What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study

Abstract

BackgroundThiazide diuretics are cost-effective for the treatment of mild to moderate hypertension, but physicians often opt for more expensive treatment options such as angiotensin II receptor blockers or angiotensin converting enzyme inhibitors. With escalating health care costs, there is a need to elucidate the factors influencing physicians' treatment choices for this highly prevalent chronic condition. The purpose of this study was to describe the characteristics of physicians' decision-making process regarding hypertension treatment choices.MethodsA comparative qualitative study was conducted in 2009 in the Canadian province of Quebec. Overall, 29 primary care physicians--who are also participating in an electronic health record research program--participated in a semi-structured interview about their prescribing decisions. Physicians were categorized into two groups based on their patterns of prescribing antihypertensive drugs: physicians who predominantly prescribe diuretics, and physicians who predominantly prescribe drug classes other than diuretics. Cases of hypertension that were newly started on antihypertensive therapy were purposely selected from each physician's electronic health record database. Chart stimulated recall interview, a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinical encounters, was used to elucidate reasons for treatment choices. Interview transcripts were synthesized using content analysis techniques, and factors influencing physicians' decision making were inductively generated from the data.ResultsWe identified three themes that differentiated physicians who predominantly prescribe diuretics from those who predominantly prescribe other drug classes for the initial treatment of mild to moderate hypertension: a) perceptions about the efficacy of diuretics, b) preferred approach to hypertension management and, c) perceptions about hypertension guidelines. Specifically, physicians had differences in beliefs about the efficacy, safety and tolerability of diuretics, the most effective approach for managing mild to moderate hypertension, and in aggressiveness to achieve treatment targets. Marketing strategies employed by the pharmaceutical industry and practice experience appear to contribute to these differences in management approach.ConclusionsPhysicians preferring more expensive treatment options appear to have several misperceptions about the efficacy, safety and tolerability of diuretics. Efforts to increase physicians' prescribing of diuretics may need to be directed at overcoming these misperceptions.

What to give the patient who has everything? A qualitative study of prescribing for multimorbidity in primary care

“…CSR also allowed probing into why certain decisions were made, which was necessary for the purpose of identifying targets for professional interventions. 19,20,23 By combining CSR and grounded theory, substantive issues for GPs emerged from the data that are additive to existing qualitative research with GPs on multimorbidity, much of which is based on case vignettes or focus groups. [24][25][26][27] Although purposive and snowball sampling were both used to recruit a sample that was representative of the national GP profile, those who participated may have had a greater interest in or a particular agenda relating to the study question.…”

An observational study on the prescription pattern of antihypertensive drugs in a private health care centre, Chennai

“…The decreasing use of diuretics, which is reflected in our study may be explained by physician misperceptions that diuretics are less effective, less safe. 15 BBs are considered as one of the first line antihypertensive drug classes, Some prefer to use BBs only in patients with compelling cardiac indications for them or as add on agents in those with uncontrolled or resistant hypertension. 16 Use of beta blockers (BB) as monotherapy has contributed around 24%.…”

Evidence-based medicine and life-long learning competency requirements in new residency teaching standards

“…The information preferred by many physicians comes from guidelines, expert consultants, colleagues and the pharmaceutical industry 8 9. Relatively few specialties require competence in the evaluation and use of information obtained from these sources, although evaluation methods are available 10–12…”