Prescribing new drugs: qualitative study of influences on consultants and general practitioners

ObjectiveTo explore consultants'' and general practitioners'' perceptions of the factors that influence their decisions to introduce new drugs into their clinical practice.DesignQualitative study using semistructured interviews. Monitoring of hospital and general practice prescribing data for eight new drugs.SettingTeaching hospital and nearby general hospital plus general practices in Birmingham.Participants38 consultants and 56 general practitioners who regularly referred to the teaching hospital.ResultsConsultants usually prescribed new drugs only in their specialty, used few new drugs, and used scientific evidence to inform their decisions. General practitioners generally prescribed more new drugs and for a wider range of conditions, but their approach varied considerably both between general practitioners and between drugs for the same general practitioner. Drug company representatives were an important source of information for general practitioners. Prescribing data were consistent with statements made by respondents.ConclusionsThe factors influencing the introduction of new drugs, particularly in primary care, are more multiple and complex than suggested by early theories of drug innovation. Early experience of using a new drug seems to strongly influence future use.

What is already known on this topic

UK studies show that use of new drugs by general practitioners is influenced by consultants, the nature of the drug, and perceived risk

What this study adds

Consultants generally introduced fewer drugs than general practitioners, usually within their specialtyDecisions were said to be based mainly on the evidence from the scientific literature and meetingsGeneral practitioners prescribed more new drugs and the basis of decisions was more variedDoctors'' interpretations of using a new drug were not consistent     

Why are clinical problems difficult? General practitioners' opinions concerning 24 clinical problems.

This study was conducted to describe the difficulties perceived by general practitioners concerning 24 common clinical problems and to compare their perceptions with those of faculty members in family medicine. A random sample of 467 general practitioners and all 182 faculty members in family medicine in Quebec were sent one of four open-ended questionnaires, each of which dealt with six clinical problems; 214 general practitioners and 114 faculty members participated. A total of 5111 difficulties were reported; the number reported by each subject varied from 0 to 13 (mean 2.6 [standard deviation 2.09]) per problem. The problems that generated the most difficulties were depression, confusion in the elderly, chronic back pain, loss of autonomy in the elderly and sexually transmitted disease. The most frequent difficulties were with the patient''s noncompliance with treatment, clinical diagnosis, failure of a specific treatment, inadequate health care resources and the physician''s own emotional reactions. The difficulties for each problem were the same in the two groups 70% of the time. Physician''s perceptions of their difficulties can be useful in the planning of initial training and continuing medical education.     

Specialist outreach clinics in general practice.

OBJECTIVES--To establish the extent and nature of specialist outreach clinics in primary care and to describe specialists'' and general practitioners'' views on outreach clinics. DESIGN--Telephone interviews with hospital managers. Postal questionnaire surveys of specialists and general practitioners. SETTING--50 hospitals in England and Wales. SUBJECTS--50 hospital managers, all of whom responded. 96 specialists and 88 general practitioners involved in outreach clinics in general practice, of whom 69 (72%) and 46 (52%) respectively completed questionnaires. 122 additional general practitioner fundholders, of whom 72 (59%) completed questionnaires. MAIN OUTCOME MEASURES--Number of specialist outreach clinics; organisation and referral mechanism; waiting times; perceived benefits and problems. RESULTS--28 of the hospitals had a total of 96 outreach clinics, and 32 fundholders identified a further 61 clinics. These clinics covered psychiatry (43), medical specialties (38), and surgical specialties (76). Patients were seen by the consultant in 96% (107) of clinics and general practitioners attended at only six clinics. 61 outreach clinics had shorter waiting times for first outpatient appointment than hospital clinics. The most commonly reported benefits for patients were ease of access and shorter waiting times. CONCLUSIONS--Specialist outreach clinics cover a wide range of specialties and are popular, especially in fundholding practices. These clinics do not seem to have increased the interaction between general practitioners and specialists.     

Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: dealing with the opiate misuser.

