Physician Prescribing Behavior Research Articles

Efficacy of interventions targeted at physician prescribers of opioids for chronic non-cancer pain: an overview of systematic reviews

BackgroundTo combat the opioid crisis, interventions targeting the opioid prescribing behaviour of physicians involved in the management of patients with chronic non-cancer pain (CNCP) have been introduced in clinical settings. An integrative synthesis of systematic review evidence is required to better understand the effects of these interventions. Our objective was to synthesize the systematic review evidence on the effect of interventions targeting the behaviours of physician opioid prescribers for CNCP among adults on patient and population health and prescriber behaviour.MethodsWe searched MEDLINE, Embase, and PsycInfo via Ovid; the Cochrane Database of Systematic Reviews; and Epistemonikos. We included systematic reviews that evaluate any type of intervention aimed at impacting opioid prescriber behaviour for adult CNCP in an outpatient setting.ResultsWe identified three full texts for our review that contained 68 unique primary studies. The main interventions we evaluated were structured prescriber education (one review) and prescription drug monitoring programmes (PDMPs) (two reviews). Due to the paucity of data available, we could not determine with certainty that education interventions improved outcomes in deprescribing. There is some evidence that PDMPs decrease the number of adverse opioid-related events, increase communication among healthcare workers and patients, modify healthcare practitioners’ approach towards their opioid prescribed patients, and offer more chances for education and counselling.ConclusionsOur overview explores the possibility of PDMPs as an opioid deprescribing intervention and highlights the need for more high-quality primary research on this topic.

Feedback Intervention for the Control of Glucocorticoid Prescription in Primary Care Institutions: A Cluster Randomized Cross-Over Controlled Trial in Southwest China.

The purpose of this study is to assess the effect of glucocorticoid prescription feedback intervention in complex primary care institutions for regulating its inappropriate use. A six-month cluster randomized cross-over controlled trial was conducted in primary care institutions. A total of 347 physicians from 69 participating institutions were randomly allocated to either group A or group B. Both groups were given feedback interventions or serve as control. The feedback intervention comprised two components: a real-time pop-up warning of inappropriate glucocorticoid prescriptions based on the Hospital Information System and a high-proportion prescription feedback intervention warning system. The primary outcome measure was the 10-day inappropriate glucocorticoid prescription rate, while the 10-day glucocorticoid prescription rate served as secondary outcome measure. At baseline, the 10-day inappropriate glucocorticoid prescription rates were 66.63% and 66.57% in group A and group B, respectively, showing no significant difference (p = 0.140). Following the intervention, group A exhibited a significant reduction in 10-day inappropriate glucocorticoid prescription rate at the crossing point by 13.69% (p < 0.001). In contrast, group B, which served as the control group, experienced an increase of 5.93% (p = 0.037) at the same crossover point. After the crossover point, there was a decrease in 10-day inappropriate glucocorticoid prescription rate for both groups. Group B as the intervention group demonstrated a reduction of 28.22% compared to the crossing point (p < 0.001), whereas group A showed a decrease of 12.20% (p = 0.339). The characteristics of physicians did not significantly influence the inappropriate glucocorticoid prescription rate. The real-time pop-up warning of inappropriate glucocorticoid prescriptions based on the Hospital Information System and high-proportion prescription feedback intervention warning system can effectively regulate the inappropriate glucocorticoid prescribing behavior of physicians. ISRCTN11747547.

Abstract 15848: Hardly a Windfall: Prescribing Practices in Pediatric Heart Failure Before and After Food and Drug Administration Approval

