Transcript Framework for Changing Drug Use Practices

Framework for Changing
Drug Use Practices
1
Framework for Changing Drug
Use Practices: Objectives
• Identify specific drug use problems and
place in perspective of underlying
causes
• Identify 8 - 10 educational, managerial,
and regulatory approaches
• Understand strengths and weaknesses
of different interventions
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Components of the Drug Use
System
Local
Manufacture
Drug Imports
The Drug Supply
Process
Provider and
Consumer Behavior
+
Hospital or
Health Center
Illness Patterns
Private Physician or
Other Practitioner
Pharmacist or
Drug Trader
Public
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Some Factors Influencing
Drug Use
Informational
Unbiased
Information
Personal
Knowledge
Deficits
Influence
of Industry
Acquired
Habits
Cultural
Beliefs
DRUG
USE
Patient
Demand
Workload &
Staffing
Workplace
Infrastructure
Interpersonal
Relation
With Peers
Authority &
Supervision
Workgroup
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Learning about Factors
Underlying Drug Use
Use qualitative methods to
identify motivations and
incentives of prescribers and
patients
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Changing a Drug Use Problem:
An Overview of the Process
1. EXAMINE
Measure Existing
Practices
(Descriptive
Quantitative Studies)
4. FOLLOW UP
Measure Changes
in Outcomes
(Quantitative and Qualitative
Evaluation)
improve
diagnosis
2. DIAGNOSE
Identify Specific
Problems and Causes
(In-depth Quantitative
and Qualitative Studies)
improve
intervention
3. TREAT
Design and Implement
Interventions
(Collect Data to
Measure Outcomes)
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Strategies to Improve Drug Use
Educational:
to inform or
persuade
Managerial:
to structure or guide
decisions
Regulatory:
to restrict or limit
decisions
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Educational Strategies
GOAL: to inform or persuade
• Training for Prescribers
– 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, television
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Training for Prescribers
• WHO has produced a
Guide for Good
Prescribing
• Developed in
Groningen
• Field tested in 7 sites
• Suitable for medical
students, post grads,
and nurses
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Printed Materials
• Cover range of
materials including
journals, newsletters,
ads, STGs, etc.
• Most useful when
combined with other
methods
• Should include key
messages and have
attractive graphics
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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
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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
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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
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Yogyakarta Diarrhea Study
Impact of Targeted Training on Health Worker Knowledge
Impact of Targeted Training on Health Worker Knowledge
10
Knowledge Score
Significant
increase pre
vs. post
8
6
Pre
Post
4
2
0
Face-to-Face
Seminar
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Yogyakarta Diarrhea Study
Impact of Targeted Training on Prescribing of ORS
% Cases Receiving ORS
Differences
from
controls not
significant
100
80
Pre
Post
60
40
20
0
Face-to-Face
Seminar
Control
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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
0
Face-to-Face
Seminar
Control
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Yogyakarta Diarrhea Study
Impact of Targeted Training on Prescribing of Antidiarrheals
% Cases Receiving Antidiarrheals
Significantly
different
from
controls,
p<0.001
100
80
60
Pre
Post
40
20
0
Face-to-Face
Seminar
Control
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Impact of Small Group Training on ORS
Sales in Kenyan Retail Pharmacies
% Prescribing ORS
100
Phase 1
Nairobi
80
Phase 2
Other Cities
60
40
20
Intervention
Control
0
Pre
Post
Pre
Post
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Impact of Patient-Provider Discussion
Groups on Injection Use in Indonesian
PHC Facilities
% Prescribing Injections
80
60
Pre
Post
40
20
0
Intervention
Control
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Effects of Opinion Leader on Choice
Antibiotic for Prophylaxis in a Teaching
Hospital
Discussion
with
Chief of
Obstetrics
% of all C-sections
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Jan
Apr
Jul
84
Oct
Jan
Apr
Jul
85
Oct
Jan
Apr
Jul
Oct
86
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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
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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
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Standard Treatment Guidelines
• STGs lead prescribers
to most cost-effective
treatments
• Particularly useful for
low-level workers
• Can be used for
training, examinations,
and audit
• Used for procurement
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Prescribing Audits plus
"Feedback" to Prescriber
Establish Criteria and Guidelines for Review
AUDIT
(COLLECT DATA ON)
PRESCRIBING
NOTIFY PRESCRIBERS
OF RESULTS
· Individuals or Groups
· Letters or Patient Notes
or in Person
AUDIT
(COLLECT DATA ON)
PRESCRIBING
· Comparison with
Guidelines
· Comparison with Peers
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Regulatory Strategies
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
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Combined Intervention Strategy
Prescribing for Acute Diarrhea in Mexico City
% cases treated in line with algorithm
100
After
Workshop
80
60
After Peer
Review
(n = 20)
37/52
Study Physicians
Control Physicians
79/115
BaselineStage
(n = 20) 42/82
18-months
Follow-up
40
31/110
25/102
20/84
16/70
11/46
20
0
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Impact of Training on Use of Diarrhea
Treatment Algorithm in Three Mexico
Settings
Intervention
given by:
Prescribers
Baseline
%
Post
%
Change
%
"Experts" in 2 clinics
(San Jeronimo)
31
24.5
71.2
+46.7
"Leaders" in 18 clinics
(Coyoacan)
65
17.7
43.4
+ 25.6
"Coordinators" in 124
clinics (Tlaxcala)
157
24.7
31.2
+ 6.5
Source: Munoz, et al, unpublished (1993)
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Conclusion: Interventions to
Change Drug Use (1)
• 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
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Conclusion: Interventions to
Change Drug Use (2)
• Few interventions in hospitals in developing
countries but great potential exists
• Consumers need to be involved. Experience
is lacking, but interactive, context-specific
programs with a mix of communication
channels likely to be effective
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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
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Activity 1
Correcting Antibiotic Misuse
in a South American City
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Activity 2
Which strategies target different
types of underlying motivation?
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