New medicines in primary care: a review of influences on general practitioner prescribing.
OBJECTIVE
The uptake of new medicines is slower in the UK than in many other countries. Previous research found that cost and price have little influence on general practitioner (GP) behaviour, but recent UK government policy may have heightened cost-consciousness. Focussing on new medicines, this review aimed to explore the determinants of uptake, the causes of geographical variations, and the influence of price, cost and financial incentives on prescribing behaviour.


METHODS
Two separate searches were conducted on nine electronic databases. Strategy 1, an update of a previous review, used key terms for primary care physicians, uptake, medicines and 'new'. Strategy 2 focussed on terms relating to incentives and prescribing. Records were screened for eligibility and data from relevant papers were extracted using Bonair and Persson's typology for determinants of the diffusion of innovation, which classified influences into three groups: actors, structural/environmental characteristics and product characteristics.


RESULTS
The searches identified 550 records and 28 studies were included in the updated review. Prescribing of new medicines needs to be understood in the context of individual patient-centred care, which is characterized by stability and continuity. Hospital doctors, pharmaceutical representatives and prescribing advisers are all influential, but GP attitudes towards these actors vary and there are notable differences between high and low prescribers of new pharmaceuticals. Support systems can help provide appropriate guidance and increase the uptake of new medicines by identifying patients who may benefit from pharmaceutical therapy. There is evidence of a shift in GP attitudes towards central policy initiatives, with doctors slowly accepting the need for external scrutiny and national standards. Although cost does appear to inform prescribing decisions, it is typically of lower importance than both safety and efficacy concerns and does not represent a significant barrier to uptake of new medicines. The impact of financial incentives on prescribing behaviour remains unclear, but is unlikely to be straightforward. No evidence exploring the reasons for geographical variations in GP uptake of new medicines was found.


CONCLUSIONS
General practitioner care has historically been patient-centred, and it is unclear whether and how GPs consider the impact of their decisions upon the wider patient population. Incorporating cost considerations into GP decision making is one way to reflect the broader impact of individual treatment decisions. Current UK government policies use incentives to improve quality and encourage financial responsibility. Although these initiatives may help foster cost-consciousness, there is a risk that unintended consequences may ensue. Therefore, future policy evaluations should assess benefits, harms and costs so that the overall impact is transparent.
Mason
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Centre for Health Economics, University of York, Heslington, York, UK. arm10@york.ac.uk
D016208:Databases, Factual; D016527:Drug Costs; D006291:Health Policy / Q000331:legislation & jurisprudence; D006801:Humans; D018802:Patient-Centered Care / Q000458:organization & administration; D010821:Physicians, Family / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D012052:Reimbursement, Incentive; D006113:United Kingdom