Prescribing Behavior Research Articles

Beyond Dual Bronchodilation - Triple Therapy, When and Why.

Although pharmacological treatment of COPD is codified in different guidelines and strategy documents, there is abundant evidence of discrepancy between what they suggest and what health professionals prescribe, especially in low-risk groups where there is widespread overprescription of triple therapy. It is therefore necessary to clarify when the use of triple therapy is indicated in COPD patients and when it is preferable to maintain treatment with dual bronchodilation. In this article, we discuss our views based on our experience and what is reported in the literature and try to give answers to these two questions. The evidence generated by pivotal RCTs supports the use of triple therapy in patients who present for the first time and have severe airway obstruction, are symptomatic, have had frequent moderate or severe exacerbations in the previous year, and have peripheral eosinophilia. However, it is difficult to determine whether step-up is useful in all other cases because the available data are quite conflicting. It is likely that the inconsistency in the information generated by the various available studies may explain the prescribing behaviour of many physicians who do not adhere to recommendations of guidelines and strategies. However, it is necessary to establish whether and when the addition of an ICS to the LAMA/LABA combination is effective, to determine whether triple therapy can induce an additional clinical benefit over dual bronchodilation, irrespective of a preventive effect on COPD exacerbations, to establish its value, and to examine whether cost differences can support the use of triple therapy over combined LAMA/LABA therapy in real life.

The pattern of antibiotics prescription and consumption

Objective: To investigate the antibiotic utilization and prescription patterns as well as define its convenience to the norm in four North-Sinai hospitals, Egypt. Antimicrobial resistance is a universal health threat. The golden era of miracle antibiotics has ended and we have faced the challenge of being troubled by infectious diseases with no discovery of new antibiotics found since 1987. Antibiotic pressure, overuse, and misuse are important risk factors for antimicrobial resistance and hospital cross-infection. To combat antimicrobial resistance, Egypt started its National Action Plan (2018-2022) aiming to optimize the usage and consumption of antibiotics. Method: This multicenter descriptive cross-sectional study was designed to describe the pattern of antibiotic prescription and consumption at four North Sinai Hospitals related to the Ministry of Health and Population. We reviewed 309 medical records of the inpatient department; the samples were selected through a stratified random sampling technique. Data were collected retrospectively from the medical records of the hospitalized patients in October, November, and December of 2020 by a paper-based method. Data were analyzed using descriptive statistics. Result: The prevalence of antibiotic consumption is near 68.9% in the four hospitals indicating that two-thirds of admitted patients receive antibiotics. Approximately 52.1% administered antibiotics for no reason. Most of the admitted patients took antibiotics on the same day of admission, regardless of the different types of hospital departments. Furthermore, 98.7% of antibiotics were prescribed without culture or order for culture and microbiological tests. Broad-spectrum antibiotics were 90% of all antibiotics prescribed. A total of 18 types of antibiotics were prescribed, cefotaxime was the most commonly prescribed antibiotic representing 26.5%. Conclusion: Judicious antibiotic prescribing behavior slows down the nature of antibiotic resistance. To guarantee the best antimicrobial use in the hospitals, standard treatment guidelines, and the Essential Medicines List for infectious diseases should be carried out and revised at least every 2 years to be a clinical reference for clinicians. Continuous education and training of clinicians and healthcare workers can contribute to optimizing the rational use of antibiotics, which in return reduces the progress of antibiotic resistance. There is an urgent need for antibiotic stewardship and surveillance and their application in all hospitals.

Evaluation and optimization of antibiotic usage in upper respiratory tract infections in children at a tertiary care outpatient department

INTRODUCTION:Inappropriate antibiotic (ab)use contributes to antimicrobial resistance. Upper respiratory tract infection (URTI) is the most common reason for antibiotic prescription in an outpatient department (OPD). Several factors influence the high and unjustified antibiotic use in a common ailment.MATERIALS AND METHODS:A clinical audit was performed to assess antibiotic prescription rate (APR) for URTI in the pediatric OPD against the available benchmark. The prescription pattern was assessed, and interventions were formulated to improve prescription behavior. Data of all children attending OPD and fulfilling the criteria for URTI group were collected from the online hospital management system and analyzed. Interventions, in the form of discussions, presentations, posters, and guidelines (Indian Ministry of Health Guidelines for URTI) regarding etiology of URTI, and indications for antibiotic prescription were implemented. Data were monitored and feedback to consultants was given.RESULTS:The baseline APR was 14.7%. There was wide variation in APR (4.1%–53.1%) among consultants. Three consultants had a rate of 53.1%, 29.7%, and 28.6%, which was very high. Postintervention, the average APR decreased to 8.7%, a reduction of 40.8%. There was a reduction in APR among consultants with high APR as well. There was reduction in the use of azithromycin, a drug recommended for patients with penicillin allergy, from 21.2% to 14.4% (32.1% reduction). Amoxycillin plus clavulanic acid combination and amoxicillin alone continued to be the most prescribed antibiotics.CONCLUSION:Interventions through clinical audit were useful in reducing APR. The APR of 8.7% achieved in this study postintervention can be used as a benchmark by other institutions to assess APR in children with URTI.

