QJM vol. 98 no. 1 © Association of Physicians 2005; all rights reserved.
Physicians' attitudes to the pharmacological treatment of patients with stable angina pectoris
From the 1Centre de recherche du Centre hospitalier de l'Université de Montréal, 2Divisions of Cardiology and Clinical Epidemiology, McGill University Health Centre, 3Collège des médecins du Québec, 4Département d'administration de la santé, Université de Montréal, and 5Agence d’évaluation des technologies et des modes d'intervention en santé and McGill University, Montreal, Quebec, Canada
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Summary |
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Background: Little is known about how physicians’ knowledge of and attitudes to practice guidelines for stable angina may influence their implementation.
Aim: To explore the association between physicians’ demographics, their knowledge, and opinions about stable angina and their self-reported adherence to guideline recommendations.
Design: Questionnaire-based survey.
Methods: We surveyed 1228 Quebec physicians using a questionnaire based on the ‘awareness-to-adherence’ conceptual framework to measure their adherence with recommendations for the pharmacological treatment of stable angina. Independent predictors of adherence with the targeted recommendations were determined by stepwise linear regression analysis.
Results: We received 877 (71.4%) responses from the 1228 eligible physicians. More than 90% of respondents were aware of and agreed with the targeted recommendations. However, the adoption rate varied, even among physicians who generally agreed with the guidelines. Factor analysis indicated that most physicians agreed with recommendations concerning ASA. More negative attitudes were expressed toward ß-blockers and hypolipaemic drugs. Respondents trusted the recommendations of a variety of scientific and professional organizations. Awareness, agreement, and adoption were the strongest predictors of adherence for the three recommendations. Physician demographics and practice characteristics did not predict adherence.
Discussion: Physicians were aware of and agreed with the recommendations, so additional large-scale dissemination of the guidelines would be unlikely to improve prescription patterns. However, negative attitudes about ß-blockers and hypolipaemic therapy affected adherence to recommendations for these drugs. Continuing medical education interventions involving local opinion leaders might address some of the obstacles identified.
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Introduction |
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Stable angina is among the most frequent manifestation of cardiovascular disease encountered in primary care. It is also one of few conditions for which there is high-level clinical evidence to support highly consistent clinical practice guidelines (CPGs).1–6 However, research suggests that guideline implementation is less than optimal, without providing a good understanding of the reasons why.7,8 Work in the area of preventive guidelines has shown that physicians’ agreement with what is presented as evidence-based guidelines should not be taken for granted, even if the science is good.9–11
Understanding physicians’ general attitude towards CPGs and the determinants of their uptake has been the object of intense research activity. According to surveys, physicians are generally favorable to CPGs. Endorsement by respected colleagues and major associations is considered important, and CPGs developed by governments and third-party payers are considered with circumspection.12–14 Factors associated with guideline uptake can be organized into five categories: physicians’ characteristics, patients’ characteristics, practice characteristics, guidelines’ characteristics, and characteristics of the environment (implementation policies, etc.).15,16 Guidelines' characteristics have a central role. Rogers, in his classic work, identified five characteristics which influence the degree of uptake of an innovation: compatibility with current knowledge, relative advantage, observability, complexity and trialability.17 These characteristics have been shown to explain up to about 47% of observed compliance rates with some specific guidelines.18 Finally, guideline uptake can also be seen as a process where physicians progress through three steps: from knowledge, to attitudes, and to behaviour.16 According to this framework, knowledge is determined by awareness of a given recommendation and familiarity with it; positive or negative attitudes are determined by the level of agreement with the recommendation and the perception of its the relative advantage; and behavior, or adherence to the recommendation, is the result of a commitment to change practice—referred to as adoption by Davies et al.19—and barriers or facilitators in the practice environment.16 Guidelines requiring complex modifications of behaviors and/or access to specific resources (such as surgical procedures or access to sophisticated diagnostic examinations) are more sensitive to practice and environmental characteristics.15,16,18
The progression through these steps is not seen as a series of purely cognitive decisions about the quality of scientific evidence. Physicians’ values, beliefs, and a variety of training and practice experiences and contextual constraints, influence their evaluation of what is good evidence and their capacity to integrate new behaviors in their practice. The reality of guideline implementation is thus a complex interaction between the categories of factors and the different steps involved in the process of implementation.16 In this regard, Freed and Pathman's extensive work on implementation of immunization policies in the US20–28 is of particular interest. From this work, Freed and Pathman proposed a comprehensive model that they called the Awareness-to-Adherence Model.29 For example, according to this model, adoption and adherence are more likely to be influenced by practical considerations, such as the complexity of the guideline, its perceived relative advantage over actual practice, practice environment and patients’ demands. The quality of the evidence, the credibility of sources and acceptance by local opinion leaders are thought to have a greater impact on agreement.29 The interest of this model is that it permits planning of guideline dissemination interventions, or diagnosis and correction of observed problems in uptake, as appropriate.
