BackgroundUnderstanding the perceptions and attitudes of physicians is important. This knowledge assists in the efforts to reduce the impact of their interactions with the pharmaceutical industry on clinical practice. It appears that most studies on such perceptions and attitudes have been conducted in high-income countries. The objective was to systematically review the knowledge, beliefs and attitudes of physicians in low and middle-income countries regarding interactions with pharmaceutical companies.MethodsEligible studies addressed any type of interaction between physicians and pharmaceutical companies. The outcomes of interest included knowledge, beliefs and attitudes of practicing physicians. The search strategy covered MEDLINE and EMBASE databases. Two reviewers completed in duplicate and independently study selection, data abstraction, and assessment of methodological features. The data synthesis consisted of a narrative summary of the findings stratified by knowledge, beliefs and attitudes.ResultsWe included ten reports from nine eligible studies, each of which had a number of methodological limitations. Four studies found that the top perceived benefits of this interaction were receiving information and rewards. In five out of eight studies assessing the perception regarding the impact of the interaction on the behavior of physician prescription, the majority of participants believed it to be minor. In one of these studies, participants perceived that impact to be lesser when asked about their own behavior. The attitudes of physicians towards information and rewards provided by pharmaceutical company representatives (PCRs) (assessed in 5 and 2 studies respectively) varied across studies. In the only study assessing their attitudes towards pharmaceutical-sponsored Continuing Medical Education, physicians considered local conferences to have higher impact. Their attitudes towards developing policies restricting physicians’ interactions with PCRs were positive in two studies. In one study, the majority of participants did not mind the public knowing that physicians were receiving gifts and awards from drug companies.ConclusionsThis review identified few studies conducted in low and middle-income countries. While physicians generally perceived the impact of interactions on their behavior to be minor, their attitudes toward receiving information and rewards varied across studies.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1299-4) contains supplementary material, which is available to authorized users.

BackgroundThere is conflicting evidence about the association between low vitamin D levels in children and development of asthma in later life. The objective of this study was to systematically review the evidence for an epidemiological association between low serum levels of vitamin D and the diagnosis of asthma in children.MethodsWe used the Cochrane methodology for conducting systematic reviews. The search strategy included an electronic search of MEDLINE and EMBASE in February 2013. Two reviewers completed, in duplicate and independently, study selection, data abstraction, and assessment of risk of bias.ResultsOf 1081 identified citations, three cohort studies met eligibility criteria. Two studies found that low serum vitamin D level is associated with an increased risk of developing asthma late in childhood, while the third study found no association with either vitamin D2 or vitamin D3 levels. All three studies suffer from major methodological shortcomings that limit our confidence in their results.ConclusionsAvailable epidemiological evidence suggests a potential association between low serum levels of vitamin D and the diagnosis of asthma in children. High quality studies are needed to reliably answer the question of interest.

A relatively high percentage of physicians in LMICs interact with pharmaceutical companies. Findings have implications for policy and practice, given the current extent of interaction is likely affecting the prescribing habits and professional behaviour of physicians.

Background: In an effort to reduce inappropriate testing of hospital-onset Clostridioides difficile infection (HO-CDI), we sequentially implemented 2 strategies: an electronic health record-based clinical decision support tool that alerted ordering physicians about potentially inappropriate testing without a hard stop (intervention period 1), replaced by mandatory infectious diseases attending physician approval for any HO-CDI test order (intervention period 2). We analyzed appropriate HO-CDI testing rates of both intervention periods. Methods: We performed a retrospective study of patients 18 years or older who had an HO-CDI test (performed after hospital day 3) during 3 different periods: baseline (no intervention, September 2014–February 2015), intervention 1 (clinical decision support tool only, April 2015–September 2015), and intervention 2 (ID approval only, December 2017–September 2018). From each of the 3 periods, we randomly selected 150 patients who received HO-CDI testing (450 patients total). We restricted the study to the general medicine, bone marrow transplant, medical intensive care, and neurosurgical intensive care units. We assessed each HO-CDI test for appropriateness (see Table 1 for criteria), and we compared rates of appropriateness using the χ2 test or Kruskall-Wallis test, where appropriate. Results: In our cohort of 450 patients, the median age was 61 years, and the median hospital length of stay was 20 days. The median hospital day that HO-CDI testing was performed differed among the 3 groups: 12 days at baseline, 10 days during intervention 1, and 8.5 days during intervention 2 (P < .001). Appropriateness of HO-CDI testing increased from the baseline with both interventions, but mandatory ID approval was associated with the highest rate of testing appropriateness (Fig. 1). Reasons for inappropriate ordering did not differ among the periods, with <3 documented stools being the most common criterion for inappropriateness. During intervention 2, among the 33 inappropriate tests, 8 (24%) occurred where no approval from an ID attending was recorded. HO-CDI test positivity rates during the 3 time periods were 12%, 11%, and 21%, respectively (P = .03). Conclusions: We found that both the clinical decision support tool and mandatory ID attending physician approval interventions improved appropriateness of HO-CDI testing. Mandatory ID attending physician approval leading to the highest appropriateness rate. Even with mandatory ID attending physician approval, some tests continued to be ordered inappropriately per retrospective chart review; we suspect that this is partly explained by underdocumentation of criteria such as stool frequency. In healthcare settings where appropriateness of HO-CDI testing is not optimal, mandatory ID attending physician approval may provide an option beyond clinical decision-support tools.Funding: NoneDisclosures: None