behaviour. This research contributes to the debate on the ways prescribing behaviour can be affected.

Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts.

Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician's prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.

Projecting the cost, utilization, and patient care impact of prescribing extended release non-abuse-deterrent opioids to chronic pain patients.

To estimate healthcare resource utilization, associated costs, and number needed to harm (NNH) from a physician's decision to prescribe extended-release (ER) non-abuse-deterrent opioids (non-ADO) as compared to ER ADOs in a chronic pain population. A 12-month probabilistic simulation model was developed to estimate the reduction of misuse and/or abuse from a physician's prescribing decisions for 10,000 patients. Model inputs included probabilities for opioid misuse and/or abuse-related events, opioid discontinuation, and switching from ADO to non-ADO. Estimated reductions in abuse associated with ADOs were obtained from positive subjective measures using human abuse liability studies. The model was run separately for commercial, Medicare, Medicaid, and Veterans Administration (VA) populations. The difference in healthcare resource utilization and associated costs (2015 USD) between the ADO and non-ADO simulations was calculated. NNH for non-ADO was also calculated. Misuse and/or abuse-related events for patients prescribed ER non-ADOs ranged from 223-1,410 and associated costs ranged from $20-$98 per patient for commercial and Medicare populations, respectively. Prescribing ER ADOs were associated with 87, 289, 264, and 417 fewer misuse and/or abuse-related events, saving $8, $35, $21, and $29 per patient in commercial, VA, Medicaid, and Medicare populations, respectively. NNH ranged from 185 in the commercial population to 40 in the Medicare population. Results were sensitive to decreases in the probability of misuse and/or abuse events but showed reductions. A physician's decision to prescribe ER ADOs could lead to large reductions in misuse and/or abuse-related events and associated costs across many patient populations.

The influence patient’s characteristics “requests and expectations” on physician prescribing behavior

PurposeThe role of patient’s characteristics in the prescribing decision of physicians comprises two major constructs: drug request and expectations. The purpose of this paper was to examine the existing literature on patient characteristics and then explore the circumstances that reinforce the connection between patient characteristics (drug requests and expectations) and physician prescribing decision.Design/methodology/approachA survey of the literature was carried out across online databases from 1994 to 2015, and 25 reviewed articles were identified. The influence of patient factors on physician prescribing decisions was identified in the articles. A conceptual model to investigate the patient characteristics that influence physicians’ prescribing decision was the developed.FindingsThere have been numerous studies on the effect of patient characteristics on physician prescription decision. Some studies discovered patient’s request for drug and expectations strongly influence physicians’ prescribing decision, whereas others found only minor or no relation. To resolve this ambiguity, there is a need to precisely understand how patient factors affect prescribing decisions of physicians, under different contexts and conditions. This review contends that contextual variables – drug characteristics, drug cost/benefits ratio and physician habit persistence – are determining factors in this debate.Research limitations/implicationsThe study recommends further studies on the influence of each factor on physician prescribing behaviour and an evaluation of the proposed model and moderating variables.Originality/valueThis paper is the first significant step towards recognizing contextual variables that may moderate the relationship between a patient’s drug request and expectations and prescribing behaviour. This research contributes to resolving the debate on the ways patient factors affect prescribing behaviour.

Moderating effects of contextual factors on relationship between pharmaceutical marketing strategies and physician prescription decision: A review

Decision–making by physicians on patients’ treatment has received increased research attention. Research on the effect of marketing strategies on prescription behaviour has tended to generate controversial results. While some researchers reported a strong influence, some found only moderate effects, while others find no influence at all. The main objective of this paper is to review the influence of the marketing strategies by pharmaceutical firms and contextual factors on physician attitude to drug prescription. The paper presents comprehensive information on pharmaceutical marketing efforts through exhaustive review of relevant literature, and identifies the moderating effects of contextual factors on physician prescribing decisions. It also presents a crucial conceptual model for explaining the theoretical linkages between marketing strategies of pharmaceutical firms, contextual factors and the decision of the physician regarding drug prescription. Keywords : Drugs, marketing strategy, Physician prescription, Drug characteristics, Physician persistence, Cost/benefit

