Transcript Promoting Rational Use of Drugs Krisantha Weerasuriya MD Objectives • Define rational use of medicines and identify the magnitude of the problem • Understand.

Promoting Rational Use of Drugs
Krisantha Weerasuriya MD
Objectives
• Define rational use of medicines and
identify the magnitude of the problem
• Understand the reasons underlying
irrational use
• Discuss strategies and interventions to
promote rational use of medicines
• Some questions to ponder
Department of Essential Medicines and Health Products
TBS 2012
The rational use of drugs requires that patients receive
medications appropriate to their clinical needs, in
doses that meet their own individual requirements for
an adequate period of time, and at the lowest cost to
them and their community.
WHO conference of experts Nairobi 1985
• correct drug
• appropriate indication
• appropriate drug considering efficacy, safety, suitability for the
patient, and cost
• appropriate dosage, administration, duration
• no contraindications
• correct dispensing, including appropriate information for patients
• patient adherence to treatment
Could there have been a better term than "Rational" ?
Department of Essential Medicines and Health Products
TBS 2012
Snapshots in Low and Middle Income Countries
% diarrhoea cases treated
Treatment of diarrhoea in private and public
sectors
70
60
50
40
30
20
10
0
ORS use
Antibiotic use
Private-for-profit (n=43,33,35,4)
Department of Essential Medicines and Health Products
TBS 2012
Antidiarrhoeal
use
STG compliance
Public (n=119, 100, 67, 80)
% STG compliance
45
40
35
30
25
20
15
10
5
0
PR_NOPROF
PR_PROF
% STG compliance
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TBS 2012
PUB
Treatment of ARI by prescriber type
% ARI cases treated
80
70
60
50
40
30
20
10
0
Cough syrup use
Approp.ABs in
pneumonia
Doctor (n=20,18,40,12)
Inapprop.ABs in
viral URTI
STG compliance
Paramedic/nurse (n=13,94,69,61)
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TBS 2012
% Com pliance w ith STGs over tim e
70
60
50
40
30
20
10
0
<1992
1992-4
1995-7
1998-00
2001-3
2004-6
Africa
L.America
E.Mediterr
Europe
SE.Asia
W.Pacific
Data from EMP Pharmaceuticals Database
Department of Essential Medicines and Health Products
TBS 2012
2007-9
Overuse and misuse of antimicrobials
contributes to antimicrobial resistance
Source: WHO country data 2000-3
• Malaria
– choroquine resistance in 81/92 countries
• Tuberculosis
– 0-17 % primary multi-drug resistance
• HIV/AIDS
– 0-25 % primary resistance to at least one anti-retroviral
• Gonorrhoea
– 5-98 % penicillin resistance in N. gonorrhoeae
• Pneumonia and bacterial meningitis
– 0-70 % penicillin resistance in S. pneumoniae
• Diarrhoea: shigellosis
– 10-90% ampicillin resistance, 5-95% cotrimoxazole resistance
• Hospital infections
– 0-70% S. Aureus resistance to all penicillins & cephalosporins
Department of Essential Medicines and Health Products
TBS 2012
Snapshots High Income Countries
Variation in outpatient antibiotic use in 26 European
countries in 2002
35
DDD per 1000 inh. per day
30
25
20
15
10
5
0
FR GR LU PT
IT
BE SK HR PL IS
IE ES
FI BG CZ SI
SE HU NO UK DK DE LV AT EE NL
Source: Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.
Department of Essential Medicines and Health Products
TBS 2012
How many LMICs can provide this data?
This provides antibiotics by class and total; how many of
your countries can provide even the total?
Whose responsibility is it to collect the data?
Are health systems in LMICs comprehensive enough to
collect this data?
Department of Essential Medicines and Health Products
TBS 2012
Snapshots High Income Countries
Top 10 drugs by Prescription counts in
Australia 2009-2010
1. atorvastatin
2. esomeprazole
3. simvastatin
4. rosuvastatin
5. paracetamol
6. perindopril
7. pantoprazole
8. metformin
9. atenelol
10. irbesartan
Source: Australian Prescriber | 2010; 33: 181
Department of Essential Medicines and Health Products
TBS 2012
2008 Generic Uptake after Patent Expiry in 2000
Unprotected market segmentation volume (SU) 2000
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
So U
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Sw and
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Sl de
ov n
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N and
or
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Tu ay
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us y
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itz stri
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Fr nd
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e
Ja ce
pa
n
Volume market share % SU
100%
ORIGINAL & LICENSED
OTHER BRANDS
UNBRANDED
Expensive access with potential for enormous savings – Policy?
