Title: Drug and Therapeutics Committee
1Drug and Therapeutics Committee
- Session 9. Strategies to Improve Medicine
UseOverview
2Objectives
- 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
3Outline
- Key definitions
- Introduction
- Methods to improve medicine use
- Educational
- Managerial
- Regulatory
- Activity 1
- Summary
4Key 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 manualDocument 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
5Introduction
- Drug and Therapeutic Committee (DTC)
responsibilities - Selecting medicines for the formulary
- Identifying medicine use problems
- Developing and implementing strategies to improve
medicine use
6Consequences 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 30130 billion
U.S. dollars per year and causes significant
morbidity and mortality
7Consequences of Irrational Use of Medicines (2)
- Antimicrobial resistance through misuse and
overuse - 24 multidrug resistance in TB, 1255
resistance to penicillin in N. Gonorrhoea and S.
Pneumonia, 1090 resistance to ampicillin or
co-trimoxazole in Shigella - Increased disease due to dirty or unnecessary
injections - 2.34.7 million hepatitis B and C infections and
up to 160,000 HIV infections per year
8Changing a Medicine Use ProblemAn Overview of
the Process
9Strategies to Improve Medicine Use
Educational to inform or persuade
Regulatory to restrict or limit decisions
Managerial to structure or guide decisions
10Educational 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)
11Printed 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
12Printed 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
13Printed 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
14Face-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
15Face-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
16Face-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
17Face-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
18Effects of an Opinion Leader on Choice Opinion
Antibiotic for Prophylaxis in a U.S. Teaching
Hospital
19Face-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
20Impact of Patient-Provider Discussion Groups on
Injection Use in Indonesian PHC Facilities
Prescribing Injections
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
42117783.
21Sites for Face-to-Face Education
- Health centers
- Hospitals
- Pharmacies
- Universities
- District-level education
22Strategies to Improve Medicine Use
Educational to inform or persuade
Regulatory to restrict or limit decisions
Managerial to structure or guide decisions
23Managerial Methods To Structure and Guide
Decisions
- STGs
- DUEs
- Clinical pharmacy programs
- Medicine restrictions and control
24Standard 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
25Randomized Controlled Trial In UgandaEffects of
Treatment Guidelines, Training, and Supervision
on the Percentage of Prescriptions Conforming to
STGs
26Audit and Feedback
- DUE
- Program of ongoing, systematic, criteria-based
evaluations of pharmaceutical therapy
27Clinical Pharmacy Programs
- Last check on correct use, doses, side effects
- Medicine information and patient education
- Correct labeling and course of treatment
packaging - Generic substitution programsbioequivalence
issues - Therapeutic substitution (interchange)substitutio
n of medicines that differ in active ingredients
but have similar therapeutic activities in terms
of efficacy and safety (e.g., lisinopril for
enalapril)
28Pharmaceutical Restrictions and Control
- Formulary list (essential medicine list)
- Structured order forms
- Automatic stop orders
29Controlling 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
30Avoiding 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)
31Improving 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) - 199394 Two areas changed to a fee per
pharmaceutical item (positive incentive) - 199295 One area continued with the flat fee
covering all medicines (control) - Prescription (Px) surveys done in
pre-intervention (1992) and post-intervention
(1995) - 1012 health facilities per area, gt 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)106571.
32Polypharmacy and Antibiotic Use On changing from
a flat medicine fee to a fee per medicine item
patients treated with antibiotics
Average number of medicines per patient
Holloway et al. (2001).
33Injection and Vitamin or Tonic UseOn changing
from a flat medicine fee to a fee per medicine
item
patients treated with vitamins/tonics
30
25
20
15
10
5
0
1-band item fee
2-band item fee
Px fee
1992
1995
1992
1995
Holloway et al. (2001).
34Treatment Cost and Compliance with STGs On
changing from flat medicine fee to fee per
medicine item
Average medicine cost per patient (NRs)
patients treated according to STGs
40
60
50
30
40
20
30
20
10
10
0
0
1-band item fee
Px fee
1-band item fee
2-band item fee
Px fee
2-band item fee
1992
1995
1992
1995
NR Nepalese rupees
Holloway et al. (2001).
35Strategies to Improve Medicine Use
Educational to inform or persuade
Regulatory to restrict or limit decisions
Managerial to structure or guide decisions
36Regulatory Methods To Restrict or Limit
Decisions
- Country pharmaceutical registrationensure only
registered medicines are used - Professional licensingemploy only licensed staff
for the level of prescribing required - Licensing of pharmaceutical outletsbuy medicines
only from licensed outlets - Regulation pharmaceutical promotion activities
37Choosing 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.
38Choosing 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.
39Combined Intervention StrategyPrescribing for
Acute Diarrhea in Mexico City
40Impact of Training on Using Diarrhea Treatment
Algorithm in Three Mexican Settings
Intervention
given by
Experts in 2 clinics
(San Jeronimo)
Leaders in 18 clinics
(Coyoacan)
Coordinators in 124
clinics (Tlaxcala)
Source Munoz, et al., unpublished (1993)
41Review of 30 Studies in Developing Countries
Medicine Use Improvements with Different
Interventions
None, minor
Large
Moderate
50
0
10
20
30
40
60
Improvement in outcome measure ()
Source Ross-Degnan et al. 1997. Plenary
Presentation, Conference on Improving the Use of
Medicines. Chiang Mai, Thailand.
42Activity 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?
43Summary (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
44Summary (2)
- Interventions (continued)
- Managerial programs
- DUE
- STG
- Clinical pharmacy programs
- Medicine restrictions and control
- Regulatory programsregistration of medicines,
professionals, facilities