Transcript Slide 1 - WHO archives

Authors: Moravcevic N, Chiperi A
Presenter Name: Natasa Moravcevic
Institution: WHO Regional Office for Europe, WHO country Office Serbia and Montenegro
Title: Drug Prescribing Habits in Primary Health Care Facilities and Availability of
Drugs in Private and State Pharmacies in the Republic of Serbia
Abstract:
Problem Statement: Irrational drug prescribing presents a major problem in the Republic of
Serbia. The availability of drugs and pricing are not consistent. A study on drug prescribing
habits in primary health care was conducted in 2000, and confirmed the situation. It also
provided significant indicators for improving the situation. Nevertheless, the situation
remains almost the same in 2003.
Objectives: To assess current drug use practices in a representative sample of primary health
care facilities, and compare the results with the previous study; show the availability of drugs
in pharmacies; and compare the prices regulated by the law, international reference prices
and prices found in selected pharmacies.
Design: Cross-sectional study with comparison.
Setting and Population: 10 state Primary Health Centers and 10 state Health Stations in
Serbia randomly selected, using patient records and interviews; the first 30 patients that
visited a health facility on October 6; 20 state pharmacies; and 20 private pharmacies chosen
by two phase cluster sampling method, using interviews.
Intervention: The study had three phases. Preparation and training of interviewers
(completed in October 2003); data were collected in the last week of October; and data
processing and analysis were finalized in November 2003.
Outcome Measures: Average number of drugs prescribed per encounter; % of prescribed
drugs from different groups; order of frequency of most frequently established diagnoses;
years of experience and gender of general practitioners; prescription made at the
recommendation (finding of specialists) versus prescriptions decided solely by the general
practitioner (GP); practices of advising patients; availability of independent information on
drugs; information on medical waste treatment; % of international median price of selected
essential drugs in private pharmacies; average difference coefficient between minimum and
maximum prices of the selected drugs in private pharmacies; average percentage of the
selected drugs available in pharmacies.
Results: Primary health care doctors serve older age groups with characteristic pathology,
and their prescribing trends are still not rational but vary from the earlier study. Doctors do
not have sufficient information, training and documentation on new drugs and treatments.
Availability of drugs both in private and state pharmacies is inadequate. Prices vary too much
considering the fact that prices for locally manufactured drugs are regulated by the law.
Conclusions: The situation turned out to be worse than expected. Enforcement of concrete
activities is necessary. The Study pointed out the need for additional studies that could
provide important information for authorities and further actions.
Study Funding: WHO Regular Country Budget for Serbia and Montenegro – Biennial
Collaborative Agreement 2002-2003, WHO Country Office, Serbia and Montenegro
(Belgrade)
BACKGROUND
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Republic of Serbia is the part of Serbia and
Montenegro (former FR Yugoslavia)
The population of Serbia is 7,478,820 (2002 census)
The economy has begun to recover but political
stability is not assured yet
Increasing inequality, decreasing purchasing power,
high unemployment
Average monthly salary about 176 Euros
Life expectancy 69 years for men and 74.46 for women
Cardiovascular diseases, cancers, and injuries
responsible for 80% of the total mortality burden
Very low availability of essential medicines in private
and public sector in last decade
Study on prescribing habits in primary health care
conducted in 2000 by WHO Office in Belgrade
Study showed high level of irrational drug prescribing
and gave significant indicators for improvement
Since 2000 various activities undertaken – new
prescription form, formulary, clinical guidelines for
some diseases
Limited public resources for improvement of the
situation
OBJECTIVES
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The objectives of the Study were:
 To describe current drug use practices in a
representative sample of primary care facilities in a
standardized, reproducible manner,
 To compare results with the 2000 Study,
 To show the availability of medicines in public
pharmacies,
 To compare the prices of medicines regulated by
law, international prices and prices found in
pharmacies.
It was expected that Study will help us:
 To show that undertaken steps were useful,
 To realize weak points in prescribing habits,
 To confirm that availability of medicines is
sufficient at least in private pharmacies,
 To prove that locally manufactured medicines have
consistent prices,
 To indicate further activities for improvement.
METHODS
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The Study was a follow-up of the 2000 Study with
additional part concerning availability and pricing
The type of Study was cross sectional survey of
representative sample
Sampling units were primary health care facility and
pharmacy:
 20 primary health facilities (10 Primary Health
Centers and 10 linked Health Stations) with 30
patient encounters in each – the first 30 files of
patients that visited one GP on October 6th, 2003.