Because there has been a substantial increase in the scale of drug misuse general practitioners have become increasingly concerned in responding to this problem. Little is known, however, about how general practitioners manage drug misusers. The findings from a national survey carried out in mid-1985 of a 5% random sample of general practitioners in England and Wales show the extent to which various actions were undertaken by general practitioners who reported on the consultation with the opiate misuser whom they last attended. In more than half of the cases the opiate misuser had been under the care of the general practitioners for this problem for at least six months. The findings indicate that most general practitioners refer these patients to specialist drug dependence clinics or to general psychiatric services but rarely to other agencies. Opiate drugs had been prescribed in nearly a third of cases. The rate of notification to the Home Office conforms with that in other studies and indicates a high degree of undernotification. More detailed study of general practitioners'' activities in managing drug misusers is needed.     

Impact of nurse practitioners on workload of general practitioners: randomised controlled trial

Objective To examine the impact on general practitioners'' workload of adding nurse practitioners to the general practice team.Design Randomised controlled trial with measurements before and after the introduction of nurse practitioners.Setting 34 general practices in a southern region of the Netherlands.Participants 48 general practitioners.Intervention Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines. The control group received no nurse.Main outcome measures Objective workload, derived from 28 day diaries, included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma, dementia, cancer), by type of consultation (in practice, telephone, home visit), and by time of day (surgery hours, out of hours). Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention.Results The number of contacts during surgery hours increased in the intervention group compared with the control group (P < 0.06), particularly for patients with chronic obstructive pulmonary disease or asthma (P < 0.01). The number of consultations out of hours declined slightly in the intervention group compared with the control group, but this difference did not reach significance. No significant changes became apparent in subjective workload.Conclusion Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners, at least in the short term. This implies that nurse practitioners are used as supplements, rather than substitutes, for care given by general practitioners.     

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

Health checks on patients 75 years and over in Nottinghamshire after the new GP contract.

OBJECTIVE--To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. DESIGN--Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. SETTING--20 general practices in one family health services authority. SUBJECTS--Patients of 75 years and over in 20 general practices. RESULTS--Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients'' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. CONCLUSIONS--The way health checks were performed varied greatly, both in their organisation and the practices'' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.     

Medical housing "lines".

General practitioners are often asked for medical certificates (housing "lines") by applicants for council housing who claim to have medical problems requiring housing priority. The results of a survey by questionnaire showed that general practitioners in Edinburgh do not know how the housing system works and that they seem to overestimate their patients'' chances of obtaining suitable council housing. General practitioners need to know how the housing system works, and communication between general practitioners and housing departments should be improved. A comparison was also made between the number of medical points awarded by a community medicine specialist and a group of general practitioners who had written housing "lines" for their patients. The general practitioners tended to award more points than the specialist. Social priority for housing should be recognised as an independent factor and a new category of top social priority added.     

The regional drug information service: a factor in health care?

Most regional health authorities throughout the United Kingdom have established drug information units to provide health service staff with a wide range of information about drugs and drug use. The units, which are staffed by drug information pharmacists, provide their service mainly by answering inquiries, although some disseminate information more positively through lectures and bulletins.An analysis of inquiries received by regional information units during 1976 showed that most were submitted by hospital doctors or pharmacists; comparatively few were received from general practitioners. Topics of inquiry included adverse effects of drugs, source of supply and identification, current treatment, dosage, route, precautions, and pharmaceutical problems such as stability or formulation of drug preparations. A more detailed analysis of the inquiries received by the North-western Regional Drug Information Service at Manchester over three years showed that the number of inquiries gradually increased and that more were received from general practitioners after a programme of lectures had been introduced to tell them about the service. The North-western service also received more requests from hospital pharmacists than other units, though many originated from clinicians.The regional drug information units consulted widely with clinical and other specialists in answering questions, but about a quarter of all inquiries were pharmaceutical, relating to stability and incompatibility. A multidisciplinary approach therefore seems necessary to provide a comprehensive and advisory drug information service.     

