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Factors that Influence Running head: FACTORS THAT INFLUENCE The Factors that Influence the Prescribing Habits of Clinicians Darren Schutt D’Youville College 1 Factors that Influence 2 Abstract An important part of the practice of medicine is a clinician’s use of prescription drugs. Many factors influence how clinicians prescribe medication. An Internet survey utilizing a Likert scale and direct questions will be employed to assess how local clinicians view the factors that influence their prescribing habits. By using professional demographical information and responses to the survey a better understanding will be gained of how local clinicians make prescribing decisions. This better understanding of the factors that shape prescribing habits can be used by educators, clinicians, and policy makers to improve healthcare. Factors that Influence Table of Contents Introduction ……………………………………………………………. p. 4 Background………………………………………………………………p. 5 Method…………………………………………………………………...p. 19 Results……………………………………………………………………p. 25 Discussion………………………………………………………………...p. 35 References………………………………………………………………...p. 43 Appendix………………………………………………………………….p. 48 Table……………………………………………………………………....p. 51 Figures……………………………………………………………………..p. 52 3 Factors that Influence 4 The Factors that Influence the Prescribing Habits of Clinicians In today ‘s society the use of prescription drugs is prevalent. For example, in 2001, Pancholi and Stgnitti (2004) reported people in the United States younger than 65 purchased a mean of 10.8 prescription drugs and those 65 or older purchased a mean of 26.5 prescription drugs. Due to the increase in the amount of medication prescribed, spending on pharmaceuticals has accelerated greatly in recent years and is now the fastest growing component of the health care budget (Heffler, Levit, & Smith, 2001). The ability to write for prescription medications is an essential part of MDs, PAs NPs clinical practice and a huge responsibility. Drug therapy can be used for a variety of purposes such as treatment of an infection, pain relief, to slow down a degenerative process, as prophylactic therapy, etc. When medications are used properly, the patient’s health will be optimized. Due to the great amount of advancements made in pharmaceutical research and production, clinicians now have a vast amount of options on what drugs they use, how to use them and when they use them. As a consequence of the complex nature of healthcare and the vast amount of medications on the market I have noticed that no two clinicians have the same prescribing habits. This is due to many factors. Some of these factors have clinical bases while others do not. An example of a factor that has clinical bases is evidence-based medicine. Evidence-based medicine is the practice of using relevant studies to determine when to prescribe a certain medicine. My particular interest in this subject is due to several non-clinical factors that influence prescribing habits. Of particular concern to me are the perceived influences pharmaceutical sales representatives and insurance companies have on a clinician’s prescribing habits. Many of these non- Factors that Influence 5 clinical factors have caused a great amount of ethical debate as people question if these factors unfairly skew a clinician’s prescribing habits and have a negative effect on our health care system. For my master project I want to find out how clinicians perceive the factors that influence their prescribing habits and if they believe these factors impede them from giving the type of drug therapy that would be of greatest benefit to a patient. By doing a literature review on this topic I have identified several prominent factors that past studies have shown to influence prescribing habits. These factors are: Evidence based medicine Patient pressure (expectations, drug seeking behavior) Pharmaceutical industries influence (samples, gift, direct to consumer advertisements) Clinical experience Peer influence Insurance formularies (copay) Clinical specialty In the following paragraphs I will outline what some of the past studies have shown on how these factors influence the prescribing habits of clinicians. Background Evidence-Based Medicine Evidence based medicine is when clinicians look at all the available medical studies and literature that pertains to an individual patient or a group of patients and use this information to help them properly diagnose illnesses, choose the best testing plan and to select the best treatments and methods of disease prevention. It involves combining the best research evidence with the patient's values to make decisions about medical care writes Janet Torpy (2005) in JAMA. In the same article, Torpy (2005) states that evidence-based medicine has helped to reduce mortality from heart attacks and improved care for persons with diabetes. In an editorial Simon R Maxwell (2005) wrote about the Factors that Influence 6 increasing emphasis being put on evidence based medicine when he stated “recently doctors could prescribe medicines without worrying that their choices might be judged against evidence accumulated in the world's literature. Now, prescribers are increasingly expected to back up their decisions with evidence” (p 247). A study that shows evidence based-medicine influences prescribing habits was published in the Journal of the American Board of Family Medicine. In this study researchers evaluated the incidence of new prescriptions written by generalists and specialists belonging to the same HMO before and after publication of a study concerning these medications (Calvo, Cecilia, and Rubinstein 2002). The data of this study showed the proportion of new prescriptions for these medications changed between a 6-month period before publication and the 6-month period after publication of the study concerning these medications (Calvo et, al. 2002) . Based on the data, collected the researchers concluded that the “change in the prescription patterns of the physicians showed a clear temporal association with the publication of new evidence” (p. 461). Similar results were also obtained in a study that investigated the effect that the Scnainavian Simvastatin Survival Study had on the rate of lipid lowering agents prescribed in a population of patients who had suffered an acute MI. This study recommended the use of a statin after a heart attack (Jackevicius, Anderson, Leiter, & TU, 2001). The researchers found that there was a steady increase in the overall rate of statin use before the publication of Scandinavian Simvastatin Survival Study (4S), but that the rate of statin use increased significantly after the publication of 4S. These findings led the authors to conclude that “It is possible to shift practice if the evidence of benefit is strong, the intervention is easy to implement and the intervention is marketed aggressively” (p187). Many other studies have shown a correlation between an Factors that Influence 7 increase in the amount of prescriptions for a certain drug and a study or guideline becoming public knowledge (Torpy, 2005; Maxwell, 2005; Calvo et al., 2002;Jackevicius et al., 2001; Ross & Macleod, 2005). Conversely, another study questioned the influence of evidence-based medicine on prescribing habits. According to this study, entitled Failure of Evidence-based Medicine in the Treatment of Hypertension in Older Patients, evidence based medicine has little effect on how hypertensive medications are prescribed (Knight, Glynn, & Levin, 2000). In this study the researchers examined if clinicians were following the JNC VI evidence-base recommendation that first line treatment for hypertension should be Beta-blockers and thizade diuretics. After examining prescribing patterns, Knight and colleagues (2000) found that Thiazide use decline relative to calcium channel blockers after the JNC VI recommendation was made . Based on these results, the researchers concluded that in older patients clinicians did not follow evidence based guidelines in the treatment of hypertension and that more of an effort had to be made to encourage evidence-driven prescribing practices (Knight et. al ). A similar study conducted by Michael Fischer and Jerry Avorn (2004) examined the same question and found, after reviewing 815,316 regiments for the treatment of hypertension, that 40% did not follow evidence based guides. According to Fisher and Avorn (2004), if evidencebased guidelines were followed in this group of patients 11.6 million dollars could have been saved. All these studies show that the exact influence of evidence-base medicine on prescribing habits is unknown and its influence varies from clinician to clinician. Patient Desire In the past the patient-clinician relationship was unilateral with the patient accepting and not questioning the treatment regiment prescribed by the doctor. With Factors that Influence 8 healthcare consistently evolving, this is no longer the case as clinicians and patients both participate in the process of forming a treatment regiment. This bilateral relationship between clinicians and patients gives patients a greater say in their care. Along with changes in the patient-clinician relationship, patients also have the opportunity to acquire a great amount of medical information on various injuries, disorders, sicknesses and medications because of the internet and other media outlets. Due to the progressive changes in the patient-clinician relationship and the patients increase awareness of available medications, more clinicians have found themselves pressured to prescribe a certain medication by patients. This has led to patients’ expectations having an influence on a clinician’s prescribing patterns. A study by Kravitz, Epstien and Fieldman (2005)l. investigated this influence on prescribing by using standardized patients who portrayed major depression or adjustment disorder. These patients presented themselves to 152 family medicine or general internist offices. The researchers found that if the standardized patient made a brand specific request (Paxil), 53% of the time they were prescribed a medication while if they made a general request, 76% of the time they were prescribed an antidepressant and those that made no request only received a medication 31% of the time (Kravitz et al., 2005). A similar study published in the British Medical Journal demonstrated the effectiveness of a patient’s request on a clinician’s prescribing tendencies. In the study Mintzes et al. (2002) surveyed a total of 1431 patients attending physicians’ offices in Sacramento and Vancouver. After controlling for various factors, the researchers examined the influence of requests on the probability that a patient received a new prescription and found patients who requested a prescription were more likely to receive one than those that did not (139/175 v 329/1256). All these results led Factors that Influence 9 Mintzes et al. (2003) to conclude that patients’ requests for medicine are a powerful driver of prescribing decisions. A different designed study that supports the findings of the last two studies consisted of clinical pharmacists’ interviews of 110 physicians who were part of a medical school-based prescribing improvement program. These physicians were identified from state Medicaid prescribing records as “moderate to high prescribers”. During the interviews, these physicians’ motives for prescribing were discussed and 51 out of 110 (or 46% ) stated that patients’ demands made them prescribe a certain medication. This was the most common answer given in the study ( Schwartz, Soumerai & Avorn, 1989) Unfortunately drug-seeking behavior leads to patients applying pressure on clinicians which ultimately influences prescribing habits. In an article reviewing opioid therapy for