1. Rational Use of Medication And
Patient Compliance
Presented by
Dr. Wadha AlFarwan

2. RATIONAL means “prescribing right drug, in adequate dose for the sufficient duration & appropriate to the clinical needs of the patient at lowest cost”

3. WHO conference of experts Nairobi 1985
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

4. Criteria for Using Medicines:
Appropriate indication.
Appropriate drug considering efficacy, safety,
suitability for the patient, and cost .
Appropriate dosage, administration, duration
Affordable
Appropriate patient
Appropriate patient information

5. Objectives To Understand: Concept of rational use of medicines
Factors influencing the irrational use of medicines
Adverse impact of irrational use of medicines
Role of doctors and pharmacist in promoting the rational use of medicines.
Importance of patient education .

6. 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

7. FACTORS THAT RAISED THE RDU :
Drug explosion: Increase in the number of drugs available has incredibly complicated the choice of appropriate drug
Efforts to prevent the development of resistance
Growing awareness: Today, the information about drug development
Increased cost of the treatment
Consumer protection Act. (CPA):- Extension of CPA in medical profession may restrict the irrational use of drugs.

8. Reason for Irrational Use
Lack of information
Role model – Teachers or seniors
Poor communication between health professional & patient
Lack of diagnostic facilities/Uncertainty of diagnosis
Demand from the patient
Defective drug supply system & ineffective drug regulation
Promotional activities of pharmaceutical industries

9. Common patterns of irrational prescribing :
The use of drugs when no drug therapy is indicated, e.g. antibiotics for viral upper respiratory infections.
The use of the wrong drug for a specific condition requiring drug therapy, e.g. tetracycline in childhood diarrhea requiring ORS.
The use of drugs with doubtful or unproven efficacy, e.g. the use of antimotility agents in acute diarrhea

10. cont.
Failure to provide available, safe and effective drugs, e.g. failure to vaccinate for measles or tetanus, or failure to prescribe ORS for acute diarrhea.
The use of correct drugs with incorrect administration, dosage and duration, e.g. using intravenous route where oral or suppository routes would be appropriate.
The use of unnecessarily expensive drugs, e.g. the use of a third generation, broad-spectrum antimicrobial when a first line, narrow spectrum agent is indicated.
Antibiotics misuse

11. Hazards of Irrational Use
Ineffective & unsafe treatment
* over-treatment of mild illness
* inadequate treatment of serious illness
Exacerbation or prolongation of illness
Distress & harm to patient
Increase the cost of treatment
Increased morbidity and mortality
Increased Adverse drug reactions and drug Resistance
Loss of patient confidence in health system

12. Obstacles exist in RDU :
Lack of objective information & of continuing education &
training programs.
Lack of well organized drug regulatory authority & supply of drugs.
Presence of large number of drugs in the market & the lucrative methods of promotion of drugs employed by pharmaceutical industries.
The prevalent belief that “every ill has a pill.”

13. Steps To Improve Rational Drug Prescribing :
Make a specific diagnosis
Consider the pathophysiology of diagnosis selected : If the disorder is well understood the prescriber is in a better position to select effective therapy.
Select a specific therapeutic objective or goal and medications should be selected based on it.
Select a drug of choice .

14. Determine the appropriate dosing regimen to obtain desired therapeutic levels and the drug must be inexpensive, easily available and should be prescribed in generic name.
Drug interaction and adverse effects must be taken into account before initiating combination of drugs.
Device a plan for monitoring the drugs action and determine an end point for the therapy.
Plan a program for patient education.

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
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

17. Managerial strategies
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

18. Avoid perverse financial incentives
Economic strategies:
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

19. Regulatory strategies
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

20. Role of Doctors and Pharmacist
They can establish a common approach to the rational use of drugs by giving advice and information to patient regarding the proper use of drugs.
They have more opportunity to interact closely with the prescriber and therefore, to promote the rational prescribing and use of drugs.

21. By having access to medical records, they are in a position to influence the selection of drugs, dosage regimens, to monitor patient compliance and therapeutics, response to drugs and to recognize and report adverse drug reactions.
They can control hospital manufacture and procurement of drugs to ensure the supply of high quality products.

22. Conclusion : The demands of rational drug use are:
Availability of essential & life saving drugs and
unbiased drug information with generic name.
Adequate quality control & drug control.
Withdrawal of hazardous & irrational drugs.
Drug legislation reform.

