Dear Mickey,
"So we have the conundrum of having lots of good health information and yet not making better decisions about prescribing."
Thank you for the comment, and this opens up a whole load of questions for discussion here on HIFA:
1. Does the prescriber have access to 'lots of good health information'?
2. What do we mean by 'good health information'? Is the information 'good' in all senses, or only in some? Is it reliable, free of errors and up-to-date? Is it adapted for the needs of the prescriber, including their language, educational level, experience and professional status? Is it relevant to the geographical location, the level of care (community, primary, secondary, tertiary), the resources available at the health facility, the specific needs of the patient? Is it always available as and when it is needed?
3. If relevant, reliable information appears to be readily available and 'good in all senses', and yet is not applied by the prescriber, a whole new set of questions is needed to try to understand why. Perhaps the information is not as 'good', from the presriber's perspective, as others assume? There are so many reasons why healthcare providers fail to prescribe rationally. Some of these relate to a (real or perceived) failure to meet their information needs (including their understanding of the importance of rational prescribing, and their attitudes to the source of the information).
Massimo and others have drawn attention to some prescribers, I suspect a minority, who *deliberately* overprescribe despite knowing full well that it is wrong and harmful to do so (both for the patient and the public health), for perverse reasons such as financial income.
It would be interesting to know what percentage of prescribers have access to unbiased information to help with the selection of medicines. Such information is arguably not widely available in a form that meets prescribers' needs - it is easy enough (with an internet connection) to get information on a specific drug (in some languages), but not so easy to get access to information that is designed to promote rational prescribing (for example, the British National Formulary used to be freely available but is now behind a paywall). A lower percentage, by definition, will have access to relevant, reliable information that truly meets their needs.
In summary there seems to be a continuum from uninformed through to informed prescribers. Being a relatively informed prescriber is a prerequisite for rational prescribing, but is not the only factor. Prescribers who have 'good health information' (in all senses) are more likely to practice rational prescribing, but other factors such as perverse financial incentives and patient expectations may sometimes distort their decision-making.
I have not even mentioned another important aspect: the ability of the prescriber to find and differentiate reliable, relevant information from unreliable and/or non-relevant information.
The systematic review undertaken in 2019/2020 by HIFA in collaboration with Nagasaki University and the London School of Hygiene and Tropical Medicine explored only a few of the above questions. 'Studies indicated a lack of up-to-date and relevant medicine information.' Below are the citation and abstract.
CITATION: How primary healthcare workers obtain information during consultations to aid safe prescribing in low-income and lower middle-income countries: a systematic review. Chris Smith, Michelle Helena van Velthoven, Nguyen Duc Truong, Nguyen Hai Nam, V Phan Anh, Tareq Mohammed Ali AL-Ahda, Osama Gamal Hassan, Basel Kouz, Nguyen Tien Huy, Malcolm Brewster, Neil Pakenham-Walsh. BMJ Global Health 2020;5:e002094. Published on 2nd April 2020
ABSTRACT
Background: We systematically reviewed the evidence on how primary healthcare workers obtain information during consultations to support decision- making for prescribing in low and lower middle- income countries.
Methods: We searched electronic databases, consulted the Healthcare Information For All network, hand searched reference lists, ran citation searches of included studies and emailed authors of identified papers. Two reviewers extracted data and appraised quality with relevant tools.
Results: Of 60 497 records found, 23 studies met our inclusion criteria. Fourteen studies were observational and nine were interventional. Frequently mentioned sources of information were books, leaflets, guidelines, aids and the internet. These sources were sometimes out of date and health workers reported being confused which to use. Internet access varied and even when it was available, use was limited by technical issues. Of the five electronic tools that were assessed, four had positive outcomes. Tools assisted prescribers with medicine selection and dosage calculations, which increased prescribing accuracy. The quality of reporting varied but was overall low.
Discussion: Studies indicated a lack of up-to-date and relevant medicine information in low and lower middle- income settings. Internet-based sources appeared to be useful when it is possible to download content for offline use and to update when there is internet access. Electronic tools showed promise, but their accuracy needs to be validated and they should focus on giving actionable advice to guide prescribers.
Looking forward to discuss more on the vital and complex topic of information and (ir)rational prescribing.
Best wishes, Neil
Coordinator HIFA Project on Information for Prescribers and Users of Medicines
http://www.hifa.org/projects/prescribers-and-users-medicines
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org