Background: Prior to the 2019 Food and Drug Administration (FDA) approval of ivabradine and sacubitril/valsartan, there were no medications approved for the treatment of pediatric heart failure (PHF). There are minimal data regarding the use of on- or off-label medications in PHF. Aims: We aim to describe medication use in PHF, factors associated with PHF medication use, and test the hypothesis that FDA approval is associated with changes in prescriber practice. Methods: Utilizing the Truven Health Marketscan Claims Encounter Database (2013-2021), we determined the prevalence of medication [diuretics, angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs), beta-blockers, pulmonary vasodilators, ivabradine, and sacubitril/valsartan] use in children ≤19yo with PHF and cardiomyopathy (CM), with a focus on use before and after FDA approval. Results: Of 2,218 children with PHF and CM, 76% were prescribed ≥ 1 HF medication. Diuretics (57%) and ACEi/ARBs (57%) were used most frequently ( Fig 1A) . Only 0.4% of patients were prescribed ivabradine and 3% sacubitril/valsartan. Patients enrolled in Medicaid were more likely to be prescribed HF medications than those with commercial insurance (OR 1.83, 95% CI 1.50-2.22). After FDA approval in 2019, sacubitril/valsartan prescription rose significantly from 0.4% in 2013-2018, to 3.9% in 2020-2021 (p &lt;0.001), and ivabradine use increased from 0.1% in 2018 to 0.5% (p = 0.043) in 2020-2021, but both remained rare (Fig 1B) . Conclusion: Diuretics and ACEi/ARBs are the most commonly used PHF medications, despite not being approved for this indication. The two FDA approved medications are used in ≤5% of patients. While FDA approval is important, it did not substantially influence physician prescribing behavior for PHF. Further study is needed to understand the value of FDA approval and the potential socioeconomic implications of the association between insurance type and medication use.

Evaluating the policy response to curb the opioid prescribing behaviour of physicians in the United States

PurposeIn 2017, the opioid epidemic was declared a public health emergency in the United States. The federal and state governments are still struggling to contain the crisis through various legislations and to stem the tide of overdoses and deaths. This paper looks specifically at the issue of high prescriptions of opioids disbursed to patients by physicians.Design/methodology/approachThis paper evaluates this evolving policy issue through a critical review and synthesis of academic literature, government policy documents (at states and national levels) and articles in the popular press.FindingsOver-prescription is a legal problem because it inevitably leads to diversion of these substances for non-medical usage. The Prescription Drug Monitoring Program (PDMP) laws have been passed by all 50 states and the main policy responses are covered. However, there are hindrances to their effectiveness, which have to be addressed. Two state level policy alternatives are discussed as potential solutions — PDMP mandates and Pain Management Clinic Laws (PMCLs). After a comparative evaluation, it is recommended that all states should pass the mandatory PDMP review and usage laws urgently.Originality/valueThis is the first detailed policy evaluation on the specific and time-sensitive aspect of physician over-prescribing, within the larger opioid abuse problem. Moreover, critique on the public health leadership issue is raised.

Examining the impact of marketing techniques on the prescription behavior of physicians with ethical ideology as a moderator

PurposeThis research paper aims to investigate the impact of pharmaceutical marketing on the prescription behavior of physicians. It further examines whether the use of various promotional techniques including advertisements, sales promotions, personal selling and direct marketing by pharmaceutical companies influences the prescription behavior of doctors. Based on the increasing ethical concerns regarding the promotion of specific drugs for personal gains, the research also investigated the moderating role of ethical ideology in the above relationship.Design/methodology/approachTo accomplish the research goals, quantitative research methods were used. Using the online questionnaire, data were collected from 93 doctors working in government and private hospitals in Pakistan, and structural equation modeling technique was used to analyze the impact of pharmaceutical marketing techniques on the prescription decisions of physicians.FindingsThe findings suggested that marketing strategies of pharmaceutical companies positively influences the prescription behavior of doctors. Further, physicians having weak ethical standards are likely to be strongly influenced by the marketing and promotional practices of companies.Practical implicationsThe research is pivotal in understanding the perspective of doctors and the ethical considerations that need to be addressed while devising the marketing campaigns by pharmaceutical companies. Further, these findings provide important implications regarding the essential linkage between ethical values and the development of right marketing tools.Originality/valueTo the best of the authors’ knowledge, this research is one of the first few to empirically develop and test the role of moral values followed by physicians when they take prescription decisions. Based on the findings, future researchers are encouraged to further investigate the need of setting boundaries for pharmaceutical companies and restricting their usage regarding the promotional tactics.

