Namibia's 3rd Drug Use Survey Poster part 1

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(No Transcript)
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Introduction

• Drugs are of special importance to any health
  care system because they save lives and improve
  health, promote trust and participation in health
  services, and are very costly. In addition the
  quality and cost-effectiveness of health care
  provision is highly dependent on the appropriate
  use of drugs.
• The development by INRUD and WHO of simple and
  uniform indicators has greatly facilitated the
  process of investigating drug use. In Namibia
  these indicators were used for the first time in
  a drug use survey conducted in the North West
  Regional Directorate in 1994. The first national
  drug use survey was conducted in 1997, and one of
  the recommendations from this survey was to carry
  out a drug use survey every 2 years in order to
  monitor trends. The second national drug use
  survey was thus conducted in 1999.
• The aim of this third national survey (conducted
  in 2001) was to monitor and obtain information
  about current drug use practices in public health
  facilities in Namibia for selected prescribing,
  patient care and facility indicators.
  Furthermore, this survey aimed to monitor the
  implementation of the NDP, which was launched in
  November 1998.
• The results of this survey were used to identify
  areas where further training is needed and
  identify knowledge gaps and areas for further
  research.

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Study Design Methodology

• A prospective cross-sectional survey, involving
  44 randomly selected health facilities was
  conducted. The health facilities included the 4
  main referral hospitals, 10 out of 30 district
  hospitals and 30 out of 97 clinics and health
  centres that see more than 30 patients per day.
• Drug use indicators as well as the sampling
  method were selected from the WHO manuals How to
  investigate drug use in health facilities and
  Core indicators on country pharmaceutical
  situation, Draft May 2000.
• Data collection took place from May to July 2001
  and was carried out by Regional and hospital
  pharmacists with support from Pharmacists
  Assistants.
• The data was collected from 30 outpatients as
  they left the health facility. The data sources
  for patient indicators were the patient health
  passports, the drug packages dispensed to the
  patients and the patients themselves.
• In addition, the pharmacies were visited to check
  on the percentage of key items in stock, expiry
  dates and stock history of key drugs, adequacy of
  storage and availability of basic reference
  material.
• The completed data collection forms were sent to
  the Division Pharmaceutical Services at national
  level, where they were analysed using a
  computerised spreadsheet program.

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Drug Use Indicators
The indicators to be included in the survey were
agreed at the National Pharmacists Workshop 2000.

• Average number of drugs per prescription
• of drugs prescribed by generic name
• of encounters with an antibiotic prescribed
• of encounters with an injection prescribed
• of prescriptions in accordance with standard
  treatment guidelines (STGs)
• of drugs actually dispensed
• of drugs adequately labelled
• of drugs prescribed according to the Essential
  Drugs List
• patients familiar with how to take their
  medicine
• of key items in stock
• of facilities where basic reference materials
  are available
• Average time key drugs out of stock
• Adequacy of storage conditions in health
  facilities.
• Only these Indicators will be discussed on
  this poster.

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Results

• Data for 1132 patient encounters, from 38 health
  facilities were included in the results analysis.
  
• The data collected from 6 clinics were not
  included because it was not possible to collect
  data from the required minimum of 30 patients in
  these facilities.
• The results obtained were compared to results
  from the previous two National Drug Use surveys
  (1997 1999).
• The average number of drugs per prescription of
  2.72 for outpatients in Namibia is relatively
  high. There has been a steady increase from 2.49
  (1997) to 2.55 (1999) to 2.72 (2001).
• Generic prescribing showed a marked improvement
  from 50 to 61 between the 1997 and 1999
  surveys. Comparing that to the current survey,
  there has been a slight decrease to 60.
• Percentage of encounters with an antibiotic
  prescribed was 51. This is higher than that
  obtained from the previous surveys (39 in 1997
  and 43 in 1999).
• Percentage of encounters with an injection
  prescribed was 9 which is slightly higher than
  in 1999 survey (7.3), but this value is still
  low enough for us not to consider the use of
  injections in Namibia a problem.
• Adherence to standard treatment guidelines is
  very low with only 53 of prescriptions according
  to the STGs.

