Why are some doctors high-prescribers of benzodiazepines and minor opiates? A qualitative study of GPs in Norway.

BACKGROUND: Registration studies have shown great variations in prescribing volume and prescribing patterns of benzodiazepines (BZDs) and minor opiates among GPs. OBJECTIVES: We aimed to form a basis for hypotheses and build theories about prescribing, in order to investigate how high-prescribing doctors can legitimize their own prescribing pattern. METHODS: A qualitative interview study of doctors with previously known high, medium and low prescribing volumes was performed. The interpretation focused on the doctors' self-explanations and how they influence their daily decision of prescribing. RESULTS AND CONCLUSIONS: It was a striking feature that many of the attitudes towards the drugs were common both within and between the three groups of prescribers. All doctors regarded the task of prescribing as difficult, and the great majority strongly advocated restriction in prescribing. In order to cope with daily practice and to live with high prescribing volumes, doctors make use of effective working strategies. These strategies, of ascribing responsibility to the previous doctor, to patient autonomy and responsibility, to the patient's age and to concomitant diseases, are described in this study. An allocation of responsibility to other persons or circumstances delimits the doctors' professional discretion in this matter. Striking differences between prescriber groups were not found in the analysis, but when all small tendencies in all steps of the decision-making process were added, a clear trend was revealed.

[Physicians' view on drug therapy for hypertension. A questionnaire in the county of Hordaland]. / Legers mening om medikamentell blodtrykksbehandling. En spørreundersøkelse i Hordaland fylke.

A questionnaire survey was conducted in Hordaland county to discover opinions on drug therapy for uncomplicated hypertensives with no other risk factors. The response rate was 66%; 179 general practitioners and 31 hospital doctors. The doctors were well informed about the documentation of the clinical benefit of various drugs. As regards the minimum blood pressure that was considered as warranting drug treatment, the majority of the doctors followed the recently issued national guidelines. For young patients the first choice drugs were beta-blockers (27%), ACE-inhibitors (25%) or calcium-blockers (20%). For older patients 65% of the doctors preferred diuretics or beta-blockers. The majority (80%) based their choice of drug primarily on documentation of clinical value or absence of side effects. The doctors underestimated the cost of the newer antihypertensive drugs.

[Control of prescriptions of B-preparations. A registry study of B-preparations in Oslo and Akershus]. / Tilsyn med B-preparatforskrivningen. En registreringsundersøkelse av B-preparater i Oslo og Akershus.

In two Norwegian counties all prescriptions for benzodiazepines and analgesics containing codeine were registered over a two month period and the records were subsequently transferred to a database. 93,000 prescriptions were registered, equivalent to this 2.8 millions DDD. The registration showed great variation, both in the doctors' volume of prescribing and their prescribing patterns. 30 doctors of the total of 4,000 were responsible for 13% of the total volume prescribed. We propose that the doctors with unacceptable prescribing rates should be offered a special education program provided by the Norwegian Medical Association. The computer routines of the pharmacies appear to be inadequate for registration and research purposes. In 2% of all the prescriptions the doctors name could not be identified. Thus it seems warranted to use the doctors' identity number on prescriptions for these drugs. A reduction of the number of tablets in the largest packages dispensed should be considered by the authorities. For effective quality control of prescribing, better understanding is needed of the differences in doctors' prescribing patterns.

[Communication in emergency health services]. / Helsetjenestens kommunikasjonsberedskap.

When the new national radio and telecommunications system for acute medical services is established in 1995, 25 years will have passed since publication of the first White Paper on the issue. By following the process of this reform as it has evolved it is possible to point out how various government bodies and professional groups have stimulated or hindered the process to suit their individual motives and needs. In addition to active involvement by enthusiastic professionals and government agencies, the approval and implementation of such a reform requires the support of other institutions, other professional groups, the media and politicians.

[The requirement to use the cheapest synonymous preparation--does it work as intended?]. / Ordningen med billigste synonympreparat--virker den etter hensikten?

A retrospective analysis of all prescriptions for hypersensitive drugs was undertaken at a pharmacy serving 20 general practitioners and 17 temporarily employed doctors. The analysis was carried out in 1992 over two three-month periods separated by an interval of five months. The Governmental regulations aimed at promoting use of the "cheapest synonymous drug" apparently had little impact on the doctors' prescriptions. During the 11 months concerned, the prescribed antihypersensitive drugs contained an increasing share of expensive alternatives with no documented ability to reduce cardiovascular morbidity or mortality.

Pharmacy personnel and fever: a study on perception, self-care and information to customers.

