Transcript Oral Presentation 1

Impact of an essential drugs
list and treatment guidelines on
prescribing in South Africa.
Pillay T, Hill SR
University of Newcastle
Background
 National Drug Policy identifies the need
for an Essential Drugs Programme.
 EDL and Standard Treatment
Guidelines published in 1998.
 No evaluation of prescriber compliance
with the guidelines.
 Pilot studies suggest that prescribers do
not follow the hypertension guidelines.
Approaches to measuring
compliance with guidelines?
 Database of prescriptions – public
sector in SA does not capture
prescription electronically.
 Indicators
 Monitoring National Drug Policy-rational
use indicators require prescription survey
 Assessing drug use at facilities require
prescription survey.
Problems with prescription
surveys for this study
 How do you choose which hospitals to
survey prescriptions?
 There are 60 hospitals (urban and rural)
in the province of KZN.
 Prescription survey will be time
consuming.
 Requires financial and human
resources.
Can we use aggregate
purchases data?
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Defined daily dose (Nordic)
Average daily quantity (UK)
Equipotent dose (Danish)
Minimum marketed dose
Prescribed daily dose
All of the above are fairly similar however
they are all based on average dsing in
other countries.
Alternative approach in resource
poor settings
Use patients ready packs as the measure
of drug use. Advantages:
 Does not reply on the average dose
prescribed in Nordic countries
 More accurate reflection of the exact quantity
of drug dispensed to a patient over a 28 day
period.
 Allows for variation in dosage
 Unit of issue ex-manufacturer
Application of methodology in
hypertension
1. Calculate the total number of PRPs
issued for each drug over a 6 month
period.
2. Add up the total number of PRPs for
each dug class ie all diuretics, beta
blockers, ACEI.
3. Then obtain a total for PRPs all
antihypertensive drugs.
Prescription survey to validate drug
supply data
 16 hospitals selected from the three categories of
methyldopa use (low, moderate and high) for survey.
 urban and rural hospitals.
 100 prescriptions presented to the outpatient pharmacy
department for the management of uncomplicated
essential hypertension.
 The prescriptions were analysed to determine:
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whether supply data and prescription data were similar
the proportion of each antihypertensive class,
monotherapy and combination therapy,
the doses prescribed
What should we expect if prescribers
followed the hypertension guidelines?
The trend in proportional use (highest to
lowest)
 Diuretics
 Reserpine
 Beta blockers
 ACEI
 Calcium channel blockers
What did we find?
Proportion of Antihypertensives Supplied to hospitals
over a six month period
60
Percentage supplied
(standard deviation)
50
40
30
20
10
0
Diuretics
ACEI
Methyldopa
Reserpine
Beta
blockers
CCB
Pharmacological Agents Supplied over 6 months
Other
Which hospitals are using large
volumes of methyldopa?
Number of hospitals in each category of methyldopa supply
Number of hospitals
40
30
20
19
18
17
low (<5%)
moderate (5-12%)
high (>12%)
10
0
Categories of methyldopa supply
How does the prescription survey compare with the estimates from
the supply data
Level of
Use
Standard
treatment
guideline
Estimated use
from the supply
data as
proportional use
Prescription
Survey expressed
as proportional
use
Prescription Survey
expressed as no. of
drugs per 100
prescriptions
1st Line
Diuretic
Diuretics 42%
Diuretics 44%
Diuretics 85%
2nd Line
Reserpine
ACEI 27%
ACEI 30%
ACEI 58%
3rd Line
Beta blocker
Methyldopa 10%
CCB 12%
CCB 24%
4th Line
ACEI
Reserpine 7%
Beta blocker 7%
Beta blocker 13%
5th Line
CCB
Beta blocker 6%
Methyldopa 5%
Methyldopa 10%
6th Line
Alpha Blocker CCB 6%
Reserpine 3%
Reserpine 5%
Conclusions
1. “Patient ready packs” provides a
useful alternative method for
estimation of drug use.
2. Supply data analysis and the
prescription survey results are similar.
3. Probably most useful for chronic
diseases
Conclusions
4. The general prescribing trend
suggests that prescribers do not follow
the guidelines.
5. Methyldopa is widely prescribed at
certain hospitals in the province.
6. ACEI are used as 2nd line add therapy.
7. Beta blockers are not widely
prescribed even though there is good
evidence to support their use and they
are cheaper.