KNOWLEDGE, ATTITUDES AND BEHAVIOUR OF PRESCRIBERS AFTER THE INTRODUCTION OF ANTIHYPERTENSIVE TREATME

1
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
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 (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
• 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.
• 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.
• 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.

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

• 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.

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.
Objectives

• Assess the general attitude of doctors to the use
  of standard treatment guidelines to guide
  prescribing.
• Assess whether prescribers were familiar with the
  standard treatment guidelines for hypertension.
• Determine whether doctors agreed with the
  pharmacological recommendations in the standard
  treatment guidelines for hypertension.
• Identify reasons for non-adherence to the
  hypertension treatment guidelines, in particular
  with respect to the prescribing of the older
  antihypertensives, methyldopa and reserpine.
• Determine whether evidence from clinical trials
  and cost price of drugs are important
  considerations for prescribers.

Figure 1 Doctors from a hospital in KwaZulu
Natal Province, South Africa
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.
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.
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.
Acknowledgements Study funded by AusAid.
WHO Collaborating Centre for Training in
Pharmacoeconomics and Rational Pharmacotherapy