Opinions, Attitudes, and Prescribing Practices of Oral Contraceptive Pills of General Practitioners and Gynecologists in India

Background To study the prescription behavior of oral contraceptive pills (OCPs) by physicians, gynecologists, and alternative medicine practitioners (AMPs). Materials and Methods Close-ended questionnaire-based cross-section study was performed between 1st September 2012 and 28th February 2014 in three groups of responders, i.e., AMP, general medical practitioners (GMPs), and obstetricians and gynecologists (ObGy). A stratified random cluster sample was used. Data of 400 subjects in all three groups were obtained using both univariate and multi-variate sophisticated statistical analyses for analyzing attitude and practices and were recorded on an ordinal scale using appropriate non-parametric test. Results Of the 1,237 subjects surveyed, 400 completed questionnaires were received from each of the three groups viz; AMPs, GMPs, and ObGy. Remaining 37 incomplete questionnaires were not included in the final analysis. Conclusion There are equal misconceptions regarding OCPs among users and prescribing physicians. Preference for OCPs in married and unmarried women is also equally low. OCP usage and their prescription practices can be improved by removing potential barriers, developing public–private partnership, and training promoters.

THE INFLUENCE OF MORAL JUDGMENT ON PHYSICIANS' PRESCRIPTION BEHAVIOUR

Pharmaceutical promotion towards physicians’ prescription behaviour is strongly interrelated. Identifying and addressing the ethical challenges in physicians’ prescription behaviour to increase the ethical predisposition of prescribing medicines is prioritized in global health and development plans. Hence, the importance of ethics in the professionalism of healthcare practitioners is now a growing concern. The main objective of this research is to investigate the influence of moral judgment on physicians' prescription behaviour. A survey has been conducted among 152 medical practitioners from private healthcare facilities in the metropolitan area of Kuala Lumpur and Selangor states of Malaysia. The principal component analysis method in EFA and structural equation modelling technique in CFA has been used to analyze the data and validate the model. The study found that physicians’ moral equity factor has a significant and positive influence on physicians’ prescription behaviour whereas their relativism and contractualism factors were not significant. The empirical evidence obtained from this study would make significant contributions to advancing the current knowledge of ethical prescription behaviour. Recommendations to physicians for more ethical prescription practices have been discussed at the end of this paper.

The effect of state policies on rates of high-risk prescribing of an initial opioid analgesic

BackgroundMultiple state policies, such as prescription drug monitoring programs (PDMPs) and duration limits, have been implemented to decrease high-risk opioid prescribing. Studies demonstrate that many policies decrease certain opioid prescribing behaviors, but few examine their intended effects on the targeted high-risk prescribing practices, nor disentangle the effects of concurrent state or federal policies likely to influence those practices. MethodsForty-one million initial prescriptions for new opioid episodes from 2007 to 2018 were identified using national pharmacy claims. We identified high-risk initial prescriptions, defined as >7 days’ supply, average daily MME >90, or concurrent with benzodiazepines and estimated three multivariable logistic regression models to assess the association between policies and outcomes controlling for patient, prescriber, and county characteristics. ResultsInitial prescriptions for >7 days declined from 23.8% in 2007 to 14.9% in 2018, associated with mandatory and interoperable PDMPs and prescription duration limits but not other policies examined. Initial prescriptions with daily MME > 90 declined from 13.2% to 1.9%, associated with pain management clinic laws but not consistently with other policies. Initial prescriptions concurrent with benzodiazepines declined only modestly from 6.9% to 6.5%, associated with pain management clinic laws but not other policies examined. ConclusionsThe opioid policy environment has changed rapidly with a range of different policies being implemented addressing high-risk prescribing. PDMP laws mandating prescriber use and pain clinic laws both appear efficacious but decrease different types of high-risk opioid prescribing. New policies should be considered in light of the prevalence of the problem being addressed.

