Is overprescribing for the benefit of doctors or their patients?

20161212130000, Chan Mei Yen
Overprescription continues despite the fact that physicians are aware of clinical guidelines and the concept of avoiding low-value care, suggests a study published online in Annals of Internal Medicine on December 5th. 

The online survey, headed by Dr. Amir Qaseem, vice president of clinical policy and chair of the high value care task force for the American College of Physicians (ACP), was completed by 5,000 ACP member physicians.

Of the various treatments being prescribed against recommended guidelines, 27% of physicians chose antibiotics, making it the most common overprescribed treatment in the survey.

“In most cases, the antibiotics are prescribed to treat upper respiratory infections even though these are most often caused by viruses unaffected by the medication,” said Dr. Qaseem.

Overuse of antibiotics was followed by excessive use of aggressive care in patients with limited life expectancy, and overprescription of narcotics, as identified by 8.6% and 7.3% of doctors respectively.

Approximately 5% of doctors identified dietary supplements, such as vitamin D, multivitamins and fish oil, as being overprescribed. A similar percentage of doctors chose statins as overused medications in the elderly and to prevent health problems.

Why do doctors overprescribe?

Some 700,000 deaths worldwide are caused by antibiotic resistance every year. “If this is left uncontrolled, the number of deaths could go up to 10 million by 2050,” said Health Minister Datuk Seri Dr S Subramaniam.

However, strategies like educating doctors on the proper use of antibiotics and electronic alerts have been unsuccessful, suggesting that despite having adequate knowledge of antibiotics and being aware of clinical guidelines, doctors are overprescribing for various other reasons.

"Clinicians who stray from guidelines may, or may not, have good reasons for doing so," said Dr. David Levine, a researcher at Brigham and Women's Hospital and Harvard Medical School.

“The guidelines may not be applicable to the patient in front of them, or they may not realise the newest recommendations now counsel against a treatment or procedure they learned in medical school,” he added.

Dr Qaseem also notes the pressure physicians face to fulfil patients’ expectations could fuel overprescribing. As mentioned by Dr Subramaniam: "It is the culture in this country for doctors to give antibiotics and those who do not give are deemed to have shirked their duties.”

“Physicians also might be practicing defensive medicine to ward off potential malpractice suits, or trying to meet clinical performance measures that call for blanket treatments that must be applied to all patients,” Qaseem said.

In many Asian countries, including Malaysia, doctors are responsible for dispensing drugs, which is a source of income that could be exploited through overprescribing.

Overcoming overprescribing

Electronic alerts bombarding the hectic practices of physicians often only serve as an annoyance, and financial incentives to prevent overprescribing are only modest relative to a doctor’s salary.

In a study published in the Journal of the American Medical Association (JAMA) earlier this year, ‘peer-comparison’ approaches were extremely effective in reducing inappropriate prescribing. In one approach, doctors were to add an ‘antibiotic justification note’ that would be visible to others.

Dr Mark Chen, assistant professor at NUS' Saw Swee Hock School of Public Health also suggests another way to avoid overprescribing. "Doctors can offer patients a deferred prescription - the patient may come back in a couple of days' time if they feel that the symptoms are getting worse, and the doctor then gets a chance to reassess the same patient to see if it is a bacterial infection that truly needs antibiotics,”

Furthermore, separating consultation and prescription services can remove potential profit from over-prescribing practices. MIMS 

Read more:
One-third of patients expect antibiotics from GPs in Singapore
Patients with sore throats to visit pharmacists first before GPs in the UK
Persistent misuse of antibiotics may cause 10 million deaths by 2050, says Malaysia’s MOH
Nations and drug companies commit to fight antibiotic resistance after U.N. assembly

Sources:
http://www.foxnews.com/health/2016/12/06/doctors-see-regular-misuse-antibiotics-narcotics.html
http://www.cbsnews.com/news/doctors-still-overprescribing-drugs-antibiotics/
http://www.thesundaily.my/news/1089439
http://www.straitstimes.com/singapore/health/too-much-antibiotics-and-how-to-stay-a-doctors-hand