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Rational Prescribing and Interpractitioner Variation: A Multilevel Approach

Published online by Cambridge University Press:  10 March 2009

Peter Davis  and
Barry Gribben
Peter Davis
Affiliation:
University of Auckland School of Medicine
Barry Gribben
Affiliation:
University of Auckland School of Medicine
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Abstract

There are marked geographical variations in rates of medical and surgical intervention at every level of aggregation and in every aspect of medical practice. These data raise a range of important theoretical, methodological, and policy issues. Much the same pattern of variation characterizes the prescription and consumption of therapeutic drugs. Data from a survey of general practice in New Zealand confirm the existence of extensive variability in prescribing. Multilevel techniques are deployed to isolate the specific interpractitioner element in this variability. Controlling for patient, diagnostic, and practitioner variables improves the predictive power of the model but does not reduce the extent of interpractitioner variability in prescribing rates. The existence of such variability raises questions about the role of clinical uncertainty and professional autonomy in the promotion of rational therapeutics in medical practice.

Type
Special Section: The Rational Use of Therapeutic Drugs
Information
International Journal of Technology Assessment in Health Care , Volume 11 , Issue 3 , Summer 1995 , pp. 428 - 442
Copyright
Copyright © Cambridge University Press 1995

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References

1.Ahonen, R., Enlund, H., Klaukka, T., & Martikainen, J.Consumption of analgesics and anti-inflammatory drugs in the Nordic countries between 1978–1988. European Journal of Clinical Pharmacology, 1991, 41, 37–42.CrossRefGoogle ScholarPubMed
2.Andersen, T. F., & Mooney, G. (eds.) The challenges of medical practice variations. London: Macmillan Press, 1990.CrossRefGoogle Scholar
3.Baum, C., Kennedy, D. L., Knapp, D. E., et al. Prescription drug use in 1984 and changes over time. Medical Care, 1988, 26, 105–14.Google Scholar
4.Beers, M. H., Fingold, S. F., Ouslander, J. G., et al. Characteristics and quality of prescribing by doctors prescribing in nursing homes. Journal of the American Geriatrics Society, 1993, 41, 802–07.CrossRefGoogle ScholarPubMed
5.Bergman, U., Grimson, A., Wahb, A. H. W., & Westerholm, B. (eds.) Studies in drug utilization: Methods and applications. WHO Regional Publications, European Series no. 8. Copenhagen: WHO, 1979.Google Scholar
6.Birkett, D. J., Mitchell, A. S., Godeck, A., et al. Profiles of antibacterial drug use in Australia and trends from 1987 to 1989. Medical Journal of Australia, 1991, 155, 410–15.CrossRefGoogle ScholarPubMed
7.Bjelle, A., & Mjorndal, T.Drug prescription patterns for rheumatic disorders in Sweden. Journal of Rheumatology, 1993, 11, 493–99.Google Scholar
8.Bunker, J. P.A comparison of operations and surgeons in the United States and in England and Wales. New England Journal of Medicine, 1970, 282, 135–44.CrossRefGoogle ScholarPubMed
9.Carrin, G.Drug prescribing: Its variability and (ir)rationality. Health Policy, 1987, 7, 73–94.Google Scholar
10.Chassin, M. R., Kosecoff, J., Park, R. E., et al. Does inappropriate use explain variations in the use of health services? A study of three procedures. Journal of the American Medical Association, 1987, 258, 2533–37.CrossRefGoogle ScholarPubMed
11.Chew, R., Teeling-Smith, G., & Wells, NPharmaceuticals in seven nations. London: Office of Health Economics, 1985.Google Scholar
12.Clark, J. A., Potter, D. A., & McKinlay, J. B.Bringing social structure back into clinical decision making. Social Science and Medicine, 1991, 32, 853–66.CrossRefGoogle ScholarPubMed
