An ethnographic exploration of influences on prescribing in general practice: why is there variation in prescribing practicesReportar como inadecuado

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Implementation Science

, 8:72

First Online: 21 June 2013Received: 22 November 2012Accepted: 14 June 2013DOI: 10.1186-1748-5908-8-72

Cite this article as: Grant, A., Sullivan, F. & Dowell, J. Implementation Sci 2013 8: 72. doi:10.1186-1748-5908-8-72


BackgroundPrescribing is a core activity for general practitioners, yet significant variation in the quality of prescribing has been reported. This suggests there may be room for improvement in the application of the current best research evidence. There has been substantial investment in technologies and interventions to address this issue, but effect sizes so far have been small to moderate. This suggests that prescribing is a decision-making process that is not sufficiently understood. By understanding more about prescribing processes and the implementation of research evidence, variation may more easily be understood and more effective interventions proposed.

MethodsAn ethnographic study in three Scottish general practices with diverse organizational characteristics. Practices were ranked by their performance against Audit Scotland prescribing quality indicators, incorporating established best research evidence. Two practices of high prescribing quality and one practice of low prescribing quality were recruited. Participant observation, formal and informal interviews, and a review of practice documentation were employed.

ResultsPractices ranked as high prescribing quality consistently made and applied macro and micro prescribing decisions, whereas the low-ranking practice only made micro prescribing decisions. Macro prescribing decisions were collective, policy decisions made considering research evidence in light of the average patient, one disease, condition, or drug. Micro prescribing decisions were made in consultation with the patient considering their views, preferences, circumstances and other conditions if necessary.

Although micro prescribing can operate independently, the implementation of evidence-based, quality prescribing was attributable to an interdependent relationship. Macro prescribing policy enabled prescribing decisions to be based on scientific evidence and applied consistently where possible. Ultimately, this influenced prescribing decisions that occur at the micro level in consultation with patients.

ConclusionGeneral practitioners in the higher prescribing quality practices made two different ‘types’ of prescribing decision; macro and micro. Macro prescribing informs micro prescribing and without a macro basis to draw upon the low-ranked practice had no effective mechanism to engage with, reflect on and implement relevant evidence. Practices that recognize these two levels of decision making about prescribing are more likely to be able to implement higher quality evidence.

KeywordsPrescribing Quality General practice Primary care Ethnographic Qualitative AbbreviationsGPGeneral practitioner

NHSNational health service

nGMSNew general medical services contract

PRISMSPrescribing information system for Scotland

CHPCommunity health partnership

BNFBritish national formulary

CPDContinual professional development

PCOPolycystic ovaries

NICENational institute for clinical excellence

SIGNScottish intercollegiate guidelines network

Electronic supplementary materialThe online version of this article doi:10.1186-1748-5908-8-72 contains supplementary material, which is available to authorized users.

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Autor: Aileen Grant - Frank Sullivan - Jon Dowell


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