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.