patients that are chronically ill or have abused opioid drugs the authors outline how these types of patients can influence prescribing habits when the authors wrote: “Pain management in this type of patient is very complex and time-consuming so physicians who do not have the resources or time to deal with this type of patient tend to bypass principles outlined in the guidelines and comply with patients’ demands for increased opioid doses” (Ballantyne & Mao, 2003 p.1950). All of these studies show that a patient’s request and expectation for a prescription medication can influence clinicians prescribing habits. Clinical experience Clinicians are no different than everyone else as they are influenced by past experiences and their age. Whether these experiences are bad or good, they shape the way a clinician prescribes medicine. A good example of clinical experience influencing prescribing behavior is a study that examined the prescribing tendencies of physicians Factors that Influence 10 caring for patients with stable angina. The Beauliu et al. (2001) found that older physicians were significantly less likely to prescribe aspirin (odds ratio for physician in practice for > 20 years compared to those in practice < 10 years 0.58) for this condition (p. 301). A similar study by Willison, Soumerai, and Palmer (2000) found that physicians’ adoption of thrombolytic therapy for acute myocardial infarction (AMI) was associated with several characteristics. One of these characteristics was age. Another study that showed age and clinical experience effect prescribing habits described the professional characteristics of doctors who prescribe appropriate medicine to nursing home residents. (the criteria for appropriate medicine was determined by a expert panel) After conducting their study Beers et al. (1993) found that older doctors belonged to the quartile for prescribing inappropriate medication. These studies agreed with a systemic review of articles published in the Annuals of Medicine entitled The Relationship between Clinical Experience and the Quality of Health Care. After reviewing 62 articles on the subject, Choudhry, Fletcher and Soumerai (2005) stated in their discussion “that older physicians seem less likely to adopt newly proven therapies and may be less receptive to new standards of care”. Contrary to these studies that showed an increase in clinical experience and age led to inappropriate drug therapy Riy-Byrne et. al (2005) found that length of time in practice did not predict appropriate prescribing. The importance of a good first impression was shown in a study by Jones et al. (2001) as it concluded early clinical experience of using a drug seems to strongly influence if a clinician uses this drug in the future. A final piece of evidence that shows the effect of clinical experience was when Klaschik and Clemens (2007) acknowledged that their experience affects the way they prescribe medicine to the chronically ill. It was their Factors that Influence 11 experience that the standard practice of using transdermal fentayl was not efficacious in relieving pain in this patient population. This clinical experience prompted them to do a study comparing the effectiveness of transdermal fentanyl and oral morphine for pain relief in the chronically ill (Klaschik and Clemens, 2007). All these findings are evidence that clinical experience helps form prescribing habits. Clinical Specialty Many studies have shown that an important influence on prescribing habits is the clinician’s specialty. For instance, consultants tend only to prescribe new drugs within their specialty (Jones et al., 2001) An example of this is Family Practice Physicians and other non-Internists are much less likely than cardiologists to prescribe beta-adrenergic blocking agents (Fehrenbach, Budnitz, Gazmararian,& Krumholz, 2001) Specialist prescribing habits are also associated with more appropriate therapy. This is shown by an audit of prescriptions for elderly patients by Anderson, Beers, and Kerluke, (1997). They concluded that “physicians without specialty certification were more likely to prescribe potentially inappropriate drugs” (Anderson, Beers & Kerluke, 1997). Peer Influence Peers influence prescribing habits as many clinicians rely on the knowledge and approval of their peers before prescribing a certain drug. An article published in the New England Journal of Medicine that assessed the relationship that clinicians have with the pharmaceutical industry suggested that the industry focus marketing efforts on physicians who are perceived as influencing the prescribing behaviors of others (Campbell et al., 2007). According to one study by Ross and Macleod (2005) clinical practices with a higher number of practitioners are more likely to prescribe medication that follows Factors that Influence 12 evidence based recommendations because of the peer pressure. Another study John Sbarbaro (2001) found one of the more effective ways to changing a physicians behavior was by using peer review. This finding and many others demonstrate the effect that peers can have on a clinician’s prescribing habits. Pharmaceutical Industry’s Influence Much of the research that has been done on the factors that influence prescribing habits has centered around two types of influences-the pharmaceutical industry’s influence and the insurance companies’ influence. Many people believe that these industries unfairly use factors that skew a clinician’s judgment into prescribing a drug that is not in the patient’s best interest. Due to this belief these, industry’s practices have been subjected to intense public scrutiny. In 1997, the FDA changed its’ guidelines for the broadcast of direct to consumer advertisements. Prior to 1997, the FDA allowed prescription drugs to be advertised on TV but rules and regulations for this type of advertising made it very difficult for the pharmaceutical companies to make effective commercials. The changes in the guidelines by the FDA made it easier to make good effective advertisements and, consequently, more direct to consumer advertisements were made. (Rosenthal, Berndt, Donohue, Frank and Epstein, 2002) The great amount of direct to consumer advertisements has become very controversial as some people question the ethnicity and believe it can lead to overuse of prescription medications because it encourages patients to pressure their doctors to prescribe a certain drug (Donohue, Cevasco, and Rosenthal, 2007; Weissman et al, 2004). Other people view the effects of direct to consumer advertisements positively as nearly half of the respondents to one survey by Lyles ( 2002) believed that Factors that Influence 13 such advertisements helped them make better decisions about their health. More than 60% who had seen a physician during the previous 3 months believed that the advertisements helped them to have better discussions with their doctors concerning their health. The same survey also found that consumers that saw an advertisement for a particular medication that they were taking felt better about the drug’s safety (Lyles, 2002). No matter how direct to consumer advertisements are perceived there is no denying that these advertisements effect prescribing habits. Recently the newspaper USA Today published the results of a survey conducted by the paper, the Kasier Family Foundation and the Harvard School of Public Health. It showed that “Prescription-drug ads prompt nearly one third of Americans to ask their doctors about an advertised medicine and 82% of those who ask say their physicians recommended a prescription”. (Appleby, 2008 p. 4D) Several other studies have shown that direct to the consumer advertisements are an effective technique that influences prescribing habits. For example, a survey of 648 physicians showed when a DTCA (direct to consumer advertised) drug was prescribed, only “46% of the physicians surveyed thought it was the most effective drug compared with 48% who felt it was as effective as other drugs but prescribed the DTCA drug in order to accommodate the patient’s request. The remaining 5% thought that other drug or treatment options may have been more effective for the patient’s condition but wanted to accommodate the patient request” (Mintzes et al., 2002 p. 279). Another survey by Lipsky and Taylor (1997) reported that “71 % of family physicians believe that direct to consumer advertising pressures physicians into prescribing drugs that they would not ordinarily prescribe”. (p. 498) All these studies findings clearly show the influence that direct to consumer advertisement has on prescribing habits. Factors that Influence 14 Direct to consumer advertisement is one way the pharmaceutical industry tries to influence prescribing habits, but in 2005, it only made up “14% of total promotional expenditures” (Donohue, Cevasco, and Rosenthal,. 2007 p. 674). The great majority of the pharmaceutical industries promotional budget is spent on marketing their products to clinicians as demonstrated by the industry spending more than 7 billon dollars which is “approximately 8,400 to 15,400 dollars per doctor per year” (Blumenthal, 2004 p. 1885). The reason for the pharmaceutical industry aggressively marketing their product to clinicians is best described by Glickman, Bruce, Caro, and Avorn (1994) in an article they wrote on the subject. In the article they describe the purchase of prescription drugs as economically unique because they are a "directed" demand. Clinicians direct the purchase of pharmaceutical’s products through drug selection and determination of appropriateness of the product. Essentially, physicians influence the market by acting as "gatekeepers" who direct prescription drug use decisions. Due to the unique and pivotal role clinicians have in the economic success of pharmaceutical companies, the industry uses many different tactics to influence prescribing habits (Glickman, Bruce, Caro, and Avorn, 1994). At the core of its’ promotional campaign, the pharmaceutical industry has “spent 5 billion dollars to create an army of nearly 90,000 sales representatives that interact directly with clinicians” (Wazana, 2000). These representatives use gifts, free meals, travel, educational programs and product samples to try to sell their product. (Glickman, Bruce, Caro, and Avorn,1994; Wazana, 2000) This relationship between doctors and the pharmaceutical industry is extensive as a National Survey of PhysicianIndustry relationship by Campbell ed. al (2007) reported. The survey’s results showed that “94% of physicians had some type of relationship with the pharmaceutical industry Factors that Influence 15 and most of the relationship (83%) involved receiving food in their workplace or receiving drug samples (78%)”(p. 1742). Other forms of the relationship that were reported were “35% of physicians received reimbursement for costs associated with professional meetings or continuing education and 28% of physicians reported receiving payments for consulting, giving lectures or enrolling patient in trials” Campbel et. al., 2007 p. 1743). According to one article these techniques do influence prescribing habits because of the social science concept of “self serving bias” (Dana and Loewenstein 2003 p. 252). This is human beings inability to make objective decisions when one of the choices will benefit them. (Dana and Loewenstein, 2003). This is shown by reviews of the literature that confirmed a direct relationship between the frequency of contact with reps and the likelihood that physicians will behave in ways favorable to the pharmaceutical industry (Wazana, 2000; “What impact does pharmaceutical”, 2008). An example of the pharmaceutical industries influence is a retrospective study by Spingarn, Berlin, and Strom (1996) that tracked house staff who attended a grand rounds given by a pharmaceutical