1. KNOWLEDGE, ATTITUDES AND BEHAVIOUR OF PRESCRIBERS AFTER THE INTRODUCTION OF ANTIHYPERTENSIVE TREATMENT GUIDELINES IN SOUTH AFRICA 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. Results 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. 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lack of consultation with prescribers on the ground, difficulty with referral to lower levels of care, guidelines are outdated, guidelines were not user friendly for nurses, and certain drugs that are essential for a district hospital require specialist approval.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. Methods (continued) Participants were informed that the interview would be audio- taped and transcribed. The tapes were transcribed by an independent person and the transcripts then checked for accuracy by two researchers. 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. 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. Figure 1: Doctors from a hospital in KwaZulu Natal Province, South Africa Pillay T, Hill SR School of Medical Practice and Population Health WHO Collaborating Centre for Training in Pharmacoeconomics and Rational Pharmacotherapy Conclusion 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. 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. 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. Background and Setting Objectives 1.Assess the general attitude of doctors to the use of standard treatment guidelines to guide prescribing. 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. Results (continued) 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. 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 effects: 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. “…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.” 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.