Physician behaviour for antimicrobial prescribing for paediatricupper respiratory tract infections: a survey in general practice inTrinidad, West Indies.

Background: Upper respiratory tract infections (URTIs) are among the most frequent reasons for physician office visits in paediatrics. Despite their predominant viral aetiology, URTIs continue to be treated with antimicrobials. We explored general practitioners' (GPs) prescribing behaviour for antimicrobials in children (¡Ü 16 years) with URTIs in Trinidad, using the guidelines from the Centers for Disease Control and Prevention (CDC) as a reference. Methods: A cross-sectional study was conducted on 92 consenting GPs from the 109 contacted in Central and East Trinidad, between January to June 2003. Using a pilot-tested questionnaire, GPs identified the 5 most frequent URTIs they see in office and reported on their antimicrobial prescribing practices for these URTIs to trained research students. Results: The 5 most frequent URTIs presenting in children in general practice, are the common cold, pharyngitis, tonsillitis, sinusitis and acute otitis media (AOM) in rank order. GPs prescribe at least 25 different antibiotics for these URTIs with significant associations for amoxicillin, co-amoxiclav, cefaclor, cefuroxime, erythromycin, clarithromycin and azithromycin (p < 0.001). Amoxicillin alone or with clavulanate was the most frequently prescribed antibiotic for all URTIs. Prescribing variations from the CDC recommendations were observed for all URTIs except for AOM (50 per cent), themost common condition for antibiotics. Doctors practicing for >30 years were more likely to prescribe antibiotics forthe common cold (p = 0.014). Severity (95.7 per cent) and duration of illness(82.5 per cent) influenced doctors' prescribing and over prescribing in general practice was attributed to parent demands (75 per cent) and concern for secondary bacterial infections (70 per cent). Physicians do not request laboratory investigations primarily because they are unnecessary (86 per cent) and the waiting time for results is too long (51 per cent).

Quality of care of hypertension in three clinical settings in Jamaica

To determine quality of monitoring and control of hypertension in Jamaica, records of patients aged >30 years attending (1) Spanish Town Health Centre (STHC), a public general clinic; (2) University Hospital Specialist Hypertension Clinic (UHWI); (3) private group general clinic (PRGP), for >1 year were reviewed. 756 records were retrieved, 500 from STHC, 119 UHWI and 137 PRGP. Age and sex distribution differed between clinics (STHC mean 60 yrs, 15 percent men; UHWI mean 54 yrs, 34 percent men; PRCP mean 51 yrs, 54 percent; p<0.001). Smoking and alcohol habits (p<0.01) and body weight (p<0.001) were recorded significantly more in UHWI patients.(AU)

Medical practitioners views on the management of hypertension in Trinidad and Tobago

We surveyed 161 medical practitioners in Trinidad and Tobago (124 reporting private sector practice and 37 describing government health centre practice) for their views on blood pressure (BP) management. 96 percent of the respondents agreed that BP should be measured on all adults seen and 90 percent agreed that diastolic pressure should be recorded as the disappearance of sounds. There was disagreement over the level of diastolic BP at which drug treatment should be initiated: 63 percent would treat diastolic BP less than 100 mm Hg, but 35 percent would only treat diastolic BP of 110 mm Hg or higher. In private practice 31 percent preferred angiotensin converting enzyme (ACE) inhibitors as treatment for an African Caribbean man with diastolic BP 110 mm Hg, but in public clinics 41 percent preferred thiazide diuretics. ACE inhibitors wre most often preferred as treatment for an Indo-Caribbean man with diabetes and diastolic BP 110 mm Hg in both public and private practice. Doctors considered that non-compliance (66 percent), lack of education (34 percent) and unhealthy lifestyles (25 percent) were important obstacles to BP control. In private practice doctors considered patients' financial constraint to be an obstacle (58 percent), whereas in the public sector limited availablity of drugs (57 percent) was felt to be more important. Less costly and possibly, more appropriate drugs were used in public clinics.(AU)

Survey of patients with sexually transmitted diseases seen by private physicans in Jamaica

