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��ࡱ�>��	jl����i��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	��zhbjbj�ޤ�	4tƴƴ�6��������	�	���������������$��&��:��������%�%�%�%�%�%�%$�(�++^&�������&������&�j�����%��%r,#T�#�����08���?��$�#�%�&0�&�#2�+$��+�#�#(�+��$��������&&����&�������������������������������������������������������������������������+����������		�:	A study to investigate the factors that influence the prescribing habits of non-consultant hospital doctors.
B Ramasubbu1, M Heron2, P Murphy1
1 Department of General Medicine, Midlands Regional Hospital, Tullamore, Ireland
2 Department of Anaesthesia, St George�s Hospital, London, United Kingdom

Abstract
The HSE estimates it spent just under � 2 billion on medicines in 2013, up slightly from the � 1.95 billion it spent the year before. With this large and ever increasing cost to the health service it is important to understand what factors affect doctors prescribing in Irish Hospitals.
One hundred and seventy-nine surveys were returned. There was no significant difference in gender. Sixty-five (36%) interns, 73 (41%) senior house officers and 41 (23%) registrars completed the survey. Consultant preference was the most influential factor in the prescription of statins, diuretics and anti-platelet agents. The most influential factor in the prescription of a proton pump inhibitor was pharmaceutical representative input. Local pharmacy/departmental policy and consultant influence were the two biggest factors influencing antibiotic prescribing. Factors that influence junior doctor prescribing vary depending on drug groups. This information is useful to direct resources appropriately and obtain optimum results for money invested. 

Introduction
The World Health Organization (WHO) defines pharmaceutical promotion as �all information and persuasive activities by manufacturers and distributors, the effect of which is to induce the prescription, supply, purchase and/ or use of medicinal drugs  1.

This is a multi-billion euro industry, not just abroad but also at home in Ireland. In Ireland, the Health Service Executive (HSE) estimates it spent just under � 2 billion on medicines in 2013, up slightly from the � 1.95 billion it spent the year before. This is in the context of a five-fold increase in the cost of medicines over a 10-year period (1999-2009) 2.  
In keeping, over the past few decades there has been a rapid increase in healthcare expenditure globally. 3, 4

With this increasing cost to the health service it is important to understand what factors affect doctors prescribing in Irish Hospitals. There is a wealth of prescribing information resources available to clinicians such as other physicians, pharmacists and pharmaceutical sales representatives (PR�s). Evidenced based research such as formularies, textbooks, clinical research data, guidelines, electronic data sources, and medical journals are also readily available to non-consultant hospital doctors (NCHD�s) in Ireland. However, there is a dearth of literature to quantify which sources are most widely used in practice. The issue is of some importance given current focus on evidence-based medicine and the broad variation of pharmaceutical expenditure between European countries. In 2010, the OECD stated that over the past decade Ireland�s pharmaceutical expenditure was significantly higher (11%) than that of the average EU countries (2012). 3

Thus, we aimed to investigate the prescription patterns and influencing factors on non-consultant hospital doctors in adult public hospitals in the republic of Ireland. To provide quantitative data regarding the sources of information NCHD�s use in commonly prescribed drugs.

Methods
Following survey construction by the survey team, an email was sent to the medical manpower offices of all adult public hospitals in Ireland for its distribution to non-consultant hospital doctors. The survey contained 4 questions about respondent�s demographics (job description, gender, university that conferred medical degree and level of entry to that university) and 9 drug groups for which they had to select which factor most influenced their prescribing of that particular drug group. They were offered 5 choices: Consultant preference, Local pharmacy/departmental policies, Knowledge obtained during medical school, Input from hospital pharmaceutical representative or Independent/self-appraisal of evidence. Replies were collated and data analysed using Excel. Tests of significance were carried out using Chi Square. 


Results
One hundred and seventy-nine surveys were returned. 

