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International Journal for Quality in Health Care Advance Access originally published online on August 24, 2007
International Journal for Quality in Health Care 2007 19(5):309-316; doi:10.1093/intqhc/mzm030
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© The Author 2007. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved

Relationship between physician characteristics and their injection use in Korea

Jeong-Hae Hwang1, Dong-Sook Kim1, Sang-Il Lee2 and Jee-In Hwang3

1 Center for Quality Evaluation and Improvement, Health Insurance Review Agency, Seoul, South Korea
2 Department of Preventive Medicine, College of Medicine, University of Ulsan, South Korea
3 Department of Nursing and Healthcare Management, College of Nursing Science, Kyung Hee University, Seoul, South Korea

Address reprint requests to: Jee-In Hwang, Medical Science BLD, Kyung Hee University Dongdaemoon-Gu Hoegi-Dong 1, Seoul, 130-701, South Korea Tel: +82-2-961-9145; Fax: +82-2-961-9398; E-mail: jihwang{at}khu.ac.kr


   Abstract
Top
 Abstract
Methods
 Results
 Discussion and Conclusion
 References
 
Objective. To determine the relationships among physicians' knowledge and beliefs, perceived patient demand and treatment with injection drugs in Korean primary care settings.

Design. A cross-sectional, nationwide survey.

Setting. A total of 644 clinics were selected from the 9660 clinics with more than 1000 patient visits from April 1 to June 30, 2004, among four specialties (general practice, internal medicine, otorhinolaryngology, family medicine) that dealt mainly with acute upper respiratory infections in primary care settings.

Participants. We surveyed one physician per clinic with a questionnaire investigating their knowledge and beliefs on and perceived patient demand for injections. Among the 644 physicians, the data of 608 were analysed after responses with incomplete data were excluded. The survey data were merged with their injection prescription rate for acute upper respiratory infections.

Main outcome measure. Prescription rate for injection drugs.

Results. The mean prescription rate for injection drugs per physician was 41.8%. Of respondents, 85.2% had faulty knowledge and beliefs about injection drugs, and 72.9% perceived a strong patient demand for injections. Older, male and generalist physicians had higher prescription rate. After controlling for physician and clinic characteristics, the prescription rates were significantly related with physicians' knowledge and beliefs on and perception of patient demand for injection drugs.

Conclusions. Physicians with faulty knowledge and beliefs on and a perception of strong patient demand for injection drugs had higher prescription rates. Some potential interventions are described to encourage primary care physicians to use injection drugs appropriately in South Korea.

Keywords: injection, knowledge and belief, perceived demand, prescription, primary care physicians

Concern has been growing over the misuse of injection drugs in recent years. Researchers have noted the popular demand for injections and the alarming use of unnecessary and unsafe injections especially in developing countries [1–4]. The popularity may lie in the fact that injective medicines are quickly distributed throughout the body and have a faster effect than oral medicines [5]. Koreans have culturally had a preference for injections since acupuncture has been one of the major treatment modalities in Korean traditional medicine. Although this preference is likely to decrease with improved education level, injections remain popular. Therefore, some physicians believe that injections can attract more patients to their office.

In this context, the widespread use of injection drugs, including antibiotics, has emerged as an important issue in Korean primary care settings. The nationwide injection prescription rate in clinics was 39.7% in 2003, which was higher than that of tertiary (8.8%) and general (13.9%) hospitals [6]. The majority of injections (92.3%) were intramuscular injection drugs, which could be replaced by the corresponding oral drug.

Since 2002, as a part of the government strategy for controlling the over-utilization of drugs, the Health Insurance Review Agency (HIRA) has begun to monitor drug utilization pattern in primary care settings. They focused on injection drugs, antibiotics and costly drugs. The nationwide prescription rate of injections remains high among primary care physicians.

Issues around injection practices in Korea differ somewhat from those in other countries [1–4]. The risk of transmission of infection due to reused syringes has decreased with the development of disinfectants and the widespread use of disposable medical devices and materials. As a result, policies and management strategies on drug utilization have focused on unnecessary injections with an emphasis on antibiotics and costly drugs, rather than on unsafe injections.

