Practice patterns in hypertension
CMAJ 1997;157:1348
Re: "Contemporary practice patterns in the management of newly diagnosed hypertension" (CMAJ 1997;157[1]:23-30 [abstract / résumé]), by Dr. Finlay A. McAlister and associates
In response to: B. Hardin
I appreciate Dr. Hardin's interest in our article but do not share his view that the discrepancies between actual practice and the hypertension guidelines are due solely to the marketing efforts of the pharmaceutical industry.
Much has been written about how physicians learn and which educational interventions are effective in altering practice.1 However, little is known about the impact on prescribing habits of "detailing" by pharmaceutical company representatives (including the provision of free samples). A recent study2 of general practitioners in England provides some insight into the factors that influence physician practice. The most important factor appeared to be "the general practitioner's personal experience of a drug," and only 1 of the 19 respondents reported being "influenced by drug company representatives."
In an attempt to verify and expand on the findings of our practice audit, we recently surveyed physicians in central and northern Alberta to determine their approach to treating hypertension.3 A total of 155 family physicians and 58 internists, approximately 67% of the eligible target audience, responded. We found that the pattern of laboratory utilization and medication prescribing closely mirrored that documented in our chart review. As part of this survey, we asked the physicians to rank the various factors that influenced their prescribing practice. Although the majority of both groups ranked personal clinical experience (79%) and the opinion of colleagues and local experts (66%) as moderate or strong influences, only 4% placed as much emphasis on "the pharmaceutical industry" (which was defined to include educational materials and free drug samples). Granted, physicians may be reluctant to admit to what extent their prescribing practices are influenced by industry representatives or advertising, but I think we should be cautious in attributing departures from recommended guidelines to the effects of advertising. As pointed out by Dr. Nuala Kenny, "clinical practice is both science and art"4 and there are many factors that may legitimately prevent the application of the guidelines to every patient. The challenge for clinicians, researchers and policy-makers is to determine whether divergence from evidence-based guidelines is systematic or random and whether the observed discrepancies are justified by the specifics of each case.
Finlay A. McAlister, MD
Clinical Scholar
Division of General Internal Medicine
Ottawa Civic Hospital
Ottawa, Ont.
References
- Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-5.
- Armstrong D, Reyburn H, Jones R. A study of general practitioners' reasons for changing their prescribing behaviour. BMJ 1996;312:949-52.
- McAlister FA, Laupacis A, Teo KK, Hamilton PG, Montague TJ. A survey of clinican attitudes and management practices in hypertension. J Hum Hypertens 1997;11:413-9.
- Kenny NP. Does good science make good medicine? Incorporating evidence into practice is complicated by the fact that clinical practice is as much art as science. CMAJ 1997;157(1):33-6.
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