1. Framework for Changing Drug Use Practices

2. Framework for Changing Drug Use Practices: Objectives
Identify specific drug use problems and place in perspective of underlying causes
Identify educational, managerial, and regulatory approaches
Understand strengths and weaknesses of different interventions
Framework for Changing Drug Use Practices

3. Components of the Drug Use System
Drug Imports
Local
Manufacture
Hospital or
Health Center
Private Physician or
Other Practitioner
Pharmacist or
Drug Trader
The Drug Supply
Process
Provider and
Consumer Behavior
Illness Patterns +
Public
Framework for Changing Drug Use Practices

4. Some Factors Influencing Drug Use
Cultural
Beliefs
Knowledge
Deficits
Unbiased
Information
Relation
With Peers
Authority &
Supervision
Influence
of Industry
Workload &
Staffing
Infra-
structure
Acquired
Habits
Patient
Demand
Interpersonal
Workplace
Workgroup
Personal
Informational
Framework for Changing Drug Use Practices

5. Learning About Factors Underlying Drug Use
Use qualitative methods to identify motivations and incentives of prescribers and patients
Framework for Changing Drug Use Practices

6. Changing a Drug Use Problem: An Overview of the Process
1. EXAMINE
Measure Existing
Practices
(Descriptive
Quantitative Studies)
2. DIAGNOSE
Identify Specific
Problems & Causes
(In-depth Quantitative
& Qualitative Studies)
3. TREAT
Design & Implement
Interventions
(Collect Data to
Measure Outcomes)
4. FOLLOW UP
Measure Changes
in Outcomes
(Quantitative & Qualitative
Evaluation)
improve
intervention
diagnosis
Framework for Changing Drug Use Practices

7. Strategies to Improve Drug Use
Educational: to inform or persuade
Managerial:
to structure or guide decisions
Regulatory:
to restrict or limit decisions
Framework for Changing Drug Use Practices

8. Educational Interventions GOAL: to inform or persuade
Training
changes in formal education
in-service training seminars
face-to-face persuasive outreach
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, televisions
Framework for Changing Drug Use Practices

9. Prescriber Training WHO has produced a Guide for Good Prescribing
Developed in Groningen
Field tested in 7 sites
Suitable for medical students, post grads & nurses
Framework for Changing Drug Use Practices

10. Printed Educational Materials
Cover range of materials including journals, newsletters, adverts, STG’s etc
Most useful when combined with other methods
Should include key messages and have attractive graphics
Framework for Changing Drug Use Practices

11. Face to Face Education
Very effective method in both developed and developing countries
Need to target prescribers
Have key messages to convey
Should reinforce messages
Framework for Changing Drug Use Practices

12. Yogyakarta Diarrhea Study A Comparison of Two Educational Interventions
Study Design
Randomized controlled trial
2 districts randomly assigned to each of 3 study groups
15 random health centers per district
Study Groups
Face to face training in health centers (staff from single unit)
Large training seminar at district office (120 per seminar)
Control group with no training
Framework for Changing Drug Use Practices

13. Yogyakarta Diarrhea Study A Comparison of Two Educational Interventions
Data Collection
Pre-post knowledge test
Retrospective prescribing audit
3 months pre vs. 3 months post
Outcome measures
Knowledge about diarrhea
% receiving ORS
% receiving antibiotics
% receiving antidiarrheals
Framework for Changing Drug Use Practices

14. Yogyakarta Diarrhea Study Impact of Targeted Training on Health Worker Knowledge
Face to Face
Seminar 2 4 6 8 10
Knowledge Score
Pre
Post
Significant increase pre vs. post
Impact of Targeted Training on Health Worker Knowledge
Framework for Changing Drug Use Practices

15. Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of ORS
Face to Face
Seminar
Control 20 40 60 80
100
% Cases Receiving ORS
Pre
Post
Differences from controls not significant
Framework for Changing Drug Use Practices

16. Significantly different
Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of Antibiotics
% Cases Receiving Antibiotics
Significantly different
from controls, p<0.001
100 80
Pre
Post 60 40 20
Face to Face*
Seminar*
Control
Framework for Changing Drug Use Practices

17. Significantly different
Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of Antidiarrheals
Significantly different
from controls, p<0.001
Face to Face*
Seminar*
Control 20 40 60 80
100
% Cases Receiving Antidiarrheals
Pre
Post
Framework for Changing Drug Use Practices