A survey of physicians in private practice in Jamaica was conducted between March and September 1993 to provide a descriptive analysis of the occurrence of patients with sexually transmitted diseases (STDs) seen in their practices. Questionnaires were delivered to 371 physicians of whom 127 (34 percent) responded, completing 683 (men 353, women 330) individual patient questionnaires. Each physician collected data over a period of one week. The median ages of the men and women were 27 years and 26 years, respectively. 464 (68 percent) patients were being seen for the first time for symptomatic STDs, and the visit was a follow-up for 132 (19 percent) who had been previously diagnosed; 40 (6 percent) patients were asymptomatic contacts referred by a sex partner, and 12 (2 percent), who were asymptomatic, asked for a "check up". A history of previous STD was given by 358 (52 percent) patients. 470 (69 percent) patients had a genital discharge (M, 65 percent; F, 73 percent; p = 0.017), 52 (8 percent) had anogenital lesions (M, 10 percent; F, 5 percent; p = 0.013) and 45 (7 percent), inguinal lymphadenopathy (M, 10 percent; F, 3 percent; p = 0.002). Among women, 131 (40 percent) had lower abdominal pain on examination and 105 (32 percent) had cervical excitation tenderness or pain suggesting pelvic inflammatory disease (PID). A working diagnosis of gonorrhoea was made in 273 (40 percent) patients, trichomoniasis in 121 (18 percent), nongonococcal infection in 114 (17 percent), syphilis in 60 (9 percent), herpes genitalis in 20 (3 percent) and chancroid in 11 (2 percent). PID was diagnosed in 121 (37 percent) women and nongonococcal urethritis in 98 (28 percent) men. The most frequently prescribed treatments were for chlamydia, gonorrhoea and trichomoniasis. In general, working diagnoses correlated well with clinical observations and treatment given, matched with diagnosis according to national guidelines. A comparison of the STD burden between the public and private sectors was not possible because of sample bias. (AU)

Antihypertensive drugs in primary care in Barbados: used or abused?

An audit of clinic records of 1016 adult Barbadians who attended their public or private primary care practitioners during July 1994 was performed. Non-drug therapy for hypertension was rarely recorded; single drug therapy was the most common regimen employed for 'treating' hypertension. There was fairly liberal use of the most expensive drugs, such as the ACE inhibitors and calcium channel blockers, which may cost up to 200 times more than thiazide diuretics. The clinic records did not indicate why certain regimens were preferred. There was minimal screening for metabolic complications. Only 18 percent of hypertensive patients had blood pressures controlled at the < 140/90 mm Hg level, even though they were all prescribed antihypertensive medication. AU.

Medical practitioners' views on the management of hypertension in Trinidad and Tobago - abstract

We surveyed 161 medical practioners in Trinidad and Tobago for their views on blood pressure (BP) management. Respondents (96 percent) agreed that the disappearance of sounds should be a measure of diastolic pressure. There was disagreement over the level of diastolic BP at which drug treatment should be initiated. 63 percent would treat BP less than 100mm Hg but 35 percent would only treat BP of 100mm Hg or higher. Treatment choices for an African Caribbean man with BP 110mm Hg included thiazide (24 percent), angiotensin converting enzyme (ACE) inhibitor (24 percent), calcium antagonist (15 percent), brinerdin (10 percent) and beta-blocker (7 percent). For an Indo-Caribbean man with diabetes and BP110mm Hg, treatment choices included ACE inhibitors (55 percent), calcium antagonist (9 percent), beta-blockers (7 percent), brinerdin (6 precent) and thiazide (5 percent). Doctors considered that non-compliance (66 percent), lack of education (34 percent) and unhealthy lifestyles (25 percent ) were important obstacles to BP control. In private practice, doctors considered patient financial constraints to be an obstacle (58 percent), whereas in the public sector limited availability of drugs (57 percent ) was felt to be important. There is a lack of consensus concerning the level of BP requiring treatment and the choice of initial therapy in hypertension. (AU)

A comparative study of drug utilization reviews on high bloodpressure and diabetes mellitus in three OECS countries: Dominica, St. Lucia and St. Vincent

