1

Drug and Therapeutics Committee

Session 9. Strategies to Improve Medicine Use—Overview

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

Outline

Key definitions Introduction

Methods to improve medicine use Educational Managerial Regulatory

Activity 1

Summary

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 manual—Document 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

Introduction

Drug and Therapeutic Committee (DTC) responsibilities—

Selecting medicines for the formulary

Identifying medicine use problems

Developing and implementing strategies to improve

medicine use

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 30–130 billion U.S. dollars per year and causes significant morbidity and mortality

Consequences of Irrational Use of Medicines (2)

Antimicrobial resistance through misuse and overuse 2–4% multidrug resistance in TB, 12–55% resistance to

penicillin in N. Gonorrhoea and S. Pneumonia, 10–90% resistance to ampicillin or co-trimoxazole in Shigella

Increased disease due to dirty or unnecessary injections 2.3–4.7 million hepatitis B and C infections and up to

160,000 HIV infections per year

Changing a Medicine Use Problem:An Overview of the Process

1. EXAMINEMeasure existing

practices(descriptive

quantitative studies)

2. DIAGNOSEIdentify specific

problems and causes(in-depth quantitative and qualitative studies)

3. TREATDesign and implement

interventions (collect data to

measure outcomes)

4. FOLLOW UPMeasure changes

in outcomes (quantitative and qualitative

evaluation)

Improve intervention

Improvediagnosis

Strategies to Improve Medicine Use

Managerial:to structure or guide

decisions

Regulatory:to restrict or limit

decisions

Educational: to inform or persuade

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)

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

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

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

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

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

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

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

Effects of an Opinion Leader on Choice Opinion Antibiotic for Prophylaxis in a U.S. Teaching Hospital

Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct84 85 86

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7Discussion withChief of Obstetrics

-- Cefazolinrecommended

— Cefoxitinnot recommended

Percentage of all cesarean sections

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

Impact of Patient-Provider Discussion Groups on Injection Use in Indonesian PHC Facilities*

% Prescribing Injections

Intervention Control0

20

40

60

80

Pre

Post

*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 42:1177–83.

Sites for Face-to-Face Education

Health centers

Hospitals

Pharmacies

Universities

District-level education

Strategies to Improve Medicine Use

Managerial:to structure or guide

decisions

Regulatory:to restrict or limit

decisions

Educational: to inform or persuade

Managerial Methods: To Structure and Guide Decisions

STGs

DUEs

Clinical pharmacy programs

Medicine restrictions and control

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

Randomized Controlled Trial In Uganda—Effects of Treatment Guidelines, Training, and Supervision on the Percentage of Prescriptions Conforming to STGs*

Randomised group

No. health facilities

Pre-intervention

Post- intervention

Change

Control group 42 24.8% 29.9% +5.1%

Dissemination of guidelines

42 24.8% 32.3% +7.5%

Guidelines + on-site training

29 24.0% 52.0% +28.0%

Guidelines + on-site training + 4 supervisory visits

14

21.4%

55.2%

+33.8%

*Kafuko, J.M., C. Zirabumuzaale, and D. Bagenda. 1996. Rational Drug Use in Rural Health Units of Uganda: Effect of National Standard Treatment Guidelines on Rational Drug Use. Final report UNICEF/Uganda.

Audit and Feedback

DUE

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

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 programs—bioequivalence issues

Therapeutic substitution (interchange)—substitution of medicines that differ in active ingredients but have similar therapeutic activities in terms of efficacy and safety (e.g., lisinopril for enalapril)

Pharmaceutical Restrictions and Control

Formulary list (essential medicine list)

Structured order forms

Automatic stop orders

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

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)

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)

1993–94: Two areas changed to a fee per pharmaceutical item (positive incentive)

1992–95: One area continued with the flat fee covering all medicines (control)

Prescription (Px) surveys done in pre-intervention (1992) and post-intervention (1995)

10–12 health facilities per area, > 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):1065–71.

Polypharmacy and Antibiotic Use: On changing from a flat medicine fee to a fee per medicine item

Holloway et al. (2001).

% patients treated with antibioticsAverage number of medicines per patient

0

20

40

60

80

0

1

2

3

4

Px fee 1-band item fee 2-band item fee

1992 1995Px fee 1-band item fee 2-band item fee

1992 1995

Injection and Vitamin or Tonic Use:On changing from a flat medicine fee to a fee per medicine item

Holloway et al. (2001).

% patients treated with injections

05

10152025

Px fee 1-band item fee 2-band item fee

1992 1995

% patients treated with vitamins/tonics

05

1015202530

Px fee 1-band item fee 2-band item fee

1992 1995

Treatment Cost and Compliance with STGs: On changing from flat medicine fee to fee per medicine item

% patients treated according to STGs

0102030405060

Px fee 1-band item fee 2-band item fee

Average medicine cost per patient (NRs)*

0

10

20

30

40

Px fee 1-band item fee 2-band item fee

1992 1995 1992 1995

Holloway et al. (2001). *NR = Nepalese rupees

Strategies to Improve Medicine Use

Managerial:to structure or guide

decisions

Regulatory:to restrict or limit

decisions

Educational: to inform or persuade

Regulatory Methods: To Restrict or Limit Decisions Country pharmaceutical registration—ensure only

registered medicines are used

Professional licensing—employ only licensed staff for the level of prescribing required

Licensing of pharmaceutical outlets—buy medicines only from licensed outlets

Regulation pharmaceutical promotion activities

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.

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.

Combined Intervention StrategyPrescribing for Acute Diarrhea in Mexico City

00

2020

4040

6060

8080

100100

% cases treated in line with algorithm

Study Physicians

Control Physicians

37/5237/5279/11579/115

20/8420/84

Baseline Stage (n = 20)

After Workshop

After Peer Review (n = 20)

18-months Follow-up

11/4611/46

31/11031/110

16/7016/7025/10225/102

42/8242/82

Impact of Training on Using Diarrhea Treatment Algorithm in Three Mexican Settings

Source: Munoz, et al., unpublished (1993)

Intervention given by:

Experts in 2 clinics(San Jeronimo)

Leaders in 18 clinics (Coyoacan)

Coordinators in 124

Prescribers

31

65

157

Baseline(%)

24.5

17.7

24.7

Post(%)

71.2

43.4

31.2

Change (%)

+46.7

+ 25.6

+ 6.5 clinics (Tlaxcala)

Review of 30 Studies in Developing Countries— Medicine Use Improvements with Different Interventions*

Improvement in outcome measure (%)

0 10 20 30 40 50 60

None, minor

Moderate Large

Large group training

Small group training

Diarr. community case mgtARI community case mgt

Info/guidelinesGroup process

Supervision/audit

EDP/medicine supply

Economic strategies

Source: Ross-Degnan et al. 1997. Plenary Presentation, Conference on Improving the Use of Medicines. Chiang Mai, Thailand.

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?

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

Summary (2)

Interventions (continued)— Managerial programs

DUE STG Clinical pharmacy programs Medicine restrictions and control

Regulatory programs—registration of medicines, professionals, facilities