Local Formulary Research Articles

The development, implementation and evaluation of a cross organisational clinical guideline for the management and prevention of wound infection

BackgroundThe Tissue Viability services in acute and primary care in Leeds had concerns about the increasing inappropriate use of topical antiseptic dressings for wound management and were aware that the use was disproportionate to the evidence supporting their prescribing. A scoping exercise of the use of topical antiseptics and systemic antibiotic usage in Leeds led to the identification of heterogeneous prescribing of systemic antibiotics and an almost £500,000 spend on topical antiseptics across Leeds community. MethodsThe project involved the following stages.1Local scoping of topical antiseptics and systemic antibiotic prescribing.2A cross organisational working group to develop and implement a clinical best practice guideline for the prevention, diagnosis and management of wound infection.3Development of a revised local dressings formulary.4The establishment of a new referral process to Tissue Viability for wounds requiring topical antiseptic treatments.5Evaluation of the new guideline through -monitoring prescribing-monitoring wound sampling-monitoring A & E admissions-collecting patient feedback through the ‘Tell Tissue Viability’ process. Results•Expenditure on topical antiseptic dressings for the period Oct 2009–Dec 2009 was £128,864 and this reduced to £65,604 for the period Nov 2011–Jan 2012. This demonstrates an overall saving of £63,260 with a projected annual saving of £237,584 within the community trust alone.•A reduction in the number of wound swabs sent to microbiology from inpatient locations by 1500/year comparing 2008/9 with 2010/11.•An increase in wound swabs sent from GPs by 100/year comparing 2008/9 with 2010/11.•A reduction in penicillin V and co-fluampicil prescriptions and an increase in flucloxacillin prescriptions in general practise suggesting greater concordance with local antibiotic prescribing recommendations. ConclusionThe implementation of a clinical guideline in association with support from the specialist team, for patients requiring topical antiseptics has resulted in a reduction in the inappropriate use of topical antiseptics in hospital and community. Wound sampling practises and prescribing practises have changed. No apparent increased risk for patients has been identified but it has not been easy to obtain details about admission to Accident and Emergency with cellulitis and optimising surveillance remains a challenge for the future.

Local formularies

The widespread availability of authoritative guidance on prescribing from a wide variety of international and national bodies calls into question the need for additional local formulary advice. This article describes contemporary local formulary management in the United Kingdom and discusses the areas where local decision making remains valuable. Local formularies can fulfil important roles which justify their continued existence, including ensuring local ownership and acceptance of advice, rapid dissemination of information, responsiveness to local circumstances and service design, sensitivity to local pricing arrangements and close professional links with commissioners, pharmacists and prescribers.

The science of prescribing

The science of prescribing

National Drug Policies to Local Formulary Decisions in Thailand, China, and Australia: Drug Listing Changes and Opportunities

This commentary is aimed at summarizing the second plenary session presented at the ISPOR 4th Asia-Pacific Conference held in 2010 and compare the issues on drug listing of Thailand, China, and Australia. These countries have substantially different demographic and economic characteristics and health-care financing structures and are in different phases of development of health technology assessment. In 2008, government expenditure on health per capita in Australia was approximately 60 times that of China and 20 times that of Thailand. The percentage of gross domestic product spent on health care in Australia is twice that of China and Thailand, and the percentage of government-funded health care of total health care is considerably low for China. The proportion of private expenditure on pharmaceuticals in both China and Australia is similar and reflects those of established market economies; in Asia, almost half of all pharmaceutical expenditure is privately funded. Each of the three countries has its own unique challenges and opportunities. These issues are presented for each country following an overview of the policy and drug listing of the three countries.

E‐SPC – delivering drug information in the 21st century: developing new approaches to deliver drug information to prescribers

e‐SPC – delivering drug information in the 21st century: developing new approaches to deliver drug information to prescribers

Treatment Satisfaction Instruments for Different Purposes during a Productʼs Lifecycle