This study compared the results of a recent Drug Utilization Review (DUR) of patients with hypertension and diabetes mellitus in Dominica (1995) with similar studies conducted earlier in St. Lucia (1992) and St. Vincent (1994). The reviews sought to assess prescribing behaviour in order to guide appropriate intervention to enchance prescribing behaviour. In each situation, more than 1000 prescriptions were collected from both public and private sector pharmacies on a pre-determined patient quota basis. As found in previous studies in St. Lucia and St. Vincent, twice as many women as men were treated for those two conditions and there was a significant number of patients (21 percent) with both conditions. The frequency of use of the hypotensive drugs, bendrofluazide and methyldopa, were similar in the three countries with St. Vincent being most conservative (39 percent and 26 percent, respectively), followed by St. Lucia (35 percent and 24 percent) and Dominica (30 percent and 19 percent). However, bendrofluazide and methyldopa were often prescribed in higher than currently recommended doses. Chlorpropamide was consistently the most popular oral hypoglycaemic drug prescribed in all countries. A notable difference among the countries was the relatively high use of metformin in Dominica and its low use in St. Lucia. The high use of insulin suggests that there is a need for a review in the treatment practices in the OECS which has a primarily non-insulin-dependent-diabetes (NIDDM) population. The results of the studies are encouraging and seem to suggest that doctors in the OECS are cost-conscious. Perhaps the Eastern Caribbean Drug Service formulary manual has influenced prescribing behaviour. It is expected that future drug utilisation reviews and continuing medical education may improve prescribing practices (AU)

The prescribing patterns of doctors in the Kingston Metropolitan region of Jamaica

Rising inflation and the instability of the Jamaican dollar have impacted negatively on the health care of the Jamaican people. Prescription drugs constitute a major component of this health care expenditure. The Generic Act was introduced to promote the dispensing of generic drugs as affordable alternatives to brand-name drugs and seminars targeted doctors to practise rational prescribing of drugs. This study examined the current prescribing patterns of medical doctors with special regard to drug cost and generic prescribing. Six pharmacies were randomly selected from a list from the Pharmaceutical Association of Jamaica, stratified according to three locations. A total of 1020 prescriptions were analyzed for number of items, generics, antibiotics, analgesics, antihypertensives, antidiabetics and whether generic substituiton or repeat was allowed. A self administered questionnaire was also delivered to 170 physicians practising in the Kingston Metropolitan Region who were chosen randomly from a list supplied by the Medical Association of Jamamica. The questionnaire elicited information on demographic charcteristics, factors influencing prescribing decision, prescribing paractice and attitude to generic law and generic prescribing, knowledge of 10 commonly used drugs and sources of information on drug costs. Analysis of prescriptions showed the mean number of drugs prescribed was 1.2 per patient, antibiotics accounted for 30.9 percent of the components of prescriptions, 0.5 percent had substitution and 6 percent were repeat prescriptions. The percentage of drugs prescribed by generic name was 22.1 accounting for 34 per cent of prescriptions. There was no significant difference found by location of pharmacies (chi-squared+2.86, d.f=2, p=0.24). Doctors indicated that drug cost was the third most influential factor determining their prescribing decisions. There were no significant difference found in the prescribing of generics between public and private doctors (chi-squared=2.42, d.f.=2, p>0.05). Most were ignorant about the Generic law as well as the estimated costs of drugs. The respondents agreed that generics were clinically equivalent and more affordable than brand-name drugs. This survey reaffirms the importance of continued medical education being made available and accessible to doctors on relevant health care issues so as to provide better service through more cost effective means. (AU)

The impact of supply protocols on equity and cost containment of the special benefit service of the Barbados drug service - abstract

