1 Julius Center for Health Sciences and Primary Care, University Medical Center (UMC), Str. 6.131, PO Box 85060, 3508 AB Utrecht; 2 NIVEL (Netherlands Institute for Health Services Research), PO Box 1568, 3500 BN Utrecht, The Netherlands
Received 4 January 2005; returned 1 March 2005; revised 25 May 2005; accepted 29 May 2005
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Abstract |
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Methods: Morbidity and antibiotic prescription data originated from the Second Dutch National Survey of General Practice (DNSGP-2). GPs' characteristics, including professional activities and views on RT symptoms and antibiotics, were measured by a written questionnaire. Multiple regression was carried out to assess associations between possible determinants and volume of second-choice antibiotic prescriptions.
Results: In 39% of acute RT episodes antibiotics were prescribed, with one-quarter being second-choice antibiotics, relatively more frequently in lower than in upper RT episodes: 30 versus 19%. GPs who were more frequently consulted by patients with RT episodes (ß = 0.29; 95% CI 0.130.41), who labelled RT episodes more as diagnoses than as symptoms (ß = 0.27; 95% CI 0.150.42), who less frequently used national GP guidelines (ß = 0.17; 95% CI 0.31 to 0.03) and who were more inclined to prescribe new drugs (ß = 0.26; 95% CI 0.130.40), prescribed more second-choice antibiotics.
Conclusions: Given the growing number of prescriptions of second-choice antibiotics, it is important to implement professional guidelines in daily practice, while training in being reluctant to prescribe new drugs and being alert to the marketing activities of pharmaceutical companies should be started in the medical curriculum.
Keywords: respiratory tract infections , pharmaceutical representatives , national guidelines
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Introduction |
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More insight into determinants of outpatient prescribing second-choice antibiotics might be helpful in designing interventions aimed at reducing inappropriate use. Therefore, this study aimed to assess the relationship between general practitioners' (GPs') characteristics and the volume of second-choice antibiotics prescribed for RT infections. This study was possible because of the availability of data from a nationwide study including GPs' characteristics, morbidity and prescription data.6
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Methods |
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We divided RT episodes into episodes labelled by GPs as symptoms, such as earache (H01) and cough (R05), and episodes labelled as infections, such as acute otitis media (H71) and acute bronchitis (R78), for upper and lower RT. As an indication of the inclination to label episodes more as infections than as symptoms, we calculated the proportion of the number of episodes labelled as infections per GP.
Prescriptions were calculated by linking prescription data with episodes on patient level and aggregated on GP level. In 22 practices with two or more GPs, patients could not be linked with a particular GP. In these cases practice prescription rates were used to estimate GP's prescription rates.
All participating GPs completed a questionnaire containing items relating to gender, years of practice, degree of urbanization of practice location (rural, urban), full-time (no/yes), number of enlisted patients (absolute number), single-handed practice (no/yes), frequency of consulting national GP guidelines (once a week or less/more than once a week), seeing pharmaceutical representatives in the last 4 weeks (no/yes), inclination to prescribe new drugs (1 = low to 5 = high), and views on RT infections and antibiotics rated on a five-point scale (1 = strongly disagree to 5 = strongly agree).7
The outcome measure was the volume of second-choice antibiotics for RT episodes (the number of prescriptions of co-amoxiclav, macrolides and quinolones for RT episodes per 1000 patients per year per GP). To describe the association between GPs' characteristics and the volume of second-choice antibiotics prescribed for RT episodes, multiple linear regression analysis was carried out using SPPS 12.0.1. Independent associations were assessed using a forward stepwise strategy followed by an enter strategy with checks on interaction and collinearity.
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Results |
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Discussion |
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Some methodological remarks have to be made. First, the proportion of antibiotic prescriptions of 56 GPs was estimated with the aid of the mean number of prescriptions per 1000 patients per practice. This implies a loss of variance in outcome measurement, so associations in the regression analysis were conservatively estimated. We did not find a difference in mean antibiotic prescribing volumes between GPs with and without estimated means, so we suppose these estimations not to yield bias. Controlling results for clustering at practice level was not indicated, because the mean number of GPs per practice was less than two, with only 11 out of 85 practices having more than three GPs. Lastly, we have to consider that our study had a cross-sectional design, so we can only assume correlations and not causal relationships.
Earlier studies have shown that the more GPs are consulted for RT episodes and the more they label these episodes as infections, the more they prescribe antibiotics.8,9 In our study this seemed also to be the case for prescribing second-choice antibiotics, which was strongly correlated with the total number of antibiotic prescriptions/1000 patients (Pearson's r = 0.60; P < 0.01). GPs who less frequently consulted national GP guidelines prescribed more second-choice antibiotics, which supports the Dutch quality assurance policy relating to rational prescribing.
The finding that GPs who were more inclined to prescribe new drugs appeared to prescribe more second-choice antibiotics is interesting, because several studies have shown an association between the inclination to prescribe new drugs and seeing pharmaceutical representatives9 (in this study Pearson's r = 0.47; P < 0.01). It is probable that there is a mutual re-enforcement between these factors: the inclination to prescribe new drugs influences seeing pharmaceutical representatives, and seeing them may enforce this inclination. This finding has also been corroborated by the qualitative study of Prosser and Walley.10 Moreover, it is noteworthy that after dividing RT episodes into episodes of the upper and lower tract, seeing pharmaceutical representatives was an independent factor in the volume of second-choice antibiotics prescribed for lower RT episodes (ß = 0.29; 95% CI 0.140.41).
Given the growing number of prescriptions of second-choice antibiotics,14 it is important to implement guidelines to set a right indication to prescribe antibiotics and to reserve second-choice antibiotics in case of failure of or intolerance to first-choice antibiotics. Furthermore, developing more critical prescribing skills, e.g. training in being reluctant to prescribe new drugs and being alert to the marketing activities of pharmaceutical companies, should be started in the medical curriculum.
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References |
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