18. Impact of Small Group Training on ORS Sales in Kenyan Retail Pharmacies
Pre
Post 20 40 60 80
100
Percentage Prescribing ORS
Phase 1 Nairobi
Intervention
Control
Phase 2 Other Cities
Framework for Changing Drug Use Practices

19. Impact of Patient-Provider Discussion Groups on Injection Use in Indonesia PHC facilities
Percentage Prescribing Injections 80 60
Pre
Post 40 20
Intervention
Control
Framework for Changing Drug Use Practices

20. Effects of Opinion Leader on Choice Antibiotic for Prophylaxis in a Teaching Hospital, !
Jan
Apr
Jul
Oct 84 85 86
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Percent of all C-sections
Discussion with
Chief of Obstetrics
-- Cefazolin
recommended
— Cefoxitin
not recommended
Framework for Changing Drug Use Practices

21. Managerial Strategies 1 GOAL: to structure or guide decisions
Changes in Selection, Procurement, Distribution
essential drugs lists
morbidity-based quantification
kit system distribution
Changes Aimed at Prescribers
utilization review (audit) and feedback
diagnostic and treatment guidelines
structured drug order forms
peer group monitoring
Framework for Changing Drug Use Practices

22. Managerial Strategies 2: GOAL: to structure or guide decisions
Changes Aimed at Dispensers
allowing generic substitution
improved labeling
course of therapy packaging
Changes in Economic Incentives
patient cost-sharing
revolving drug funds
cost controls
Framework for Changing Drug Use Practices

23. Standard Treatment Guidelines
STG’s lead prescribers to most cost-effective treatments
Particularly useful for low level workers
Can be used for training, examinations and audit
Used for procurement
Framework for Changing Drug Use Practices

24. Prescribing Audits plus "Feedback" to Prescriber
Establish Criteria & Guidelines for Review
AUDIT
(COLLECT DATA ON) PRESCRIBING
· Comparison with Guidelines
· Comparison with Peers
NOTIFY PRESCRIBERS
OF RESULTS
· Individuals or Groups
· Letters or Patient Notes or in Person
Framework for Changing Drug Use Practices

25. Regulatory Options GOAL: To Restrict Decisions
Market Controls
Limiting Drug Registration
Banning Previously Registered Drugs
Rx - only to OTC
Controlling Content in Drug Advertising
Prescribing and Dispensing Controls
Limiting Drugs Supplied in Public Sector
Restricting Specific Drugs to Higher Levels of Care
Required Generic Prescribing
Allowing Generic Substitution
Limits on Number or Quantity of Drugs per Patient
Framework for Changing Drug Use Practices

26. Combined Intervention Strategy Prescribing for Acute Diarrhea in Mexico City20 40 60 80
100
% cases treated in line with algorithm
Study Physicians
Control Physicians
37/52
79/115
20/84
Baseline Stage
(n = 20)
After Workshop
After Peer Review
18-months Follow-up
11/46
31/110
16/70
25/102
42/82
Framework for Changing Drug Use Practices

27. Impact of Training on Use of Diarrhea Treatment Algorithm in Three Mexico Settings
Intervention
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%
given by:
"Experts" in 2 clinics
(San Jeronimo)
"Leaders" in 18 clinics
(Coyoacan)
"Coordinators" in 124
clinics (Tlaxcala)
Source: Munoz, et al, unpublished (1993)
Framework for Changing Drug Use Practices

28. Conclusion: Interventions to Change Drug Use
Best evidence in PHC area
Focused, problem oriented repeated training
Supervision or self monitoring with simple indicators
Peer group oriented guideline development
Evidence lacking for :
Private sector, adults, and chronic diseases
Framework for Changing Drug Use Practices

29. Conclusion: Interventions to Change Drug Use (2)
Few interventions in hospitals in developing countries but based on experience in developed countries great potential exists for hospital interventions to be successful
Consumers need to be involved. Experience is lacking but interactive, context specific programs using a mix of communication channels are likely to be effective
Framework for Changing Drug Use Practices

30. Conclusion: Interventions to Change Drug Use (3)
Drug retailers sales practices can be improved!
Studies on impact of economic and drug sector policy changes sorely lacking
Need for more indicators for adequacy of diagnosis, guideline compliance, quality of care, cost, inpatient drug use, success of P&T committees and community programs
Framework for Changing Drug Use Practices

31. Correcting Antibiotic Misuse in a South American City
Activity One
Correcting Antibiotic Misuse
in a South American City
Framework for Changing Drug Use Practices

32. Which strategies target different types of underlying motivation
Activity Two
Which strategies target different types of underlying motivation
Framework for Changing Drug Use Practices