Prescription Behavior of Physicians in the Public and Private Sector

Prescription Behavior of Physicians in the Public and Private Sector

Rents for Pills: Financial incentives and physician behavior

We study the impact of financial incentives on the prescription behavior of physicians based on a recent reform in two large Swiss cities. The reform opened up an additional income channel for physician by allowing them to earn a markup on drugs they prescribe to their patients. We find that the reform leads to an increase in drug costs by about 4%–5% per patient translating to significantly higher physician earnings. The revenue increase can be decomposed into a substitution and rent-seeking component. Our analysis indicates that physicians engage in rent-seeking by substituting larger with smaller packages and by cherry-picking more profitable brands. Although patient health is not sacrificed, the rent-seeking behavior results in unnecessary costs for society.

Interim Clinical Utility Findings of a Transcriptomic Psoriasis Biologic Test Demonstrate Altered Physician Prescribing Behavior and Improved Patient Outcomes

Objective: This study (MATCH) was designed to assess the clinical utility of a machine-learning based tool (Mind.Px) that predicts patient response to the most common biologic drug classes used in the management of psoriasis patients.&#x0D; Methods: The MATCH study was designed to assess Mind.Px utility in physician decision making and patient outcomes. Psoriasis patients who were biologic naïve or those who were approaching a change due to non-response were enrolled into the study (N=112). At baseline, a dermal biomarker patch was applied to lesional skin and Mind.Px test results were provided to physicians prior to biologic selection. The choice of biologic for each patient was recorded and in the case of physician non-concordance with Mind.Px test results, a questionnaire completed to determine the reason for non-concordance. Patients were evaluated at weeks 4, 8, 12, and 16 after baseline using PASI, PGA, and BSA. Statistical analysis between groups was performed using Fisher’s exact test.&#x0D; Results: Physician prescribing behavior was measured with and without the inclusion of Mind.Px test results in the decision-making process. This data set was compared to a previously obtained data set in which dermal biomarker patches were applied at baseline, but Mind.Px results were not provided to physicians at any point during treatment (N=180). Statistical analysis of concordance between the Mind.Px-informed and Mind.Px-uninformed groups within the MATCH study (84.4% vs 53.8%, respectively) showed that when given access to Mind.Px results, physician behavior was significantly altered (p = 0.0022). Furthermore, analysis of those patients who have completed the study showed improved clinical outcomes in those patients whose physicians were provided Mind.Px test results. Specifically, this cohort reached PASI75 sooner than those who were not provided test results (p = 0.004).&#x0D; Conclusion: These results provide an interim measurement of the clinical utility of Mind.Px by demonstrating that physicians will utilize this test in psoriasis biologic decision making and by doing so, this leads to improved patient outcomes. These improved patient outcomes can also potentially translate into tremendous cost savings for healthcare systems. Mind.Px can effectively minimize the trial-and-error approach to psoriasis treatment, and provide physicians, patients, and payers with a powerful tool for improving psoriasis patient management.

The factors influencing customer choice of pharmaceutical brands in Sulaimani

The pharmaceutical industry is an important component of health care systems throughout the world; it is comprised of many public and private organizations that discover, develop, manufacture and market medicines for human and animal health, as Physicians play major role in the selection of medicine to consume, this study aims to determine the most important factors influencing physician prescription behavior (medicine brand choice).&#x0D; In order to achieve this objective, a self-administered questionnaire designed, it was completed by 77 physicians in Sulaimani city. Iraq. Data were analyzed applying various statistical methods, such as descriptive statistics, and ANOVA.&#x0D; The results show that, the most important factors influence physician’s prescription behavior are patient compliance, medicine efficacy, patient buying power, and medicine availability respectively.&#x0D; this research suggests that future research may explore the factors influencing patient’s choice for over the counter medicine (OTC).