We report the results of a sample survey of general practitioners, cardiologists, and internists working in the province of Quebec, Canada, that aimed to explore the association between their characteristics, knowledge, and opinions about the treatment of stable angina and their self-reported adherence to the three cornerstone recommendations of anti-angina therapy: the prescription of anti-platelet agents (namely acetylsalicylic acid, ASA), ß-blockers (for patients without contraindications), and hypolipaemic drugs. This survey was part of an intervention to disseminate CPGs on the treatment of stable angina developed and endorsed by the major physician associations of the province.30
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Methods |
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Study population
The study was conducted in the province of Quebec (population 7.4 million), where there is universal health insurance, and where drug costs are covered for all citizens 65 years of age and older, as well as for younger people who do not have private insurance.
The reference population was composed of the 3293 eligible physicians who were the target of the dissemination intervention.30 The study population and sampling procedure have been described in detail previously.7,30 Briefly, they consisted of physicians from three geographically distinct regions—the metropolitan region of Montreal, a sub-urban region and a rural region—who had been prescribing cardiovascular medications during the year 1999, according to the computerized databases of the Régie de l'Assurance Maladie du Québec (RAMQ, the Quebec Health Insurance Board). These linked databases contain data on all physician as well as patients’ visits, interventions, and prescriptions (for Quebec residents 65 years of age and older). The validity of these databases for drug prescriptions is well established.31 The survey was sent to a random sample of 1275 physicians, stratified according to specialty (one of every three family physicians, as selected at random by computer, and all internal medicine and cardiology specialists).
Survey variables
The three recommendations that were the object of the study were: (i) writing a prescription for ASA (as opposed to only recommending this drug, which can be purchased over the counter); (ii) favouring ß-blockers as the first-choice anti-angina drug when there are no contraindications, and (iii) prescribing hypolipaemic treatment when the patient cannot attain 
2.6 mmol/l low-density lipoprotein (LDL) cholesterol through diet alone. The questionnaire consisted of four sections: the first three dealt with physicians’ progression from awareness to adherence, according to Pathman's model, and perceptions of the guideline characteristics related to each of the three target recommendations, and the fourth section dealt with physicians and practices’ characteristics.
Progression from awareness to adherence
The questionnaire was based on the four steps of Pathman's ‘awareness-to-adherence’ questionnaire,10,29 which we obtained from the author, along with data on psychometric characteristics (D.E. Pathman, personal communication between July and September 1998). According to Pathman, ‘Awareness’ was evaluated as the response, on a five-point Likert scale, to the question ‘How much have you heard or read about the recommendation to ... ?’ ‘Agreement’ is evaluated by the question ‘Do you agree with this recommendation?‘: response choices are ‘yes,’ ‘no,’ ‘unsure—I have enough information but I have not yet decided,’ and ‘unsure—I need more information to decide.’ The ‘Adoption’ question has respondents indicate from among several posed options the one that best matches how they provide care in their own practices; only one option matches recommended care. Respondents who indicate that their intended practice matches recommended care are classified as ‘adopters.’ Finally, the ‘Adherence’ question asks for a self-report of the percentage of eligible patients in the respondent's practice who have received the proposed intervention (e.g. ‘What proportion of your patients without contraindications to beta-blockers do you estimate receive this medication?’).
Guideline characteristics
Again according to Pathman's framework, the awareness-to-adherence questions were followed by questions to evaluate knowledge and perceived barriers to guideline uptake from the provider's perspective, according to a five-point Likert scale.
Physicians and practices characteristics
The following physicians’ characteristics were ascertained: age; sex; medical training; professional experience; attendance to continuing medical education (CME) on stable angina within the last year; and opinions on the role of various organizations in formulating practice guidelines.
The following practice characteristics were ascertained: region of practice (urban, sub-urban, rural); main location of practice (hospital, private practice; practice in community health center); reimbursement modalities.