Preliminary findings on the effects of medication advocacy and daily behavior ratings on prescriber behavior

AbstractOver a 1‐year period, we trained caregivers to employ a color‐coded daily behavior rating system whereby green denoted a high level of appropriate behavior, yellow denoted a mix of some appropriate behavior and mild problem behavior, and red denoted a high level of problem behavior. We then used these ratings to generate graphs that caregivers brought to their child's prescriber appointments. Preliminary data comparing unconditional and conditional probabilities from 25 prescriber visits with 12 participants indicate prescribers were most likely (a) to decrease psychotropic medication following green ratings, (b) increase psychotropic medication following red ratings, and (c) make no changes following yellow ratings. Across participants, prescribers' decisions matched the color code for 76% of trials. These preliminary findings support continued inclusion of the medication‐advocacy training component to facilitate deprescribing of psychotropic medication within our state‐funded project.

Effectiveness and Cost-Effectiveness of 360 Disease-Modifying Treatment Escalation Sequences in Multiple Sclerosis

ObjectivesThe rapid expansion in treatment options for relapsing-remitting multiple sclerosis (RRMS) of the past decade requires clinical decision making on the sequential prescription of these treatments. Here, we compare 360 treatment escalation sequences for patients with RRMS in terms of health outcomes and societal costs in The Netherlands. MethodsWe use a microsimulation model with a societal perspective, developed in collaboration with MS neurologists, to estimate the effectiveness and cost-effectiveness of 360 treatment sequences starting with first-line therapies in RRMS. This model integrated data on disease progression, disease-modifying treatment efficacy, clinical decision rules, age-dependent relapse rates, quality of life, healthcare, and societal costs. ResultsCosts and health outcomes were overlapping among different treatment escalation sequences. In our model for RRMS treatment, optimal lifetime health outcomes (20.24 ± 1.43 quality-adjusted life-years [QALYs], 6.11 ± 0.30 relapses) were achieved with the sequence peginterferon-dimethyl fumarate-ocrelizumab-natalizumab-alemtuzumab. The most cost-effective sequence (peginterferon-glatiramer acetate-ocrelizumab-cladribine-alemtuzumab) yielded numerically worse health outcomes per patient (19.59 ± 1.43 QALYs, 6.64 ± 0.43 relapses), but resulted in €98 127 ± €19 134 less costs than the most effective treatment sequence. ConclusionsEffectiveness estimates of treatments have overlapping confidence intervals but the treatment sequence that yields most QALYs is not the most cost-effective option, also when taking uncertainty into account. It is important that neurologists are aware of cost constraints and its relationship with prescription behavior, but treatment decisions should be individually tailored.

Determinants of Clinician and Patient to prescription of antimicrobials: case of Mulanje, Southern Malawi

Background: Antimicrobial resistance is an emerging problem in low- and middle-income countries. The problem is exacerbated by inappropriate prescription of antimicrobials. Factors leading to overuse or inappropriate prescription of antimicrobials by the cadre of medical assistants, clinical technicians and clinical officers have received limited attention. This study investigated factors that influence prescription behaviours of antimicrobials among clinical officers in various health facilities in Mulanje district, Southern Malawi. Methods: In-depth interviews (n=18) and focus group discussions (n=2) were conducted with COs from four health facilities in Mulanje district. Purposive sampling was done to arrive at a sample size of 30 health cadres. Results: Participants pointed out that patient preferences, belief and clinicians’ inadequate education on this issue were among the factors that contribute to inappropriate antimicrobial prescription. 75-% of clinicians showed lack of knowledge on the definition of antibiotic and antimicrobial resistance. Conclusion: Inappropriate use of antimicrobials is facilitated by prescribing decisions made by clinicians who are greatly influenced by their patients. Interventions aimed at improving antimicrobial prescription should target both clinicians and patients.

