1. INFLUENCING PRESCRIBING BEHAVIOUR Dr Martin Duerden 1

2. From dissemination to implementation Changing clinical practice 2

3. 3 Prescribing new drugs – the GP view (Prosser, Almond & Walley. Family Practice 2003;20:61-68) 107 GPs – interviewed. Initial info. sources 616 prescriptions of black triangle drugs: Drug rep. 33% Media 16% “Grey literature” 16% Promotional literature 15% Hospital doctor 10% HA/PC0/Adviser 5% Patient 3% DTB/MeReC/BNF etc. 1% Actively searching for info. 5%

4. 4 Pharmaceutical Promotion Sheer size of marketing investment suggests it works: doctors, nurses and others have considerable interaction with industry Much PG education is paid for by industry Doctors have contradictory views; enjoy the contact but don’t rate the content USA evidence that such contact (particularly symposia) affects prescribing and formulary choice Prescribers may have poor insight No evidence that restrictive policies work (yet!)

5. Marketing Strategies Representatives Detail aids and information Diagnostic services Specialist nurse support Loss leaders Drug trials, post- marketing studies Training of staff Patient information – websites Adverts Sponsorship of meetings Other educational initiatives - books, videos, podcasts, software, memory sticks Patient information leaflets Doctor and Nurse Education – use of opinion leaders Etc…… 5

6. http://nofreelunch.org/ 6

7. See also: Cochrane Effective Practice and Organisation of Care (EPoC) Group Reviews http://epoc.cochrane.org/epoc-reviewshttp://epoc.cochrane.org/epoc-reviews 7

8. Evidence-based implementation 8

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12. December 2007 12

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14. SIGN: Potential external barriers to implementation include Structural factors (e.g. financial disincentives) Organisational factors (e.g. inappropriate skill mix, lack of facilities or equipment) Peer group (e.g. local standards of care not in line with desired practice) Individual factors (e.g. knowledge attitudes, skills) Professional-patient interaction (e.g. problems with information processing). 14

15. Some ideas and conclusions There is increasing evidence on the best ways to implement evidence-based medicine and change clinical practice Some of this may involve strategies adopted from marketing Usually a range of approaches will be required – passive dissemination is not enough Don’t forget the power of informed patients Don’t overestimate the understanding of risk and risk communication, even in ‘senior’ colleagues Opinion-leaders can be powerful but may not be objective 15