Transcript the relationship between drug supply and

THE RELATIONSHIP BETWEEN
DRUG SUPPLY AND PRESCRIBING
PATTERNS IN DISTRICT
HOSPITALS IN UGANDA
Ogwal-Okeng JW, Obua C, and Anokbonggo WW.
International Conference on Improving Use of
Medicines
Chiang Mai, Thailand
April 1, 2004
INRUD Uganda and Makerere University
Project supported as part of the Joint Initiative on Improving
Use of Medicines under a grant from ARCH
ABSTRACT
Problem Statement: In Uganda, the supply and availability of essential drugs have continued to be a problem even after the
passing of a Local Government Act (LGA) in 1993, which shifted responsibilities for health services delivery from the
Central Government to district level decision-making. The new policy was intended to enhance the quality of health
services, improve pharmaceutical supplies, and increase the patronage of health facilities. INRUD-Uganda recently
conducted a study on the effect of the policy on drug stock levels in two district hospitals. It was found that resource
constraints and an erratic supply system prevented either district from achieving a full supply of drugs in the hospitals.
Drugs tended to cycle through periods of adequate stocks and stock outs. We do not know how the prescribing behavior of
the prescribers is influenced by the drug supply situations. This study therefore proposes to study the relationship between
drug supply level and prescribing decisions for treatment of acute respiratory infection (ARI), diarrhoea and malaria in the
two districts. Our hypothesis is that rational prescription may not be affected by changes in pharmaceutical supply levels.
Objectives: 1). To explore the prescribing patterns for malaria, ARI and non-infective diarrhoea when there are fluctuations
in drug supply; 2). To establish the overall distribution of drugs prescribed to treat malaria, ARI and diarrhoea; 3). To
investigate the effects of change of drugs recommended in the Uganda STG on prescription adherence to the guideline
recommendation; 4). To investigate the effects of the availability of non-first line drugs on the prescribing adherence to
recommended guidelines for malaria, ARI and diarrhoea; 5). To investigate the effects of the non-availability of
recommended drugs on prescribing behavior for malaria, ARI and diarrhoea.
Study Design: Analytical and descriptive study. It will be a retrospective evaluation of the prescriptions at various levels of
stocks in the two hospitals using interrupted time series analysis. Outcome measures will be the selection of drugs for
malaria, ARI and non-infective diarrhoea, and stock levels over a period of time.
Study Setting and Population: Prescriptions will be collected for malaria, ARI and non-dysenteric diarrhoea in Lira and
Apac hospitals in the period extending one year before and two years after decentralization. Outcome Measures: 1). Drug
selection/choices for malaria, ARI and diarrhoea when the guideline recommended drugs increase or decrease in stock;
2). Overall distribution of drugs prescribed for malaria, ARI and diarrhoea during this period. Data will be collected
retrospectively from outpatient records and hospital stock records.
Results: This paper will present the prescription choices for ARI, malaria and diarrhoea during periods when the
recommended drugs are in stock and when there are stock outs.
Study Funding: International Network for Rational Use of Drugs (INRUD) through a grant from the United States Agency
for International Development (USAID).
BACKGROUND
•
Inadequate and uncertain availability of essential drugs is
a common phenomenon in Uganda health units.
•
The decentralization policy operates on a pull
system of procurement of health supplies.
•
Resource constraints contributed to erratic supply of
drugs in two district hospitals studied.
•
Drug supply tended to cycle through periods of adequate
stocks, low stocks, and stock-outs.
•
Need to know (compare) how prescribing was influenced
by drug supply (stock levels).
OBJECTIVES
To explore the relationship between availability of drugs and
prescribing patterns for malaria and ARI during when availability was
changing rapidly and to assess if fluctuations in drug supply is a
determinant of inappropriate prescribing patterns.
Specific Objectives
• To establish the over all distribution of drugs prescribed to treat
malaria, ARI and diarrhoea.
• To explore the prescribing patterns for malaria, ARI and non-infective
diarrhoea when there are fluctuations in drug supply.
• To investigate the effects of the non-availability of recommended drug
on the prescribing behavior for malaria, ARI and diarrhoea.
• To investigate the effects of the availability of non-first line drugs on the
prescribing adherence and behavior to recommended guidelines for
malaria, ARI and diarrhoea.
METHODS
•
Retrospective interrupted time series analysis of prescriptions at various
levels of stocks in two district hospitals in Uganda.
•
Prescription data collected retrospectively one before and two years after
decentralization from the district hospitals of Apac and Lira, Uganda.
•
Outcome measures being drug selection choices for malaria, ARI and noninfective diarrhoea and stock levels over a period of time, with reference to
national guidelines.
•
Overall distribution of drugs prescribed for malaria, ARI and diarrhoea.
METHODS CONT.
Specific Variables:
• Level of stocks – actual counts by the middle of each month
• Prescription - # of drugs per case,
- drug distribution as frequency of prescribing of
individual drug per condition
- # drug choices conforming with national
guidelines by middle of each month
- # drug choices outside the national guidelines by
middle of each month
300
250
ch o ices%
Cq S to cks(x1000) an d Dru g
Figure I: Drug Choices and Stock Levels
of Chloroquine- Lira Hospital
Cqavial
200
Cqc hoic e
150
Q NNc hoic
100
S pc hoic e
50
0
1
4
7
10
13
16
19
22
T im e S e rie s (m o n th s)
25
Cq Stocks(x1000)/drugchoices
%
Figure II: Drug Choices and Stock Levels of
Chloroquine- Apac Hospital
180
160
140
120
100
80
60
40
20
0
Cqavail
Cqchoice
QNNchoic
Spchoice
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
Time Series (months)
RESULTS
• Figure I, relationship between choices
antimalarial drugs and stock levels of
chloroquine.
• Lira -Chloroquine choice not vary with
stock level.
- Prescription of other antimalarials
left chloroquine stock levels high.
RESULTS (CONT).
• Apac
-Chloroquine stock levels were
influenced by prescribing choice.
-Prescribing alternative drugs led
to less choice of chloroquine and
this left the stock levels high.
CONCLUSIONS
• Stock levels of chloroquine did not influence the
choice of antimalarial drugs.
• Stock levels were influenced by prescribing
choices.
• Drugs were prescribed because of availability.
• Chloroquine seems to have been supplied with the
other antimalarials, so they became available at
the same time.