From 1986, the Barbados Drug Service (BDS) has used Supply Protocols to help contain its costs, including that of its Special Benefit Service, and to develop equity in terms of the distribution and utilisation of pharmaceuticals. The special Benefit Service provides drugs free of cost (at the point of delivery) to the elderly and the young and to patients with common chronic illness. The programme has expanded over the years and beneficiaries receive the same pharmaceuticals irrespective of whether they saw physicians in the public or private sector; there is no discrimination based on colour, class economic or social status. The number of prescriptions filled in the public sector at the start of the implementation of Supply Protocols in December, 1986 was 915,753 (1987/88) and this decreased by 8 percent to 844,789 in 1993/94 while expenditure increased by 18 percent from BD$8,536,816 to $9,440,576 for the same time period. Prescriptions from the private sector increased by 85 percent from 300,000 to 554,000 for the same period and expenditure by 116 percent, from BD$3,346,816 to $7,228, 270. Total prescriptions increased by 15 percent and expenditure by 40 percent (AU)

Assessing family planning service-delivery practices: the case of private physicians in Jamaica

This report presents a study of the family planning service-delivery practices of private physicians in Jamaica. All 367 private physicians in Jamaica who offer family planning services, counseling, or referral were included in the survey. The study revealed that a client seeking services might be given a method by one provider and not by another, and that the methods clients use are likely to be influenced by the providers' preferences. Private physicians in Jamaica are in need of access to current international guidance on contraceptive methods and service practices. (AU)

Factors influencing doctors' knowledge and prescribing habit concerning antimicrobial drugs: issues emerging from a pilot study - abstract

Although many antimicrobial drugs are available in Jamaica, hitherto no surveys have been done to assess doctors' knowledge and usage of these drugs. The authors report on a pilot study of this kind carried out at the Spanish Town Hospital. Thirty-three of 39 doctors on staff were available and completed a questionnaire which enquired about knowledge of certain older and newer antimicrobials, sources from which doctors were first introduced to the drugs

Drug prescribing for diabetes mellitus in primary care: a comparison of public and private practice in three Caribbean countries - abstract

Examining the appropriateness of drug prescribing for people with diabetes mellitus in Caribbean countries is important because of the high cost of drug treatment, the potential for improved control of the disease and the possibility of reducing adverse side effects of treatment. This study examined patterns of drug prescribing for diabetes mellitus in public and private sector primary care settings in three Caribbean countries. The sample included 690 patients in Barbados (BDS, 24 percent private), 791 in Trinidad and Tobago (TT, 13 percent private) and 180 in Tortola (BVI, 31 percent private). Patients treated in public health care facilities were prescribed significantly more drugs than those treated in private practice. Few patients had diabetes mellitus managed by diet alone (8 percent public, 15 percent private). Metformin was rarely used as single agent therapy (3 percent public, 6 percent private). Most patients were treated with sulfonylurea drugs alone or in combination with metformin (75 percent public, 67 percent). The proportion of sulfonylurea prescriptions for chlorpropamide varied (Public: BVI 80 percent, TT 60 percent, BDS 10 percent; Private: BVI 41 percent, TT 28 percent, BDS 7 percent) as did prescriptions for gliclazide and glipizide (Public: BDS 41 percent, BVI 3 percent, TT 1 percent; Private: BVI 51 percent, BDS 46 percent, TT 19 percent). A high proportion of patients were treated for hypertension (public 49 percent, private 40 percent). In private practice, ACE inhibitors and diuretics were the most frequently prescribed drugs. In the public sector, Brinderin accounted for 53 percent of prescriptions in TT while thiazides, methyldopa, betablockers and ACE inhibitors were the most frequently prescribed drugs in BDS and BVI. These variations in prescribing practice among countries of the region suggest that factors other than patients' needs or the cost effectiveness of treatment are important in determining prescribing practices. Individual countries should examine how efficiency and effectiveness of drug use could be improved (AU)

A prescription analysis study of drug utilisation in polyclinics in Barbados - abstract

