Influence of physician specialty on adoption and relinquishment of calcium channel blockers and other treatments for myocardial infarction

Abstract

OBJECTIVE: Recent reports have linked calcium channel blockers (CCBs) with an increased risk of acute myocardial infarction (AMI). We sought to determine to what extent physicians relinquished CCBs following these adverse reports and if there were differences in the use of CCBs and other AMI therapies across 3 levels of specialist involvement: generalist attendings, collaborative care (generalist with cardiologist consultation), and cardiologist attendings. DESIGN:We measured use of CCBs during hospitalization for AMI before (1992±1993) and after (1995±1996) the adverse CCB reports, controlling for hospital-, physician-, and patient-level variables. We also examined use of effective medications (aspirin, b b-blockers, thrombolytic therapy) and ineffective AMI treatments (lidocaine).SETTING: Thirty-seven community-based hospitals in Minnesota.PATIENTS: Population-based sample of 5,347 patients admitted with AMI. MEASUREMENTS:The primary outcome was prescription of a CCB at the time of discharge from hospital. Secondary outcomes included use of other effective and ineffective AMI therapies during hospitalization and at discharge. . From 1992±1993 to 1995±1996, the use of CCBs in patients with AMI decreased from 24% to 10%, the net result of physicians starting CCBs less often and discontinuing them more often. In multivariate models, the odds of CCB relinquishment after the adverse reports (adjusted OR, 0.33; 95% CI, 0.27 to 0.39) were independent of, and not modified by, the involvement of a cardiologist. CONCLUSIONS:Compared with cardiologists, generalist physicians were less likely to adopt some effective AMI therapies, particularly those associated with risk such as thrombolytic therapy. However, generalists were as likely as cardiologists to relinquish CCBs after the adverse reports. This pattern of practice may be the generalist physicians' response to an expanding, but increasingly risky and uncertain, pharmacopoeia.

Explanatory model of prescribing behavior in prescription of statins in family practice

“…All four items also compose a distinctive factor "Effi cacy of the drug" revealed in factor analysis, which explains 14.9% of the variation. We could link effi cacy and safety to the fi ndings of previous research on prescribing [1,3,9,11,12]. However, the results of our study show that even when we expected socially desirable answers in favor of scientifi c-medical reasons infl uencing doctors' decisions, the answers encompassing hard scientifi c infl uences explained a far smaller proportion of the variation than did other factors (Table 4).…”

“…Side eff ects, effi cacy and personal experience drive the decision process in drug prescribing [1,[9][10][11]. Among the key infl uencing factors are those that are medical-evidence based; clinical trials can lower the barriers for adoption of new drugs [12].…”

From knowledge to practice in chronic cardiovascular disease: a long and winding road

“…Although clinician age, gender, and year of graduation appear to be associated with practice variation in some, but not all, studies, it is recognized that prescribing patterns (and sometimes clinical outcomes) do vary by physician specialty, even after adjusting for differences in case mix (17). Of note, although there is a relatively rich database documenting differences between specialties in the management of hospitalized patients with acute myocardial infarction (MI) or HF (17)(18)(19), the evidence base is less robust for differences in outpatient care and is an area of active research (20,21). Although being aware of new evidence is a prerequisite to changing practice, studies examining physician knowledge while simultaneously measuring clinical practice have found remarkably consistent gaps between what we know and what we do, with a median absolute difference of 28% (22).…”

Promotion and Prescribing of Hormone Therapy After Report of Harm by the Women’s Health Initiative

“…5 These studies are descriptive in nature and postulate that the decreases in use of the implicated medications were a result of the dissemination of evidence of harm through scientific channels to physicians (eg, presentations at meetings and publication in journals) and through lay media channels to patients (eg, newspaper and television reports). [4][5][6][7] To our knowledge, the response of the pharmaceutical industry to evidence of harm has not been studied. This response may be particularly important to understand because many studies have documented that patterns of physician practice are often more aligned with promotional messages than with scientific evidence.…”