Questionnaire development
We adapted Pathman's questionnaire, originally developed to study dissemination of vaccination recommendations,10 to the case of stable angina. We kept the exact wording of Pathman's four awareness-to-adherence questions, and substituted the wording of the angina CPG recommendation for that of the vaccination question. The questions about barriers had to be adapted for each of three recommendations of interest, but we kept the same balance of questions than Pathman's to evaluate the following: scientific knowledge; negative experience with the recommendation; perceptions of patient-related barriers (the wording of the items is presented in the Results section at Table 2). We used translation-retranslation validation, since the study was conducted in both French and English, and we tested the questionnaire on 10 French-speaking and English-speaking physicians.
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Administration of the survey
The Collège des médecins du Québec (CMQ, the Quebec College of Physicians) mailed the survey in May 1999, three months after it had mailed a one-page, user-friendly summary of the Quebec guideline on the pharmacological treatment of stable angina.1 The messages in the summary, which were consistent with current guidelines,1–5 were to write a prescription for ASA, to favour ß-blockers as first-choice anti-anginal medication, and to control LDL cholesterol at a level below 2.6 mmol/l. The ASA recommendation warrants some clarification. In Quebec, ASA can be purchased over the counter. However, when a prescription for enteric coated ASA product is written by a physician, the cost is covered by public insurance, and the patient is exempt from paying sales taxes. The low prescription rate observed in our first study7 was considered a potential indicator of sub-optimal exposure to ASA, and it was therefore decided to encourage physicians to formally write prescriptions for ASA, to emphasize its importance in the treatment of cardiovascular disease.
The survey was accompanied by a letter of endorsement signed by the presidents of the provincial associations of internists, cardiologists, and general practitioners. To preserve anonymity, physicians returned a response card to the CMQ and the anonymous completed questionnaire to the research team. Non-responders received two reminders, at 3 and 9 weeks after the initial request. The questionnaires were not matched with administrative physician database information, in order to preserve physician anonymity.
Statistical analysis
We performed a factor analysis32 to determine the factors related to perceived barriers to guideline implementation and those related to information sources used to maintain knowledge. Analysis yielded a four-factor model: the use of a variety of information sources to maintain knowledge on practice guidelines; perceived barriers to ß-blockers (more secondary effects, lower safety levels in elderly patients, equivalent effectiveness of calcium-channel blockers and ß-blockers); favourable opinion toward the CMQ as a source of guidelines, among other associations and government agencies; and perceived barriers toward hypolipaemic agents (costs for patients and uncertainty about the appropriateness of these drugs for patients not motivated to change their eating habits). These factors were retained for the multivariate analyses. We conducted a linear regression analysis to explore associations between these factors and specialty training.
We performed stepwise linear regression analysis, applying a forward fitting strategy, to determine the predictors of adherence with the three targeted recommendations, which was defined as the outcome measure. To test Pathman's model of progression from awareness to adherence and to explore the relative contributions of the independent variables, the first three stages of Pathman's model were entered in the regression equations. Physicians’ characteristics variables were entered in the second step of the forward fitting strategy, and practice variables as well as the four factors described above were entered in the third step. At each step we kept the variables that were statistically significant at the 0.05 level. We present here the results of the final regressions.32
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Results |
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Respondents’ characteristics
Of the 1275 physicians randomly selected for the survey, 47 were later determined to be ineligible (retired, moved outside the region, on sabbatical, on sick leave, or deceased).We received 877 (71.4%) responses from the 1228 eligible physicians. There were no statistically significant differences between respondents and the study population as a whole in terms of the variables for which data were available (Table 1).
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From awareness to adherence
Figures 1a to 1c illustrate the progression from awareness to adherence for the three prescribing behaviours. More than 90% of respondents were aware of each of the recommendations and totally agreed, or more or less agreed, with them. As expected, disagreement was associated with lower adoption and adherence rates. However, the adoption rate—the proportion of physicians who declare that they have adopted the recommendation in their day-to-day practice—varied according to the target recommendation among physicians who generally agreed with it: 90.7% for writing a prescription for ASA; 76.9% for beta-blockers; and 55.5% for prescription of hypolipaemics. Finally, the level of adherence of the adopters, defined as the estimated proportion of patients in the respondent's practice under the given medication, is higher than the one reported by non-adopters, as expected, but varied according to the target medication: 94% of their patients with stable angina, that they prescribed ß-blockers for 81.1% of their eligible patients, and that they prescribed a hypolipaemic drug if LDL cholesterol did not reach 2.6 mmol/l or less for 75.3% of their patients. We found no association between physicians’ and practice's characteristics and adoption and adherence variables.
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Perceived barriers and sources of information
Table 2 summarizes the mean scores for each of the opinion statements about knowledge and perceived barriers related to the three classes of drugs used for the medical treatment of stable angina, as well as opinions on the utility and credibility of various sources of recommendations.