Demographics
Eighty-eight (49%) were female and 91 (51%) male. There was no significant difference in gender (P=0.82). Sixty-five (36%) interns, 73 (41%) senior house officers and 41 (23%) registrars completed the survey. Thirty-three (18%) were post-graduate and 146 (82%) were under-graduate. There were significantly more under-graduates than post-graduates (p<0.01). Figure 1 highlights that the most surveys were completed by graduates from Trinity College Dublin 46/179 (26%) followed by those from University College Dublin 42/179 (23%). 

Outcomes
Of the prescription of analgesia, 90/179 (50%) of NCHDs used either a self-appraisal of evidence (38/179) or knowledge obtained during medical school (52/179) to formulate a decision about prescribing. In stark contrast only 18/179 (10%) of junior doctors used these to prescribe an anti-coagulant/DVT prophylaxis. Within this drug group, 53/179 (30%) were most influenced by consultant preference, 58/179 (32%) by local pharmacy/departmental policies and 50/179 (28%) by pharmaceutical representative influence. 

Consultant preference was significantly the most influential factor in the prescription of a statin, diuretic and anti-platelet agent. This was demonstrated by 69/179 (39%), 98/179 (55%), 75/179 (42%) of NCHDs surveyed respectively for each group. P<0.01 for each.

For night sedation, 59/179 (33%) stated Local pharmacy/departmental policies most influence their decision to prescribe a particular drug whereas 63/179 (35%) utilised knowledge obtained during medical school to decide. Similar results were shown for anti-emetics with 51/179 (28%) using local policy to prescribe and 62/179 (35%) using knowledge obtained during medical school. Knowledge obtained during medical school was significantly more influential in the prescribing of night sedation and anti-emetics than pharmaceutical rep influence, consultant preference and self-appraisal of evidence (p<0.05). However, it was not significantly more influential than local pharmacy/departmental policies in the prescribing of night sedation (p=0.8) and anti-emetics (p=0.4).

Figure 2 demonstrates that the most influential factor in the prescription of a proton pump inhibitor by NCHDs in Ireland was pharmaceutical representative input with 59/179 (33%) stipulating this. This was significantly greater than the influence from consultant preference (p<0.05), knowledge obtained during medical school (p<0.05) and independent/self-appraisal of evidence (<0.01). However, the influence of a pharmaceutical representative was not significantly greater than local pharmacy/departmental policies when it came to the prescribing of a PPI (p=0.07).
Local pharmacy/departmental was significantly the most influential factor in the prescribing of an antibiotic (p<0.01).

Discussion
Demographics
Data obtained from the surveys is representative of the Irish NCHD community. There is an even split of gender and a good representation of all job descriptions 36% interns, 41% senior house officers and 23% registrars. Additionally, all medical colleges in Ireland are well represented with significantly more under-graduates than post-graduates (p<0.01) which is to be expected as graduate entry medical schools have only come into being in the past 8 years.

