Perceived barriers for treatment of chronic heart failure in general practice; are they affecting performance?

BACKGROUND: The aim of this study is to determine to what extent barriers perceived by general practitioners (GPs) for prescribing angiotensin-converting enzyme inhibitors (ACE-I) in chronic heart failure (CHF) patients are related to underuse and underdosing of these drugs in actual practice. METHODS: Barriers were assessed with a semi-structured questionnaire. Prescribing data were extracted from GPs' computerised medical records for a random sample of their CHF patients. Relations between barriers and prescribing behaviour were assessed by means of Spearman rank correlation and multivariate regression modelling. RESULTS: GPs prescribed ACE-I to 45% of their patients and had previously initiated such treatment in an additional 3.5%, in an average standardised dose of 13.5 mg. They perceived a median of four barriers in prescribing ACE-I or optimising ACE-I dose. Many GPs found it difficult to change treatment initiated by a cardiologist. Furthermore, initiating ACE-I in patients already using a diuretic or stable on their current medication was perceived as barrier. Titrating the ACE-I dose was seen as difficult by more than half of the GPs. No significant relationships could be found between the barriers perceived and actual ACE-I prescribing. Regarding ACE-I dosing, the few GPs who did not agree that the ACE-I should be as high as possible prescribed higher ACE-I doses. CONCLUSION: Variation between GPs in prescribing ACE-I for CHF cannot be explained by differences in the barriers they perceive. Tailor-made interventions targeting only those doctors that perceive a specific barrier will therefore not be an efficient approach to improve quality of car

Dutch GP's perceptions: the influence of out-of-pocket costs on prescribing

The aim of this study was to explore the impact of out-of-pocket costs on Dutch general practitioners' prescribing. A qualitative study using focus groups was conducted. An open-ended topic guide was used to elucidate the influence of out-of-pocket costs on decision making for the treatment of dyspepsia, hay fever, hormone replacement therapy, and hypertension. A total of 21 Dutch GPs from University Departments of General Practice participated in four separate focus groups. These discussions were held between November 1998 and March 1999. Each discussion was tape-recorded and transcribed verbatim. From this transcription, key factors and issues were identified. GPs reported that they do not generally take out-of-pocket costs into account. Fully reimbursed drugs were usually prescribed and GPs felt that most patients were highly motivated and thus willing to pay for their medication. The patient charges were seen to be low and not likely to affect patients' willingness to pay. GPs felt that patients need not have to pay for their medication. They adjusted their drug choice in order to avoid co-payment and were willing to agree to a patient's demand for a reimbursed prescription. GPs describe their prescribing as not influenced by out-of-pocket costs. GPs seem inclined to avoid co-payment for patients when patients have financial difficulties and the disease is perceived as severe. They chose fully reimbursed drugs. (C) 2002 Elsevier Science Ltd. All rights reserved