International Journal of Pharmaceutical and Healthcare Marketing

The influence patient’s characteristics “requests and expectations” on physician

prescribing behavior: A review
Mohsen Ali Murshid Zurina Mohaidin Goh Yen Nee
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Mohsen Ali Murshid Zurina Mohaidin Goh Yen Nee , (2016),"The influence patient’s characteristics
“requests and expectations” on physician prescribing behavior A review ", International Journal of
Pharmaceutical and Healthcare Marketing, Vol. 10 Iss 4 pp. 390 - 411
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IJPHM
10,4
The influence patient’s
characteristics “requests and
expectations” on physician
390 prescribing behavior
Received 30 January 2016
Revised 7 May 2016
A review
Accepted 25 July 2016
Mohsen Ali Murshid, Zurina Mohaidin and Goh Yen Nee
Graduate School of Business, Universiti Sains Malaysia, Penang, Malaysia
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Abstract
Purpose – The role of patient’s characteristics in the prescribing decision of physicians comprises two
major constructs: drug request and expectations. The purpose of this paper was to examine the existing
literature on patient characteristics and then explore the circumstances that reinforce the connection
between patient characteristics (drug requests and expectations) and physician prescribing decision.
Design/methodology/approach – A survey of the literature was carried out across online databases
from 1994 to 2015, and 25 reviewed articles were identified. The influence of patient factors on physician
prescribing decisions was identified in the articles. A conceptual model to investigate the patient
characteristics that influence physicians’ prescribing decision was the developed.
Findings – There have been numerous studies on the effect of patient characteristics on physician
prescription decision. Some studies discovered patient’s request for drug and expectations strongly
influence physicians’ prescribing decision, whereas others found only minor or no relation. To resolve
this ambiguity, there is a need to precisely understand how patient factors affect prescribing decisions
of physicians, under different contexts and conditions. This review contends that contextual variables –
drug characteristics, drug cost/benefits ratio and physician habit persistence – are determining factors
in this debate.
Research limitations/implications – The study recommends further studies on the influence of
each factor on physician prescribing behaviour and an evaluation of the proposed model and
moderating variables.
Originality/value – This paper is the first significant step towards recognizing contextual variables
that may moderate the relationship between a patient’s drug request and expectations and prescribing
behaviour. This research contributes to resolving the debate on the ways patient factors affect
prescribing behaviour.
Keywords Expectations, Prescribing, Physician, Patient, Requests
Paper type Literature review

Introduction
In recent times, there has been increased concern over an upsurge in irrational prescribing
International Journal of behaviour (Theodorou et al., 2009). The irrational prescription is certainly a health issue with
Pharmaceutical and Healthcare
Marketing the potential to harm individuals and the society at large, particularly in developing
Vol. 10 No. 4, 2016
pp. 390-411
countries (Afi Kayi et al., 2015; Delirrad et al., 2015). Several recent studies attribute
© Emerald Group Publishing Limited
1750-6123
inappropriate prescribing to factors related to the behaviour of physician prescribing
DOI 10.1108/IJPHM-01-2016-0010 (Adorka et al., 2013). Patient characteristics (requests and expectations) are identified as a
 major controlling factor of inappropriate prescribing (Faber et al., 2010; Kotwani et al., 2010; Patient’s
Prosser et al., 2003). In practice, physicians frequently exaggerate patients’ requests for characteristics
prescription and hence may overprescribe (Knight, 2013). There is existing evidence that
these requests negatively influence prescribing (Venkataraman and Stremersch, 2007). In
certain cases, physicians often assert that patients’ requests of for a specific brand are a
crucial reason for over-prescribing (Holloway et al., 2002); however, the extent, nature and
impact of such requests remains ambiguous (Kravitz et al., 2003). Results of experimental 391
studies revealed that a patient request for a drug drastically increases the level of prescribing
(McKinlay et al., 2014), which can result in the loss of a patient’s health and quality of life.
In this context, numerous administrative procedures, which include guidelines for
prescribing and educational interventions, have been developed to regulate these
inappropriate prescriptions (Roque et al., 2014). Nonetheless, these efforts were
unsuccessful at improving prescribing behaviour, possibly because of the lack of
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properly understanding the factors that controlling prescribing behaviour. The patient
factors that affect prescribing decisions are expected to be vital for defining responses to
over-prescribing (Lucas et al., 2012). Therefore, additional studies are required to
improve the knowledge of factors that affect prescribing practices in a community
setting. From a policy perspective, understanding patients’ expectations and requests
are important for improving drug prescription.
In the meantime, several attempts have been made to analyse the patient
characteristics that influence physician decision to prescribe (El-Dahiyat et al., 2014;
Kravitz et al., 2003; McKinlay et al., 2014; Stremersch et al., 2012); however, controversy
has been raised. Although some scholars discovered a strong and positive influence of
patient factors (Cockburn and Pit, 1997; Knight, 2013; Mintzes et al., 2003; Stremersch
et al., 2012; Webb and Lloyd, 1994), others found only moderate (Cutts and Tett, 2003)
and negligible effects (Adorka et al., 2013). Thus, there is no definitive conclusion or
consistency in studies carried out on the size effect of patient request on physician
prescribing decision (Carrera et al., 2013). Moreover, studies those assert a strong
connection between the patient factors and drugs prescription behaviour lack hard
evidence. Given this subject is of great importance to scholars and academicians, this
paper will increase the understanding of the relationship between these constructs
compared to earlier researchers, which only studied the existence of the main effect.
Consequently, there is still a need to fully understand the contextual and conditional
influences of patient factors on physician prescription behaviour. Given that contextual
variables such as drug characteristics, physician habit of persistence and drug benefit/
cost are potential sources of the responsiveness of physician’s prescribing behaviour to
patient characteristics, this paper may contribute to resolving the debate on the effect of
patient characteristics (requests and expectations) on prescribing behaviour.
In addition, former reviews are now obsolete, narrowly focused and only partially
indicate that patients’ expectations and requests are the most influential factors of
physician prescribing behaviour in antibiotics context (Salmi et al., 2015). The review by
Chauhan and Mason (2008) concluded there is a dearth of evidence supporting the
influence of patient (not specify any related factor) on physician prescribing behaviour.
Thus, it can be inferred that there have been no comprehensive reviews of the
relationship between patient characteristics and physician’s prescription, including the
moderators. To fill this gap, this review, therefore, the researchers undertake a
semi-systemic review (a review uses predefined criteria to identify 25 studies on a given
 IJPHM topic) to re-examine the influence of patient characteristics (patient request and
10,4 expectations) on physicians’ prescribing decisions.
Based on this review, this paper explores the circumstances that reinforce the
connection between patient characteristics (drug requests and expectations) and
physician prescribing decision. The authors of this review suggest three contextual
moderators (such as drugs attributes, physician habit persistence and cost – benefit
392 ratio of a drug) on the relationship between patient characteristics (patient requests and
expectations) and physician prescribing decision. The last section of this review will
suggest some future research directions and propose a conceptual model based on the
literature review. This novel model has the potential for use in further research.

