Rational Use of Drugs in the Public and Private Sectors

Document Sample
Rational Use of Drugs in the Public and Private Sectors Powered By Docstoc
					           Rational use of drugs:
                an overview



                             Kathleen Holloway
                          Technical Briefing Seminar
                                      November 2008


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Objectives

     • Define rational use of medicines and identify the
       magnitude of the problem

     • Understand the reasons underlying irrational use

     • Discuss strategies and interventions to promote
       rational use of medicines

     • Discuss the role of government, NGOs, donors and
       WHO in solving drug use problems


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
   The rational use of drugs requires that patients receive
   medications 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
   them and their community.
                                              WHO conference of experts Nairobi 1985
  • correct drug
  • appropriate indication
  • appropriate drug considering efficacy, safety, suitability for the
    patient, and cost
  • appropriate dosage, administration, duration
  • no contraindications
  • correct dispensing, including appropriate information for patients
  • patient adherence to treatment

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
     Adequacy of diagnostic process
     Source: Thaver et al SSM 1998, Guyon et al WHO Bull 1994, Krause et al TMIH
     1998, Bitran HPP 1995, Bjork et al HPP 1992, Kanji et al HPP 1995.



           Pakistan

        Bangladesh

      Burkino Faso

            Senegal

             Angola

           Tanzania

                      0        10         20        30        40      50           60
           % observed consultations where the diagnostic process was adequate

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
          5-55% of PHC patients receive injections -
          90% may be medically unnecessary
                                                   Source: Quick et al, 1997, Managing Drug Supply
                A F R IC A

                  G ha na

            C a m e ro o n

                 N ige ria

                   S uda n

               T a nza nia

             Z im ba bwe

                    A S IA

                  Yemen

              Indo ne s ia

                   N e pa l
                                           15 billion injections per year globally
   L.A M E R . & C A R .

                E c ua do r                half are with unsterilized needle/syringe
            G ua t e m a la

           E l S a lv a do r
                                           2.3-4.7 million infections of hepatitis B/C
                J a m a ic a                and up to 160,000 infections of HIV per
   E a s t e rn C a ribe a n
                                            year associated with injections

                          0%   10%       20%         30%         40%         50%        60%
                               % of primary care patients receiving injections

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
                                  Variation in outpatient antibiotic use
                                  in 26 European countries in 2002
                            35


                            30
DDD per 1000 inh. per day




                            25


                            20


                            15


                            10


                            5


                            0
                                 FR GR LU PT IT   BE SK HR PL IS   IE ES FI BG CZ SI SE HU NO UK DK DE LV AT EE NL



                                       Source: Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
            % compliance with clinical guidelines over
                         time by region
    70
    60
    50
    40
    30
    20
    10
     0
             <1992           1992-5          1996-9           2000-3         2004-7

           Africa (n=125)                             Asia/Pacific (n=61)
           Central Asia/Mediterranean (n=22)          Latin America (n=31)



Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
                                      Treatment of diarrhoea in private and public
                                                        sectors

                                 70
     % diarrhoea cases treated




                                 60
                                 50
                                 40
                                 30
                                 20
                                 10
                                 0
                                      ORS use         Antibiotic use         Antidiarrhoeal   STG compliance
                                                                                  use

                                         Private-for-profit (n=43,33,35,4)     Public (n=119, 100, 67, 80)



Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
                                        Treatment of ARI by prescriber type

                            80
                            70
      % ARI cases treated




                            60
                            50
                            40
                            30
                            20
                            10
                            0
                                 Cough syrup use   Approp.ABs in   Inapprop.ABs in   STG compliance
                                                    pneumonia         viral URTI

                                      Doctor (n=20,18,40,12)   Paramedic/nurse (n=13,94,69,61)



Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Overuse and misuse of antimicrobials
      contributes to antimicrobial resistance
                                                Source: WHO country data 2000-3
     • Malaria
        – choroquine resistance in 81/92 countries
     • Tuberculosis
        – 0-17 % primary multi-drug resistance
     • HIV/AIDS
        – 0-25 % primary resistance to at least one anti-retroviral
     • Gonorrhoea
        – 5-98 % penicillin resistance in N. gonorrhoeae
     • Pneumonia and bacterial meningitis
        – 0-70 % penicillin resistance in S. pneumoniae
     • Diarrhoea: shigellosis
        – 10-90% ampicillin resistance, 5-95% cotrimoxazole resistance
     • Hospital infections
        – 0-70% S. Aureus resistance to all penicillins & cephalosporins

