1 Drug and Therapeutics Committee Session 9. Strategies to Improve Medicine Use—Overview.
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Transcript of 1 Drug and Therapeutics Committee Session 9. Strategies to Improve Medicine Use—Overview.
1
Drug and Therapeutics Committee
Session 9. Strategies to Improve Medicine Use—Overview
Objectives
Identify effective strategies to improve medicine use
Choose an appropriate strategy for improving medicine use based on an identified problem
Understand the importance of educational, managerial, and regulatory interventions in promoting rational use of medicines
Outline
Key definitions Introduction
Methods to improve medicine use Educational Managerial Regulatory
Activity 1
Summary
Key Definitions
Standard treatment guideline (STG)—Systematically developed statement that assists practitioners and patients in making decisions about appropriate health care for specific clinical circumstances
Formulary manual—Document that describes medicines that are available for use in hospitals or clinics (provides information on indications, dosage, length of treatment, interactions, precautions, contraindications)
Drug use evaluation (DUE)—Ongoing, systematic, criteria-based program of medicine evaluations that helps ensure appropriate medicine use; if therapy is determined appropriate, interventions with providers or patients will be necessary to optimize pharmaceutical therapy
Introduction
Drug and Therapeutic Committee (DTC) responsibilities—
Selecting medicines for the formulary
Identifying medicine use problems
Developing and implementing strategies to improve
medicine use
Consequences of Irrational Use of Medicines (1)
Waste of resources
Up to half the value of all medicines may be wasted through inappropriate use
Morbidity due to adverse drug reactions (ADRs)
In the United States, ADRs cost 30–130 billion U.S. dollars per year and causes significant morbidity and mortality
Consequences of Irrational Use of Medicines (2)
Antimicrobial resistance through misuse and overuse 2–4% multidrug resistance in TB, 12–55% resistance to
penicillin in N. Gonorrhoea and S. Pneumonia, 10–90% resistance to ampicillin or co-trimoxazole in Shigella
Increased disease due to dirty or unnecessary injections 2.3–4.7 million hepatitis B and C infections and up to
160,000 HIV infections per year
Changing a Medicine Use Problem:An Overview of the Process
1. EXAMINEMeasure existing
practices(descriptive
quantitative studies)
2. DIAGNOSEIdentify specific
problems and causes(in-depth quantitative and qualitative studies)
3. TREATDesign and implement
interventions (collect data to
measure outcomes)
4. FOLLOW UPMeasure changes
in outcomes (quantitative and qualitative
evaluation)
Improve intervention
Improvediagnosis
Strategies to Improve Medicine Use
Managerial:to structure or guide
decisions
Regulatory:to restrict or limit
decisions
Educational: to inform or persuade
Educational Methods: To Inform and Persuade Printed materials
Pharmaceutical bulletins and newsletters
Formulary manuals and STGs
Face-to-face activities
Group: in-service education, workshops, seminars
Individual: face-to-face (academic detailing)
Printed Educational Materials (1)
Newsletters and bulletins
International newsletters
Local newsletters Brief, to the point, articles of interest to medical staff Tailor to problems seen at hospitals and clinics Produce regularly
Need to be coupled with other approaches
Printed Educational Materials (2) Pharmaceutical newsletters are more likely to be
effective in improving rational use of medicines if they do the following— Describe the reasons for prescribing behavior Offer concise, up-to-date information that can be used
immediately Provide limited information and repetition of key points Have attractive graphics Provide references in the newsletter to information derived from
reputable journals and services Provide information oriented toward actions and decisions
Obtain feedback from the professional staff on the value of newsletter and institute changes as necessary
Printed Educational Materials (3) Formulary manuals
Reference source for education and training for all providers
Provide a listing of medicines available and information on the formulary medicines
Source of price information
STGs Reference source for education and for prescription audit Lists the preferred pharmaceutical and
nonpharmaceutical treatments
Face-to-Face Educational Methods (1)
In-service education, workshops, seminars Focuses on information of local relevance Is kept brief (i.e., messages are few and clear,
descriptions of what to do are concise) Supports the repetitive information needed for
individuals to learn Is run by a presenter who has in-depth knowledge
and an effective teaching style
Face-to-Face Educational Methods (2)
Person-to-person educational outreach (academic detailing)—most effective form of education
Focuses on specific problems and targets the prescribers
Addresses the underlying causes of prescribing errors such as inadequate knowledge
Face-to-Face Educational Methods (3)
Person-to-person educational outreach (continued) Allows for interactive discussion with targeted
audience
Uses concise and authoritative materials to augment presentations
Gives sufficient attention to solving practical problems encountered by prescribers in real settings
Face-to-Face Educational Methods (4)
Influencing opinion leaders Chiefs of service Dominant and experienced physicians in
community settings University professors Important and respected traditional healers
Effects of an Opinion Leader on Choice Opinion Antibiotic for Prophylaxis in a U.S. Teaching Hospital
Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct84 85 86
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7Discussion withChief of Obstetrics
-- Cefazolinrecommended
— Cefoxitinnot recommended
Percentage of all cesarean sections
Face-to-Face Educational Methods (5)
Patient education Patients provided with education will—
Have fewer demands for medicines Show improved compliance with pharmaceutical
therapy Have improved quality of care and outcomes
Must be provided by authoritative persons, such as physicians, pharmacists, and nurses in an organized, systematic approach
Impact of Patient-Provider Discussion Groups on Injection Use in Indonesian PHC Facilities*
% Prescribing Injections
Intervention Control0
20
40
60
80
Pre
Post
*Hadiyono, J.E., S. Suryawati, S.S. Danu, et al. 1996. Interactional Group Discussion: Results of a Controlled Trial Using a Behavioral
Intervention to Reduce the Use of Injections in Public Health Facilities. Social Science Medicine 42:1177–83.
