Transcript Poster presentation

Improving Chloroquine Prescribing in
PrivateClinics in Lagos State, Nigeria
*Taylor O, **Momodu RO, **Odufalu O
*World Health Organisation
**National Agency for Food and Drug Administration
and Control (NAFDAC)
Introduction/Background
Chloroquine has been very valuable for the chemotherapy of
malaria for several decades by virtue of its safety, wide
availability and affordability. However, chloroquine is fast
becoming ineffective in the management of malaria due the
development of chloroquine resistant plasmodium parasites.
It is thought that irrational prescribing of chloroquine among
other factors is responsible for the development of resistance.
Studies show that less than half of chloroquine prescriptions in
private and public health facilities were inappropriate in Lagos
State, Nigeria.
The study describes an intervention to determine the best
approach to improve multiple dosing regimen such as found in
chloroquine among private health facilities in Lagos State. The
effect of using an aidememoire and dosing information printed
on a sheet of paper was compared.
Objectives/Study Questions
It is hypothesised that the various dosing
schedules for different ages may be difficult
for prescribers to remember. The objective
of the study is to test the effectiveness of
an aidememoire placed on the table in
comparison with the same information
printed on a sheet of paper handed over to
the prescriber after face to face academic
detailing in improving chloroquine
prescribing.
METHODS
The prescribing patterns of chloroquine were surveyed before
and after intervention in 13 private health facilities in Lagos State,
Nigeria. All chloroquine-containing prescriptions were recorded in
each of the facilities between April to December 1999. Intervention
was carried out in January 2000 and prescriptions were recorded for
the post intervention study between February and July 2000.
Improvement in the prescription of chloroquine after
intervention was judged on the basis of the following outcome
indicators:
Increase in the percentage of prescriptions having the correct
chloroquine doses.
Increase in the percentage of chloroquine prescriptions with the oral
dosage form
Increase in the percentage of prescriptions with chloroquine
injections followed up with the oral form.
Decrease in the percentage of prescriptions with chloroquine
injections only.
INTERVENTION METHODS
13 private health facilities were randomly assigned as follows:
 Group 1: 5 hospitals received academic detailing and an
aidememoire with the dosing schedule of chloroquine
 Group 2: 4 hospitals received academic detailing and printed
dosing schedule of chloroquine.
 Group 3: 4 hospitals did not receive any information on
chloroquine dosing.
Academic Detailing:
Two persons visited the prescribers in their health facilities. A
computer notebook using the Microsoft Power Point software was used
to make presentations to the physicians in their consulting rooms. The
key messages were:
a) Using the oral dosage form as the preferred route of administration.
b) Using injections only when the oral route becomes impossible but
including the oral dosage form as a follow up to injections.
INTERVENTION METHODS
AIDEMEMOIRE
The aidememoire consists of a plastic box filled with loose
sheets. These are gift items that are used by corporate bodies for
publicising either their products or their organisations. The dosing
schedules corresponding to different age groups were printed on
plastic boxes placed on the physicians' tables after the educational
encounter and the prescribers were encouraged to refer to them
while prescribing.
DRUG INFORMATION SHEETS
The same dosing schedules printed on the plastic boxes were
printed on a sheet of paper and handed over to the prescribers
after the face to face training.
RESULTS
Baseline results
Figure 1 shows that 2 (15%) of the clinics had between 50% and
80% prescriptions in the recommended dose while 11 (85%) had
between 0% and 50%.
Increase in the percentage of prescriptions having the correct dosing
schedule of chloroquine.
Figure 2 shows the percentage of chloroquine prescribed in the
recommended dosage form increased by 26% in the aidememoire
group. The use of drug information sheets did not elicit an
appreciable improvement in prescribing since the recommended
dose only increased by 4%. In the control group the
recommended dose remained approximately the same.
Decrease in the percentage of prescriptions with chloroquine
injections only.
The message, which emphasised the reduction in the use of
injections alone, was heeded by the group that was given the
aidememoire as a 24% decrease was recorded after the
intervention. The group that received drug information sheets
also recorded a decrease of 14% in the use of injections alone
while the control had a 5% increase.
RESULTS (CONTD)
Increase in the percentage of prescriptions with
chloroquine injections followed up with the oral form.
Only the aidememoire group increased their use of injection
followed up with the oral dosage forms by 11% while the drug
information group had no appreciable increase (1%). There was
a 22% reduction in the use of the injection with the oral dosage
form in the control group.
Increase in the percentage of chloroquine
prescriptions with the oral dosage form
The use of the oral form of chloroquine increased in all the
groups; 16% in the aidememoire group, 13% in the drug
information sheet group and 16% in the control group.
PERCENTAGEOF PRESCRIPTIONS
FIGURE 1: PERCENTAGE OF PRESCRIPTIONS IN
RECOMMENDED DOSES
80
73
PRE
70
POST
60
50
47
51
52
44
44
40
30
20
10
0
AIDEMEMOIRE
DRUG
INFORMATION
CONTROL
PERCENTAGE OF PRESCRIPTIONS
FIGURE 2 PERCENTAGE OF PRESCRIPTIONS
WITH CHLOROQUINE ONLY INJECTIONS
50
45
40
35
30
25
20
15
10
5
0
PRE
POST
47
42
40
33
26
9
AIDEMEMOIRE
DRUG
INFORMATION
CONTROL
PERCENTAGEOF PRESCRIPTIONS
FIGURE 3: PERCENTAGE OF PRESCRIPTIONS
TABLET AND INJECTIONS
50
45
PRE
POST
45
40
35
34
30
30
25
20
20
19
15
9
10
5
0
AIDEMEMOIRE
DRUG INFORMATION
CONTROL
PERCENTAGE OF PRESCRIPTIONS
FIGURE 4: PERCENTAGE OF PRESCRIPTIONS
AS ORAL DOSAGE FORM
60
PRE
54
POST
47
50
44
41
40
31
28
30
20
10
0
AIDEMEMOIRE
DRUG
INFORMATION
CONTROL
IMPLICATIONS/RECOMMENDATIONS
There is lack of attention paid to the private sector despite the
fact that about 60% of the Nigerian population use the private
sector. In this study, baseline studies showed most of the
facilities recorded very low percentage of prescriptions in the
recommended dose. It is noteworthy that one of the facilities
had not even one correct prescription. For drugs that are subject
to development of resistance such as anti-infectives, it is
important that monitoring of therapy should not be limited to
the public sector if drug resistance is to be mitigated.
Adequate attention was not paid to rational use of chloroquine
and today, it is no longer effective in the malaria treatment
despite its advantages. Most countries are turning to the
artemisinin derivatives as first line antimalarials. It is important
that efforts be made to preserve the long term use of these drugs
and other new antimalarials to mitigate future development of
resistance.
Use of newer antimalarials need to be closely monitored in both
private and public sectors and any irrational behaviour promptly
corrected. Aidememoires can immediately be put into use to
test their effectiveness in preventing irrational prescribing of
newer antimalarials.