Resolution on the quality of prescribing

Creation: committee Permanente de Médicos Europeos.
sourceSpanish Medical Association.
language original: Spanish.
Approval: committee General of Medical Colleges, Brussels, 30 August 2003.
Publication: 15 December 2003.
Checked on 11 May 2005.

The quality of prescribing

Introduction

The physician is obliged to provide his patient with quality service. One of the clauses of the Hippocratic Oath was: "I will apply my treatments for the good of my patients according to my ability and good judgement". This demand for quality is today stronger than ever because medicine has entered the field of forces (social, economic and legal) that have been promoting quality services in our society. People are no longer satisfied with just any subject medical care, they want it to be of the highest possible quality.

Health is the social fact with the greatest repercussions in Western society, and when tragic episodes occur, such as those that periodically hit the media, alarm is triggered and society wonders whether it is not defenceless in such important matters as medical prescription or in the face of the powerful pharmaceutical industry, and whether the essential controls are in place to ensure the quality of the medicine so that people can continue to trust in pharmaceuticals.

We must consider that in European society a change in the doctor-patient relationship is consolidating, fundamentally due to a change in the role of the latter, a more informed patient has emerged, with a greater Degree of training, awareness and awareness of the disease, therapy and consumption of medicines, health is an increasingly demanding demand by the citizen who wishes to access the highest possible level of quality of life in relation to their health and who demands quality and safety in relation to medicines. For their part, doctors are also aware of this change and must act accordingly with greater rigour when prescribing, taking into account their patients' rights, based on information and autonomy staff when deciding on the most appropriate therapeutic opinion.

Public health systems, aware of the freedom that doctors enjoy when it comes to prescribing and the economic impact of their decisions, want to place limits, restrictions and guidelines on doctors' work, with the purpose and the conviction that this will reduce the expense on medicines and the health system as a whole. Prescribing medicines will be an act increasingly conditioned by both economic criteria aimed at reducing the public expense on medicines, and therapeutic criteria aimed at greater rationalisation and participation of scientific criteria.

The quality of prescribing is becoming a permanent social and political demand, in relation to the adaptation of prescribing efficiency and the rationalisation of the pharmaceutical expense , as a social and economic measure in the process of containing the expense health care, attributing resources to inappropriate prescribing, which could be directed to other areas of healthcare, and stressing the doctor's responsibility in this matter which, in any case, will be shared with other agents involved in the healthcare process and the medicine (Administration, Pharmaceutical Industry, dispensing pharmacists and patients).

The CPME (committee Standing Committee of European Doctors) must respond to these demands to defend the compatibility between the quality of prescribing, efficiency and the essential principles of the medical profession, in relation to the freedom of prescribing and in defence of the priority of patient rights in relation to medical care in general and pharmaceutical care in particular.

We doctors cannot avoid the economic dimension of our decisions, but our ethical duty is to ensure the highest quality of medical acts, so we believe that we have to focus on improving the quality of prescribing and on how to make it more effective, improving the efficiency of our professional actions, so that we would foreseeably contribute to reducing the expense.

Prescribing is an activity resulting from a diagnostic orientation, from the assessment of possible interactions with other treatments and from the consideration of the patient's willingness and ability to use the medicines. It is important to remember that prescribing should be a logical deductive process, based on complete and objective information, and should not be a knee-jerk reflex, a routine act or a response to commercial pressure. Prescribing quality control must take into account the relevance and appropriateness of the prescription in relation to the patient's presenting problem. Quality in the use of medicines is synonymous with the rational use of medicines in the broadest sense of the term.

Quality prescribing must take into account the cost of drugs so that treatment is as economically inexpensive as possible for the patient and the healthcare system. Good prescribing is that which best combines efficacy, safety, convenience for the patient and also cost. There are currently opinions that insist that the benefit-risk balance no longer depends exclusively on the drug, but is conditioned especially by the prescribing doctor and the quality of his or her professional performance. The discussion on the economic sustainability of this permanent increase in the pharmaceutical expense must necessarily involve doctors, as we have an important responsibility in this expense through our prescriptions. One of the ways of participating in this discussion is by committing ourselves to the permanent improvement of the quality of prescribing in all aspects.

It is essential to involve primary care doctors in the different objectives of rationalising the use of medicines, implementing the exclusive control measures of expense developed so far, with measures aimed at knowledge of the reality in the primary care setting, informing their staff health care and training of the same in tasks of evolution of new therapeutic strategies, monitoring of the most recently marketed drugs from the dual perspective of effectiveness and safety, review and control of the information and training measures and strategies developed, and, lastly, raising awareness based on evidence of the best therapeutic measure to be used in a specific patient, the employment of the drug with the lowest cost expense.

