Identification of influences on the quality use of medicines in general practice in rural Australia

The disparities in health in rural Australia are well established. Rural General Practice is also recognised as a unique environment. Doctors may frequently practice alone with limited facilities providing primary and secondary care. Prescribing is a complex decision-making process with many 'non-medical' influences on prescribing contributing to appropriate and inappropriate prescribing. There is limited evidence available on the influence of rural location on prescribing, particularly from an Australian perspective. This thesis describes the known non-medical influences on prescribing and investigates the effect of rural location on prescribing.n The first part of this thesis describes a questionnaire study with rural (n=142) and metropolitan doctors (n=137) to detect perceptions of influences on prescribing. Interviews were undertaken with twenty-five rural doctors to validate and expand the data. The results showed that rural doctors perceived that they prescribed differently, on some occasions, to doctors in metropolitan areas. The study detected that rural doctors, compared to metropolitan doctors, were more likely to perceive the effect of practice location (71% of rural group vs. 44% of the urban group), the isolation of a patient's home location (78% vs. 9%) and local climate on prescribing (51% vs. 3%). Rural doctors considered they dealt with more complex problems, frequently having to prescribe 'specialist' drugs. It was shown that rural doctors perceived they avoided drugs with significant monitoring requirements and would choose a new drug with reduced monitoring requirements. It is acknowledged that these perceived differences could be prestige bias. Continuing medical education (86% vs. 73%), the Pharmaceutical Benefits Scheme (95% vs. 94%), specialists (89% vs. 81%), patient expectation for a prescription (66% vs. 55%), and a patient's access to drug therapy (72% vs. 67%) were recognised by both rural and metropolitan doctors as influences on prescribing, as described similarly in the literature. Both groups failed to recognise the influence of the pharmaceutical industry on prescribing. This thesis recognises this is likely to be a socially acceptable response. This study showed a significantly lower uptake of the prescribing of selected newly registered drugs by rural doctors, compared to metropolitan colleagues and may be related to the identified reduced levels of pharmaceutical industry promotion in rural areas or other confounding factors. A variety of differences in the perception of influences on prescribing were shown between the rural doctors practising in areas of differing isolation. The more remote doctors were more likely to report the differences described above, however, many of these differences were not statistically significant. Considering, rural doctors perceived problems associated with prescribing for patients living in isolated locations, the final part of this thesis investigated patient expectation, doctors' perception of patient's expectation and influences on the decision to prescribe in rural locations. The study used patient and doctor matched questionnaires distributed at doctors' practices in different rural locations in Queensland. A total of 481 patients were recruited into the study from five rural locations in Queensland involving 17 rural doctors. An increase in distance a patient lived from a doctor's practice was not seen to increase the level of a patient's expectation for a prescription (p=0.847), the doctor's perception of patient's expectation for a prescription (p=0.670) or the decision to prescribe (p=0.704). These results contradict the perceptions of the doctors in the interview and questionnaire study. This is the first study, to the best of the author's knowledge, to investigate the relationship between a patient's home location and prescribing. Rural patients demonstrated similar levels of expectation for a prescription compared to urban studies. The strongest predictors for increased demand were male gender (p=0.001), patients who were children, older patients and previous prescribing of a medication. Rural doctors demonstrated similar difficulty in perceiving patient expectation for a prescription as previously reported in the literature. A similar rate of prescribing (55.5% of all consultations) was detected as in previous studies. There was strong association between perception of expectation and a patient's demand for a prescription. Logistic regression showed that the strongest predictor for the decision to prescribe was the doctor's perception of a patient expectation for a prescription, similar to previous urban studies. Much lower levels of doctors experiencing patient pressure were identified in this rural study compared to the previous urban studies (25 consultations in 481 consultations). The limitations of the methodologies used are recognised and described. In qualitative research there are relatively few opportunities to validate obtained data. These issues must be considered when interpreting the results and conclusions. In conclusion, the relevance of these differences in the influences on prescribing must be considered when developing medicines policy and prescribing intervention strategies for rural prescribers. There is no evidence that prescribing patterns in the rural areas are inappropriate, but rural doctors must be provided with the appropriate skills, knowledge and resources to allow them to deal with the specific situations effectively. Failure to appreciate these differences may result in interventions being considered as irrelevant and not applicable in rural practice.n