Patient Medication Adherence and Physician Agency Problems

Patient medication adherence is important for health, but its causes are not well-understood. I study an under-explored cause of non-adherence: physician agency problems. Because adherence rates differ across therapeutically similar products, physician prescribing decisions, and agency problems, can influence adherence rates. Using insurance claims data on the initial prescriptions and subsequent adherence choices of half a million patients taking statins, I develop and estimate a dynamic model of physician-patient interactions. Imperfectly altruistic physicians trade-off patient utility against other concerns. Agency problems reduce adherence because they imply that physicians do not prescribe their patients' preferred drug, and patients are more likely to adhere to drugs they prefer. Using the estimated model, I find that eliminating agency problems would raise adhere and reduce drug spending as physicians substitute towards cheaper, higher-quality drugs. Relying on stronger assumptions, I also quantify the impact of agency problems on patient welfare and health.

Effects of patient medication requests on physician prescribing behavior: results of a factorial experiment.

Because of internet searches, advice from friends, and pharmaceutical advertising, especially direct-to-consumer advertising, patients are increasingly activated to request medications during a physician encounter. To estimate the effect of patient requests for medications on physician-prescribing behavior, unconfounded by patient, physician, and practice-setting factors. Two experiments were conducted among 192 primary care physicians, each using different video-based scenarios: an undiagnosed "patient" with symptoms strongly suggesting sciatica, and a "patient" with already diagnosed chronic knee osteoarthritis. Half of patients with sciatica symptoms requested oxycodone, whereas the other half requested something to help with pain. Similarly, half of knee osteoarthritis patients specifically requested celebrex and half requested something to help with pain. To increase generalizability and ensure sufficient numbers were available, we recruited 192 primary care physicians from 6 US states. The primary outcome was whether physicians would accede to a patient's request for a medication. Alternative pain medications prescribed were secondary outcomes. 19.8% of sciatica patients requesting oxycodone would receive a prescription for oxycodone, compared with 1% of those making no specific request (P = 0.001). Fifty-three percent of knee osteoarthritis patients requesting celebrex would receive it, compared with 24% of patients making no request (P = 0.001). Patients requesting oxycodone were more likely to receive a strong narcotic (P = 0.001) and less likely to receive a weak narcotic (P = 0.01). Patients requesting celebrex were much less likely to receive a nonselective nonsteroidal anti-inflammatory drugs (P = 0.008). No patient attributes, physician, or organizational factors influenced a physician's willingness to accede to a patient's medication request. In both scenarios, activated patient requests for a medication substantially affected physician-prescribing decisions, despite the drawbacks of the requested medications.

Evaluating the Clinical Utility of a Biomarker

Biomarkers, broadly defined, are markers of a biological process or state.1 Biomarkers are often used in research studies, but they may also be useful for clinicians and patients if they provide information about current status or future risk of disease. It is not always clear, however, when a novel biomarker provides enough useful information to justify measuring it in the context of clinical care. Evaluating the clinical utility of a novel biomarker requires a phased approach.2 Early-phase studies must prove that the biomarker is associated statistically with the clinical state of interest and adds information about presence or risk of disease above and beyond established markers. Midphase studies describe how often this incremental information might alter physician prescribing decisions. Early- and mid-phase studies are useful because they help investigators compare biomarker performance in terms that are generic (ie, not dependent on the specifics of the disease state being studied). Generic measures of biomarker performance have been reviewed previously2,–,16 and are described in Table 1 along with relevant published examples.17,–,32 View this table: Table 1. Generic Measures of Biomarker Performance Measuring biomarker performance in generic terms, however, is not sufficient for demonstrating clinical utility.6 The decision to use a biomarker in clinical practice should be based on an expectation that it will have a positive net health impact, and measuring health impact, by definition, requires use of measurements that consider the specific disease state being studied and its consequences. The goal of this review is to describe the methods by which evidence about the health impact of measuring a biomarker may be generated (late-phase evidence2) using examples relevant to cardiovascular disease and with a focus on the use of randomized clinical trials and modeling for estimating health impact. ### Mechanisms by Which Biomarker Measurement Can Impact Health There are 3 fundamental …