Outcomes
Knowledge obtained during medical school was the most influential factor in the prescribing of analgesia (29%). This combined with self-appraisal of evidence (21%) means that over 50% of analgesia prescription by non-consultant hospital doctors in Ireland is based on these two factors. 
On the contrary only 10% of NCHDs use these two factors when prescribing anti-coagulation/DVT prophylaxis. Thirty percent are most influenced by their consultant preference and 32% by local pharmacy/departmental policies. Twenty-eight percent prescribe based on input by pharmaceutical representative in the hospital and so when trying to introduce an anti-coagulant or DVT prophylaxis into a hospital the approach should focus on these three areas with equal distribution of resources.
Figure 2 shows that pharmaceutical representatives were most influential when it came to the prescribing of proton pump-inhibitors (PPI) (59/179, 33%). Also when looking at the other four influencing factors they are quite evenly distributed (18%, 20%, 16%, 13%) and so when introducing a new PPI into a hospital or area more resources should focus on the NCHDs themselves to achieve the optimum results. Thus, PR presence around hospitals is extremely useful for the marketing of this drug group. This is critical information and should be utilised as this a multi-million dollar industry in Ireland. For PPI therapy alone, over � 88 million was claimed under the HSE Primary Care Reimbursement Services (PCRS) scheme in 2007 5.
The prescription pattern for night sedation and anti-emetics follow a similar pattern. For both, approximately one third prescribe based on knowledge obtained during medical school and one third based on local pharmacy/departmental policies. There is also a smaller peak for evidence base with one fifth stating this is their most influential factor. Thus, direct contact of the pharmaceutical representative with the NCHDs or consultants has little impact on the prescription of these two drug groups in Ireland. Instead these results suggest a change of tact to focus more resources onto those in charge of local policies within the hospital (ie. Clinical Lead and Head of Pharmacy) and also medical students themselves. It seems that one third of NCHDs have already formulated prescribing behaviours of night sedation and anti-emetics before even commencing their internship. Thus, if a company's desire is to increase prescribing of these drugs by NCHDs they must first focus on the NCHDs of the future, by targeting those still in medical school.
The prescription of Statin's and Anti-Platelet agents follows a top down approach. Approximately 40% of junior doctors prescribe these two groups based on their consultant preference with the remaining influencing factors having a balanced input. Consultant preference was significantly greater than all other factors for influencing prescription of statins and anti-platelets. Thus, additional resources should be given to consultant persuasion and discussion when promoting these two drug groups as their opinion filters down to the NCHDs and alter their prescribing habits. Considering that statin therapy accounted for over 10% of total drug acquisition costs (87.5 million euros) under the Community Drugs Scheme in Ireland in 2004 cornering the market for this drug group is worth wise and heavy investment for pharmaceutical companies. 6
The British Hypertension Society, recommend that diuretics and calcium channel blockers should be first-line drugs in hypertensive patients aged e"55 years or black patients of any age 7 and estimated money spent in the US annually on treating hypertension is 3.8 billion dollars 8. Over 50% of junior doctors  state that their most influential factor in the prescription of a diuretic is their consultant preference. With this in mind, in a multi-billion dollar industry, promotion of diuretic costs should majorly be focused towards consultant persuasion in an attempt to obtain expenditure to income efficiency.
Figure 3 demonstrates the influential factors on antibiotic prescribing. Local pharmacy/departmental policies (59%) was significantly more influential than any other factor (p<0.01). Additionally, consultant preference is a main contributing factor for 24% of NCHDs. This distribution is expected and reassuring to find as utility of antibiotics depends on location and purpose of its use. Hence, local policies and consultant input should be paramount in the decision making process to prescribe these drugs.
Looking at the grouped data for all drugs in Table 1, it can be seen that over half (53%) of all doctors prescribing is influenced by either consultant preference or local pharmacy/departmental policies. This should encourage pharmaceutical companies to direct resources accordingly.

Factors that influence junior doctor prescribing vary depending on drug classes/groups. This information is useful to direct resources appropriately and obtain optimum results for money invested. 

References
[1] World Health Organization. Ethical criteria for medicinal drug promotion. Geneva, 1988; p. 5
[2] 'Irishpharmacist', Issue 5 Volume 16, May 2014

[3] OECD (2012), Education at a Glance 2012: OECD Indicators, OECD Publishing.  HYPERLINK "http://dx.doi.org/10.1787/eag-2012-en" mxyz{����)	*	+	-	.	4	
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[4] Theodorou et al. �Factors influencing prescribing behaviour of physicians in Greece and Cyprus: results from a questionnaire based survey.� BMC Health Serv Res. 2009; 9: 150. Published online Aug 20, 2009. doi:  10.1186/1472-6963-9-150
[5] Cahir et al. �Proton pump inhibitors: potential cost reductions by applying prescribing guidelines.� BMC Health Services Research�2012,�12:408��

[6]  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=Walshe%20V%5BAuthor%5D&cauthor=true&cauthor_uid=16892920" Walshe et Al. �Cost effectiveness of statin therapy for the primary prevention of coronary heart disease.�  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/16892920" \o "Irish medical journal." Ir Med J.�2006 May;99(5):144-5.
[7] Grossmann et Al. �Diuretic Treatment of Hypertension�. Diabetes Care�May 2011�vol. 34no. Supplement 2�S313-S319

[8] Chen et Al. �A cost-minimization analysis of diuretic-based antihypertensive therapy reducing cardiovascular events in older adults with isolated systolic hypertension.�
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