Transcript Poster presentation

Abstract ID: 155
Author Name: Mariam
Cassimjee
Email: [email protected],
[email protected]
Presenter Name: Mariam Cassimjee
Authors: Cassimjee M, Khan R, Ramasir K, Moolman M
Institution: KwaZulu Natal Department of Health
Title: Evolving Systems for Promoting Rational Drug Use in Public Health
Facilities in KwaZulu-Natal, South Africa
Problem Statement: More than the adoption of an essential medicines list
(EML) is necessary for the promotion and practice of rational drug use (RDU).
Objective: To instill RDU concepts and practices in state health facilities
within the province of KwaZulu-Natal using the most suitable system for the
facility related to the assessor’s position, the level of development, and time.
Design: Randomized, retrospective, segmented time-series design with
comparisons over time.
Setting and Study Population: Randomly selected outpatient prescriptions
of five public health facilities: (1) primary health care facility, a 24-hour facility
in a rural area with an average of 209 prescriptions per day; (2) district
hospital, a 264-bed facility with an average of 158 outpatient department
(OPD) prescriptions per day; (3) district hospital, a 268-bed hospital with an
average of 213 OPD prescriptions per day; (4) regional hospital, a 450-bed
facility with an average of 408 OPD prescriptions per day; (5) regional
hospital, a 328-bed facility with an average of 404 OPD prescriptions per day.
Intervention: (1) Formation of Drug and Therapeutics Committees (DTCs)
within the facilities with evidence of their activity to promote the essential
drugs program; (2) reports of the measures taken to correct identified
irrational practices; (3) follow-up of reports with electronic and face-to-face
communication to promote RDU using a team approach; (4) repeat
assessments to measure change with feedback and reports to senior
management.
Outcome Measures: Percentage of change in the following: understanding
the core concepts of the essential drugs program; prescribing drugs
generically; number of antibiotics prescribed; number of injections prescribed;
number of drugs prescribed according to standard treatment guidelines; and
problems identified within the facility regarding the correct prescribing of
antibiotics, injections, and statins.
Results: Before the adoption of the EML, corrective measures using a DTC
and protocols enabled rational drug use in one of the regional hospitals, with a
change from the use of the more expensive and E. coli–resistant
cephalosporin to the use of amoxicillin for urinary tract infections; as well as
more cost-effective prescribing of angiotensin-converting enzyme inhibitors
(ACEIs) and the elimination of a steroid injection and diazepam tablets for
minor to moderate muscle aches. After the adoption of the EML and
educational interventions, the outcomes were measured against the baseline
studies.
Study Funding: None (done as part of the services of the KwaZulu-Natal
Department of Health)
Phases in Pursuing
Rational Drug Use (RDU)
The study spans over 1994 to 2004 of drug use
patterns in pursuing.
Prior to 1996: Medicines were selected off the
Provincial Medical Supplier’s catalogue. There
existed an open and a restricted code with a
number of choices for prescribing within a class
of drugs. Marketing forces were strong and
prevailed over the prescriber’s pen.
March 1996: A DTC was formed which initially
served 3 hospitals and spread to the district.
The purpose of the DTC: to advise on drug use,
develop STGs and protocols for antimicrobials.
May 1996: The PHC Essential Medicine List
(EML) arrived. Did it bring change for the
better? Was there strong trends to adherence?
May 1999:The EMP with an EML and STGs for
all levels of healthcare was launched.
Study Question: Four years after
the launch of the EMP, is there
compliance or is more than an EML
required for the promotion and
practice of RDU?