173. Antimicrobial Stewardship Education Changes Prescribing Behavior and Reduces Treatment of Asymptomatic Bacteriuria

BackgroundTreatment of asymptomatic bacteriuria (ASB) outside of pregnancy and urological procedures increases the risk of antibiotic resistance without improving outcomes. At Olive View-UCLA Medical Center (Sylmar, CA), the CDC U.S. Antibiotic Awareness Week (AAW) was utilized as a platform to promote antimicrobial stewardship (AS) for ASB. We evaluated the incidence of antibiotic treatment of ASB pre-AAW vs post-AAW, and the impact of AS education on future prescribing practices for ASB.MethodsIn this single-center retrospective observational study, AS education defining ASB vs urinary tract infection (UTI) was provided via visual aids distributed throughout the hospital during AAW from 11/18/2020 to 11/24/2020 (Figure 1). All positive urine cultures (Ucx) for adult inpatients were reviewed prior to AAW from 9/2020 to 11/2020 and after AAW from 12/2020 to 1/2021. Patients were excluded if they were unable to report UTI symptoms, pregnant, or undergoing urological procedure. The incidence of ASB treatment pre- and post-AAW was compared. A survey was sent to providers to compare the impact on antibiotic prescribing behavior for ASB pre- and post-AAW. Fisher’s exact and Chi-squared tests were used for statistical analysis.Figure 1. Antimicrobial Stewardship Education and Poster Distribution ResultsA total of 260 cases met study eligibility. In the pre-AAW group, 56 of 131 cases presented with ASB, of which 16 were treated with antibiotics (28.6%). In the post-AAW group, 55 of 129 cases presented with ASB, and 5 were treated with antibiotics (9.1%). Antibiotics were prescribed more often for patients with ASB in the pre-AAW group compared to those in the post-AAW group (p=0.014). Forty providers completed the survey, of which 97.5% had seen the visual aids, 70% had found the education "very” or “extremely" useful, and 43.6% reported they “always or sometimes” treated ASB pre-AAW vs 15% post-AAW (p< 0.01).ConclusionAS posters and education defining ASB significantly decreased the treatment of ASB. AAW education on ASB antimicrobial stewardship demonstrated a high value and shifted prescribing behavior to avoid antibiotic treatment of ASB. A similar approach to deliver provider education could serve as a valuable model to change provider AS practices for ASB.Disclosures All Authors: No reported disclosures

Adherence to National Antimicrobial Guidelines in Hospitalized Geriatric Patients with Community-Acquired Pneumonia: A Prospective Observational study in a Malaysian Hospital

The evaluation of disease progression and onsite therapeutic care choices for community-acquired pneumonia (CAP) patients is vital for their well-being and the optimum utilization of healthcare resources. The current study was conducted to assess physicians’ adherence to clinical practice standards and antibiotic prescribing behavior for the treatment of CAP in older people. A prospective study that included 121 consecutive patients admitted for CAP was conducted at Kulim Hospital, Kedah, from March 2020 to August 2020. Medical records including demographic data, comorbidity, physical examination, laboratory or radiologic findings, and drugs used for the treatment of CAP were accessed from bed head tickets (BHT). The mean age for patients was 73.5 ± 6.2 years, 73 (60.3%) and 48 (39.6%) were males and females, respectively. Amoxicillin/clavulanate (19.8%) was the most prescribed antibiotic for non-severe pneumonia followed by ampicillin sodium/sulbactam sodium (6.6%), while in patients with severe CAP beta-lactam + beta lactamase inhibitors (BLIs) with a combination of macrolide were the most common antibiotics prescribed either in patients with (21.4%) or without co-morbidities (8.2%). The average length of stay in the hospital with severe pneumonia was 6–7 days for 23.9% of patients and < 5 days for 21.4% of patients. The duration of intravenous antibiotics in patients with severe pneumonia was 6–7 days for 32.2% of patients. The present findings revealed the adherence of antibiotic prescribing practices to the Malaysian National Antimicrobial Guideline 2019 for CAP therapy among geriatric patients and adherence to the CAP criteria for hospital admissions.

