Challenges of rational drug use

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Challenges of rational drug use

• The need for innovative strategies

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Problems of irrational drug use
Serious public health problems quality
access of health services
Adverse impacts - Quality - Cost - Adverse
reaction - psycho-social
Intervention is possible it should be an
integral part of the healthcare system

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What is Rational Use of Drugs?

• The rational use of drugs requires that patients
  receive medicines 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 the community.
  
• (WHO 1988)

Appropriate indication, drug, dosage
administration, patient and information
The risks (adverse reaction cost ) do not
outweigh the possible benefits
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Common examples characteristics

• - The use of drugs when no drug therapy is needed
• - The use of wrong drugs for a specific condition
• - The use of drugs with doubtful efficacy
• - The use of drugs of uncertain safety status
• - Failure to prescribe safe, effective drugs
• - Incorrect administration, dosages, or duration
• The overuse of antibiotics
• Indiscriminate use of injections IV fluids
• Multiple or over-prescription
• Antibiotics for mild, non-bacterial infections
• ARI, acute diarrhea etc

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Common examples

• Mongolia ? in average 13 injections are given
  per year
• per person.
• Cambodia ? almost 100 in patients receive
  infusions
• antibiotics.
• Infusions are used to prolong/
  retain patient
• hospital stay or to increase
  charge in private
• practices.
• Laos ? 73 of hospital patients receiving
  antibiotics
• 60 - 80 patients receiving
  injection

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Examples from Cambodia
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Factors underlying irrational drug use practices
?
Factors deriving from providers
Factors deriving from patients communities
Multiple factors
Information pharmaceutical promotion
Factors deriving from health care system
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Strategies to improve drug use

• Educational strategy ? persuasion
• - training, seminar, information,
• media campaign, etc.
• Managerial strategy ? guidance
• EDL, STG, monitoring supervision
• Regulatory strategy ? enforcement
• - regulation, sanction, drug withdrawal
• restriction of prescription etc.
• Financing strategy ? (dis-) incentives
• - re-imbursement payment system

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Levels of changes from any drug use interventions

• Intellectual component
• Improved awareness knowledge
• Psycho-motor component ? Improved skills
• Clinical skills, problem-solving,
• 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

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Framework of changing drug use practices
Examination drug use survey (indicator)
Diagnosis (underlying reasons)
Evaluation Any changes ?
Treatment Select/implement intervention
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Principles of effective interventions

• Evidences for effective interventions ?
• Focused on specific problem,
• Addressing the underlying problems
• Problem-solving approach
• Repeated interventions
• Interactive interventions
• Feedback of performance to providers
• Monitoring and supervision
• Peer group guidelines development

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Common pitfalls practices in drug use
intervention

• Unfocused --gt intervention too general
• Training only intervention
• Drug information printed material only
• Treatment Guidelines only
• Single episode, no reinforcement of messages
• No field-testing of intervention materials
• No evaluation of the impacts
• Interventions activities are not integrated as
  part of
• the day to day healthcare management
• Interventions activities are not well-designed
  to
• address specific drug use behavior
• Etc

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Factors influencing success in changing
prescribing behavior

• Individual factors of providers
• Intellectual component improved knowledge
• Psychomotor component improved skills
• Behavioral component improved motivation
• System component
• Feedback on performance
• Incentives and disincentives, etc.
• Socio-cultural environment
• Public awareness consumer empowerment
• Control of unethical promotion,etc.

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Conventional strategies

• Conventional training only intervention
• Development of drug list only
• Development of Treatment Guidelines only
• Distribution of unfocused printed materials
• newsletter
• Drug information services
• Seminar, continuing education, workshop

Do these interventions improve prescribing drug
use ?
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Innovative strategies

• Small group interactive learning
• Problem solving and problem-oriented
• Monitoring and feedback of practices
• On site supervision
• Combined and multiple interventions
• Consumer empowerment

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The impact of an interactive discussion followed
by self monitoring on the use of injection
(Gunung Kidul, Indonesia)
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The impact of interactive discussion and self
monitoring on the use on antibiotic injection
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Integrated monitoring and supervision of drug
management use Cambodia (1)

• 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

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Integrated monitoring and supervision of drug
management use Cambodia (1)

• 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
• Copies of standard treatments for CDD, ARI and
  malaria available
• of drugs dispensed with correct labels
• of patients able to report correct dosages
• Average consultation time
• Average dispensing time

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Monitoring training and planning (MTP) approach
for RDU

• 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

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Innovative strategy Monitoring training and
planning

y I
Sleman District (4 HCs)
Yogya District (6 HCs)
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Challenging areas

• Private practice
• Hospital setting
• Communities
• Antibiotics

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Drug use in hospital ?

• Drug use in hospitals contribute significantly
• to the overall pharmaceutical consumption.
• Medically ineffective, un-safe and costly
• prescribing practices are also common in
• hospitals.
• Irrational prescribing behaviour usually easily
  
• spread to the surrounding communities.
• Experiences for RDU interventions in hospital
• settings are very limited ? the need of RDU
• 
  intervention !

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Conventional RDU interventions in hospitals

• Drug information services
• Standard Treatment Guidelines
• Hospital Formulary
• Seminar, training, continuing education on RDU
• Continuing education on specific clinical
  subjects, etc

Do these interventions change prescribing
practices ?
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Functions of Drugs Therapeutics Committee ?

• Advice to medical staff, management
• pharmacy
• Develop (hospital) drug policies
• Evaluate select drugs and formulary list
• Develop standard treatment guidelines (STGs)
• Assess drug use and to identify problems
• Conduct effective RDU intervention
• Manage adverse drug reaction
• Manage medication errors
• Information dissemination

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Recommendations from ICIUM (International
Conference on Improving Use of Medicines, Chiang
Mai, 1997) (1)

• Develop and use of national (hospital)
• Standard Treatment Guidelines (STG).
• Develop, revise and implement EDL
• (or hospital formulary).
• Establish Pharmacy Therapeutics Committee
• with defined responsibilities for
  monitoring
• and promoting quality use of medicines.
• Implement problem based training in
  pharmacotherapy
• in medical and paramedical education
  based on STGs .
• Encourage targeted problem based in service
  educational
• programme by professional societies,
  universities and
• the MOH.

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Recommendations from ICIUM (International
Conference on Improving Use of Medicines, Chiang
Mai, 1997) (2)

• Stimulate an interactive group process among
  health
• providers and consumers .
• Train pharmacists (and drug sellers) to be
  active
• members of the healthcare team and to offer
  useful
• advice to consumers about health and drugs.
• Encourage active involvement of consumers in
• public education about drugs.
• Develop strategic approach to improve
  prescribing in
• the private sector through appropriate
  regulation and
• long term collaborations with professional
  societies.
• Establish system to monitor key pharmaceutical
• indicators routinely in order to track the
  impact of
• health sector reform and regulatory changes.
• to review and apply information about

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Successful implementation of effective
interventions and sustaining their impacts

• Leadership commitment
• Solid team
• Local support resources
• Technical cultural feasibility
• Pilot testing prior to wide implementation
• Monitoring of implementation
• Evaluating impact
• Incentives - disincentives for providers
• Integrated into the existing management

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Conclusions

• Irrational drug use practices will remain
• big challenge for many healthcare system
• Effective innovative strategies need to be
  developed
• and implemented depending on the existing
• healthcare situation
• Indicator-based monitoring is an effective
  strategy,
• its continuous implementation and
  strengthening
• is important