Sites for Face-to-Face Education
Health centers
Hospitals
Pharmacies
Universities
District-level education
Strategies to Improve Medicine Use
Managerial:to structure or guide
decisions
Regulatory:to restrict or limit
decisions
Educational: to inform or persuade
Managerial Methods: To Structure and Guide Decisions
STGs
DUEs
Clinical pharmacy programs
Medicine restrictions and control
Standard Treatment Guidelines Advantages
Standardized treatment guidance to all practitioners Dictates the most appropriate medicines Provides basis for evaluating quality of care
Disadvantages Difficult to produce accurately Inaccurate or incomplete guidelines will provide the wrong
information and do more harm than good Guidelines may not be based on the most reliable information
Randomized Controlled Trial In Uganda—Effects of Treatment Guidelines, Training, and Supervision on the Percentage of Prescriptions Conforming to STGs*
Randomised group
No. health facilities
Pre-intervention
Post- intervention
Change
Control group 42 24.8% 29.9% +5.1%
Dissemination of guidelines
42 24.8% 32.3% +7.5%
Guidelines + on-site training
29 24.0% 52.0% +28.0%
Guidelines + on-site training + 4 supervisory visits
14
21.4%
55.2%
+33.8%
*Kafuko, J.M., C. Zirabumuzaale, and D. Bagenda. 1996. Rational Drug Use in Rural Health Units of Uganda: Effect of National Standard Treatment Guidelines on Rational Drug Use. Final report UNICEF/Uganda.
Audit and Feedback
DUE
Program of ongoing, systematic, criteria-based evaluations of pharmaceutical therapy
Clinical Pharmacy Programs
Last check on correct use, doses, side effects
Medicine information and patient education
Correct labeling and course of treatment packaging
Generic substitution programs—bioequivalence issues
Therapeutic substitution (interchange)—substitution of medicines that differ in active ingredients but have similar therapeutic activities in terms of efficacy and safety (e.g., lisinopril for enalapril)
Pharmaceutical Restrictions and Control
Formulary list (essential medicine list)
Structured order forms
Automatic stop orders
Controlling Pharmaceutical Promotion All promotional claims concerning medicines should
be reliable, accurate, truthful, informative, balanced, capable of substantiation, and in good taste
Control access of medical representatives to prescribers in the hospital during working hours
Organize meetings of discussion between medical representatives and prescribers to allow DTC to evaluate the medicine of interest
Avoiding Perverse Economic Incentives Separation of the prescribing and dispensing functions
Avoidance of flat prescription fees that encourage polypharmacy
Avoidance of percentage dispensing fees that encourage the sale of more expensive medicines
Avoidance of polypharmacy where prescribers earn part of their income from the sale of medicines (including the use of expensive medicines where cheaper one would be just as good)
Improving Prescribing by Changing Financial Incentives from User Fees* Pre- and post-study with control
1992: All three areas used flat fee covering all medicines in whatever quantities (perverse financial incentive)
1993–94: Two areas changed to a fee per pharmaceutical item (positive incentive)
1992–95: One area continued with the flat fee covering all medicines (control)
Prescription (Px) surveys done in pre-intervention (1992) and post-intervention (1995)
10–12 health facilities per area, > 30 prescriptions per facility*Holloway, K.A., B.R. Gautam, and B.C. Reeves. 2001. The Effects of Different Kinds of User Fees on Prescribing Quality in Rural Nepal. Journal of Clinical Epidemiology 54(10):1065–71.
