Knowledge, Attitude and Behaviour of prescribers after the introduction of the treatment guidelines in South AfricaPillay T, Hill SR

University of Newcastle

Background

Treatment guidelines were introduced in 1998.

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 guidelinesLack of familiarity or awareness

Attitude to the guidelinesLack of agreement, motivation, challenging autonomy.

Behaviours Patient factors Guideline factors Environmental factors

Objectives1. 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 designDoctors 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 Questions1. 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 hypertensionRecall 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 makingclinical 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.”

ConclusionsGuideline 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.