Acute upper respiratory infections were one of the leading causes for clinic visit [7]. In particular, overuse of injections for acute upper respiratory infections, including the common cold, has been reported as a quality problem in primary care settings. The injection drugs used for acute upper respiratory infections were mainly antibiotics and non-steroid anti-inflammatory drugs [6]. Furthermore, 86% of Streptococcus pneumonias cases in Korea reported resistance to penicillin [8]. Inappropriate use of antibiotics may result in the development of bacterial resistance to antibiotics.

Previous studies reported that variations in the prescription patterns depended on physicians' characteristics such as gender [9] and clinical specialty [10–12]. Along with patient medical condition, physicians' knowledge and beliefs on their treatment modalities significantly influenced their use of drug [13, 14]. In addition, physicians' perceptions of patient demand and expectations for drug prescription were found to influence their prescribing behaviour [15–17]. Positive associations existed between patients' expectation and physicians' perceptions of patients' expectations and medication prescription [16]. However, there are few reports on physicians' knowledge on and perception of patient demand for injection drugs in relation to injection use.

This study examined the relationships between injection prescription and physicians' knowledge and beliefs on and perceived patient demand for injection drugs in a primary care setting. An understanding of the determinants of current injection practices is necessary to plan relevant and effective intervention.


   Methods
Top
 Abstract
 Methods
Results
 Discussion and Conclusion
 References
 
A nationwide, cross-sectional survey was conducted in September, 2004. The target subjects were physicians providing medical services for acute upper respiratory infections in primary care settings. We chose clinics with representative specialties of general practice, internal medicine, otorhinolaryngology and family medicine as they are the main specialties providing medical services for acute upper respiratory infections in primary care settings [6]. According to the health insurance claims data in the third quarter of 2003, these clinics covered 93% of all acute upper respiratory infection cases. Among 9660 clinics with more than 1000 patient visits during the 3 months prior to June 30, 2004, as determined using the HIRA database, 1596 clinics were selected for the intended sample using simple random sampling method. Among them, we surveyed 644 physicians (40.4%) who were willing to participate in this study.

One physician per clinic was interviewed by telephone using a structured questionnaire. Most clinics are operated by one physician in Korea. As for clinics with two or more physicians, we surveyed the physician who is the clinic owner. The questionnaire was designed to obtain information on physician's knowledge about injection drugs, perceptions of patient demand for injections and general characteristics. The questions on the knowledge and perceptions of patient demand were measured using a five-point scale (5, strongly agree; 4, agree; 3, neutral; 2, disagree; 1, strongly disagree). The questions were developed through literature review and meetings with related experts, including the authors. The validity of the questions was reviewed by a committee consisting of four physicians, five nurses, one pharmacist and one survey consultant.

The knowledge and beliefs about injections were investigated with the following four statements: ‘Injection drugs have better treatment effect than oral drugs’, ‘Injection drugs result in rapid recovery, compared to oral drugs’, ‘Injection drugs decrease complications due to the disease’ and ‘Injection drugs have fewer side effects than oral drugs’. In the results, the response of each item was converted into a dichotomous variable to differentiate the misconception. The values of ‘5’ and ‘4’ were coded as ‘0’, indicating misconception and faulty beliefs. The others were coded into ‘1’, representing correct knowledge and beliefs on injection drugs. After that, the overall knowledge was divided into two categories: ‘correct’ and ‘incorrect’. If all responses to the four questions were ‘1’, the overall knowledge and beliefs was coded as ‘1 (correct)’, otherwise as ‘0 (incorrect)’.

The perception of patient demand for injections was measured with two questions: ‘Do you think that the patients who visit your clinic want you to prescribe injection drugs?’ and ‘Do you think that the prescription of injections makes your patients psychologically comfortable?’ The response of each question was also converted into a dichotomous variable. The values of ‘5’ and ‘4’ were coded as ‘1’, the others as ‘0’. For the variable of the perception of patient demand, if the responses of both questions were ‘1’, the perception of patient demand was coded as ‘1 (strong)’, indicating a strong perception of patient demand, otherwise as ‘0 (weak)’, representing a weak perception of patient demand.

The general characteristics included the physician's demographics (age, gender), clinical specialty, training institution, location of clinic and the daily patient census. In this study, clinical specialty refers to the clinic's main specialty as registered in the National Health Insurance database.