The existing evidence on the quality of medicine consumption and utilisation, while improving daily, is far from satisfactory. The internationally accepted response to improve the quality and consumption of medicines is rational medicine use programmes. In this regard, it is worth recalling that the WHO defines rational use of medicines as the prescription of the most appropriate medicine, its timely use, its affordable price, its dispensing under appropriate conditions and its use by the patient at the prescribed intervals and for the prescribed period of time, availability .

To assess the quality of prescribing, it is convenient to distinguish between aspects of pharmacological rationality (efficacy of the drug) and economic rationality (efficiency of the drug), taking into account the clinical data and the diagnostic tests performed on each patient. In other words, the quality of the prescription implies that from a clinical point of view the pharmacological treatment is effective at the lowest possible cost.

Drug misuse has a high economic, social and health care cost. In recent years, the incidence of medication-related problems in the healthcare systems of developed countries has increased considerably, due to numerous factors related to the organisation of healthcare systems, technological complexity, the organisation of work and lags in the management therapeutic. In addition, the implementation and development of a safety culture within healthcare organisations is necessary.

In view of all these aspects and others foreseeable in the foreseeable future, the perspective required of doctors on prescribing needs to be addressed and changed. Sustained efforts need to be made by Education to create the necessary sensitivity to quality issues, if necessary by modifying the process of work of the physician and the context in which it takes place. At final, there must be a global commitment by all physicians to the quality of prescribing, and the public or private administrations on which physicians depend must encourage their efforts to promote the quality of prescribing by means of appropriate instruments.

Requirements for good prescribing

The quality of prescribing is undoubtedly linked to training and the permanent professional development , to the information the doctor receives and to the conditions and environment in which he/she works work.

trainingPhysicians must acquire an adequate training in medical therapeutics, initiated in the period of undergraduate training , continued in postgraduate studies, and updated throughout their professional life. The training is essential for making therapeutic decisions based on the best evidence available.

Information - Physicians should be concerned throughout their professional life with having access to up-to-date, independent and truthful information that allows them to retain maximum autonomy in their decisions and to avoid pressures from other agents that may influence or interfere with the prescribing process.

The information provided to the doctor, which must not be punitive, must be based on well-tested clinical evidence evaluated by the academic community, and there can be no contradictions, such as, for example, advocating the use of generics and, at the same time, introducing medicines that have not been shown to be bioequivalent to the medicine from reference letter ("copies"), among the lists of therapeutic options in the computer programmes of the doctors' surgeries.

Conditions of work. The act of prescribing requires sufficient time and a suitable environment that allows communication between doctor and patient. Excessive pressure of care and lack of coordination between the different levels of care have a negative impact on the quality of prescribing.

Actors and external factors influencing medical prescribing

Although prescribing is a medical act and therefore the doctor should be considered as practising it freely, assuming responsibility, there is no doubt that he/she is subject to various influences by other actors, especially the health administration and the pharmaceutical industry, but also by the patients themselves and by the organisation of the health care system.

• Health authorities are responsible for monitoring the quality of medicines, regardless of whether they are generic or branded. But it is clear that the priority goal of the health administration and the companies in this sector is to contain a steadily growing pharmaceutical expense , which represents a very significant part of the global pharmaceutical expense . Doctors cannot accept that the responsibility for the growth of the pharmaceutical expense should be attributed to us alone, but it is reasonable that we participate manager and actively in the discussion on measures that can contribute to a better management of prescribing.

• The pharmaceutical industry - The pharmaceutical industry has been and continues to be a very important element of partnership and financial aid to the training Continuing Medical Education through its sponsorship of academic and training activities. This partnership is not disinterested, as it aims at the same time to exert a direct or indirect influence on doctors' prescribing decisions.

• Patients - Social changes in recent years have shaped a change in the role of the patient in their relationship with the doctor. Doctors have also become aware of their obligation to respect patients' rights to information and autonomy (freedom and decision-making capacity). It is the physician's responsibility to decide which prescription he/she thinks is best for his/her patient. He or she will always inform the patient appropriately and take the patient's views into account. The therapeutic alliance that emerges from this noble exchange will result in adequate therapeutic compliance.

proposal of reforms to improve prescribing

In order to improve the quality of prescribing, a number of reforms must be pursued, namely:

1. To ensure adequate conditions of care practice, so that prescribing is the logical consequence of a well-done medical act.

2. To make available to prescribing physicians independent, effective and quality information systems that are problem-oriented, easily accessible, reliable and up-to-date. promote the training Continuing Medical Education of physicians on this subject, guaranteeing its objectivity, effectiveness and independence, through appropriate mechanisms and with the participation of the National Medical Associations.