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Adverse drug events
                                                Source: Review by White et al,
                                                Pharmacoeconomics, 1999, 15(5):445-458


     • 4-6th leading cause of death in the USA
     • estimated costs from drug-related morbidity &
       mortality 30 million-130 billion US$ in the USA
     • 4-6% of hospitalisations in the USA & Australia
     • commonest, costliest events include bleeding,
       cardiac arrhythmia, confusion, diarrhoea, fever,
       hypotension, itching, vomiting, rash, renal failure



Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Changing a Drug Use Problem:
      An Overview of the Process

                                        1. EXAMINE
                                      Measure Existing
                                         Practices
                                        (Descriptive
                                     Quantitative Studies)
                                           improve
         4. FOLLOW UP                                              2. DIAGNOSE
        Measure Changes                   diagnosis              Identify Specific
          in Outcomes                                           Problems and Causes
     (Quantitative and Qualitative                            (In-depth Quantitative
           Evaluation)                                        and Qualitative Studies)
                                            improve
                                         intervention

                                          3. TREAT
                                     Design and Implement
                                        Interventions
                                       (Collect Data to
                                     Measure Outcomes)


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
     Many Factors Influence Use of Medicines
                                                         Intrinsic
                                            Prior
                                          Knowledge
                       Scientific
                                                                 Habits
   Information        Information

          Influence                                                         Social &
            of Drug                                                         Cultural
           Industry                                                         Factors
                                      Treatment                                  Societal
          Workload &
                                       Choices                         Economic &
           Staffing                                                   Legal Factors

   Workplace             Infra-                               Authority &
                       structure         Relationships        Supervision
                                          With Peers
                                                         Workgroup

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Strategies to Improve Use of Drugs

               Educational:                                Managerial:
      Inform or persuade                        Guide clinical practice
       – Health providers                         – Information systems/STGs
       – Consumers                                – Drug supply / lab capacity


                                      Use of
                                     Medicines

                Economic:                                  Regulatory:
     Offer incentives                           Restrict choices
      – Institutions                              – Market or practice controls
      – Providers and patients                    – Enforcement


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
     Educational Strategies
     Goal: to inform or persuade
   • Training for Providers
        –   Undergraduate education
        –   Continuing in-service medical education (seminars, workshops)
        –   Face-to-face persuasive outreach e.g. academic detailing
        –   Clinical supervision or consultation
   • Printed Materials
        – Clinical literature and newsletters
        – Formularies or therapeutics manuals
        – Persuasive print materials
   • Media-Based Approaches
        – Posters
        – Audio tapes, plays
        – Radio, television

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Impact of Patient-Provider Discussion Groups
      on Injection Use in Indonesian PHC Facilities
                                              Source: Hadiyono et al, SSM, 1996, 42:1185

                  % Prescribing Injections

          80



          60

                                                                                 Pre
          40                                                                     Post



          20



           0
                        Intervention                    Control

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
     Training for prescribers
     The Guide to Good Prescribing



    • WHO has produced a Guide for Good
      Prescribing - a problem-based method
    • Developed by Groningen University in
      collaboration with 15 WHO offices and
      professionals from 30 countries
    • Field tested in 7 sites
    • Suitable for medical students, post grads,
      and nurses
    • widely translated and available on the WHO
      medicines website


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
     Managerial strategies
     Goal: to structure or guide decisions

   • Changes in selection, procurement, distribution to
     ensure availability of essential drugs
        – Essential Drug Lists, morbidity-based quantification, kit systems

   • Strategies aimed at prescribers
        – targeted face-to-face supervision with audit, peer group
          monitoring, structured order forms, evidence-based standard
          treatment guidelines

   • Dispensing strategies
        – course of treatment packaging, labelling, generic substitution


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
    RCT in Uganda of the effects of STGs, training and
    supervision on % of Px conforming to guidelines
                                              Source: Kafuko et al, UNICEF, 1996.

