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Promoting Rational Use of Drugs

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Presentation on theme: "Promoting Rational Use of Drugs"— Presentation transcript:

1 Promoting Rational Use of Drugs
Krisantha Weerasuriya MD

2 Objectives Define rational use of medicines and identify the magnitude of the problem Understand the reasons underlying irrational use Discuss strategies and interventions to promote rational use of medicines Some questions to ponder

3 Could there have been a better term than "Rational" ?
The rational use of drugs requires that patients receive medications 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 their community WHO conference of experts Nairobi 1985 correct drug appropriate indication appropriate drug considering efficacy, safety, suitability for the patient, and cost appropriate dosage, administration, duration no contraindications correct dispensing, including appropriate information for patients patient adherence to treatment No definition BUT a description. The difficulty of defining " Rational" use – other words "Quality" use? Could there have been a better term than "Rational" ?

4 Snapshots in Low and Middle Income Countries
Why is the public sector better? No financial incentive to prescribe medicines?

5 But non-profts may have income from medicines which gives them incentive to prescribe.


7 Snapshots High Income Countries
Variation in outpatient antibiotic use in 26 European countries in 2002 Total outpatient antibiotic use in 26 European countries in 2002 (WHO ATC/DDD version 2003). This are ESAC data to position Belgium among other European countries… This lead to action in France and consumption has decreased – Greece still remains at the top. Source: Goosens et al, Lancet, 2005; 365: ; ESAC project.

8 How many LMICs can provide this data?
This provides antibiotics by class and total; how many of your countries can provide even the total? Whose responsibility is it to collect the data? Are health systems in LMICs comprehensive enough to collect this data? This strongly illustrious the principle that there must be data to define the problem. While date at national level would be ideal, interventions can be done when data is available at an institutional level. A drug consumption study using the standard WHO methodology for classifying medicines and quantifying doses – WHO ATC DDD (search the Internet for that) would give very useful information on what the medicines that are being consumed. Such a drug utilisation study could be done very easily with a simple spreadsheetwhich incorporates the ATC DDD classification.

9 2008 Generic Uptake after Patent Expiry in 2000
Despite cheaper generics being available, the more expensive brand name drugs are the majority in some countries. Expensive access with potential for enormous savings – Policy? Data Source IMS Health 2009

This was data from Turkey. The top line shows the consumption by a profligate prescriber who was able to be tracked because the data is available; the intervention was a call from the Minister of Healthand as can be seen it was very successful! Very detailed drug consumption data is available in Turkey – this is because the government reimburses the cost of medicines to the social welfare system and therefore requires detailed drug use data. The Rational Use of Medicines Department took her "piggyback" ride on this data and was able to quantifydrug consumption data in the country. It is very unlikely that such a system could have been put in place solely to monitor medicines consumption – the government would not have seen it as being cost-effective. However when it came to reimbursing medicines and therefore monitoring the costs, such a detailed system was extremely cost-effective. It was put in place by the social welfare system; the Ministry of health took a ride on it and did activities on rational use of medicines. sssssssss

11 Changing a Drug Use Problem: An Overview of the Process
1. EXAMINE Measure Existing Practices (Descriptive Quantitative Studies) 2. DIAGNOSE Identify Specific Problems and Causes (In-depth Quantitative and Qualitative Studies) 3. TREAT Design and Implement Interventions (Collect Data to Measure Outcomes) 4. FOLLOW UP Measure Changes in Outcomes (Quantitative and Qualitative Evaluation) improve intervention diagnosis Here again, note the necessity to "measure".

No. of Units % J01 ,00 15,46 J02 ,00 0,20 D01AB ,00 0,12 J04AB ,00 0,24 J05 ,00 0,09 P01AB ,00 0,27 A07AA ,00 0,05 J0 ,00 16,11 TOTAL (all types) ,00 100,00 Again data from Turkey. sssssssss

13 ITS DATA FOR JUNE-JULY 2012 Monthly Average No of Units Yearly Average
Monthly Average No of Units Yearly Average P. Warehouses-P. Warehouses P. Warehouses-Pharmacies P. Warehouses-Hospitals Clearly the activities should be focused on the pharmacies – this was useful data to see where the majority of the consumption was. Where should the focus of activities be ? Hospitals or Pharmacies? sssssssss

14 Many Factors Influence Use of Medicines
Treatment Choices Prior Knowledge Habits Scientific Information Relationships With Peers Influence of Drug Industry Workload & Staffing Infra- structure Authority & Supervision Societal Information Intrinsic Workplace Workgroup Social & Cultural Factors Economic & Legal Factors Rank them in importance? During the Technical Briefing Seminar about 20 of the 25 that answered said that the most important influence was NOT scientific information. Medicines should be used on rational clinical scientific basis and if not being used in that manner, clearly that use is not rational and providing the maximum benefit. Some said that the influence of the drug industry is predominant others said that social and cultural factors were number one. Emerging if a pilot in an aeroplane were to pilot the plane according to social and cultural factors or the influence of the aviation industry? Would they are travel be as safe as it is now? On the other hand, if the pilot makes a mistake he dies along with his or her passengers – the prescriber does not have to die along with the patient!