This review investigates whether the development and implementation of treatment satisfaction instruments during a product's lifecycle are informed by their purpose. A basic literature review was performed between 2000 and 2010 using electronic databases (PubMed, PsycINFO®, and EMBASE) and the keywords 'satisfaction' and 'questionnaire' and 'medication' or 'drug'. Relevant articles were reviewed to extract the following information: type of study; study objectives; treatment satisfaction instrument used; clinical condition/indication; purpose of instrument; development of instrument; association of satisfaction with other endpoint measures; and main results and conclusions. Of 875 abstracts, 80 articles were further considered. Treatment satisfaction instruments were most commonly used in observational studies and interventional clinical trials. The review indicated similarities regarding the development and validation of satisfaction instruments, such as using patient input to derive the items and exploring classical measurement properties specific to the target population. Although some differences were apparent between instruments intended for use in clinical trials and clinical practice (e.g. the approaches used to enable the interpretation of satisfaction scores), the specificities of the implementation of treatment satisfaction during a product's lifecycle were rarely considered. By 'keeping the end in mind', data from treatment satisfaction instruments can help at three key stages: (i) product access to market: generating evidence as part of an overall value proposition to facilitate product reimbursement at a national level; (ii) market access to product: making the product available at a local level (e.g. local hospital formularies); and (iii) clinical practice: enhancing market penetration and product expansion after launch, and demonstrating value for prescribers. Furthermore, the development, validation, and interpretation of scores from treatment satisfaction instruments should be sensitive to the intended purpose. By considering the stage in the product lifecycle when an instrument is to be used, treatment satisfaction instruments can be developed with the specific research purpose and target audience in mind - whether it be patients, payers, or prescribers. In the future, treatment satisfaction instruments will become increasingly important for informing decisions at the individual level, giving patients a voice towards their overall management and care, and enhancing the relationship between doctor and patient.

Compliance with gentamicin guidelines at Lewisham Hospital

ObjectivesTo determine the proportion of patients:▶receiving the recommended dose of gentamicin (based on most appropriate guideline)▶having first blood levels of gentamicin measured and recorded at correct date/time▶having details completed on...

Antimicrobial resistance: Consideration as an adverse drug event

Antimicrobial resistance has increased dramatically in the past 15 to 20 yrs and presents a patient safety concern unlike any other in the intensive care unit. Antimicrobial resistance in critically ill patients increases morbidity, mortality, length of hospital stay, and healthcare costs. Some organisms may have intrinsically high levels of resistance or may be spread between patients by poor infection control practices. However, a major driver of antimicrobial resistance is antibiotic use. As such, the development of antimicrobial resistance can often be thought of as an adverse drug event. This article explores the link between drug use, drug dosing, other selective pressures and resistance, and describes concepts to minimize the negative impact of antimicrobial therapy. Two broad themes of these concepts are minimizing the use of antibiotics whenever possible and optimizing antibiotic usage when they are needed. Strategies for minimizing the use of antimicrobials include using optimal diagnostic procedures to ensure the need for antimicrobials, streamlining or discontinuing therapy when possible based on culture results, and using the shortest duration of therapy needed for documented infections. Strategies for optimizing antimicrobial use include using optimal dosing based on the manufacturer's instructions and current pharmacodynamic data, guiding better prescribing based on local susceptibility patterns and formulary restriction, and avoiding drugs with more propensity to foster resistance.

Inventory of Drug Samples in a Health Care Institution

Few data exist on the presence of drug samples in health care facilities. Although the use of drug samples has potential benefits, this practice is also controversial, as it can contribute to non-optimal drug use. The objective of this study was to evaluate the inventory of drug samples in a health care institution and to determine compliance with existing policies and procedures. This descriptive observational study was conducted in a university hospital centre from October 18 to November 1, 2007. A standardized data collection form was used for a physical inventory, which was intended to identify all drug samples available in the institution. The following information was recorded: number of locations where drug samples were found, primary patient care activity performed at each location, number of storage areas in the location, type of storage, presence of a lock, location of the key (if a lock was present), medical specialty, number of physicians and nurses likely to use the samples, reasons given for handing out samples, presence of a designated person to manage the samples, physical inventory (i.e., various details for each distribution unit), and declaration of samples to the pharmacy department. The inventory was conducted by 2 research assistants during day shifts. A total of 84 locations were included in the inventory, and drug samples were found in 21 locations (with a total of 31 storage areas). All of the locations were intended for ambulatory patients (outpatient clinics and day centres). No drug samples were found in inpatient care units. The drug samples, which came from 62 different pharmaceutical companies, represented a total of 159 generic entities and 266 different brands. Of the distribution units for drug samples that were identified during this inventory, 59% were not on the hospital's local formulary. Furthermore, only 3.5% of the distribution units had been declared to the pharmacy department, in accordance with established policy. The sample distribution units, including expired units, totalled 78 955 doses, with a total value of Can$48 783 (based on unit prices in effect in October 2007). This study presents an inventory of drug samples in an urban health care institution and reports compliance with the institution's policies and procedures regarding drug samples. Samples were found only in outpatient clinics and represented 2.4 times the hospital's floor stock of medications. Most of the samples inventoried were not listed on the hospital's formulary. It appears that the use of drug samples is underestimated in hospital settings. Further studies are needed to evaluate the importance of drug samples and the risks associated with their use.

