Majumdar Sumit R, McAlister Finlay A, Soumerai Stephen B
Division of Genral Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Canada.
Am J Med. 2003 Oct 15;115(6):467-72. doi: 10.1016/s0002-9343(03)00422-4.
Few studies have examined the effect of new evidence from clinical trials on physician practice. We took advantage of differences in promotional activity in Canada and the United States for the Heart Outcomes Prevention and Evaluation (HOPE) study and the Randomized Aldactone Evaluation Study (RALES) to determine if publication of new evidence changes practice, and the extent to which promotion influences adoption of new evidence.
We used longitudinal dispensing data, collected from 1998 to 2001, to examine changes in prescribing patterns for ramipril and other angiotensin-converting enzyme (ACE) inhibitors before and after the HOPE study. We also obtained estimates for promotional expenditures. We stratified analyses by country, to isolate the effect of promotion, and used interrupted time series methods to adjust for pre-existing prescribing trends. Similar analyses were conducted for spironolactone use before and after RALES.
Publication of the HOPE study results was associated with rapid increases in the use of ramipril. After adjusting for pre-existing prescribing trends, ramipril prescribing increased by 12% per month (P = 0.001) in Canada versus 5% per month (P = 0.001) in the United States after the study results were presented and published. One year later, ramipril accounted for 30% of the ACE inhibitor market in Canada versus 6% in the United States. The year before publication of these results, expenditures for detailing increased by 20% in Canada (to 18 US dollars per physician) but decreased by 7% in the United States (to 13 US dollars per physician); the year after publication, spending increased to 27 US dollars per physician in Canada versus 23 US dollars per physician in the United States. In the absence of promotional activity for RALES in either country, publication of results was associated with more modest but similar increases of 2% per month (P = 0.001) in spironolactone use in both countries.
Publication of new evidence is associated with modest changes in practice. Promotional activity appears to increase the adoption of evidence. Rather than relying on the publication of articles and creation of guidelines, those wishing to accelerate the adoption of new evidence may need to undertake more active promotion.
很少有研究探讨临床试验的新证据对医生临床实践的影响。我们利用加拿大和美国针对心脏结局预防评估（HOPE）研究以及随机螺内酯评估研究（RALES）开展的推广活动差异，来确定新证据的发表是否会改变临床实践，以及推广活动在多大程度上影响新证据的采用。
我们使用了1998年至2001年收集的纵向配药数据，来研究HOPE研究前后雷米普利及其他血管紧张素转换酶（ACE）抑制剂的处方模式变化。我们还获取了推广支出的估计数据。我们按国家进行分层分析，以分离推广活动的影响，并使用中断时间序列方法来调整先前存在的处方趋势。对RALES研究前后螺内酯的使用情况进行了类似分析。
HOPE研究结果的发表与雷米普利使用量的迅速增加相关。在调整先前存在的处方趋势后，在研究结果公布并发表后，加拿大雷米普利的处方量每月增加12%（P = 0.001），而美国为每月增加5%（P = 0.001）。一年后，雷米普利在加拿大的ACE抑制剂市场中占30%，而在美国占6%。在这些结果发表前一年，加拿大的详细推广支出增加了20%（至每位医生18美元），而美国则下降了7%（至每位医生13美元）；发表后一年，加拿大每位医生的支出增加到27美元，而美国为每位医生23美元。在两国均未对RALES进行推广活动的情况下，结果的发表与两国螺内酯使用量每月较为适度但相似的2%的增加相关（P = 0.001）。
新证据的发表与临床实践中的适度变化相关。推广活动似乎会增加证据的采用。那些希望加速新证据采用的人可能需要开展更积极的推广活动，而不是依赖文章发表和指南制定。