15 Strategies to Improve Use of Drugs
Economic: Offer incentives Institutions Providers and patients Managerial: Guide clinical practice Information systems/STGs Drug supply / lab capacity Regulatory: Restrict choices Market or practice controls Enforcement Educational: Inform or persuade Health providers Consumers Use of Medicines

16 Educational Strategies Goal: to inform or persuade
Training for Providers Undergraduate education Continuing in-service medical education (seminars, workshops) Face-to-face persuasive outreach e.g. academic detailing Clinical supervision or consultation Printed Materials Clinical literature and newsletters Formularies or therapeutics manuals Persuasive print materials Media-Based Approaches Posters Audio tapes, plays Radio, television Now with smartphones, information at the bedside; has it changed practice? May change practice but it may also be that false dawn of hope. When the WHO model formulary was available is a CD and could be installed on a personal computer, it was thought having the information accessible would improve prescribing. Unfortunately there was no measurable change. However this depended on the computer being available – in the case of smart phones, it is an individual posession and would be "at hand" much more than a computer or a book.

17 Training for prescribers The Guide to Good Prescribing
WHO has produced a Guide for Good Prescribing - a problem-based method Developed by Groningen University in collaboration with 15 WHO offices and professionals from 30 countries Field tested in 7 sites Suitable for medical students, post grads, and nurses widely translated and available on the WHO medicines website Needs to be updated

18 Managerial strategies Goal: to structure or guide decisions
Changes in selection, procurement, distribution to ensure availability of essential drugs Essential Drug Lists, morbidity-based quantification, kit systems Strategies aimed at prescribers targeted face-to-face supervision with audit, peer group monitoring, structured order forms, evidence-based standard treatment guidelines Dispensing strategies course of treatment packaging, labelling, generic substitution Drug utilisation databases down to the facility level – there is feedback on what is being used. The impetus for such databases has been financial – reimbursement but can be used for medicines utilisation studies.

19 Economic strategies: Goal: to offer incentives to providers an consumers
Avoid perverse financial incentives prescribers’ salaries from drug sales insurance policies that reimburse non-essential drugs or incorrect doses flat prescription fees that encourage polypharmacy by charging the same amount irrespective of number of drug items or quantity of each item (reverse – Quebec, dispensing fee is given even if pharmacist does not dispense for good reason) Reimburse without treatment guidelines (ceftriaxone as an OPD medicine)

20 Regulatory strategies Goal: to restrict or limit decisions
Drug registration Banning unsafe drugs - but beware unexpected results substitution of a second inappropriate drug after banning a first inappropriate or unsafe drug Regulating the use of different drugs to different levels of the health sector e.g. licensing prescribers and drug outlets scheduling drugs into prescription-only & over-the-counter Regulating pharmaceutical promotional activities Only work if the regulations are enforced

21 What are countries doing to promote the rational use of medicines
What are countries doing to promote the rational use of medicines? national policies Source: EMP pharmaceutical policy database

22 Basic training and obligatory continuing medical education (CME) available for health professionals
Source: EMP pharmaceutical policy database How many of the countries present in TBS teach Essential Medicines concept in undergraduate teaching?

23 However, is it all Doom and Gloom? Having a Policy does help
Countries that have it vs Countries that do not have the plicies. Comparison of countries with and without specific policies Weighted mean of differences for 12 INRUD/IMCI indicators (bars denote % difference and 95% CI)

24 Reminder: 10 national strategies to promote RUM need political support, investment and staff
Source: WHO Policy Perspectives no.5 1. Evidence-based standard treatment guidelines 2. Essential Medicines Lists based on treatments of choice 3. Drug & Therapeutic Committees in hospitals 4. Problem-based pharmacotherapy teaching in universities 5. Continuing medical education as a licensure requirement 6. Independent drug information e.g bulletins, formularies 7. Supervision, audit and feedback 8. Public education about medicines 9. Avoidance of perverse financial incentives 10. Appropriate and enforced drug regulation

25 Why does irrational use continue?
Very few low and middle income countries regularly monitor drug use and implement effective nation-wide interventions - because… they have insufficient funds or personnel? they lack of awareness about the funds wasted through irrational use? there is insufficient knowledge of concerning the cost-effectiveness of interventions? they do not bear the cost of irrational use? (OOP?) Out of Pocket Payment (OOP).. All these factors contribute but the main factor may be the last – when governments do not have to bear the cost of irrational treatment, they can afford to ignore it.

26 Conclusions Irrational use of medicines is a very serious global public health problem. Much is known about how to improve rational use of medicines but much more needs to be done policy implementation at the national level implementation and evaluation of more interventions, particularly managerial, economic and regulatory interventions Rational use of medicines could be greatly improved if a fraction of the resources spent on medicines were spent on improving use. (WAIT!) Some discussion on what percentage of the medicines budget would be sufficient to produce a good Drug Information Service. If a country were to spend hundred million USD on medicines, if 1% is given for drug information (that be sufficient to produce a formulary, have a few drug information centres), would it save more than 1% of the drug budget? Remains a strong theoretical possibility but we do need studies to prove it.

27 Some issues to think about
There are textbook cases of Technical Success in RUM Tools to identify the problem, design an intervention to measure the effect, feedback and adjust BUT What is more important than Technical Excellence? What maybe the proportion spent for medicines from the health budget if RUM is implemented? What role does Universal Health Coverage play in the success of RUM? Can single interventions help in RUM in low and middle income countries? Can single interventions help in high income countries?

28 Some issues to think about
Can we achieve RUM in a health sector dominated by the private sector? Is quality of medicines an important issue in RUM? (Does it differ between LMICs and HICs?) Is Information Technology important in promoting RUM? Can it accelerate progress or be the "fix" for irrational use? What is the most important lessons that we can learn from high income countries in RUM ? Would Universal Health Coverage be the driver for RUM? What would be stronger for RUM? Health? Cost to Health care systems?

29 Dr K Weerasuriya, Medical Officer Medicines Access and Rational Use (MAR) Essential Medicines and Pharmaceutical Policies (EMP) World Health Organization CH-1211 Geneva 27 Switzerland Comments and Questions welcome Some notes in individual slides

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