company speaker and found them more likely to prescribe that company's drug as a treatment than did their colleagues .Wanzana’s (2000) review of articles written on the subject found that pharmaceutical sponsored CME events and a clinician accepting funding for travel or lodging for these educational symposia were associated with increase prescription rates of the sponsor’s medication. Another study reviewed, showed the effects free samples have on prescribing as “FPs who distribute free samples are more likely to prescribe those medications than their counterparts who do” (Symm et al., 2006 p. 448). A study by Adair and Holmgren found that free samples same effect on prescribing habits: “Medical residents prescribed more advertised drugs and fewer over- Factors that Influence 16 the-counter medications if they had access to prescription drug samples than residents without access” (cited in Levin, 2005 p. 28) Due to the great amount of media attention this relationship between clinicians and the pharmaceutical industry has received, the subject is widely studied. As a consequence, these studies and papers are just a few examples of the many writings on the topic. The last way the pharmaceutical industry affects the prescribing habits of clinicians is by setting the price of medications it produces. In the United States prices for brand-name prescription drugs are 35 to 55 percent higher than in other industrialized countries as the US is one of the only developed nation that does not regulate the cost of medication (cited in Frank, 2004). As a result the pharmaceutical companies charge high prices of brand name medications. Due the high cost of medications many clinicians consider this a factor when they prescribe certain types of pharmocotherapy. An example of this is a study by Reichert, Simion and Halm (2000) that surveyed how physicians measure their attitudes about prescribing and their knowledge of the cost of medications. The survey revealed that “Eighty-eight percent of physicians felt the cost of medicines was an important consideration in a prescribing decision, and 71% were willing to sacrifice some degree of efficacy to make drugs more affordable for their patients” (p. 2799) These results also show that a percentage of clinicians believe the cost of medicine inhibits them from giving prescription drugs they believe is in the patients best interest. (Reichert, Simion and Halm, 2000). Another study by Pham, Alexander, and O’Malley reveled similar results as 78 % of the physicians they surveyed routinely considered out of pocket cost before prescribing medications for a patient (2007). Factors that Influence 17 Insurance companies The cost of medicine is an issue of national concern as the increasing cost of prescription drugs has received a great amount of attention. The US, unlike most other developed countries, has no governmental body that regulates the price of drugs or the profits of pharmaceutical companies. International price comparisons often show the US citizens pay more than anyone else for drugs. Due to the lack of government regulation, insurance companies, Medicaid, and Medicare all use drug formularies to curve the cost of expensive drugs (Altman & Thomas 2002). These drug formularies consist of multitiered copayment systems that motivate patients and clinicians to use medically equivalent generic substitutes. The most common tier system is a three-tier formulary, as in 2002, “57% of the workers in the US who had drug benefits were enrolled in plans with a three-tier formulary” (Kaiser Family Foundation and Health Research and Educational Trust [KFFHRET],2002). It is setup in a way that encourages clinicians and patients to pick the drugs that insurances/HMOs prefer. The first tier consists of generic drugs that require the lowest copay. The second-tier is composed of drugs that are brand name drugs that are preferred by the insurance/HMO. These drugs require a higher copay than the first-tier medications. The third-tier is made up of brand name drugs that are not preferred by the insurance company. Therefore, they require the highest copay ([KFFHRET],2002). In order to increase compliance with a drug regiment, clinicians must consider the cost of medications and their copayment as one study shows that two thirds of older adults planned to underuse their medications because of cost (Piette, Heisler, and Wagner, 2004). A similar constructed study by Soumerai et al. (2006) concluded that “Medicare part D patients have a high rate of cost related nonadherence Factors that Influence 18 and this was particularly a problem among those in poor health, multiple morbidities and limited drug coverage” (p. 1834). Based on these results, the authors urged clinicians to always be aware of the cost of medication and the type of insurance the patient has in order to increase compliance (Soumerai et al., 2006 p. 1835) In a study that examined the effects a tier based formulary has on antihypertensive drug selection and spending it was found that patients in a tiered cost-sharing plan might be using less costly drug classes rather than the ACE inhibitors and ARB which are considered first line therapy for hypertension (Kamal-Bahl & Briesacher, 2004) . This finding is troubling, as it shows that formularies and copayments might have restrict clinicians from delivering optimal therapy. These findings show that insurance companies and cost of medication do influence prescribing patterns but a study by Ernst et al. (2000) yielded different results. In their study on the subject, Ernst et al. (2000) found that family physicians do not know the cost of common prescription drugs and thus do not consider this factor when they prescribe medicine. Another way insurance companies can dictate the prescribing habits of clinicians is by using prior authorization. Insurance companies to help control the cost of medicine implanted this process. It involves a clinician getting authorization from an insurance company before prescribing a certain drug. Sometimes this request is denied as Hamel and Epstien (2004) write that prior authorization programs “have the potential to reduce patient’s access to beneficial drugs, especially when requirement for documentation are onerous and the appeals process is restrictive.” (p. 2156) All these studies mentioned above suggest that insurance formularies and prior authorization programs of effect prescribing habits but the extent of these factors’ influence varies among clinicians. Factors that Influence 19 Method Survey Using a web based survey design, this investigation will examine the factors that influence prescribing habits and how important these factors are to clinicians when they are making prescribing decisions. Using a Likert scale the respondents will be asked to assess the extent of influence the following factors have on their prescribing habits: Evidence based medicine Patient pressure/desire (expectation) Pharmaceutical industry’s influence (samples, gifts, direct to consumer advertising) Clinical experience Peer influence Insurance policies (Prior authorization, formularies, etc.) Clinical specialty A four-point scale was chosen as it adequately covers the range of responses that a potential candidate filling out the survey would require. This number of points also will not result in “hair-splitting” that only serves to fragment the data and the time required to view the range of responses is manageable (HOW… to develop an effective survey response, 2000). The four points are: No influence, Minimal influence, Influence Great influence. A Likert scale is ideal to answer this question because it allows those surveyed to rate how much weight they attach to each factor. Another advantage of a Likert scale is it will make it easy to quantify the responses for statistical measurement (Blessing J. D., 2006). Factors that Influence 20 To further assess clinicians’ opinions on the factors that influence prescribing, the respondents will also to be directly asked which factor from above list has the greatest influence and which factor has the least influence on their prescribing habits. Another question asked to the respondents doing this survey, is if any of the above mention factors that influence prescribing habits hinder a clinician from giving the type of care they believe would be in a patient’s best interest. In order to do this the following question was asked “Please mark the factors, if any, that impede you from giving your patients the pharmacological therapy that would be in the patient's best interest.”. The clinicians completing the survey can pick from a list of the above mention factors as well as “none of these factors impede me from prescribing medication that I believe would be in my patient’s best interest”. Respondents many also choose more than one factor to answer the question. Both these options are given to avoid bias. The survey is set up on the internet and is voluntary. An internet survey was chosen because this method of collecting survey information generally has a higher rate of response compared to other forms of survey designs (Blessing J. 2006). Other advantages to an internet based survey is it gives access to a broader potential pool of candidates, is economical, the data is immediately available and you do not have the risk of losing paper surveys that were filled out (Blessing J. 2006). The website Survey Monkey® will be used to accomplish this task. This website will be used to design the survey, make the survey accessible to the sample pool via a link, collect the accumulated data and do basic statistical analysis. Factors that Influence 21 Sample The potential sample will be all the members of the Monroe County Medical Society who receive their internet newsletter. The organization is composed of approximately 1,700 physicians. Of the 1,700 members, 1,200 of these members are actively practicing medicine in Monroe and its’ surrounding counties. The Nurse Practitioner Association-Greater Rochester Chapter has also agreed to post a link to my study on their website as well as to notify their members of the survey in a newsletter that the organization circulates. The third and final group that will make up my sample is the physician assistant that are members of WYNPAA (Western New York Physician Assistant Association). This organization will inform its members of the survey via email and a link. All these organization’s members practice medicine in Western New York, have members practicing in all specialty areas and in many different clinical settings which eliminates many of the variables that could lead to inaccurate comparison between the three types of clinicians. The recruitment email sent to these organizations’ members, will outline the goals of the survey, the reason for conducting the survey and a link to the survey. It will also explain that no personal identifying information is asked and the respondents are anonymous. In order to achieve the greatest amount of participants the recruitment letter will also invite the recipients of the letter to encourage colleagues to partake in the survey. The letter will also outline that the survey will only take approximately five minutes to complete and by filling out the survey the receipts will be giving informed constant. Copies of the three different recruitment emails that will be sent are appendix A,B, and C. Factors that Influence 22 Number of participants To increase the amount of respondents to the survey a convenience sample will be used. This approach only samples those that are available and willing to participate in the survey. According to the U.S. Department of Labor Bureau of Labor Statistics and the AANP facts and information sheet, there are currently 663,000 physicians, 66,000 PAs, 23,500 NP’s practicing medicine in the US. When