Framework for Changing Drug Use Practices

Transcription

1 Framework for Changing Drug Use Practices 1

2 Framework for Changing Drug Use Practices: Objectives Identify specific drug use problems and place in perspective of underlying causes Identify 8-10 educational, managerial, and regulatory approaches Understand strengths and weaknesses of different interventions Framework for Changing Drug Use Practices 2

3 Components of the Drug Use System Drug Imports Local Manufacture The Drug Supply Process Provider and Consumer Behavior + Hospital or Health Center Private Physician or Other Practitioner Pharmacist or Drug Trader Illness Patterns Public Framework for Changing Drug Use Practices 3

4 Some Factors Influencing Drug Use Informational Unbiased Information Knowledge Deficits Personal Acquired Habits Influence of Industry Workload & Staffing DRUG USE Cultural Beliefs Patient Demand Interpersonal Workplace Infrastructure Relation With Peers Authority & Supervision Workgroup Framework for Changing Drug Use Practices 4

5 Learning About Factors Underlying Drug Use Use qualitative methods to identify motivations and incentives of prescribers and patients Framework for Changing Drug Use Practices 5

6 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 & Qualitative Evaluation) improve diagnosis improve intervention 2. DIAGNOSE Identify Specific Problems & Causes (In-depth Quantitative & Qualitative Studies) 3. TREAT Design & Implement Interventions (Collect Data to Measure Outcomes) Framework for Changing Drug Use Practices 6

7 Strategies to Improve Drug Use Educational: to inform or persuade Managerial: to structure or guide decisions Regulatory: to restrict or limit decisions Framework for Changing Drug Use Practices 7

8 Educational Interventions GOAL: to inform or persuade Training changes in formal education in-service training seminars face-to-face persuasive outreach 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, televisions Framework for Changing Drug Use Practices 8

9 Prescriber Training WHO has produced a Guide for Good Prescribing Developed in Groningen Field tested in 7 sites Suitable for medical students, post grads & nurses Framework for Changing Drug Use Practices 9

10 Printed Educational Materials Cover range of materials including journals, newsletters, adverts, STG s etc Most useful when combined with other methods Should include key messages and have attractive graphics Framework for Changing Drug Use Practices 10

11 Face to Face Education Very effective method in both developed and developing countries Need to target prescribers Have key messages to convey Should reinforce messages Framework for Changing Drug Use Practices 11

12 Yogyakarta Diarrhea Study A Comparison of Two Educational Interventions Study Design Randomized controlled trial 2 districts randomly assigned to each of 3 study groups 15 random health centers per district Study Groups Face to face training in health centers (staff from single unit) Large training seminar at district office (120 per seminar) Control group with no training Framework for Changing Drug Use Practices 12

13 Yogyakarta Diarrhea Study A Comparison of Two Educational Interventions Data Collection Pre-post knowledge test Retrospective prescribing audit 3 months pre vs.. 3 months post Outcome measures Knowledge about diarrhea % receiving ORS % receiving antibiotics % receiving antidiarrheals Framework for Changing Drug Use Practices 13

14 Yogyakarta Diarrhea Study Impact of Targeted Training on Health Worker Knowledge 10 Impact of Targeted Training on Health Worker Knowledge Knowledge Score Significant increase pre vs. post Pre Post 2 0 Face to Face Seminar Framework for Changing Drug Use Practices 14

15 Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of ORS % Cases Receiving ORS Differences from controls not significant Pre Post 20 0 Face to Face Seminar Control Framework for Changing Drug Use Practices 15

16 Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of Antibiotics % Cases Receiving Antibiotics Significantly different from controls, p<0.001 Pre Post Face to Face* Seminar* Control Framework for Changing Drug Use Practices 16

17 Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of Antidiarrheals % Cases Receiving Antidiarrheals Significantly different from controls, p< Pre Post 20 0 Face to Face* Seminar* Control Framework for Changing Drug Use Practices 17

18 Impact of Small Group Training on ORS Sales in Kenyan Retail Pharmacies Percentage Prescribing ORS Phase 1 Nairobi 60 Phase 2 Other Cities Pre Post Pre Post Intervention Control Framework for Changing Drug Use Practices 18

