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. 2002 Jun;11(2):137–143. doi: 10.1136/qhc.11.2.137

Scope and nature of prescribing decisions made by general practitioners

P Denig, C Witteman, H Schouten
PMCID: PMC1743618  PMID: 12448805

Abstract

Background: This study describes cognitive processes of doctors who are deciding on the treatment for a patient. This helps to uncover how prescribing decisions could benefit from (computerised) support.

Methods: While thinking aloud, 61 general practitioners made prescribing decisions for five patients with urinary tract infections or stomach complaints. The resulting 305 transcripts were analysed to determine the scope and nature of the decision processes. Differences in the process were related to case or doctor characteristics, and to differences in the quality of prescribing behaviour.

Results: The decision processes were not extensive, particularly for patients with a urinary tract infection. The doctors did not actively consider all possible relevant information. Considerations referring to core aspects of the treatment were made in 159 cases (52%) and to contextual aspects in 111 cases (36%). Habitual behaviour, defined as making a treatment decision without any specific contemplation, was observed in 118 cases (40%) and resulted in prescribing first choice as well as second choice drugs. For stomach complaints, second choice drugs were often prescribed after considering other treatments or in view of specific circumstances. Experience of the doctor was not related to the type of decision process.

Conclusions: The processes observed deviate from the decision theoretic norm of thoroughly evaluating all possible options, but these deviations do not always result in suboptimal prescribing. Decision support is useful for bringing pertinent information and first choice treatments to the prescriber's attention. In particular, information about relevant contraindications, interactions, and costs could improve the quality of prescribing.

