SESSION ONE MUHAS - PM604-Rational Use of Medicines Recovered)

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY
PM604: Session 1: Rational Use of Medicines
Objectives
y Define Rational Use of Medicines (RUM) y Explain the importance of RUM y Describe the different types of irrational use of medicines y Discuss the factors influencing the use of medicines y Consequences of irrational use of medicines
Session Outline
y Definition and dimensions of RUM y Components of the Drug Use Cycle y Importance of RUM y Different aspects of irrational use of medcines y Consequences of Irrational Use of Medicines y Factors Influencing the Use of Medicines
Buzz session
y The term appropriate/rational drug use means different
things to different people. What does the term mean from the perspective of: y Patient y Prescriber y Dispenser y Health Service Manager
Rational Use of Medicines

The rational use of drugs requires that patients receive medicines 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 the community. World Health Organization, 1988
Dimensions of Rational Use of Medicines

y Appropriate indication y Appropriate drug y Appropriate administration, dosage,
and duration y Appropriate patient y Appropriate patient information y Appropriate evaluation (estimate or cost)
Components of the Drug Use System Supply

Manufacture, Registration Procurement, Supply Drug Imports Local Manufacture
Provider & Consumer Interaction
spital Centre Ho
Public & Private Health Facilities Epidemiology, Care Seeking Access, Affordability
Private MDs/ Other Providers
Pharmacies/ Drug Sellers
Consumers
Demand
WHY RATIONAL USE OF MEDICINES?
Importance of Rational Use of Medicines 1

y Irrational Drug Use can destroy all the benefits of careful, cost
effective selection, procurement and distribution of drugs.

y Resources spent on procurement are lost if the correct drugs are
not prescribed and dispensed to the patient, who in turn uses them in a correct manner
Importance of the Rational Use of Medicines 2

y Medicines constitute the largest household expenditures
in most developing countries

y A major percentage (at least 30%) of the budget on
health care is spent on medicines

y Medicines make health care delivery credible
Common Patterns of Irrational Use of Medicines

y The use of drugs when no drug therapy is indicated y The use of wrong drugs for a specific condition requiring drug therapy y The use of drugs with doubtful or unproven efficacy y The use of drugs of uncertain safety status y Failure to prescribe available, safe, & effective drugs y Incorrect administration, dosages, or duration
MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY Problems of Irrational Drug
Use
11
The Medicine Use Process
Aspects of Irrational Use of Medicines Diagnosis (1)

y Inadequate examination of client/patient y Incomplete communication between client/patient
and doctor y Lack of documented medical history
Aspects of Irrational Use of Medicines Prescribing 2a

Under-prescribing:
Needed medications are not prescribed. Dosage is inadequate. Length of treatment is too brief.
Aspects of Irrational Use of Medicines Prescribing (2b)

Incorrect prescribing
Medication is given for incorrect diagnosis. Wrong medication is selected for diagnosis. Prescription is prepared improperly. Adjustments are not made for coexisting medical, genetic, environmental, or other factors.
Aspects of Irrational Use of Medicines Prescribing (2c)

Extravagant prescribing:
Less-expensive medication provides comparable efficacy and safety. Symptomatic treatment of mild conditions diverts funds from treating serious illness. Brand-name medicine is used when less expensive equivalents are available
Aspects of Irrational Use of Medicines
Prescribing (2d)
Over-prescribing
Medication is not needed. Dose is too large. Treatment period is too long. Quantity dispensed is too great for current course of treatment.
Aspects of Irrational Use of Medicines Prescribing (2e)

Multiple prescribing
Two or more medications are used when fewer would achieve same effect. Several related conditions are treated when treatment of primary condition would improve or cure the other conditions.
Aspects of Irrational Use of Medicines (3)

y Dispensing
y Incorrect interpretation of the prescription y Retrieval of wrong ingredients y Inaccurate counting, compounding, or pouring y Inadequate labeling y Unsanitary procedures

y Packaging
y Poor-quality packaging materials y Odd package size, which may require
repackaging y Unappealing package

y Labeling/Counseling
y Poor labeling y Inadequate oral instructions y Inadequate counseling to encourage adherence y Inadequate follow-up or support of
clients/patients y Treatments or instructions that do not consider the client s/patient s beliefs, environment, or culture
Problems with Irrational Drug Use: Poor Compliance
Compliance is the degree to which the patient follows the physician s instructions on how to take the prescribed drug and treatment.
Many studies about outpatient compliance carried out in developing countries indicate that only about 50% of patients follow the instructions given by the physician

Causes of poor compliance include: 1. Improper labelling
Neither the name of the patient, nor the name of the drug is on the container labels when dispensed. If two nor more drugs are dispensed together, the patent does not know which drug he/she is taking
2. Inadequate instructions:
The instructions on dosage frequency must be written on the drug label, or the patient could forget how to take it when he/she arrives home and becomes involved in other activities