General practitioners and management of infection with HIV

General practitioners will have an increasingly important role in the management of patients with the acquired immune deficiency syndrome (AIDS) and infections with human immunodeficiency virus (HIV) as the numbers of cases increase. Altogether 280 general practitioners working in Oxfordshire were sent a postal questionnaire inquiring about their education, knowledge, current practice, and attitudes in relation to managing infections with HIV. Of the 235 (84%) general practitioners who replied, nine out of 10 were giving advice about infection with HIV to their patients. One in two were testing patients for such infection, and one in four were caring for infected patients. Nevertheless, uncertainty remained about the risks of transmission of infection with HIV and general practitioners'' knowledge of educational activities for their patients could be improved.The introduction of a facilitator to work with general practitioners in managing patients with AIDS or infection with HIV is planned, especially to help general practitioners develop the skills needed for prevention.     

General practitioner response to elderly patients discharged from hospital.

OBJECTIVE--To determine the effect of discharge information given to general practitioners on their management of newly discharged elderly patients. DESIGN--A random sample of 133 elderly patients who had unplanned readmission to a district general hospital within 28 days of discharge was compared with a matched control sample of patients who were not readmitted. Information was gathered from the hospital, the patients, the carers, and the general practitioners about the information that the hospital had sent the general practitioner and the general practitioners'' response to this information. SETTING--All specialties in a district general hospital. PATIENTS--266 Patients aged over 65 representative in the main demographic indices of the population of elderly patients admitted to hospital. RESULTS--Ten weeks after discharge the doctors had received notice of discharge about 169 of the patients, but fewer than half the discharge notices were received within the first week. General practitioners were dissatisfied with the information in 60 cases. A general practitioner visited 174 of the patients after their discharge from hospital and three quarters of the visits took place within two weeks of the discharge. These visits were more likely to have been initiated by patients or families than by the doctor, and this was not influenced by the doctor receiving notice of the patient''s discharge. Older patients and those who had carers were the most likely to be visited. Nearly half of the carers were dissatisfied with some aspect of general practitioner care, problems with home visiting being the commonest source of complaint. CONCLUSIONS--Hospital communications to general practitioners about the discharge of elderly patients still cause concern, particularly in the time they take to arrive. Written instruction to vulnerable elderly patients asking them to inform their general practitioner of the discharge might be helpful. Carers complained of lack of support, and it is clearly important for someone (either the general practitioner or another health worker) to visit elderly people shortly after their discharge.     

General practitioner obstetrics in the Northern region in 1983.

In late 1983 a four page questionnaire on general practitioner obstetrics was sent to a 50% random sample of general practitioners in the Northern region of England; 84% responded. Half of them said that they had access to general practitioner facilities for delivery, and half of these used them. A quarter of all respondents had provided intranatal care previously but had given it up, most of them during the late 1970s. Younger general practitioners were more highly qualified in obstetrics than older ones but did not do more intranatal work. Isolated general practitioner maternity units were much more likely to be used than those that were alongside consultant units or integrated with them. Ninety per cent of respondents provided antenatal care, 77% of these at special clinics and 88% with midwives in attendance. Teamwork, however, was not well developed. Increasing general practitioner participation in obstetric care seems feasible but depends heavily on more appropriate training and intranatal facilities being provided for general practitioners in association with specialist units.     

Policies on antibiotics of south east London general practitioners for managing acute otitis media in children.

Questionnaires on antibiotic treatment of acute otitis media in children were sent to the general practitioners who make regular referrals to clinics in the King''s College Hospital group. The most popular first choice of drug was amoxycillin (44%), but 37% of general practitioners said that they often used oral phenoxymethylpenicillin. This drug has relatively low activity against Haemophilus influenzae and many strains of Staphylococcus aureus. It is poorly absorbed from the stomach, does not penetrate the middle ear well, and its use may be one factor in the development of chronic middle ear effusions after acute otitis media. Sixty two per cent of the doctors who replied never treated acute otitis media with intramuscular antibiotics, but 57% used oral loading doses. Ninety seven per cent never treated their patients without antibiotics.     

