Challenges of rational drug use

1
Challenges of rational drug use

• The need for innovative strategies

2
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

3
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

4
Examples of irrational prescribing
- Use of drugs when no drug therapy is needed -
Use of wrong drugs - Use of drugs with doubtful
efficacy - Use of drugs with uncertain safety
status - Failure to prescribe safe, effective
drugs - Incorrect administration, dosages, or
duration

• Mongolia 13 injections per person per year
• Cambodia most hospitalized patients receive i.v.
  fluids
• Laos 73 of hospitalized patients receive
  antibiotics,
• 60- 80 patients receive injections

YOUR COUNTRY?
5
Overuse of antibiotics and iv fluids
6
Why irrational?
Patients Community?
Providers?
Drug use
- Information - Commercial promotion?
Healthcare system?
7
Strategies to improve drug use

• Educational strategy
• Managerial strategy
• Regulatory strategy

Financing strategy?
8
Levels of changes

• Intelectual improve awareness knowledge
• Psycho-motor improve skills
• Behavioral changes in motivation, attitude, and
  
• practices
• System healthcare environment support the
• desired behavior
• Sustaining the desired changes

9
Framework to improve prescribing
EXAMINATION How severe?
EVALUATION Any improvement?
DIAGNOSIS Why? Who? How?
TREATMENT Select/implement intervention
10
Failures in intervention

• Intervention too general, unfocus
• Seminar only
• Printed material only
• Single activity, no reinforcement
• Intervention materials not field-tested
• No evaluation on impacts
• Interventions are difficult to adopt
• Etc.

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Factors of success

• Providers
• Improved knowledge
• Improved skills
• Improved motivation
• System
• Feedback on performance
• Incentives and disincentives, etc.
• Socio-cultural environment
• Public awareness patient empowerment
• Control of unethical promotion, etc.

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Principles of effective interventions ICIUM,
1997

• Focus on specific problem
• Address the underlying motivation
• Problem-solving approach
• Repeat interventions
• Interactive interventions
• Feedback of performance to providers
• Monitoring and supervision
• Peer-group guideline development

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Examples of innovative strategy

• Small-group interactive
• Problem-solving and problem-oriented
• Monitoring and feedback of practices
• On site supervision
• Combined interventions
• Community/patient empowerment

14
Interactive discussion
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Integrated monitoring-supervision in Cambodia
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Monitoring-Training-Planning (MTP)

y I
Sleman District (4 HCs)
Yogya District (6 HCs)
17
Drug use in hospital?

• High pharmaceutical consumption
• Ineffective, un-safe, costly prescribing
• Irrational prescribing easily widespread to
  surrounding communities
• Limited experience for interventions in hospital

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Conventional 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 DTC?

• 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

Role of DTC to promote RDU?
20
MTP at Private Hospitals
Problem - Overuse of ABs in acute respiratory
tract infections - Overuse of ABs in
non-specific acute diarrhea Indicator -
patients receiving antibiotics
PKU
Panti Rapih
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Successful implementation of interventions

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

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Conclusions

• Irrational drug use practices remain big
  challenge
• Strategies should be selected depend on the
  existing situation
• Indicator-based monitoring is effective,
  sustainability is important