Thesis Presentation New

Studies on drug use pattern and cost Studies on drug use pattern and cost efficiency in Upazilla Health efficiency in Upazilla Health Complexes in BangladeshComplexes in Bangladesh

H. M. AlamgirH. M. Alamgir

Department of Clinical Pharmacy and PharmacologyFaculty of PharmacyUniversity of Dhaka

Why this study?Why this study?

• In the developing countries like Bangladesh, In the developing countries like Bangladesh, inappropriate, ineffective and economically inappropriate, ineffective and economically inefficient use of drug is widespread in health inefficient use of drug is widespread in health care facilities like Upazilla Health Complexes in care facilities like Upazilla Health Complexes in Bangladesh.Bangladesh.

• The cost of such irrational use of drugs is The cost of such irrational use of drugs is enormous in terms of both resources and the enormous in terms of both resources and the adverse clinical consequences of which have adverse clinical consequences of which have many risks without any objective benefits.many risks without any objective benefits.

Studies on Drug Use Pattern and Cost Efficiency 2

Why this study?Why this study?

• This misuse or irrational use of drugs must be This misuse or irrational use of drugs must be minimized to an affordable limit to save limited minimized to an affordable limit to save limited resources and the consumers from unnecessary resources and the consumers from unnecessary sufferings from adverse effects of pharmaceutical sufferings from adverse effects of pharmaceutical products. products.

3Studies on Drug Use Pattern and Cost Efficiency

Studies on Drug Use Pattern and Cost Efficiency 4

Research ObjectivesResearch Objectives

• To assess the drug use pattern on 6 common To assess the drug use pattern on 6 common diseases in Bangladeshdiseases in Bangladesh

• To identify magnitude and nature of To identify magnitude and nature of inappropriate drug utilizationinappropriate drug utilization

• To understand the adverse impacts of To understand the adverse impacts of inappropriate use of drugsinappropriate use of drugs

• To examine the impact of irrational prescribing To examine the impact of irrational prescribing on the drug cost for treatment of 6 selected on the drug cost for treatment of 6 selected common diseasescommon diseases

Research ObjectivesResearch Objectives

• To identify factors that influence the behavior of To identify factors that influence the behavior of prescribers and patientsprescribers and patients

• To assess the availability of essential drugs in To assess the availability of essential drugs in health facilitieshealth facilities

• To assess the availability of EDL and STG in To assess the availability of EDL and STG in health facilitieshealth facilities

• To identify the role of economic incentives, To identify the role of economic incentives, professional controls and bureaucratic professional controls and bureaucratic regulations in the prescribing pattern of the regulations in the prescribing pattern of the health care professionals and providershealth care professionals and providers


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What Is Rational Use of Drugs?What Is Rational Use of Drugs?

The rational use of drugs requires that patients receive medicines The rational use of drugs requires that patients receive medicines appropriate to their clinical needs, in doses that meet their own individual appropriate to their clinical needs, in doses that meet their own individual

requirements, for an adequate period of time, and at the lowest cost to requirements, for an adequate period of time, and at the lowest cost to them and the community.them and the community.

(WHO 1988)(WHO 1988)

Appropriate indicationAppropriate indication Appropriate drugAppropriate drug Appropriate administration, dosage and durationAppropriate administration, dosage and duration Appropriate patientAppropriate patient Appropriate patient informationAppropriate patient information Appropriate evaluationAppropriate evaluation

Studies on Drug Use Pattern and Cost Efficiency

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Irrational Use of DrugsIrrational Use of Drugs

• The use of drugs when no drug therapy is indicatedThe use of drugs when no drug therapy is indicated

• The use of wrong drugs for a specific condition The use of wrong drugs for a specific condition requiring drug therapyrequiring drug therapy

• The use of drugs with doubtful or unproven efficacyThe use of drugs with doubtful or unproven efficacy

• The use of drugs of uncertain safety statusThe use of drugs of uncertain safety status

• Failure to prescribe available, safe & effective drugsFailure to prescribe available, safe & effective drugs

• Incorrect administration, dosages or durationIncorrect administration, dosages or durationStudies on Drug Use Pattern and Cost Efficiency

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Examples of Common Inappropriate Examples of Common Inappropriate Prescribing PracticesPrescribing Practices

• Overuse of antibiotics and antidiarrheals for Overuse of antibiotics and antidiarrheals for nonspecific childhood diarrheanonspecific childhood diarrhea

• Indiscriminate use of injections for malariaIndiscriminate use of injections for malaria• Multiple or overprescriptionMultiple or overprescription• Use of antibiotics for mild, nonbacterial Use of antibiotics for mild, nonbacterial

infection, e.g., ARIinfection, e.g., ARI• Tonics and multivitamins for malnutritionTonics and multivitamins for malnutrition


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Components of the Drug Use Components of the Drug Use SystemSystem

