Transcript Rational prescription

Rational prescription
C H Chen
Nov., 2001
Mr. Wong, 65 years old,
attended for follow up
Ex-smoker, non drinker
Come for medications 2-monthly as usual
Good tolerance to med. Apart from on
and off dizziness, but no history of
syncope
Problem lists : HT, IHD, AF, Dizziness
Con’t ( case 1 )
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Drug lists ( total 8 weeks of med.)
isordil 10mg tds po
Digoxin 0.25mg qd po
Adalat retard 40mg bd po
Natrilix 2.5mg om po
Stemetil 1 tab tds po prn
Panadol 500mg qid po prn
What will you do ? (case 1 )
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Continue current regime for 8 weeks
more ?
Any things do you want to know ?
Case 1
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BP this time > 102/78
Pulse 68 regular
Physical exam revealed no sign of acute
heart failure, but mild pitting ankle
edema only
No evidence of GIB, no pallor
HS dual , no definite murmur heard
Clinically not in distress
Case 1
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Previous BP : range from 98 to 180 systolic
and 60 to 100 diastolic
No ECG available in the old files
Digoxin and isordil was prescribed by one of
his private physician previously as he was told
that he got IHD and arrthymia.
Latest elecrolyte in Sept., 1999 > K 3.3 with
normal creatinine, corresponding notes
reviewed encourage fruit intake.
Discussion (Case 1 )
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Blood pressure control
Diagnosis of AF and IHD
Dizziness
Good prescribing
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What do patients want and need?
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Advice
Cure: symptom relief
Prognosis
Certificates
4 aims to achieve for
prescribers
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Maximize effectiveness
Minimize risks
Minimize costs
Respect the patient’s choice
Maximize effectiveness
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Pharmacological manipulation of the
body to improve or remove a condition
Use some objective, numerical
measurement to assess effect ( eg., BP
measurement for BP control )
Minimize risks
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Reduce probability of an untoward
happening resulting from drug
treatment
Include transient, minor side effect and
adverse drug reaction
Respect the patient’s choice
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Ethical/practical choice behind patient
Informed choice
Ironically, complying with patient’s choice of
treatment means poor prescriber
Patients are more satisfied if doctors listen to
their views, negotiating the details of drug
treatment may improves compliance
conflicts
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Effectiveness and risks
Cost effectiveness and patient’s choice
Rational prescribing
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Correct diagnosis
Appropriate drug, dose, route and duration
Simple regimen
Avoid drugs if therapeutic advantage not
supported by independent evidence
Avoid drugs with poor risk/benefit ratios
Review regularly and terminate if no longer
needed
The most powerful drug:
doctor
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Understanding
Explanation
Reassurance and prognosis
Placebo effect
Adverse drug reaction (ADR)
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Generally under-reported
A threat to patient’s health and quality
of care
Generates significant expenses
ADR
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Unwanted or unintended effects of a
medicine which occur during its proper
use
Extrinsic and intrinsic factors
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Extrinsic
> Errors in manufacturing, supplying,
prescribling, giving or taking medicine
Intrinsic
> inherent properties of the medicine
itself may cause unwanted effects
Medication related problems
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Prescription cascade
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Misinterpretation of an adverse drug event
as another medical condition
Prescription of additional medications
Non-adherence
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poor therapeutic outcomes
higher dosages or more potent therapies
ADR
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Survey done at one of the university
hospital in Switzerland
6 months of surveying to all primary
admissions to medical emergency department
Total about 7% of admissions related to ADR
Most common being of GIB, follow by febrile
neutropenia
Anti-cancer drugs in 22.7% of cases
ADR
Anticoagulants, analgesic and nonsteroidal anti-inflammatory drugs in 8
% of cases each
Case 2
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Mr. Chan, 60 years old, attended for
follow up as usual
Chronic smoker, social drinker
Presented with exertional dysneoa and
wheezing
Associated with chronic dry cough
No recent hospitalization
Case 2
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Claimed good drug compliance with
regular usage of puffer
ET > level ground only
Problem list : COAD, HT
Drugs list
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Ventolin puff 2 puffs qid prn
Atrovent puff 2 puffs qid prn
Theodur 100mg tds po
Bricanyl durule 7.5mg bd po
Ventolin 4mg tds po
Inderal 40mg tds po
Betaloc 50mg bd po
Case 2
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Clinically not in distress with occ.
Coughing only
Chest occ. Rhonchi with poor expansion
of lung and hence poor air entry
BP 155/90, P 66 with occ. Ectopic heart
beat
PFR 130/150
Discussion (case 2 )
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Coad control
BP control
Side effect profiles
Alternative choice of agents
Treatment other than drugs
Are Hong Kong doctors overprescribing?
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Expenditure on drugs per capita in HK
2-3X that of UK
Items prescribed:
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HK Government OPD:just under 3
UK:just over 1
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Regional/international standards
(national library of med. )
2 for the average of the drug
17% for injection
50% for antibiotics
A pill for every ill??
Random sample of 1068 HK Chinese
interviewed by telephone done in 1995
results
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40% thought illnesses always needed
drug treatment
76% expected prescription
Almost 100% got prescription in their
last consultation
85% prescription > 3 or more drugs
< 50% finished all the medication
result
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Younger age and higher education
associated with less likelihood of
expecting prescription
conclusion
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Chinese do not expect a pill for every ill
but doctors prescribe in nearly 100% of
consultations
Doctors created high expectation for a
prescription in every consultation
through their own prescribing habit
The influence of patients’ hopes of
receiving a prescription on doctors’
perceptions and the decision to
prescribe: a questionnaire survey
BMJ Vol 315 6 Dec 97
Design
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Questionnaires to patients waiting to
see GP and to doctors immediately after
their consultations
Subjects
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544 unselected patients consulting 15
GP
Results
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67% patient hope for prescription
Doctors perceived 56% patients wanted
prescriptions
59% doctors prescribed
25% of patients hoped for a
prescription did not receive one
Conclusion
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Decision to prescribe was closely related
to actual and perceived expectations,
the latter being more significant
Over-prescription of antibiotics
in primary care
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20-50% believed to be unnecessary
Factors responsible for
inappropriate antibiotic use
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Patient factors
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Misconception about what antibiotics do
Misconception about healing power of
antibiotics
Factors responsible for
inappropriate antibiotic use
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Physician factors
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Real or perceived patient pressure
Economic concern for self e.g. loss of
clients
Physician fallibility:inadequate knowledge
Uncertainty of the diagnosis
Easing himself ( something done )
Factors responsible for
inappropriate antibiotic use
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Other factors
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Cost saving pressures to substitute therapy
for diagnostic test
Reduce appointment time per patient
Misleading advertisement
Cultural factor
Final comments
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Do he needs prescriptions
Is it indicated
Adverse drug reactions
Risk and benefits ratio
Polypharmacy
Always review drug lists
Review drug regimen
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All new medication should started as a
trial
Substitute instead of adding on new
medications
Look for signs of adverse reactions and
drug induced problems
Improving rational prescription
Physician training
>more training to communicate with
patients about risk and benefit
>training in decision analysis
>undergraduate/continuing education in
therapeutics
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Improving rational prescription
Patient education
 Public need to be educated about the
risks and benefits of medical
interventions
Government
Pharmacist
media
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