Jamie Hayes

Clinical Trial Patient ?

Real Patient ?

Prescribing decisions Other parties actively passively influencing Patient Prescriber making decisions Patient Knowledge, attitudes, habits, experiences Knowledge, attitudes, habits, experiences

In the black box Knowledge Drug outcomes, guidelines, what others believe & do Values Relative importance of above Attitudes Role of drugs, risk-taking, doctor-patient relationship, professionalism Experience Patients, drugs, personal Habits & strategies Consultation management, information seeking, making prescribing decision Patient Prescriber Prescription

Parties influencing black box Patient Prescriber Prescription Government Health insurers Pharmaceutical industries Academia, C(ME) Professional organisations Colleagues Other professionals Patient (organisations)

Targeting ‘contents’ of black box Knowledge Values Habits & Strategies Experience Attitudes Information Selection, retrieval and interpretation Education Approach: how people learn, use their knowledge, motivation for learning Persuasion/Marketing (Academic) detailing, opinion leaders, media Decision aids Protocols, decision rules, computer programmes Feedback/reminders Pro-active & re-active correction

Steps in black box Definition of problem Possible set of treatment opinions Final choice for individual patient Patient/disease characteristics Prescribe drug or not Personal set of prescriber Decision strategy followed

Decisions underlying prescribing Decision to adopt (new) drug in personal set Decision to prescribe or not Decision what to prescribe for individual - which drug substance - brand/generic - administration form - dosage - duration

Decisions to change personal set 150 – 200 drugs, up to 5% changed per year External influences - industry, colleagues, government, academia Internal influences - knowledge & values: obvious advantage - experiences: personal or ‘dramatic’ cases - attitudes: early later adapters

Decisions to prescribe or not External influences: culture - to prescribe: patients, pharmaceutical industry - not to prescribe: governments, health insurers Internal influences: - values & attitudes: role of drugs, risk taking, avoid difficult dealings with patient, feeling the need to do something - strategies: end consultation

Decisions for individual patient Wide variations between/within countries Evoked set of 1-5 possible treatments External influences:patients, precedents set by colleagues, and through evoked set Internal Influences:depending on decision strategy followed

Possible decision strategies Rational:weighing pros and cons => knowledge & values Pragmatic:followed fixed routines or rules set by others => habit Experience:rely on past experiences and intuition => experiences Emotional:preventing regret or trying to please someone => values & attitudes

Overview There is more to prescribing than knowing all about drugs and diseases Prescribing is result of an interaction between external and internal factors To alter prescribing focussing on only one aspect in the black box is usually not enough

Theory of Planned Behaviour Attitudes Subjective Norms Perceived Behavioural Control Behavioural IntentionsBehaviour

To predict whether a person intends to do something, we need to know: Whether the person is in favour of doing it (‘attitude’) How much the person feels social pressure to do it (‘subjective norm’) Whether the person feels in control of the action in question (‘perceived behavioural control’) By changing these three ‘predictors’, we can increase the chance that the person will intend to do a desired action and thus increase the chance of the person actually doing it.

A patient with atrial fibrillation presents to their GP for an annual review. The patient is not currently being treated with warfarin. Will the GP prescribe warfarin? The answer to this depends on whether the GP intends to do so.

It is not an automatic, habitual or thoughtless action. The intention, in turn, depends on:- Whether, overall, the GP has a positive or negative attitude to prescribing warfarin for patients with AF To what extent the GP perceives that they experience social pressure to prescribe or not, including whether the GP thinks that: the patient wants warfarin professional colleagues would approve of prescribing; the health care system encourages prescribing and how important these various people’s opinions are to the GP Whether the GP finds it difficult to prescribe i.e. how difficult it is to enact the behaviour in the given context.

Principles of Academic Detailing 1. Conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns. 2. Focusing programmes on specific categories of physicians as well as on their opinion leaders. 3. Defining clear educational and behavioural objectives. 4. Establishing credibility through a respected organisational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues. 5. Stimulating active physician participation in educational interactions. 6. Using concise graphic educational materials. 7. Highlighting and repeating the essential messages. 8. Providing positive reinforcement to improved practices in follow- up visits.

Much of this has been recognised in previous reports

See also: Cochrane Effective Practice and Organisation of Care (EPoC) Group Reviews

How do we introduce ourselves? How are we introduced? –Does it matter?

Research suggests that nurses who wear stethoscopes, an emblem symbolising a physician’s expertise, are viewed as more authoritative than those who do not

How are we doing? Good teams in place Much resource spent on improving diagnosis and therapeutic decision Systems in place to decide on which medicines are clinically and cost effective... But there’s much more to it

How can the science of persuasion help?

Summary The many reports make a lot of sense We still tend (naturally) to concentrate on the therapeutics/knowledge Perhaps we should take a closer look at human behaviour –patients –prescribers How do our teams go about their business... Role of health psychologists?