Drug ImportsDrug ImportsLocalLocal

ManufactureManufacture

HospitalHospital or or HealthHealth CenteCenterr

Private Physician orPrivate Physician or Other PractitionerOther Practitioner Pharmacist orPharmacist or

Drug TraderDrug Trader

The DrugThe Drug SupplySupply ProcessProcess

Provider andProvider and Consumer BehaviorConsumer Behavior

Illness PatternsIllness Patterns

++

PublicPublic


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Factors Underlying Irrational Use Factors Underlying Irrational Use of Drugsof Drugs

• inefficient inefficient managementmanagement

• nonavailability nonavailability of required of required drugsdrugs

Drug SupplyDrug Supply

• availability of availability of non-essential non-essential drugsdrugs

• informal informal prescribersprescribers

Drug RegulationDrug Regulation

• promotionpromotion• misleading misleading

claimsclaims

IndustryIndustry

• lack of education lack of education and trainingand training

• lack of drug lack of drug informationinformation

• heavy patient loadheavy patient load• pressure to pressure to

prescribeprescribe• generalization of generalization of

limited beliefslimited beliefs• misleading beliefs misleading beliefs

about efficacyabout efficacy

PrescribersPrescribers• drug drug

misinformationmisinformation• misleading misleading

beliefsbeliefs• inability to inability to

communicate communicate problemsproblems

PatientsPatients


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Impact of InappropriateImpact of InappropriateUse of DrugsUse of Drugs

Reduced Reduced quality of quality of therapytherapy

•morbiditymorbidity•mortalitymortality

Waste of Waste of resourcesresources Risk of Risk of

unwanted unwanted effectseffects

•patients rely on patients rely on unnecessary drugsunnecessary drugs

Psychosocial Psychosocial impactsimpacts

•reduced availabilityreduced availability•increased costincreased cost

•adverse reactionsadverse reactions•bacterial resistancebacterial resistance


Study SettingStudy Setting

Area Dhaka DivisionFacilities Included 20 (Out of 119 UHCs)

Facility Selection Procedure Systemic Random Sampling

Time Frame of Study 1 Year

Prescribing or Patient Care Encounters Per Facility

30

Type of Prescribing or Patient Care Data

Prospective


Selection of Health FacilitiesSelection of Health Facilities


Selected Health FacilitiesSelected Health Facilities

Serial No. UHC Serial No. UHC

1 Goshaipur 11 Kaliakair

2 Sibehar 12 Sakhipur

3 Gopalganj 13 Sarisabari

4 Faridpur 14 Bakshiganj

5 Pangsha 15 Nalitabari

6 Ghior 16 Mymensingh

7 Keraniganj 17 Nandail

8 Tongibari 18 Bhairab

9 Araihazar 19 Tarail

10 Shibpur 20 Mohonganj14Studies on Drug Use Pattern and Cost Efficiency

Study IndicatorsStudy Indicators

Prescribing Indicators • Average number of drugs per encounterAverage number of drugs per encounter• % of drugs prescribed by generic name% of drugs prescribed by generic name• % of encounters with antibiotic prescribed% of encounters with antibiotic prescribed• % of encounters with injection prescribed% of encounters with injection prescribed• % of drugs prescribed from essential drug list% of drugs prescribed from essential drug list• Providers knowledge about standard treatment Providers knowledge about standard treatment

practices and prescribing drugspractices and prescribing drugs• Use and application of regulatory measures Use and application of regulatory measures

necessary to implement rational drug usenecessary to implement rational drug use15Studies on Drug Use Pattern and Cost Efficiency


Patient care indicators • Average consultation timeAverage consultation time• Average dispensing time Average dispensing time • % of drug actually dispensed% of drug actually dispensed• Patients knowledge of correct dosePatients knowledge of correct dose



Health Facility Indicators • Availability of copy of essential drug list or Availability of copy of essential drug list or

formularyformulary• Availability of key drugsAvailability of key drugs• Total drug costs of the UHC per dayTotal drug costs of the UHC per day• Average drug cost per encounterAverage drug cost per encounter• Total cost and average cost of antibiotics per Total cost and average cost of antibiotics per

encounterencounter• Cost of ARI treatment etcCost of ARI treatment etc


6 Common Diseases to be 6 Common Diseases to be ConsideredConsidered

• DiarrheaDiarrhea• DysenteryDysentery• Acute Respiratory tract InfectionAcute Respiratory tract Infection• ScabiesScabies• Worm InfectionsWorm Infections• Fungal Skin InfectionsFungal Skin Infections


Drug Use Indicator Drug Use Indicator Consolidation Form Consolidation Form

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Click Here


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Average Number of Drugs per Average Number of Drugs per EncounterEncounter


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Percent of Drugs Prescribed as Percent of Drugs Prescribed as GenericsGenerics


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Percent of Encounters with Percent of Encounters with AntibioticsAntibiotics


Percent of Encounters with Percent of Encounters with InjectionsInjections

• Not a single encounter with injection Not a single encounter with injection was observed in any health complex was observed in any health complex under investigation. This trend is very under investigation. This trend is very appreciable and encouraging. appreciable and encouraging.