13.Cochrane, A. L.Effectiveness and efficiency: Random reflections on health services. London: Nuffield Provincial Hospital Trust, 1972.Google Scholar
14.Conrad, P.The discovery of hyperkinesis: Notes on the medicalization of deviant behavior. Social Problems, 1975, 23, 12–21.CrossRefGoogle ScholarPubMed
15.Davis, P. Accounting for variation in drug therapy: Clinical uncertainty, professional autonomy, and the issue of rational prescribing. In Harding, G. et al. (eds.), Social pharmacy: Innovation and change. London: The Pharmaceutical Press, 1994, 130–43.Google Scholar
16.Davis, P. B., Lay Yee, R., & Millar, J.Accounting for medical variation: The case of prescribing activity in a New Zealand general practice sample. Social Science and Medicine, 1994, 39, 367–74.CrossRefGoogle Scholar
17.Denig, P., Haaijer-Ruskamp, F. M., Wesseling, H., & Versluis, A.Towards understanding treatment preferences of hospital physicians. Social Science and Medicine, 1993, 36, 915–24.CrossRefGoogle ScholarPubMed
18.Denig, P., Haaijer-Ruskamp, F. M., & Zijsling, D. H.How physicians choose drugs. Social Science and Medicine, 1988, 27, 1381–86.CrossRefGoogle ScholarPubMed
19.Dickson, M., & Poullier, J.-P. Prescription reimbursement systems in selected European countries. In Huttin, C. & Bosanquet, N. (eds.), The prescription drug market: International perspectives and challenges for the future. Amsterdam: Elsevier Science Publishers, 1992, 109–37.Google Scholar
20.Diehr, P., et al. What is too much variation? The null hypothesis in small-area analysis. Health Services Research, 1990, 24, 741–71.Google ScholarPubMed
21.Divine, G. W., Brown, J. T., & Frazier, L. M.The unit of analysis error in studies about physicians’ patient care behavior. Journal of General Internal Medicine, 1992, 7, 623–29.Google Scholar
22.Eddy, D. M.Clinical decision making: Anatomy of a decision, Journal of the American Medical Association, 1990, 263, 441–43.CrossRefGoogle ScholarPubMed
23.Enlund, H., et al. The use of prescription drugs among elderly Finnish men. Journal of Clinical Pharmacy and Therapeutics, 1990, 15, 115–22.CrossRefGoogle ScholarPubMed
24.Eraker, S. A., & Politser, P.How decisions are reached: Physician and patient. Annals of Internal Medicine, 1982, 97, 262–68.CrossRefGoogle ScholarPubMed
26.Ferguson, J. A.Drug prescribing habits related to characteristics of medical practice. Journal of Social and Administrative Pharmacy, 1990, 7, 34–47.Google Scholar
25.Evans, R. G. The dog in the night-time: Medical practice variations and health policy. In Andersen, T. F. and Mooney, G. (eds.), The challenges of medical practice variations. London: Macmillan Press, 1990, 117–52.CrossRefGoogle Scholar
27.Forster, D. P., & Frost, C. E. B.Use of regression analysis to explain the variation in prescribing rates and costs between family practitioner committees. British Journal of General Practice, 1991, 41, 67–71.Google ScholarPubMed
28.Fox, J. S., & Harron, D. W. G.Trends in prescribing of anti-infective drugs in Northern Ireland (1978–1985). International Pharmacy Journal, 1988, 2, 7–10.Google Scholar
29.Glover, J. A.The incidence of tonsillectomy in school children. Proceedings of the Royal Society of Medicine, 1938, 31, 1219–36.Google Scholar
30.Gribben, B., Bonita, R., Broad, J., et al. Geographical variations in the organisation of general practice. New Zealand Medical Journal, in press.Google Scholar
31.Griffin, J. P. Factors affecting medicine usage and rates of consultation. In Griffin, J. (ed.). Factors influencing clinical decisions in general practice. London: Office of Health Economics, 1990, 5–12.Google Scholar
32.Gross, T. P., Wise, R. P., & Knapp, D. E.Antihypertensive drug use: Trends in the United States from 1973 to 1985. Hypertension, 1989, 13(suppl. 1), 1–113–18.Google Scholar