these numbers are totaled, the number of prescribing clinicians in the United States is 752,500 (“U.S. Department of Labor, Occupational Outlook Handbook”, 2007a, “U.S. Department of Labor, Occupational Outlook Handbook” 2007b, “Nurse Practitioner s Fact Sheet” 2000). In order for the results of my survey to approximate the feelings of all prescribing clinicians in the US to a 95% confidence level in a confidence interval of + 10, the sample size would have be 93 clinicians. To obtain the same confidence level in a +5 confidence interval the sample size would have to be 289 clinicians (“The Survey System” 2007). The following is the calculation for finding sample size: Ss = Z2*(p) *(1-p) C2 Z= 1.96 which is a 95% confidence level P= percentage for picking a choice as decimal (.25 because the amount of max. variability, can pick 1 out of 4 possible answers) C= confidence interval expressed as decimal (+10=.10) Ss= predictive sample size to have a confidence level of 95% within a +10 of median in a population of 762,500 clinicians in the US Factors that Influence 23 If the confidence interval is + 10 the sample size needed to achieve 95% confidence level is 93 If the confidence interval is + 5 the sample size needed to achieve 95% confidence level is 289 Due to these factors the study will be available online for one week after the recruitment emails are sent with greater than 100 responses the goal. If this goal is met the results would have a 95 % confidence level within + 10 confidence interval for predicting the general response of all clinicians to the survey’s questions. Duration of time to collect responses In order to meet the goal of 100 participants the survey will be available online for one week after the recruitment emails are sent. If this goal is not met another email will be sent reminding people about the survey and the survey will be available for another week. At this time period the survey will be closed and the data will be analyzed. Statistical analysis As stated above, the advantage of the Likert scale is it allows researchers to quantify the participant’s responses. In order to do this, a numerical value is assigned to each possible response. For the Likert scale used in this survey the numerical value will directly correlate with the influence; the greater the influence the greater the numerical value. No influence =0 Minimal influence =1 Influence = 2 Greatly influence = 3 Factors that Influence 24 These values than can be compiled and the factors that have the greatest influence on prescribing habits will have the highest mean values (total Likert score/number of clinicians). The Likert scale data can also be analyzed for the median. These scores than can be broken down into various subgroups and used to make bar graphs comparing how clinicians with different demographical characteristics answered the questions. The demographics that will be compared are: The different specialty MD vs. PA vs. NP Clinicians that practice medicine inpatient vs those that practice outpatient Patient insurance: insured vs uninsured patient population Years of experience practicing medicine. Gender of the clinician The questions that do not involve a Likert scale will be elevated for the most prominent answer. Professional demographical information can than be used to form subgroups to compare how these questions were answered. All statistical analysis and graphical representation of the data will be done using Survey Monkey® and Microsoft Excel® Distribution of the results A copy of the survey’s results as well as the final paper will be given to each of the organizations whose members participated in the survey. These organizations than can make the results of the survey and the final paper available to the participates. Factors that Influence 25 Results General There were 201 clinicians that participated in the survey. Of these 201 clinicians that participated 99 (49.3 %) were MDs, 68 (33.8%) were PAs, and 34 (16.9%) were NPs (figure 1). The range of clinical experience was from 0 to greater than 50 years. The majority of the participants surveyed (67.8%) had 0-20 years of clinical experience. More female clinicians filled out the survey than males (female 58.2% > male 41.8). These clinicians primarily treat patients with private insurance but clinicians that primarily treat patients with Medicaid, Medicare and no insurance were also represented in the survey. The setting that these participants work in is predominately outpatient as for every one participate that practices medicine in an inpatient setting there is approximately four participants that work in an outpatient setting (36 vs. 165). Baseline demographical characteristics of those surveyed are listed in Table 1. Those that were surveyed represent all types of medical specialties. Figure 1 is a graphical representation of the number of participants per specialty. The factor that the clinicians surveyed gave the highest average Likert score too was clinical experience. Clinical experience’s Likert score was 3.71. The second highest average Likert score was given to the factor of evidence-based medicine. Its’ Likert score was 3.54. Insurance policies and clinical specialty also received Likert scores greater then three. The lowest Likert score was 2.12 which was given to the pharmaceutical industries influence. Peer influence and patient preference were factors that also had average Likert Factors that Influence 26 scores that were less than three. Figure 2 is a graphical summarization of the average Likert scores from all 201 participants. When asked directly to pick the one factor that has the most influence on their prescribing habits, 85 (42.3 %) participants choose clinical experience. This was the most popular answer. Evidence based medicine was the second most picked answer as 83 (41.3%) of the participants picked this factor. 17 (8.5%) clinicians picked clinical specialty as the factor that had the greatest influence on their prescribing habits. The factor patient preference was not chosen by a single participate as the factor that has the most influence on their prescribing. Figure 3 is a graphical representation of the results from this question “Which factor has the greatest influence on your prescribing habits?” The pharmaceutical industries influence was the factor that was picked by the most participants as the answer to the question “Which factor has the least influence on your prescribing habits.” 117 (58.8%) of the those surveyed picked this factor. The second most common factor picked was the pharmaceutical industry’s influence as 31 (15.5%) of the participants chose this factor. Clinical experience was not chosen by anyone surveyed and evidence based medicine was only chosen by one participate making these factors the least prominent factors picked by those answering this question. Clinical specialty, patient preference, peer influence and insurance policies were factors that were picked by some of the clinicians taking part in the survey but these factors were neither the least common nor the most common answers to the question. Figure 4 is a graphical representation of the results gathered concerning the question “Which factor has the least amount of influence on your prescribing habits” Factors that Influence 27 The question “which factor if any impedes you from giving your patients the pharmacological therapy that would be in the patient’s best interest” was responded to by 197 of the 201 clinicians that fill out the survey. The most popular answer to this question was insurance companies’ policies as 151 (76.6%) of the participants chose this answer. Patient preference was chosen by 39 participants (19.8) as a factor that inhibits practitioners from prescribing certain therapies. This factor was the second most popular pick. Thirty one clinicians (15.7% ) filling out the survey believe that none of factors that were listed restricted their prescribing habits. The pharmaceutical industries influence also had greater than 30 participants choose it as a factor that restricts their prescribing habits. Evidence based medicine, clinical experience and peer influences were all factors that three people filling out the survey thought inhibited their ability to prescribe pharmacological therapy. Only two people surveyed believed that clinical specialty restricted their prescribing habits. This was the least prominent factor picked. Figure 5 is a bar graph that shows how many clinicians partaking in the survey believe a certain factor inhibits their prescribing habits. Demographical Characteristics Results Type of clinician When the answers to the survey questions are separated and tabulated based on if the participate is a MD, PA or NP, the results are found to be similar between the three groups of clinicians. (When the data is broken down according to the demographical characteristic, clinician type, similar results are found.) MDs, PAs and NPs all gave the highest Likert scores to clinical experience and evidence based medicine. Based on the MDs responses the average Likert score was 3.73 for clinical experience and 3.64 for Factors that Influence 28 evidence based medicine. PAs’ responses yielded similar average Likert scores for these two factors. PAs gave clinical experience a Likert score of 3.69 and 3.49. NPs’ responses to the Likert scale questions resulted in an average score of 3.68 for both these factors (clinical experience and evidence based medicine). Pharmaceutical industries influence received the lowest average Likert scale from all three types of clinicians. Figure 6 is a graphical representation of the average Likert scores based on the MDs’, PAs’, and NPs’ responses to the survey questions. When asked to pick the one factor that has the greatest influence on prescribing habits, evidence based medicine was the factor picked the most by NPs and MDs. The factor that was picked most by PAs was clinical experience. Figure 7 is composed of pie charts that show the percentage of MDs, PAs, and NPs that picked a certain factor as the factor that has the greatest influence on their prescribing habits. The pharmaceutical industries influence was the factor picked the most by all three types of clinicians to answer the question “Which factor has the least amount of influence in shaping your prescribing habits” . Greater than 80% of NPs surveyed believe that insurance companies impede their prescribing habits. The percentage of MDs and PAs that believe this is slightly less as 76.3 % of the MDs and 73.5 % of the PAs surveyed think that insurance companies inhibit their prescribing. This factor was the most picked factor among PAs, MDs, and NPs as the answer to the question which factor(s) impede you from giving your patients the pharmacological therapy that is in the patient’s best interest. Figure 8 is a graphical representation of the results to this question. Clinical experience Factors that Influence 29 When the data from the survey is broken down and analyzed based on groups formed by clinical experience, the Likert scores were similar for each factor. The factors with the highest Likert scores for all the age groups were evidence based medicine and clinical experience. All the age groups also gave their lowest Likert scale score to the pharmaceutical industries influence. Figure 9 is a graphical representation of the average Likert scores that the different clinical experience groups gave to each factor. When asked to pick the factor that has the most influence on their prescribing habits, 46.3 % of clinicians with 0-10 years of clinical experience chose the factor of clinical experience. This factor was the most popular choice for clinicians with 0-10 years of clinical experience. The most popular answer to this question for all the other age groups was evidence based medicine. Figure 10 shows the percentage of participants within a certain range of clinical experience that pick one factor as having the most influence on their prescribing habits. More than 40% of the clinicians surveyed in each group -except for the those clinicians with greater than 50 years of experience- believed that the pharmaceutical industries influence had the least amount of influence on their prescribing decisions. This factor was the most popular choice for all the groups with less than 50 years of experience as the answer to the question “Which factor has the least amount of influence on your prescribing habits?”