Percent of Drugs Prescribed Percent of Drugs Prescribed from EDLfrom EDL


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Average Consultation TimeAverage Consultation Time


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Average Dispensing TimeAverage Dispensing Time


Percent of Drugs Actually Percent of Drugs Actually DispensedDispensed


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Percent of Patients with Percent of Patients with Adequate Dosing KnowledgeAdequate Dosing Knowledge


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Percent of Key Drugs in StockPercent of Key Drugs in Stock


Disease PrevalenceDisease Prevalence


Health Care ExpenditureHealth Care Expenditure


Cost of Antibiotics for ARICost of Antibiotics for ARI


Drug Cost for Each Selected Drug Cost for Each Selected Category DiseaseCategory Disease


Percent Drug Cost for Each Percent Drug Cost for Each Selected Category DiseaseSelected Category Disease


ConclusionConclusion

• High number of drugs (3 per encounter) High number of drugs (3 per encounter) prescribed to patients tends to increase prescribed to patients tends to increase the risk of drugs interactions, affects the risk of drugs interactions, affects patient compliance, encourages patient compliance, encourages polypharmacy and causes serious patient polypharmacy and causes serious patient harmharm

• Generic prescription of drugs was Generic prescription of drugs was considerably low (49%)considerably low (49%)



• Not a single encounter with injection was Not a single encounter with injection was observed in any health facility under observed in any health facility under investigation which is very appreciable and investigation which is very appreciable and encouraging (0%)encouraging (0%)

• Prescribing of antibiotics in the health Prescribing of antibiotics in the health facilities was very high (44%)facilities was very high (44%)



• Mean duration for consultation (2 min) and Mean duration for consultation (2 min) and for dispensing (22 sec), both considered for dispensing (22 sec), both considered as insufficient for effective patient careas insufficient for effective patient care

• Average percent availability of drugs in the Average percent availability of drugs in the health facilities was very poor (51%)health facilities was very poor (51%)



• Many of the health facilities visited did not Many of the health facilities visited did not have copies of EDL; however, 59% drugs have copies of EDL; however, 59% drugs prescribed were listed on the EDLprescribed were listed on the EDL

• Only four out of twenty health complexes Only four out of twenty health complexes were found to possess the national were found to possess the national essential drug list (18%)essential drug list (18%)



• Almost all health facilities lacked STGs for Almost all health facilities lacked STGs for common diseases except diarrheacommon diseases except diarrhea

• Marketing and product promotion Marketing and product promotion strategies may lead to unnecessary drugs strategies may lead to unnecessary drugs useuse

• Doctors in most cases prescribe helplessly Doctors in most cases prescribe helplessly inappropriate drugs for the patients due to inappropriate drugs for the patients due to inadequate supply of key essential drugs inadequate supply of key essential drugs



• Not a single dispensed drug was Not a single dispensed drug was adequately labeled (0%)adequately labeled (0%)

• Poor adequate knowledge of patients on Poor adequate knowledge of patients on correct dose (36% only)correct dose (36% only)

• Cost of drugs per encounter was very high Cost of drugs per encounter was very high (Tk.236)(Tk.236)



• Majority of the dispensers interviewed did Majority of the dispensers interviewed did not have any formal trainingnot have any formal training

• Many of the dispensaries visited lacked Many of the dispensaries visited lacked the necessary dispensing tools the necessary dispensing tools


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RecommendationsRecommendations

Interventions toInterventions to improve drug use can reduce improve drug use can reduce unnecessary drug expenditure and lead to unnecessary drug expenditure and lead to improvement in the quality of health and improvement in the quality of health and medical care.medical care.

33 major approaches are----major approaches are----

Educational : Educational : Seek to inform or persuade Seek to inform or persuade prescriber, dispenser and patients to use drug in prescriber, dispenser and patients to use drug in rational wayrational way



Managerial : Managerial : Guide decision through the Guide decision through the use of specific process, packages or use of specific process, packages or monetary incentivesmonetary incentives

Regulatory : Regulatory : Seek to restrict decisionSeek to restrict decision



For policy implications, findings suggest For policy implications, findings suggest the below courses of actions:the below courses of actions:

Continuous monitoring and supervision of Continuous monitoring and supervision of the drugs management system the drugs management system

Continuous development for health Continuous development for health providers to reduce indiscriminate providers to reduce indiscriminate prescribing and dispensing prescribing and dispensing



Availability of the STGs, EDL and Availability of the STGs, EDL and appropriate dispensing tools in all health appropriate dispensing tools in all health facilities and prescribers be mandated to facilities and prescribers be mandated to adhere to the use of these documents in adhere to the use of these documents in prescribing drugsprescribing drugs


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