Switching within glaucoma medication class

In the current medical care environment, switching within class is often demanded by cost consideration, medical insurance coverage, or formulary restriction. With many choices of drugs available within a glaucoma medication class, questions exist whether switching within class is beneficial. The purpose of this article is to provide a clinical update on the feasibility of switching among the frequently used drugs within glaucoma medication class. Although efficacies of medications within a therapeutic class are similar and significant differences are generally not observed in clinical trials, response to medication often varies among individual patients in a clinical practice. Such variation may be secondary to differences in drug-receptor interactions, patient's compliance and tolerability to medical treatment, or bioavailability of the medication in individual ocular condition. In addition, switching within class is often necessary to minimize the systemic or local adverse reactions from the active or inactive ingredients of the medication. In addition to keeping up-to-date with the efficacy and safety profiles of drugs within each glaucoma medication class, clinicians should familiarize themselves with the different formulations available, preservative systems used, generics availability and compatibility, and the local insurance formulary restriction to deliver an effective glaucoma management.

Key principles for the improved conduct of health technology assessments for resource allocation decisions

Health technology assessment (HTA) is a dynamic, rapidly evolving process, embracing different types of assessments that inform real-world decisions about the value (i.e., benefits, risks, and costs) of new and existing technologies. Historically, most HTA agencies have focused on producing high quality assessment reports that can be used by a range of decision makers. However, increasingly organizations are undertaking or commissioning HTAs to inform a particular resource allocation decision, such as listing a drug on a national or local formulary, defining the range of coverage under insurance plans, or issuing mandatory guidance on the use of health technologies in a particular healthcare system. A set of fifteen principles that can be used in assessing existing or establishing new HTA activities is proposed, providing examples from existing HTA programs. The principal focus is on those HTA activities that are linked to, or include, a particular resource allocation decision. In these HTAs, the consideration of both costs and benefits, in an economic evaluation, is critical. It is also important to consider the link between the HTA and the decision that will follow. The principles are organized into four sections: (i) "Structure" of HTA programs; (ii) "Methods" of HTA; (iii) "Processes for Conduct" of HTA; and (iv) "Use of HTAs in Decision Making."

Safe prescribing by junior doctors

Tobaiqy et al. in a recent study have reported that Foundation Year 1 (FY 1) doctors lack confidence in prescribing several groups of drugs [1]. The majority of the FY 1 doctors felt that undergraduate education in clinical pharmacology and therapeutics (CPT) had not prepared them adequately for prescribing duties. CPT of drugs that are commonly prescribed across specialties, e.g. analgesics, anti-inflammatories, antacids, antibiotics, antihypertensives and anticoagulant drugs, should be adequately taught to medical students because they are likely to be encountered on a doctor's first day on the ward after graduation. However, it is not possible to teach the whole formulary in depth to medical students, and drugs that are more specific to certain specialties are probably best taught during specialty postings. Moreover, there are considerable differences in local formularies between NHS hospital trusts in the UK. This poses a challenge in terms of what drugs should be taught and in how much detail, as students may move to a new region for FY training following graduation. Confidence in prescribing comes from practice and familiarity with a particular drug on the ward. CPT is taught in most medical school curricula, but students have difficulty translating the theory into practice until they are faced with the responsibility of making prescribing decisions [2, 3]. Even though medical students may be taught to write prescriptions which are countersigned by a doctor, confidence only comes with practice, responsibility and adequate supervision. Aronson [4] has rightly noted that the writing of the prescription is a late event in the prescribing process and describes four preceding steps: (i) making an accurate diagnosis, (ii) assessing the balance of benefit to harm, (iii) choosing the right drug among a range of alternatives and the right dose regimen, and (iv) discussion with the patient about the proposed treatment and potential beneficial and adverse effects. It would be difficult to teach medical students all of these steps for all the drugs in the formulary and it is not time efficient to attempt to do so. More focus should be placed on teaching the principles of writing a proper prescription, which applies to any drug being prescribed. This is relevant to medical students as well as practising doctors, and should be a core part of continuous professional development programmes. Many doctors who are able to prescribe drugs confidently are unfortunately unable actually to write clear legible prescriptions that can be dispensed or administered without confusion [5, 6]. These findings are in keeping with unpublished audits done by the authors in two District General Hospitals in the north and south of England. A snap-shot of prescribing practices in the orthopaedic directorate of both hospitals was done at the beginning of the audit cycle. The percentage of inpatient prescription charts with errors in both hospitals was 54% and 60%, respectively. Most of the drugs were analgesics, anti-inflammatory drugs and antibiotics. There were no FY 1 doctors working in either of the units, so all the prescriptions had been done by doctors who had been prescribing for >1 year. The doctors frequently did not know the local prescribing guidelines or how to obtain them. We think that these audits suggest that prescription writing is poor even among doctors who are confident about the CPT of the prescribed drugs, and that knowing what drug to prescribe to which patient does not necessarily translate to a good prescription. Various reasons have been identified for doctors writing wrong prescriptions [7], but it is an issue that needs to be addressed continuously throughout a doctor's professional career. We do not believe all drug-prescribing issues can be adequately and sufficiently addressed during undergraduate medical training.

