Research On Prescription Behavior Preferences Of Rural Physicians Based On Preference-Shaping Policy Theory

Background and objectivesThe problem of irrational use of drugs in rural areas of China is still serious.Therefore,it is important to analyze the decision-making process of doctors’ prescribing behavior in rural areas,explore the relationship and mechanism between health policies and doctors’ prescribing behavior through scientific theoretical methods,and propose rationalization suggestions for the existing policies,which have important academic and application values,and are important for further adjustment and improvement to promote the rational use of drugs in rural areas.It is of great practical significance to further adjust and improve the rational use of drugs in rural areas.Therefore,this study is guided by preference-shaping policy theory,applies discrete choice experiments to measure physicians’ prescribing behavior preferences in rural areas,constructs utility functions to quantify preferences,and clarifies the prescribing decision process.The study also adopts a policy analysis method to investigate the shaping mechanism of policy measures on prescribing behavior preferences,so as to provide scientific suggestions for further regulating doctors’ prescribing behavior and improving drug use policies to promote the rational use of drugs in rural areas.Research theories and methodologiesBased on the preference-shaping policy theory in economics,this study uses discrete choice experiments to quantitatively study physicians’ prescribing behavior preferences in rural areas and interviews and other methods to qualitatively study the preference-shaping mechanisms of policies.For the quantitative study,the factors influencing rural physicians’prescribing behavior were first summarized through a scoping review to form an experimental attribute pool.Then,discrete choice experimental attributes(drug efficacy,monthly cost,reimbursement rate,patient preference for medication,and physician experience with medication)were identified through expert consultation and other methods,and a discrete choice experimental questionnaire was designed.The experimental simulated prescription scenario was a common chronic disease prescription decision in rural areas.Finally,a questionnaire survey was conducted in Shandong province,in which the sample was first ranked according to the per capita income of residents in each district and county,and then 35 sample townships in 9 districts and counties were identified by stratified systematic random sampling.The response rate was 90.92%.The results of the preference survey were analyzed using mixed logit models and latent variable logit models to determine the homogeneity and heterogeneity of physicians’ prescribing preferences in rural areas,as well as the marginal economic value of drugs and the probability of prescription choice scenarios.For the qualitative study,policy measures were firstly analyzed based on the 4E theory.Secondly,key person interviews were conducted with 43 people,including the head of the township health center,health center doctors and village doctors,and the results of the interviews were analyzed using the thematic framework method.Finally,based on the research theoretical framework,the mechanism of shaping physicians’ prescribing behavior preferences by health policy measures in rural areas was analyzed.Key findings(1)The study of factors influencing prescribing behavior found that from an international perspective,the factors of prescribing behavior of healthcare providers are divided into five main categories:internal factors,environmental factors,patient factors,economic factors,and drug attributes.Focusing on rural areas in China,the factors influencing prescribing behavior can be divided into internal factors of doctors(occupational characteristics,demographic characteristics,etc.),policy factors(essential drug policy,medical insurance policy,drug supply guarantee policy,etc.),economic factors(drug cost and reimbursement ratio,local economic level,etc.),patient attributes(patient demographic characteristics,preferences and willingness,etc.),drug attributes(drug efficacy,quality and manufacturers,etc.)and other factors(geographical differences,working environment,etc.).(2)The results of the analysis of rural physicians’ prescribing behavior preferences showed that of the 1995 physicians included in the study,702 were health center physicians and 1293 were village physicians,and about half of the physicians had a secondary school or technical school as their highest education.For simulated scenarios of prescribing decisions for common chronic diseases,all five attributes of the study’s included utility function were statistically significant.The drug with the highest level of efficacy corresponded to the highest utility,followed by the drug for which the doctor had experience with the drug and the highest reimbursement rate,and the lowest utility for patient preference for the drug.The lower the price of the drug,the higher the physician’s willingness to choose it.The marginal economic value of the drug with the highest level of efficacy relative to the drug with the lowest level of efficacy was RMB 726.8,and the marginal economic value of the drug with patient medication preference relative to the drug without preference was RMB 261.9.In the prescription choice scenario,physicians were 78.1%more likely to choose the drug with a moderate level of efficacy and 40%reimbursement than the drug with the lowest level of each attribute(baseline drug),and 97.3%more likely to choose the drug with the highest level of efficacy and reimbursement and experience with the drug than the baseline drug.(3)The results of the heterogeneity analysis of rural physicians’ prescribing behavior preferences showed that for the prescription decision scenario of common chronic diseases,the decisive factor in the prescribing decision of health center physicians was efficacy.In contrast,village doctors would consider both efficacy and their own experience and were more sensitive to drug prices.Among the demographic characteristics,practice qualification does not affect preference heterogeneity;female doctors pay more attention to their own experience compared with male doctors;older and less educated doctors pay less attention to patients’ medication preference;doctors with bachelor’s degree or above pay relatively more attention to drug efficacy.In terms of economy and geography,physicians in low economic areas were more concerned about drug prices and reimbursement rates.According to the potential heterogeneity of physicians,34.3%of physicians have a general preference that is consistent with the whole group,19.8%are patient-centered,15.8%place more importance on economic factors,17.5%place more importance on their own experience,and 12.4%are authoritative physicians who do not want patients to express their preferences.