 20 state pharmacies within those centers plus 20
private pharmacies randomly selected
Simple random sampling was used for health facilities
and combined two-phase cluster sampling for
pharmacies
There were exclusion criteria:
 Specialist primary health care doctors –
immunization, pediatrics, gynecology and
obstetrics, occupational health
 Foreign doctors employed by international
organizations
 Patients under 16
METHODS
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6 students from Faculty of Pharmacy were engaged
and trained for data collection – groups of two students
visited each facility
Students were supervised by authors of the Study
Data processing and analysis were done in EPI INFO
according to validated questionnaires
Questionnaires were created based on the number of
indicators considering:
 Data on doctors
 Data on patients
 Diagnoses
 Prescribed drugs – groups of drugs, different forms
of drugs
 Available literature
 Treatment of medical waste
 Generic substitution (local and foreign)
 Availability
 Prices
 Inspection visits
RESULTS
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There is a high number
of patients elder than 61
Surprising number of
female GPs
All GPs have some kind
of professional literature:
 Drug register (89,2%
mainly old edition)
 Reimbursable drug
list (94,6 %)
 Treatment protocols
(43%) – at the
moment exist only
for 4 diseases
 Professional
magazines (30%)
 Advertising material
(20%)
Patient
age
Patient gender
more
than 61
years
female
54,33 %
54,33
45,67
(60*) % (40*) %
GP age
male
GP gender
male
female
0-5 years
10-15
years
More
than 15
5,41 %
94,59 %
27,03 %
24,32 %
48,65 %
RESULTS
Morbidity of the sampled patients and top 10 diagnosed
diseases
#
code International Classification of Diseases
%
1
I
Diseases of the circulatory system
(I10-17.2%; I25-2.97%; I20-2.73%;
I49-2.73%)
32.70
2
J
Diseases of the respiratory system
(J02-4.99%; J42-2.38%)
15.81
3
M
Diseases of the musculoskeletal
system and connective tissue (M544.64%)
9.87
4
E
Endocrine, nutritional and metabolic
diseases (E11-4.52%; E14-3.21%)
9.75
5
F
Mental and behavioral disorders
7.25
6
K
Diseases of digestive system (K262.26%)
6.54
7
N
Diseases of genito-urinary system
3.92
8
S
Injury, poisoning and certain other
consequences of external causes
3.09
9
G
Diseases of the nervous system
2.73
10 H
Diseases of the eye and adnexa
2.50
RESULTS
Average # of
diagnosis per
patient
1-2 diagnosis
per patient
3 diagnosis 4-5 diagnosis
per patient
per patient
2000
2003
2000
2003
2000 2003 2000
1.252 1.402
86.67
%
91.83
%
4.8% 6.5% 1.1% 1.34%
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2003
All medicines are prescribed as brands; practice of
generic prescribing is not in place yet
There are insufficient information and lack of training
in generic prescribing
In 13,2% cases GPs prescribe drugs according to
specialist recommendation
In 34,2% of cases GPs verbally recommend: vitamin
C, diet, hydration, resting
Total # Total
of
# of
patients drugs
600/
1800*
1398/
3497*
Average 0 drugs
drugs
prescr.
per
(%)
patient
2.33/
1.94*
3/
18.4*
1-3
drugs
prescr.
4-6
drugs
prescr.
7 and
more
drugs
prescr.
77.67/
67.88*
18/
13.3*
1.33/
1.01*
RESULTS
Most prescribed medicines (presented as generics)
2000 Study
#
2003 Study
%
#
%
1
Diazepam
8.07
1
Diazepam
7.87
2
Diclofenac
sodium
6.21
2
Diclofenac
sodium
6.29
3
Captopril
4.06
3
Enalapril
5.36
4
Indapamide
3.95
4
Bromazepam
3.58
5
Ibuprofen
3.00
5
Ibuprofen
3.15
6
Nifedipine
2.89
6
Ranitidine
2.86
7
Ranitidine
2.37
7
Amoxicillin
2.79
8
Verapamil
2.26
8
Verapamil
2.72
9
Cotrimoxasole
2.14
9
Cephalexin
2.58
10 Aminophylline
1.80
10 Aminophylline
2.36
RESULTS
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81.62% (84.11% in 2000) of prescribed drugs were
oral
13.45% (14.33% in 2000) were prescribed injections
Cardio-vascular diseases – the most prescribed were
ACE inhibitors, Ca antagonists and diuretics
Benzodiazepins are less prescribed than in 2000
Most prescribed antibiotics are amoxicillin, cephalexin
and cotrimoxasole
9.73% oral antibiotics and 2.07% injections (better
than in 2000 – 12.22/4.67)
Other significantly prescribed groups:
 Analgesics
 Vitamins
 Steroids
 H2-blockers
 Beta-blockers
 Antidiabetics
RESULTS
Availability of drugs and pricing
 10 out of 18 studied medicines were taken for analysis
(cephalexin, gentamycine, ibuprofen, nimesulid,
alprazolam, fluoxetin, dexamethasone,
methylprednisolone, enalapril, verapamil)
 All chosen medicines are in reimbursable list and have
marketing authorization
 Availability is not satisfactory especially in private
pharmacies
 Price ranges are too high considering the regulated
prices for domestic manufacturers
 Prices are compared with median prices from
International Drug Price Indicator Guide (2002 edition)
and medicines in Serbian market is much more
expensive
Conclusions:
 Drug pricing system needs to be adapted
 Control mechanism for prices in pharmacies need to be
enforced
 The reimbursable list needs to be reviewed
 Training and strengthening of pharmacists awareness is
necessary
CONCLUSIONS
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The situation is slightly different than in 2000
Rational drug prescribing promotion for professionals
is necessary
Introduction of generic prescribing is needed
Introduction of new clinical guidelines and adequate
promotion of new and existing guidelines
Public and patient education would be useful – there is
a pressure on professionals since in last decade practice
of self-medication was intensified
Preventive health care system has to be strengthen as
well as health promotion
Efficient control mechanisms for pricing and
prescribing have to be developed