| Abstract |
Introduction: Prescribing represents a fundamental component of patient care. Rational prescribing is crucial for patients' health and the health system. However, globally irrational prescribing is common and has a negative impact on clinical outcomes and the efficiency of health system. On the other hand, prescribing patterns determine the volume of pharmaceutical consumption and consequently pharmaceutical expenditure. However, in Greece there are only limited research evidence from specific health centers and there are no sufficient data neither for GPs' prescribing patterns in primary health care, nor for their beliefs regarding prescribing.
Objectives: The aim of the present study was to record prescribing patterns of GPs and identify the specific prescribing circumstances in primary health care in Greece compared to other European countries. Furthermore, the present study aimed at identifying GPs' beliefs regarding prescribing.
Methods: For this purpose a combination of qualitative and quantitative methods was used in order to capture and understand the different perspectives of GPs' prescribing behavior. At first, a qualitative study took place using the method of Focus Groups, and 19 GPs from 3 geographically defined regions in Greece participated. Discussions were recorded after participants' written informed consent and a directed content analysis was used, guided by the Theory of Planned Behavior in order to identify and classify GPs' salient beliefs regarding prescribing. The results from this qualitative study were used to inform the development of two (2) questionnaires. The aim of the first questionnaire was to record prescribing patterns of Greek GPs and was used in a prospective cross-sectional study that took place in Crete and in Athens. 13 GPs completed the questionnaire giving data for 1,202 patients and then specific prescribing rates were calculated. The second questionnaire was developed based on the TPB and the aim was to explore GPs' intention to prescribe medicines to a patient during a consultation in a primary care facility, and the antecedents of this intention. 699 GPs from 7 European countries (Cyprus, Czech Republic, France, Greece, Malta, Sweden and Turkey) participated.
Results: GPs that participated in the qualitative study acknowledged that medicines are an important tool in clinical practice and that prescribing is the most important method for treating diseases in primary care. This finding was confirmed in the following stages of the research, since participated GPs actually prescribed medicines to the majority of their patients. The qualitative study also, revealed the specific circumstances that GPs face during prescribing in primary care. These phenomena were important barriers in prescription choice and were identified as: (a) prescribing through a third person, (b) repeat prescribing for chronic diseases without examination and (c) prescribing following patient's prescription request for prescribed medicines that they have already purchased over the counter through pharmacies. The aforementioned situations are phenomena of irrational prescribing and the present study confirmed that these constitute over 50% of the total prescriptions in Greece. These phenomena are also common in all countries, although in different extent. GPs from Sweden and Czech Republic were more reluctant to prescribe under these circumstances. In all countries GPs had a positive attitude towards prescribing and were in control of prescribing decision. GPs from Greece and Cyprus claimed to feel social pressure to prescribe. Especially, Greek GPs considered that prescribing had many advantages for patients' health and the health system as well. They acknowledged that there are also disadvantages regarding adverse drug reactions and increased cost for the patient because of the copaymets. Patients and their family were identified as the groups of people that place pressure on GPs to prescribe. Other groups that place pressure on GPs to prescribe but to a lesser extent are pharmaceutical sales representatives. Correct diagnosis, guidelines and the sufficient time to explain the use of medicines were considered to facilitate prescribing decision. On the other hand, special situations in prescribing (phenomena of irrational prescribing) and the limited time for consultation were identified as important barriers to prescribing. The present study also shed light to the needs of GPs regarding continuing education and their positive attitude towards guidelines, audit and their motivation to comply with the recommendations of the Public Health Authorities. GPs' prescribing intention was different in participating countries and GPs from Sweden and Malta were less inclined to prescribe. Correlations between TPB explanatory measures and prescribing intention were weak and TPB direct measures explained about 25% of variance in intention to prescribe in Malta and Czech Republic.
Conclusions: The present study explored for the first time in Greece GPs' beliefs regarding prescribing using the theoretical model of the Theory of Planned Behavior, which was then applied in 7 European countries. The present study also, identified and measured the special situations in prescribing in primary care not only in Greece but in all participating countries. Furthermore, it was the first time that the special situation of prescribing for medicines already bought from pharmacy was identified and measured in Greece. The results of the present study show the prescribing is not always a rational decision, but it is subject to various beliefs and factors that are different in each country. Consequently, there is a need to improve prescribing and the present study shed light to the areas and situations that need to be addressed in future. Also, the aforementioned findings are expected to contribute to the better understanding of continuing education needs not only for GPs but for pharmacists and patients as well. Finally, these findings are expected to have an impact on designing of suitable policies towards rational prescribing and guiding future research.
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