Combining specialist and primary health care teams for HIV positive patients: retrospective and prospective studies.

OBJECTIVE: To develop and evaluate a model of health care for HIV positive patients involving specialist, hospital based teams and primary health care teams. DESIGN: One year retrospective and a 2 1/2 year prospective study. SETTING: Two hospitals in West London and 88 general practitioners in 72 general hospitals. SUBJECTS: 209 adults with HIV infection. INTERVENTION: General practitioners enrolled in the project were faxed structured outpatient clinic summaries. When hospital inpatients were discharged, a brief discharge summary was faxed. General practitioners had access to consultant physicians skilled in HIV medicine through a 24 hour mobile telephone service. An HIV/AIDS management and treatment guide containing relevant local information was produced. Quarterly discussion forums for general practitioners were held, and a regular newsletter was produced. MAIN OUTCOME MEASURES: Hospital attendance and general practitioner consultations; perceived benefits and problems of patients and general practitioners. RESULTS: The average length of a hospital inpatient stay was halved for those patients who had participated in the project for two years, and the average number of visits to the outpatient clinic per month fell for patients with AIDS. There was a substantial increase in the number of visits to general practitioners by patients with AIDS and symptomatic HIV infection. Patients and general practitioners both felt that the standard of health care provided had improved. CONCLUSIONS: This model of health care efficiently and effectively utilised existing teams of hospital and primary health care professionals to provide care for HIV positive patients. Simple, prompt, and regular communication systems which provided information relevant to the needs of general practitioners were central to its success.     

Electronic communication between providers of primary and secondary care.

OBJECTIVE--To study the effects of the introduction of electronic data interchange between primary and secondary care providers on speed of communication, efficiency of data handling, and satisfaction of general practitioners with communication. DESIGN--Comparison of traditional paper based communication for laboratory reports and admission-discharge reports between hospital and general practitioners and electronic data interchange. SETTING--Twenty-seven general practitioners whose offices were equipped with a practice information system and two general hospitals. OUTCOME MEASURES--Paper based communication was evaluated by questionnaire responses from and interviews with care providers; electronic communication was evaluated by measuring time intervals between generation and delivery of messages and by assessing doctors'' satisfaction with electronic data interchange by questionnaire. RESULTS--Via paper mail admission-discharge reports took a median of 2-4 days, and laboratory reports 2 days, to reach general practitioners. With electronic data interchange almost all admission-discharge reports were available to general practitioners within one hour of generation. When samples were analysed on the day of collection (as was the case for 174/542 samples in one hospital and 443/854 in the other) the laboratory reports were also available to the general practitioner the same day via electronic data interchange. Fifteen general practitioners (of the 24 who returned the questionnaire) reported that the use of electronic admission-discharge reports provided more accurate and complete information about the care delivered to their patients. Ten general practitioners reported that electronic laboratory reports lessened the work of processing the data. CONCLUSION--Electronic communication between primary and secondary care providers is a feasible option for improving communication.     

Are general practitioners ready to prevent the spread of HIV?

General practitioners are excellently placed to assess a person''s risk of being infected with the human immunodeficiency virus (HIV) and to give advice on reducing that risk. Their attitudes to the acquired immune deficiency syndrome (AIDS) and infection with HIV are, however, unknown. A questionnaire survey of 196 general practitioners in East Berkshire Health District was used to assess general practitioners'' readiness to undertake opportunistic health education to prevent the spread of infection with HIV. Altogether 132 replied. Sixty four of them expressed little interest in health education about HIV, and one in six would not dissent from the notion that AIDS could be controlled only by criminalising homosexuality. Only 75 of them had initiated discussions about HIV with patients. Moreover, many underestimated the risks from heterosexual sex while exaggerating the risks from non-sexual contact.Advice from general practitioners if given extensively might reduce the spread of infection with HIV. How best this may be achieved needs to be considered urgently.     