33.Haaijer-Ruskamp, F. M., & Dukes, M. N. G.Drugs and money: The problem of cost containment, 6th ed.Groningen: Styx Publications, 1991.Google Scholar
34.Ham, C. (ed.) Health care variations: Assessing the evidence. London: King's Fund, 1988.Google Scholar
35.Hancher, L. Pharmaceutical policy and regulation in the EC. In Davis, P. (ed.), Contested ground: Public purpose and private interest in the regulation of prescription drugs. New York: Oxford University Press, in press.Google Scholar
36.Harris, C. M., Heywood, P. L., & Clayden, A. D.The analysis of prescribing in genera practice: A guide to audit and research. London: HMSO, 1990.Google Scholar
37.Hart, J. T.The inverse care law. Lancet, 1971, 1, 405–12.Google Scholar
38.Hartley, R. M., Charlton, J. R., Harris, C. M., & Jarman, B.Patterns of physician's use of medical resources in ambulatory settings. American Journal of Public Health, 1987, 77, 565–67.Google Scholar
39.Hartzema, A. G., & Christensen, D. B.Nonmedical factors associated with the prescribing volume among family practitioners in an HMO. Medical Care, 1983, 21, 990–1000.Google Scholar
40.Henry, D. A., Ruth Cully, L., Grigson, T., & Lee, C.Recent trends in the prescribing of cholesterol lowering drugs in Australia. Medical Journal of Australia, 1991, 155, 332–36.CrossRefGoogle ScholarPubMed
41.Higginbotham, N., & Streiner, D. L.The social science contribution to pharmacoepidemiology. Journal of Clinical Epidemiology, 1991, 44(suppl. 2), 73S–82S.CrossRefGoogle ScholarPubMed
42.Hlatky, M. A., Lee, K. L., Botvinick, E. H., & Brundage, B. H.Diagnostic test use in different practice settings. Archives of Internal Medicine, 1983, 143, 1886–89.CrossRefGoogle ScholarPubMed
43.Hox, J. J., & Kreft, I. G. G.Special issue: Multilevel analysis methods. Sociological Methods and Research, 1994, 22, 283–399.CrossRefGoogle Scholar
44.Illich, I.Medical nemesis. New York: Pantheon, 1976.Google Scholar
45.Inman, W., & Pearce, G.Prescriber profile and post-marketing surveillance. Lancet, 1993, 342, 658–61.Google Scholar
46.Jones, K., Moon, G., & Clegg, A.Ecological and individual effects in childhood immunisation uptake: A multi-level approach. Social Science and Medicine, 1991, 33, 501–08.CrossRefGoogle ScholarPubMed
47.Kay, E. A., & Pullar, T.Variations among rheumatologists in prescribing and monitoring of disease modifying antirheumatoid drugs. British Journal of Rheumatology, 1992, 31, 477–83.Google Scholar
48.Kesten, S., Rebuck, A. S., & Chapman, K. R.Trends in asthma and chronic obstructive pulmonary disease therapy in Canada, 1985 to 1990. Journal of Allergy and Clinical Immunology, 1993, 92, 499–506.CrossRefGoogle ScholarPubMed
49.Kuyvenhoven, M., de Melker, R., & van der Velden, K.Prescription of antibiotics and preservers’ characteristics: A study into prescription antibiotics in upper respiratory tract infections in general practice. Family Practice, 1993, 10, 366–70.CrossRefGoogle Scholar
50.Lamberts, H., & Woods, M. (eds.). ICPC. International classification of primary care. Oxford: Oxford University Press, 1987.Google Scholar
51.Lexchin, J. Interactions between physicians and the pharmaceutical industry: What does the literature say? Canadian Medical Association Journal, 1993, 1401–07.Google Scholar
52.Lipton, H. L., & Bird, J. A.Drug utilization review in ambulatory settings: State of the science and directions for outcomes research. Medical Care, 1993, 31, 1069–82.CrossRefGoogle ScholarPubMed
53.Luft, H. S.Variations in clinical practice patterns. Archives of Internal Medicine, 1983, 143, 1861–62.Google Scholar
54.Macukanovic, P., Rabin, D. L., Mabry, J. H., & Simic, D. Use of medicines. In Kohn, R. & White, K. L. (eds.), Health care: An international study. London: Oxford University Press, 1976, 223–77.Google Scholar