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Selected References

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  1. Buetow S. A., Sibbald B., Cantrill J. A., Halliwell S. Prevalence of potentially inappropriate long term prescribing in general practice in the United Kingdom, 1980-95: systematic literature review. BMJ. 1996 Nov 30;313(7069):1371–1374. doi: 10.1136/bmj.313.7069.1371. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Coste J., Venot A. An epidemiologic approach to drug prescribing quality assessment: a study in primary care practice in France. Med Care. 1999 Dec;37(12):1294–1307. doi: 10.1097/00005650-199912000-00012. [DOI] [PubMed] [Google Scholar]
  3. Denig P., Haaijer-Ruskamp F. M. Do physicians take cost into account when making prescribing decisions? Pharmacoeconomics. 1995 Oct;8(4):282–290. doi: 10.2165/00019053-199508040-00003. [DOI] [PubMed] [Google Scholar]
  4. Denig P., Haaijer-Ruskamp F. M. Therapeutic decision making of physicians. Pharm Weekbl Sci. 1992 Feb 21;14(1):9–15. doi: 10.1007/BF01989219. [DOI] [PubMed] [Google Scholar]
  5. Denig P., Haaijer-Ruskamp F. M., Wesseling H., Versluis A. Towards understanding treatment preferences of hospital physicians. Soc Sci Med. 1993 Apr;36(7):915–924. doi: 10.1016/0277-9536(93)90083-g. [DOI] [PubMed] [Google Scholar]
  6. Di Caccavo A., Reid F. Decisional conflict in general practice: strategies of patient management. Soc Sci Med. 1995 Aug;41(3):347–353. doi: 10.1016/0277-9536(94)00331-m. [DOI] [PubMed] [Google Scholar]
  7. Elstein A. S., Holzman G. B., Belzer L. J., Ellis R. D. Hormonal replacement therapy: analysis of clinical strategies used by residents. Med Decis Making. 1992 Oct-Dec;12(4):265–273. doi: 10.1177/0272989X9201200404. [DOI] [PubMed] [Google Scholar]
  8. Hurenkamp G. J., Grundmeijer H. G., Bindels P. J., Tytgat G. N., van der Hulst R. W. Chronisch gebruik van maagzuursecretieremmende medicatie in de huisartsenpraktijk in de regio Amsterdam. Ned Tijdschr Geneeskd. 1999 Feb 20;143(8):410–413. [PubMed] [Google Scholar]
  9. Jones T. V., Gerrity M. S., Earp J. Written case simulations: do they predict physicians' behavior? J Clin Epidemiol. 1990;43(8):805–815. doi: 10.1016/0895-4356(90)90241-g. [DOI] [PubMed] [Google Scholar]
  10. Lipman T., Price D. Decision making, evidence, audit, and education: case study of antibiotic prescribing in general practice. BMJ. 2000 Apr 22;320(7242):1114–1118. doi: 10.1136/bmj.320.7242.1114. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Mancuso C. A., Rose D. N. A model for physicians' therapeutic decision making. Arch Intern Med. 1987 Jul;147(7):1281–1285. [PubMed] [Google Scholar]
  12. Moskowitz A. J., Kuipers B. J., Kassirer J. P. Dealing with uncertainty, risks, and tradeoffs in clinical decisions. A cognitive science approach. Ann Intern Med. 1988 Mar;108(3):435–449. doi: 10.7326/0003-4819-108-3-435. [DOI] [PubMed] [Google Scholar]
  13. Nightingale P. G., Adu D., Richards N. T., Peters M. Implementation of rules based computerised bedside prescribing and administration: intervention study. BMJ. 2000 Mar 18;320(7237):750–753. doi: 10.1136/bmj.320.7237.750. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Persson M., Mjörndal T., Carlberg B., Bohlin J., Lindholm L. H. Evaluation of a computer-based decision support system for treatment of hypertension with drugs: retrospective, nonintervention testing of cost and guideline adherence. J Intern Med. 2000 Jan;247(1):87–93. doi: 10.1046/j.1365-2796.2000.00581.x. [DOI] [PubMed] [Google Scholar]
  15. Poses R. M., Anthony M. Availability, wishful thinking, and physicians' diagnostic judgments for patients with suspected bacteremia. Med Decis Making. 1991 Jul-Sep;11(3):159–168. doi: 10.1177/0272989X9101100303. [DOI] [PubMed] [Google Scholar]
  16. Purves I. N. PRODIGY: implementing clinical guidance using computers. Br J Gen Pract. 1998 Sep;48(434):1552–1553. [PMC free article] [PubMed] [Google Scholar]
  17. Purves I. Prodigy, a computer assisted prescribing scheme. Interim data show that it is worth taking the scheme further. BMJ. 1996 Dec 14;313(7071):1549–1549. doi: 10.1136/bmj.313.7071.1549b. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Steven I. D., Malpass A., Moller J., Runciman W. B., Helps S. C. Towards safer drug use in general practice. J Qual Clin Pract. 1999 Mar;19(1):47–50. doi: 10.1046/j.1440-1762.1999.00302.x. [DOI] [PubMed] [Google Scholar]
  19. Taylor R. J., Bond C. M. Change in the established prescribing habits of general practitioners: an analysis of initial prescriptions in general practice. Br J Gen Pract. 1991 Jun;41(347):244–248. [PMC free article] [PubMed] [Google Scholar]
  20. Veninga C. C., Lundborg C. S., Lagerløv P., Hummers-Pradier E., Denig P., Haaijer-Ruskamp F. M. Treatment of uncomplicated urinary tract infections: exploring differences in adherence to guidelines between three European countries. Drug Education Project Group. Ann Pharmacother. 2000 Jan;34(1):19–26. doi: 10.1345/aph.19068. [DOI] [PubMed] [Google Scholar]
  21. Walton R. T., Gierl C., Yudkin P., Mistry H., Vessey M. P., Fox J. Evaluation of computer support for prescribing (CAPSULE) using simulated cases. BMJ. 1997 Sep 27;315(7111):791–795. doi: 10.1136/bmj.315.7111.791. [DOI] [PMC free article] [PubMed] [Google Scholar]

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