Personal &amp; Professional Qualities of Medical Representative and Impact on Doctor's Prescribing Behavior

Background: The promotion of a pharmaceutical product is based on the effective collaboration between medical representatives (MR) & physicians. Pharmaceutical companies are following many doctor-consulting strategies and have found a way to promote their products through MR. But it's only possible if the MR communicates the brand's benefit effectively to the doctor. Aims and Objectives: To identify the personal and professional qualities of MRs that affect doctors' prescribing behavior. The impact of three variables like product detailing of MR, MR's attire, and MR's knowledge has been measured on doctor's prescription behavior. Methodology: Three personal and/or professional qualities of MR have been identified (effective detailing, personal attire, and scientific knowledge of MRs) and studied the influence of these qualities on physician's prescribing habits. Responses were collected through self-administered questionnaires from general practitioners, physicians, gynecologists, pediatricians, and dentists. ANOVA & regression analysis models were used to analyze the hypothesis. Result: Eighty-seven percent of the doctors agreed that pharmaceutical companies should train MRs properly about the detailing of brand and product knowledge, 64% of doctors agreed-upon personal attire of MRs attract their attention, and 92% agreed that MR knowledge plays a crucial role in influencing their prescribing behavior. The hypothesis was accepted for detailing, personal attire, and scientific understanding of MRs regarding their influence on doctor's prescription. Conclusion: The role of detailing, personal attire, and scientific knowledge of MR is well established to influence the practice of physicians. Pharmaceutical companies should train their sales team properly, starting from personal grooming to every aspect of brand and therapy for practical in-clinic discussion and doctor conversion.

Prescriber Attitudes, Experiences, and Proclivities Toward Digital Medicine and How They Influence Adoption of Digital Medicine Platforms.

BackgroundPsychiatric prescribers (prescribers) typically assess medication adherence by patient or caregiver self-report. Despite likely clinical benefit of a new digital medicine technology, the role of specific prescriber attitudes, behaviors, and experiences in the likelihood of adoption is unclear.ObjectiveTo identify prescriber characteristics that may affect adoption of the ingestible event marker (IEM) platform.DesignA survey of prescribers treating seriously mentally ill patients was conducted. Factor analysis was performed on 11 items representing prescriber characteristics believed to be related to endorsement of the IEM platform. Four factors were extracted. Regression analysis was used to test the strength of the relationships between the factors and likelihood of adoption of the IEM platform.ResultsA total of 131 prescribers completed the survey. Most (84%) agreed that visits allow enough time to monitor adherence. Factor analysis revealed four underlying dimensions: 1) perspectives on the value of adherence; 2) concerns about measuring adherence; 3) views toward digital health technologies; and 4) views on payer role/reimbursement. Factors 1 and 3 were related to gender, the belief that computerization benefits prescribers, the presence of office support staff, and the belief that new digital medicine (DM) technology will be cost prohibitive. Willingness to adopt the IEM platform was related to gender (p < 0.05) and perspectives on the value of adherence (p < 0.05), with those scoring higher on that measure also being more likely to adopt.ConclusionPsychiatric prescribers are concerned about medication adherence, perceive current monitoring tools to be problematic, and are open to using digital technologies to improve accuracy of adherence assessment. Relationships among prescriber characteristics, beliefs, and experiences should be considered when developing educational materials, particularly when the goal is to encourage adoption and use of the IEM platform.

Pain self-management interventions for community-based patients with advanced cancer: a research programme including the IMPACCT RCT

Pain self-management interventions for community-based patients with advanced cancer: a research programme including the IMPACCT RCT

Effect of Antibiotics in Preventing Hospitalizations From Respiratory Tract Infections in Children With Down Syndrome

