Promoting Rational Use of Drugs Krisantha Weerasuriya MD Objectives • Define rational use of medicines and identify the magnitude of the problem • Understand.
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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
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Discuss strategies and interventions to promote rational use of medicines
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Some questions for the countries ?
Department of Essential Medicines and Pharmaceutical Policy TBS 2011
• • • • • • •
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
Department of Essential Medicines and Pharmaceutical Policy TBS 2011
Variation in outpatient antibiotic use in 26 European countries in 2002
35 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 Pharmaceutical Policy TBS 2011
How many of your countries 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 Pharmaceutical Policy TBS 2011
DDD/1000 inhabitants/day
Source: Bavestrello & Cabello, ICIUM 2004 Department of Essential Medicines and Pharmaceutical Policy TBS 2011
Top 10 drugs by Prescription counts in Australia 2007-2008
1. atorvastatin 2. simvastatin 3. esomeprazole 4. perindopril 5. omeprazole 6. paracetamol 7. atenelol 8. pantoprazole 9. irbesartan 10. metformin Source: Australian Prescriber | Volume 31 | NUMBER 6 | DECEMBER 2008 Department of Essential Medicines and Pharmaceutical Policy TBS 2011
% Compliance w ith STGs over time
70 60 50 40 30 20 10 0 <1992 1992-4 Africa 1995-7 Europe 1998-00 L.America
2001-3 2004-6 E.Mediterr
SE.Asia
W.Pacific
2007-9 Data from EMP Pharmaceuticals Database Department of Essential Medicines and Pharmaceutical Policy TBS 2011
Treatment of diarrhoea in private and public sectors 70 60 50 40 30 20 10 0 ORS use Antibiotic use Antidiarrhoeal use STG compliance Private-for-profit (n=43,33,35,4) Public (n=119, 100, 67, 80)
Department of Essential Medicines and Pharmaceutical Policy TBS 2011
% STG compliance 45 40 35 30 25 20 15 10 5 0 PR_NOPROF PR_PROF % STG compliance PUB Department of Essential Medicines and Pharmaceutical Policy TBS 2011
Treatment of ARI by prescriber type 80 70 60 50 40 30 20 10 0 Cough syrup use Approp.ABs in pneumonia Inapprop.ABs in viral URTI STG compliance Doctor (n=20,18,40,12) Paramedic/nurse (n=13,94,69,61)
Department of Essential Medicines and Pharmaceutical Policy TBS 2011
• • • • • • •
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 Pharmaceutical Policy TBS 2011
Changing a Drug Use Problem:
An Overview of the Process 4. FOLLOW UP Measure Changes in Outcomes
(Quantitative and Qualitative Evaluation)
1. EXAMINE Measure Existing Practices
(Descriptive Quantitative Studies)
improve diagnosis improve intervention 2. DIAGNOSE Identify Specific Problems and Causes
(In-depth Quantitative
and Qualitative Studies)
3. TREAT Design and Implement Interventions
(Collect Data to Measure Outcomes)
Department of Essential Medicines and Pharmaceutical Policy TBS 2011
Many Factors Influence Use of Medicines
Information
Scientific Information Prior Knowledge
Intrinsic
Habits Influence of Drug Industry
Treatment Choices
Workload & Staffing
Workplace
Infra structure Relationships With Peers Authority & Supervision
Workgroup
Department of Essential Medicines and Pharmaceutical Policy TBS 2011
Social & Cultural Factors
Societal
Economic & Legal Factors
Strategies to Improve Use of Drugs
Educational: Inform or persuade
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Health providers
–
Consumers
Managerial:
Guide clinical practice
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Information systems/STGs
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Drug supply / lab capacity
Use of Medicines Economic:
Offer incentives
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Institutions
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Providers and patients
Regulatory:
Restrict choices
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Market or practice controls
–
Enforcement
Department of Essential Medicines and Pharmaceutical Policy TBS 2011
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 Pharmaceutical Policy TBS 2011
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 Pharmaceutical Policy TBS 2011
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 Pharmaceutical Policy TBS 2011
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) Department of Essential Medicines and Pharmaceutical Policy TBS 2011
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 Pharmaceutical Policy TBS 2011
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 100 Department of Essential Medicines and Pharmaceutical Policy TBS 2011
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 100 Department of Essential Medicines and Pharmaceutical Policy TBS 2011
Making a list of Medicines – how it affects Rational Use
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Department of Essential Medicines and Pharmaceutical Policy TBS 2011
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 Pharmaceutical Policy TBS 2011
Why does irrational use continue?
Very few 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 cost effectiveness of interventions?
Department of Essential Medicines and Pharmaceutical Policy TBS 2011
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.
Department of Essential Medicines and Pharmaceutical Policy TBS 2011
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 the dominance of state health care sector 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 Pharmaceutical Policy TBS 2011
Some issues to think about
• Can we achieve RUM in a health sector dominated by the private sector?
• • How can we get Ministries to spend on drug information from the drug budget?
• Is quality of medicines an important issue in RUM?
• Is Information Technology important in promoting RUM?
What is the most important lessons that we can learn from high income countries in RUM ?
Department of Essential Medicines and Pharmaceutical Policy TBS 2011
• 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 • • • Skype WHOHQGVA1 (then dial 12357) email: [email protected]
Comments and Questions welcome Department of Essential Medicines and Pharmaceutical Policy TBS 2011