Most physicians know about and believe in the value of ASA. A third of the physicians agreed to some degree with the statement that patients prefer to purchase ASA without a prescription (item 3). Barriers to the prescription of ß-blockers were related to perceived secondary effects and potential dangers in elderly patients. A third of the physicians felt that their colleagues favoured classes of anti-angina drugs other than ß-blockers. More negative attitudes were expressed toward hypolipaemic drugs. A third of the respondents challenged the quality of the evidence on the effectiveness of lowering LDL cholesterol below 2.6 mmol/l, nearly half considered this target unattainable, and a comparable proportion felt that their patients did not buy their prescribed medication because of high cost. Respondents trusted the recommendations of a variety of scientific and professional organizations. Guidelines produced by para-government agencies are the least trusted.
We used linear regression to compare the factorial scores for the three categories of respondents (internists, cardiologists, and general practitioners). There were no statistically significant differences among the categories in their opinions about various sources of information. However, general practitioners expressed more negative opinions about ß-blockers and stringent cholesterol control (ß-blockers, mean square between groups 25.61, mean square within groups 0.69, F = 37.09, p < 0.001; hypolipaemic drugs, mean square between groups 8.82, mean square within groups 0.78, F = 11.35, p < 0.001).
Predictors of adherence
Table 3 summarizes the results of the final linear regression models for the adherence variable. Awareness, agreement, and adoption were the strongest predictors of adherence for the three recommendations, with the exception of agreement, which had no impact on adherence with the hypolipaemic recommendation (Table 3). Having more than 30 years of experience statistically increased the likelihood of a physician prescribing ß-blockers. There was a general trend to prescribe BB with increasing experience, but this was not statistically significant. Other sociodemographic variables had no impact. The four factors identified in the factor analysis affected each of the outcome variables differently. Credibility of the CMQ only affected adherence to the ASA recommendation. Negative attitudes toward ß-blockers and stringent cholesterol control were associated with a lower level of adherence with the respective recommendations. A greater number of information sources was associated with an increased likelihood of prescribing hypolipaemic drugs.
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Discussion |
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The results of this study contribute to a better understanding of physicians’ attitudes and practices related to the three cornerstones of medical treatment for stable angina: prescription of ASA, use of ß-blockers as first-choice therapy for patients without contraindications, and stringent cholesterol control. It also increases the body of knowledge on the factors related to implementation of clinical practice guideline.
In our model, very few physician or practice characteristics were associated with the outcome measure. Professional experience was associated with higher adherence with beta-blockers prescription, which may reflect longstanding experience with this medication, the first anti-angina drug marketed after nitroglycerine products. Exposure to more sources of medical information was associated with higher adherence to stringent cholesterol control, which may reflect a more ‘evidence-based medicine’ attitude in some respondents.
Using the ‘awareness-to-adherence’ model helped us to gain a better understanding of why physicians may not follow practice recommendations. As predicted by the model, Awareness and agreement were strong predictors of adherence with the recommendations, the outcome variable. However, awareness of recommendations does not appear as an issue, considering the high reported level. Additional large-scale dissemination of the guidelines would be unlikely to contribute to improvement in practice.
Global agreement with each recommendation was also high, which suggests that their scientific credibility is not questioned by the majority. It is the exploration of some of the practical considerations of their application that led to more insights on the barriers to adherence. Negative attitudes toward ß-blockers, particularly the perception that they are associated with more side-effects and risks for elderly patients, remained the factor most consistently associated with lower adherence to the ß-blocker recommendation. These opinions were more prevalent among general practitioners, which is consistent with practices observed in other studies in Quebec.8 The extent to which these perceptions represent actual experiences with this class of medication, or the perpetuation of beliefs based on the first generation of ß-blockers, is unclear. Clinical studies of newer ß-blockers do not support these beliefs.33 The selective promotion of new agent over old off-patent agent is likely to exert a strong influence. Still, our findings may reflect the experience of ordinary practitioners, outside the context of clinical research (where patients are often followed very closely), and deserve further investigation.
