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Biomedical subjects

Atle Fretheim

Publications and source records attributed to Atle Fretheim.

At least 19 recordsLinked to original sources
PubMed2005

International variation in prescribing antihypertensive drugs: its extent and possible explanations.

BACKGROUND: Inexpensive antihypertensive drugs are at least as effective and safe as more expensive drugs. Overuse of newer, more expensive antihypertensive drugs is a poor use of resources. The potential savings are substantial, but vary across countries, in large part due to differences in prescribing patterns. We wanted to describe prescribing patterns of antihypertensive drugs in ten countries and explore possible reasons for inter-country variation. METHODS: National prescribing profiles were determined based on information on sales and indications for prescribing. We sent a questionnaire to academics and drug regulatory agencies in Canada, France, Germany, UK, US and the Nordic countries, asking about explanations for differences in prescribing patterns in their country compared with the other countries. We also conducted telephone interviews with medical directors of drug companies in the UK and Norway, the countries with the largest differences in prescribing patterns. RESULTS: There is considerable variation in prescribing patterns. In the UK thiazides account for 25% of consumption, while the corresponding figure for Norway is 6%. In Norway alpha-blocking agents account for 8% of consumption, which is more than twice the percentage found in any of the other countries. Suggested factors to explain inter-country variation included reimbursement policies, traditions, opinion leaders with conflicts of interests, domestic pharmaceutical production, and clinical practice guidelines. The medical directors also suggested hypotheses that: Norwegian physicians are early adopters of new interventions while the British are more conservative; there are many clinical trials conducted in Norway involving many general practitioners; there is higher cost-awareness among physicians in the UK, in part due to fund holding; and there are publicly funded pharmaceutical advisors in the UK. CONCLUSION: Two compelling explanations the variation in prescribing that warrant further investigation are the promotion of less-expensive drugs by pharmaceutical advisors in UK and the promotion of more expensive drugs through "seeding trials" in Norway.

Antihypertensive Agents↗
PubMed2005

[Guidelines in general practice--are they read and are they used?].

BACKGROUND: Many guidelines are not developed from systematic models and are not based on high-quality evidence. The existence of a guideline does not in itself lead to changes in practice and many guidelines are not used once they have been issued. MATERIAL AND METHODS: A questionnaire on continuing education and the use of guidelines was sent to 1500 general practitioners (GP) and GP assistants in 1321 general practices in Norway. 857 GPs and 948 GP assistants returned the questionnaire. RESULTS: There was a large variation in the extent to which guidelines were known and used. Many GPs and GP assistants had little knowledge of guidelines published in the Journal of the Norwegian Medical Association or by the Norwegian Medicines Agency, the Norwegian Board of Health or the Norwegian Centre for Health Technology Assessment. There were exceptions: 52% of GPs used the Norwegian College of General Practitioners' treatment programme for diabetes and 77% of GP assistants used the Norwegian quality assurance programme for laboratory services in primary care. INTERPRETATION: Guidelines should be based on the best available evidence but this in itself is not enough to ensure that they are adhered to. Effective strategies for implementation are also important.

Education, Medical, Continuing↗
PubMed2005

[What do general practitioners do to keep themselves up to date?].

BACKGROUND: Continuing education should ensure that a doctor provides effective care based on the best available evidence. But not all continuing education is equally effective. MATERIAL AND METHODS: A questionnaire on continuing education was sent to 1500 general practitioners (GPs) in Norway. The response rate was 58%. RESULTS: GPs spent on average 2.3 hours per week on continuing education. Discharge reports were used daily for continuing education by 75% of GPs and represented 10% of the total time spent on continuing education in a 30-day period. Courses were not used so often but took up a lot of time when attended. Traditional lectures accounted for 80% of course instruction. Learning something new and improving practice were the two most important objectives for participating in continuing education. Around every second GP participated in a small group of colleagues. INTERPRETATION: GPs spend a lot of time on continuing education activities that research has shown to have little or no effect on practice. It is essential that the activities used are evaluated to a much greater extent than what they are now.

Clinical Competence↗
PubMed2005

[How do general practice assistants keep themselves up to date?].