To study the fever perception and self-care of pharmacy personnel as well as the information given to customers about the management of fever problems, a random sample of 152 Norwegian pharmacists and 150 pharmacy technicians were interviewed, in 1989, by a national opinion poll company. One-third thought that body temperatures between 39.0 degrees C and 40.5 degrees C could be life-threatening. Of all respondents 24% (33% of technicians, 16% of pharmacists) assumed body temperatures to be rising when sweating accompanied fever. In cases of common cold or influenza accompanied by fever 56% of the personnel would use antipyretics. 7% Of the staff (14% of technicians, 1% of pharmacists) believed penicillin to be effective against viral infections. Antipyretic drug preferences were consistent, but a wide range of perceptions was revealed, in particular with respect to start of antipyretic therapy and seeking medical care for children. Undergraduate and postgraduate education of pharmacy personnel should aim more at satisfying the demand for information of the general public and focus more on the symptomatic treatment of fever and minor illness in general. Pharmacists in charge have a special responsibility in counselling their assistants.

General practitioners and fever: a study on perception, self-care and advice to patients.

To investigate their perception of fever problems, self-care and information given to patients, a random sample of 100 Norwegian general practitioners were interviewed in 1989-1990 by telephone. More than two-thirds of the general practitioners would define fever as a body temperature above 38.0 degrees C. One-third would wait with antipyretic drug therapy for children until the temperature was above 39.5 degrees C. When dealing with fever in their own children, one-third would not follow their own recommendations to parents with febrile children. 43% Had not discussed guidelines for the management of febrile patients with their receptionists. Only 7% had discussed such guidelines with the local pharmacists. Lack of consistency in the information given to patients may result in confusing advice. General practitioners, their receptionists and the local pharmacists should discuss and define guidelines for fever management and information to patients and parents. These should include information about antipyretic therapy and consultation behaviour.

[Diagnosis of migraine in general practice]. / Migrenediagnostikk i allmennpraksis.

195 patients with headache were examined by general practitioners and neurologists, and their diagnoses were compared. The general practitioners diagnosed migraine in 116 cases, the neurologists in 144 cases, and in 104 cases their diagnoses agreed. Thus, migraine can be difficult to diagnose, and this study indicates underdiagnosis of this common condition by general practitioners. This may result in overuse of analgesics and alternative therapies, and too little prescription of specific migraine medication. Greater familiarity with the diagnostic criteria of the International Headache Society should make it easier to arrive at a correct migraine diagnosis.

[Access to family practitioners by telephone. A practical example of quality assurance]. / Telefontilgjengelighet i allmennpraksis. Et praktisk eksempel på kvalitetssikring.

A record of telephone calls in a Norwegian town (Molde) in 1987 showed that fewer inquiries were answered by general practitioners and their receptionists than by personnel in any other profession or trade. The general practitioners and the receptionists agreed on measures to improve accessibility, and more records of telephone calls were made. The measures and the process are described. At local level, a record of calls which differentiates between those answered by the providers of primary care and those answered by automatic machines seems to be a simple and useful means of quality assurance which we encourage others to apply.

[Complaints about primary care physicians]. / Klager på leger i primaerhelsetjenesten.

The most serious complaints against general practitioners are investigated and dealt with by the Directorate of Health. A systematic review of 100 cases of complaint from 1983 up to 21 May 1992 showed that 57 of them concerned an urgent need of medical assistance and deputizing service. One-quarter of the complaints concerned telephone consultations. Incorrect diagnosis was the most frequent reason for the complaint. More than half of the cases referred to acute somatic diseases and accidents. The results will be used jointly by the Directorate of Health and the Norwegian Medical Association to improve practice.

[Diagnosis of migraine in general practice]. / Migrenediagnostikk i allmennpraksis.

195 patients with headache were examined by general practitioners and neurologists, and their diagnoses were compared. The general practitioners diagnosed migraine in 116 cases, the neurologists in 144 cases, and in 104 cases their diagnoses agreed. Thus, migraine can be difficult to diagnose, and this study indicates underdiagnosis of this common condition by general practitioners. This may result in overuse of analgesics and alternative therapies, and too little prescription of specific migraine medication. Greater familiarity with the diagnostic criteria of the International Headache Society should make it easier to arrive at a correct migraine diagnosis.

Fever in general practice. II. Reasons for encounter, management and duration of fever conditions.

A sample of 80 direct and 36 telephone encounters for fever was established in 1988 as part of a Norwegian study on fever as a clinical problem in general practice. Reasons for encounter (ICPC) and clinical examinations were recorded along with clinical laboratory tests, treatment, management and follow up (IC-Process-PC). The doctors assessed the diagnostic process by means of visual analogue scale. Duration of the fever conditions was estimated through a postal questionnaire. Patients with direct encounters presented a wide range of reasons for the encounters. Fever was the most frequent single presenting complaint (31%). The general practitioners put major emphasis on the clinical examinations. They prescribed drugs in 68% of the direct encounters. Seventy per cent of the prescriptions were general systemic anti-infectives. Penicillin accounted for 58% of antibiotics. Six (8%) patients were hospitalized, and three (4%) were referred to a specialist. The mean time until complete recovery was 15 days for direct and 19 days for telephone encounters. Fever may be a sign even when it is not a presenting complaint. Major emphasis is probably put on the clinical examination of febrile patients because of the complexity of symptoms and the wide range of diagnoses associated with fever.

Fever in general practice. I. Frequency and diagnoses.