Polypharmacy and Antibiotic Use: On changing from a flat medicine fee to a fee per medicine item
Holloway et al. (2001).
% patients treated with antibioticsAverage number of medicines per patient
0
20
40
60
80
0
1
2
3
4
Px fee 1-band item fee 2-band item fee
1992 1995Px fee 1-band item fee 2-band item fee
1992 1995
Injection and Vitamin or Tonic Use:On changing from a flat medicine fee to a fee per medicine item
Holloway et al. (2001).
% patients treated with injections
05
10152025
Px fee 1-band item fee 2-band item fee
1992 1995
% patients treated with vitamins/tonics
05
1015202530
Px fee 1-band item fee 2-band item fee
1992 1995
Treatment Cost and Compliance with STGs: On changing from flat medicine fee to fee per medicine item
% patients treated according to STGs
0102030405060
Px fee 1-band item fee 2-band item fee
Average medicine cost per patient (NRs)*
0
10
20
30
40
Px fee 1-band item fee 2-band item fee
1992 1995 1992 1995
Holloway et al. (2001). *NR = Nepalese rupees
Strategies to Improve Medicine Use
Managerial:to structure or guide
decisions
Regulatory:to restrict or limit
decisions
Educational: to inform or persuade
Regulatory Methods: To Restrict or Limit Decisions Country pharmaceutical registration—ensure only
registered medicines are used
Professional licensing—employ only licensed staff for the level of prescribing required
Licensing of pharmaceutical outlets—buy medicines only from licensed outlets
Regulation pharmaceutical promotion activities
Choosing an Intervention (1) A single educational strategy is usually not too
effective and the impact is not sustainable.
Printed materials alone are not effective or advisable.
A combination of strategies, particularly of different types (e.g., educational and managerial) always produces better results than a single strategy.
Choosing an Intervention (2)
Focused small groups and face-to-face interactive workshops have been shown to be effective.
Monitoring (audit) and feedback and peer review are effective strategies to improve medicine use.
Economic strategies are powerful strategies to change medicine use but may be difficult to introduce.
Treatment guidelines are effective when used with other interventions.
Combined Intervention StrategyPrescribing for Acute Diarrhea in Mexico City
00
2020
4040
6060
8080
100100
% cases treated in line with algorithm
Study Physicians
Control Physicians
37/5237/5279/11579/115
20/8420/84
Baseline Stage (n = 20)
After Workshop
After Peer Review (n = 20)
18-months Follow-up
11/4611/46
31/11031/110
16/7016/7025/10225/102
42/8242/82
Impact of Training on Using Diarrhea Treatment Algorithm in Three Mexican Settings
Source: Munoz, et al., unpublished (1993)
Intervention given by:
Experts in 2 clinics(San Jeronimo)
Leaders in 18 clinics (Coyoacan)
Coordinators in 124
Prescribers
31
65
157
Baseline(%)
24.5
17.7
24.7
Post(%)
71.2
43.4
31.2
Change (%)
+46.7
+ 25.6
+ 6.5 clinics (Tlaxcala)
Review of 30 Studies in Developing Countries— Medicine Use Improvements with Different Interventions*
Improvement in outcome measure (%)
0 10 20 30 40 50 60
None, minor
Moderate Large
Large group training
Small group training
Diarr. community case mgtARI community case mgt
Info/guidelinesGroup process
Supervision/audit
EDP/medicine supply
Economic strategies
Source: Ross-Degnan et al. 1997. Plenary Presentation, Conference on Improving the Use of Medicines. Chiang Mai, Thailand.
Activity 1. Case Study: Generic and Brand Name Antibiotics
What are the major pharmaceutical management problems in this case presentation?
Clearly define the beliefs and motivations of the prescribers that may contribute to the observed behavior.
Once the problem has been defined, what kinds of strategies or interventions would you use to improve pharmaceutical therapy and to lower medicine costs in this hospital?
Summary (1)
Strategies to improve medicine use include the following types of interventions— Educational programs
In-service education Pharmaceutical bulletins and newsletters Formulary manuals Face-to-face education
Summary (2)
Interventions (continued)— Managerial programs
DUE STG Clinical pharmacy programs Medicine restrictions and control
Regulatory programs—registration of medicines, professionals, facilities