55.Malcolm, L. Growth of primary medical care related expenditure in New Zealand, 1983–1993. Unpublished report. Wellington: Ministry of Health, 1993.Google Scholar
56.Mant, A., Lansbury, G., & Bridges-Webb, C.Trends in psychotropic drug prescribing in Australia. Medical Journal of Australia, 1987, 146, 208–10.Google Scholar
57.Martin, J. P.Social aspects of prescribing. London: Heineman, 1957.Google Scholar
58.McAvoy, B., Davis, P., Raymont, A., & Gribben, B.The Waikato Medical Care (WaiMedCa) Survey, 1991–1992. New Zealand Medical Journal, 1994, 107(suppl. part 2), 387–433.Google Scholar
59.McKinlay, J. B.From ‘promising report’ to ‘standard procedure’: Seven stages in the career of a medical innovation. Milbank Memorial Fund Quarterly, 1981, 59, 374–411.CrossRefGoogle ScholarPubMed
60.McPherson, K. Why do variations occur? In Andersen, T. F. and Mooney, G. (eds.), The challenges of medical practice variations. London: Macmillan Press, 1990, 16–35.CrossRefGoogle Scholar
61.McPherson, K., Strong, P. M., Epstein, A., & Jones, L.Regional variations in the use of common surgical procedures: Within and between England and Wales, Canada and the United States of America. Social Science and Medicine, 1982, 15A, 273–83.Google Scholar
62.Miles, D. L.Multiple prescriptions and drug appropriateness. Health Services Research, 1977, 12, 3–10.Google Scholar
63.Miller, M. E., et al. Estimating physician costliness: An empirical Bayes approach. Medical Care, 1993, 31(suppl.), YS16–YS28.Google Scholar
64.Multilevel Models Project. A Guide to ML3 Macros: Multilevel Binary Response Models. London: Institute of Education, 1993.Google Scholar
65.Niskanen, L., et al. Therapeutic traditions in type 2 diabetes: Are they changing? European Journal of Clinical Pharmacology, 1994, 46, 101–05.CrossRefGoogle ScholarPubMed
66.O'Brien, B.Patterns of European diagnoses and prescribing. Unpublished report. London: Office of Health Economics, 1984.Google Scholar
67.Paul-Shaheen, P., Clark, J. D., & Williams, D.Small area analysis: A review and analysis of the North American literature. Journal of Health Politics, Policy and Law, 1987, 12, 741–809.CrossRefGoogle ScholarPubMed
68.Payer, L.Medicine and culture: Varieties of treatment in the United States, England West Germany, and France. New York: Henry Holt and Company, 1988.Google Scholar
69.Pitts, J., & Vincent, S.What influences doctors’ prescribing? Sore throats revisited. Journal of the Royal College of General Practitioners, 1989, 39, 65–66.Google Scholar
70.Poses, R. M., et al. Practice variation in the management of pharyngitis: The importance of variability in patients' clinical characteristics and in physicians' response to them. Medical Decision Making, 1993, 13, 293–301.Google Scholar
71.Prosser, R., Rasbah, J., & Goldstein, H.ML3: Software for Three-Level Analysis Users' Guide for V.2. London: Institute of Education, 1993.Google Scholar
72.Quick, J. D., Laing, R. O., & Ross-Degnan, D. G.Intervention research to promote clinically effective and economically efficient use of Pharmaceuticals: The international network for rational use of drugs. Journal of Clinical Epidemiology, 1991, 44(suppl. 2), 57S–65S.Google Scholar
73.Ray, W., & Griffin, M. R.Medicaid data for pharmacoepidemiology. American Journal of Epidemiology, 1989, 129, 837–49.CrossRefGoogle ScholarPubMed
74.Roemer, M. I.Hospital utilization and the health care system. American Journal of Public Health, 1976, 66, 953–56.Google Scholar
75.Schroeder, S. A., Renders, K., Cooper, J. K., & Piemme, T. E.Use of laboratory tests and Pharmaceuticals. Journal of the American Medical Association, 1973, 225, 969–73.Google Scholar
76.Segal, R., & Hepler, C. D.Drug choice as a problem-solving process. Medical Care, 1985, 23, 967–76.CrossRefGoogle ScholarPubMed