BACKGROUND: The opportunities for continuing education among general practice (GP) assistants vary because of their dependence on their employers' attitudes and interests. Not all available continuing education activities are equally effective. The purpose of this study was to describe GP assistants' use of a range of quality improvement and continuing education activities, especially with regard to how much time was spent on each activity and how often the activities were used. MATERIAL AND METHODS: A questionnaire was sent to GP assistants in 1321 general practices. RESULTS: 948 GP assistants returned the questionnaires. They spent on average one hour per week on continuing education. The primary activities were discussions with colleagues (daily), and meetings with pharmaceutical industry representatives (weekly). The use of courses was relatively modest; more than half of them were organised by pharmaceutical companies. Learning something new, improving practice and personal development were the most important motives for participating in continuing education. INTERPRETATION: The opportunities for continuing education available to GP assistants vary a great deal and are to a large extent left to the pharmaceutical industry. Many if not most of the opportunities available cannot be expected to lead to changes in practice. Those responsible for general practice - GPs as well as the health authorities--should ensure that GP assistants have a wider and better range of options for continuing education.

Clinical Competence↗
PubMed2004

Improving prescribing of antihypertensive and cholesterol-lowering drugs: a method for identifying and addressing barriers to change.

BACKGROUND: We describe a simple approach we used to identify barriers and tailor an intervention to improve pharmacological management of hypertension and hypercholesterolaemia. We also report the results of a post hoc exercise and survey we carried out to evaluate our approach for identifying barriers and tailoring interventions. METHODS: We used structured reflection, searched for other relevant trials, surveyed general practitioners and talked with physicians during pilot testing of the intervention. The post hoc exercise was carried out as focus groups of international researchers in the field of quality improvement in health care. The post hoc survey was done by telephone interviews with physicians allocated to the experimental group of a randomised trial of our multifaceted intervention. RESULTS: A wide range of barriers was identified and several interventions were suggested through structured reflection. The survey led to some adjustments. Studying other trials and pilot testing did not lead to changes in the design of the intervention. Neither the post hoc focus groups nor the post hoc survey revealed important barriers or interventions that we had not considered or included in our tailored intervention. CONCLUSIONS: A simple approach to identifying barriers to change appears to have been adequate and efficient. However, we do not know for certain what we would have gained by using more comprehensive methods and we do not know whether the resulting intervention would have been more effective if we had used other methods. The effectiveness of our multifaceted intervention is under evaluation in a randomised controlled trial.

Anticholesteremic Agents↗
PubMed2003

Back to thiazide-diuretics for hypertension: reflections after a decade of irrational prescribing.

BACKGROUND: Whether newer antihypertensive drugs, such as calcium channel blockers, angiotensin converting enzyme inhibitors and alpha blockers are more effective than thiazides and beta blockers in preventing coronary disease, has been debated for years. DISCUSSION: Recently several trials addressing this issue have been finalised, and they provide a convincing answer: the newer drugs are no better than the older ones. In the largest trial to date (ALLHAT), thiazide-type diuretic was found to offer advantages over newer drugs. The medical community should now be capable of reaching consensus, and recommend thiazides as the first line therapy for the treatment of hypertension. Prescribing physicians, cardiologists, drug companies and health authorities are all partly responsible for the years of irrational prescribing that we have witnessed. SUMMARY: All stakeholders should now contribute in order to achieve what is clearly in the public's interest: implementing the use of thiazides in clinical practice.

Antihypertensive Agents↗
PubMed2003

The potential savings of using thiazides as the first choice antihypertensive drug: cost-minimisation analysis.

BACKGROUND: All clinical practice guidelines recommend thiazides as a first-choice drug for the management of uncomplicated hypertension. Thiazides are also the lowest priced antihypertensive drugs. Despite this, the use of thiazides is much lower than that of other drug-classes. We wanted to estimate the potential for savings if thiazides were used as the first choice drug for the management of uncomplicated hypertension. METHODS: For six countries (Canada, France, Germany, Norway, the UK and the US) we estimated the number of people that are being treated for hypertension, and the proportion of them that are suitable candidates for thiazide-therapy. By comparing this estimate with thiazide prescribing, we calculated the number of people that could switch from more expensive medication to thiazides. This enabled us to estimate the potential drug-cost savings. The analysis was based on findings from epidemiological studies and drug trials, and data on sales and prescribing provided by IMS for the year 2000. RESULTS: For Canada, France, Germany, Norway, the UK and the US the estimated potential annual savings were US13.8 million dollars, US37.4 million dollars, US72.2 million dollars, US10.7 million dollars, US119.7 million dollars and US433.6 million dollars, respectively.

Adult↗