To determine the impact of antibiotic prescription for respiratory tract infections (RTIs) on the subsequent risk of RTI-related hospitalizations in children with Down syndrome (DS).Children aged ≤18 years (defined in groups: 0–1 years; 1–5 years; 5–10 years; and 10–18 years), with DS (as identified by Read and International Statistical Classification of Diseases and Related Health Problems 10th Revision, codes) were included. Each child with DS in the cohort were frequency matched by general practitioner (GP), sex, birth year (+/− 5 years), and start of follow-up age ≤18 years (follow-up was defined as a period of 28 days from the initial RTI-related GP consultation or until the first RTI-related hospitalization).Information regarding health care use was extrapolated from Clinical Disease Research Using Linked Bespoke Studies and Electronic Health Records, an electronic health records database in the United Kingdom, on the basis of Read and International Statistical Classification of Diseases and Related Health Problems 10th Revision, codes, to classify types of RTIs (lower respiratory tract infection; upper respiratory tract infection; unclassified) and probable versus possible RTI, identify diagnosis of DS and other comorbidities, and determine admission and discharge dates. Extracted data were reviewed and confirmed by a committee of clinicians and academic professionals. Logistic regression models were used to assess the impact of antibiotic prescriptions on the risk of subsequent RTI-related hospitalization in DS patients with RTI-related GP consultations. In subgroup analyses, the researchers further explored the effect of antibiotics across different age groups and type of RTI.Both cohorts (DS: 992; control: 4874) had similar demographic characteristics for sex and age. There were more White individuals in the group with DS versus in the control group (58.5% vs 41.8%) and more comorbidities in the group with DS. Antibiotic prescriptions after an RTI-related GP consultation did not significantly reduce the risk of the 28-day RTI-related hospitalization for either group, even after adjusting for antibiotic prescription, age group, sex, presence of congenital heart disease, presence of asthma, and number of previous RTI-related hospitalizations and RTI-related GP consultations in the previous 6 months. When adjusted for the same covariates, RTI-related hospitalizations were significantly reduced in DS individuals aged 0–1 years who were prescribed antibiotics for RTI-related concerns (adjusted odds ratio: 0.260; 95% confidence interval: 0.077 to 0.876) but not in other age groups. This protective effect was also not seen by type of RTI or in the control group.Aside from infants aged 0 to 1 years with DS, antibiotic prescriptions did not reduce RTI-related hospitalizations.It appears that children with DS are frequently prescribed antibiotics for viral infections in the United Kingdom. Although antibiotics have not been shown to reduce hospitalizations for RTI in the general pediatric population, in previous studies, researchers did not include children with comorbidities, prompting these authors to specifically examine children with DS. It is unclear how antibiotic prescribing behavior for this special population compares between the United Kingdom and the United States, thus limiting the generalizability of these results. Nevertheless, the authors surmise that nonantibiotic interventions to manage RTIs in medically complex children can be effective, which is consistent with our outpatient stewardship efforts to combat antibiotic misuse and resistance in the United States.

Clinical characteristics and comorbidities associated with testosterone prescribing in men.

Testosterone replacement therapy (TRT) is recommended for the treatment of symptomatic hypogonadism in men. Data on prescription behaviours are, however, limited and conflicting. The objective of this study was to investigate clinical characteristics associated with the likelihood of being prescribed TRT by general practitioners (GP) in North-West London (NWL). Retrospective cohort study using Discover database of GP-registered patients in NWL between 2015 and 2019. We identified 20,299 men aged ≥18 years with serum total testosterone measurement (TT) and without prior TRT prescription records. We determined whether TRT was subsequently commenced, while analysing clinical characteristics related to hypogonadism. Of all men having TT measurement, 19,583 (96.4%) were not commenced on TRT (Group A) and 716 (3.5%) men were commenced on TRT (Group B). Men prescribed TRT (Group B) had higher mean age, body mass index (BMI) and higher risks of hypertension, depression type 2 diabetes and ischaemic heart disease; conversely, men in Group B had lower mean pretreatment TT and were less likely to have prostate cancer. Four-hundred and thirty-six men (24.3%) with TT < 8 nmol/L and symptoms of low libido were not prescribed TRT. Our study highlights several factors which may influence the decisions made by clinicians when initiating TRT in primary care. Clearer guidance for clinicians may help to improve the consistency of treatment of men with hypogonadism.

Estimating variations in the use of antibiotics in primary care: Insights from the Tuscany region, Italy

BackgroundPractice variation is a well‐known phenomenon that affects all aspects of healthcare delivery and leads to suboptimal health outcomes as well as poor resource allocation. Given the global rise of antimicrobial resistance, practice variation is of particular concern when it comes to the prescription of antibiotics. A growing number of healthcare systems are tackling this issue at all levels of healthcare governance.Aims and objectivesThis study sought to estimate the variation in antibiotic use across different levels of Tuscany's primary care, and assess the extent to which the organization of primary care delivery is responsible for this variation.MethodsWe analysed the performance and variation for seven indicators related to the use of antibiotics at three levels of healthcare governance: (i) the clinician level (2619 general practitioners [GPs]); (ii) the peer‐group level (all 116 GP group practices) and (iii) the institutional level (all 26 health districts). For the statistical analysis, we built three‐level mixed effects models that were fitted with 2619 GPs, 116 GP group practices and 26 health districts.ResultsThe multi‐level models suggested that the grand majority of the variation in antibiotic use was located at the GP level (75% to 97%). However, the percentage of variation associated with GP group practices and health districts ranged from 3% to 25%, depending on the type of indicator analysed.ConclusionWhile the variation was found to be in large part due to differences between GPs themselves, the influence exerted by peer groups and institutional mechanisms does have a significant impact as well. Further research needs to be conducted regarding the institutional and contextual factors that prompt GPs to harmonize their prescribing behaviour in line with best practices and lead to not only improved patient outcomes but also large cost‐savings.

