Prescriber behaviour

Srisurapanont, M., Garner, P., Critchley, J. Wongpakaran, N. (2005). Benzodiazepine prescribing behaviour and attitudes a survey among general practitioners practicing in northern Thailand. BMC Fam. Pract., 6, 27. 

The dissemination of well-designed educational material constitutes a complement to other strategies, especially as a basis for training measures (face-to-face interviews or feedback systems), its relatively low added cost being a factor to take into consideration. However, disseminating this type of material alone hardly has any effect on prescriber behaviour. 

Figure 10.8 Factors that influence prescribing behaviour.

GPs, by the very nature of their job, will use new drugs in many different therapeutic areas. Here they wdll be guided by what the local consultants are recommending and by discussion with their peers. Detailing by company representatives is a significant factor in influencing prescribing behaviour and the information delivered by the representatives is seen to be of value by both hospital specialists and GPs. ... 

J. Avorn, M. Chen and R. Hartley, Scientific vs commercial sources of influence on physician prescribing behaviour. Am. J. Med. 73 (1982), 4-8. 

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Orth has applied the concepts of the D-value as used in sterilization technology (Chapter 20) to the interpretation of challenge testing. E q)iessing of the rate of microbial inactivation in a preserved system in terms of a D-value enables estimation of the nominal time to aehieve a prescribed proportionate level of kill. Problems arise when trying to prediet the behaviour of very low levels of survivors, and the method has its detractors as well as its advocates. 

It is not often that researchers find their work leading to such widespread changes of behaviour. Still, the 44 per cent figure reveals a split opinion. Most physicians did not intend to alter their prescribing practices. Our analysis has provoked a vociferous and continuing debate on the effectiveness of antidepressants and the circumstances under which they should be prescribed. In this chapter I consider and respond to the various criticisms that have been levelled at our data-based conclusions about the efficacy of antidepressants. 

More recently, large databases have been used to estimate the effect of drug co-payment in the USA under different insurance schemes.10 The conclusion reached is that there is a significant interaction effect between the behaviour of demand and prescriber incentives. Thus, larger prescription drug copayments are associated with lower expenditure when the doctor does not share the financial risk of the cost of the drugs (that is, practises in an independent practice association) but this effect is barely perceived in managed care models in which the doctor has incentives for cost containment. 

Co-payment is an instrument that should not be used on its own. Neither efficiency in drag use nor equity nor the control of pharmaceutical expenditure can rest solely on co-payment. Its effectiveness is reinforced when it is combined with other instruments and incentives. In fact, all European countries combine, in different doses and proportions, multiple instruments that influence the behaviour of the industry, prescribes and patients. It is sufficient to recall that pharmaceutical expenditure is the product of price by quantity, and to consider the enormous international variability of drag prices,35 in order to understand the limitations of co-payment regulation in comparison with other policies that influence prices. Policies aimed at price control can be as effective as co-payment - or more so - for purposes of cost containment. 

To summarize, it should be highlighted that in general terms the issue of prescribing incentives is approached with a marked lack of consideration of such fundamental concerns as their impact on health, although this aspect is indirectly addressed by non-financial incentives and mixed formulas such as those discussed above. Financial incentives alone appear to lack effectiveness as instruments of pharmaceutical policy. Incentives aimed at prescribers should under no circumstances create a clash of interests between their fees and the quality of the care they provide for their patients, and therefore adjustment must be made in these terms. In turn, we cannot ignore that the effect of this type of mechanism on physicians behaviour will depend on, among other factors, the quality of available information on the aspects taken into consideration in their application. 

The use of benzodiazepines should be avoided. There are other safer pharmacological alternatives. Benzodiazepine withdrawal may play a role in the occurrence of delirium in the elderly. Other withdrawal symptoms include tremor, agitation, insomnia and seizures (Turnheim 2003). Thus, when there is long-term use of benzodiazepines abrupt discontinuation might be difficult. Discontinuation should however not be withheld but done slowly and step-wise. If benzodiazepines are used in the elderly, short-acting benzodiazepines such as oxazepam are preferred, because they do not accumulate in the elderly to the same extent (Kompoliti and Goetz 1998). If short-acting benzodiazepines are used they should be prescribed with caution, at low doses, and for short periods. As with all pharmacotherapy the effects should be evaluated. Benzodiazepines are sometimes used as a behavioural control. One should always ask if this use is for the benefit of staff or the benefit of the patient. The presence of staff may be sufficient for behavioural control. 

The Swiss Agency of Environment and Landscape decided to re-evaluate mechanical metal separation techniques to reduce the landfill volume and to improve the BA quality for deposition by exploiting metal resources. A sampling campaign in all 28 incineration plants was initiated to verify BA quality and to establish a solid data base. A common sampling procedure, sample treatment, and analytical method were prescribed in order to obtain consistent information of chemical and structural composition and the leaching behaviour of current BA. This paper is focused on the chemical and mineralogi-cal results from the study. 

---