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Rational use of drugs: an overview

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Title: Rational use of drugs: an overview


1
Rational use of drugsan overview
  • Kathleen Holloway
  • Technical Briefing Seminar 2003
  • Essential Drugs and Medicines Policy
  • WHO Geneva

2
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

3
PHC patients treated according to guidelines
Africa/Asia 1990/1 1992/3 1994/5 1996/7
1998/9 2000/1 no.countries 5/5 3/3 10/3
12/5 12/5 3/2 no.surveys 9/7 4/6
16/6 15/6 14/7 3/4
Source WHO database on drug use 2003
4
drugs that are prescribed unnecessarilyestimate
d by a comparison of expected versus actual
prescriptionChalker HPP 1996, Hogerzeil et al
Lancet 1989, Isah et al 2000
5
Adequacy of diagnostic process 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.
6
5-55 of PHC patients receive injections - 90
may be medically unnecessary
  • 15 billion injections per year globally
  • half are with unsterilized needle/syringe
  • 2.3-4.7 million infections of hepatitis B/C and
    up to 160,000 infections of HIV per year
    associated with injections

of primary care patients receiving injections
Source Quick et al, 1997, Managing Drug Supply
7
30 to 60 of PHC patients receive antibiotics -
perhaps twice what is clinically needed
of PHC patients receiving antibiotics
Source Quick et al, 1997, Managing Drug Supply
8
Overuse and misuse of antimicrobials contributes
to antimicrobial resistance
  • Malaria
  • choroquine resistance in 81/92 countries
  • Tuberculosis
  • 2 - 40 primary multi-drug resistance
  • Gonorrhoea
  • 5 - 98 penicillin resistance in N. gonorrhoeae
  • Pneumonia and bacterial meningitis
  • 12 - 55 penicillin resistance in S. pneumoniae
  • Diarrhoea shigellosis
  • 10-90 amp, 5-95 TMP/SMZ resistance

Source DAP, EMC, GTB, CHD (1997)
9
Adverse drug eventsReview 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

10
Drug Purchases through the Private Sector
  • 50-90 of all drug purchases are private
  • 25 to 75 illness episodes self-medicated
  • 1/2 consumers buy 1-day supply at a time
  • 50 of people worldwide fail to take drugs
    correctly
  • Results not always therapeutic
  • over-treatment of mild illness
  • inadequate treatment of serious illness
  • mis-use of anti-infective drugs
  • over-use of injections

11
Prescribing by dispensing and non-dispensing
doctors in Zimbabwe Trap et al 2000
12
Changing a Drug Use ProblemAn Overview of the
Process
13
Many Factors Influence Use of Medicines
14
Strategies to Improve Use of Drugs
  • Managerial
  • Guide clinical practice
  • Information systems/STGs
  • Drug supply / lab capacity
  • Educational
  • Inform or persuade
  • Health providers
  • Consumers
  • Economic
  • Offer incentives
  • Institutions
  • Providers and patients
  • Regulatory
  • Restrict choices
  • Market or practice controls
  • Enforcement

15
Educational StrategiesGoal to inform or persuade
  • Training for Providers
  • Undergraduate education
  • Continuing in-service medical education e.g.
    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

16
Training for prescribersThe 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

17
Impact of Patient-Provider Discussion Groups on
Injection Use in Indonesian PHC
FacilitiesHadiyono et al, SSM, 1996, 421185
Prescribing Injections
80
60
40
20
0
Intervention
Control
18
Effects of Opinion Leader on Choice Antibiotic
for Prophylaxis in a Teaching Hospital
19
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
  • Avoidance of perverse financial incentives
  • prescribers salaries from drug sales, flat
    prescription fees,
  • insurance policies that reimburse non-essential
    drugs or incorrect doses

20
Review of 59 evaluations of clinical
guidelinesGrimshaw Russell, Lancet, Nov.27
1993, 3421317-1322
  • Significant improvement found in
  • 55/59 studies concerning the process of care
  • 9/11 studies concerning patient outcome
  • Size of the improvement varied 5-60 and was
    higher if there was
  • involvement of users in guideline development
  • a specific educational intervention
  • a patient-specific reminder at consultation e.g.
    a decision by a funding body not to reimburse
    prescriptions not meeting guidelines

21
RCT in Uganda of the effects of STGs, training
supervision on the of Px conforming to
guidelines Kafuko et al, UNICEF, 1996.
22
Pre-post with control study of an economic
intervention (user fees) on prescribing in
NepalHolloway, Gautam Reeves, HPP, 2001
23
Tetracycline prescription rate
tetracycline-resistant E.Coli in hospital
isolates, 2 municipalities in Denmark,
01/1994-12/1999
Change in subsidization from 50 to 0 (01/1996)
Tetracycline-R E. coli Hospital Isolates (,
5-month moving average)
Tetracycline Use ( prescriptions per 1,000
inhabitants)
Sources Danish Medicines Agency H. Westh,
Hvidovre Hosp, 2000. Monnet DL., 40th ICAAC,
Toronto, Canada, 527 abstr. 628.
24
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

25
Choosing an Intervention
  • A single educational strategy is often not
    effective and does not have a sustainable impact
  • Printed materials alone are not effective
  • Combination of strategies, particularly of
    different types (e.g. educational managerial)
    always produces better results than a single
    strategy
  • Focused small groups and face to face interactive
    workshops have been shown to the effective
  • Audit and feedback, peer review, are very
    effective
  • Economic strategies are very powerful strategies
    to change drug use but may be difficult to
    introduce