Factors influencing prescribing behaviour of physicians in Greece and Cyprus: results from a questionnaire based survey

BackgroundOver the past few decades, drug and overall healthcare expenditure have risen rapidly in most countries. The present study investigates the attitudes and the factors which influence physician prescribing decisions and practice in Greece and Cyprus.MethodsA postal questionnaire was developed by researchers at the Department of Health Economics at the National School of Public Health in Greece, specifically for the purposes of the study. This was then administered to a sample of 1,463 physicians in Greece and 240 physicians in Cyprus, stratified by sex, specialty and geographic region.ResultsThe response rate was 82.3% in Greece and 80.4% in Cyprus. There were similarities but also many differences between the countries. Clinical effectiveness is the most important factor considered in drug prescription choice in both countries. Greek physicians were significantly more likely to take additional criteria under consideration, such as the drug form and recommended daily dose and the individual patient preferences. The list of main sources of information for physicians includes: peer-reviewed medical journals, medical textbooks, proceedings of conferences and pharmaceutical sales representatives. Only half of prescribers considered the cost carried by their patients. The majority of doctors in both countries agreed that the effectiveness, safety and efficacy of generic drugs may not be excellent but it is acceptable. However, only Cypriot physicians actually prescribe them. Physicians believe that new drugs are not always better and their higher prices are not necessarily justified. Finally, doctors get information regarding adverse drug reactions primarily from the National Organisation for Medicines. However, it is notable that the majority of them do not inform the authorities on such reactions.ConclusionThe present study highlights the attitudes and the factors influencing physician behaviour in the two countries and may be used for developing policies to improve their choices and hence to increase clinical and economic effectiveness and efficiency.

Drug utilization of ezetimibe in rehabilitation centres: registry analysis of factors influencing prescription and effectiveness of treatment

ABSTRACTBackground: While randomized controlled trials (RCTs) generate informative data about clinical outcomes, by their nature they cannot provide information about drug utilization and factors influencing prescribing decisions. In the secondary prevention of patients with cardiac events, lipid lowering therapy with statins and other agents, such as cholesterol absorption inhibitors (CAI, e.g. ezetimibe) plays a pivotal role and is often initiated or modified in rehabilitation centres. The aims of the present study were to analyse factors that influence the prescribing decisions of physicians, and to investigate success rates of lipid lowering therapy with ezetimibe after adjustment for covariates.Methods: Ninety-three rehabilitation centres throughout Germany documented a total of 17 029 patients in cardiac rehabilitation, of which 6976 (41.6%) were prescribed a CAI. A logistic regression model with forward selection based on 31 potential regressors for ezetimibe prescription (demographics, diagnosis, risk factors etc.) was used to construct a propensity score, which reflects the inclination of physicians to prescribe CAI. This score was subsequently used for bias reduction in the comparison of co-medications and success rates.Results: Nineteen variables were associated with ezetimibe prescriptions, the most important ones being total cholesterol, level of education, unstable angina pectoris and arterial hypertension. Ezetimibe was more frequently prescribed together with simvastatin and pravastatin than with other statins, and frequently together with aspirin or beta blockers, respectively. After adjustment for baseline lipid values and covariates, the probability of target level achievement appears to be substantially higher for patients on ezetimibe than for those without ezetimibe.Conclusions: Other factors than conventional risk factors contribute to the CAI prescription habits of physicians. Additional lipid level reductions due to ezetimibe are seen in routine health care corresponding to findings from randomized studies.