Effects of pharmaceutical promotions on antibiotics prescribing behavior of Nigerian private medical practitioners

Objectives: About 80% of pharmaceutical marketing efforts are directed toward physicians who are important decision-makers to patients’ medication needs. Pharmaceutical marketing can affect drug prescriptions, which, in turn, may adversely impact prescription practices. This study investigated the effect of pharmaceutical promotions on the antibiotic prescribing behavior of private practice physicians. Materials and Methods: A cross-sectional and descriptive design was employed. Self-administered questionnaires, scaled on a linear 5-point Likert Scale, were distributed among 268 physicians attending the 44th annual scientific conference of the Association of Nigerian Private Medical Practitioners at Ibadan, in Southwest Nigeria. Results: The study achieved a response rate of 94%, and 243 completely filled questionnaires were included for data analysis using R version 4. Cronbach’s alpha reliability of the research instrument was found to be 0.991, indicating an excellent internal consistency. Most of the physicians were male (71%), medical officers (83%), and 49% were between the ages of 51 and 60 years. About 65% had over 20 years of practice experience. A majority, 211 (87%), have prescribed antibiotics under the influence of pharmaceutical companies’ promotions. However, Fisher’s exact tests demonstrated a weak association between relevant independent variables and the dependent variable (P &gt; 0.05). Conclusion: Product detailing by pharmaceutical sales representatives was the most popular form of promotion and company-sponsored presentations had the greatest influence on the physicians’ prescription practice. It is, therefore, recommended that pharmaceutical promotions should be well regulated to guard against unethical practices.

Analyzing trends in treatment of acne vulgaris and adherence to the American Academy of Dermatology guidelines: A retrospective study

To the Editor: Acne vulgaris is a chronic inflammatory skin disease with varying treatments.1 Limited literature exists on the prescription behavior of physicians for acne. Evidence-based clinical guidelines from the American Academy of Dermatology (AAD) for acne vulgaris were published in 2016.2 Our objective was to analyze adherence to a subset of the AAD guidelines regarding antibiotic and combination therapy (Table I).

The Effects of the Medicaid Expansion on Prescription Drug Behavior.

The objective of this empirical exercise was to examine how drug providers in states that implemented the Medicaid expansion in 2014 reacted to the expansion compared with providers in states where Medicare was not expanded. Medicaid beneficiaries have been susceptible to higher cost and lower quality of health care. The Affordable Care Act increased access to drugs for uninsured people. Numerous studies highlighted the effects of the Medicaid expansion on beneficiaries. However, there is a gap in the literature that looks at prescription behavior of physicians during the Medicaid expansion that compared expanded states versus nonexpanded states. A difference-in-differences regression was used to estimate the average treatment effect of implementing the Medicaid expansion on each of the 6 outcomes of interest: (1) total cost of prescribing drugs, (2) number of total drug claims for non-Medicaid beneficiaries, (3) number of drug claims for Medicaid beneficiaries, (4) number of beneficiaries, (5) number of beneficiaries who were 65 years old or older, and (6) ratio of brand-name drugs. To address potential estimation biases, a matching procedure was used to ensure that pre- and post-Medicaid period trends were parallel. Our results provide evidence that, on average, the Medicaid expansion led each provider in expanded states prescribed more drugs for beneficiaries with low-income subsidies, whereas prescribed less drugs for other beneficiaries including those over 65 years old. The authors also show the proportion of brand-name drugs prescribed by a provider in expanded states declined due to the implementation of the Medicaid expansion. These results suggests that the Medicaid expansion has contributed to increasing access to health care by low-income citizens who were in need of prescriptions.