Although fever is a common symptom, few studies have broadly addressed this as a clinical problem in general practice. The aims of this study were to determine the frequency of fever among general practice patients in two rural municipalities in Norway, the diagnoses (according to ICHPPC-2-def.) of conditions causing fever, and the receptionist's role in the management of these problems. All the general practitioners and their receptionists within the study area participated. During 4 weeks throughout 1988 all individuals attending their general practitioner had their body temperature measured with an electronic thermometer (orally > or = 7 years, rectally < 7 years). Fever was defined as an oral body temperature > or = 37.5 degrees C (rectally > or = 38.0 degrees C in those < 7 years). All telephone applications, including telephone encounters for fever, were recorded. Fever was detected in 80 (5%) of a total of 1610 direct encounters: 36% of those below 7 years of age (n = 70) were febrile. One-third of the total encounters for fever were telephone encounters (n = 36), of which 30% were managed by the receptionists. A wide range of diagnoses were made, most of which were associated with infectious diseases. The distribution of the diagnoses of primary care patients with fever is different from those admitted to hospital for fever of unknown origin. General practitioners and their receptionists should consider fever a diagnostic challenge, especially when the patient is handled over the telephone.

[Standards as basis for medical audit]. / Standarder som grunnlag for medical audit.

Medical audit usually implies evaluation of medical practice in order to control whether certain standards are complied with. Research on decision making has disclosed, however, that standards for clinical problem solving are not always easy to establish. It has been difficult to influence doctors to adhere to standards defined by experts. We therefore propose that medical audit should focus more on education than on control. If standards are to be used, the doctors participating in medical audit projects should also help to define the standards. We suggest the following procedure for medical audit projects: observe practice--reflect on it--identify changes--formulate standards--implement changes--evaluate changes--give feedback to the group about the outcome. Standards defined by experts working remote from medical practice, must be replaced by standards based on practical knowledge acquired by doctors with common experience.

[Antibiotic prevention of bacterial endocarditis]. / Antibiotikaprofylakse mot bakteriell endokarditt.

Bacterial endocarditis is a serious condition with high lethality. The authors review the etiology of the disease and conditions and procedures associated with increased risk, and give recommendations on choice and dosage of effective antibiotics. Most cases of endocarditis are caused by gram-positive cocci of the genera Streptococcus, Enterococcus or Staphylococcus. The number of cases caused by staphylococci has increased in recent decades. Risk of acquiring endocarditis is higher, for example, in patients with prosthetic cardiac valves and in patients with a previous history of endocarditis. Interventions associated with increased risk include various procedures in the mouth, throat and upper airways, since this is where the bacteria most often causing endocarditis are to be found. A single oral dose of amoxycillin is recommended for standard prophylaxis, and ampicillin in combination with an aminoglycoside for parenteral use. In cases of penicillin allergy, a single oral dose of clindamycin is recommended in patients at risk of bacteriemia from the respiratory tract, with trimetoprim as an alternative for genito-urinary and gastrointestinal procedures. Vancomycin or vancomycin plus aminoglycoside is recommended as a parenteral regimen in cases of penicillin allergy.

[How do people perceive fever and what is done for it?]. / Hvordan oppfatter mennesker feber og hva gjør de?

The perception of fever has changed throughout history. Fever is a common symptom, and nowadays antipyretics are widely used. However, our knowledge of layman's perception of fever and self-care is rather limited. Unfounded parental concern of fever in children ("fever phobia") has not been found in Nordic studies. However, the findings indicate a need for more definite and consistent information on fever and fever management, including self-medication. This is a joint challenge to primary health care workers and local pharmacists.

Fever: management and self-medication. Results from a Norwegian population study.

A representative sample of the Norwegian population was interviewed in 1988 as part of a monthly national opinion poll to investigate lay management and self-medication of fever. Six hundred and nineteen women and 592 men over the age of 15 were interviewed in their homes. Approximately one-fifth reported inappropriate measuring of body temperature. A variety of management and self-medication was found. In cases of common cold or influenza with fever, 35% would use antipyretics. Forty per cent would start to use antipyretics at a temperature below 39.0 degrees C. Forty-four per cent did not know any antipyretic brand names at all. The results indicate a need for more definite and consistent information to make fever management and self-medication more rational. Such information should be discussed and given by general practitioners, nurses at child welfare centers and pharmacists.

Fever: knowledge, perception and attitudes. Results from a Norwegian population study.

To investigate the layman's knowledge, perception and attitudes regarding normal body temperature, fever, infections and the effect of penicillin on virus infections a representative sample of the Norwegian population (619 women and 592 men over the age of 15) was interviewed in 1988 as part of a monthly national opinion poll. One-third thought body temperatures up to 40.5 degrees C to be life-threatening, but the results do not justify the application of the term 'fever phobia' as described in other studies based on non-representative samples. More respondents were afraid of viral infections (48%) than bacterial infections (9%), which may be due to the media focus upon the HIV/AIDS epidemic. Thirty-five per cent believed penicillin to be effective against virus infections. Educational programmes on fever should also include information about virus infections and their treatment.