Av Monthly Usage Costs of
Amoxycillin & Cephradine
Pre-DTC Intervention: 11/96
R
RE
24%
e
G
g
iI
oO
nN
a
A
l
76%
Amoxycillin 250mg (15) - R2.80
Cephadrine 500mg (20) - R25.60
Post-DTC Intervention: 11/96
L
26%
H
O
74%
Amoxycillin 250mg (15) - R2.80
S
Resist Org
Multi Res
12/98
07/98
01/98
0
12/97
2
0
09/97
L
4
0
05/97
A
Tot Resist
12/96
T
Microbial Resistance Numbers
06/96
I
6
0
01/96
P
Cephadrine 500mg (20) - R25.60
E.Coli resistant
to Cephalosporin
amongst
resistant orgs.
DTC Intervention:
Dr “Valium’s” OPD Prescription
Pre – DTC Era:
March 1996
Post DTC
formation: Nov ’98
For any muscle
ache:-
Addiction to
benzodiazepine
cured! Rx read only:-
Bethamethasone
5mg injection
Diclophenac 75mg
injection
Ibuprofen 400mg
tds for 10 days
Valium 5mg bd for
10 days
N.B. Rx not from
Casualty, Orthopaedic or Arthritic
clinics!
Ibuprofen 200mg
tds for 10 days
Bethamethasone &
Diclophenac
injections reserved 
orthopaedic, arthritic,
pain & oncology
clinics!
KZNPA
benzodiazepine policy
strictly applied.
Pre-DTC or EML/STGs
• Many drugs prescribed with not many
questions asked!
DTC intervention:
• Drew up a STG for the treatment of
muscle aches  effected changes with
restriction on diazepam tablets,
diclophenac and betamethasone injs.
Av Monthly Usage of Long
Acting ACEIs
(not standardised for equivalent doses)
Jul-97
8%
23%
6%
1%
62%
Perindopril 4m g - R16.94
Ram ipril 2.5m g R23.37
Enalapril 10m g - R12.80
Enalapril 5m g - R11.78
Quinapril 10m g - R12.54
Jul-98
10%
0%
28%
25%
37%
Perindopril 4mg - R16.94
Ramipril 2.5mg R23.37
Enalapril 10mG - R12.80
Enalapril 5mg - R11.78
Quinapril 10mg - R12.54
•The many long
acting ACEinhibitors
afforded
prescribers the
use of many
expensive
choices! Both
Perindopril
and Ramipril
were mostly
used!
•To curtail
unwarranted
expenditure
and marketing
influences, an
EML with
STGs introduced in May
1999 made a
logical
progression to
RDU.
Baseline Indicator Study
in OPDs: August 2003
Alarming baseline results of August 2003,
using WHO indicators and a questionnaire to
determine understanding the core concepts
of the EMP programme, at a PHC clinic, a
district hospital and at a regional hospital
were noted.30 randomly sampled
retrospective prescriptions for the sample
size in each facility were used.
The results were compared six months
later to determine progress after
interventions.
Interventions After
Baseline
 Reports of the baseline evaluations,
furnished to the facility clinical manager,
included: Drug utilisation reviews (DURs) for
problematic drugs to verify usage
 Recommendations with respect to all
aspects of the tests
 Data on how to investigate drug use in
health facilities
 Strategies to monitor progress or regression
Strategies Used for
Correction
 Top management involvement for
endorsement of process and for referee
function.
 Communications broadened: Email,
telephonic & face-to-face support.
 Audits: Inputs from manager to identify
possible misuse / irrational prescribing
 Measure or map the outcomes
 Facility to determine the process to
follow to correct problem from
recommendations
 Of paramount importance: the
facility’s management is accountable
for the quality of their service
delivery and budgets. Their
autonomy was therefore honoured
by allowing them to decide on their
interventions and processes to
follow for addressing the identified
problems. It also served as
empowerment for the service and
improved networking and
communication.
