Change in antihypertensive drug prescribing after guideline implementation: a controlled before and after study

Abstract

BackgroundAntihypertensive drug choices and treatment levels are not in accordance with the existing guidelines. We aimed to assess the impact of a guideline implementation intervention on antihypertensive drug prescribing.MethodsIn this controlled before and after study, the effects of a multifaceted (education, audit and feedback, local care pathway) quality programme was evaluated. The intervention was carried out in a health centre between 2002 and 2003. From each health care unit (n = 31), a doctor-nurse pair was trained to act as peer facilitators in the intervention.All antihypertensive drugs prescribed by 25 facilitator general practitioners (intervention GPs) and 53 control GPs were retrieved from the nationwide Prescription Register for three-month periods in 2001 and 2003. The proportions of patients receiving specific antihypertensive drugs and multiple antihypertensive drugs were measured before and after the intervention for three subgroups of hypertension patients: hypertension only, with coronary heart disease, and with diabetes.ResultsIn all subgroups, the use of multiple concurrent medications increased. For intervention patients with hypertension only, the odds ratio (OR) was 1.12 (95% CI 0.99, 1.25; p = 0.06) and for controls 1.13 (1.05, 1.21; p = 0.002). We observed no statistically significant differences in the change in the prescribing of specific antihypertensive agents between the intervention and control groups. The use of agents acting on the renin-angiotensin-aldosterone system increased in all subgroups (hypertension only intervention patients OR 1.19 (1.06, 1.34; p = 0.004) and controls OR 1.24 (1.15, 1.34; p < 0.0001).ConclusionsA multifaceted guideline implementation intervention does not necessarily lead to significant changes in prescribing performance. Rigorous planning of the interventions and quality projects and their evaluation are essential.

Assessing the effectiveness of strategies to implement clinical guidelines for the management of chronic diseases at primary care level in EU Member States: A systematic review

“…Ten studies implemented national guidelines [11,12,23,25,27,[30][31][32][33]36,37], while four studies adapted national guidelines to be used locally [13,14,21,22,29,34]. In four studies local guidelines were developed by multidisciplinary teams [15][16][17][18]26,28].…”

“…Seven studies assessed the implementation of more than one guideline [13,14,26,32,33,36,37]. In total, two studies assessed the implementation of guidelines on osteoarthritis [19,20,37], four on COPD [13,14,25,33,34], four on hypertension [24,32,36,37], six on coronary heart disease [17,18,23,26,32,36,37], six on asthma [13,14,26,27,30,33,34] and finally seven on type two diabetes mellitus [11,12,15,16,21,22,28,29,31,35].…”

“…One study for each Member State was performed in Finland [23], France [24], Germany [19,20], Italy [15,16], Spain [25] and Sweden [17,18], three studies were performed in the UK [26][27][28] and in Denmark [11,12,29,30], while nine studies were performed in the Netherlands [13,14,21,22,[31][32][33][34][35][36][37]. GPs with access to a specific medical information system were included.…”

“…While seven studies assessed the implementation of a single strategy [11][12][13][14][15][16]25,27,30,34], fourteen assessed the effectiveness of multifaceted interventions, with the number of interventions varying from 2 to 5 [17][18][19][20][21][22][23][24]26,28,29,[31][32][33][35][36][37].…”

“…Most of the included studies were cluster-RCTs, for which the randomization process occurred at practice or general practitioner level [11][12][13][14][15][16][17][18][19][20][21][22][25][26][27]29,31,32,36], three studies were RCTs [24,28,30], three studies had a controlled-before-and-after design [23,[32][33][34] and one study was a controlled clinical trial [35].…”