Patient information source

Patient requests for specific drugs are enthused by direct-to-consumer advertising
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(DTCA), (Mukherjee et al., 2013) notwithstanding if it’s permitted (Stremersch et al.,

2012). Most of the research that establishes the effects of patient requests for drugs on
physician decision prescribing is driven by the growing importance of direct to DTCA,
especially in the USA (Stremersch et al., 2012; McKinlay et al., 2014). DTCA is an
important driver of patient requests (Mukherjee et al., 2013), and researchers have only
studied patient requests when triggered by DTCA rather than any other reason. Mintzes
et al. (2003) examined the relationship between DTCA and patients’ requests for
prescriptions and the relationship between requests and prescribing decisions. The
authors found that DTCA leads to more requests for advertised drugs and more
prescriptions. Lee (2012) argues that DTCA is positively associated with patient drug
requests, but the results did not support any effect of DTCA on the refusal status.
However, Stremersch et al. (2012) proved that effect of DTCA is a negative on patient
requests for drugs. Similarly, McKinlay et al. (2014) find potential negative impacts of
DTCA and other forms of patient activation in drug requests. Campo et al. (2005)
mentioned that some of the patients’ requests are based on “publicity” rather than
DTCA. In the fact, there are still several unanswered issues about DTCA advertising
regarding its effect on patient requests (Manchanda et al., 2005).
Drug requests may also be activated by sources apart from DTCA such as web
searches (Arney et al., 2014), media dissemination (Savage, 2011) and counsel from
friends, idle talk amongst patients and between patients and their friends (McKinlay
et al., 2014), as well as the financial circumstances (Al-rukban and Rizvi, 2014). Prior
symptoms treated by similar drugs prescribed in previous sessions have a significant
effect on physician prescribing decisions (McKinlay et al., 2014; Stremersch et al., 2012).

Patient characteristics
Patient requests for specific drugs
Patients may proclaim their preference for specific drugs via a direct verbal request to
the physician (Kravitz et al., 2003) or by describing symptoms of a particular disease (Afi
Kayi et al., 2015; Knight, 2013). Prescription drug request of the patient plays a
significant role in medical prescription decision-making (Knight, 2013;
Patel-Dovlatabadi, 2014). Drug requests by brand name are generally assumed to have
a positive effect on the physician prescriptions for the requested brand (Stremersch et al.,
2012). This positive relationship is motivated by patient demands, and studies have
shown that patients are less content with their visit to the physician when their requests
 do not comply with (El-Dahiyat et al., 2014; Kravitz et al., 2003). One study concluded Patient’s
that patients believed they would react negatively if their physician refused to discharge characteristics
a request for advertised drug in the general media (Bell et al., 1999).
In reality, patient’s expectations demand that physicians discharge their requests
smoothly (Lee, 2012). Evidence shows that physicians prescribe a new drug at a patient’s
request, and, actually, patients requesting a drug are more likely to receive a prescription,
even if the request is in conflict with the physician’s inclination or assessment of the drug’s 393
efficacy (Thistlethwaite et al., 2010). In one study, above 50 per cent of physicians were
requested by patients to prescribe specific drugs, and most of the general practitioners (GPs)
generally met these requests (Kersnik and Peklar, 2006). A related study showed that in 40
per cent of cases where drug prescription was based on a patient’s request, physicians were
uncertain about the medicine to prescribe (Mintzes et al., 2003). Physicians seem to
overestimate the patient demand. On average, estimates have been found of 56 per cent
(Arney et al., 2014), 43 per cent (Campbell, 2013) and 50 per cent (McKinlay et al., 2014). From
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an agency perspective, physician decision will be under duress and may be adversely
selective (over prescription), thus negatively affecting patient wellbeing. In this
circumstance, it could be debated that agency effects may to a certain extent be due to social
normative pressures, which influence physician prescribing behaviour.
Although drug requests have a positive effect, there exists great dispute on the
degree to which patient drugs requests by brand name impact on physician prescription
behaviour. Patients are more likely to go to physicians with the desired treatment plan
already in mind (Lee, 2012), such as a prescription for a particular brand. Nonetheless, a
number of studies suggested some benefits that can be derived from patient’s drug
request such as increased satisfaction and their active involvement in decision-making
regarding health issues (Lee, 2012). In this case, physicians may accommodate demands
to increase patient satisfaction (Stremersch et al., 2012). A patient drug request may be
valuable by creating awareness regarding a problem (Knight, 2013). For instance,
antidepressant requests increase depression history taking (Feldman et al., 2006).
Therefore, the question generally still remains concerning the influence of patient drug
request on physician prescribing behaviour and if the moderating effect or influence
changes the patient request or physician prescribing behaviour.

