Transcript Promoting the rational use

Promoting the rational use
of medicines
Hans V. Hogerzeil, MD, PhD, FRCP Edin
WHO Essential Drugs and Medicines Policy
October 2002
Overview of the presentation
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Access framework
Examples of irrational use of medicines
Measuring drug use (indicators)
How to promote rational prescribing
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Proven effective interventions
Probably effective interventions
Probably ineffective interventions
Promoting rational prescribing in the
private sector
Access framework
Practical implications of the access framework
1. Rational
selection
3. Sustainable
financing
ACCESS TO
ESSENTIAL MEDICINES
2. Affordable
prices
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4. Reliable
systems
Example irrational use
Irrational use of medicines
is a widespread hazard to health
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Only half of 102 countries surveyed regulate drug
promotion
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In some areas, by age 2 children have had more than
20 injections
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15 billion injections aregiven per year - and half of them
are unsterile
Example irrational use
Published examples of irrational prescribing in
teaching hospitals in developing countries
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Yemen 1990: 68% of hypertensive patients receive
diazepam; 80% of UTI receive furosemide, 80% of
osteoarthritis receive vitamins
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Ilorin 1991: 33% of inpatients are on tranquillizers
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Kathmandu 1992: Only 70% of medicines prescribed are
from the national list of essential medicines
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Thailand 1991: 79% of surgical antibiotic prophylaxis is
inappropriate (choice, dose and/or duration)
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South Africa 1991: 54% of antibiotic treatment in
gynaecology inpatients is inappropriate
Example irrational use
Examples of irrational prescribing from 4800 general
practices in the UK (1995)
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Ulcer healing medication used “presumptively”
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In 0-90% of patients,SSRIs have replaced tricyclic
antidepressants
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In 0-56% of patients, buspirone has replaced diazepam
(300x as expensive)
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0-97% of patients on beta-blockers receive long-acting
betablockers (16-25x as expensive)
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Other inhalors prescribed instead of salbutamol: (cost 8x)
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Combination medicines (cost up to 16x)
Measuring drug use
How to measure irrational drug use?
WHO/INRUD indicators (1)
Prescribing indicators
 Average number of drugs per encounter (<2)
 Percentage of drugs prescribed by generic name
(close to 100%)
 Percentage of encounters with an antibiotic prescribed
(<30%)
 Percentage of encounters with an injection prescribed
(<10%)
 Percentage of drugs prescribed from EDL or formulary
(close to 100%)
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Measuring drug use
How to measure irrational drug use?
WHO/INRUD indicators (2)
Patient care indicators
 Average consultation time
 Average dispensing time
 Percentage of drugs actually dispensed (100%)
 Percentage of drugs adequately labelled (100%)
 Patients’ knowledge of correct dosage (100%)
Facility indicators
 Availability of copy of EDL or formulary (100%)
 Availability of key drugs (100%)
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Interventions
Promoting rational prescribing:
Proven effective interventions
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Standard treatment guidelines, when evidence-based,
developed with end-users, with active dissemination and
follow-up
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Essential Medicines lists, when linked to treatment
guidelines and used for training and supply
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Hospital Drugs and Therapeutic Committees
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Undergraduate training
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Comprehensive approach, with all components
Selection
The Essential Medicines Target
National list of
essential medicines
Registered medicines
All the drugs
in the world
Levels of use
S
CHW
S
dispensary
Health center
Hospital
Referral hospital
Private sector
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Supplementary
specialist
medicines
Selection
Clinical guidelines and a list of essential medicines
lead to better prevention and care
List of common diseases and complaints
Treatment choice
Treatment guidelines
Essential medicines list /
National formulary
Training and
Supervision
Financing and
Supply of drugs
Prevention
and care
Health Technology and Pharmaceuticals
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Challenges
Example of challenge:
New essential drugs are expensive
Antibiotics for gonorrhoea:
Antimalarial drugs:
Antituberculosis:
Antiretrovirals:
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50-90x price of penicillins
chloroquine $0.10 per treatment
artemether-lumefantrine $2.50/pp (25x)
atovaquone-proguanil $40/pp (400x)
$15 for DOTS vs $300 for MDR (20x)
$300-600/year; but 38 countries with
a drug budget <$2 pp/year
Selection
WHO Model List of Essential Drugs
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1977 First Model list published, ± 200 active substances
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List is revised every two years by WHO Expert Committee
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Last revision (April 2002) contains 325 active substances
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2002 Revised procedures approved by WHO
The first list was a major breakthrough in the history
of medicine, pharmacy and public health
Médecins sans Frontières, 2000
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Selection
The WHO Model List of Essential Medicines is a
model product, model process and public health tool
Model product: list of essential drugs with information
Core list: minimum drug needs for a basic health care
system, listing the most cost-effective drugs for priority
conditions (selected on the basis of public health
relevance and potential for safe and cost-effective
treatment).