Malaria in Birmingham and a London teaching hospital.

During the past five years the incidence of imported malaria increased among patients seen in East Birmingham Hospital and in St Thomas''s Hospital, London. Plasmodium vivax was the predominant species in Birmingham, and was almost always acquired by Asian immigrants visiting the Indian subcontinent. In St Thomas''s P falciparum was most commonly imported, usually by African immigrants visiting Nigeria and Ghana. Two patients (one Irish, one Japanese) died of falciparum malaria after visiting tropical Africa. In both hospitals the immigrant patients had seldom taken prophylactic drugs, and the few who had, ceased to do so on arrival in the UK and sometimes before leaving the malarious country. Apparently immigrants who visit their homeland do not consult their general practitioners before travelling, are given inappropriate advice, or do not take appropriate advice when given. Since the incidence of imported falciparum malaria in the UK is rising, the following points should be considered: the infection may be lethal, particularly in patients lacking immunity; it can mimic other diseases, which may lead to delayed diagnosis; severe disease may be associated with few parasites on a blood film, and even if the result is negative further tests should be performed; clinicians and hospital pharmacists should be aware of the need to keep permanent stocks of parenteral chloroquine and quinine preparations.     

Psychological and social problems in HIV infection: interviews with general practitioners in London.

OBJECTIVE--To assess current practice and opinions of general practitioners in London about managing psychological and social problems relating to HIV infection. DESIGN--A stratified random sample of general practitioners, including those with a range of experience of people with HIV infection, were interviewed by medically trained interviewers. SETTING--Doctor''s surgeries. PARTICIPANTS--270 General practitioners working within the area covered by London postcodes. RESULTS--Two thirds of doctors had treated at least one patient with HIV infection and described their work with these patients. General practitioners were counselling and educating many of their patients about AIDS and associated risk behaviours and were aware of the need for careful attention to confidentiality. Doctors with no experience of patients with HIV infection were often older, in singlehanded practice, less inclined to deal with drug abusers or to counsel their patients on risk behaviours, and more in favour of insurance companies'' policies towards people with HIV infection. CONCLUSIONS--General practitioners in London are quickly becoming involved in the care of patients with HIV infection and their relatives and friends. Many are counselling patients and testing for antibodies themselves and regard this as an integral part of their work. A considerable workload in primary care comprised patients who obsessively fear contracting HIV infection.     

Organisation of telephone services and patients' access to doctors by telephone in general practice.

OBJECTIVES--To assess how accessible general practitioners are to patients by telephone and to examine the relations between organisation, number of lines, and number of patient-doctor calls. DESIGN--Postal survey of a random sample of general practitioners stratified by rural and urban practice areas, with differential sampling fractions. SETTING--General practices in England and Wales. SUBJECTS--2000 general practitioners, of whom 1459 (74%) responded. MAIN OUTCOME MEASURES--Number of calls received by general practitioner a day, time reserved for patients'' calls, and communication of availability of telephone contact. RESULTS--1421 general practitioners said that they accepted non-emergency calls from patients during the day and 285 reported reserving specific times of the day for this purpose. 848 estimated that they received four or fewer patient calls a day. The number of calls was significantly related to reserving time for calls (p less than 0.001), informing patients that the doctor was accessible by telephone (p less than 0.00001), and the number of periods when calls were accepted (p less than 0.00001). On average there were 3659 patients per incoming line; the number of patients per incoming line rose significantly as practice size increased (p less than 0.00001). CONCLUSIONS--The apparent willingness of general practitioners to accept calls was not reflected in the number of calls received. Reserving time, increasing periods of availability, and publicising telephone access increased the number of doctor-patient telephone contacts. Line congestion may be a problem, and impartial advice and guidance on telephone organisation and line requirements would be helpful.