Patient expectations of receiving particular prescription

Drugs prescription without a specific patient request is a normal occurrence as
physicians regularly prescribe according to their own observation of patient
expectations in order to maintain the patient–physician’s rapport (Thistlethwaite et al.,
2010). Physicians acknowledged that patients’ expectations are a foremost reason for
prescribing antibiotics (Faber et al., 2010). Patients shape their expectations before any
consultation about what the physician is going to do (Ion, 2013). From the perspective of
a physician, the patient expectation is described as physician’s perception of a patient’s
need for treatment during medical consultations (Lado et al., 2008; Little et al., 2004).
However, related studies revealed that the effect of expectations are not directly related
to the patients but the physician’s perception of the patients’ expectations, which goes
on to directly influence the physician’s decisions to prescribe the drug (Cockburn and
Pit, 1997; Ion, 2013; Tušek-Bunc et al., 2010).
Studies discovered that patient expectations increase the likelihood of receiving
a particular prescription by three times, but the physician’s perception of the
 IJPHM patients’ expectations increase the likelihood of receiving a particular prescription
10,4 by 10 times (Cockburn and Pit, 1997; Knight, 2013). Another study indicated that
physicians observed that 56 per cent of patients sought prescriptions (Britten and
Ukoumunne, 1997). The study also found that physicians prescribed drugs to 59
per cent of patients that came for consultations. One study has shown that people
who had previously seen their physicians for the same conditions were more likely
394 to expect drugs, suggesting that patient knowledge and experience influence
expectations (Cockburn and Pit, 1997). Thus, it can be inferred that physician’s
perception of the patient expectation is the real motivating factor of drug
prescription (Tušek-Bunc et al., 2010). However, it remains undecided which is the
most influencing factor, the patient expectations or the physician’s perception of
these expectations. This quagmire needs to be addressed.
Although the effect of patient expectations is a popular notion, different opinions are
held on this issue. There is the common belief that patient expectations are responsible
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or at least partially drive the over prescription dilemma presently being witnessed
(Faber et al., 2010). The excessive prescriptions of the drugs are influenced in general by
the patient expectations regarding the medication which they are to get from the
physician (Ion, 2013). Some studies infer that patient expectations increase the possibility
that a drug will be prescribed (Cockburn and Pit, 1997), whereas others put forward that
patients may be discontented if their expectations are not fulfilled, which doubles the
possibility of consulting other physicians over a similar problem (Knight, 2013).

Methodology for the review

Search methods for identification of studies
Scientific articles indexed in Google Scholar, Science Direct and Pub Med was selected for
review. To make the review consistent with the current practice, this research was restricted
to studies published between 1994 and June 2015. We have looked for additional articles in
the references of each retrieved article, including review articles. Once the searches had been
run, articles were downloaded and entered into reference manager software (Mendeley).
Articles were then screened for eligibility for inclusion.

Criteria for including studies

To be included in the review, studies needed to evaluate the patient request for a drug and
patient expectations affecting the physician prescribing. Only articles published in the
English language were included. Articles that assess effects in different contexts and
different countries were included only where their contribution involved patient factors that
pertain to the physician prescribing decision. Qualitative/interview, quantitative, cohort,
focus group discussion and observation studies designs were eligible for inclusion. Types of
participants are physicians and patients or mix. The review included the influence of patient
characteristics on physician prescribing behaviour (e.g. patient request, patient expectations
and physician perceptions of patients’ expectation). Types of outcomes – for the purpose of
this paper, we used the following classification: influencing physician prescribing decision;
physician prescribing behaviour; and physician decision to prescribe the drug.

Criteria for excluding studies

Abstracts, case series, case reports and short communications, short reports were
excluded. Articles related to patient request and expectation for health-care services
were excluded from the current review (i.e. physician services and hospital services). We
 acknowledge that patient request for drugs may be undertaken by non-physicians, for Patient’s
example, nurses and pharmacists. However, these articles have been also excluded from characteristics
this review as our focus was on physicians.

The terms of search strategy

Key phrases input in search engines include “patient request for a drug”, patient
expectations’, factors influencing physician prescribing’, “effect of patient
characteristics on prescribing”, “effect of patient requests on prescribing” and “the
395
influence patient expectations on prescribing”. For physicians, the following
keywords were used: doctor(s), prescriber(s), GP(s) and physician(s).

General characteristics of studies

For this study, 25 studies conducted in different countries (USA, UK, Germany,
Australia, Spain, Canada, Nepal, India, Slovenia, South Africa and Lesotho) were
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selected. About 40 per cent of the included studies were conducted in the USA; 14 of the
25 studies utilised the cross-sectional survey design (Adorka et al., 2013; Arney et al.,
2014; Campbell, 2013; Britten and Ukoumunne, 1997; Cockburn and Pit, 1997; Cutts and
Tett, 2003; Hoffman et al., 2003; Hummers-Pradier et al., 1999; Macfarlane et al., 1997;
Mangione-Smith et al., 1999; Mintzes et al., 2003; Parker and Pettijohn, 2005; Von Ferber
et al., 2002; Tusek-Bunc et al., 2010).
Four of the studies were experimental (McKinlay et al., 2014; Stremersch et al., 2012;
Venkataraman and Stremersch, 2007; Webb and Lloyd, 1994); four focused on
qualitative methods, interview and focus group discussion (Holloway et al., 2002;
Kotwani et al., 2010; Naik et al., 2009; Hyde et al., 2005) and two observations (Little et al.,
2004; Miller et al., 1999), whereas the remaining was cohort study (Lado et al., 2008; Von
Ferber et al., 2002).
Three studies selected patients as subjects (Hoffman et al., 2003; Lado et al., 2008; Von
Ferber et al., 2002). Over half (13) of studies employed physicians as respondents (Adorka
et al., 2013; Arney et al., 2014; Campbell, 2013; Cutts and Tett, 2003; Kotwani et al., 2010; Hyde
et al., 2005; Macfarlane et al., 1997; McKinlay et al., 2014; Miller et al., 1999; Naik et al., 2009;
Mintzes et al., 2003; Parker and Pettijohn, 2005; Tusek-Bunc et al., 2010).
Four studies used both patients and physicians (Cockburn and Pit, 1997; Britten and
Ukoumunne, 1997; Hummers-Pradier et al., 1999; Little et al., 2004), three used
prescription data (Stremersch et al., 2012; Venkataraman and Stremersch, 2007; Webb
and Lloyd, 1994) and the last two were mixed (Holloway et al., 2002; Mangione-Smith
et al., 1999). The scope of the studies also varied. Ten studies directly related a patient’s
request to physician prescribing behaviour; 12 studies explored the effect of patient
expectations on physician prescribing behaviour, and 2 were mixed. One study
examined the parent expectations in physician prescribing are outlined in Table I.