19 Impact of Patient-Provider Discussion Groups on Injection Use in Indonesia PHC facilities 80 Percentage Prescribing Injections Pre Post 20 0 Intervention Control Framework for Changing Drug Use Practices 19

20 Effects of Opinion Leader on Choice Antibiotic for Prophylaxis in a Teaching Hospital Jan Percent of all C-sections Apr Discussion with Chief of Obstetrics Jul Oct Jan Apr Jul Oct Jan Apr Jul Framework for Changing Drug Use Practices 20 Oct -- Cefazolin recommended Cefoxitin not recommended

21 Managerial Strategies 1 GOAL: to structure or guide decisions Changes in Selection, Procurement, Distribution essential drugs lists morbidity-based quantification kit system distribution Changes Aimed at Prescribers utilization review (audit) and feedback diagnostic and treatment guidelines structured drug order forms peer group monitoring Framework for Changing Drug Use Practices 21

22 Managerial Strategies 2: GOAL: to structure or guide decisions Changes Aimed at Dispensers allowing generic substitution improved labeling course of therapy packaging Changes in Economic Incentives patient cost-sharing revolving drug funds cost controls Framework for Changing Drug Use Practices 22

23 Standard Treatment Guidelines STG s lead prescribers to most cost-effective treatments Particularly useful for low level workers Can be used for training, examinations and audit Used for procurement Framework for Changing Drug Use Practices 23

24 Prescribing Audits plus "Feedback" to Prescriber Establish Criteria & Guidelines for Review AUDIT (COLLECT DATA ON) PRESCRIBING NOTIFY PRESCRIBERS OF RESULTS Individuals or Groups Letters or Patient Notes or in Person AUDIT (COLLECT DATA ON) PRESCRIBING Comparison with Guidelines Comparison with Peers Framework for Changing Drug Use Practices 24

25 Regulatory Options GOAL: To Restrict Decisions Market Controls Limiting Drug Registration Banning Previously Registered Drugs Rx - only to OTC Controlling Content in Drug Advertising Prescribing and Dispensing Controls Limiting Drugs Supplied in Public Sector Restricting Specific Drugs to Higher Levels of Care Required Generic Prescribing Allowing Generic Substitution Limits on Number or Quantity of Drugs per Patient Framework for Changing Drug Use Practices 25

26 Combined Intervention Strategy Prescribing for Acute Diarrhea in Mexico City % cases treated in line with algorithm After Workshop 37/52 After Peer Review (n = 20) 79/115 Study Physicians Control Physicians 60 BaselineStage (n = 20) 42/82 18-months Follow-up 40 25/102 20/84 16/70 11/46 31/ Framework for Changing Drug Use Practices 26

27 Impact of Training on Use of Diarrhea Treatment Algorithm in Three Mexico Settings Intervention given by: Prescribers Baseline % Post % Change % "Experts" in 2 clinics (San Jeronimo) % 71.2% +46.7% "Leaders" in 18 clinics (Coyoacan) % 43.4% % "Coordinators" in 124 clinics (Tlaxcala) % 31.2% + 6.5% Source: Munoz, et al, unpublished (1993) Framework for Changing Drug Use Practices 27

28 Conclusion: Interventions to Change Drug Use Best evidence in PHC area Focused, problem oriented repeated training Supervision or self monitoring with simple indicators Peer group oriented guideline development Evidence lacking for : Private sector, adults, and chronic diseases Framework for Changing Drug Use Practices 28

29 Conclusion: Interventions to Change Drug Use (2) Few interventions in hospitals in developing countries but based on experience in developed countries great potential exists for hospital interventions to be successful Consumers need to be involved. Experience is lacking but interactive, context specific programs using a mix of communication channels are likely to be effective Framework for Changing Drug Use Practices 29

30 Conclusion: Interventions to Change Drug Use (3) Drug retailers sales practices can be improved! Studies on impact of economic and drug sector policy changes sorely lacking Need for more indicators for adequacy of diagnosis, guideline compliance, quality of care, cost, inpatient drug use, success of P&T committees and community programs Framework for Changing Drug Use Practices 30

31 Activity One Correcting Antibiotic Misuse in a South American City Framework for Changing Drug Use Practices 31

32 Activity Two Which strategies target different types of underlying motivation Framework for Changing Drug Use Practices 32