Attitude towards pharmaceutical promotional tools and its influence on physicians’ prescribing behaviour in Sudan

PurposeDue to the proliferation of generic medicines, pharmaceutical marketing has become increasingly competitive, and marketing executives are now focusing their attention on understanding the prescribing behaviour of physicians to enable them to devise marketing strategies that would put them at a superior business position relative to their competitors. Previous studies carried out either lack a sound theoretical foundation, or report contrasting results, making generalizations sketchy. Thus, a better understanding of attitude-prescribing axiom is needed. Underpinned by the theory of reasoned action (TRA), this study aims to empirically examine the factors that predict the prescribing behaviour of physicians.Design/methodology/approachA conceptual model was developed and tested on a sample of 355 respondents drawn from 76 private and 50 public hospitals in Sudan. The data set from the questionnaire survey included both general practitioners (N = 200) and specialists (N = 155). Primary data gathered were analysed using partial least squares structural equation modelling (PLS-SEM).FindingsThe findings reveal that the prescribing behaviour of physicians is positively influenced by the physician’s attitude towards direct marketing, personal selling, educational travel and public relations, but negatively influenced by gifts. Besides, the moderating effect of subjective norms showed no significant influence on the relationship between attitude and prescribing behaviour. However, gender seems to moderate the attitude towards health sector-related charity on prescribing behaviour and the attitude towards scientific conferences on prescribing behaviour.Research limitations/implicationsThe findings gathered from this study offers a significant contribution to the ongoing debate on the essential factors that influence the prescribing behaviour of physicians in the hospital setting.Originality/valueBy examining the essential factors that predict physicians’ prescribing behaviour, pharmaceutical companies can improve their understanding of physicians’ attitudes towards the pharmaceutical promotional tools. This is an aspect that is ill reflected in the literature.

Use of a Telemedicine Team to Improve Guideline-Based Antibiotic Prescribing

Assessing the impact of a virtual antibiotic team (VAT) on appropriateness of antibiotic prescribing behavior of older care physicians, regarding urinary tract (UTI), respiratory tract (RTI), and skin and soft tissue infections (SSTI), in residents of long-term care facilities (LTCF). Before-after trial; introduction of a VAT consisting of a clinical microbiologist, older care physician, and a pharmacist. Eight LTCFs in Amsterdam, the Netherlands. The VAT was introduced on April 1, 2019. Meetings were held via weekly teleconferencing. VAT advised about treatment indication, antibiotic choice, and additional diagnostics. Data were retrospectively extracted from resident files regarding infection episodes for which antibiotics had been prescribed during 12months before (period I) and 11months after VAT introduction (period II). Appropriateness of antibiotic prescriptions was assessed using national guidelines and an algorithm developed for antimicrobial stewardship in nursing homes. Antibiotic prescription rates per 100 person-years (py) were estimated and compared between periods using incidence rate ratio (IRR) with 95% confidence intervals (CIs). Proportions of appropriate antibiotic prescriptions were compared between periods using the chi-squared test. A total of 524 infection episodes for which antibiotics were prescribed were identified: 284 in period I and 240 in period II. Antibiotic prescription rates before VAT introduction were 73 per 100 py in period I and decreased to 68 in period II (IRR 0.9, 95% CI 0.8-1.1). Of all prescriptions, 23.9% were assessed as appropriate during period I, which increased to 40.4% in period II (P < .001). Appropriate antibiotic use increased after VAT introduction for RTI (12.5% to 48.2%, P < .001) and SSTI (47.5% to 74.3%, P= .02) but remained similar for UTI (23.5% to 28.8%, P= .29). After implementation of VAT in LTCFs, appropriate antibiotic use increased significantly overall, and for RTI and SSTI particularly. Improving prescribing behavior regarding UTI might need extra strategies.

The Effect of Biosimilar Prescription Targets for Erythropoiesis-Stimulating Agents on the Prescribing Behavior of Physicians in Germany