Department of Essential Medicines and Health Products
TBS 2012
Data Source IMS Health 2009
Changing a Drug Use Problem:
An Overview of the Process
1. EXAMINE
Measure Existing
Practices
(Descriptive
Quantitative Studies)
4. FOLLOW UP
Measure Changes
in Outcomes
(Quantitative and Qualitative
Evaluation)
improve
diagnosis
improve
intervention
3. TREAT
Design and Implement
Interventions
(Collect Data to
Measure Outcomes)
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TBS 2012
2. DIAGNOSE
Identify Specific
Problems and Causes
(In-depth Quantitative
and Qualitative Studies)
Many Factors Influence Use of Medicines
Information
Scientific
Information
Influence
of Drug
Industry
Habits
Social &
Cultural
Factors
Treatment
Choices
Workload &
Staffing
Workplace
Intrinsic
Prior
Knowledge
Infrastructure
Relationships
With Peers
Department of Essential Medicines and Health Products
TBS 2012
Societal
Economic &
Legal Factors
Authority &
Supervision
Workgroup
Strategies to Improve Use of Drugs
Educational:
 Inform or persuade
– Health providers
– Consumers
Managerial:
 Guide clinical practice
– Information systems/STGs
– Drug supply / lab capacity
Use of
Medicines
Economic:
 Offer incentives
– Institutions
– Providers and patients
Regulatory:
 Restrict choices
– Market or practice controls
– Enforcement
Department of Essential Medicines and Health Products
TBS 2012
Educational Strategies
Goal: to inform or persuade
• Training for Providers
–
–
–
–
Undergraduate education
Continuing in-service medical education (seminars, workshops)
Face-to-face persuasive outreach e.g. academic detailing
Clinical supervision or consultation
• Printed Materials
– Clinical literature and newsletters
– Formularies or therapeutics manuals
– Persuasive print materials
• Media-Based Approaches
– Posters
– Audio tapes, plays
– Radio, television
Department of Essential Medicines and Health Products
TBS 2012
Training for prescribers
The Guide to Good Prescribing
• WHO has produced a Guide for Good
Prescribing - a problem-based method
• Developed by Groningen University in
collaboration with 15 WHO offices and
professionals from 30 countries
• Field tested in 7 sites
• Suitable for medical students, post grads,
and nurses
• widely translated and available on the WHO
medicines website
Department of Essential Medicines and Health Products
TBS 2012
Managerial strategies
Goal: to structure or guide decisions
• Changes in selection, procurement, distribution to
ensure availability of essential drugs
– Essential Drug Lists, morbidity-based quantification, kit systems
• Strategies aimed at prescribers
– targeted face-to-face supervision with audit, peer group
monitoring, structured order forms, evidence-based standard
treatment guidelines
• Dispensing strategies
– course of treatment packaging, labelling, generic substitution
Department of Essential Medicines and Health Products
TBS 2012
Economic strategies:
Goal: to offer incentives to providers an consumers
• Avoid perverse financial incentives
– prescribers’ salaries from drug sales
– insurance policies that reimburse non-essential drugs
or incorrect doses
– flat prescription fees that encourage polypharmacy by
charging the same amount irrespective of number of
drug items or quantity of each item
– (reverse – Quebec, dispensing fee is given even if
pharmacist does not dispense for good reason)
– Reimburse without treatment guidelines (ceftriaxone as
an OPD medicine)
Department of Essential Medicines and Health Products
TBS 2012
Regulatory strategies
Goal: to restrict or limit decisions
• Drug registration
• Banning unsafe drugs - but beware unexpected results
– substitution of a second inappropriate drug after banning a first
inappropriate or unsafe drug
• Regulating the use of different drugs to different
levels of the health sector e.g.
