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Impact of Pilot Intervention
(Training) on Prescribing
Patterns in Tajikistan
Isupov S., Makhmudova M.,
Pachadjanova Sh.,
Bobo-khojaeva Z.
WHO Project Strengthening
the pharmaceutical sector of
Tajikistan
Abstract ID: 526
Email: [email protected]
Author Name: Mavlyuda Sharofovna
Makhmudova
Presenter Name: Mavlyuda Sharofovna Makhmudova
Authors: Isupov S., Makhmudova MS, Pachajanova Sh., Bobokhojaeva Z.
Institution: World Health Organization
Title: Impact of Pilot Intervention (Training) on Prescribing Patterns in Tajikistan
Problem Statement: A quantitative drug use indicator study was conducted by the World
Health Organization and the International Network for Rational Use of Drugs to characterize
prescribing practices in primary health care in Tajikistan. Identified drug use problems
include polypharmacy, overprescribing of antibiotics and injections, and insufficient
prescription of generic drugs and pharmaceuticals from the essential medicines list (EML).
Objectives: Interventions (training) were selected with the aim of improving prescribing
practices among doctors in primary health care in Tajikistan.
Design: Twenty-three health facilities were selected by systematic random sampling;
prescribing indicators were measured at these facilities prior to the interventions. Five health
facilities in pilot regions were also selected by systematic random sampling, and their
prescribing indicators were measured after the interventions.
Setting: The study was conducted in public sector facilities (outpatient departments) in all
regions of Tajikistan before the interventions and in five public sector facilities (outpatient
departments) in pilot regions of Tajikistan after the interventions.
Study Population: Doctors from outpatient departments.
Intervention: A participatory, interactive intervention package, including educational and
managerial strategies, was launched. Doctors from outpatient departments of five pilot
regions were trained at workshops on rational drug use.
Outcome Measures: The impact of the pilot intervention was assessed 12 months later by a
repeat drug use indicator study in the intervention group. Primary study outcome
measurement has improved drug prescribing indicators.
Results: When comparing groups before the intervention (control group) and after the
intervention (intervention group), the interventions had little to no effect on the prescribing
of generic drugs (60% of the control group versus 61.4% of the intervention group),
essential drugs (66% versus 67.2%), antibiotics (47% versus 49.6%), and injections (48%
versus 49.6%). Number of drugs prescribed per patient decreased slightly (2.7 versus 2.3).
Conclusions: The intervention itself (baseline/repeat study, visit to health facilities, etc.)
seemed to have little positive effect on prescribing patterns of prescribers. The prescribing
indicators of main concern (i.e., number of antibiotics and injections prescribed) were not
changed by the intervention. This prescribing behavior is deeply ingrained and rooted in
sociocultural conditions and may be due to patient expectations, prescriber (doctor) selfinterest, and peer norms. More effective and repeat educational programs that include
supervision of prescribers and patient education may be necessary. Development of standard
treatment protocols and education programs addressing them may also be necessary.
Study Funding: World Health Organization
• Introduction
Tajikistan is the poorest post-soviet country
which tremendously depends on external aid. The
disintegration of the USSR in 1991, gaining
independence and economical crisis has brought
Tajikistan to the crossroads of political, social and
cultural transformations. Following the brutal civil
war of 1992-1993, migration flow by non-natives
and internal migration by Tajiks from different
regions of Tajikistan have been creating an
educational gap as well as in industry and health
care system including pharmaceutical sector.
•
In developing country like Tajikistan with 6
million people, limited financial resources in the
health sector (expenditure of pharmaceutical
products per capita in 2002 was US $ 0.19), poor
social economic conditions and with high
prevalence of poverty diseases the rational use of
drugs is essential. No comprehensive study has
been conducted to assess the extent of rational
prescribing of drugs in Republic of Tajikistan.
Taking into consideration that conducting such
studies can be a powerful tool for reduction
treatment cost of diseases, specialists of WHO
Project Strengthening of pharmaceutical sector of
Tajikistan conducted study of drug prescribing
practice in PHC health facilities (outpatient
department) in all regions of Tajikistan. Study of
drug prescribing practice includes determination
of the following indicators:
•
•
•
•
•
•
Average number of drugs per prescription,
Percentage of patients receiving antibiotics,
Percentage of patients receiving injections,
Percentage of drugs prescribed as generics,
Percentage of drugs enlisted in National EDL.