A drug utilisation review was carried out in three polyclinics in Barbados by analysing prescriptions. The prescribing patterns of seven doctors were assessed with respect to (1) the total number of different drugs prescribed, (2) the therapeutic category of each drug, (3) whether they were prescribed by generic or trade name, (4) the number of drugs per patient visit, (4) the cost of one in five prescriptions and (5) the choices within the three most prescribed categories, i.e. analgesics and anti-inflammatory drugs, antibiotics and diruetics. The number of different drugs used by individual doctors was extremely modest. It ranged from 29 to 60 (mean 47). The number of drugs used correlated positively with the number of items per patient visit. The mean items per patient ranged from 1.82 to 3.12. Eighty-eight per cent of prescriptions were written by trade name. Only one doctor, the most highly trained, showed a noticeable preference for generic prescribing, and in spite of a relatively high score of items per patient visit his prescription costs were below the average. Paracetamol (cost 1.5 cents) and then bendrofluazide (cost 1.1 cents) were the two most frequently prescribed drugs. This illustrates prescriber compliance with formulary recommendations. Some other prescribing practices were much less rational and economical. Prescription analysis is an essential tool for monitoring drug use. It reveals bad prescribing practices and can assess responses to education. It provides a logical and cost-effective means of physician audit with potential for improving prescribing practices and hence health care (AU)

Drug therapy in an isolated rural community - abstract

This study was conducted in Carriacou, one of the Grenadine islands affiliated to Grenada, between October 1985 and Janaury 1986, to determine the extent and pattern of drug-prescribing in the island. Three doctors on the island provided general practitioner services at five clinics. From the case-notes, the name, age, sex, diagnosis, treatment and duration of treatment were collected. The diagnosis and treatment were coded and the information processed by computer. A total of 1,349 patients was seen 2,034 times: 17.1 percent of attending patients received no medication, 54.6 percent received one drug per prescription and only 3.4 percent per cent three or more drugs per prescription; 49.2 percent of prescriptions were for less than 14 days whilst 37.3 percent were for 28 days or more. Penicillins were most commonly prescribed, accounting for 10.1 percent of all prescribed drugs. This was followed by aspirin (8.1 percent) and antacids (7.3 percent). Pencillins were the most frequently prescribed drugs for patients under 45 years of age. Antihypertensives were the most frequently prescribed drugs for patients over 45 years of age. There was not excessive prescribing of psychotropic drugs, antibiotics and analgesics when compared with more developed countries. The most frequently recorded health problems were hypertension (14.2 percent), upper respiratory tract infection (8.7 percent) and dyspepsia (6.5 percent). The high incidence of dyspepsia was related to the high alchohol intake and the use of aspirin to treat osteoarthritis. An examination of prescribing practices, increased community education and patient participation can result in more effective and economical use of drugs (AU)

Prescribing practices for hypertension and diabetes mellitus in government and private clinics in Barbados - abstract

A random sample of prescriptions for hypertension (485) and diabetes mellitus (843) was taken from the Queen Elizabeth Hospital dispensary and a large private dispensary. Prescribing practices were compared for Special Benefit Service patients, private patients paying full cost of their prescriptions, hospital "walk-in-clinic" patients and hospital outpatients' clinic patients. The major differences in prescribing for hypertension were: lower use of beta-blockers in the hospital clinics (12 and 16 percent) than in private offices (33 and 28 percent); higher use of methyl dopa by "walk-in" clinic doctors (28 percent); higher use of diruetics in hospital clinics (56 and 49 percent) than in private offices (39 and 47 percent); a surprisingly high use of methyl dopa by "walk-in" clinic doctors (28 percent); higher use of vasodilators in hospital outpatients (11 percent) than in private clinics (5 percent); and higher use of all other drugs by private doctors. The major differences in prescribing for diabetes mellitus were the very low use of insulin in private (4 percent) and "walk-in" clinic (2 percent) patients compared with hospital outpatients (22 percent) and benefit service patients (25 percent); high use of chlorpropamide by private doctors (54 percent); high use of glibenclamide in the "walk-in" clinic (33 percent) and higher metformin use at the hospital (32 and 27 percent) than in private clinics (21 and 20 percent). There was a consistent trend for use of less drugs per patient in private offices, and there was a significantly lower age range of patients attending private offices, compared with those attending hospital clinics and utilising the Drug Benefit Service. Prescription costs were not strikingly different, but private prescription costs appeared to be kept low by using less drugs of greater cost. These data indicate an important place for education/intervention strategies for doctors in therapeutics, to improve prescribing practices, particularly in private and "walk-in" casualty type settings (AU)