– licensing prescribers and drug outlets
– scheduling drugs into prescription-only & over-the-counter
• Regulating pharmaceutical promotional activities
Only work if the regulations are enforced
Department of Essential Medicines and Health Products
TBS 2012
What are countries doing to promote the rational
use of medicines? national policies
Source: EMP pharmaceutical policy database
Drug use audit in last 2 years (n=87)
National strategy to contain AMR (n=102)
Antibiotic OTC non-availability (n=60)
Public education on antibiotic use (n=107)
DTCs in most referral hospitals (n=92)
Drug Info Centre for prescribers (n=118)
EML in insurance reimbursement (n=90)
STGs updated in last 2 years (n=42)
EML updated in last 2 years (n=78)
0
20
40
60
80
% countries implementing policies
Department of Essential Medicines and Health Products
TBS 2012
100
Basic training and obligatory continuing medical
education (CME) available for health professionals
Source: EMP pharmaceutical policy database
Obligatory CME
(n=99-105)
Pharmaco-therapy
(n=60-73)
Prescribing concepts
(n=63-76)
Clinical Guidelines
(n=68-80)
Essential Medicines
(n=68-89)
0
20
40
60
80
% countries with basic training available
Doctors
Nurses and paramedics
Department of Essential Medicines and Health Products
TBS 2012
100
oc
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at
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AM ost tib re
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However, is it all Doom and Gloom?
Having a Policy does help
20
15
10
5
0
-5
-10
-15
Comparison of countries with and without specific policies Weighted mean of
differences for 12 INRUD/IMCI indicators (bars denote % difference and 95% CI)
Department of Essential Medicines and Health Products
TBS 2012
Reminder: 10 national strategies to promote RUM
need political support, investment and staff
Source: WHO Policy Perspectives no.5
1. Evidence-based standard treatment guidelines
2. Essential Medicines Lists based on treatments of choice
3. Drug & Therapeutic Committees in hospitals
4. Problem-based pharmacotherapy teaching in universities
5. Continuing medical education as a licensure requirement
6. Independent drug information e.g bulletins, formularies
7. Supervision, audit and feedback
8. Public education about medicines
9. Avoidance of perverse financial incentives
10. Appropriate and enforced drug regulation
Department of Essential Medicines and Health Products
TBS 2012
Why does irrational use continue?
Very few low and middle income countries
regularly monitor drug use and implement
effective nation-wide interventions because…
• they have insufficient funds or personnel?
• they lack of awareness about the funds wasted
through irrational use?
• there is insufficient knowledge of concerning the costeffectiveness of interventions?
• they do not bear the cost of irrational use? (OOP?)
Department of Essential Medicines and Health Products
TBS 2012
Conclusions
• Irrational use of medicines is a very serious global
public health problem.
• Much is known about how to improve rational use of
medicines but much more needs to be done
– policy implementation at the national level
– implementation and evaluation of more
interventions, particularly managerial, economic and
regulatory interventions
• Rational use of medicines could be greatly improved if
a fraction of the resources spent on medicines were
spent on improving use.
• (WAIT!)
Department of Essential Medicines and Health Products
TBS 2012
Some issues to think about
• There are textbook cases of Technical Success in RUM
Tools to identify the problem, design an intervention to
measure the effect, feedback and adjust BUT
• What is more important than Technical Excellence?
• What maybe the proportion spent for medicines from the
health budget if RUM is implemented?
• What role does Universal Health Coverage play in the
success of RUM?
• Can single interventions help in RUM in low and middle
income countries?
• Can single interventions help in high income countries?
Department of Essential Medicines and Health Products
TBS 2012
Some issues to think about
• Can we achieve RUM in a health sector dominated by the
private sector?
• Is quality of medicines an important issue in RUM? (Does it
differ between LMICs and HICs?)
• Is Information Technology important in promoting RUM?
Can it accelerate progress or be the "fix" for irrational use?
• What is the most important lessons that we can learn
from high income countries in RUM ?
• Would Universal Health Coverage be the driver for RUM?
• What would be stronger for RUM? Health? Cost to Health
care systems?
Department of Essential Medicines and Health Products
TBS 2012
•
Dr K Weerasuriya, Medical Officer
Medicines Access and Rational Use (MAR)
Essential Medicines and Pharmaceutical Policies (EMP)
World Health Organization
CH-1211 Geneva 27
Switzerland
•
•
•
email: [email protected]
Comments and Questions welcome
Some notes in individual slides
Department of Essential Medicines and Health Products
TBS 2012