Prescribing of the antidepressant duloxetine: Can local clinical audit findings facilitate medicines management decisions?

Introduction. Discussions regarding the inclusion of a new antidepressant within local formulary lists and prescribing guidelines may be facilitated by audits of local prescribing practice, conducted some months after the drug first becomes available for clinical use. Method. Development of five audit standards and retrospective case-note review of prescribing recommendations for the serotonin-noradrenaline reuptake inhibitor duloxetine, made in five local outpatient clinics. Results. Follow-up data were available for audit in 27 of 43 sets of medical notes. In the majority of patients (84%), the primary diagnosis was recurrent unipolar depressive disorder, the current episode having proven resistant to treatment with two other antidepressants. Where comments were made, notes indicated that 81% of patients that received duloxetine had improved and 94% had tolerated it without reported problems. Conclusions. In this sample, duloxetine prescribing in the first months after it became available appeared to occur within an appropriate patient group. Prospective evaluations in other clinical samples are warranted.

Cost-effectiveness analysis and formulary decision making in England: Findings from research

In a context of rapid technological advances in health care and increasing demand for expensive treatments, local formulary committees are key players in the management of scarce resources. However, little is known about the information and processes used when making decisions on the inclusion of new treatments. This paper reports research on the use of economic evaluations in technology coverage decisions in England, although the findings have a relevance to other health care systems with devolved responsibility for resource allocation. It reports a study of four local formulary committees in which both qualitative and quantitative data were collected. Our main research finding is that it is an exception for cost-effectiveness analysis to inform technology coverage decisions. Barriers to use include access and expertise levels, concerns relating to the independence of analyses and problems with implementation of study recommendations. Further barriers derive from the constraints on decision makers, a lack of clarity over functions and aims of local committees, and the challenge of disinvestment in medical technologies. The relative weakness of the research-practice dynamics in this context suggests the need for a rethinking of the role of both analysts and decision makers. Our research supports the view that in order to be useful, analysis needs to better reflect the constraints of the local decision-making environment. We also recommend that local decision-making committees and bodies in the National Health Service more clearly identify the 'problems' which they are charged with solving and how their outputs contribute to broader finance and commissioning functions. This would help to establish the ways in which the routine use of cost-effectiveness analysis might become a reality.

Multicentre study of antimicrobial resistance and antibiotic consumption among 6,780 patients with bloodstream infections

