Transcript Poster presentation

KNOWLEDGE, ATTITUDES AND BEHAVIOUR OF PRESCRIBERS
AFTER THE INTRODUCTION OF ANTIHYPERTENSIVE TREATMENT
GUIDELINES IN SOUTH AFRICA
Pillay T, Hill SR
School of Medical Practice and Population Health
Abstract
Knowledge, Attitudes and Behaviour of Prescribers After the Introduction of
Antihypertensive Treatment Guidelines in South Africa
Pillay T, Hill SR
Problem Statement: A drug utilisation review (DUR) of antihypertensive prescribing in public
hospitals concluded that prescribers do not follow the hypertension treatment guidelines.
Objectives: To assess prescriber knowledge, attitudes to guidelines and their reasons for
non-compliance with the guidelines.
Design: Semi-structured face-to-face interviews were conduct with prescribers at 8
hospitals.
Setting: Public hospitals in the province of KwaZulu Natal, South Africa.
Study Population: Twenty-five interviews were conducted with prescribers at the selected
hospitals.
Methods: A semi-structured interview schedule was used to canvass the key issues:
knowledge and attitudes towards the hypertension treatment guidelines; and reasons for
non-compliance with the guidelines, especially the reasons for prescribing or not prescribing
methyldopa, short-acting nifedipine and reserpine. The interview sessions were audio taped
and the transcripts transcribed by two researchers (independently).
Results: Overall, participants were ambivalent about the hypertension treatment guidelines.
They were not adverse to the general concept of guidelines however they did not adhere to
the hypertension treatment guidelines. The main reason for their non-adherence was their
lack of knowledge about the guidelines. This was further compounded by other general
criticism about the guidelines: inappropriate guideline referral recommendations, outdated
information in the guidelines and lack of consultation with prescribers during the drafting
process. Consequently, participants used their personal preferences in choosing to
prescribe drugs such as methyldopa and nifedipine.
Conclusions: Prescribers knew very little about the hypertension treatment guidelines since
they were never involved in the development process nor were they formally introduced the
guidelines. It is not surprising that prescribers did not follow the guidelines. This study
illustrates the consequences of passive guideline distribution as an implementation strategy
for guidelines promotion. These results also serve to support the findings of previous studies,
i.e. changing prescriber behaviour requires a multifaceted guideline implementation strategy.
Methods (continued)
Results (continued)
Participants were informed that the interview would be audiotaped and transcribed. The tapes were transcribed by an
independent person and the transcripts then checked for
accuracy by two researchers.
Approach to the management of hypertension
Diuretics were prescribed as 1st line drugs, followed by
ACEI then CCBs. A minority of prescribers used
reserpine. Methyldopa was the preferred agent amongst
prescribers (after diuretics) at hospitals with high
methyldopa use.
The interviews were aimed primarily at eliciting the
participants’ opinions and knowledge of standard
treatment guidelines and possible reasons for any
differences between prescription patterns and the
treatment guidelines. The interviews lasted around 20
minutes in most cases (range 15 to 35 minutes).
The questions in the interview schedule were broadly divided
into three sections:
1. General knowledge and attitude to the standard
treatment guidelines
The key questions in this section were: awareness of the
guidelines, whether they had a personal copy, whether
they commented on the draft guidelines and their
understanding of the guideline development process.
Background and Setting
In 1998 The National Department of Health published
treatment guidelines for various medical conditions
including hypertension. A drug utilisation review (DUR) of
antihypertensive prescribing was conducted in the
province of KwaZulu Natal to assess the impact of the
guidelines on antihypertensive prescribing . The DUR
identified a number of interesting trends:
•thiazide diuretics were used as first line therapy
•ACEI and short-acting calcium antagonists were widely
prescribed compared to beta blockers and reserpine
•a third of the hypertensive patients were prescribed
methyldopa (at some hospitals).
The results suggest that antihypertensive prescribing
practices in KZN deviated from the standard treatment
guidelines.
The most interesting deviations were:
•A preference for methyldopa which is not
recommended in the guidelines for hypertension
•a general preference for ACEI and short acting calcium
channel blockers rather than the recommended drugs
i.e. beta-blockers and reserpine.
2. Knowledge and prescribing practices in relation to
hypertension
The key questions in this section were: do you remember the
guidelines recommendations for hypertension, do you
agree with this approach, outline your management of
hypertension and the reasons for deviations from the
guidelines.
3. The role of evidence and cost information on
prescriber decision making
The key questions in this section were: the importance of
clinical trial evidence vs. personal experience and how
important are drug costs in prescribing decisions.
Objectives
1.Assess the general attitude of doctors to the use of
standard treatment guidelines to guide prescribing.
Figure 1: Doctors from a hospital in KwaZulu Natal Province, South Africa
2.Assess whether prescribers were familiar with the
standard treatment guidelines for hypertension.