ObjectivesThis study aimed to aid decision makers by analyzing the impact of introducing biosimilar prescription targets on physician prescribing behavior in the prescription of biologic erythropoiesis-stimulating agents in Germany. MethodsWe combined secondary data of regional level biosimilar prescription targets and secondary data of routinely collected claims data of dispensed prescriptions by physicians operating within the statutory health insurance system in ambulatory care across 7 German regions from 2009 to 2015. Two-way fixed-effects regression analysis was used to identify the average treatment effect of introducing biosimilar prescription targets at the physician level. The main outcome of interest was the share of biosimilar prescriptions on all prescriptions within the substance group. We compared 6 regions that introduced biosimilar prescription targets with 1 region without any prescription target policy. ResultsIntroducing biosimilar prescription targets increased the average share of biosimilars between 6 percentage points (P < .05) in Hamburg and up to 20 percentage points (P < .001) in Saxony-Anhalt. Stratification of specialists by prescription volume and adoption status indicated heterogeneous effects. We identified similar but higher effects for high-volume prescribers. Disentangling of effects with regard to the composition of biosimilar share suggested that the increase in biosimilar share was driven by increased biosimilar use accompanied by a nonsignificant decrease in original biologics prescriptions. ConclusionsPrescription targets to alter physician prescribing behavior meet their intended goals by increasing biosimilar share. Physicians partly responded to the policy by decreasing overall prescriptions of the target substance. Prescription targets might be a useful tool, but decision makers need to consider all aspects of potential responses.

The Effect of an Automated Order on Postpartum Opioid Use After Uncomplicated Vaginal Deliveries.

Background: To address the opioid epidemic, physicians are encouraged to identify means of reducing patient opioid exposure. Electronic medical records (EMRs) often include default order sets with automated orders for opioid medications, which may influence how much opioids physicians prescribe. We sought to evaluate the impact of de-selecting an automated order for oxycodone-acetaminophen from an EMR order set for postpartum vaginal deliveries on inpatient opioid exposure by comparing the proportion of patients who received an opioid after an uncomplicated vaginal delivery before and after the EMR change. As secondary outcomes, the impact on average total morphine milligram equivalents (MMEs) and discharge opioid prescriptions was investigated. Materials and Methods: A quality improvement study was conducted through retrospective chart review of uncomplicated vaginal deliveries for the four quarters before and after the EMR order set change occurred. The total proportion of patients who received an opioid in the postpartum period was then determined for the preexposure and postexposure groups. The total average MME consumed for patients who received an opioid in each group was determined and the total proportion of patients who received an opioid prescription at discharge was compared. Results: A total of 5826 records of uncomplicated vaginal deliveries met the criteria for analysis. In the preintervention group, 32.9% of patients received an opioid postpartum, compared to 12.5% of patients in the postintervention group, representing a decrease of 62.0% (p < 0.001). Of those who received opioids, the preintervention mean total opioid consumption was 28.4 MME (±27.6) compared to 33.6 MME (±46.4) postintervention, and there was no significant difference in median total opioid consumption: 22.5 MME (interquartile range [IQR]: 7.5-47.5) preintervention compared with 20.8 MME (IQR: 7.5-45.0) postintervention (p = 0.902). No significant difference was found with discharge opioid prescriptions between the two groups. Conclusion: Order sets within EMR systems appear to have a significant influence on physician prescribing behaviors and removing these automated orders for opioids should be considered.

Assessing physician prescribing behaviors in first-line (1L) advanced renal cell carcinoma (aRCC): A case-based study.