. There were three clinicians with greater than 50 years of experience that filled out the survey and each of these participants picked a different factor that had the least amount of influence on their prescribing habits. The factors chosen by these three clinicians were evidence based medicine, patient expectations, and pharmaceutical industry’s influence. Figure 11 is a graph that shows the percentage of Factors that Influence 30 participants within a certain range of clinical experience that pick one factor as having the least amount of influence on their prescribing habits. Insurance companies’ policies was the factor that was chosen by the highest percentage of participants in each group when those surveyed were asked to pick the factors that impede their prescribing habits. The factor that had the second highest percentage of participants per grouping pick it varied. In the groups with less than 30 years of clinical experience the factor that was the second most popular choice was the pharmaceutical industry’s influence. For clinicians with more than 30 years of clinical experience the second most popular choice was “none of the factors listed affected the way they prescribed medications”. Figure 12 is clinicians with a certain amount of clinical experience that believe a factor impedes their prescribing habits. Gender When the responses to the survey are separated by gender, clinical experience is the factor given the highest Likert score. Males gave this factor a Likert score of 3.68 while females gave it a Likert score of 3.73. Both genders gave the second highest Likert score to evidence based medicine. The pharmaceutical industry’s influence was given the lowest Likert score by both genders. Females gave this factor an average Likert score of 2.25 while males gave it a lower score of 1.94.Figure 13 shows the average Likert scores that the different genders assessed each factor surveyed. When asked to pick the one factor that had the greatest influence on their prescribing habits, 52.4 % of males picked evidence based medicine while 40.5 % of males chose clinical experience. The most popular choice to answer this question by females was clinical experience. 43.6 % of the females surveyed picked this factor. Factors that Influence 31 Evidence based medicine was the second most popular choice among females as 33.3 % of females surveyed picked this factor. Figure 14 shows the percentage of males and females that picked a certain factor as having the most influence on their prescribing habits. The most prominent factor picked by both genders to answer the question “What factor has the least amount of influence on prescribing habits?” was the pharmaceutical industry’s influence. 57.1 % of males and 59.1 % of females responding to the survey thought this was true. The only factor that was not picked to answer this question by both genders was clinical experience. Figure 15 shows the percentage of males and females that picked a certain factor as having the least amount of influence on their prescribing habits. The percentage of male participants that believed a certain factor impeded their prescribing decisions ranged from 1.2 % to73.2 %. Clinical specialty was the factor that 1.2% of the male participants believed inhibited their prescribing decisions while 73.2% of males surveyed believed insurance companies’ policies inhibited their prescribing decisions. The percentage of female participants that thought a factor inhibited their prescribing decision ranged from 0.9 % (Clinical specialty, patient preference) to 79.1 % (insurance policies). Similar percentages of males and females believed that none of the factors inhibited their prescribing decisions. 15.9% of males and 15.7% of females thought this. Figure 16 shows the percentage of males and females that believe a certain factor impedes their prescribing decisions. Primary Insurance of patients Factors that Influence 32 The participants were broken down into four groups based on the type of insurance (Medicaid, Medicare, private insurance, and no insurance) that was carried by most of their patients and Likert scores were computed for each factor. The Likert scores ranged from 1.67 – 3.81. Clinical experience was the factor that received the highest Likert score in all four groups. The second highest Likert score was given to evidence based medicine in all four groups. All four groups also had the same factor receive the lowest Likert score. This factor was the pharmaceutical industry’s influence. Figure 17 shows the average Likert scores that were given by 4 groups of participants that were formed by the type of insurance their patients carry (Medicaid, Medicare, private insurance or no insurance). When asked to pick the single factor that had the greatest amount of influence on their prescribing habits, the most popular choice among participants whose patient population mainly carries Medicaid was clinical experience. For participants whose patient population mainly carries no insurance the prominent chose was evidence based medicine. Participants that care for people with private insurance did not overwhelming pick one factor as 43.2% picked evidence based medicine and 42.4 % picked clinical experience as the answer to this question. Similar results were also evident in the group of clinicians who mostly care for patients that have Medicare as 40.6 % chose evidence based medicine and 43.8% chose clinical experience. Patient preference was the only factor that was not picked by any of the participants as an answer to this question. Figure 18 shows the percentage of participants that care for patients with a type of insurance that picked one factor as having the most influence on their prescribing habits. Factors that Influence 33 The highest percentage of participants whose patient population mainly carry Medicare, Medicaid, and private insurance, picked the pharmaceutical industry’s influence as the factor with the least amount of influence on their prescribing habits. The most prominent answer given by clinicians who predominately take care of patients with no insurance to answer this question (What factor has the least amount of influence on your prescribing decisions?) was patient preference. 50% of those surveyed who take care of patients with no insurance believed patient preference was the factor that had the least amount of influence on their prescribing decisions. Evidence based medicine and clinical experience were two factors that were not chosen by any of the participants to answer this question. Figure 19 shows the percentage of participants that care for patients with a type of insurance that picked one factor as having the least amount of influence on their prescribing habits. The percentage of clinicians in each group (primarily treat patients with Medicaid, Medicare, private insurance, or no insurance) that believe a certain factor impedes them from making prescribing decisions ranged from 0% to 79.3%. Over 70 % of the clinicians who predominantly care for patients with Medicaid, Medicare, and private insurance believe that the insurance industries policies impede their prescribing habits. The most popular choice among clinicians surveyed who care for patients with no insurance was the answer of “none” of these factors inhibit prescribing decisions. All the factors listed that could impede prescribing decisions were at least picked by one of the participants that care for people with private insurance. Figure 20 shows the percentage of participants that care for patients with a type of insurance that believe a factor impedes their prescribing decisions. Factors that Influence 34 Clinical setting: outpatient vs. inpatient After separating the participants responses based on the clinical setting that they work in, the Likert scores were similar for all the factors assessed. The factor with highest average Likert score for both groups was clinical experience. Participants that work in an inpatient environment gave this factor an average Likert score of 3.69 while those that work in an outpatient setting gave this factor an average Lickert score of 3.71. The lowest average Likert score for both groups was given to the pharmaceutical industry’s influence on prescribing habits. Figure 21 is a bar showing the different average Likert scores given to each factor by inpatient and outpatient clinicians. When asked what one factor had the greatest influence on their prescribing habits participants that practice in an inpatient setting and outpatient setting mostly picked clinical experience and evidence based medicine. Of the clinicians surveyed that practice medicine in an inpatient environment, 41.7 % picked evidence based medicine as the factor that had the greatest influence on shaping their prescribing habits while 33.3 % thought clinical experience was this factor. From the clinicians that practice medicine in an outpatient setting, 41.2 % picked evidence based medicine while 44.2 % choose clinical experience to answer this question. Patient preference and the pharmaceutical industries influence were two factors that were not picked to answer this question by participants that practice medicine in an outpatient setting. Participants that practice medicine in an inpatient setting did not pick patient preference and peer influence as answers to this question. Figure 22 is a bar graph that shows the percentage of clinicians who practice in either an inpatient or outpatient setting that chose a factor as having the most influence on their prescribing habits. Factors that Influence 35 When asked to pick the one factor that had the least amount of influence on their prescribing decisions, over 50% of the participants in both groups, choice the pharmaceutical industries influence. This was the most popular chose to answer this question among participants that practice medicine in an inpatient setting and those that practice in an outpatient setting. Figure 23 is a bar graph that shows the percentage of clinicians who practice in an inpatient and outpatient that chose a factor as having the least amount of influence on their prescribing habits. The percentage of participants that work in an outpatient setting that believe a certain factor inhibits their ability to prescribe medicine ranges from 0.6 % to 78.9 %. The most popular factor picked that impedes prescribing among participants that work in an outpatient setting was the insurance industry’s policies. 