3.Determine whether doctors agreed with the
pharmacological recommendations in the standard
treatment guidelines for hypertension.
4.Identify reasons for non-adherence to the hypertension
treatment guidelines, in particular with respect to the
prescribing of the older antihypertensives, methyldopa
and reserpine.
5.Determine whether evidence from clinical trials and cost
price of drugs are important considerations for
prescribers.
Methods
Selection of Hospitals
Eight hospitals were purposively selected for the study.
Four hospitals were high users of methyldopa and the
other four were low users of methyldopa. There was an
equal number of urban and rural hospitals in the sample.
Selection of Participants
Doctors responsible for the care of hypertensive patients at
each of the 8 hospital out-patient departments were invited
to participate in this survey.
Consenting prescribers were contacted by telephone to
arrange a convenient day, time and venue for the in-depth
interview. Most hospital superintendents allowed three or
four physicians to participate in the interviews. In total
twenty-five interviews were conducted.
Methyldopa use
The reasons for prescribing methyldopa were unrelated to
evidence of effectiveness and based on personal
experience and previous prescribing practices.
Prescribers argued that since patient blood pressures
were controlled and patients did not seem unhappy with
the treatment, there was no need to justify the treatment
choice with clinical trial evidence.
When questioned about whether patients experienced any
side effects related to methyldopa use, the response was
that patients did not experience the side effects reported
in the literature. However, none of the prescribers knew
what the side effects of methyldopa were. The following
response probably illustrates the uncertainty about side
“…there are so many patients that we have to
effects:
treat at the clinic. It would be impossible for us to
ask them about side effects. If the side effects are
really troubling them they will report it.”
Nifedipine
The participants that prescribed nifedipine (short-acting) for
chronic hypertension were unaware of the literature
cautioning against use in ischaemic heart disease
patients. The reasons for using nifedipine were: it was a
cheap drug and effective in reducing blood pressure.
Reserpine
Reserpine was not widely prescribed because clinicians had
no experience with the drug, and it was not commonly
prescribed at their hospital. The side effects also
concerned most prescribers, particularly depression.
Evidence and guidelines
When participants were asked whether they would prefer a
guideline developed using the principles of evidence
based medicine rather than clinical experience, most
seemed to prefer guidelines developed using scientific
evidence.
Drug costs and prescribing
Drugs costs were reported to be important considerations in
prescriber decision-making however they were unable to
estimate the costs of drugs or to rank them by cost.
Results
Conclusion
Awareness of the guidelines
Participants reported that they did not receive any
background information about the purpose of the
guidelines. Medical officers were either given a copy of the
guidelines or made aware of the guidelines in meetings
with management or the pharmacy department. A few
community service doctors remembered being told about
guidelines at medical school, but this was never
emphasised.
The guideline implementation process was poorly coordinated
– draft guidelines were not widely disseminated for comment,
prescribers were not introduced to the guidelines nor were
they given the policy framework of the guidelines. These
issues may explain to some extent why prescribers have not
taken the guidelines more seriously.
Knowledge of guideline development
None of the participants were aware of the criteria applied to
the selection of drugs. A few respondents felt that the cost
of the drugs was probably the only criterion.
Limitations of the guidelines
The key problems were the lack of consultation with
prescribers on the ground, difficulty with referral to lower
levels of care, guidelines are outdated, guidelines were
not user friendly for nurses, and certain drugs that are
essential for a district hospital require specialist approval.
General knowledge about the hypertension guidelines
Participants had a vague recollection of the hypertension
guidelines but were unable to recall accurately the order in
which the antihypertensives were recommended. Most
participants were aware that the guidelines suggested
diuretics as the first choice agent in hypertension.
Thereafter, most believed that the second-line agent was
a choice between either ACEIs, CCBs or beta blockers. A
few participants did recall that reserpine appeared on the
guidelines. Most prescribers were uncertain about the role
of methyldopa in the hypertension guidelines.
The lack of in-depth knowledge of the guidelines is reflected
in prescribing practices of the older antihypertensives.
Methyldopa use is influenced by previous prescribing
practices, practices of fellow colleagues and poor
understanding of how black patients report side effects.
The lack of knowledge has been shown in the prescribing of
short-acting nifedipine to ischaemic heart disease patients or
the ignorance of the side effect profile of methyldopa.
Participants in urban and rural settings identified a need for
continuing medical education.
Overall, the results of the study suggest that prescribers have
limited knowledge about the guidelines due to an ineffective
implementation strategy. Prescribers are generally positive
about the concept of standard treatment guidelines despite
their lack of involvement in their development. The ineffective
implementation strategy has had little impact on prescriber
behaviour. This is reflected in the continued use of
methyldopa and short acting nifedipine.
Acknowledgements
Study funded by AusAid.
WHO Collaborating Centre for Training in Pharmacoeconomics and Rational Pharmacotherapy