• Inappropriate drug use has been identified by
conducted study. Educational and managerial
strategies were selected with the aim of improving
prescribing practices among doctors in primary
health care in Tajikistan. Doctors from outpatient
departments from five pilot regions were trained at
workshops on rational drug use. 12 months later
drug use indicators study was conducted with the
purpose of assessing pilot intervention.
Objectives
•
•
•
•
General
To assess impact of pilot intervention (training) on
prescribing patterns in Republic of Tajikistan
Specific
To find out the prescribing pattern in PHC medical
facilities in all regions of Tajikistan before pilot
intervention
To find out the prescribing pattern in PHC medical
facilities in five pilot regions of Tajikistan after pilot
intervention
To compare the prescribing pattern in PHC
medical facilities before and after pilot intervention
Methods
• Twenty-three PHC facilities (outpatient
departments) were selected by systematic
random sampling. Drug prescribing indicators
were measured at these health facilities prior to
the interventions. Five health facilities in pilot
regions (Dangara, Varzob, Leninskiy, Bokhtar and
Kuliab) were also selected by systematic random
sampling, and their prescribing indicators were
measured after the interventions.
• Study Population:
• Doctors from outpatient departments.
The total study sample covered 1460
prescriptions, 1200 prescriptions pre- and 260
post- the intervention.
• Prescriptions were evaluated using INRUD
indicators (WHO/DAP 1993).
•
•
•
•
•
Parameters studied:
[1] Average number of drugs per prescription
[2] Percentage of patients receiving antibiotics
[3] Percentage of patients receiving injections
[4] Percentage of drugs prescribed as generics
[5] Percentage of drugs enlisted in National EDL.
Results
Prescribing
indicators
Before
intervention
(control
group
After
intervention
(intervention
group)
1.
Average number of
drugs per
prescription
2.7
2.3
2.
Percentage of
patients receiving
antibiotics
47
49.6
3.
Percentage of
patients receiving
injections
48
49.6
4.
Percentage of drugs 60
prescribed
as
generics
61.4
5.
Percentage of drugs
enlisted in National
EDL
67.2
66
Figure 1: Average number of drugs per
prescription before and after intervention
2.8
2.6
the number of drugs
2.4
2.2
2
before intervention after intervention
Figure 2: Comparison of drug prescribing
practice (antibiotics and injections) before and
after intervention
50
49
48
antibiotic
47
injection
46
45
before
after
Figure 3: Comparison of drug prescribing practice
(essential drugs and generics) before and after
intervention
70
65
Essential drugs
Generic drugs
60
55
before intervention
after intervention
Figure 1.
• Results showed that the average number of drugs
prescribed per prescription decreased slightly
from 2.7 in control group to 2.3 in intervention
group.
Figure 2.
• Results showed that the intervention had no effect
on the prescribing antibiotics (percentage of
patients receiving antibiotics increased from 47%
in control group to 49.6% in intervention group),
and injections (percentage of patients receiving
injections increased from 48% in control group to
49.6% in intervention group).
Figure 3.
• Results showed that the interventions had little
effect on the prescribing of generic drugs (60% of
the control group versus 61.4% of the intervention
group) and essential drugs (66% in control group
versus 67.2% in intervention group).
Implications/
Conclusions
• Irrational drug use and inappropriate prescribing
is a global phenomenon which also exists within
Tajikistan.
• Study of drug prescribing practice in PHC facilities
(outpatient departments) in Tajikistan shows:
• Over use of antibiotics, especially in children age
group
• Indiscriminate use of injections
• Inadequate education and training of prescribers
• Lack of educational programs
• Lack of unbiased drug information.
Conclusions
The intervention itself (baseline/repeat study, visit to
health facilities, etc.) seemed to have little positive
effect on prescribing patterns of prescribers. The
prescribing indicators of main concern (i.e., number
of antibiotics and injections prescribed) were not
changed by the intervention. This prescribing
behavior is deeply ingrained and rooted in
sociocultural conditions and may be due to patient
expectations, prescriber (doctor) self-interest, and
peer norms. More effective and repeated educational
programs that include supervision of prescribers and
patient education may be necessary. Development of
standard treatment protocols and education
programs addressing them may also be of great
importance.