Addressing conflict of interest driving irrational prescribing of antibiotics in pluralistic health systems: an interventional study in Pakistan

这里提出的这项研究应用了尖端的卫生政策和系统研究，以应对一个关键的、解决得不好的全球卫生挑战：阻碍私营医疗保健提供者提供的护理质量提高的利益冲突(COI)。我们将COI定义为一种情况，在这种情况下，医疗保健提供者的判断的公正性可能会受到次要利益的影响，例如经济收益，从而导致不符合患者最佳利益的决定。有强有力的证据表明，寻求从患者会诊中获利的私人医生经常经历COI，导致处方药物或诊断测试，这些药物或诊断测试要么是不必要的，要么比现有的替代方案更昂贵。我们关注巴基斯坦私人医生不合理的抗生素处方，巴基斯坦是世界上人口第六多的国家，超过80%的人首先向私人医生寻求治疗，而且该国的抗生素使用量位居世界前列。巴基斯坦和其他中低收入国家的研究，包括我们自己的早期研究表明，私人医生在患者不需要的时候开出多种抗生素，以便从制药公司获得好处，或者从药品销售中获利。尽管这一问题的规模和紧迫性影响着数以百万计的人，并导致可能在世界各地传播的抗菌素耐药性，但关于在执行规则的资源和政治支持不足的情况下有效的战略的证据极其有限。因此，培训干预措施的重点是增加知识和技能，以影响私营提供者的自愿行为改变，这是最常用的方法。然而，这些干预措施的成功是有限的，因为不合理的处方主要是出于盈利而不是缺乏知识；在这里，与职业道德相关的规范和价值观是通过干预措施来解决的关键。我们的研究有四个相互关联的目标，这四个目标加在一起将产生新的证据，证明继续医学教育干预的影响，通过特别设计的信息来提高医生对职业道德和COI的敏感性，以及对需要克服的障碍的关键见解，以促进这种干预在当地卫生系统中的扩大。由于负责解决私人医生执业问题的有影响力的利益攸关方本身可能正在跨越职业道德界限，通常通过不披露的多个收入来源，我们的第一个目标是了解巴基斯坦有影响力的利益攸关方是如何概念化COI和职业道德的，以便确定我们干预的潜在支持者和反对者。接下来，我们将重点放在私人医生身上，调查他们如何决定在通过开抗生素获得个人利益方面，什么是伦理上不可接受的和可接受的。我们的第三个目标是了解如何最好地传达信息，使私人医生对职业道德和利益冲突驱动不合理抗生素处方的作用敏感，以便设计我们的干预措施。我们的最终目标是评估我们的干预对私人医生的行为和态度的影响，这些行为和态度涉及制药公司为开抗生素带来的不道德利益。拟议中的研究的一个关键优势是，它是与巴基斯坦研究人员和政策制定者共同设计的，建立在研究委员会之前在巴基斯坦和柬埔寨资助的两个项目的基础上。除了提供新的证据，为正在进行的提高护理质量和解决抗菌素耐药性方面的投资提供信息外，我们关于COI的医学教育材料可以用于其他环境的研究和培训，作为我们创新的卫生系统研究方法的一部分开发的工具将用于未来的研究。

The study proposed here applies cutting-edge health policy and systems research to address a critical and poorly addressed global health challenge: conflict of interest (COI) hindering improvements in the quality of care delivered by private healthcare providers. We define COI as a situation whereby the impartiality of a healthcare provider's judgment may be influenced by a secondary interest, such as financial gain, leading to a decision that is not in the patient's best interest. There is strong evidence that private doctors seeking to make a profit from patient consultations often experience a COI resulting in prescription of medication or diagnostic tests that are either unnecessary or more costly than available alternatives. We focus on irrational prescribing of antibiotics by private doctors in Pakistan, the sixth most populous country in the world, where more than 80% of people first seek care at private doctors and where antibiotic usage is among the highest in the world. Studies in Pakistan and other low and middle income countries, including our own earlier research, show that private doctors prescribe multiple antibiotics when patients do not need them in order to receive benefits from pharmaceutical companies, or make profits from the medicine sales. Despite the scale and urgency of this issue, which affects millions of people and drives antimicrobial resistance which can spread across the world, there is extremely limited evidence on strategies that are effective in contexts where resources and political support for the enforcement of rules are low. Therefore, training interventions focusing on increasing knowledge and skills to affect voluntary behaviour change in private providers is the most common approach used. However, these interventions have had limited success when irrational prescribing is mainly motivated by profit-generation rather a lack of knowledge; here norms and values associated with professional ethics are critical to address with interventions.Our study has four linked objectives, which together will generate new evidence about the impact of a continuing medical education intervention with specially designed messages to sensitise doctors to professional ethics and COI, as well as critical insights about barriers that need to be overcome in order to facilitate scale-up of this intervention in the local health system. Since influential stakeholders responsible for addressing practices of private doctors may be crossing professional ethics boundaries themselves, often by having multiple income streams without disclosure, our first objective is to understand how COI and professional ethics is conceptualised by influential stakeholders in Pakistan in order to identify potential supporters and opponents of our intervention. We next focus on private doctors, investigating how they decide what is ethically unacceptable and acceptable with respect to getting personal benefits from prescribing antibiotics. Our third objective is to understand how best to present messages that sensitise private doctors to professional ethics and the role of conflict of interest driving irrational prescription of antibiotics in order to design our intervention. Our final objective is to assess the impact of our intervention on the behaviour and attitudes of private doctors with respect to unethical benefits from pharmaceutical companies for prescribing antibiotics.A key strength of the proposed study is that it has been co-designed with Pakistani researchers and policymakers, building on two previous research council funded projects in Pakistan and Cambodia. In addition to producing new evidence to inform ongoing investments in improving quality of care and tackling antimicrobial resistance, our medical education material on COI can be used for research and training in other settings, and the tools developed as part of our innovative health systems research methods will be made available for future studies.