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• There has been a steady decrease since the 1997
  baseline survey in percentage of drugs dispensed
  1997 96, 1999 95 and 2001 93, however a
  result above 90 is encouraging.
• Percentage of drugs adequately labelled was 67.
  This is a significant improvement from the 1997
  and the 1999 surveys, when only 48 of drugs were
  adequately labelled.
• On average, 93 of key items were available. If
  the expired key items (0.7) are considered out
  of stock the national result drops to 92. This
  is a slight drop from the 1999 result of 93 of
  key items available but an improvement from the
  baseline result of 89 available.

Average No. Drugs per Prescription
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Discussion

• The steady increase in number of drugs prescribed
  to outpatients is a worrying trend. Analysis of
  the Standard Treatment Manual reveals that the
  mean number of drugs proposed for treatment is
  1.7 per condition. Therefore the national result
  of 2.72 drugs prescribed clearly indicates a
  problem with polypharmacy which can increase the
  incidence of adverse drug reactions and drug
  drug reactions and also wastes scarce resources.
• One of the contributing factors to polypharmacy
  is obviously over prescribing of antibiotics,
  with every second prescription containing an
  antibiotic. This overuse of antibiotics is not
  only a waste of resources but is a matter of
  global concern as it accelerates development of
  antibiotic resistance.
• Going hand in hand with overuse of antibiotics is
  the non-adherence to STGs. Further analysis of
  the data for this indicator revealed that 86 of
  the prescriptions that were found not to be
  according to STGs were due to inappropriate
  antibiotic use. Most commonly this involved
  prescribing an antibiotic for a non-bacterial
  condition.
• Adherence to STGs was found to be lowest at
  clinic level (where prescribers are nurses) and
  may therefore indicate shortcomings in diagnostic
  skills.
• An intervention study on antibiotic prescribing
  habits conducted in clinics in Central
  Directorate, Namibia

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• revealed that two rounds of face to face
  education significantly improved antibiotic
  prescribing habits. This approach should be
  seriously considered country wide to address
  misuse of antibiotics.
• Generic prescribing has improved since 1997 but
  still is far from ideal. Nurses had better rates
  for generic prescribing than doctors, which maybe
  due to a slower turn over in nurses (Namibians)
  than doctors (mainly non-Namibians on 2 year
  contracts).
• The improvement in labelling of dispensed drugs
  must be commended but still one in 3 drugs is
  inadequately labelled so more work is needed.

Pharmacy Staff in Katutura State Hospital
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Implementation of the NDP
Education on antibiotic prescribing habits in
Okanguati Clinic, Kunene Region

• The goals of the NDP are constant availability of
  safe and efficacious drugs, equitable access and
  rational use of essential drugs.
• Drug availability, as reflected by key drugs in
  stock (92) and percent of drugs dispensed (93),
  is fairly good.
• Equitability of access is somewhat lacking as the
  results show that during times of drug shortages
  preference is given to hospitals over health
  centres and clinics.
• Rational drug use in Namibia has dropped since
  the baseline study in 1997, with increasing
  polypharmacy and prescribing of antibiotics and
  poor adherence to STGs.

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Conclusion Recommendations

• The results show that despite on going work since
  1998 to implement the National Drug Policy,
  several key factors of drug use in Namibia have
  steadily worsened since the baseline survey in
  1997.
• Areas requiring particular attention are mainly
  associated with prescribing of drugs, such as
  number of items prescribed per prescription,
  prescribing of antibiotics, generic prescribing
  and adherence to STGs.
• It is well known that the task of changing
  prescribing habits is a difficult one, however it
  is clear that this needs to be tackled as a
  matter of urgency in Namibia if the goals of the
  NDP are to be reached.
• The report recommends that the urgent action be
  taken to address the major problems identified.
  This includes a country wide campaign of face to
  face education to reduce the over-prescribing of
  antibiotics. Other key recommendations are for
  increased efforts to be made to enforce adherence
  to STGs, promote generic prescribing and ensure
  availability of drugs at clinics and health
  centres during times of shortage.
• The report also recommends that the next drug use
  survey only be conducted after concrete
  interventions have been implemented. The next
  survey can thus be used to assess the impact of
  these interventions.

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Prescribing Indicators
80
60
1997
1999
40
2001
67
61
51
50
43
20
39
9
7
0
of Drugs
of Rx Including
of Rx Including
Prescribed by
an Antibiotic
an Injection
Generic Name
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Dispensing and Drug Availability Indicators
100
80
60
1997
96
1999
95
93
93
92
89
40
2001
67
48
48
20
0
of Drugs
of Drugs
of Key Items in
Adequately
Dispensed
Stock
Labelled