DPI Course

1
Improving prescribing practicesEfficacy,
feasibility and sustainability

• Problems of irrational use of drugs
• How to identify to measure ?
• How to explore underlying causes ?
• How to improve prescribing practices ?
• How to implement effective intervention ?
• How to sustain the impact ?
• Common practices in improving drug use
• The need for more innovative strategy

2
Problems of irrational prescribing

• Significant problems in all healthcare settings
• Unless measurement of prescribing practices
• are properly undertaken nobody can be sure
• that there is no prescribing problem in any
• healthcare setting
• Adverse impacts
• Health medical impacts
• Economic impacts
• Escalating cost of treatment
• Waste of resources
• Social impacts

3
Framework to improve prescribing practices ?

• Measuring drug use practices
• - Quantitative drug use indicators
• - Drug consumption analysis
• Identifying underlying possible causes
• - Qualitative methodology
• Selection and field-testing of intervention
• - Control study
• Implementation of intervention
• Evaluation of impact of intervention

4
Method to improve prescribing practices

• Educational informational intervention
• Persuasive targeted to individuals
• Training, workshop, seminar, dissemination
• of information materials
• Managerial intervention
• Improving management support system
• Selection of drugs formulary
• Development and implementation of Practices
• Guidelines
• Drug utilization review and feedback
• Regular monitoring and supervision of
  prescribing practices
• Regulatory intervention
• Enforcement of regulation
• Drug withdrawal, penalty, prescribing
  restriction etc

5
Levels of changes from any intervention

• Intellectual component
• Improved awareness
• Increased knowledge
• Psycho-motor component --- Improved skills
• Clinical skills
• Problem-solving skills
• Communication skills
• Prescribing skills
• Behavioral component
• Feedback, reflection of experiences and values
  
• Motivation, attitude changed practices
• System healthcare environment ---
  support system
• 
  incentives disincentives
• Sustaining the desired changes

6
Characteristics of effective intervention

• Focused intervention
• Repetition and enforcement of messages
• Small-group face to face
• Interactive process
• Feedback of performance
• Combined intervention

• Examples of existing intervention policy
  tools
• Formulary list
• Treatment Guidelines
• Conventional vs small group training
• Regular monitoring and supervision
• Drug utilization review plus feedback
• Interactive discussion between consumers and
  providers

7
Implementing effective intervention and
sustaining impacts

• Leadership commitment
• Team building
• Mobilizing support
• Technical feasibility
• Mobilizing local resources
• Pilot testing
• Monitoring of implementation
• Evaluating impact
• Incentives - disincentives

8
Common practices in improving prescribing

• Conventional training only intervention
• No reinforcement
• No evaluation of impact
• External activities and not part of the
  existing healthcare management
• No pilot testing prior to implementation
• Treatment guidelines and formulary list are
  developed their use are
• not enforced nor monitored

9
The need for innovative approach

• Combined intervention
• Development of Treatment Guidelines Formulary
  List
• RDU training and the use of STG and Formulary
• Implementation of supervision, monitoring and
  feedback
• Innovative strategy
• Involvement of consumers patients

10
Challenging areas

• Private practice
• Hospital setting through Pharmacy Therapeutic
  Committee
• Chronic diseases
• Antibiotic use

11
Integrated monitoring and supervision of drug
management use - Cambodia

• Drug management
• of expired drugs in stock
• of drugs overstock
• of drugs stock out
• of drugs not on NEDL
• of overstock medical consumables
• of correct inventory
• Reports sent to operational district
• Monthly drug consumption reports correctly
  completed
• Drug use
• Average number of drugs/case
• of patients prescribed with antibiotics
• of patients given injection
• of drugs prescribed by generics
• of drugs prescribed on NEDL
• correct treatment for malaria
• under-fives with acute diarrhea receiving ORS
• under-fives with acute diarrhea receiving
  antibiotics
• under-fives with ARI receiving antibiotics

12
Monitoring training and planning (MTP) approach
for hospital PTC

• A indicator based monitoring and problem solving
  approach
• in a small group on a periodic cycle. A
  specific problem will be dealt
• at one time requiring 3 sequential monthly
  meetings
• A regular monthly meeting involving will focus
• Monitoring - what is the extent of problem ?
• Training - why it happen and how to improve
  it. Problem solving
• with support from
  collected data and information.
• Planning - what level of improvement is
  targeted for the coming
• month