Prescribing consumption and economics

The reasons for taking a drug history from patients are:

• Drugs are a cause of disease. Withdrawal of drugs, if abrupt, can cause disease, e.g. benzodiazepines, antiepilepsy drugs.

• Drugs can conceal disease, e.g. adrenal steroid.

• Drugs can interact causing positive adverse effect, or negative adverse effect, i.e. therapeutic failure.

• Drugs can give diagnostic clues, e.g. ampicillin and amoxicillin causing rash in infectious mononucleosis — a diagnostic adverse effect, not a diagnostic test.

• Drugs can cause false results in clinical chemistry tests, e.g. plasma Cortisol, urinary catecholamine, urinary glucose.

• Drug history can assist choice of drugs in the future.

• Drugs can leave residual effects after administration has ceased, e.g. chloroquine, amiodarone.

• Drugs available for independent patient self-medication are increasing in range and importance.

(See also Appendix 2, The prescription.)

Prescribing should be appropriate.34

Appropriate [prescribing is that] which bases the choice of a drug on its effectiveness, safety and convenience relative to other drugs or treatments (e.g. surgery or psychotherapy), and takes cost into account only when those criteria for choice have been satisfied. In some circumstances appropriateness will require the use of more costly drugs. Only by giving appropriateness high

34 The text on appropriate prescribing and some quotations (designated Report) are based on a UK Parliamentary Report (The National Health Service Drugs Budget 1994 HMSO London). Twelve Members of Parliament took evidence from up to 100 organisations and individuals orally and/or in writing. It is both a surprise and a pleasure to be able to continue to quote with approval from such a source. PNB, MJB.

priority will [health payers] be able to achieve their aim of ensuring that patients' clinical needs will be met (Report).

Prescribing that is inappropriate is the result of several factors:

• Giving in to patient pressure to write unnecessary prescriptions. The extra time spent in careful explanation will, in the long run, be rewarded.

• Continuing patients, especially the elderly, on courses of medicinal treatment over many months without proper review of their medication.

• Doctors 'frequently prescribe brand-name drugs rather than cheaper generic equivalents, even where there is no conceivable therapeutic advantage in so doing. The fact that the brandname products often have shorter and more memorable names than their generic counterparts' contributes to this. (Report) (see also Ch. 6).

• 'Insufficient training in clinical pharmacology. Many of the drugs on the market may not have been available when a general practitioner was at medical school.35 The sheer quantity of new products may lead to a practitioner becoming over-reliant on drugs companies' promotional material, or sticking to "tried and tested" products out of caution based on ignorance' (Report).

• Failure of doctors to keep up-to-date (see Doctor compliance).

Computerising prescribing addresses some of these issues, e.g. by prompting regular review of a patient's medication, by instantly providing generic names from brand names, by giving ready access to formularies and prescribing guidelines.

Cost-containment

Cost-containment in prescription drug therapy attracts increasing attention. It may involve two particularly contentious activities:

35 This statement illustrates a common and serious misunderstanding of the role of medical schools. Their role is to teach the scientific basis of clinical pharmacology and safe drug therapy so that doctors can handle existing and future drugs intelligently, using current data sheets, formularies, etc. It is not to attempt to teach enormous numbers of impossible-to-remember facts, the deadening effect of which on a thinking approach would be disastrous.

1. Generic substitution, where a generic formulation (p. 85) is substituted (by a pharmacist) for the proprietary formulation prescribed by the doctor.

2. Therapeutic substitution, where a drug of different chemical structure is substituted for the drug prescribed by the doctor. The substitute is of the same chemical class and is deemed to have similar pharmacological properties and to give similar therapeutic benefit. Therapeutic substitution is a particularly controversial matter where it is done without consulting the prescribes and legal issues may be raised in the event of adverse therapeutic outcome.

The following facts and opinions are worth thinking about:

• The UK National Health Service (NHS) spending on drugs has been 9-11% per year (of the total cost) over nearly 50 years.

• 80% of the total cost of drugs is spent by general practitioners, i.e. in primary care.

• People over the age of 65 years receive on average 13 prescriptions per year — twice as many as the population in general.

• "The average cost per head of medicines supplied to people aged over 75 is nearly five times that of medicines supplied to those below pensionable age (currently in UK women

• 'Underprescribing can be just as harmful to the health of patients as overprescribing.'

It is crucially important that incentives and sanctions address quality of prescribing as well as quantity: 'it would be wrong if too great a preoccupation with the cost issue in isolation were to encourage underprescribing or have an adverse effect on patient care' (Report).

Reasons for underprescribing include: lack of information or lack of the will to use available information (in economically privileged countries there is, if anything, a surplus of information); fear of being blamed for adverse reactions (affecting doctors who lack the confidence that a knowledge of pharmacological principles confers); fear of sanctions against over-costly prescribing. Prescrip tion frequency and cost per prescription are lower for older than for younger doctors. There is no reason to think that the patients of older doctors are worse off as a result.

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