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Doctors paid on a fee for service basis write more prescriptions for antibiotics than their salaried counterparts, according to recently published Canadian research. Researchers found Newfoundland’s 322 fee paid general practitioners were much more likely to prescribe at rates in excess of the provincial median 1.5 prescriptions per patient annually. In addition, the busier the doctors’ practices were, the greater the number of prescriptions of antibiotics doctors tended to write, whether they were paid a fee for service or salaried. Both findings, say the authors, are likely to be generalisable across North America and abroad. “I think we’ve shown quite clearly that there are other forces, beyond medical indications, that influence antibiotic prescribing,” says Dr Jim Hutchinson, lead researcher on the project and assistant professor of medicine (medical microbiology) at Memorial University, Newfoundland. “This phenomenon, of prescribing rates outpacing the incidence of the conditions prescriptions are being written for, is arguably one of today’s largest public health issues.” Newfoundland’s 476 GPs wrote 800 000 prescriptions for oral antibiotics in a population of 550 000; around 600 000 of these were handed out for respiratory infections. Such high prescription rates could be justified, says Dr Hutchinson, only if rates of pneumonia, sinusitis, group A streptococcal infection, and otitis media were higher than 1000 per 1000 patient years. Widely accepted figures on incidence, however, peg rates at far lower levels. The incidence of community acquired pneumonia, for example, is thought to run at only about 10-20 per 1000 patients annually. Similarly, just 10-20% of patients with sore throats have group A streptococcal infection. The study looked at 1996 administrative data from the Newfoundland Drug Plan, which provides full coverage for about 120 000 residents. Canada spends close to $500m (£313m) annually on prescriptions for antibiotics. Dr Hutchinson says that, given the realities of low pay per patient, and high volume practices, frequent prescribing of antibiotics may be viewed by fee for service doctors as necessary to retain patients.