26
Review of 30 studies in developing countries
size of drug use improvements with various
interventions
Minor
Moderate
Large
Large group training
Small group training
Diarr. community case mgt
ARI community case mgt
Info/guidelines
Group process
Supervision/audit
EDP/Drug supply
Economic strategies

10
20
30
40
50
60
0
Improvement in outcome measure ()
Source Ross-Degnan et al, Plenary presentation,
Conference on Improving the Use of Medicines,
1997, Chiang Mai, Thailand.
27
Combined Intervention StrategyPrescribing for
Acute Diarrhea in Mexico City
28
Impact of Training on Use of Diarrhea Treatment
Algorithm in Three Mexico Settings
Intervention
given by
"Experts" in 2 clinics
(San Jeronimo)
"Leaders" in 18 clinics
(Coyoacan)
"Coordinators" in 124
clinics (Tlaxcala)
Source Munoz, et al, unpub. (1993) Guiscafre,
et al, Arch. Med. Res. (1995)
29
Impact of multiple interventions on injection use
in Indonesia
Source Long-term impact of small group
interventions, Santoso et al., 1996
30
Drug Therapeutic Committee Activitiesvery
little data on drug use impact
31
10 national strategies to promote RUDneeds
sufficient govt. investment for medicines staff
!
  • 1. Evidence-based standard treatment guidelines
  • 2. Essential Drug Lists based on treatments of
    choice
  • 3. Drug Therapeutic Committees in hospitals
  • 4. Problem-based training in pharmacotherapy in
    UG training
  • 5. Continuing medical education as a licensure
    requirement
  • 6. Independent drug information e.g bulletins,
    formularies
  • 7. Supervision, audit and feedback
  • 8. Public education about drugs
  • 9. Avoidance of perverse financial incentives
  • 10. Appropriate and enforced drug regulation

32
Why does irrational use continue?
  • Very few countries regularly monitor drug use
    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?

33
WHO future priorities
  • Developing a model formulary process, the WHO
    Essential Drugs Library
  • Training programmes
  • Pilot projects to contain antimicrobial
    resistance
  • Promoting drug therapeutic committees
  • Intervention research to promote RUD
  • cost-effectiveness of interventions, policies
  • Advocacy for the rational use of drugs (RUD)
  • Essential Drug Monitor, effective drug
    information
  • ICIUM2004

34
Creating the WHO Essential Drugs Libraryto
facilitate the work of national committees
Evidence-based Clinical guideline
Summary of clinical guideline
WHO Model Formulary
Reasons for inclusion Systematic reviews Key
references
WHO Model List
Quality information - Basic quality tests -
Internat. Pharmacopoea - Reference standards
Cost - per unit - per treatment - per month -
per case prevented
35
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/WHO Promoting rational use
    of drugs in the community
  • Newcastle, Australia/WHO Pharmaco-economics
  • Boston University, USA/WHO Drug Policy Issues

36
Local pilot projects to contain AMR
  • Objectives
  • develop, implement evaluate interventions to
    contain AMR using surveillance data in local
    sites
  • to develop a new method for the integrated
    surveillance, at community level, of
    antimicrobial use and resistance that can be used
    in many different countries
  • to build local capacity in developing a
    multi-disciplinary approach to the containment of
    AMR
  • 3 phases
  • (1) set up surveillance,
  • (2) develop, implement evaluate interventions
  • (3) expand to other sites

37
No.drugs
Antibiotics
Injections
38
Identifying effective strategies to promote more
rational use of drugs
  • Joint research initiative between WHO/EDM, MSH
    and ARCH
  • over 20 intervention research projects in
    developing countries
  • WHO database on drug use
  • quantitative data on drug use and interventions
    to improve drug use over the last decade

39
ICIUM20042nd International conference for
improving use of medicines
  • Next milestone in assessing progress on global
    medicines agenda
  • Chiang Mai, Thailand, Mar 30-Apr 2, 2004
  • Objective Examine state of the art in improving
    medicines use in focus areas
  • Intl. policy systems - Natl. policy systems
  • Hospitals - Primary care
  • Private pharmacies - Community use

40
ICIUM2004 topic tracks
  • Meetings Within a Meeting
  • Key constituencies and interest groups working on
    pharmaceutical issues
  • Summarize topical lessons and research needs
  • Preliminary topic tracks include
  • Child health - Malaria
  • TB - HIV/Aids, STIs
  • Chronic diseases - Antimicrobial resistance
  • Impact of access on use

41
ICIUM2004 who should attend?
  • Researchers
  • Leading drug use researchers methodologists
  • Fertilization across interest areas
  • Policymakers
  • Learn cutting edge behavior change approaches
  • Assessment of pharmaceutical policy impacts
  • NGOs and Donors
  • Add value to existing programs
  • Coordinate with global medicines initiative

42
ActivityDiscuss in groups the following questions
  • Choose a major drug use problem in your country
    or project
  • Identify the causes underlying the problem
  • What are the main 1-2 strategies being undertaken
    to address this problem?
  • Are these 1-2 strategies being evaluated? If so,
    how?
  • What should be the roles of government, NGOs,
    donors, and WHO be in filling the gap in
    strategies/policies to address this problem?
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