Methodological characteristics
Table I also shows the methodological characteristics of the included studies. The
methodology of the studies was diverse. Four studies used random sampling (Arney et al.,
2014; Lado et al., 2008; Campbell, 2013; Tusek-Bunc et al., 2010). Two studies used the
convenience sampling (Holloway et al., 2002; Miller et al., 1999). One study used cluster
sampling (Mintzes et al., 2002); another study used purposive sampling (Naik et al., 2009),
whereas the study by McKinlay et al. (2014), used both purposive and random sampling.
One study used none-probability sampling but not specified (Cockburn et al., 1997).
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10,4

396

findings)
Table I.
IJPHM

the author,
participants,
A summary of
characteristics of

constructs, study
included studies (by

design and then main

First author,
year and Constructs-related patient
country Participants characteristics Design and sampling method Main findings

Adorka et al. 39 physicians Patient request Cross-sectional self-administered Patients’ request and their expectations for
(2013) Patient expectations questionnaire antibiotics appear to influence nurses but
Lesotho Sampling method: not reported not physicians
Kotwani et al. 36 physicians Patient request Qualitative methods (focus Patient demand and expectations are
(2010) Patient expectations group discussion) important factors for antibiotic
India Sampling method: not reported prescriptions
Pilot study: not reported
Holloway et al. 218 patients and health Patient request Qualitative interview and focus Patients’ requests did not influence
(2002) worker interviews group discussion physician prescribing
Nepal Sampling method: convenience
sampling
McKinlay et al. 192 primary care Patient request Experimental study: using Patient request for a specific drug
(2014) physicians different video-based scenarios increases the rate at which physicians
USA Sampling method: purposively prescribe that drug
and randomly sampling
Stremersch et al. 142,180 prescriptions Patient request Experimental study: the Patient requests have a positive effect on
(2012) for 2,294 physicians database included prescriptions prescribing decision
USA of statin categories
Miller et al. 20 family physicians Patient request Observational study using two 80% of physicians did not think that the
(1999) survey approaches patient request had much influence on
Canada Sampling method: a convenience their decision to prescribe an anti-infective
sample drug
Arney et al. 500 office-based Patient request Cross-sectional questionnaire 56.9% of physicians reported having
(2014) physicians Sampling method: probability fulfilled the drug request
USA sampling
Mintzes et al. 87 physicians Patient request Cross-sectional survey Patients’ requests for medicines are a
(2003) Sampling method: a cluster powerful driver of prescribing decisions
USA sampling
(continued)
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First author,
year and Constructs-related patient
country Participants characteristics Design and sampling method Main findings

Naik et al. (2009) 25 physicians Patient request Qualitative: in-depth interviews Patient requests for specific brands
USA Sampling method: purposively influence physician prescribing behavior
sampling
Venkataraman Panel data of 2774 Patient request Experiments study physician- Patient requests for drugs have influence
et al. (2007) physicians level panel data interviews, drug physician prescribing behavior
USA approval database and clinics
reports
Parker et al. 363 staff physicians Patient request Cross-sectional questionnaire Physicians did not believe that patients’
(2005) Sampling method: no reported requests affected their prescriptions
USA
Campbell (2013) 3500 physicians in 7 Patient request Cross-sectional survey 43% of physicians often give in to
USA specialties Sampling method: random patients’ requests for brand name drugs
sampling
Cockburn et al. 22 general physicians Patient expectations Cross-sectional survey The perception of physician that the
(1997) and 336 of their Sampling method: none random patient expects a prescription is a strong
Australia patients sampling driver to prescribe the drug
Webb et al. 1,080 prescriptions Patient expectations Experimental study Patient’s expectations were most strongly
(1994) with 12 general associated with physician prescribing
UK physicians
Cutts et al. 258 physicians Patient expectations Qualitative study using a self- 66.1% of physicians felt that patient
(2003) administered questionnaire expectations influence their prescribing
Australia Sampling method: not reported
Lado et al. 937 patients Patient expectations Cohort study – questionnaire Physicians’ perception of patients’
(2008) Sampling method: sample expectations has an association with drug
Spain randomly stratified prescribing
Tusek-Bunc 250 physicians Patient expectations Cross-sectional questionnaires Physicians’ perception of patient
et al. (2010) Sampling method: randomly expectation was considered to have an
Slovenian sampling influence (9.5%)
(continued)

Table I.
397
Patient’s
characteristics
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10,4

398

Table I.
IJPHM

First author,
year and Constructs-related patient
country Participants characteristics Design and sampling method Main findings

Britten et al. 544 patients consulting Patient expectations Cross-sectional questionnaires Physicians’ perceptions of patients’
(1997) 15 general Sampling method: no reported expectations were the strongest predictor
UK practitioners of the decision to prescribe the drug
Little et al. 30 physicians, 847 Patient expectations Observational study Physicians’ perceptions of patient need
(2004) patients questionnaires were strongly associated with prescribing
UK Sampling method: no reported
Von Ferber et al. 618 patients Patient expectations Cross-sectional questionnaire Patient’s expectations are less effect
(2002) Sampling method: no reported physicians prescribing
Germany
Hoffman et al. 402 patients and 13 Patient expectations Cross-sectional questionnaire Physicians perception of Patient
(2003) GPs Sampling method: no reported expectation were associated with antibiotic
South Africa prescribing
Hyde et al. 27 GPs Patients’ expectations Qualitative study of five focus Physician decision to prescribe the drug is
(2005) groups with shaped by patient expectations
Germany
Macfarlane et al. 76 physicians Patients’ expectations Cross-sectional questionnaire Patients’ expectations have a significant
(1997) Sampling method: no reported influence on prescribing
USA
Hummers- 417 physicians (280 Patients’ expectations Cross-sectional questionnaire Patient expectations are extremely
Pradier et al. matched doctor-patient Sampling method: no reported important when prescribing medicines for
(1999) questionnaires) cold and cough
Germany
Mangione-Smith 10 physicians and 306 Patients’ expectations Cross-sectional questionnaire Parent expectation did not influence the
et al. (1999) parents Sampling method: no reported decision to prescribe
USA
 However, the method of the sampling was not reported for 11 studies (Adorka et al., 2013; Patient’s
Britten and Ukoumunne, 1997; Cutts and Tett, 2003; Hoffman et al., 2003; Hummers-Pradier characteristics
et al., 1999; Kotwani et al., 2010; Little et al., 2004; Macfarlane et al., 1997; Mangione-Smith
et al., 1999; Parker and Pettijohn, 2005; Von Ferber et al., 2002). Three studies used
experimental methods (Stremersch et al., 2012; Venkataraman and Stremersch, 2007; Webb
and Lloyd, 1994), whereas just one study used the qualitative method (Hyde et al., 2005). Key
characteristics of the included studies are shown in Table I. 399
Results
Table I shows key results of included studies in this review. The findings of each study
were described. A careful review of the content of research articles reveals two main
patient factors influencing physician decision to prescribe the drug: patient request for
drugs and physician perceptions of patients’ expectation. Below, we summarize these
findings grouped by the following two topics:
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(1) Patient request for specific drugs and physician prescribing decision.
(2) Patient expectations of receiving particular prescription and physician prescribing
decision.

