A Study On Transparency Mechanism Of Prescribing Quality Information Based On Perceived Stress

[Purpose]This study applied the design of matched-cluster randomized trial to study the regulatory transparency in primary care in China. With consideration of features and transparency situations, this study is to explore the transparency mechanism of drug use, and further provide the evidence to develop the regulatory transparency theory of drug use. Primary health institutions are the research sites and the physicians are the main participants. According to the literature review, from aspects of information disclosure, perceived stress and prescribing behavior reactions, finally we develop the transparency mechanism.[Methods]This study was conducted by quantitative and qualitative methods. At first, based on literature review, and the study of economic, psychological, and organizational theory, we therefore proposed the basic concept of transparency, regulatory transparency, drug information disclosure and perceived stress, and the hypothesis. Then, applying paired-cluster randomized design, we chose20primary health institutions in X city of Hubei province of China. They were assigned to control and intervention groups (each group has10institutions). Transparency package of prescribing quality implemented monthly in intervention group. Prescribing quality indicators included the percentage of prescriptions requiring the antibiotics, percentage of prescriptions requiring injections and average expenditure of per prescription. Physicians’prescribing data was collected from hospital information management system. Questionnaires were developed to collect the information of institution characteristics, perceived stress of physicians under transparency intervention. Structured interviews were conducted to study the mechanism barriers, effects and related recommendations. We used NVivo software to analyze the qualitative materials. Data from questionnaires were input in Epidata3.1. Statistical analysis was conducted in Stata12.0, including the difference-in-difference models, hierarchical regressions and generalized estimated equations.[Results]1. Conceptual and theoretical studies of transparency mechanism Based on domestic and foreign medical information transparency researches, the concept of transparency, regulatory transparency, transparency perceived stress, and medication information disclosure had been defined. Quality of information disclosure improved the quality of providers’service through three pathways.2. Evaluation on effects of prescribing information transparency Throughout the study period, the intervention of prescription transparent did not lead to significant improvement in the quality of doctors’prescriptions. There was no significant reduction in antibiotic abuse, injections abuse and prescription costs. Doctors’antibiotic rate, injection rate had some improvements, i.e. the antibiotic prescription rate decreased1.32percentage points (95%CI-3.26%to0.63%), injection prescription rate decreased0.99percentage points (95%CI-3.08%to1.09%), but changes did not reach a statistically significant level. Doctors’average prescription costs in the intervention group had a slight rise of4%(95%CI from0%to8%). The analysis about most common outpatient diseases, the upper respiratory infection showed that transparent intervention made the proportion of prescription requiring oral antibiotics dropped9percentage points (95%CI-17.36to-1.07), the joint antibiotics prescription rate has dropped7percentage points (95%CI-13.94to0.00). But intervention did not have significant impacts on intravenous injection rate, the infusion rate and prescription costs. Transparent intervention had limited effects.3The analysis of transparency mechanism based on perceived stress Primary care doctors’perceived stress was at the lower-middle level. Rankings and publicly reporting of antibiotic prescription rate, injections prescription rate and average prescription costs did not introduce a corresponding perceived pressure at the beginning. In the terminal phase of the study, the perceived pressure in intervention group was significantly higher than that in the control one, although overall the two groups of physician’s perceived stress were low. Female doctors and older physicians’ perceived pressure for regulatory transparency are higher; indicating that these groups are more sensitive to transparent information. Overall, perceived stress scores did not have obvious correlation with prescription quality indicators. Based on hierarchical regression analysis, it showed that under transparency intervention, the doctor pressure has no significant impacts on the prescribing practices. It means that no matter what primary care doctor’s perceived stress levels are, it will not affect the rate of antibiotic prescribing, injection rate and average prescription costs. The results did not support the hypothesis that perceived stress can influence and regulate the doctor’s prescribing behavior. In the models, the doctor’s age, income, job title, workload, departments had significant impacts on prescribing practices.4. Analysis of physicians’ interview and typical cases The majority of physicians did not think that publicly reporting would introduce transparency perceived stress. The vast majority of doctors believed that drug information transparency will not affect the number of patient admissions; few doctors believed that when you rank poorly, there will be some impacts. Because the payer and manager did not combine supervision with information disclosure, the pressure from the transparent regulation is very limited. The vast majority