77.Skegg, D. C. G., & Doll, R.Record linkage for drug monitoring. Journal of Epidemiology and Community Health, 1981, 35, 25–31.Google Scholar
78.Sleator, D. J. D.Towards accurate prescribing analysis in general practice: Accounting for the effects of practice demography. British Journal of General Practice, 1993, 43, 102–06.Google Scholar
79.Soumerai, S. B., McLaughlin, T. J., & Avorn, J.Improving drug prescribing in primary care: A critical analysis of the experimental literature. Milbank Quarterly, 1989, 67, 268–317.Google Scholar
80.Stano, M.Further issues in small area variations analysis. Journal of Health Politics, Policy and Law, 1991, 16, 573–88.Google Scholar
81.Stano, M.Evaluating the policy role of the small area variations and physician practice style hypotheses. Health Policy, 1993, 24, 9–17.CrossRefGoogle ScholarPubMed
82.Stolley, P. D., Becker, M. H., Lasagna, L., et al. The relationship between physician characteristics and prescribing appropriateness. Medical Care, 1972, 10, 17–28.CrossRefGoogle ScholarPubMed
83.Sutton, F.Trends in pharmaceutical benefit expenditure over the last decade. Wellington, New Zealand: Department of Health, 1988.Google Scholar
84.Teeling-Smith, G.Patterns of Prescribing. London: Office of Health Economics, 1991.Google Scholar
85.U.S. Department of Health, Education, and Welfare. National ambulatory medical care survey: Background and methodology. Vital and Health Statistics, vol. 2, 1974.Google Scholar
86.Von Korff, M., Koepsell, T., Curry, S., & Diehr, P.Multi-level analysis in epidemiologic research on health behaviors and outcomes. American Journal of Epidemiology, 1992, 135, 1077–82.Google Scholar
87.Wennberg, J. E.On patient need, equity, supplier-induced demand and the need to assess the outcome of common medical practices. Medical Care, 1985, 23, 512–50.CrossRefGoogle ScholarPubMed
88.Wennberg, J. E.Population illness rates do not explain population hospitalization rates. Medical Care, 1987, 25, 354–59.Google Scholar
89.Wennberg, J. E., Barnes, B. A., & Zubkoff, M.Professional uncertainty and the problem of supplier-induced demand. Social Science and Medicine, 1982, 16, 811–24.Google Scholar
90.Wennberg, J. E., & Gittelsohn, A.Small area variations in health care delivery. Science, 1973, 182, 1102–08.Google Scholar
91.Williams, J. R., & Hensel, P. J.Changes in physicians’ sources of pharmaceutical information: A review and analysis. Journal of Health Care Marketing, 1991, 11, 46–60.Google Scholar
92.Wilson-Davies, K., & Stevenson, W. G.Predicting prescribing costs: A model of Northern Ireland general practices. Pharmacoepidemiology and Drug Safety, 1992, 1, 341–46.Google Scholar
93.Wong, G., and Mason, W.The hierarchical logistic regression model for multi-level analysis. Journal of the American Statistical Association, 1984, 80, 513–24.Google Scholar
94.World Health Organization. The world drug situation. Geneva: WHO, 1988.Google Scholar
95.World Health Organization (WHO) Collaborating Centre for Drug Statistics Methodology. ATC index including DDDs for plain substances. Oslo: WHO, 1990.Google Scholar
96.World Health Organization (WHO) Drug Utilization Research Group (DURG). Therapeutic traditions in Northern Ireland, Norway and Sweden, I: Diabetes. European Journal of Clinical Pharmacology, 1986, 30, 513–19.CrossRefGoogle Scholar
97.World Health Organization (WHO) Drug Utilization Group (DURG). Therapeutic traditions in Northern Ireland, Norway and Sweden, II: Hypertension. European. Journal of Clinical Pharmacology, 1986, 30, 521–25.Google Scholar
98.Wysowski, D. K., Kennedy, D. L., & Gross, T. P.Prescribed use of cholesterol-lowering drugs in the United States, 1978–1988. Journal of the American Medical Association, 1990, 263, 2185–88.Google Scholar