Patient request for specific drugs and physician prescribing decision (12 studies)
Twelve studies (Table I) looked for the influence of patient request for specific drugs and
physician prescribing decision. In the USA, one study finds that drug requests from
patients have a strong positive influence on drug prescription (Stremersch et al., 2012).
In the study reporting qualitative data, physicians considered the patient request as an
important factor influencing prescribing (Kotwani et al., 2010). In another qualitative
study, Naik et al. (2009) observed that patient requests for specific brands influence
physician prescribing behaviour. A cross-sectional survey found the physicians
reported the patients’ requests for drugs are a powerful driver of prescribing a specific
drug (Mintzes et al., 2003). Two cross-sectional studies also discussed the containment of
physicians for patient requests. In the first study, Campbell (2013) found that 43 per cent
of physicians often give patients’ requests for brand drugs. In the second study, 56.9
per cent physicians reported having fulfilled the drug request (Arney et al., 2014).
Results from this factorial experiment reveal that request of the patient for a specific
drug dramatically increases the rate at which physician prescribe that medication
(McKinlay et al., 2014). In another experiment study, Venkataraman and Stremersch
(2007) found that patient requests for drugs have influence physician prescribing
behaviour. They also reported that drug attributes moderate the relationship between
patient request and physician prescribing. However, Miller et al. (1999) showed that 80
per cent of physicians do not concur with supposed influence of patient drug request on
their prescription decision-making. This view is supported by Adorka et al. (2013),
Holloway et al. (2002) and Parker and Pettijohn (2005), who were unable to deduce any
significant effect of patient request on drug prescribing.

Patient expectations of receiving particular prescription and physician prescribing

decision (15 studies)
Fifteen studies (Table I) were examined the influence of patient expectations on physician
prescribing decision. Three studies found that physicians’ perception of patient expectations
strongly influences the prescribing decision of physicians (Britten and Ukoumunne, 1997;
 IJPHM Little et al., 2004; Webb and Lloyd, 1994). Two studies physicians reported that patient
10,4 expectations are important factors in physician prescribing a specific drug
(Hummers-Pradier et al., 1999; Kotwani et al., 2010). In Australia, one a cross-sectional survey
found that the perception of patient expectation by the physician is a strong driver to
prescribe the drug (Cockburn and Pit, 1997). From included studies, only two studies
detected an association between physicians’ perception of patient expectation and
400 prescribing decision (Hoffman et al., 2003; Lado et al., 2008).
Qualitative study using a self-administered questionnaire found that 66.1 per cent of
GPs felt that patient expectations influence their prescribing (Cutts and Tett, 2003). One
study by Hyde et al. (2005) explored GPs decisions to prescribe the drug. They found
that the physician decision to prescribe the drug is shaped by their perception of patient
expectations. In the context of antibiotic prescribing, Macfarlane et al. (1997) examined
the patient expectations. The author found that patients’ expectations have a significant
influence on prescribing.
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On the contrary, some studies showed that patient expectations had no or less
influence over physician prescribing behaviour. An observational study found that
patient’s expectations have a minor effect on the prescribing behaviour of physicians
(Von Ferber et al., 2002). A cross-sectional study assessed the attitudes of physicians
towards prescribing statins in a family practice setting. The authors found that
physicians’ perception of patient expectation was a significant factor influencing statin
prescribing and explained 9.5 per cent of the variance (Tusek-Bunc et al., 2010).
Two studies in the antibiotics context reported that physician prescribing not
influenced by patient expectations. In the first study, Mangione-Smith et al. (1999)
examined the parents’ expectations among children infected with a probable viral cause.
The results found that the parent expectation did not influence the physician decision to
prescribe. In the second study, Adorka et al. (2013) investigated the attitudes and
perceptions of health-care providers regarding antibiotic prescribing, it was found that
patient expectation did not influence the physician decision to prescribe antibiotic.

Discussions of findings
We identified 25 studies assessing the influence of patient characteristics such as the
requests and expectations of patients. The influence of patient requests on physician
prescribing varied across studies. Some studies report strongly positive effects of the
requests patients, whereas other found the only minor effect or no effect. The size of the
expectations of patient effects has been under debate; some find positive effects, whereas
others find no effects. There is no consensus on the role of patient requests and expectations
in prescribing. This compensates for the fact that existing literature dealing with the
influence of patient characteristics (patients request for drug and expectations) on the
prescribing behaviour of a physician are limited, unconvincing and highly debatable.
Moreover, the moderating impact of organisational factors on the effect of patient factors
upon prescribing remains unclear.