Several lines of evidence suggest there is a causal association between the use of antimicrobial agents and the prevalence of antimicrobial resistance in hospitalacquired bacterial pathogens [1, 2]. However, recently published works have indicated the magnitude of the association may be lower than that previously observed and that many other variables, such as patient factors may be responsible for the development of antimicrobial resistance [3, 4]. The specific goals of this study were (1) to estimate antimicrobial resistance rates for four epidemiologically important pathogens causing bloodstream infections (BSI), (2) to compare the antimicrobial resistance rates with the hospital’s antibiotic consumption data, and (3) to determine a possible relationship between the use of antimicrobial agents and the prevalence of drug resistance in these microorganisms. The participating hospitals were partners in the TREAT project, financed by the European Community (EC, 5th Framework, 1999) and focusing on the application of an electronic decision support system to reduce antimicrobial resistance in hospitalised patients [5] This multicentre study was conducted at Freiburg University Hospital, Freiburg, Germany; Rabin Medical Center, Tel Aviv (Petah Tiqva), Israel; Aalborg Hospital, Aalborg, Denmark; and Catholic University Hospital, Rome, Italy. Data on consumption of antibiotics (from 1998 to 2001) were supplied by the hospital pharmacies and expressed in daily defined doses (DDD) per 1,000 bed-days, as outlined by the World Health Organisation. Data on consumption of the following drugs were provided (if included in the local formulary): clindamycin, trimethoprim-sulfamethoxazole, imipenem, ampicillin, ceftazidime, cefepime, piperacillin, piperacillin-tazobactam, and gentamicin. We prospectively included, from 1998 to 2001, all consecutive non-repeat blood isolates of patients with nosocomial BSI according to the definition given by the Centers for Disease Control and Prevention (Atlanta, GA, USA). Mixed cultures were excluded. Selected isolates from patients with bacteraemia included Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa. Microorganisms were identified using standard methods. Trends in resistance and the possible correlation between resistance and consumption were analysed using the logit regression line. Antimicrobial consumption patterns varied widely at the four sites. The most frequently prescribed drugs (>40 DDD per 1,000 bed-days) were ampicillin and gentamicin in Denmark and Israel and ceftazidime in Germany and Italy. Eur J Clin Microbiol Infect Dis (2006) 25:815–817 DOI 10.1007/s10096-006-0211-2

Use of centrally developed pharmacoeconomic assessments for local formulary decisions

The distribution, content, timeliness, use, and influence of pharmacoeconomic assessments (PEAs) of drugs in New Zealand public hospitals were examined. In April 2005, a questionnaire-based, cross-sectional survey was sent to chief pharmacists at all 29 New Zealand hospitals employing a pharmacist. The questionnaire asked pharmacists about the use and influence of PEAs in their hospitals' formulary decision-making process. Answers were given using a scale of 1 to 6, with 1 being the most positive response. Of the 29 surveys mailed, 24 (83%) were completed. Data on 12 PEAs were analyzed. Assessments were seen and summaries read in most hospitals (median, 77% and 65%, respectively). Full documents were read in fewer hospitals (35%). In general, the PEAs were considered moderately easy to understand, provided a concise summary, and contained adequate detail of the methodology. Of the 24 respondent hospitals, 21 had assessment processes for new medicines; hence, a total of 252 hospital evaluations of Pharmaceutical Management Agency (PHARMAC)-assessed drugs were possible. A total of 132 possible evaluations (52%) were undertaken. More evaluations (106 [42%]) took place before PHARMAC's PEAs were distributed and fewer (26 [10%]) after distribution. Where used, the PEAs appeared to have a modest effect on hospital decisions. The provision of 12 PEAS by PHARMAC to hospitals in New Zealand had only a modest influence on their formulary decision-making process, mostly due to the lack of timeliness of the PEAs. The timely delivery of centrally developed PEAs may be essential to generating a greater effect on the formulary decisions at a wider level.

Assisting Aboriginal patients with medication management

he burden of acute and chronic disease in the Aboriginal and Torres Strait Islander population is well documented. Medicines are important for treatment and prophylaxis, but there are many factors which continue to impede medication management in Aboriginal populations. These include access and financial barriers, the nature of the therapeutic regimen and cultural, socioeconomic and geographic factors. The patient-clinician interaction and the organisational aspects of healthcare practices also have an impact. Solutions may include the selection of appropriate formulations, simple dose regimens, tailored use of medication aids, local formularies and a greater role for Aboriginal health workers.

Reimbursement and clinical guidance for pharmaceuticals in Sweden

Introduction of the new Pharmaceutical Benefits Board (LFN; 1 October 2002) has markedly changed the principles of pricing and reimbursement of drugs in Sweden. The Board is required to make decisions based on information on cost-effectiveness, and pharmaceutical companies must submit economic evaluations when relevant as part of their applications for reimbursement. This study examined experience to date regarding the use of health-economic evaluations and cost-effectiveness information by the LFN. We also describe activities and the use of cost-effectiveness analysis by Swedish local formulary committees organized by the 21 county councils. It is concluded that economic evaluations have supported decision making by LFN, although cost-effectiveness seems to be of varying importance in different situations. While the use of health-economic evaluations and the outcome of decision making by LFN are similar to comparable committees in other countries, there is presently a gap in this sense between the LFN and Swedish local formulary committees. Coordinated decision making is much needed but may be difficult to implement as the perspective, expertise, and objectives of the two public authorities differ.