of doctors believed that it did not affect the reputation; few doctors believed that transparency introduced some impacts on reputation. Many doctors can understand the indicators, but there are still some doctors do not know the exact connotation of prescribing quality indicators. Primary care doctors’perceived stress and response strategies varied due to personal characteristics, but the environment plays an important role inside. The doctors who concerned and perceived reputation impacts will significantly take more active measures to improve prescribing behavior.S. Analysis of the obstacles in transparent mechanism(1) Doctors’ perceived pressure from patients was very limited. There are many reasons. Doctors generally believed that the patient will not be concerned about the quality of information, furthermore only a few people understood information. Users’feedback is an essential part in the transparent mechanism. If patients are not concerned, it does not produce the appropriate pressure, and then the doctor will lose an important driving force for behavior changes. Doctors also believe that the vast majority of drug information disclosure and transparency ranking does not affect the amount of the patient’s admissions.(2) The pressure from assessment based on information transparency was lack. Current interventions did not have any assigned assessment measures, so the corresponding perceived pressure is very limited. Doctors believed that transparent quality information did not affect personal income. Some people thought there may be in the future, but also recognized that there would not be much of its influences. Because they have perceptions of that public reporting of quality information will not have any impacts on incomes. (3) Corresponding pressure from the reputation and social image was also low. The vast majority of doctors feel that transparency have no effects on honorary, only a few doctors think that it will affect the reputation. Chinese doctors have more pressing needs for material interests. In the Chinese medical service areas, the fame and material rewards are relatively fragmented, so they seek material rewards in the short term, rather than pay attention to the peer reputation. The leadership for a transparent and openness attitude is very important, and perceived pressure varies by different leaderships.[Conclusions] In the current reality, the effects of transparent mechanism based on perceived pressure were restricted in many ways. Transparency itself is not direct to introduce effects; therefore transparency mechanism needs to meet certain conditions to make better effects.(1) Scientifically rigorous designs of transparent public policies are needed. The form of organized healthcare market, as the characteristic of market competition, is an important factor for public reporting to improve quality. Transparent policy should adapt to local macro and micro environment. Which level of the evaluation quality should be transparent is the first issue to be considered. Given the complexity of medical services, there are a lot of factors have impacts on the results. Therefore it is essential to develop risk-adjusted quality measures. It is important to make transparent manner rich and effective, with a broad impact. The website platform is the inevitable trend of medical services information disclosure.(2) To improve the awareness and use of publicly reporting information. To enhance the mechanism of the effect of transparency, the urgent movement is to raise public awareness of the medical quality of information, to enhance the public’s information literacy. Health literacy affects the understanding and use of medical services information. It is essential to help the public improve awareness of seeking information, and evaluate the suitability of the information, and ultimately apply health care quality information.(3) Stimulating provider response for publicly reporting. Different forms of organization have their corresponding effective management. The leader to improve the quality generated in a different form of organization is different. In China’s public hospitals, leadership’s attention of transparency will greatly enhance effects by force from disclosure of medical quality. The corresponding economic stimulus measures could be designed to improve doctors concern about information disclosure. International studies have shown that the quality of reports combined with economic stimulus induce providers greater perceived pressure to adopt more quality improvement actions. In addition, efforts should be made to improve doctors’professional pride. Finally, we should be cautious to avoid the unintended effects caused by prescription quality transparency.[Innovations and limitations](1) Research innovations First, international transparent concept of medical quality was introduced into the field of irrational use of drugs in primary health care. Secondly, this study presented perceived pressure of transparency to carry out empirical research of transparent mechanism. Furthermore, this study used a higher strength of the evidence in the study design-matched cluster randomized controlled trials, in order to minimize confounders.(2) The limitations First, the study was conducted in primary health care institutions, in which doctors’ awareness of transparency and public health literacy are low. Second, the intervention package design has limitations, and the time for intervention is limited. Third, the regulatory policies and the economic operations inside institutions are lack of investigations. Fourth, the actual intervention may be affected by other factors beyond the control.