Drug and Therapeutics Committee

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Drug and Therapeutics Committee

• Session 7A. Identifying Problems with
• Medicine Use Indicator Studies

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Objectives

• Describe how indicators can be used to identify
  medicine use problems
• Perform a prescribing indicator study on a sample
  of prescriptions and explain how it can be used
  to identify medicine use problems

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OutlinePart A

• Introduction
• WHO/INRUD indicators in primary health care
• Prescribing indicators
• Patient care indicators
• Facility indicators
• Hospital indicators
• Activities
• Summary

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Introduction

• Irrational medicine use is widespread and results
  in
• Poor patient outcome
• High cost of inappropriate medicine use
• Increased risk of ADRs
• Emergence of antimicrobial resistance
• Measuring medicine use problems is the first step
  to improving use

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Methods to Investigate Medicine Use

• Indicator study methods
• Use data collected at the individual
  levelpatient, health facility
• Data insufficient to judge appropriateness of a
  medicine for a specific diagnosis
• Aggregate data methods
• Use routine data (e.g., stock records) not
  collected at the individual patient level
• Give an overview of medicine use and can
  highlight problem areas
• In-depth investigation of medicine use
• Prescription audit, patient record review
• Drug use evaluation (DUE)
• Qualitative methods to understand causes of a
  medicine use problem

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Indicators for Health Care Facilities (1)

• Measure specific aspects of medicine use and
  health provider activities in a hospital or
  health center
• Provide information to health care managers
  concerning medicine use, prescribing habits, and
  important aspects of patient care to compare or
  monitor facilities over time

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Indicators for Health Care Facilities (2)

• Characteristics of sound indicators
• Relevant
• Easily generated and measured
• Reliable
• Valid
• Action-oriented

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Indicators for Health Care Facilities (3)

• Use of indicators
• Determine where medicine use problems may
  existwhen an indicator study shows an extreme
  result, the DTC can investigate and, as
  necessary, take action to improve the situation.
• Provide a monitoring mechanism
• Motivate health care providers to improve and
  follow established standards

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WHO Indicators for PHC

• Developed by INRUD and WHO
• Used for assessing health care and medicine use
  for primary health care (PHC) in dispensaries,
  clinics or hospitals
• Prescribing indicators
• Patient care Indicators
• Facility indicators
• Complementary medicine use indicators

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Prescribing IndicatorsPHC

• WHO/INRUD health facility prescribing indicators
• Average number of medicines per encounter
• of medicines prescribed by generic name
• of encounters with an antibiotic prescribed
• of encounters with an injection prescribed
• of medicines prescribed which are from the
  essential medicines list or formulary list

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Prescription 1
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Prescription 2
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Prescription 3
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Prescription 4
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Prescription 5
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Prescription 6
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Patient Care IndicatorsPHC

• WHO/INRUD health facility patient care indicators
• Average consultation time
• Average dispensing times
• of medicines actually dispensed
• of medicines that are adequately labeled
• of patients who know how to take their
  medicines

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Health Facility IndicatorsPHC

• WHO/INRUD health facility indicators
• Availability of essential medicine list or
  formulary
• Availability of key set of indicator medicines
• Availability of standard treatment guideline
  (STG)

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Complementary IndicatorsPHC

• WHO/INRUD medicine use indicators with less
  standardization and less experience in actual use
• of patients treated without medicines
• Average medicine costs per encounter
• of medicine cost spent on antibiotics
• of medicine cost spent on injections
• of prescriptions in accordance with STG
• of patients satisfied with care provided
• of facilities with access to impartial
  information

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Performing an Indicator Study (1)

• Determine objectives, priorities, and indicators
• Determine study design according to objectives
• Monitoring over time, comparing facilities
• Cross-sectional survey, time series
• Evaluating interventions
• Randomized controlled trial, pre/post with
  control, time series
• Define indicators and data collection procedures
• Pilot-test procedures

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Performing an Indicator Study (2)

• Train data collectors
• Randomly select facilities (at least 20 if
  possible) in the region from which to collect
  data
• Obtain approximately 30 medicine use encounters
  for each facility (100 if only one facility is
  chosen)
• Analyze data
• Provide results to DTC for evaluation and
  follow-up

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Results of Indicator Studies

• Results can be used as follows
• Describing current treatment practices
• Comparing the performance of individual
  facilities or practitioners
• Periodic monitoring and supervision of specific
  medicine use behaviors
• Identifying potential medicine problems that
  affect patient care
• Assessing the impact of an intervention

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Graphs of Indicator Data (1)Facility-Specific
Antibiotic Use
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Graphs of Indicator Data (2)Facility-Specific
Consultation Times
Average Time (minutes)
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Hospital Antimicrobial Indicators (1)(Developed
and being field-tested by MSH)

• Designed to evaluate and improve
• antimicrobial use
• Facility indicators (four indicators)
• Existence of STG and a formulary with approved
  antimicrobials
• Availability of a key set of antimicrobials
• Average number of days that this key set of
  antimicrobials are out of stock over 12 months
• Expenditure on antimicrobial medicines as a
  percentage of total hospital medicine costs

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Hospital Antimicrobial Indicators (2)

• Prescribing indicators (eight indicators)
• of hospitalizations with one or more
  antimicrobials prescribed
• Average number of antimicrobial medicines
  prescribed per hospitalization with
  antimicrobials prescribed
• of antimicrobials prescribed consistent with
  formulary
• Average cost of antimicrobials prescribed from
  hospitalizations with one or more antimicrobial
  prescribed

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Hospital Antimicrobial Indicators (3)

• Prescribing indicators (continued)
• Average duration of prescribed antimicrobial
  treatment
• of surgical patients who receive antimicrobial
  prophylaxis
• of pneumonia patients who are prescribed
  antimicrobials in accordance with STG
• of antimicrobials prescribed by generic name

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Hospital Antimicrobial Indicators (4)

• Patient care indicators
• of doses of prescribed antimicrobial medicines
  actually administered
• Average duration of stay of patients who receive
  antimicrobials
• Supplemental indicator
• Number of antimicrobial medicine sensitivity
  tests reported

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Hospital Indicators Developed and Used in
Australia and Zimbabwe

• Designed to evaluate and improve medicine use and
  health
• care
• Average number of days per hospital admission
• Average number of medicines prescribed per
  hospital admission
• prescribed medicines consistent with hospital
  formulary list
• Average medicine cost per inpatient day
• patients with morbidity due to a preventable
  ADR
• inpatient deaths due to a preventable ADR
• patients reporting adequate post-operative pain
  control
• surgical patients receiving appropriate
  antimicrobial prophylaxis
• Average number of antimicrobial sensitivity tests
  per hospital admission

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Activities 1 and 2

• Activity 1
• Calculating prescribing indicators from
  prescription records
• Activity 2
• Calculating patient care indicators from
  observing role-play consultations

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Summary

• A major function of a DTC is to identify medicine
  use problems and to implement corrective measures
• Performing an indicator study is useful method
  to
• Identify medicine use problems at the individual
  patient level
• Monitor medicine use by prescribers
• Evaluate the impact of interventions