14.3% of clinicians surveyed that practice in an outpatient setting believe that no factor assessed inhibits them from prescribing medicine that would be in the patient’s best interest. The percentage of participants that treat patients in an inpatient setting that believe a certain factor inhibits their ability to prescribe medicine ranges from 2.8% to 66.7%. The factor that 66.7 % of those that were surveyed who work in an inpatient setting believe inhibits their ability to prescribe medicine is the insurance industry’s policies. Of those that practice medicine in an inpatient setting, 22.2 % believe that none of the factors assessed inhibit their ability to prescribe medications. Figure 24 is a bar graph that shows the percentage of participants that work in either an inpatient or outpatient clinical setting who believes a factor impedes their ability to prescribe medicine. Most influential prescribing specialty insurance Factors that Influence 36 Discussion This study evaluated the extent of influence that clinicians believe certain factors have on their prescribing habits. By surveying local clinicians that have the ability to prescribe medicine with a Likert scale I was able to gain insight into how these clinicians make prescribing decisions. The study showed that all the factors assessed do have some influence on prescribing decisions as no factor received an average Likert score of zero. The lowest average Likert score was 2.12 and it was given to the pharmaceutical industries influence. This factor was also the most popular choice to the question “Which factor has the least amount of influence on your prescribing habits” further supporting the minimal amount of influence the pharmaceutical industry has on a clinician’s use of medication. The pharmaceutical industry’s influence on clinicians is very controversial and a topic of public interest. As explained earlier, the reason this industry tries to influence clinicians’ choices concerning medications is that providers act as “gatekeepers” that direct the use and purchase of prescription drugs (Glickman et al.). This makes the pharmaceutical industry’s profits dependent on how clinicians view a particular drug. Due to this relationship, many people believe that pharmaceutical companies use their sales representatives, advertisements and other forms of marketing to pressure clinicians to prescribe their medications. According to the results of this survey, clinicians acknowledge this industry’s influence but believe it to be minimal. The minimal amount of influence that clinicians attach to the pharmaceutical industry’s efforts to manipulate their prescribing decisions shows that local people should not be concerned about the relationship a clinician has with this industry. Factors that Influence 37 The factors receiving the highest average Likert scores based on the responds to the survey were clinical experience and evidence based medicine. Clinical experience received the highest average Likert score of 3.71 while evidence based medicine received a slightly lower score of 3.59. The results of the question “Which factor has the greatest influence on your prescribing habits” showed similar results as evidence base medicine was picked by 83 clinicians and clinical experience was picked by 85 clinicians. It was hypothesized that these two factors would have the highest average Likert scores before the participants were surveyed. The great amount of influence clinicians attach to these factors is probably due to how they are educated. Medicine is a science that is based on research and the evidence. Throughout their training and education clinicians are taught how to think scientifically. The importance of clinical trials to determine the effectiveness of a drug is repeatedly emphasized to them. Before a drug is approved by the FDA it must survive numerous clinical trails that assess the risk and benefits of the drug. Clinical journals are consistently publishing research articles on how a certain drug performs within a define population of patients. It is interesting, however, that clinical experience had a higher Likert score than evidence based medicine and was picked by more clinicians as the factor with the greatest influence on their prescribing habits. These results show the limitations of evidence based medicine as Monico, Moore and Calise pointed out that many questions and situations in medicine are without controlled clinical trails. When these questions and situations arise, clinicians must rely on past experiences to help guide and/or treat their patients. A simple example of this is every patient is that unique and no one is sure how a person will react to a medication even if a clinical trial has shown that a person can benefit from taking the drug. Another reason why clinical Factors that Influence 38 experience might be viewed as more influential than evidence based medicine is the massive amount of journal articles a clinician would have to read to be aware of all the new research that is being done. In today’s healthcare environment this task would be impossible as it would demand too much of a clinician’s time. The insurance companies’ policies received an average score of 3.04 on a four point Likert scale as a factor that influences prescribing. Of great concern is that 76.6 % of the clinicians surveyed thought that insurance companies’ policies impeded their ability to prescribe medications that they believe would be in the patient’s best interest. This result is most likely due to insurance companies use of a tier system which encourages clinicians to prescribe medications preferred by these companies. Through my own clinical experiences I have often overheard clinicians voicing their frustration about this system and its ability to manipulate how they prescribe medicines. Only 15.7 % of those surveyed believe that none of the factors listed affect the way they prescribe medicine. Since 84.7 % of the participants think that there are factors that inhibit them from giving a patient the pharmacotherapy that they believe is necessary, follow up studies need to done. These studies should evaluate if these factors that inhibit clinicians from prescribing certain medications lead to a patient’s health being adversely affected. For example, a study could be designed to compare adverse outcomes between similar groups of patients. One of these groups’ provider must practice following the rules and regulations that an insurance company enforces and the other group’s provider does not have to follow these rules and regulations. The patient populations than can be evaluated for specific outcomes. One such study has already been done. Published in the New Factors that Influence 39 England Journal of Medicine a study entitled Cardiovascular Outcomes after a Change in Prescription Policy for Clopidogrel concluded that “removal of a prior authorization program led to improvement in timely access to clopidogrel for coronary stenting and improved cardiovascular outcomes” (Jackevicius, et. al., 2008, p.1806) . If more studies like this one show that the factors that clinicians believe impede their prescribing decisions adversely affect a patient’s health, various reforms must be taken to eliminate these factors from the practice of medicine. A growing problem in modern day medicine is the overuse of antibiotics which has created resistance bacteria. Many people feel that this problem has been created by providers giving into patients’ request for antibiotics when they are not needed. An example of this line of thinking is Richard Colgan and John Powers who wrote “Patients want antibiotics and physicians continue to prescribe them in situations where antibiotics may be withheld for many reasons.” (2004, p. 1003) In the same article Colgan and Powers also wrote “physicians often feel compelled to prescribe an antibiotic to satisfy patient demands.” (p. 1004)) According to the average Likert scores found by conducting this survey, patient preference has a minimal amount of influence on clinicians’ prescribing decisions. This contradicts Colgan and Powers statement on the cause of antibiotic resistance. When the participants’ responses to the Likert scale and the survey questions were grouped by demographical characteristics and these subgroups’ results compared there was no obvious differences found. The demographical characteristics that were studied for their affects on the survey’s results were: gender, clinical setting a participant works in, clinical experience, type of clinician and primary insurance that the Factors that Influence 40 participants’ patients carry. The results showed that for all the demographical groups studied, evidence based medicine and clinical experience were the factors that had the most influence on prescribing habits while the pharmaceutical industry’s affect on prescribing was found to be the least influential factor. Insurance companies’ policies was the most popular choice of the different demographic groups as a factor that inhibits prescribing. Based on these results one could conclude that the different demographical characteristics have no affect on prescribing habits which is not what was hypothesized. The demographical characteristics having no affect on prescribing habits is most likely due to all clinicians being educated and trained the same way. Areas of Strength One area of strength for this study is the group of participants. 201 clinicians took part in the survey, this meets my goal of greater than 100 participants. With greater than 100 clinicians taking part in the survey the results approximates the feelings of all prescribing clinicians in the US to a 95% confidence level with a confidence interval of + 10 . This group of 201 participants was composed of a wide range of clinicians representing many different personal and professional characteristics. The results of this survey are given more creditability because of this diversity. The diversity of the participants also allowed me to compare if certain demographical characteristics affect the way clinicians view their prescribing habits. Another area of strength of this survey is that it uses a Likert scale to evaluate the extent of influence various factors have on prescribing habits. Many studies in the past have evaluated if a particular factor affects prescribing habits but this study is unique Factors that Influence 41 because by using a Likert scale I was able to evaluate the extent of influence a certain factor has on prescribing habits. Weaknesses and limitation of study One shortcoming of this study is that t only evaluates the extent of influence that clinicians perceive certain factors have on prescribing. This study is limited because it does not assess how clinicians actually practice medicine. How a clinician practices medicine might be totally different than how a clinician perceives they practice medicine. For instance, a clinician might undervalue the pharmaceutical industries influence on prescribing because this industry’s influence is frowned upon by people that practice medicine. As a consequence of this attitude people might unconsciously devalue this industry’s influence. Another weakness of this survey is the factors that were listed to be assessed do not stand on their own. Many of the factors that were listed in the survey that affect prescribing habits are associated with another factor. For instance, much of the evidence based research that evaluates a drugs safety, efficiency, etc. is sponsored by pharmaceutical companies. Another example of this is direct to consumer advertising. Drug advertisements on TV, in magazines and newspapers might provoke a patient to demand that a clinician prescribes a medication. Due to this someone filling out the survey might find this overlap confusing. The study is also limited by the sample population being composed of clinicians who all belong to three medical organizations. This could skew the data because members of an organization usually have common beliefs and characteristics, which can lead to an organization’s views being over represented in this study. All the medical Factors that Influence 42 organizations from which the sample population is obtained from do promote different forms of continuing education. This could lead to evidence based medicine being deemed more influential than it actually is. Areas of uncertainty and future area of research As stated earlier, this study is limited because it is based on a survey that evaluates how clinicians perceive a certain factor influences their prescribing habits. It is not known if the way a clinician perceives a factor influences their prescribing habits is actually the amount of influence a factor has on how they practice medicine. Future studies could also be done to evaluate if these factors assessed by the survey have an adverse or beneficial affect on patient care. Conclusion This study utilized a survey composed of a Likert scale and questions about prescribing habits to assess the way 201 clinicians in the western New York area view the influences certain factors have on their prescribing habits. The factors that were assessed were evidence based medicine, clinical specialty, clinical experience, the pharmaceutical industry’s influence, patient preference and insurance companies’ policies. The results show that the two factors that have the most influence on prescribing habits are clinical experience and evidence based medicine while the factor with the least amount of influence was the pharmaceutical industry’s influence. 