title: Reasons for overprescription of mononitrates: the paradigm of stable angina pectoris treatment.
abstract: BACKGROUND
  Oral nitrates, beta-blockers, and calcium channel blockers are used to treat stable angina pectoris (SAP). The 2 therapeutic subtypes of oral nitrates are mononitrates and dinitrates, with no evidence that 1 subtype is more efficacious than the other. Although practice guidelines in Great Britain and Israel recommend dinitrates as the first-line drug for SAP, in practice, many physicians in those 2 countries prescribe mononitrates.
  
  
  OBJECTIVE
  The aim of this study was to identify factors that influence specialist physicians (family practitioners, internists, and cardiologists) in Israel when prescribing nitrates for the prevention of SAP symptoms.
  
  
  METHODS
  A group of specialists was given a self-administered questionnaire regarding their treatment of choice for a patient with SAP described in a hypothetical case vignette. End points for prescribing preferences were evidence-based information, cost, and the influence of pharmaceutical company representatives.
  
  
  RESULTS
  One hundred ten specialists were given the questionnaire. Eighty-nine specialists (45 men, 44 women; mean age, 50.4 years; range, 34-67 years; response rate, 80.9%) completed it (39 family practitioners, 29 internists, and 21 cardiologists). Seventy-eight respondents (87.6%) chose to prescribe nitrates for the case vignette, and among those, 54 (69.2%) chose mononitrates and 24 (30.8%) chose dinitrates (P = 0.034). The choice of mononitrates over dinitrates was mainly affected by habit (25/54 [46.3%]) and the belief that mononitrates are more effective, safer, and/or less expensive than dinitrates (21/54 [38.9%]). Drug costs for the patient significantly influenced more family practitioners than hospital specialists (P<0.05).
  
  
  CONCLUSIONS
  In contrast to guideline recommendations, the paradigm of SAP treatment with nitrates in this study was characterized by significantly more prescriptions for mononitrates than dinitrates. This situation contributes to the erosion of the scarce resources of the health care system in Israel. Further efforts are needed to increase physicians' awareness of quality, cost, and choices when prescribing drugs.
authors.affiliation: Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
authors.forename: Mickie
authors.initials: M
authors.lastname: Preis
authors.affiliation: Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel ; Epidemiology Research Institute, Barzilai Medical Center, Ashkelon, Israel.
authors.forename: Ronit
authors.initials: R
authors.lastname: Peled
authors.affiliation: Toxicology Unit, Soroka University Medical Center, Beer-Sheva, Israel ; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
authors.forename: Matityhau
authors.initials: M
authors.lastname: Lifshitz
authors.affiliation: Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
authors.forename: Asher
authors.initials: A
authors.lastname: Elhayani
authors.affiliation: Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
authors.forename: Asaf
authors.initials: A
authors.lastname: Toker
authors.affiliation: Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
authors.forename: Haim
authors.initials: H
authors.lastname: Reuveni
keywords: dinitrates; guideline; mononitrates; nitrates; stable angina pectoris