(4)The results of the analysis on the shaping of physicians’ prescribing behavior by policy measures revealed that physicians’ preference for drug efficacy was shaped by the debenefitization of medical service delivery;the incomplete protection of patients’ welfare by policy made physicians still need to consider the economic factors of drugs;the concept of"patient-centeredness" advocated by policy did not become an important shaping factor for physicians’ prescribing behavior.The heterogeneity of prescribing behavior preferences is shaped by the professional and geographical differences of physicians;education and training make the prescribing behavior preferences of doctors in health centers more balanced and mature;the imperfection of supporting policies makes some village doctors more experienced and authoritative in their prescribing behavior preferences.Economic factors are the most direct factors in shaping doctors’ prescribing behavior preferences,and for health center doctors,their prescribing behavior preferences are more influenced by health insurance policies than basic drug policies;performance evaluation essentially shapes doctors’ prescribing behavior preferences through economic rewards and punishments.Research conclusionsFor common chronic diseases in rural areas,the generalized decision-making process for physician prescribing behavior is that for drug regimens appropriate to the patient’s condition,the more efficacious drug is preferred.When the efficacy is moderate,drugs with experience or higher reimbursement rates are selected,and the patient’s medication preference is not a decisive factor.The lower the price of the drug,the higher the physician’s willingness to choose it.In the real world,differences in physicians’ medical institutions,geographic economic levels,and individual factors in rural areas,as well as factors not directly observed,can cause differences in physicians’ prescribing decision processes,causing some physicians to focus on certain factors such as patients’ wishes,economic factors,and medication experience.The policies in question do shape physician prescribing behavior by prompting physicians to develop desired prescribing behavior preferences through specific policy measures,which in turn increase the probability that physicians will engage in desired prescribing behavior.The major prescribing behavior preference-shaping policies include essential drug policies,health insurance policies,performance appraisal policies,and medical personnel education and training policies,among which the policy purpose of essential drug policies to shape physicians’prescribing behavior has not been fully realized.Economic-related policies and measures have played a decisive role in shaping physicians’ prescribing behavior preferences in rural areas.Education and training can achieve the purpose of shaping doctors’ prescribing behavior preferences to a certain extent,and the policy effect is more significant if it can be implemented together with other measures.The development of a targeted policy system from the perspective of health system and institution building is more conducive to shaping homogeneous physician prescribing behaviors.Policy recommendations(1)To form a preference-shaping policy system for rational prescribing behavior of rural doctors that includes measures in education,economy,implementation,and engineering.(2)Indepth implementation of the original purpose of the basic drug policy to promote rational use of drugs,ensuring the safety and effectiveness of drugs in the basic drug catalog,and selecting drugs that meet the actual clinical work in rural areas for inclusion in the catalog,ensuring compensation and reimbursement for drugs in the basic drug catalog,and doing a good job of clinical training related to basic drugs to shape doctors’ preferences for basic drugs.(3)Unify the policy objectives of drug-related economic measures in rural areas to ensure that patients,doctors and medical institutions correspond to the same objectives of drug-related economic measures and to shape reasonable prescribing behavior of doctors.(4)Appropriately shift the starting point of policy formulation and adopt preference-adapted policy measures from the perspective of doctors,with more incentives and less regulation,which is more conducive to achieving policy goals.(5)Adopting different training measures for physicians with different prescribing behavior characteristics to improve their prescribing behavior in a targeted manner.Innovations and limitationsInnovations:(1)This study explores the application of the preference-shaping policy theory of economics to the health field,expanding the application scope of the original theory with certain theoretical innovations.(2)This study quantifies the utility function of prescribing behavior by discrete choice experimental method,takes common chronic diseases as simulation scenarios,incorporates influencing factors common to prescribing behavior,and obtains a utility function model reflecting prescribing behavior preferences.(3)This study focuses on rural areas in China,bridging the gap in research related to prescribing behavior preferences in rural areas,and clarifying the relationship and mechanism of action between health policies and physicians’ prescribing behavior in rural areas.Limitations:(1)The limitations of the discrete choice experimental method do not allow perfect simulation of subjective choice behavior.Future studies can further verify the differences between physicians’ prescribing behavior preferences measured by discrete choice experiments and real-world prescribing behavior preferences.In addition,the online survey method cannot explain the questionnaire questions to the respondents face to face,quality control questions have been designed in the questionnaire,and the research leader has been arranged in each sample township to explain the questionnaire to guarantee the quality of questionnaire completion.(2)The field survey of this study was only conducted in the more economically developed Shandong Province,which may have some differences with the less economically developed areas and affect the extrapolation of the results,and comparative studies can be conducted in the less economically developed areas in the future to enrich the research results.