Drug and Therapeutics Committee

1
Drug and Therapeutics Committee

• Session 9. Strategies to Improve Medicine
  UseOverview

2
Objectives

• Identify effective strategies to improve medicine
  use
• Choose an appropriate strategy for improving
  medicine use based on an identified problem
• Understand the importance of educational,
  managerial, and regulatory interventions in
  promoting rational use of medicines

3
Outline

• Key definitions
• Introduction
• Methods to improve medicine use
• Educational
• Managerial
• Regulatory
• Activity 1
• Summary

4
Key Definitions

• Standard treatment guideline (STG)Systematically
  developed statement that assists practitioners
  and patients in making decisions about
  appropriate health care for specific clinical
  circumstances
• Formulary manualDocument that describes
  medicines that are available for use in hospitals
  or clinics (provides information on indications,
  dosage, length of treatment, interactions,
  precautions, contraindications)
• Drug use evaluation (DUE)Ongoing, systematic,
  criteria-based program of medicine evaluations
  that helps ensure appropriate medicine use if
  therapy is determined appropriate, interventions
  with providers or patients will be necessary to
  optimize pharmaceutical therapy

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Introduction

• Drug and Therapeutic Committee (DTC)
  responsibilities
• Selecting medicines for the formulary
• Identifying medicine use problems
• Developing and implementing strategies to improve
  medicine use

6
Consequences of Irrational Use of Medicines (1)

• Waste of resources
• Up to half the value of all medicines may be
  wasted through inappropriate use
• Morbidity due to adverse drug reactions (ADRs)
• In the United States, ADRs cost 30130 billion
  U.S. dollars per year and causes significant
  morbidity and mortality

7
Consequences of Irrational Use of Medicines (2)

• Antimicrobial resistance through misuse and
  overuse
• 24 multidrug resistance in TB, 1255
  resistance to penicillin in N. Gonorrhoea and S.
  Pneumonia, 1090 resistance to ampicillin or
  co-trimoxazole in Shigella
• Increased disease due to dirty or unnecessary
  injections
• 2.34.7 million hepatitis B and C infections and
  up to 160,000 HIV infections per year

8
Changing a Medicine Use ProblemAn Overview of
the Process

9
Strategies to Improve Medicine Use
Educational to inform or persuade
Regulatory to restrict or limit decisions
Managerial to structure or guide decisions
10
Educational Methods To Inform and Persuade

• Printed materials
• Pharmaceutical bulletins and newsletters
• Formulary manuals and STGs
• Face-to-face activities
• Group in-service education, workshops, seminars
• Individual face-to-face (academic detailing)

11
Printed Educational Materials (1)

• Newsletters and bulletins
• International newsletters
• Local newsletters
• Brief, to the point, articles of interest to
  medical staff
• Tailor to problems seen at hospitals and clinics
• Produce regularly
• Need to be coupled with other approaches

12
Printed Educational Materials (2)

• Pharmaceutical newsletters are more likely to be
  effective in improving rational use of medicines
  if they do the following
• Describe the reasons for prescribing behavior
• Offer concise, up-to-date information that can be
  used immediately
• Provide limited information and repetition of key
  points
• Have attractive graphics
• Provide references in the newsletter to
  information derived from reputable journals and
  services
• Provide information oriented toward actions and
  decisions
• Obtain feedback from the professional staff on
  the value of newsletter and institute changes as
  necessary

13
Printed Educational Materials (3)

• Formulary manuals
• Reference source for education and training for
  all providers
• Provide a listing of medicines available and
  information on the formulary medicines
• Source of price information
• STGs
• Reference source for education and for
  prescription audit
• Lists the preferred pharmaceutical and
  nonpharmaceutical treatments

14
Face-to-Face Educational Methods (1)

• In-service education, workshops, seminars
• Focuses on information of local relevance
• Is kept brief (i.e., messages are few and clear,
  descriptions of what to do are concise)
• Supports the repetitive information needed for
  individuals to learn
• Is run by a presenter who has in-depth knowledge
  and an effective teaching style

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Face-to-Face Educational Methods (2)