Factors that Influence Prescribers in their Selection and use of COX-2 Selective Inhibitors as Opposed to Non-selective NSAIDs*

To identify factors that influence prescribers in their selection and use of cyclo-oxygenase-2 (COX-2) selective inhibitors as opposed to non-selective non-steroidal anti-inflammatory drugs (NSAIDs) and report the tendency to co-prescribe gastro-protection with these agents. All 579 general practitioners (GPs) in one geographical area, Lothian, Scotland, UK. Postal questionnaires; simple and factorial designed case series questionnaire. Categorisation of responses to clinical and non-clinical factors into highly, partially or not influential. The quantitative influence of the most prominent clinical factors on prescribing choice and the tendency of co-prescription of gastro-protection with these agents. Responses from 229 (40%) GPs suggested the following as most influential: Drug Evaluation Panel recommendations, Lothian Joint Formulary, local practice formulary, history of peptic ulcer disease (PUD), history of gastro-intestinal (GI) adverse effects with NSAIDs and advanced age. Advice from other physicians, patient demand, history of alcohol gastritis, history of gastro-oesophageal reflux disease, history of functional dyspepsia, concomitant use of low dose aspirin and concomitant use of gastro-protective agents were regarded to have moderate influence. Information directly from pharmaceutical industry and regular smoking were regarded as having weak influence. An 18% response to the factorial designed questionnaire using the most prominent clinical factors suggested that history of either GI adverse effects associated with non-selective NSAIDs or PUD resulted in more pronounced increase in the frequency (15%) of decision to prescribe COX-2 selective inhibitors than advanced age (10%). Concomitant use of low dose aspirin had little effect on GPs' decisions. The mean percentage of GPs choosing to co-prescribe gastro-protection was higher with non-selective NSAIDs (64%) than with COX-2 selective inhibitors (22%). Local authoritative guidance and history of GI complications highly influenced the GPs in their use and choice of either COX-2 selective inhibitors or non-selective NSAIDs. As expected the use of gastro-protection was more frequently chosen with non-selective NSAIDs than COX-2 selective inhibitors.

Antihypertensive drug prescribing in Grampian

To assess the cost implications of changing prescribing patterns for antihypertensive drugs and to analyse adherence to guidelines and formulary in Grampian region over a 1 year period. Data on all prescriptions for antihypertensive medicines between November 2001 and October 2002 were obtained from Grampian Health Board. The total quantity and cost of each drug prescribed was calculated and compared with November 1998 to October 1999. Adherence to the local formulary and 1999 British Hypertension Society guidelines for first line agents and prescribing of generic drug names were analyzed for each practice. There was an increase in the total number of prescriptions for antihypertensive drugs from 504929 in 1998/99 to 741620 in 2001/02, and a corresponding increase in total cost from pound 4.52 million to pound 6.79 million. Increases were seen in all drug classes, particularly angiotensin II antagonists (246.27%). Adherence to the local formulary was good, with an average of 91.25% (SD 5.94%) of prescribing consistent with recommended agents. This fell to 71.70% (SD 23.10%) for angiotensin II antagonists. Prescription using generic name was related to whether the practice dispensed medication or not: the mean level of generic prescribing in dispensing practices was 75.25% and in nondispensing practices was 89.02% (mean difference 13.76 (9.27, 18.26), P < 0.001). There was a substantial increase in prescribing volume and cost of antihypertensives between 1998/99 and 2001/02. This trend is likely to have continued, given changing targets and indications for therapy. Although practices generally showed high concordance with formulary recommendations, newer agents such as angiotensin II antagonists were less consistent, possibly related to pharmaceutical influences on prescribing. Dispensing practices were more likely to prescribe branded drugs which may reflect current reimbursement policies. Changing prescribing practices by encouraging formulary based prescribing and prescribing of generic agents may help offset the cost implications of guideline driven increases in antihypertensive drug prescribing. Education, and reviewing payment practices in dispensing and smaller practices, may also have a role.