355 Background: Over the past decade, immune checkpoint inhibitors (ICIs) have become foundational to aRCC management. Tyrosine kinase inhibitors (TKIs) remain a mainstay, resulting in the potential for ICI/TKI combination regimens. Four ICI/TKI combinations (pembrolizumab/axitinib [PA], nivolumab/cabozantinib [NC], pembrolizumab/lenvatinib [PL], and avelumab/axitinib [AA]) have shown promising results compared to single-agent sunitinib in randomized clinical trials (KEYNOTE-426 [KN426], CheckMate 9ER [CM9ER], CLEAR, and JAVELIN RENAL 101 [JR101], respectively); national guidelines recommend them as 1L options. Further, an ICI-based regimen of nivolumab/ipilumumab (NI) is a treatment option for poor-risk RCC based on CheckMate 214 (CM214) results. We sought to understand how community oncologists perceive data from these trials and what aspects influence their clinical decisions. Methods: In May 2021, medical oncologists experienced in treating aRCC were presented with key results from these trials and 2 clinical vignettes. Treatment preferences and reasons for decisions were captured via an audience response system. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 103 U.S. medical oncologists participated; most risk-stratify their patients with either IMDC (44%), MSKCC (34%), or both (14%). When presented with simulated case studies, most (76%) indicated they are not likely to order PD-L1 testing, yet 81% will treat with an ICI-based regimen. Participants are more likely to prescribe ICI/TKI over ICI/ICI (65% vs 47%) in favorable-risk aRCC. Yet in poor-risk RCC, they are more likely to prescribe ICI/ICI over ICI/TKI (52% vs 15%). Among ICI/TKI regimen, participants showed a small preference toward PA over NC for both the poor-risk (21% vs 20%) and intermediate-risk (30% vs 23%) patient case. In the favorable-risk case, PA was significantly preferred over NC, 46% vs 19%. Most participants were aware of the trial data (91% KN426, 82% CM9ER, 57% CLEAR, 96% CM214); and more found the data from CM9ER most compelling compared to KN426 and CM214 (32%, 29%, and 23%, respectively). The participants viewed trials that met primary or survival endpoints as strong. Major limitations in each trial commonly identified were trial design (KN426, 27%); short follow-up (CM9ER, 48%); short follow-up and no OS data (CLEAR, 39% and 38%, respectively), and high discontinuation rate (CM214, 42%). Conclusions: Providers typically will treat aRCC patients with ICI-based regimens regardless of PD-L1 status and are more likely to prescribe an ICI/TKI regimen for favorable-risk and an ICI/ICI regimen for poor-risk aRCC. Meeting primary endpoints is a strong influencer in providers’ decision-making. Given the nonsignificant difference in preference for PA over NC, further research is needed to assess factors influencing providers’ decisions.

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.

Use of a point-of-care web-based application to enhance adherence to the CANMAT and ISBD 2018 guidelines for the management of bipolar disorder.

While clinical guidelines exist for the management of bipolar disorder (BD), there are significant challenges to their widespread dissemination and implementation in clinical practice. The Canadian Network of Mood and Anxiety Treatment Improving Patient Care and Outcomes in the Treatment of Bipolar Disorder (C-IMPACT BD) web-based application was developed for use at the point-of-care to improve adherence to guidelines for evidence-based pharmacological management of BD. C-IMPACT BD uses a point-of-care practice assessment which, via adaptive questioning of patient-specific information, text/video descriptions of the guidelines, and pop-up prompts delivers personalized, evidence-based treatment recommendations for patients with BD. In order to inform quality improvement of the newly developed tool, a sample of Canadian physicians were invited to use the application and record its influence on their prescribing behavior. Of 375 patients with bipolar I (BD-I) or bipolar II (BD-II) disorder for whom a point-of-care practice assessment was completed, a change in therapy was considered for 225 (60.0%). Prior to completing the assessment, 59.6% of these patients were receiving first-line therapy recommended for their phase of illness. Following the assessment, the overall number of patients for whom a first-line recommended therapy was being considered increased significantly to 76.9% (p=0.0001). Outcomes suggest that the C-IMPACT BD web-based application has the potential to improve physician adherence to clinical treatment guidelines. Formal research investigations are warranted to explore the impact of this tool on physician prescribing behavior and patient outcomes.

Pharmaceutical opioid marketing and physician prescribing behavior.

Physicians' relationships with the pharmaceutical industry have recently come under public scrutiny, particularly in the context of opioid drug prescribing. This study examines the effect of doctor-industry marketing interactions on subsequent prescribing patterns of opioids using linked Medicare Part D and Open Payments data for the years 2014-2017. Results indicate that both the number and the dollar-value of marketing visits increase physicians' patented opioid claims. Furthermore, direct-to-physician marketing of safer abuse-deterrent formulations of opioids is the primary driver of positive and persistent spillovers on the prescribing of less safe generic opioids - a result that we show appears to be driven by insurance coverage policies. These findings suggest that pharmaceutical marketing efforts may have unintended public health implications.