Limitations of included studies

One of the limitations is that we only included studies published in 1994 and above.
Other limitations relate to patient characteristics including only studies regarding
requests and expectations of patients: none assessed factors behind the patient requests.
Most of the available literature lacks rigor, and studies empirically testing the
 hypothesis are few, therefore, weakening any argument made on its basis. Moreover, all Patient’s
of the included studies had design limitations. For example, the studies conducted in characteristics
different settings and health-care systems, small sample size and mostly non-validated
questionnaires and pilot tests. Although the included studies were a questionnaire,
however, they did not measure associations or not prove causation.
From the evidence presented, patient factors, as influencers, are not well established,
the sizes of effects reported vary considerably, and the mechanism by which influence is 401
exerted remains unclear. Evidence reported the effect of the patient requests for a drug
on the prescribing, and whether such influences are modified by both patient and
physician characteristics or by organisational factors is still unclear (McKinley et al.,
2014). Therefore, this review is the first significant step towards recognizing contextual
variables that may moderate the relationship between a patient’s drug request and
expectations and prescribing behaviour.
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Contextual factors as moderators

Based on the results of the review, because the increasing debate about the influence of
patient requests and their expectations on physician prescribing is a global
phenomenon among researchers, and few limited studies carried out in the context, it is
essential for understanding moderating factors on this link. Therefore, this study
attempts to resolve the debate on the effect of patient factors on prescription behaviour.
Literature addressing the effectiveness of patient factors may be moderated by
specific variables (Venkataraman and Stremersch, 2007). Evidence from empirical
research provides a critical argument that there seems to be conclusive evidence about
the high influence related to medicine (drug attributes), patient (cost/benefit ratio of a
drug) and physician (habit persistence) on physician prescribing behaviour.
Venkataraman and Stremersch (2007) published in the Journal of Management Science
similar research directions as indicated in this paper. The authors used both
physician-level panel data and reports – clinical trial in the econometric model analysis.
The main results of the research found that responsiveness of the prescribing decision of
physician’ to marketing efforts and patient request depends on upon the characteristics
of the drug. The authors suggested that a further research is needed for studying the
moderating of drug attributes on the effect patient request on physician prescribing,
which may prove to bear new conceptual insights.
The necessity for more research in this area is also stated by Mukherjee et al.’s (2013)
review of 130 published studies to determine the direct-to-consumer advertising of
prescription drug. According to Mukherjee et al. (2013), future researchers should focus on
“the effect of drug cost of on physicians’ behavior in response to patient requests for the drug,
would help develop the future health policy”. Investigation on physician persistence in the
prescribing is critical to the understanding of decision physicians’ response to
pharmaceutical marketing activities (Janakiraman et al., 2008; Abdul Waheed et al., 2011);
hence, additional study on the moderating role of this variable is in response to patient
characteristics is needed. Thus, research considers that the habit persistence should be
viewed as a potential barrier to the improvement physician behaviour, and, therefore, the
mechanism by which it can moderate the marketing efforts-prescribing relationship could
be similar to that of the patient characteristics-prescribing interaction and worthy of
empirical investigation. These factors contextual are present at the time of prescribing
 IJPHM decision-making and modulate the level of uncertainty, so influencing physician decision to
10,4 prescribe the drug.
This study puts forward three prominent contextual components based on evidence
that confirms their strong influence: physician habit persistence (Janakiraman et al.,
2008), drug characteristics (Venkataraman and Stremersch, 2007) and benefit- cost of a
drug (Ladeira et al., 2011). In addition, these factors significantly influence physician
402 decision making regarding drug prescribing by moderating uncertainty. They also
serve as modulators of interventions of patient requests.
To date, the majority of implemented moderators are drug characteristics such as
efficiency and side effect (Venkataraman and Stremersch, 2007). However, given the
growing attention in the direction of the impact of social structural factors (physician habit
persistence and benefit/cost ratio of a drug), the timely information provided in this paper is
crucial. Indeed, there is the need for further research to enhance understanding of the
conditions and contexts explaining the reasons previous studies have reported such a broad
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range of effect sizes of patient characteristics–physician prescribing relationship.

Drug characteristics
Drug characteristics are the attributes that differentiate it from other products on the
market and identified as important when making a decision of prescribing include
efficacy, adverse effects, quality and quantity (Dickov et al., 2011). A drug can be
characterised along many attributes, such as its approved interactions, its collateral
effects, its kind of product category, its quality, its time on and new in the market
(Ahmed et al., 2014; Ladeira et al., 2011). In another study, Tušek-Bunc et al. (2010) found
that drug characteristics (such as efficacy and utility) are important factors that
influence prescribing decisions (Tušek-Bunc et al., 2010).
Normally, these elements are not included in the prescription but are incorporated in
the physician information provided with the drug (Ladeira et al., 2011). However,
physicians do take drug characteristics into consideration when prescribing a drug
(Prosser et al., 2003; El-Dahiyat et al., 2014). Nonetheless, a positive perception of a
physician for the drug’s characteristics will positively influence their prescription
behaviour. Decisions about the prescription of new drugs are generally driven by
evidence of drug characteristics such as efficacy and safety of the drug (Tobin et al.,
2008). As a result, drug characteristics are dynamic and context dependent.
Physicians have provided several reasons for not prescribing a requested drug. The
most commonly cited reasons were that the characteristics of the drug requested were
inappropriate for the patient and that a different drug was more suitable (Afi Kayi et al.,
2015). Thus, it is logical to assume that drug characteristics influence situations,
wherein patients demand or expect for prescription drugs. Experimental studies
support this assumption. For instance, Afi Kayi et al. (2015) asserted that physician’s
response to patient requests for a specific drug was influenced by drugs characteristics.
Likewise, Venkataraman and Stremersch (2007) eloquently argued that moderating
attributes such as drug efficacy and side effects affect patient request across brands.
Similarly, Arney et al. (2014) found that drug characteristics are significant predictors of
discharging a patient’s drug request. The drug characteristics aid the physician in
fulfilling patients’ requests and to decide if the drug is appropriate for the patient.
In the case of patient expectations, this research refers to previous studies that reveal
that patient expectations occur more frequently in mild conditions (Table I). This paper
 proposes that patient requests or expectations with higher drug characteristics are Patient’s
relatively more honoured by the physician compared to drug requests with lower characteristics
characteristics. Based on the physician perspective, drugs with lower characteristics are
more detrimental to the patient than any damage possibly caused by physician–patient
relationship (Knight, 2013). In addition, a physician may react more positively to
effective patient expectations (high drug characteristics) as she/he has less uncertainty
about the drug’s efficacy. Hence, the physician is more likely to garner positive feedback 403
afterwards than when he reacts favourably to a patient expectation for an ineffective
drug (drugs of low characteristics).
In general, physicians are favourably inclined towards patient expectations as
regards effective drug but decrease their reaction to patient expectations when it
concerns ineffective drugs. Based on these arguments, this paper asserts that drug
characteristics are a potential moderator of the responsiveness of physicians’
prescription behaviour to patient characteristics (requests and expectations) and, thus,
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deserves further study and hypothesised that:

H1. The higher the drug characteristics, the stronger relationship between the
patient characteristics: patient request for a drug and physician’s perception of
the patients’ expectations and physician decision to prescribe the drug.