Each physician's survey data were merged with his/her prescription rate for injection drugs for acute upper respiratory infections derived from the National Health Insurance claims database. The prescription rate was the proportion of patients given any injection drug among those with acute upper respiratory infections who visited the clinics during the first quarter of 2004. Acute upper respiratory infections included acute nasopharyngitis (J00), acute pharyngitis (J02), acute tonsillitis (J03), acute upper respiratory infections of multiple and unspecified sites (J06) and other diseases of the upper respiratory tract (J39) according to the ICD-10 code.

Among the 644 physicians, 32 questionnaires were excluded due to incomplete information on some of the study variables. The remaining 608 questionnaires (256 general practitioners, 206 internists, 100 otorhinolaryngologists and 46 family physicians) were used for the final analysis.

Data were analysed using SAS statistical program (Version 8.2). Descriptive statistics were used to capture the overall trends. ANOVA and t-tests were performed to identify the differences in the prescription rate of injections according to physicians' characteristics. Tukey's studentized range test was used for post hoc comparisons. In addition, chi-square tests were conducted to determine the differences in the knowledge and perceived patient demand according to physicians' characteristics. Multiple linear regression was conducted to determine the factors associated with physicians' prescription of injection drugs. Additionally, we performed residuals analysis to check the assumption of the linear regression model. The residual plot (predicted injection rates vs. residuals) indicated that the residuals (error terms) were independent and normally distributed.


   Results
Top
 Abstract
 Methods
 Results
Discussion and Conclusion
 References
 
General participant characteristics and injection prescription rates
Among the 608 clinics, 90.3% (549) were operated by one physician, 7.7% (47) by two physicians, 1.5% (9) by three physicians and 0.5% (3) by four physicians. Of the respondents, 89.5% were male and 64.3% were between the age of 40 and 59 (mean ± SD: 46.1 ± 10.0). Most physicians (69.2%) had been trained at the university hospitals. The clinical specialty distribution of the respondents was 37.5% in general practice, 34.5% in internal medicine, 16.3% in otorhinolaryngology and 11.7% in family medicine. More than half of the clinics were located in metropolitan areas (52.0%). The mean number of patient visits was 71.2 ± 34.4 per day (Table 1).


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  		Table 1 General characteristics of respondents and prescription rate of injection drugs

 
The mean prescription rate of injection drugs was 41.8 ± 27.3% (range: 0.0–98.6%): 17.4% in the first quartile, 40.9% in the 50th percentile and 65.0% in the third quartile. The rate differed significantly according to physicians' gender (P = 0.002), age (P < 0.001), clinical specialty (P < 0.001), type of hospitals where they had been trained (P < 0.001) and clinic location (P = 0.002).

Older, male physicians had a significantly higher injection prescription rate. In multiple comparisons using Tukey's studentized range test, the injection prescription rate was the highest among generalists. With regard to training institution, physicians who had no training at accredited hospitals for their internship/residency had the highest injection prescription rate. Among physicians trained at the other institutions, there was no statistically significant difference in the prescription rates according to training institution. The injection prescription rate was the highest among physicians who were practicing in rural areas, but there was no significant difference between those in metropolitan areas and smaller cities.

Knowledge and beliefs on and perception of patient demand for injection drugs
Among the respondents, only 14.8% had correct knowledge and beliefs about all four questions on injection drugs (Table 2). Those who correctly answered were 41.3% for ‘treatment effect’, 42.9% for ‘recovery’, 58.6% for ‘complication’ and 57.2% for ‘side effect’. There was a significant difference in the prescription rates according to their overall knowledge and beliefs on injection drugs (Table 2, P = 0.002). Physicians with faulty knowledge and beliefs on injection drugs had higher injection prescription rates. Meanwhile, there was no significant difference in the prescription rate depending on the knowledge and beliefs on ‘side effect’.


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  		Table 2 Physicians' knowledge and beliefs on and perceived patients' demand for injections

 
Of the physicians, 72.9% responded that they perceived a strong patient demand for injection drugs, 80.4% that their patients wanted injection drugs and 86.8% that an injection prescription makes their patients psychologically comfortable and satisfied with the received treatment. There were significant differences in the injection prescription rates, according to their perception of patient demand for injection drugs (P < 0.001). Physicians who perceived a strong patient demand had higher rates for injection prescription.

