Knowledge, Attitude and Behaviour of prescribers after the introduction of the treatment guidelines in South Africa Pillay T, Hill SR University of Newcastle

Background  Treatment guidelines were introduced in  DUR study suggests that prescribers are not following the hypertension guidelines.  Doctors at certain hospitals continue to prescribe methyldopa.

General barriers to guideline adherence  Knowledge about guidelines Lack of familiarity or awareness  Attitude to the guidelines Lack of agreement, motivation, challenging autonomy.  Behaviours  Patient factors  Guideline factors  Environmental factors

Objectives 1.Assess the general attitude of doctors to treatment guideline. 2.Assess whether prescribers were familiar with the t guidelines for hypertension. 3.Determine whether doctors agreed recommendations in the 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.

Study design Doctors were invited to participate in an in-depth interview at the hospitals selected  8 hospitals were purposively selected for the study.  4 hospitals were high users of methyldopa and  4 were low users of methyldopa (?compliant with the guidelines) There was an equal number of urban and rural hospitals in the sample.

Interview Questions 1.General knowledge and attitude to the guidelines aware of the guidelines, personal copy, understanding of the guideline development process. 2.Knowledge and prescribing practices in relation to hypertension Recall 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 clinical trial evidence vs. personal experience and importance of drug costs in prescribing.

Results: General knowledge and attitude to the guidelines Awareness of the guidelines  No introduction to the guidelines  Doctors sometimes made aware of the guidelines by the pharmacy department.  Community service doctors remembered being told about guidelines at medical school, but this was never emphasised. Knowledge of guideline development  None of the participants were aware of the criteria applied to the selection of drugs. Limitations of the guidelines  Lack of consultation with prescribers on the ground,  difficulty with referral to lower levels of care,  guidelines are outdated and  certain drugs that are essential for a district hospital require specialist approval.

Knowledge and prescribing practices in relation to hypertension  Vague recollection of the hypertension guidelines;  unable to recall accurately the order in which the antihypertensives were recommended. Most participants were aware that the guidelines suggested diuretics the first choice agent in hypertension. Most believed that the second-line agent was a choice between either ACEI, CCBs or beta blockers.

Methyldopa  Reasons for prescribing  prescriber belief in the effectiveness of methyldopa,  personal experience and previous prescribing practices  Methyldopa reduces blood hence must be effective – no other evidence required Side effects “Patients did not experience the side effects reported in the literature” “…there are so many patients that we have to 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.”

Conclusions Guideline implementation process was poorly coordinated :  draft guidelines were not widely disseminated for comment,  prescribers were not introduced to the guidelines  No clear policy framework of the guidelines. Prescribing practices influenced by:  previous prescribing practices  practices of fellow colleagues and  poor understanding of how black patients report side effects.

Implications  Passive dissemination of guidelines are ineffective.  Pharmacists at hospitals are required to play a greater role in education.  Education about drug costs are important.