Inappropriate practices in prescribing: Who decides and how?
Online posting: April 3, 1997
Published in print: June 15, 1997 (CMAJ 1997;156:1695)
Re: Defining inappropriate practices in prescribing for
elderly people: a national consensus panel, by Dr. Peter J.
McLeod and colleagues, CMAJ 1997;156:385-91 [full text / résumé].
Although I support the effort to define and guide optimal
prescribing, and I agree that elderly people are an important
group, I have reservations about the methods employed in this
study and the meaning of the findings.
Some aspects of the methods are not described, including the
method by which the expert panel was recruited, whether any of
those approached had declined (and any reasons for doing so), and
whether there was an evaluation of the validity of the source
lists from standard textbooks. It is not stated whether any of
the experts are authors of the lists on which the project was
based. It would be interesting to know the degree of agreement on
items contributed by individual panel members compared with those
assembled from independent lists. We should also know whether
panel members were excluded from ranking their own submissions.
The method of handling the suggestions for lower-risk alternative
therapies was not specified.
The panel members scored the clinical importance of the
potential adverse effects of each practice on a 4-point ordinal
scale. There is no indication of advance agreement on the scoring
process, and the instrument does not discern between the
likelihood of a problem and its potential severity. The method of
analysis is a simple arithmetic mean, whereas a Delphi technique
(alluded to in the introduction but not clearly employed) would
have permitted better resolution of any disagreement.
Some of the specific panel views are difficult to reconcile.
In Table 1, ß-adrenergic blocking agents are deemed relatively
inappropriate for the treatment of hypertension in patients with
heart failure. Without access to the scenario, we cannot know
whether heart failure is likely to result from impaired systolic
function, which is key to the issue. Despite their agreement on
that point, only 78% of panellists could agree with the use of
either a diuretic or an angiotensin-converting-enzyme inhibitor
as an alternative agent. (How many other options are there?) Up
to 94% of these experts, in the treatment of angina in patients
with heart failure, may prefer a calcium-channel blocker over a
ß-adrenergic blocking agent, which is perplexing, given
longstanding concerns about the use of calcium-channel blockers
in heart failure and the evidence of benefit from ß-adrenergic
blocking agents in this setting.
James R. Busser, MD, MHSc
Clinical Assistant Professor
Division of General Internal Medicine
Department of Health Care and Epidemiology
Clinical Skills Subcommittee Chair
Faculty of Medicine
University of British Columbia
Vancouver, BC
busser@unixg.ubc.ca
www.interchange.ubc.ca/busser/
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