INTRODUCTION
It is widely recognised that the more medicines patients take, the
greater the risk of adverse drug reactions and
hospitalisation.1 Indeed, prescription medication is
implicated as a causal factor in approximately 7% of hospital
admissions. 2 However, when treating patients with
multiple morbidities, deciding which of several medicines are
appropriate (‘appropriate polypharmacy’) and which are not (‘problematic
polypharmacy’) 3 represents a prescribing decision
dilemma, that, to date, remains largely unresolved especially when
multiple prescribers focus upon different disease processes.
A comprehensive review of theories and models of prescribing decisions
by Murshid and Mohsen describes a wide range of variables that relate to
physicians’ decisions to prescribe medicines. 4 The
theories of persuasion, planned behaviour and agency theory have
enhanced our understanding of how prescribing decisions may be
influenced by the characteristics of patients, (e.g. patient
expectations), pharmaceutical marketing5 6, the
characteristics of drugs, the ratio of drug cost to benefit and
physician habit persistence. Social power theory is also important in
terms of understanding how pharmacist – physician collaboration and the
level of trustworthiness between health care professionals may influence
prescribing decisions. However, in our experience, this knowledge has
not yet been consistently translated into practice to ensure problematic
polypharmacy is avoided.
There is no shortage of professional guidance on how best to encourage
appropriate prescribing in the UK in the face of
polypharmacy.3 7 8 9 10 11 Indeed, prescribing
guidance tools such as Beers criteria for the elderly12 and STOPP/START13, are readily
available. However, a recent randomised controlled trial carried out in
six European hospital medical centres reported poor uptake by clinicians
of SENATOR software-generated medication advice based upon STOPP/START
prescribing rules.14 A shared aim of all polypharmacy
guidance is to recognise the patient as an individual who often has
multiple problems, rather than as a series of individual conditions
where multiple individual clinical guidelines may be applied. Thus, some
goals may need to be modified to enable the overall health of an
individual to be optimised whilst ultimately ensuring prescribed
medicines are safe.
Owing to the on-going conflict between problematic polypharmacy and
patients’ presentation to hospital with multimorbidity, we decided to
find out whether prescribing decisions are influenced by factors other
than those that have already been identified by existing theories and
models of prescribing. We, therefore, decided to evaluate the mindset of
doctors and pharmacists involved in making prescribing decisions in an
acute hospital medical unit (AMU). The term ‘mindset’ reflects the
habitual attitudes and ways of thinking that contribute towards a mental
framework within which prescribing decisions are made. The primary aim
of the study was to gain an understanding of the mindset of prescribers
during routine practice and to evaluate whether this mindset, embedded
within real-life decision-making scenarios, relates to existing theory
and models of prescribing decisions.