Changing physician practice a challenge

Data can take years to influence standard procedure

After reviewing results of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), some physicians predicted that the findings would soon change medical practice in hypertension.

Such a conclusion would ignore human nature, says Daniel Albrant, PharmD, president of Pharmacy Dynamics, a pharmaceutical consulting company in Arlington, VA. "It is very hard to change physician practice through research reports. We know for a fact that data take somewhere between eight and 10 years to disseminate into practice."

Claude Lenfant, MD, director of the National Heart, Lung, and Blood Institute (NHLBI) in Bethesda, MD, might agree. Back in 1997, he wrote an article in the Dec. 3 Journal of the American Medical Association asking why more physicians weren’t heeding the recommendation of the reports of NHLBI’s Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC). The JNC had analyzed research results and over the years had issued six reports of the National High Blood Pressure Education Program. The reports included guidelines to improve health care providers’ ability to manage hypertension.

JNC reports have little effect on practice

The JNC-V report recommended that traditional agents for treating hypertension, such as diuretics and beta-blockers, be considered as initial therapy because of their proven benefits in reducing mortality. An outside study, however, found that newer agents (such as calcium channel blockers and angiotensin-converting enzyme inhibitors) were being prescribed more frequently than traditional agents. The researchers concluded that the recommendations in the JNC-V reports had had little effect on prescribing patterns in the United States.

After JNC-VI, NHLBI launched a marketing research study to examine physicians’ reactions to and use of NHLBI guidelines, which also are issued for management of high blood cholesterol and asthma. The aim of the study was to learn how guidelines could be formatted, organized, and disseminated more effectively. The results then guided the development of the JNC-VI report, although the recommendation for first-line hypertension treatment did not change.

Even with this extra effort, committee members continue to be discouraged that the findings of their report have not been implemented more widely, Albrant says. "We know from previous studies that diuretics and beta-blockers should be first-line therapy. That still isn’t fully implemented into practice."

This happens for several reasons, he says. Some physicians don’t keep up with the medical literature; they get into a pattern of treating patients a certain way. Others will read the literature, but will glean only what is consistent with their practice — even if the trial is as large and as long-term as ALLHAT. If the recommendations in the literature are contrary to their current practice, the physicians may find a reason to discount the research.

"None of our studies are ever going to be perfect," Albrant says. For example, physicians may say that even though a trial population is huge, it doesn’t reflect the patients they treat. "It’s really a no-win situation."

Stay current with literature

Good data from a research trial are only pieces in the puzzle, he continues. The next, and more difficult, step is to get physicians to believe the trial’s conclusions and to incorporate the new information into their practice.

The role of the pharmacist is to try to stay current on the literature and to interpret it for physicians based on the pharmacist’s knowledge of pharmacology. "We say, Here is what the literature says what might do best in this patient based on concomitant diseases and age and other factors.’" Pharmacists could develop standard order forms or protocols that make it easier for physicians to order the recommended medications. Once physicians are ordering the medications that pharmacists think are optimal for the patient, pharmacists and physicians can work together to get the patient to stick with the therapy.

"It’s a reality check," Albrant concludes. "The data might be great and help us codify what we already know, but the kicker is getting people to fill the prescription initially and then refill it routinely, taking it as we intended and working toward their goals as part of an overall health benefit plan."