In the relationships with physician's characteristics, there was no significant difference in overall knowledge and beliefs according to physician's gender, age, or clinical specialty. Significant differences by physicians' age and clinical specialty were found in perceived patient demand. Perception of patient demand was high among physicians aged 60 or more and generalists (Table 3).


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  		Table 3 Knowledge and beliefs on and perceived demand for injection drugs according to physician's characteristics

 
Relationship between injection prescription rates and knowledge and beliefs on and perception of patient demand for injection drugs
Multiple linear regression was conducted on the prescription rate of injection drugs as a dependent variable. The model explained 20% of the variances (P < 0.001). After controlling for the physician (gender, age and training institution) and clinic characteristics (representative clinical specialty, clinic location and daily patient census) as potential confounders, the prescription rate for injection drugs was significantly related with physicians' knowledge and beliefs on and perception of patient demand for injection drugs. Physicians with faulty knowledge and beliefs on and a perception of strong patient demand for injection prescribed injection drugs more frequently (Table 4).


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  		Table 4 Multiple linear regression result on the prescription rate of injection drugs

 

   Discussion and Conclusion
Top
 Abstract
 Methods
 Results
 Discussion and Conclusion
References
 
Physicians with incorrect knowledge on injection drugs and strong perception of patient demand prescribed more injection drugs, after adjusting for physician and clinic characteristics. Korea has a high prescription rate for injection drugs in primary care settings. In this study, we focused on the use of injection drugs for acute upper respiratory infections, and on its association with physicians' characteristics. The mean prescription rate of injection drugs for acute upper respiratory infections was approximately 42%. Older, male physicians and generalists had higher injection prescription rates.

The prescription rate for injection drugs in this study was relatively high, compared to the median of 25% in 13 developing countries, regardless of the disease type [18]. This result was lower than the reported rate of 55% in Pakistan, of which the majority (94.3%) was unnecessary [19]. Our study results contained a wide variation of 0.0% to 98.6%, depending on physicians' characteristics, indicating that some interventions are needed to control the overuse of injections in the primary care setting. Several such interventions are suggested below.

The main study finding was that physicians' knowledge and beliefs on and perception of patient demand for injection drugs were modifiable factors, which influenced the injection prescriptions. Drug use is associated with the knowledge and beliefs on treatment outcomes and the value of those outcomes [20]. The finding demonstrated that a substantial proportion of physicians had misconceptions about ‘treatment effectiveness’, ‘recovery’, ‘complication’, or ‘side effect’ of injection drugs, compared to oral drugs. Physicians with misconception had higher prescription rates. This finding indicated that faulty knowledge and beliefs on injection drugs caused unnecessary overuse, and supported the previous finding that health care providers' strong beliefs about the effectiveness of injections and lack of recognition of the risks were the reasons for injection overuses [21]. This result was also similar to a previous report in general population that a lack of awareness of the risks and a strong belief in the fast action of injections were driving factors of injection overuse [5].

These findings confirm the need for educational interventions to correct physicians' inaccurate knowledge and beliefs on injection drugs in order to decrease the unnecessary overuse of injections in the Korean primary care setting. Clinical practice guidelines for injection use should be developed to reduce the variations in the use of injection drugs [22]. Educational programs will include the provision of information about the guidelines, formulary restriction and regulations. In this process, the involvement of professional medical bodies is critical to disseminate evidence-based information and to create peer pressure.

Physicians who perceived a strong patient demand prescribed more injections. This finding was consistent with the reports that patients' expectation of a prescription influenced the amount of care they received [15–17]. These results outweighed the impact of physicians' perceptions of consumer demand for and expectation of injection drugs. Meanwhile, this finding suggests that physicians have a misperception about patient demand for injections [23]. Although this study did not measure the discrepancy of physicians' perception and patient demand, exploring the level of such phenomenon of cognitive dissonance would be helpful to develop interventions to decrease injection prescription rates.