3. Stimulate the development of clinical guidelines and therapeutic protocols in all healthcare centres and update them periodically, based on the best scientific evidence available.

4. promote a modern and appropriate prescription form that includes the necessary information to ensure the patient's compliance with the instructions given by the physician.

5. Recommend to the Schools of medicine the introduction of improvements in the teaching of pharmacological therapeutics, enhancing skills in prescribing and in communication with patients.

6. Establish ethical criteria in the relations of individual doctors and scientific societies with the pharmaceutical industry that take into account the following points: gifts to doctors, medical congresses, activities of training continuing medical education, conflicts of interest, advertising, promotional activities, publications, clinical trials...

7. Open a dialogue with the pharmaceutical industry aimed at seeking new formulas for relations with doctors that go beyond the traditional mechanisms of the medical visit as an instrument for informing doctors about new products.

8. Establish a publicly funded independent body to assess the effectiveness and efficiency (cost-optimality and cost-effectiveness) of marketed medicines to inform and make recommendations to physicians and health authorities.

9. apply for The regulatory authorities should limit the number of brands of the active ingredient itself to issue in order to reduce the promotional pressure of each brand and the resulting disadvantages for the price of the drugs and for the doctors themselves, especially for those "copy" drugs that have not undergone the appropriate bioequivalence tests programs of study .

10. To initiate a dialogue between the corporate organisations of doctors and pharmacists aimed at defining the respective roles of the professionals and establishing the necessary collaborations to dignify the two professions and optimise the use of medicines.

11. Analyse the expected impact of new technologies on prescribing, establish the technical and ethical criteria for remote prescribing (Internet) and implement measures to prevent the risks that may arise from their use.

12. Forcing the pharmacist to substitute the medicinal product without the doctor's authorisation could create high-risk ethical and legal situations, if such a substitution were to have effects. In any case, the substitution cannot be carried out without the patient's and the doctor's authorisation. For, although pharmacists are obliged by their profession to be knowledgeable about medicines, they cannot forget that doctors are knowledgeable about the processes and pathologies affecting their patients and, therefore, ultimately responsible for their patients' good health.

proposal of resolution

Objectives

The committee Permanent European Doctors, based on the general principles of medicine and respecting both Community and national legislation on the prescription of medicines, has drawn up this resolution with the following objectives:

• Clarify your position on prescription of medicines to Community Institutions.

• To disseminate this position among European doctors.

• To study and study in depth the problem of prescription quality, its causes and solutions; and

• Propose to improve the quality and efficiency of the medical internship .

The CPME, aware of the importance of all the factors that influence the medical act, of which pharmaceutical prescription is an important part, and considering the social demand for a permanent adaptation of the efficacy, effectiveness and efficiency of prescription and the rational use of medicines, as well as the rationalisation of the pharmaceutical expense and the impact of new information technologies on the professional practice of the doctor, with an impact on prescribing, believes it is advisable to consider the current and future factors that affect the prescribing of medicines by doctors, in order to promote the appropriate changes and adaptations that will make possible quality prescribing, always adapted to the demands and requirements of patients and society at each historical moment and to the circumstances of the doctor's professional practice.

Quality in medical services is a permanent social demand that must have an impact on such an important part of the medical act as prescribing. Doctors must provide their patients with the best and most qualified care possible attendance , as a reflection of their professional and ethical duty to the patient, to society and to their public or private manager. In prescribing, physicians should also consider efficiency, i.e. maximum effectiveness at the lowest cost.

The impact of new technologies on prescribing is evident and doctors have to adapt with skill to these technologies that can improve the quality of prescribing in many aspects, facilitate the necessary partnership with other professionals and can improve information and communication with the patient, in search of the best care for the patient.

While the technological, economic and social changes that affect doctors' pharmacological prescribing are important, the topic of medical liability is no less so. Reports of medical errors are recurrent, with unfortunate consequences, many of which are due to medication-related problems which, although they cannot be attributed exclusively to doctors, as their responsibility is distributed throughout the care system, generate suffering and increase expense. Doctors must commit themselves to putting the appropriate means in place to avoid them, promoting a culture of safety, to permanently improve the quality of the services they provide and to adapt to the new demands and changes that society and patients require. Qualified training , objective and independent information and appropriate work conditions are instruments to achieve these goals.

CPME urges national organisations to promote the quality of prescribing medicines among their members, to consider the results of technological changes on prescribing, to seek the most qualified patient care and to avoid medical errors in the use of medicines and prevent medication-related problems. To this end, it will promote, in the first place, the training and the continuous and adequate professional development in this subject, independent and objective information, obtaining the appropriate means and conditions of work , permanent consideration of the ethical values of the medical profession and the partnership with other professionals involved in medication, in order to facilitate the best quality care for the patient.