23. Policy implementation at the national level
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.

24. Definition of compliance
Compliance, simply defined as “agreement.” With regard to medicine, compliance means agreeing to take medicine(s) as directed, and then following through with that agreement…..accepting the responsibility of taking medicine(s) as agreed8

25. Definition of Adherence
Adherence is defined as the extent to which a patient’s health behavior coincides with their physician’s recommendations, whether taking medications or following advice for some type of behavioral change.

26. Adherence vs. Compliance
Adherence is a more accurate term than compliance.
Compliance suggests a process in which dutiful patients passively follow the advice of their physicians
Adherence, in contrast, better fits how most patients actively participate in their care and decide for themselves when and whether to follow their doctor’s advice.

27. Non compliance can be caused by:
Failure to understand instructions
Non comprehension
Volitional non compliance
How big a problem is medication non compliance?
Up to 60% of all medication prescribed is taken incorrectly or not taken at all!

28. Medication noncompliance includes:
Not filling a prescription
Over medication
Taking wrong medication
Taking right medication in a wrong time
Forgetting to take medication
Deliberately under dosing or not taking medication

29. Overall Rates Of Noncompliance
90% of elderly patients make some medication errors.
35% of elderly patients make potentially serious errors.
50% of all long term medications are abandoned in the first year.
75% of chronic care patients prescribed drugs either stop taking their medication at some point or don’t take them as directed.
Only 75% of patients who understand and agree with treatment are compliant.

30. Noncompliance in medication taking can be classified as:
Noncompliance causes admission of 380,000 patients to nursing homes (23% of all admissions) and is the key factors in admissions.
Noncompliance in medication taking can be classified as:
Errors of omission
Errors of commission
Dosage errors
Scheduling errors

31. Patient’s noncompliance is important from at least 4 perceptions:
Individual patient care.
Public health efforts.
Interpretation of the medical literature.
Economic consequences.

32. Exacerbation of disease Increases frequent physician visits
Health Effects:
Increase morbidity
Treatment failure
Exacerbation of disease
Increases frequent physician visits
Increases hospitalization
Death

33. Increases absenteeism Lost productivity at work
Economic Effects
Increases absenteeism
Lost productivity at work
Lost revenues to pharmacies
Lost revenues to pharmaceutical
manufacturers

34. Measurements of Compliance
Approaches to assessing compliance behavior in patients by
Asking
Medication counting
Assay
Supervision
Often necessary to use more than one method to arrive at a reasonably valid estimate of compliance in the individual patient.

35. 1. Asking: Ability to predict compliance Methods of measurement:
Sometimes no better than would be expected by chance
Methods of measurement:
1. Asking:
Simplest and most practical method of assessing compliance behavior.
Self-reports of noncompliance are valid, but often result in underestimation of the degree of noncompliance.
Only 40%-80% of patients admit their noncompliance .
Self-reported compliance over estimate true compliance rates.
Manner of asking influences the accuracy of patient response.

36. 2. Medication Counting : 3. Assays :
More objective but it has problems:
Overestimation
Underestimation
3. Assays :
Limitations:
Assays can be expensive.
Multiple measurements are required over extended period of time.
Patient may take medicine immediately before the collection of specimen but not at other time.

37. Differences in drug absorption, distribution, metabolism, excretion
Differences in drug absorption, distribution, metabolism, excretion.(whether a low level represents noncompliance or inadequate dosage in patient???). Collection of specimens has to be timed correctly, at appropriate times, absence of any drugs in the specimen suggests noncompliance. Assays are not available for many medications.

38. Patient Considerations
Factors believed to affect compliance:
Patient knowledge.
Prior compliance behavior
Ability to integrate into daily life / Complexity of the particular drug regimen.
Health beliefs and perceptions of possible benefits of treatment (self efficiency)
Social support (including practitioner relationships)

39. Factors which NOT believed to be associated with compliance:
Age, race, gender, income or education.
Patient intelligence.
Actual seriousness of the disease or the efficiency of the treatment.

40. Patients in Higher Risk: Asymptomatic conditions
Hypertension.
Chronic conditions
Hypertension, arthritis, diabetes.
Cognitive impairment
Dementia, Alzheimer.
Complex regimens
Poly pharmacy.

41. 5. Multiple daily dosing 6. Patient perceptions 7. Poor communication
Effectiveness, side effects, cost.
7. Poor communication
Patient practitioner rapport
8. Psychiatric illness
Less likely to comply.

42. Any Questions?

43. Thank You