Flipping the script: The effects of opioid prescription monitoring on specialty-specific provider behavior.

Mandatory access Prescription Drug Monitoring Programs (MA-PDMPs) aim to curb the epidemic at a common point of initiation of use, the prescription. However, there is recent concern about whether opioid policies have been too restrictive and reduced appropriate access to patients with the most need for opioid pharmaceuticals. We assess MA-PDMP's effect on specialty-specific opioid prescribing behavior of Medicare providers. Our findings suggest that requiring providers to query a PDMP differentially affects opioid prescribing across provider specialties. We find a three to four percent decrease in prescribing for Primary Care and Internal Medicine providers. This result is driven by healthcare providers at the lower end of the prescribing distribution. There is also suggestive evidence of an increase in opioid use disorder treatment drugs prescribed by these same providers. We also find no evidence for the hypothesis that MA-PDMPs restrict prescribing by providers who treat patients with potentially high levels of pain, few drug substitutes, or urgency for pain treatment (e.g., Oncology/Palliative care). This result is not dependent on whether a state provides exemptions for these providers. Our results indicate that MA-PDMPs may help close provider-patient informational gaps while retaining a provider's ability to supply these drugs to patients with a need for opioids.

Exploring Providers’ Perception to Naloxone Education for Opioid Overdose After Receiving Academic Detailing at the U.S. Department of Veterans Affairs

Introduction: The U.S. Department of Veterans Affairs (VA), in partnership with the Opioid Overdose Education and Naloxone Distribution (OEND) Program, implemented the National Academic Detailing Service to deliver naloxone education to providers with patients at-risk for opioid-related overdose. Methods: We administered a 26-item online survey to VA providers to explore their perceptions about prescribing naloxone for opioid overdose emergencies and their experience with academic detailing between August 2017 and April 2018. Responses were analyzed using descriptive statistics to (1) explore their current perceptions of naloxone prescribing and their experience with academic detailing, (2) identify differences across provider types [primary care providers (PCP), specialists, and others], and (3) assess perceived naloxone prescribing behavior change after an academic detailing visit. Results: Providers (N = 137) indicated that they were practicing at a level that was consistent with VA goals to promote take-home naloxone to reverse opioid-related overdose events. Average domain scores were similar across PCP, specialist, and other provider types. Specialists reported a higher average attitude domain score (+.56, P = .011) and perceived barriers domain score (+.82, P = .009) than PCPs. Most providers agreed that they prescribed naloxone more frequently due to academic detailing (53%) and indicated that they synthesized information from the academic detailer to change their naloxone prescribing practice (60%). Discussion: VA providers’ perceptions of take-home naloxone were aligned with current evidence-based practice. Moreover, providers reported increasing their naloxone prescribing and synthesizing OEND-related information after an academic detailing interaction. Understanding providers’ perceptions can be used to improve and enhance the academic detailing program’s effectiveness.

Pharmaceutical Sales Representatives in the United States and China: The Need for Professional Public Space.

Pharmaceutical sales representatives (PSRs) are one of the most frequently used drug information sources for physicians in both the United States and China. During face-to-face interactions, PSRs use various promotional strategies to impact the prescribing behavior. In the United States, PSRs provide physicians small gifts, free drug samples, and “sincere friendships”, whereas in China, they played an indispensable role in medical corruption over the past three decades. To cope with the undue influence of PSRs, both these countries have taken positive but insufficient measures to eliminate the effect thus far. By comparing the strategies of American and Chinese PSRs, it was found that building a friendly personal relationship with physicians in a relatively closed private environment (such as physician’s office) is a key factor to exert an individualized influence on physicians, even in different social backgrounds and healthcare contexts. Therefore, this essay suggests that it is necessary to limit the establishment of personal relationships and maintain a more professional interaction to reduce the personalized psychological and emotional influences on physicians’ professional judgment. To achieve this goal, it is proposed to transfer the physician-PSR interaction to a professional public space as a supplement to current countermeasures and suggestions. The presence of others and the possibility of third party participation will stimulate more ethical and reputational concerns. It is hoped that the increased transparency of the interaction will promote participants to consider more professional norms and mitigate the undue influence of PSRs’ individualized strategies.