Inappropriate practices in prescribing:
Who decides and how?
CMAJ 1997;156:1696
In response to: J.R. Busser; F. Vickerson
As we indicated in our article, the consensus panel members were selected arbitrarily, and an effort was made to assure a reasonable balance among geographic regions and among relevant specialties. We chose individuals with established reputations in the field of drug therapy, particularly as it affects elderly people. One family physician invited to participate refused because there was no remuneration for the task.
We did not evaluate the validity of the standard textbooks used in developing the drug lists. None of the experts on our consensus panel was an author of the lists on which the project was based. Our study design was not intended to evaluate agreement on specific items contributed by panel members, nor did it require that we exclude panel members from rating their own submissions. Since 32 specialists were responsible for developing the consensus, it is unlikely that an eccentric rating by 1 member would have an impact on the final ratings.
It is unclear to us why advance agreement on the scoring process would be necessary in a consensus procedure. We arbitrarily selected the 4-point rating scale, and none of the panel members objected to using it. As we outlined, panel members were asked to rate the clinical importance of the potential adverse drug effects by taking into account 3 criteria: (1) the prescription introduces a substantial and clinically significant increase in the risk of a serious adverse effect, (2) equally effective or more effective and less risky alternative therapy is available for most patients and (3) the practice is likely to occur often enough that a change in practice could decrease morbidity in elderly people.
As we indicated, we used a modified Delphi technique to arrive at consensus recommendations. We did not feel that the repeated iterations needed in an "actual" Delphi process would improve the clinical usefulness of the final recommendations.
We agree with Dr. Busser that some of the panel's views are difficult to reconcile. One's own biases often lead one to disagree with consensus recommendations. For example, although some of us feel that ß-adrenergic blocking agents have some limited usefulness in severe heart failure, clinical experience and conventional wisdom dictate that these drugs are risky in patients with heart failure. With respect to the treatment of hypertension in patients with a history of heart failure, there are several alternatives to diuretics and angiotensin-converting-enzyme inhibitors, including alpha1-adrenergic agents and centrally acting antiadrenergic drugs. We cannot explain why 94% of the experts agreed with the use of calcium-channel blocking agents to treat angina in a patient with a history of heart failure since we did not ask the panel members to outline the reasons for their selections.
We thank Dr. Vickerson for bringing to our attention the recent study of the use of dipyridamole for stroke prevention. We do not know how many panel members were aware of the results of the European stroke-prevention study when we were carrying out our study.
Peter J. McLeod, MD
Robyn M. Tamblyn, PhD
McGill University
Montreal, Que.
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