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Variation in prescribing costs between general practitioners is well documented.1 We previously found that frequent general practitioner contact with drug industry representatives was strongly and independently associated with higher prescribing costs.2 This paper describes the attitudes and behaviour of general practitioners who report seeing drug representatives frequently.
We sent a questionnaire to all general practitioners in 200 English practices randomly selected from three groups defined as the bottom, middle, and top fifths of prescribing costs. The questionnaire elicited general practitioners' personal and practice characteristics and their agreement with a series of statements about their prescribing attitudes and behaviour. Full details of the methods have been published.2
In all, 1097 of the 1714 general practitioners (64%) responded. We included the responses to each statement in a set of univariable logistic regression models in which the dependent variable was whether the general practitioner reported seeing drug representatives at least once a week. The table shows the statements that were significant (P < 0.05) in the univariate analysis. We entered these variables into a multivariable logistic regression model together with nine general practitioner and practice variables. This model found that frequent contact with a drug representative was significantly associated with a greater willingness to prescribe new drugs and to agree to patients' requests to prescribe a drug that is not clinically indicated, dissatisfaction with consultations ending in advice only, and receptiveness to drug advertisements and promotional literature from drug companies (table).
General practitioners who report weekly contact with drug representatives are more likely to express views that will lead to unnecessary prescribing than those who report less frequent contact. Little et al showed that prescribing antibiotics rather than giving advice on self management of sore throat can result in increased workload for general practitioners, through repeat attendance.4 Using Little et al's data, Marshall calculated that if a general practitioner prescribed antibiotics for sore throat to 100 fewer patients every year, 33 fewer would believe antibiotics were effective, 25 fewer would intend to consult with the problem in the future, and 10 fewer would come back within the next year.5 If some general practitioners' reluctance to end consultations without prescribing extends to other self limiting conditions, the effect on reattendance rates and thus workload could be substantial. Perhaps this is why general practitioners who see drug representatives most often report experiencing the most consultations when they feel under pressure of time.
When new drugs became available, general practitioners who saw drug representatives at least weekly were more likely, as their first course of action, to prescribe them for a few patients and monitor the results. This conflicts with the advice given by health commissioners to use published sources of evidence such as the British National Formulary.
General practitioners who see drug representatives most often tend to be those who are isolated from their colleagues (singlehanded practitioners and those uninvolved in general practitioner training) and to work in deprived areas. For some general practitioners, the frequency of contact must be greater than their need to know more about new drugs. Such visits possibly fulfil a pastoral rather than an educative role.
This cross sectional analysis cannot identify the direction of causality. Indeed, the observed associations may be due both to frequent drug representative contact leading to attitudes and behaviour associated with higher cost prescribing and to drug representatives targeting those general practitioners known to have more responsive attitudes or to be high cost prescribers. More research on the nature of this relationship would help primary care trusts to adopt policies encouraging more cost effective prescribing.
We thank David Roberts and Conrad Harris for help in advising on study design and for identifying the samples of general practitioners. We thank Isobel Clark for secretarial support and Marjorie Weiss, Helen Watkins, and Stuart Barton for comments on earlier drafts of this paper. We also thank Tim Coleman for his valuable referee's comments.
Contributors: CW and IH were responsible for the conception, design, initiation, and overall coordination of the study. LM analysed and interpreted the data. PC designed and produced the questionnaire and subsequently obtained, analysed, and interpreted the data. ER and RB were involved in designing the study and interpreting the data. CW prepared the manuscript and all investigators contributed to the final version of this paper. CW is the guarantor.
Funding: This study was supported by a grant from the Research and Development Directorate of the South and West NHS Region of the NHS Executive. The paper was written while Chris Watkins was in receipt of a research placement award from the South and West NHS region of the NHS Executive, to work in the MRC Health Services Research Collaboration. Both Ian Harvey and Chris Watkins are members of the MRC Health Services Research Collaboration and Chris Watkins is a partner in the Backwell and Nailsea Medical group, which receives funding from the NHS Executive. The views expressed in this publication are those of the authors and not necessarily those of the NHS Executive or of the MRC Health Services Research Collaboration. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.
Competing interests: None declared.