Results of Pilot Sites:
Baseline (8/2003) & Post (3/2004) Study
Indicators Used
PHC Clinic
District
Hosp
Regional
Hosp
Base
Post
Base
Post
Base
Post
Understanding & promoting core
concepts of the EMP- %age score:
(Pharmacy or facility Manager)
90
85
40
70
25
45
Average No. of drugs per encounter
2.3
1.7
3
3.8
3.6
3.3
%age drugs prescribed generically
55
80
35
23
0
15
%age encounters with an antibiotic
55
43
37
9
6.7
5.3
%age injections prescribed per
encounters of sample
6.7
27
30
0.6
6.7
7.4
%age drugs prescribed according to
the EMP - STGs
15
80
14
50
6.4
30
Problem areas: %age for the correct
prescribing of antibiotic/statin/NSAID
injection (A=Amoxycillin) (I=
Diclophenac sod) (S= Atorvastatin
/Simvastatin)
50
(A)
60
(A)
0
(I)
83
(I)
3.9
(S)
83
(S)
%age for the availability of EML Items
95
100
100
100
100
100
KEY:
Scores to be read with compliance to the STGs. Determines correct from
incorrect usage.
 = Area of Concern
 = Marked Improvement after intervention
 = Some Improvement after an intervention
 = Change in person answering questions.
 = to be read with compliance to STGs  mostly correct usage for STIs
Discussion
The baseline results as depicted in red
print were alarming.
• First concern: Reasons for the gaps in knowledge of the core concepts of the EMP & HPT
STGs? Is there need to market the EMP
more comprehensively in structured
workshops?
• RDU of antibiotics especially at PHC level:
The Provincial Medical Suppliers were unable
to keep up with the demand of Amoxycillin
suspension in June 2003. This raises
questions about the judicious use of
antibiotics, more so by the fact that in the
post baseline test sampling of 30
prescriptions in the district hospital, there
were 10 prescriptions with antibiotics, of
which one was resistant to amoxyciilin!
The need for research into amoxycillin
resistance from PHC up the line seems
warranted especially in view of the fact
that the recently amended STGS for
otitis media advocate the use of
amoxyciilin.
• +ve change: from 3.9% to 83.3% in the use
of statins according to the STGs, training
of medical officers to prescribe correctly
with monitoring to ensure patient
safety.
Distant Support - District
Hospital
• Baseline DUR for the statins (01 Jan 2003 to 01
July 2003)  high usage
• Problems identified: – Prescribed outside the specialist prescriber
level and outside STGs.
– Non-drug measures & biochemical monitoring
not followed.
– Total cost over 7 months = R18,851 per month.
Results - Statin Usage
Baseline
Aug 2003
Post – 6 months
later -March 2004
Units per month
99
105
Cost per month
R18,851
R7,460.70
??
Dietician, Lipid levels,
Biochemical (6
monthly)
Monitoring
Support: young proactive Pharmacy Manager at
a Distant District Hospital.
Electronic communication: furnished strategies
and DURs  corrections achieved.
Correct practices: moderate hypercholesterolaemia treated with a generic simvastatin   of
more than 50% in expenditure with no
compromise to the patient.
Conclusions
• Almost 5 years after the
launch of the EMP, non
compliance was evident by
the low scores.
• An EMP with EML & STGs do
not in themselves promote
RDU
• Appropriate interventions for
the province & its health
facilities, considering their
level of development,
physical accessibility, busy
personnel schedules and
demands are very necessary
• More research into bridging
gaps with respect to the
implementation of the EMP is
necessary
• Therefore…........
Systems Needed to
Promote RDU
• An EMP with EML & one set of STGs
• DTCs at all levels: National, provincial, districts
and at health facilities.
• Promoters, educators and marketers
– Dedicated provincial person/s to promote,
evaluate & assist district teams using an
ambassadorial approach.
– To facilitate educational workshops
within establishments  to bridge
gaps and build in continuity for annual
and other changes in staff
• Finely tuned communication systems 
bulletins, minutes of meetings, network
groups, electronic and face-to-face.
• Human monitors based provincially, within
the districts and health facilities.
• Accountable management team within
health facilities to perform audits and
feedback.
• Ongoing vigilance and research into
antimicrobial resistance patterns at all
levels of care.