Healthy Skepticism Library item: 14717

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Publication type: news

Lexchin J.
Pushing pills: who's to blame for so much poor prescribing
The Globe and Mail 1988 Dec 13

Full text:

YOU HAVEN’T been feeling well for a couple of days, nothing serious – just a bit of a cough, a sore throat and a low-grade fever, but to be on the safe side you decide to pay your doctor a visit. If your doctor is like the majority of general practitioners studied recently in Hamilton, Ont., you stand a better than 50-50 chance of leaving the office with a prescription for an antibiotic.
The problem is that your symptoms were almost certainly due to a viral infection, and antibiotics are useless against viruses. Your prescription will do you no good, but it will still cost you money and then, of course, you run the risk of developing one of the side effects associated with antibiotics.
Going to the doctor with a sore throat isn’t the only time you run the risk of getting an antibiotic misprescribed. Studies in hospitals across Canada have shown that only 52 per cent of the prescriptions for antibiotics are appropriate. Antibiotics are also not the only group of drugs that are often misprescribed. Cimetidine, the widely used ulcer drug, is prescribed correctly only 50 per cent of the time. In 1982, 2.4 million prescriptions were issued for it.
Why don’t doctors prescribe better? In some cases, they are under pressure from their patients to prescribe a drug and feel that if they don’t, the patient will go elsewhere. While this argument may have some validity, it isn’t completely supported by the facts. Eighty per cent of British physicians estimated that patients expected a prescription in 89 per cent of consultations, but in a national survey in England, patients indicated that they expected a prescription in only 43 to 52 per cent of visits.
It would appear that doctors themselves have to take most of the blame for poor prescribing. Sometimes doctors just don’t know what they are prescribing. More than 75 per cent of all prescriptions are written using the brand name of the drug, as opposed to the generic name. Brand names are often “catchy,” easier to remember and spell, and the drug companies spend more than $300-milion a year promoting these names among doctors.
But when doctors prescribe by brand name, they may not know what is in the drug. Sixty Montreal physicians were asked to name the active ingredients in three fixed-dose products that they had
prescribed in the previous year. (A fixed-dose product contains more than one active ingredient.) A total of 23 drugs were named by the 60 doctors; in only four of the 23 cases did most of them know all the ingredients.
While the available evidence is not conclusive, there are strong reasons to think that the patient’s gender may play a role. Study after study has demonstrated that women are prescribed tranquillizers, such as Valium, twice us often as men. One reason may be that male doctors do most of the prescribing.
The bias of one group of male physicians was reflected in some of their comments about women: “It’s constitutional. The female’s nervous system is more sensitive. They’re affected by problems and emotional upsets more. That’s the way the Lord made them” … “Females have more time to indulge in neuroses than men. They’re bored, often, and frustrated. As they get older, there’s the menopause, which we men do not indulge in.”
The same group of male general practitioners was asked to describe a typical complaining patient. The question made no reference to sex but 4 per cent of the doctors said men are particularly trouble-some, 24 per cent mentioned neither sex and 72 per cent cited women. Seventy-eight per cent of these doctors reported that they wrote more mood-modifying prescriptions for their female patients.
The type of practice doctors have also influences their use of drugs. In Montreal, “simulated” patients (students trained to describe symptoms) complaining of tension headaches were sent to see a random sample of salaried physicians practicing government-financed community health centres (CHCs) and physicians practicingg in fee-for-service groups. Whereas more than half of the physicians in private clinics prescribed an “inadequate” therapy, only one-quarter of CHC physicians did so. They also were twice as likely to provide explicit warnings on the implications and dangers of chronic use of the medications that they prescribed.
One reason community health centre physicians are better at prescribing drugs is that they can spend more time with patients without worrying about any financini penalty. The average fee-for-service doctor sees a new patient every 10 to 12 minutes and so has little time to go into a patient’s problem in any depth.
Finally, where doctors get their information about drugs seems to be a major contributing factor on how well they prescribe. Many doctors rely heavily on the drug companies for information. While
that may seem reasonable, since whoever makes the drugs should know the most about them, the companies are not unbiased. Their aim is to sell as much as they can; they will present their drugs in the best light possible.
It should come as no surprise, therefore, to learn that the more doctors rely on drug company sources for their information, the less rational they are as prescribers. This conclusion has been reached by five separate studies n the United States, Britain, the Netherlands and Belgium.
The consequences of poor prescribing are not innocuous. Almost 20 per cent of 170 admissions to a geriatrics ward in a Saskatoon hospital were attributed to adverse reactions to prescribed drugs. Fifteen to 30 per cent of patients in hospital are believed to have adverse drug reactions some time during their stay.
Not all adverse reactions are the result of misprescribing, but it is estimated that about three quarters could be avoided if prescribing were done correctly. While the financial cost of adverse drug reactions is obviously secondary to the health aspect, it is not trivial. Back in the mid-1970s, the cost was in the range of $300-million a year for all of Canada and it can only have climbed since then.
What can be done to improve doctors’ prescribing? Since physicians not in fee-for-service settings appear to be better, there should be more encouragement by government of alternatives such as community health centres and health service organizations, and less resistance from the medical community to their adoption.
Although there are more than 3,500 different prescription drugs on the Canadian market, the average general practitioner uses only a few dozen to write more than 50 per cent of his or her prescriptions. While general practitioners use relatively few drugs, it is not likely that their choice of products is based entirely on objective scientific criteria.
One concept is that general practitioners should rationalize the decision about which drugs to use by scientifically evaluatitlg the range of drugs available and then choosing the ones that would best suit the kinds of patients they deal with. This type of a list is called a general practice formulary. It a clearly easier to become familiar with the indications, effects, side-effects, interactions and contra-indications of a limited number of preparations.
Formularies of this sort are already in operation in Britain where it is felt that their use will lead to improvements in prescribing and a curbing of prescribing costs. Indeed, one health centre in South-western Ontario uses a formulary of 175 drugs and has dropped the price of a prescription by 10 per cent compared to the provincial average.
Finally, given that the use of company sources of prescribing information is incompatible with appropriate prescribing, measures have to be taken to provide doctors with independent factual sources of information. If such efforts are to be able to counter the $300-million promotional budget of the drug industry, they have to be more than mere tokenism.
One measure is the use of face-to-face educational interventions. Here, specially trained drug educators, either physicians or pharmacists, meet with doctors individually to go over their prescribing to identify problems and offer suggestions for improvement. The aim is not punishment, but education.
In U.S. studies, such educators made long-term improvements in the prescribing of a wide variety of drugs. Particularly encouraging is that few doctors seem to be resistant to these educational visits.
In Ontario, a provincially appointed commission headed by Dr. Frederick Lowy is studying the use of prescription drugs. Dr. Lowy is due to submit his report to Health Minister Elinor Caplan next spring. Will luck, the report will incorporate some of these suggestions so that the next time you go to your doctor with a sore throat you leave with some good advice rather than a prescription for a worthless antibiotic.