[One of the authors responds:]
Murray M. Finkelstein quite rightly points out a potential methodological flaw in our study of antibiotic prescribing practices in Newfoundland. I agree that the better denominator would have been total patients seen or total number of patients in a given physician's practice; however, these data were not available. In Newfoundland there is no rostering of patients, and salaried physicians are not obliged to report patient numbers.
Finkelstein also, quite rightly, points out that if a physician prescribes to 1 individual with a given condition 3 times in a year and 49 others with that same condition receive no prescription then the physician's rate of prescription is 3 using our methods. There is a possibility that this type of variance in physician behaviour explains the difference among Newfoundland physicians that cannot be refuted by our data. It is my opinion, however, that it is unlikely.
It must be remembered that all of the physicians in the province were studied and that to explain the large differences found between all the fee-for-service and all the salaried general practitioners using the proffered logic one must infer that the predominant pattern of practice among fee-for-service general practitioners is a high threshold before the first antibiotic is prescribed (conservative prescribing) and then a low threshold thereafter for those patients prescribed to once already (liberal prescribing) as in Finklestein's example. It is more likely that a given physician's pattern of prescription remains quite constant and that the associations described in our paper are valid.
As for Patrick J. Potter's concerns that the patient populations may be inherently different between fee-for-service and salaried practitioners, this may be true. I'm not sure that it matters from the overall perspective of the urgent necessity to reduce antibiotic prescription rates in Canada. This study was not perfect science and I do not, in general, advocate one type of physician remuneration over another. I am, however, extremely concerned with antibiotic prescription rates overall in Canada. Recently the first strains of vancomycin-resistant Staphylococcus aureus and Streptococcus pneumoniae were described. Will they appear in Canada? Of course they will. Yet we Canadian physicians continue to prescribe antibiotics at rates of close to 1 prescription per person per year. [1] It is time that we band together and markedly change this circumstance before it is too late. If that means discussing the influence of physician organization and remuneration then let's discuss it, quickly.
James M. Hutchinson, MD
St. John's, Nfld.
References
- 1.↵