Impact of an essential drugs list and treatment guidelines on prescribing in South Africa'

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Impact of an essential drugs list and treatment
guidelines on prescribing in South Africa. Pillay
T, Hill SR University of Newcastle
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Background

• National Drug Policy identifies the need for an
  Essential Drugs Programme.
• EDL and Standard Treatment Guidelines published
  in 1998.
• No evaluation of prescriber compliance with the
  guidelines.
• Pilot studies suggest that prescribers do not
  follow the hypertension guidelines.

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Approaches to measuring compliance with
guidelines?

• Database of prescriptions public sector in SA
  does not capture prescription electronically.
• Indicators
• Monitoring National Drug Policy-rational use
  indicators require prescription survey
• Assessing drug use at facilities require
  prescription survey.

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Problems with prescription surveys for this study

• How do you choose which hospitals to survey
  prescriptions?
• There are 60 hospitals (urban and rural)
• in the province of KZN.
• Prescription survey will be time consuming.
• Requires financial and human resources.

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Can we use aggregate purchases data?

• Defined daily dose (Nordic)
• Average daily quantity (UK)
• Equipotent dose (Danish)
• Minimum marketed dose
• Prescribed daily dose
• All of the above are fairly similar however they
  are all based on average dsing in other
  countries.

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Alternative approach in resource poor settings

• Use patients ready packs as the measure of drug
  use. Advantages
• Does not reply on the average dose prescribed in
  Nordic countries
• More accurate reflection of the exact quantity of
  drug dispensed to a patient over a 28 day period.
• Allows for variation in dosage
• Unit of issue ex-manufacturer

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Application of methodology in hypertension

• Calculate the total number of PRPs issued for
  each drug over a 6 month period.
• Add up the total number of PRPs for each dug
  class ie all diuretics, beta blockers, ACEI.
• Then obtain a total for PRPs all antihypertensive
  drugs.

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Prescription survey to validate drug supply data

• 16 hospitals selected from the three categories
  of methyldopa use (low, moderate and high) for
  survey.
• urban and rural hospitals.
• 100 prescriptions presented to the outpatient
  pharmacy department for the management of
  uncomplicated essential hypertension.
• The prescriptions were analysed to determine
• whether supply data and prescription data were
  similar
• the proportion of each antihypertensive class,
• monotherapy and combination therapy,
• the doses prescribed

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What should we expect if prescribers followed the
hypertension guidelines?

• The trend in proportional use (highest to lowest)
• Diuretics
• Reserpine
• Beta blockers
• ACEI
• Calcium channel blockers

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What did we find?
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Which hospitals are using large volumes of
methyldopa?
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How does the prescription survey compare with
the estimates from the supply data
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Conclusions

• Patient ready packs provides a useful
  alternative method for estimation of drug use.
• Supply data analysis and the prescription survey
  results are similar.
• Probably most useful for chronic diseases

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Conclusions

• The general prescribing trend suggests that
  prescribers do not follow the guidelines.
• Methyldopa is widely prescribed at certain
  hospitals in the province.
• ACEI are used as 2nd line add therapy.
• Beta blockers are not widely prescribed even
  though there is good evidence to support their
  use and they are cheaper.