Cost/benefit profile of drug

Under the context of drug prescription, the cost-benefit ratio plays a significant role at
the time of the prescription (Diehl et al., 2008). Kim and King (2009) suggest that the
physicians should be knowledgeable on the significance of cost-benefit ratio at the time
of drug prescription. Physicians have pointed out that costs should be considered a
priority when prescribing drugs (Buusman et al., 2007). In addition, it has been
discovered that cost possibly influences the prescription of new drugs (Chauhan and
Mason, 2008). For instance, El-Dahiyat et al. (2014) found that 58.5 per cent of physician
have the impression that drug cost influences prescribing. Ladeira et al. (2011) linked
drug consumption in developing countries to the financial status of patients. Thus, in
poor countries, cost plays a critical role in determining the availability of drugs to
patients (Al-tahami, 2010). Al-Areefi et al. (2013) found that the patients’ economic
condition and ability to pay strongly influences the prescribing decisions of Yemeni
physicians. Therefore, it is irrational not to expect the influence of benefit-cost profile of
a drug on physician prescribing behaviour. It is generally specified that physician’s rate
cost significantly influences prescribing behaviour (Tušek-Bunc et al., 2010; Hart et al.,
1997; Theodorou et al., 2009). In the course of emphasizing on clinical efficiency,
physicians prioritize cost under certain conditions (Ladeira et al., 2011).
However, the benefit-cost profile and utility of a drug are dynamic factors that
moderate the physician prescribing decision (Tušek-Bunc et al., 2010). Benefit/cost ratio
is capable of strengthening physician–patient relationship by increasing the level to
which requests or expectations of patients influence physicians’ prescribing decisions.
Arney et al. (2014) found the cost/risks and benefits of the drug are important predictors
of satisfying a patient’s drug request by the physician. Invariably, physicians are more
enthusiastic to accommodate requests when they are not concerned about the cost of a
highly beneficial drug. This helps the physicians create a balance between their sense of
the need, benefits and possible harms of accepting patients’ drug requests with their
degree of disposition to do so. It was subsequently inferred that physicians’ decisions to
 IJPHM accommodate drug requests may be formed by their perceptions of their patients. Thus,
10,4 it is predictable that patient requests and expectations for drugs with a higher value are
honoured by the physician in more cases compared to requests or expectations for drugs
with lower utility:
H2. The higher the cost/benefits ratio of a drug, the stronger the relationship
404 between the patient characteristics: patient request for a drug and physician’s
perception of the patients’ expectations and physician decision to prescribe the
drug.

Physician habit persistence

Over time, physicians develop certain schemes of prescribing drugs. Once a drug is
preferred as part of physicians’ personal formulary, it has a high tendency to be
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prescribed regularly through the habit of persistence (Janakiraman et al., 2008). In

other words, it is essential for the physician to inculcate habits to lessen the
encumbrance of decision-making associated with prescribing. It may be debated
that habit persistence of the physician is an indication of the physician’s loyalty for
the brand drug (Grebowski and Vernon, 1992). Physicians normally display
consistent drug prescription behaviour (Godin et al., 2008), which is harder to alter
(Erplanken and Wood, 2006), and, thus, drugs are prescribed without cognitive
interest (Zerzan et al., 2011). Thus, this study believes that habit persistence should
be considered as a possible hindrance to the enhancement of physician behaviour
and, as a result, the mechanism by which it can moderate the patient factors
(requests and expectations) prescribing relationship.
Janakiraman et al. (2008), for example, affirmed that physician habit persistence is one of
the characteristics of physicians’ decision-making that has garnered the interest of
researchers in recent times (Janakiraman et al., 2008; Mizik and Jacobson, 2004). Others have
asserted that physician habit persistence is a strong influencing factor in physician
decision-making (Zerzan et al., 2011). The strong influence of habit persistence on physician
prescribing is not unexpected when in view of the intricacies of medical decisions.
In addition, habit persistence may hinder the role of the physician to the level that
patient requests and expectations affect the physician prescribing behaviour. A number
of physicians approve and prescribe the drugs of certain companies or brands based on
the success of former treatments. Such physicians become devoted to the drugs of these
companies (Al-Areefi et al., 2013). Therefore, it can be argued that habit persistence of
physicians modulates the influence patient factors have on physician prescribing
decision. Nonetheless, no study has made attempts to address the moderating effect of
physician habit persistence on the relationship between patient factors (requests and
expectations) and physician prescribing behaviour. Therefore, future studies should
focus on this moderating effect of habit persistence in order to develop a more
comprehensive health policy regarding drug prescription:
H3. The higher the physician-level habit persistence, the weaker the relationship
between the patient characteristics: patient request for a drug and physician’s
perception of the patients’ expectations and physician decision to prescribe the
drug.
 Proposed conceptual model Patient’s
This paper is an attempt to develop and create a general conceptual theoretical model of characteristics
patient – physician prescribing based upon the concise review of existing literature. The
model comprises two major components:
(1) antecedents such as the requests and expectations of patients; and
(2) the moderators such as drug characteristics, physician habit persistence, and
drug cost/benefits ratio. 405
The theoretical model was developed to provide an all-inclusive view of patient factors
and their impact on physician prescribing (Figure 1). It is an approach to examine the
moderating effect of contextual factors on the relationship between drug requests and
expectations of patient and physician prescribing.
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Strengths and weaknesses of the review