Complementary list: essential drugs for which specialised
diagnostic or treatment facilities may be needed
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Selection
WHO Essential Medicines Library
Combining information from various partners
WHO clusters
Clinical
guideline
WHO/EC, Cochrane
Reasons for inclusion
Systematic reviews
Key references
WHO/EDM
Summary of clinical guideline
BNF
WHO Model
Formulary
WHO
Model List
WHO/EDM
MSH
Cost:
UNICEF - per unit
- per treatment
MSF
- per month
- per case prevented
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Statistics:
- ATC
- DDD
WCCs
Oslo/Uppsala
Quality information:
- Basic quality tests
- Intern. Pharmacopoea
- Reference standards
Selection
The WHO Model List of Essential Medicines is a
model product, model process and public health tool
Model process: example for national committees
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Independent Membership of the Committee, careful
consideration of conflict of interest
Transparent process, standard application, web review
Link to evidence-based clinical guidelines
Systematic review of comparative efficacy, safety, costeffectiveness and public health relevance
Rapid dissemination, electronic access
Regular review
Achievements
The essential drugs concept is nearly universal
a floor, not a ceiling - applied differently in different settings
By Dec.1999:
156 countries with EDLS
1/3 within 2 years
3/4 within 5 years
National Essential Drugs List
< 5 years (127)
> 5 years (29)
No NEDL (19)
Unknown (16)
Countries with an official selective list for training, supply, reimbursement or related health objectives.
Some countries have selective state/provincial lists instead of or in addition to national lists.
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Achievements
Treatment guidelines and formulary manuals put the
essential drugs concept into clinical practice
 135 countries have treatment guidelines, formularies
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DAP’s role
Achievements
Training in rational prescribing has expanded in
universities throughout the world
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Problem-based pharmacotherapy
In 21 languages
For medical students,
clinical officers
Measurable improvement in
prescribing
Now also: Teacher’s Guide to
Good Prescribing
Interventions
Impact of problem-based pharmacotherapy teaching
on examination scores (Argentina, 1999-2002)
1999(n=802)
52
2000(n=559)
41,5
2001(n=855)
40
2002(n=131)
36
37,6
16
42,7
20%
40%
3
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15
36
25,2
0%
9,5 2,4
4-5
24,4
60%
6-7
80%
>8
5,9
6,9
8,4
100%
Measuring drug use
Example of an indicator survey time series:
Percent prescriptions by generics, from EDL, and actually
dispensed (Delhi State, 1995-2000)
120
Availability
100
80
60
Generics
40
20
EDL
0
1995
1997
1999
2000
Year under review
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Trends in research:
From drug utilisation to cost-effective intervention (1)
Drug utilisation studies
tend to be descriptive, aggregated data : WHAT?
Indicator studies
more focused on rational drug use:
Qualitative studies
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WHAT?  HOW MUCH?
WHY?
Trends in research:
From drug utilisation to cost-effective intervention (2)
Intervention studies
HOW MUCH? WHY? (intervention) HOW MUCH NOW?
Conclusion  DOES
IT WORK? IS THE INTERVENTION
EFFECTIVE?
Management studies
IS THE INTERVENTION REPRODUCABLE?
IS IT COST-EFFECTIVE?
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Trends in research
Example: Is it reproducable and cost-effective?
Mexico (1992-1994)
Adequate treatment
Diarrhoea: % change
ARI: % change
Cost-benefit ratio
Diarrhoea:
ARI:
Research
District State
46.7
32.6
25.6
28.8
29.3
8.5
3.3
16.2
3.9
18.4
4.4
21.6
Source: Guiscafre et al. Arch Med Res 1995; 26, Supp. S31-39
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Interventions
Promoting rational prescribing:
Interventions which need more testing
Probably effective:
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Drug sellers interventions
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Public education
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Changing fee structure
Probably ineffective:
 Drug information bulletins and other printed materials
 Banning ineffective/dangerous medicines
 Arbitrary prescription limitations, counter signatures
 Traditional stand-up lecturing
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Interventions
Promoting rational prescribing:
Possible interventions in the private sector
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Regulation: market approval, re-licensing, re-evaluation
per therapeutic category, regulation of promotion
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Training: basic training, national clinical guidelines,
continuing medical education by universities and
professional bodies, re-licensing of professionals on basis
of education points, district DThCommittees, medical
audit, patient information leaflets, public education
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Financial incentives: separate prescribing from
dispensing, dispensing fee (flat or tiered), price controls on
generic/brand drugs, contracting out
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Insurance: reimbursement limited to essential medicines,
reference pricing
Interventions
Where to start
in countries with a strong private sector?
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Regulation: market approval, re-licensing, re-evaluation
per therapeutic category, regulation of promotion
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Training: basic training, national clinical guidelines,
continuing medical education by universities and
professional bodies, re-licensing of professionals on basis
of education points, district DThCommittees, medical
audit, patient information leaflets, public education
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Financial incentives: separate prescribing from
dispensing, dispensing fee (flat or tiered), price controls on
generic/brand drugs, contracting out
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Insurance: reimbursement limited to essential medicines,
reference pricing
Conclusion
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Good experiences, policy advice, training
tools and national expertise are available
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Future of essential medicines lies with the
public sector and insurance systems
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There are many effective interventions
possible for the private sector
Thank you
www.who.int / medicines