• Person-to-person educational outreach (academic
  detailing)most effective form of education
• Focuses on specific problems and targets the
  prescribers
• Addresses the underlying causes of prescribing
  errors such as inadequate knowledge

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Face-to-Face Educational Methods (3)

• Person-to-person educational outreach (continued)
• Allows for interactive discussion with targeted
  audience
• Uses concise and authoritative materials to
  augment presentations
• Gives sufficient attention to solving practical
  problems encountered by prescribers in real
  settings

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Face-to-Face Educational Methods (4)

• Influencing opinion leaders
• Chiefs of service
• Dominant and experienced physicians in community
  settings
• University professors
• Important and respected traditional healers

18
Effects of an Opinion Leader on Choice Opinion
Antibiotic for Prophylaxis in a U.S. Teaching
Hospital
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Face-to-Face Educational Methods (5)

• Patient education
• Patients provided with education will
• Have fewer demands for medicines
• Show improved compliance with pharmaceutical
  therapy
• Have improved quality of care and outcomes
• Must be provided by authoritative persons, such
  as physicians, pharmacists, and nurses in an
  organized, systematic approach

20
Impact of Patient-Provider Discussion Groups on
Injection Use in Indonesian PHC Facilities
Prescribing Injections
Hadiyono, J.E., S. Suryawati, S.S. Danu, et al.
1996. Interactional Group Discussion Results of
a Controlled Trial Using a Behavioral
Intervention to Reduce the Use of Injections in
Public Health Facilities. Social Science Medicine
42117783.
21
Sites for Face-to-Face Education

• Health centers
• Hospitals
• Pharmacies
• Universities
• District-level education

22
Strategies to Improve Medicine Use
Educational to inform or persuade
Regulatory to restrict or limit decisions
Managerial to structure or guide decisions
23
Managerial Methods To Structure and Guide
Decisions

• STGs
• DUEs
• Clinical pharmacy programs
• Medicine restrictions and control

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Standard Treatment Guidelines

• Advantages
• Standardized treatment guidance to all
  practitioners
• Dictates the most appropriate medicines
• Provides basis for evaluating quality of care
• Disadvantages
• Difficult to produce accurately
• Inaccurate or incomplete guidelines will provide
  the wrong information and do more harm than good
• Guidelines may not be based on the most reliable
  information

25
Randomized Controlled Trial In UgandaEffects of
Treatment Guidelines, Training, and Supervision
on the Percentage of Prescriptions Conforming to
STGs
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Audit and Feedback

• DUE
• Program of ongoing, systematic, criteria-based
  evaluations of pharmaceutical therapy

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Clinical Pharmacy Programs

• Last check on correct use, doses, side effects
• Medicine information and patient education
• Correct labeling and course of treatment
  packaging
• Generic substitution programsbioequivalence
  issues
• Therapeutic substitution (interchange)substitutio
  n of medicines that differ in active ingredients
  but have similar therapeutic activities in terms
  of efficacy and safety (e.g., lisinopril for
  enalapril)

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Pharmaceutical Restrictions and Control

• Formulary list (essential medicine list)
• Structured order forms
• Automatic stop orders

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Controlling Pharmaceutical Promotion

• All promotional claims concerning medicines
  should be reliable, accurate, truthful,
  informative, balanced, capable of substantiation,
  and in good taste
• Control access of medical representatives to
  prescribers in the hospital during working hours
• Organize meetings of discussion between medical
  representatives and prescribers to allow DTC to
  evaluate the medicine of interest

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Avoiding Perverse Economic Incentives

• Separation of the prescribing and dispensing
  functions
• Avoidance of flat prescription fees that
  encourage polypharmacy
• Avoidance of percentage dispensing fees that
  encourage the sale of more expensive medicines
• Avoidance of polypharmacy where prescribers earn
  part of their income from the sale of medicines
  (including the use of expensive medicines where
  cheaper one would be just as good)

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Improving Prescribing by Changing Financial
Incentives from User Fees