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Med 167,7, 663-668 Reichert, S., Simon, T., and Halm, E., (2000) Physicians’ attitudes about prescribing and knowledge of the cost of common medication. Arch Intern. Med. 160, 2799-2803. Review: What impact does pharmaceutical promotion have on behavior (June 2, 2003) Drug Promotion Database Retrieved April 4 2008 from http://www.drugp romo.info/read-reviews.asp?id=4 Rosenthal M, Berndt E, Donohue J, Frank R, and Epstein A. (2002) Promotion of prescription drugs to consumers. N Engl J Med, 346, 498-505. Ross S, and Macleod M,(2005). Antihypertensive drugs prescribing Grampain. Br J Clin Pharmacology, 60, 300-305 Roy-Byrne P, Russo J, Dugdale DC, Lessler D, Cowley D, and Katon W (2002) Undertreatment if of panic disorder in primary care: Role of patient and physician characteristics. J Am Board Fam. Pract., 15 443-50 Sbarbaro J, (2001) Supplement Article: Can we influence prescribing patterns? Clinical Infectious Diseases i-e56 Schwartz R, Soumerai S, and Avorn J.(1989) Physician motivation for nonscientific drug prescribing. Soc. Sci Med, 28, 577-582 Soumerai SB, Pierre-Jacques M, Zhang F, et al. (2006) Cost-related medication nonadherence among elderly and disabled Medicare beneficiaries: a national survey 1 year before the Medicare drug benefit. Arch Intern Med, 166, 1829–35 Factors that Influence 48 Spingarn R, Berlin J and Strom B. (1996) When pharmaceutical manufacturers' employees present grand rounds, what do residents remember? Acad Med., 71, 86-88. Symm et al.(2006) Effects of using free sample medication on the prescribing practices of Family Physicians. J. Am board Fam. Med, 19, 443-449 The Survey System: sample size formulas (2007). Creative Research System. Retrieved April 19, 2008, from http://www.surveysystem.com/ssformu.htm Torpy, J. (2005) Evidence Based Medicine, JAMA 296, 1192. U.S. Department of Labor, Occupational Outlook Handbook, 2008-09 Edition Physician Assistants. (December 18, 2007 ) Bureau of Labor Statistics,. Retrieved April 19, 2008 from http://www.bls.gov/oco/ocos081.htm. U.S. Department of Labor, Occupational Outlook Handbook, 2008-09 Edition, Physicians and Surgeons, (December 18, 2007 ) Bureau of Labor Statistics. Retrieved April 19, 2008 from http://www.bls.gov/oco/ocos074.htm Wazana A. (2000) Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA, 283, 373-380 Weissman J, Blumenthal D, Silk A, et al (2004) Physicians report on patient encounters involving direct-to-consumer advertising.[Electronic verion] Health Aff., Retrieved March 28 from doi:10.1377/hlthaff.w4.219. Willison DJ, Soumerai SB, and Palmer RH (2000) Association of physician and hospital volume with use of aspirin and reperfusion therapy in acute myocardial infarction. Med Care., 38,1092-102. Factors that Influence 49 Appendix A Recruitment email to members of Monroe County Medical Society Dear Clinicians: I am writing you in hopes that you will help me with my master by participating my study. The purpose of this study is to measure how certain factors affect the way you make prescribing decisions. I am inviting you to participate in this survey because of your experience and ability to prescribe prescription medication. This research project has been approved by the D’youville college’s IRB and Monroe County Medical Society. This survey is Web-based. If you choose to participate, please click on the following link: http://www.surveymonkey.com/s.aspx?sm=D7io24b1yh6trdn48j4iMg_3d_3d Completion of the survey will take approximately 5 minutes. You may choose not to participate in this survey. The survey will be open for approximately a week. Depending on the initial response to the survey a second email might be sent reminding you of the survey and the survey will remain open for an extended length of time. No personal identifying information is asked and all information is confidential. There are no known psychological or physical risks from being in this study and you will not benefit from it personally. However, I hope that information gained in this study will benefit all healthcare personal. If you know of any colleagues that would like to participate in this survey please forward the link to them. If you have any questions about the research study, please contact Darren Schutt at [email protected] This research project has been approved by the D’youville college IRB and Monroe County Medical Society. Sincerely, Darren Schutt Factors that Influence 50 Appendix B Recruitment email to members of Nurse Practitioner Association Greater Rochester Chapter Dear Clinicians: I am writing you in hopes that you will help me with my master by participating my study. The purpose of this study is to measure how certain factors affect the way you make prescribing decisions. I am inviting you to participate in this survey because of your experience and ability to prescribe prescription medication. This research project has been approved by the D’youville college’s IRB and the board of Nurse Practitioner Association Greater Rochester Chapter. This survey is Web-based. If you choose to participate, please click on the following link: http://www.surveymonkey.com/s.aspx?sm=D7io24b1yh6trdn48j4iMg_3d_3d Completion of the survey will take approximately 5 minutes. You may choose not to participate in this survey. The survey will be open for approximately a week. Depending on the initial response to the survey a second email might be sent reminding you of the survey and the survey will remain open for an extended length of time. No personal identifying information is asked and all information is confidential. There are no known psychological or physical risks from being in this study and you will not benefit from it personally. However, I hope that information gained in this study will benefit all healthcare personal. If you know of any colleagues that would like to participate in this survey please forward the link to them. If you have any questions about the research study, please contact Darren Schutt at [email protected] This research project has been approved by the D’youville college’s IRB and Nurse Practitioner Association Greater Rochester Chapter. Sincerely, Darren Schutt Factors that Influence 51 Appendix C Recruitment email to members of WNYPAA Dear Members of WNYPAA: I am writing you in hope that you will help me with my master by participating in my study. Most of you already know about the survey as do to miscommunication a recruitment email was already sent out to members of your organization. Unfortunately, for those of you that have already filled out the survey I could not use your original responses for the study because IRB did not give my project formal approval. Instead, your original participation was used to evaluate the quality of the survey and identify portion of the survey that were confusing. Due to your participation I have made some changes to survey to make it clearer and easier to fill out. Now that I have IRB’s formal approval of the study would you please take five minutes to fill out this online survey. I am sorry for the inconvenience and thank you for your participation. For those of you who do not know about the project I am inviting you to participate in this survey because of your experience and ability to prescribe medication. The purpose of this study is to measure how certain factors affect the way you make prescribing decisions. This research project has been approved by the D’youville college IRB and WNYPAA. This survey is Web-based. If you choose to participate, please click on the following link: http://www.surveymonkey.com/s.aspx?sm=D7io24b1yh6trdn48j4iMg_3d_3d Completion of the survey will take approximately 5 minutes. You may choose not to participate in this survey. The survey will be open for approximately a week. Depending on the initial response to the survey a second email might be sent reminding you of the survey and the survey will remain open for an extended length of time. No personal identifying information is asked and all information is confidential. There are no known psychological or physical risks from being in this study and you will not benefit from it personally. However, I hope that information gained in this study will benefit all healthcare personal. If you know of any colleagues that would like to participate in this survey please forward the link to them. If you have any questions about the research study, please contact Darren Schutt at [email protected] This research project has been approved by the D’youville college’s IRB and WNYPAA. Sincerely, Darren Schutt Factors that Influence 52 Table 1 Demographical characteristics of participants Table 1 The type of clinician Number of participants PA 68 MD 99 NP 34 The gender of the participants Number of participants male 84 female 117 Clinical setting Number of participants Outpatient Inpatient 165 36 Number of years practicing Number of participants 0-10 years 11-20 years 82 56 21-30 years 33 31-40 years 24 Primary insurance carried by participates’ patient population Number of participants Medicare 32 Medicaid 30 Private insurance 132 No insurance 6 41-50 years greater 50 years 3 3 Factors that Influence 53 Figure Captions Figure 1. Number of participants per specialty. Figure 2 Average Likert score for each factor based on all participants responses Figure 3 Results from the survey question asking clinicians to pick the factor that has the most influence on prescribing Figure 4 Results for the survey question asking clinicians to pick the factor hat has the least amount influence on their prescribing habits Figure 5 Results from the survey question asking clinicians to pick the factors if any impede them from giving patients the pharmacological therapy that would be in the patient’s best interest. Figure 6 Average Likert scores from based on MDs, NPs, PAs’ responses to survey questions Figure 7 Pie charts representing the percentage of MDs, PAs, and NPs that picked a certain factor as the factor that has the most influence on their prescribing habits Figure 8 Bar graph showing the percentage of MDs, PAs, and NPs that picked a certain factor that impedes them from giving a patient the pharmacological therapy that they believe is in the patient’s best interest. Figure 9 Graphical representation of the average Likert scores that the different clinical experience groups gave to each factor Figure 10 The percentage of participants within a certain range of clinical experience that pick one factor as having the most influence on their prescribing habits. Figure 11 The percentage of participants within a range of clinical experience that pick one factor as having the least amount of influence on their prescribing habits. Factors that Influence 54 Figure 12 The percentage of participants within a range of clinical experience that believe certain