Stringent cholesterol control, to reach a level of 2.6 mmol/l LDL cholesterol, appeared to be the recommendation most difficult to adopt and implement. Some respondents felt that the evidence for the effectiveness of stringent cholesterol control was not as strong as that for other therapeutic options, particularly within the elderly population. Furthermore, when this survey was conducted, there were few convincing data that lowering cholesterol below 3.0 mmol/l was associated with improvements in health outcomes.1 The negative attitude of some physicians regarding patients who are not motivated to change their eating habits (item 15 in Table 2) was surprising and at least moderately disturbing. Given the difficulty of changing personal lifestyle habits (for a variety of reasons, including socioeconomic factors34) and the effectiveness of cholesterol-lowering medications as secondary prevention,35,36 such attitudes should be challenged. Also disturbing was the perception of certain practitioners that some patients cannot afford hypolipaemic drugs, especially in a health system that prides itself on its universality. These perceptions accord with the results of Tamblyn et al.,37 who showed that the recent elimination in Quebec of complete coverage of prescription drugs for patients receiving welfare and those over 65 years of age has been associated with a decrease in the purchase of essential medications. Efforts should be made to remove financial barriers to obtaining essential medications.
It is difficult to compare our findings with others, since no studies have explored the relation between physicians’ characteristics and attitudes and their prescribing behaviour for coronary artery disease. Similar attitudes towards ß-blockers have been expressed by family physicians in relation to hypertension treatment.38 Hypertension studies have suggested that family physicians are more reluctant to adopt recommendations favouring stringent control of blood pressure levels39 and cholesterol levels.40,41 In a survey conducted in Canada in 1998, only 21.2% of family physicians interviewed believed that interventions to control cholesterol levels were highly effective.42 It has been suggested that general practitioners give relatively less weight to ‘evidence’ and more to clinical experience and their perceptions of patient-related factors in their evaluation of clinical practice guidelines.11
Our study had several strengths. The response rate was high, which is probably attributable to the endorsement of the survey by the provincial specialist associations. Our questionnaire was based on a validated questionnaire, and on a comprehensive conceptual framework which takes into account the different categories of factors known to impact on guideline dissemination and uptake.10,29 The main limitation of this study is that adherence to recommendations was ascertained by self-reported measures. Physicians self-reported adoption levels usually underestimate their actual practices. They are however correlated. Self reports of prescriptions of laboratory tests or medications have been shown to be more correlated to actual practices than self report of counselling interventions.43 We have data from the same sample of physicians that permit estimation of the gap between their self-reported adherence of angina medical treatment, as reported in the survey, and their actual behaviours, as observed in the database.30 For ß-blockers, there is only a 10% difference between the self-reported prescribing rate (72%) and the observed rate of 62% obtained from database analysis of the prescribing profiles of the same sample of physicians.30 The difference between self-reported and observed prescribing rates for hypolipaemic agents (69% vs. 39%) was more substantial, but may be explained by the fact that the survey question referred to all patients with stable angina, whereas the database provided information only for patients 65 years of age and older. This may explain why we did not find an association between adherence and specialty training, although being a cardiologist was associated with higher prescription rates of ß-blockers in the prescription profiles.30 Self-reported measures, although less accurate that observed practices, can be appropriate surrogate measures in survey research, considering their correlation with the actual practices.
Another limitation of the study is that we did not explore the contribution of patients characteristics or of the practical considerations of practice organization, for example patients’ expressed preferences for a given course of treatment, and the perception of competing priorities within a given visit, which may relegate the implementation of a recommendation to later times.44,45
Looked at through the lens of Rogers’ innovation theory,17 practice guidelines on the medical treatment of stable angina do not rate high on barriers related to their inherent characteristics. From the consistency of the published guidelines, they appear compatible with current knowledge, and prescribing can be considered as not too complex to implement. Using Rogers’ terminology, one could say that the issue with the guidelines on the medical treatment of stable angina is more one of perception of the relative advantage of the intervention for some patients. CME interventions can be used to address some of the obstacles identified in this study. Multifaceted CME that allows for exchanges with peers and local opinion leaders could help to correct some of the misconceptions about pharmacological treatment of stable angina.46,47 Our study also points to the importance of practice-based research to gain a better understanding of physicians’ and patients’ experiences with the day-to-day management of chronic diseases.
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Acknowledgments |
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We thank Donald E. Pathman for sharing with us the ‘awareness-to-adherence’ questionnaire and his experience with the psychometric proprieties of the instrument. We also thank Ms Peggy Robinson for her help in the preparation of the manuscript.
Dr Brophy receives financial support from le Fonds de Recherche en Santé du Québec (FRSQ). This project was funded by the Health Transition Fund, Health Canada. The results do not necessarily reflect the opinions of Health Canada.
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Footnotes |
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Address correspondence to Professor M.-D. Beaulieu, Centre de recherche du CHUM, Hôpital Notre-Dame, Pavillon L.-C. Simard, 8e étage1560, rue Sherbrooke Est., Montréal (Québec), Canada H2L 4M1. e-mail: maried.beaulieu{at}sympatico.ca
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