From another perspective, the finding of a perception of strong patient demand for injections suggests that consumer group campaigns to reduce injection prescription rates may decrease unnecessary injection use. Although physicians' perception of patient demand was measured, this finding indirectly reflected the patients' general preference for injections. Because patients could more easily identify injection drugs when receiving them, the role of consumers should not be underestimated. This suggested the importance of providing relevant information to consumers to change their knowledge, attitude and beliefs in order to encourage appropriate utilization of injections. These programs would include education through mass media or Internet, as well as traditional methods of posters and booklets [18, 24].

Considering that the present study subjects were primary care physicians, they would be more likely to be responsive to patient-initiated demand, compared with physicians providing care in more organized care environments such as hospitals. Some physicians might believe that an injection prescription meets the patients' expectations, and consequently influences their revisit to their clinic. In this study, there was no significant relationship between the prescription rate of injection drugs and patient number, which does not seem to support this view. Clinic volume is a function of multiple factors such as years in practice, gender and geographic location. Therefore, exploring the relationship of injection prescriptions with clinic volume needs further investigation.

On the other hand, the previous studies found that injection administration was driven by economic incentives [4, 25]. In Korea, injection drugs are the only exception to the regulations that were introduced in 2000 to separate the dispensing and prescribing of medical drugs. Injection drugs can be prescribed and administered directly by physicians, unlike other drugs and the cost for drug injection is directly reimbursed to the clinic in addition to a professional fee for injection. Thus this situation may partly contribute to the overuse of injection drugs, especially expensive drugs. Therefore, efforts to decrease injection use should take into account economic incentives from the physicians' perspective. Recently, the government began to release the injection prescription rates of clinics for a common cold to the public through mass communications.

Monitoring physicians' prescription patterns for injection drugs and developing a feedback mechanism comparing physicians' own data with their peer group could change the prescribing patterns [26, 27]. Furthermore, public reporting and incentives for physicians and/or institutions with good compliance to guidelines or improved performance could be considered. These measures would encourage voluntary efforts by physicians themselves to reduce unnecessary use of injections.

The strong point of this study is that we used the actual prescription data of each physician in the ‘real’ clinical practice, as well as survey data to investigate the prescribing behaviour and related factors. However, this study suffered several limitations. First, as the study was based only on the utilization of injection drugs for acute upper respiratory infections in the primary care environment, the generalization of the study findings was limited. Secondly, caution needs to be applied in interpreting the results of this study due to the small sample size and low response rate. We performed the survey during clinic opening time. Most physicians working alone at their clinics did not have sufficient time to participate in the survey during the clinic opening time. To increase the response rate, we therefore tried to interview the physicians through re-contact, and encouraged their participation and cooperation by explaining the purpose of this survey and confirming the confidentiality of their response. In addition, physicians with high preference for injections were less likely to participate in the survey. On the other hand, we compared all the target physicians and the actual sample using available clinic information, including name, contact number, zip code, practice duration and percentile of injection prescription rates. The analysis revealed no significant differences between the target population and actual subjects by clinical specialty, clinic location, practice duration and percentile distributions of injection rates. We therefore considered that serious sampling bias was unlikely to have occurred.

This study did not consider the clinical appropriateness of an injection prescription. Therefore, future studies might explore the appropriateness of injection drug prescription and patient outcome. In addition, consumers' preference for injections and related characteristics deserve to be investigated in future study rather than the physicians' perception of patient demand. Cluster sampling design is recommended because the patients presenting for treatment at the clinics are naturally clustered at the clinics [28–30].

In summary, this study has demonstrated the substantial proportion and variations of unnecessary injections in primary care clinics in Korea. The physicians' prescription rate for injection drugs was significantly related with their knowledge and beliefs and perception of patient demand. Physicians with faulty knowledge and beliefs and perceptions of strong patient demand for injections prescribed injections more frequently. These findings confirm the need for some interventions to curb unnecessary injection use. Educational initiatives with clinical practice guidelines and system-based, quality improvement programs promise to be effective to control the overuse of injections. In addition, investigating patient demand for injections and the discrepancy of physicians' perception on such demand will be helpful to develop strategies for appropriate injection use. Finally, combined interventions directed at both consumers and physicians may be effective in improving the prudent use of injection drugs among primary care physicians.


   References
Top
 Abstract
 Methods
 Results
 Discussion and Conclusion
 References
 

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Accepted for publication June 11, 2007.


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