Factors in choosing atypical antipsychotics: Toward understanding the bases of physicians’ prescribing decisions

Objective Off-label prescribing of medications, polypharmacy, and other questionable prescribing practices have led investigators to examine a large VA pharmacy database to determine if physician prescribing decisions appear reasonable. Method The current study addresses the question of physician prescribing of atypical antipsychotics in 34,925 veterans with schizophrenia, using a series of signal detection analyses. Results These results suggest that only three factors (hospital size, age, and secondary diagnosis) allow classification of patients prescribed atypicals into three groups with frequencies of use of atypicals ranging from 43% to 79%, and that these results are consistent with reasonable clinical practice. Conclusions Results of two-stage signal detection analyses are readily interpretable by clinicians and administrators who are faced with the task of evaluating how physicians prescribe medications in clinical practice. Physicians’ decisions to prescribe atypical antipsychotics are based on both patient and fiscal considerations. This likely reflects a combination of clinical judgment and institutional guidelines.

Bridging the gap between therapeutic research results and physician prescribing decisions: knowledge transfer, a prerequisite to knowledge translation.

A wide gap continues to exist between available therapeutic research results and physician's prescribing. Numerous explanations account for this gap, but one central reason is the difficulty in transferring comprehensive research information to practicing clinicians. This problem arises from information overload and the growing complexity of research findings. We propose a multistep process that can be used to develop systems to bridge this information/prescription gap. The steps include: comprehensively collecting and summarizing clinical trial reports, scoring and ranking these according to their level of evidence, exploring and synthesizing the data using meta-analyses, summarizing these results, representing them in an easily understandable form, and transmitting the overview findings to prescribers at the time they need them. This ambitious endeavor is needed to ensure that prescribers have access to pertinent research results for use in their prescription decisions. We demonstrate in this article that there are no theoretical or technical obstacles to make the proposed system workable.

Ethics in Pharmaceutical Advertising

Pharmaceutical manufacturing is one of the most financially lucrative industries in America due, in part, to massive marketing and advertising. The content of many symposia and medical journals as well as physician prescribing decisions seems to be influenced by the promotional efforts of pharmaceutical companies. In an effort to increase sales, the industry now advertises directly to the public. The role of the Food and Drug Administration and ethical standards established by medical organizations are discussed.

Micro/Macro Strategies for Improving Hospital Formulary Performance

The majority of American hospitals utilize a drug formulary to guide the prescribing decisions of physicians who practice within this setting. In order to strengthen formulary performance, six administrative procedures - periodic evaluation, informal screening, explicit drug approval, educational campaigns, informal assessment, and periodic surveys of users—are recommended. Because of certain limitations inherent in these micro inputs, four macro strategies are proposed to support formulary implementation.Presented at the 25th Annual Pharmacy Congress, St. John's University, Jamaica, NY, April 7, 1983.

Factors Influencing Prescribing Decisions of Physicians: A Review

The pharmaceutical bill is increasing at an alarming rate. The physician practice variation has a pronounced effect on healthcare spending. A number of factors can influence the prescribing behavior of physicians. The aim of this review was to identify the factors affecting the prescribing decision of physicians. Electronic databases including Scopus, PubMed/MEDLINE CENTRAL, Cochrane Libraries and Google scholar were searched systematically for literatures on factors influencing prescribing decisions of physicians from 2000 to 2016. There was no restriction on the study designs. Thirty-three studies met the inclusion criteria from 1122 search results. A total of 33 factors were identified. The most frequent factors were patients' clinical condition, pharmaceutical industries, physician attributes, patient preference and cost of medicine. Physicians' personal attributes, cost of the medicine and pharmaceutical industries' marketing and promotion strategies were mostly mentioned to influence prescribing decision. The identified factors showed that prescribing is not only geared for patient benefit, but also towards personal interest. The use of valid and reliable practice guidelines could reduce the negative impact of wide ranges of factors and promote the rational prescribing effectively.