    Randomised              No. health      Pre-         Post-               Change
    group                    facilities intervention intervention

    Control group                42           24.8%           29.9%           +5.1%


    Dissemination of             42           24.8%           32.3%           +7.5%
    guidelines

    Guidelines + on-             29           24.0%           52.0%           +28.0%
    site training

    Guidelines + on-
    site training + 4            14           21.4%           55.2%           +33.8%
    supervisory visits

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Economic strategies:
      Goal: to offer incentives to providers an consumers


     • Avoid perverse financial incentives
          – prescribers’ salaries from drug sales
          – insurance policies that reimburse non-essential
            drugs or incorrect doses
          – flat prescription fees that encourage polypharmacy
            by charging the same amount irrespective of
            number of drug items or quantity of each item




Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
     Pre-post with control study of an economic
     intervention (user fees) on prescribing quality in Nepal
                                              Source: Holloway, Gautam & Reeves, HPP, 2001


     Fees (complete        control fee / Px 1-band item fee 2-band item fee
     drug courses)              n=12             n=10            n=11

     Av. no. items              2.9 2.9               2.9 2.0               2.8 2.2
     per prescription            (+/- 0)                (-0.9)               (-0.6)

     % prescriptions          23.5 26.3             31.5 45.0             31.2 47.7
     conforming to             (+2.7%)               (+13.5%)             (+16.5%)
     STGs

     Av.cost (NRs)            24.3 33.0             27.7 28.0             25.6 24.0
     per prescription           (+8.7)                (+0.3)                (-1.6)


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      PHC prescribing with and without Bamako
      initiative in Nigeria
                                                   Source: Scuzochukwu et al, HPP, 2002


     no.EDL drugs avail                    15.3
                                                         35.4
       % pres EDL drugs                      21
                                                                                     93
   % Px with antibiotics                          25.6
                                                                      64.7
    % Px with injections                                  38
                                                                          72.8
        no.drug items/Px           2.1
                                     5.3

                               0           20            40      60          80       100

                     21 Bamako PHCs               12 non-Bamako PHCs

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
     Regulatory strategies
     Goal: to restrict or limit decisions

    • Drug registration
    • Banning unsafe drugs - but beware unexpected results
        – substitution of a second inappropriate drug after banning a first
          inappropriate or unsafe drug
    • Regulating the use of different drugs to different
      levels of the health sector e.g.
        – licensing prescribers and drug outlets
        – scheduling drugs into prescription-only & over-the-counter
    • Regulating pharmaceutical promotional activities

          Only work if the regulations are enforced

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Impact of multiple interventions on injection
      use in Indonesia

                            100%                   Interactive group discussion (IGC group only)
     Proportion of visits




                                                                Seminar (both groups)
        with injection




                            80%
                                                                           District-wide monitoring
                            60%                                            (both groups)

                            40%

                            20%

                             0%
                                   1   3   5   7      9   11    13 15   17 19   21 23    25
                                                               Months
                                   Comparison group       Interactive group discussion

         Source: Long-term impact of small group interventions, Santoso et al., 1996

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Varying intervention impact in developing countries
      Source: WHO database 2007


  Intervention type               No.studies     Median impact   Range
  Printed materials               5              6%              +1% to +8%
  Community education             3              13%             0% to +26%
  Provider education              24             10%             -2% to +31%
  Provider+Comm.educ              14             11%             -4% to +32%
  Provider supervision            23             14%             +1% to +39%
  Community case mgt              6              19%             +3% to +29%
  Provider group process          9              20%             +4% to +41%
  Essential drug program          2              21%             +16% to +25%
  Provider & Community            7              21%             +11% to +49%
  education + supervision


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
  What are countries doing to promote the rational
  use of medicines? national policies
                                                    Source: EMP pharmaceutical policy database

        Drug use audit in last 2 years (n=87)

   National strategy to contain AMR (n=102)

       Antibiotic OTC non-availability (n=60)

   Public education on antibiotic use (n=107)

       DTCs in most referral hospitals (n=92)

    Drug Info Centre for prescribers (n=118)

     EML in insurance reimbursement (n=90)

        STGs updated in last 2 years (n=42)

         EML updated in last 2 years (n=78)

                                                0        20      40      60       80        100
                                                       % countries implementing policies


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Basic training and obligatory continuing medical
      education (CME) available for health professionals
                                               Source: EMP pharmaceutical policy database

         Obligatory CME
           (n=99-105)
      Pharmaco-therapy
         (n=60-73)
    Prescribing concepts
         (n=63-76)
      Clinical Guidelines
           (n=68-80)
     Essential Medicines
         (n=68-89)

                            0       20             40         60            80         100
                                     % countries with basic training available

                                         Doctors    Nurses and paramedics


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Why does irrational use continue?


         Very few countries regularly monitor drug
         use and implement effective nation-wide
         interventions - because…
     • they have insufficient funds or personnel?
     • they lack of awareness about the funds wasted
       through irrational use?
     • there is insufficient knowledge of concerning the cost-
       effectiveness of interventions?



Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
     What are we spending to promote rational
     use of medicines ?

  • Global sales of medicines 2002-3 (IMS):                   US$ 867 billion

  • Drug promotion costs in USA 2002-3:                       US$ >30 billion

  • Global WHO expenditure in 2002-3:                         US$ 2.3 billion
       – Essential Medicines expenditure                      2% (of 2.3 billion)
       – Essential Medicines expenditure on
         promoting rational use of medicines                  10% (of 2%)
       – WHO expenditure on promoting
         rational use of medicines                            0.2% (of 2.3 billion)



Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
     2nd International Conference for Improving
     Use of Medicines, Chiang Mai, Thailand, 2004
     472 participants from 70 countries


     http://www.icium.org


      Recommendations for countries to:
      • Implement national medicines programmes to
        improve medicines use
      • Scale up successful interventions
      • Implement interventions to address community
        medicines use



Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      WHO priorities

     • Resolution WHA60.16
          – Urges Member States " to consider establishing and/or
            strengthening…a full national programme and/or
            multidisciplinary national body, involving civil society and
            professional bodies, to monitor and promote the rational use
            of medicines "
          – WHO to support countries to implement resolution

     • Continue to give technical advice to countries
          –   Model EML and formulary
          –   Training on promoting RUM in community, PHC, hospitals
          –   Research to identify cost-effective interventions
          –   Advocacy
Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
               Health systems with no national programs:
               •No coordinated action
               •No monitoring of use of medicines

                                              Situational analysis



                                               WHO facilitating
                                               multi-stakeholder     Develop
                     Modifying
                                               action in countries   national plans
                     action plans
                                                                     of action


                                             Implement & evaluate
                                             national action plans

                 Health systems with national programs:
                 •Coordinated action
                 •Regular monitoring of use of medicine

Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
    WHO Goal: to support establishment of national programs coordinated
    by mandated, resourced, multi-disciplinary, national bodies


    Specific Objectives
    1.   Develop and pilot a standardised tool to undertake situational
         analysis and then undertake it in selected countries
    2.   Support establishment of national programs in selected
         countries using a multi-stakeholder approach, involving civil
         society & professional bodies and based on situational analysis
    3.   Establish global mechanism for sharing info & lessons learnt
       –    Global steering committee to guide global program
       –    Meetings for stakeholders from participating countries
    4.   External evaluation of strategy after 5 years to review progress
         with recommendations next 6 years


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Creating the WHO Essential Drugs Library
      to facilitate the work of national committees

       Evidence-                  Summary of clinical
     based clinical                  guideline
       guideline
                                                                         WHO Model
                                                                         Formulary
 Reasons for inclusion                      WHO
 Systematic reviews                       Model List
 Key references

           Cost:                                              Quality information:
           - per unit
           - per treatment                                    - Basic quality tests
           - per month                                        - Internat. Pharmacopoea
           - per case prevented                               - Reference standards


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      WHO-sponsored training programmes

   • INRUD/MSH/WHO: Promoting the rational use of drugs
   • MSH/WHO: Drug and therapeutic committees
   • Groningen University, The Netherlands / WHO:
     Problem-based pharmacotherapy
   • Amsterdam University, The Netherlands / WHO:
     Promoting rational use of drugs in the community
   • Newcastle, Australia / WHO: Pharmaco-economics
   • Boston University, USA / WHO: Drug Policy Issues


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Identifying effective strategies to promote
      more rational use of drugs

     • Joint research initiative between WHO/PSM, MSH,
       Harvard and Boston Universities, and ARCH
        – over 20 intervention research projects in
          developing countries

     • WHO/EMP databases on drug use and policy
       – quantitative data on drug use and interventions to
         improve drug use over the last decade
       – data from MOHs on pharmaceutical policies


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Conclusions

    • Irrational use of medicines is a very serious global
      public health problem.

    • Much is known about how to improve rational use of
      medicines but much more needs to be done
         – policy implementation at the national level
         – implementation and evaluation of more interventions,
           particularly managerial, economic and regulatory interventions

    • Rational use of medicines could be greatly improved if
      a fraction of the resources spent on medicines were
      spent on improving use.


Department of Essential Medicines and Pharmaceutical Policy
TBS 2008
      Activity
      Discuss in groups the following questions


    • What should be the roles of:
             • government,
             • NGOs and donors,
             • WHO,
        in promoting the rational use of medicines?




Department of Essential Medicines and Pharmaceutical Policy
TBS 2008

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:9
posted:10/4/2012
language:English
pages:38