factor impedes their ability to prescribe medicine Figure 13 Average Likert scores that the different genders assessed to each factor surveyed Figure 14 Bar graph showing the percentage of males and females that picked a certain factor as having the most influence on their prescribing habits. Figure 15 Bar graph showing the percentage of males and females that picked a certain factor as having the least amount of influence on their prescribing habits. Figure 16 Bar graph showing the percentage of males and females that believe a certain factor impedes their prescribing decisions. Figure 17 Bar graph showing the average Likert scores that given by 4 groups of clinicians that were form by the type of insurance their patients have (Medicaid, Medicare, private insurance, or no insurance) participants Figure 18 Bar graph showing the percentage of participants that care for patients with a type of insurance that picked one factor as having the most influence on their prescribing habits. Figure 19 Bar graph showing the percentage of participants that care for patients with a type of insurance that picked one factor as having the least amount of influence on their prescribing habits. Figure 20 Bar graph showing the percentage of participants that care for patient with a type of insurance that believe a factor impedes their prescribing decisions. Figure 21 Bar graph showing the different average Likert scores given to each factor by inpatient and outpatient clinicians Factors that Influence 55 Figure 22 Bar graph that shows the percentage of clinicians who practice in an inpatient and outpatient that chose a factor as having the most influence on their prescribing habits. Figure 23 a bar graph that shows the percentage of clinicians who practice in an inpatient and outpatient that chose a factor as having the least amount of influence on their prescribing habits. Figure 24 is a bar graph that shows the percentage of participants that work in an inpatient and outpatient clinical setting believe a factor impedes their ability to prescribe medicine. 0 clinical specialty 35 1 1 other 3 infection disease radiologist 1 opthhalomology 5 oncology 1 nephrology 5 5 dermatology 3 allergist geroatrics 6 psychiatry 2 pediatric 13 endocrinology 15 OB/GYN 5 urology surgery 8 cadiologist 2 neurologist 10 emergency medicine hospitalist 25 internal medicine family medicine 15 orthopedics anestesiologist numberof particpants Factors that Influence Figure 1 clinical specialty 33 31 30 24 20 15 12 8 5 2 56 3.04 Factors clinical specialty 2.7 insurance policies 3.59 peer influence 4 clinical experience pharmaceutical industries 3 Patient preference Evidence Based medicine Average Likert Factors that Influence Figure 2 Likert scoring 3.71 3.5 3.14 2.65 2.5 2.12 2 1.5 1 0.5 0 57 Factors that Influence Figure 3 Which factor has the most influence on shaping prescribing habits 85 90 83 Evidence Based Percentage of particpants 80 5% 60 Patient preference 2% 42% pharmaceutical industries 50 clinical experience 40 30 43% 17 20 0 1 pharmaceutical industries 10 Patient preference 11 4 clinical specialty insurance policies peer influence clinical experience factor 0% 0% peer influence insurance policies clinical specialty 0 Evidence Based medicine number participants 70 medicine 8% 58 Factors that Influence Figure 4 Response to which factor has the least amount influence on your prescribing habits 140 117 120 7% 100 # of participants 8% 1% 15% 11% 80 0% 60 40 58% Evidence Based medicine 31 Patient preference 23 15 20 1 13 0 0 clinical experience peer influence Ba se d Pa me ph t i en dic ar m t ine pr ac e eu fer tic en al ce i cli nic ndu str al ies ex pe rie pe nc er e inf ins lue ur an nc ce e po cli nic lic ies al sp ec ial ty insurance policies ide nc e Ev pharmaceutical industries factor clinical specialty 59 ar m ce 60 31 ind cli us nic trie al s ex pe rie nc pe e er inf ins lue ur nc an e ce po cli lic nic ies al sp ec ial ty ca l ne ine fer en dic No 20 ac eu ti en me tp re Ba se d Pa ti ce 40 ph Ev ide n # number of participants Factors that Influence Figure 5 Factors that restrict prescribing 160 151 140 120 100 80 39 27 3 3 factors 3 0 2 60 Factors that Influence 61 Figure 6 Type of clinician 4 Evidence Based medicine 3.5 Patient preference 3 Likert Scoring average 2.5 pharmaceutical industries 2 clinical experience 1.5 peer influence 1 insurance policies 0.5 0 Clinical specialty PA MD Type of clinician NP , Factors that Influence 62 Figure 7 What Factor Has the Greatest Influence on Prescribing Habits? 9% PA 2% 2% MD Evidence Based medicine 4% 4% 28% 3% 51% Patient preference 41% 0% pharmaceutical industries 2% 0% 54% clinical experience NP peer influence 21% 40% 18% insurance policies clinical specialty 0% 21% 0% Factors that Influence Figure 8 Factors that clinicians believe inhibit them from giving patients the therapy they believe is necassary Percetage of clinicians surveyed 100 None 90 80 Evidence based medicine 70 Patient preference 60 pharmaceutical industries 50 clinical experience 40 peer influence 30 insurance policies 20 clinical specialty 10 0 PA MD Type of clinician NP 63 Factors that Influence Figure 9 Years praciticing medicine 4 evidence based medicine patient preference 3 2.5 2 pharmaceutical industries clinical experience 1.5 1 peer influence 0.5 0 Years practicing medicine greater 50 years 41-50 years 31-40 years 21-30 years 11-20 years insurance policies 0-10 years Average Likert Scores 3.5 clinical specialty 64 Factors that Influence 65 Figure 10 Most influential factor on prescribing decision vs. clinical experience % of participants with a certain amout of clinical experinece 100 90 80 70 evidence based medicine Patient preference pharmaceutical industries clinical experience peer influence insurance policies clinical specialty 60 50 40 30 20 10 0 0-10 years 11-20 years 21-30 years 31-40 years 41-50 years greater 50 years Years of clinical experience Factors that Influence 66 Figure 11 Factor with the least amount influence on prescribing habits vs. clincial expeience % of clinicains with a certain amount of clincial experience 100 90 80 70 evidence based medicine patient preference pharmaceutical industries clinical experience peer influence insurance policies clinical specialty 60 50 40 30 20 10 0 0-10 years 11-20 years 21-30 years 31-40 years 41-50 years greater 50 years Years of clinical experience Factors that Influence 67 Figure 12 Factors that impede prescribing vs. clinical experience % of clinicians that believe a certian factor impedes prescribing 100 90 80 70 none evidence based medicine patient preference pharmaceutical industries clinical experience peer influence insurance policies clinical speciailty 60 50 40 30 20 10 0 0-10 years 11-20 years 21-30 years 31-40 years 41-50 years greater 50 years Clinical experience Factors that Influence Figure 13 Average Likert score by gender 4 3.68 3.62 3.73 3.57 Average Likert scoring 3.5 3 2.9 2.67 3.05 2.73 2.73 2.55 2.5 2 3.153.21 2.25 evidence based medicine patient preference 1.94 pharmaceutical industries clinical experience 1.5 1 peer influence 0.5 insurance policies 0 clinical specialty male female Gender 68 Factors that Influence 69 Figure 14 % of females and males that picked a factor that has the most influence on their prescribing % of participants that picked a certain factor as having the most influence on prescribing 100 90 80 70 evidence based medicine patient preference pharmaceutical industries clinical experience peer influence insurance policies clinical specialty 60 52.4 50 43.6 40.5 40 33.3 30 20 12 7.7 10 3.6 1.2 2.4 0 0 0 0.9 0 male female Gender 2.6 Factors that Influence 70 Figure 15 % of males and females that picked a certain factor as having the least amount of influence on prescribing % participants that picked a certain factor as having the least amount of influence on prescribing 100 90 80 70 60 evidence based medicine patient preference pharmaceutical industries clinical experience peer influence insurance policies clinical specialty 59.2 57.1 50 40 30 17.2 20 13.1 13.1 12.9 9.5 10 6.9 6 1.2 3.4 0 0 0 0 male female Gender Factors that Influence 71 Figure 16 % of males and females that believe a certain factor impedes their prescribing decisions % of participants that believe a certain factor impedes prescribing 100 90 79.1 80 73.2 70 None evidence based medicine patient preference pharmaceutical industries clinical experience peer influence insurance policies clinical specialty 60 50 40 30 20 20.7 18.3 15.9 19.1 15.7 10.4 9 10 2.4 3.7 1.2 1.2 1.7 0.9 0 male female Gender 0.9 Factors that Influence Figure 17 Type of insurance affect on Likert scoring 4 Evidence based medicine Patient preference 3 2.5 2 pharmaceutical industries clinical experience 1.5 1 0.5 peer influence 0 ce No ur ins e Pr iv at ins an ur an ce aid ed ic M ed ic ar e insurance policies M Likert scoring average 3.5 Primary insurance of patients clinical specialty 72 Factors that Influence 73 Figure 18 Patients insurance affect on the % of participants that pick one factor as having the most influence on prescribing % of participants that picked one factor as having the most influence on prescribing 100 90 80 70 Evidence based medicine Patient preference pharmaceutical industries clinical experience peer influence insurance policies clinical specialty 60 50 40 30 20 10 0 Medicare Medicaid Private insurance Patients' insurance type No insurance Factors that Influence 74 Figure 19 Factors with least amount of influence on prescribing vs. patients' insurance % of participants that pick a factor as having the least amount of influence on prescribing 100 90 80 70 Evidence based medicine Patient preference pharmaceutical industries clinical experience peer influence insurance policies clinical specialty 60 50 40 30 20 10 0 Medicare Medicaid Private insurance Primary insurance of patients No insurance Factors that Influence Figure 20 Percentage of participants that care for patient with a certain type of insurance that believe a factor impedes their prescribing % participants that believe a factor impedes prescribing 100 90 80 None 70 Evidence based medicine Patient preference 60 pharmaceutical industries clinical experience 50 40 peer influence 30 insurance policies 20 clinical specialty 10 0 Medicare Medicaid Private insurance Primary insurance of patients No insurance 75 Factors that Influence Figure 21 Inpatient vs. outpatient Lickert scores 4 Evidence based medicine Patient preference Average Lickert score 3.5 3 pharmaceutical industries clinical experience 2.5 2 peer influence 1.5 insurance policies 1 clinical specialty 0.5 0 Outpatient Inpatient Clinical setting 76 Factors that Influence 77 Figure 22 Most influential factor on perscribing for inpaitent and outpatient clinicians 100 % of clincians that pick factor as most influential 90 80 70 Evidence based medicine Patient preference pharmaceutical industries clinical experience peer influence insurance policies clinical specialty 60 50 40 30 20 10 0 Outpatient Inpatient clinical setting Factors that Influence 78 Figure 23 Least influential factor on prescribing for inpatient and outpatient clinicians % of participants that pick factor as least influential 100 90 80 70 Evidence based medicine 60 Patient preference pharmaceutical industries 50 clinical experience 40 peer influence insurance policies 30 clinical specialty 20 10 0 Outpatient Inpatient clinical setting Factors that Influence 79 Figure 24 % of inpatient and outpatient clinicians who believe a factor impedes perscribing % of clinicians that believe a factor impedes prescribing 100 90 80 70 None Evidence based medicine Patient preference pharmaceutical industries clinical experience peer influence insurance policies clinical specialty 60 50 40 30 20 10 0 Outpatient Inpatient clinical setting Factors that Influence 80