• Pre- and post-study with control
• 1992 All three areas used flat fee covering all
  medicines in whatever quantities (perverse
  financial incentive)
• 199394 Two areas changed to a fee per
  pharmaceutical item (positive incentive)
• 199295 One area continued with the flat fee
  covering all medicines (control)
• Prescription (Px) surveys done in
  pre-intervention (1992) and post-intervention
  (1995)
• 1012 health facilities per area, gt 30
  prescriptions per facility

Holloway, K.A., B.R. Gautam, and B.C. Reeves.
2001. The Effects of Different Kinds of User Fees
on Prescribing Quality in Rural Nepal. Journal of
Clinical Epidemiology 54(10)106571.
32
Polypharmacy and Antibiotic Use On changing from
a flat medicine fee to a fee per medicine item
patients treated with antibiotics
Average number of medicines per patient
Holloway et al. (2001).
33
Injection and Vitamin or Tonic UseOn changing
from a flat medicine fee to a fee per medicine
item
patients treated with vitamins/tonics
30
25
20
15
10
5
0
1-band item fee
2-band item fee
Px fee
1992
1995
1992
1995
Holloway et al. (2001).
34
Treatment Cost and Compliance with STGs On
changing from flat medicine fee to fee per
medicine item
Average medicine cost per patient (NRs)
patients treated according to STGs
40
60
50
30
40
20
30
20
10
10
0
0
1-band item fee
Px fee
1-band item fee
2-band item fee
Px fee
2-band item fee
1992
1995
1992
1995
NR Nepalese rupees
Holloway et al. (2001).
35
Strategies to Improve Medicine Use
Educational to inform or persuade
Regulatory to restrict or limit decisions
Managerial to structure or guide decisions
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Regulatory Methods To Restrict or Limit
Decisions

• Country pharmaceutical registrationensure only
  registered medicines are used
• Professional licensingemploy only licensed staff
  for the level of prescribing required
• Licensing of pharmaceutical outletsbuy medicines
  only from licensed outlets
• Regulation pharmaceutical promotion activities

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Choosing an Intervention (1)

• A single educational strategy is usually not too
  effective and the impact is not sustainable.
• Printed materials alone are not effective or
  advisable.
• A combination of strategies, particularly of
  different types (e.g., educational and
  managerial) always produces better results than a
  single strategy.

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Choosing an Intervention (2)

• Focused small groups and face-to-face interactive
  workshops have been shown to be effective.
• Monitoring (audit) and feedback and peer review
  are effective strategies to improve medicine use.
• Economic strategies are powerful strategies to
  change medicine use but may be difficult to
  introduce.
• Treatment guidelines are effective when used with
  other interventions.

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Combined Intervention StrategyPrescribing for
Acute Diarrhea in Mexico City
40
Impact of Training on Using Diarrhea Treatment
Algorithm in Three Mexican Settings
Intervention
given by
Experts in 2 clinics
(San Jeronimo)
Leaders in 18 clinics
(Coyoacan)
Coordinators in 124
clinics (Tlaxcala)
Source Munoz, et al., unpublished (1993)
41
Review of 30 Studies in Developing Countries
Medicine Use Improvements with Different
Interventions
None, minor
Large
Moderate
50

0
10
20
30
40
60
Improvement in outcome measure ()
Source Ross-Degnan et al. 1997. Plenary
Presentation, Conference on Improving the Use of
Medicines. Chiang Mai, Thailand.
42
Activity 1. Case Study Generic and Brand Name
Antibiotics

• What are the major pharmaceutical management
  problems in this case presentation?
• Clearly define the beliefs and motivations of the
  prescribers that may contribute to the observed
  behavior.
• Once the problem has been defined, what kinds of
  strategies or interventions would you use to
  improve pharmaceutical therapy and to lower
  medicine costs in this hospital?

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Summary (1)

• Strategies to improve medicine use include the
  following types of interventions
• Educational programs
• In-service education
• Pharmaceutical bulletins and newsletters
• Formulary manuals
• Face-to-face education

44
Summary (2)

• Interventions (continued)
• Managerial programs
• DUE
• STG
• Clinical pharmacy programs
• Medicine restrictions and control
• Regulatory programsregistration of medicines,
  professionals, facilities