The strengths of this review are to conduct a comprehensive review of the effect of patient
characteristics on physician prescribing behaviour. In the fact, we did not find to date other
similar reviews conducted on the same topic in the region of our interest. A recently
published systematic review by Salmi et al. (2015) focusing on the knowledge, perceptions
and physicians behaviour regarding antibiotic prescribing. They reviewed the literature
from 1990 to 2014. This eventually reviews involved 19 articles. The review has only
identified that patients’ expectations and demand of patients for drugs were the most factors
influence the physician prescribing behaviour. The literature included in this review does
not clearly distinguish between patient request and their expectations as an independent
factor influencing physician prescribing as the current review. Moreover, the authors do not
discuss the link between the patient constructs and physician prescribing. The older review
published by Chauhan and Mason (2008) in 2008 conducted on determinants of uptake of
new drugs in secondary. This review finds little evidence on the influence of patients (not
specify any related factors) upon prescribing decisions. Therefore, this review has updated
and expanded the results of previous reviews regarding the effects patient request and
patient exception on physician prescribing decision.

Moderators
- Drug Characteristics +

- Drug Cost/ Benefit Ratio +

- Physician Habit Persistence –

Patient Characteristics

- Patient request for a

drug Physician
Decision to
- Physician perception Prescribe Figure 1.
of Patient Expectations Drugs A conceptual model
of patient–physician
prescribing decision
 IJPHM Implications for policy makers
10,4 Research on patients’ expectations and requests has implications for policy, as well as
practice. This review proved that patients (requests and expectations) are active
participants in prescribing decision, with wide-ranging yet specific expectations that
they frequently (if not likely) communicate to their physicians, then it must be true that
patients influence both the behaviour and quality of the prescription drug. This review
406 provides new insights into the relationship between patient factors and physician
prescribing by studying contextual factors that strength or weakness the relationship.
Based on this review, there is also need to develop guideline which set out what
should be considered the appropriate interaction between physicians and patients while
seeking to diminish if not the apparent ethical conflicts of interest to the relationship
between the two sectors. There is also a need to develop and disseminate standard of
care professional guideline, scope, practice and may choose to develop guideline which
is related to physician interaction with the patient request for drugs.
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Implications for future research

This review deduced that a great deal of the existing studies on patient characteristics is
generally investigative and based on the content analysis in developing and developed
countries. However, we identified few studies carried out in the developing countries, it
is essential for understanding the patient factors on prescribing drugs in such countries.
In contrast, questionnaire data or focus group discussions and studies that directly test
the relationships are limited. Therefore, future studies should consider these limitations
in order to augment the development of a significant research on the effect of patient
characteristics on physician prescribing.
Physicians’ prescribing behaviour requires understanding patients’ expectations as
regards drug prescriptions (Von Ferber et al., 2002). Hence, further research on its effect
on patient expectations on physician prescription will be beneficial for practitioners and
may provide useful insights for researchers.
From the evidence showed in this review, there appears to be a consensus on drug
attributes, cost/benefit ratio of drug and physician habit persistence as moderators on
the relationship between patient characteristics and physician prescribing behaviour
and therefore worthy of empirical research in the future. Finally, this review provides
the crucial information that will be valuable to researchers working on studies to
improve physician prescribing behaviour regarding patient characteristics.

Conclusion
In conclusion, this paper is the first to review the effect of patient characteristics on
physician prescribing behaviour. Patient request for a drug has been found to influence
the prescribing decision. However, the evidence showed in the current review
supporting this result is debatable. Patient expectations have been found that it is not
the expectation, but rather the physician’s perception of the patient expectations that
directly influencing prescribing behaviour of a physician, and as a consequence, no
conclusion could be drawn as to their role in physician prescribing.
This research contributes to resolving the debate on the ways patient factors
affect prescribing behaviour. More specifically, this research investigates the level
to which the effects of patient characteristics on physician decision making may
depend on upon contextual factors. Although it is possible shortcomings, this
 review is intended to facilitate a discussion of the importance of understanding Patient’s
patient factors influencing the prescribing decision and to identify potential characteristics
moderators’ factors avenues for further research.

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About the authors

Mohsen Ali Murshid is a PhD Candidate in the Graduate School of Business (GSB), Universiti
Sains Malaysia – Malaysia. His current research interests include factors influencing physician
prescribing behaviour. He received a Msc from Universiti Malaysia Perlis (UniMAP) – Malaysia
(2014). His research addresses quantitative research, pharmaceutical marketing mix strategy and
physician satisfaction. He has published several articles in indexed journals. Mohsen Ali Murshid
is the corresponding author and can be contacted at: mohsen092@gmail.com
Dr Zurina Mohaidin is a Marketing lecturer in Graduate School of Business. She currently
teaches Marketing Management and Research Method for postgraduates and specializes in
research relating to marketing and consumer behaviour. She graduated with a PhD in Marketing
from Cardiff University, UK. Her PhD research was basically about understanding consumer
behaviour from the perspective of Evolutionary Psychology and Foraging. Her thesis also
includes Behavioural Economics and Evolutionary Psychology, looking at the branding and
consumer choices. She graduated both her MBA and BSc in Marketing from Bridgeport
University, USA. Dr Zurina has done a few consultancy project, among others with Mutiara
Timur Hotel and consultancy with TNB on Customers Satisfaction in Pulau Pinang. She has been
a trainer for Basic Marketing Training to the small- and medium-sized entrepreneurs (SME)
organised by Lembaga Kemajuan Wilayah Pulau Pinang (PERDA). A particular focus of her
previous research has been on consumer behaviour and marketing. She is interested in looking at
the patterns of brand and product selection by consumers and relates it to the philosophy of
economic psychology, specifically the explanation of consumer choice where she has presented
numerous papers in conferences and published research articles.
Goh Yen Nee is a Senior Lecturer in the Graduate School of Business (GSB), Universiti Sains,
Malaysia. She received a Doctorate degree in Business Administration from GSB, Universiti
Sains, Malaysia. She has been a Visiting Scholar at Department of Business Administration,
Georg Simon Ohm University of Applied Sciences Nuremberg, Germany. Her current research
interests include consumer behaviour, green marketing, tourism marketing and medical tourism.
She has published several articles in Indexed Journals.

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