3. Treatment /instructions that do not consider the socio-
economic and cultural aspects of the patient

For example, in cases where the patient does not know how to read, proper instructions would include graphic symbols of how to take the drug. For a treatment of three days, for example, you could number the days 1 to 3, and then below each day, make a mark for each time the drug must be taken that day
Some Examples of Drug Use Studies
% Prescribed as Generics
Public Sector Indicator Studies, 1990 1994
Sudan Zimbabwe Tanzania Nigeria Cameroon Ghana Uganda Mozambique Swaziland Indonesia Nepal Ecuador Guatemala El Salvador Jamaica East. Carib.
0%
25%
50%
75%
100%
% Receiving Antibiotics
Public Sector Indicator Studies, 1990 1994
Sudan Malawi Zimbabwe Tanzania Cameroon Ghana Uganda Nigeria Yemen Indonesia Bangladesh Nepal Ecuador Guatemala El Salvador Jamaica East. Carib.
0%
25%
50%
75%
% Receiving Injections
Public Sector Indicator Studies, 1990-1994
Uganda Sudan Malawi Zimbabwe Tanzania Cameroon Ghana Mozambiqu Swaziland Nigeria Yemen Indonesia Bangladesh Nepal Ecuador Guatemala El Salvador Jamaica East. Carib.
0%
25%
50%
75%
f P ti ts K T k Dr gs
P lic S ct r I ic t r St
Malawi Indonesia Bangladesh Tanzania Nigeria Nepal Eastern Caribbean Ghana 0%
i gH
i s, -
25%
50%
75%
100%
% of ey Drugs in Stock
Public Sector Indicator Studies, 1990-1994
Malawi Tanzania Nigeria Nepal Ecuador Cameroon Ghana El Salvador Guatemala Jamaica 0%
25%
50%
75%
100%
Impact of Inappropriate Use of Medicines

Reduced quality of therapy Waste of resources
Risk of unwanted effects
Psychosocial impacts patients rely on unnecessary drugs
morbidity mortality
reduced availability increased cost
adverse reactions bacterial resistance
Factors Influencing the Use of Medicines

Policy, legal, and regulatory framework
Prescriber, dispenser, and their workplaces
Rational use of medicines
Client/patient and community
Pharmaceutical supply system
Factors Influencing the Rational Use of Medicines: Pharmaceutical Supply System

Pharmaceutical quality problems Unreliable suppliers Poor forecasting/poor quantifications Inadequate inventory management (expired
medicines, shortages, and so forth) Pressure and lobbying from industry (promotional activities and misleading claims)
Factors Influencing the Rational Use of Medicines: Drug Regulation

Non-formal prescribers
Lack of regulation enforcement Non-essential drugs available
Factors Influencing the Rational Use of Medicines: Prescriber

Inappropriate role models Lack of objective pharmaceutical information Limited experience Outdated knowledge Lack of skill or conscientiousness Unlicensed practitioners Inadequate pharmacology training Inappropriate prestige over-prescribing Fear-induced prescribing ( uncertain diagnosis ) Misleading beliefs about drug efficacy Incorrect generalizations from experience
Factors Influencing the Rational Use of Medicines: Dispenser

Inability to read or interpret prescription Outdated knowledge about drugs Inadequately trained dispensers Poor attitude about dispensing Poor attitude about packaging
Factors Influencing the Rational Use of Medicines: Workplace

Lack of adequate laboratory capacity Lack of equipment or facilities No packaging materials Adequate packaging thought to be too costly Lack of continuing education Pressure to prescribe Pressure to dispense Insufficient staffing Inadequate supervision of practitioners
Factors Influencing the Rational Use of Medicines Economic Motivations of Providers and Consumers
Provider preference to earn more money
salaries independent of services provided payment according to non-drug services provided (consultation fees, per
capita payment) profit from drug sales (dispensing doctors, dispensing pharmacist fees)
Patient preference to pay less for drugs

overuse of free drugs versus decreased access with full payment Reimbursement of essential drugs and treatments compliant with guidelines
Factors Influencing the Rational Use of Medicines Drug Financing Systems

y Public financing through central revenues
y
good drug selection and quality control, but danger of limited access if govt. budget insufficient
y Health Insurance - sharing payment risk

public compulsory y private voluntary (community pre-payment, HMO)
y
y User fees - money paid by patients for drugs

revolving drug funds run by govt. or community y private purchase y co-payments in insurance systems
y
Factors Influencing the Rational Use of Medicines Drug Financing Systems

Public financing through central revenues
y
good drug selection and quality control, but danger of limited access if govt. budget insufficient
y Health Insurance - sharing payment risk

public compulsory y private voluntary (community pre-payment, HMO)
y
y User fees - money paid by patients for drugs

revolving drug funds run by govt. or community y private purchase y co-payments in insurance systems
y
Factors Influencing the Rational Use of Medicines Sales profits and pricing policies
Lower prices for essential drugs & higher prices for non-essential drugs
should lead to greater use of essential drugs, but:

higher prices for non-essential drugs may lead to their greater use by dispensing
prescribers who are motivated by profit less effective
patients may prefer more expensive drugs if they feel that the cheaper drugs are
dispensing fees that are % of the price of a drug may encourage the sale of
more expensive drugs
flat dispensing fees irrespective of drug prices lower the cost to patients of
expensive medicines but may lead to price increases for cheaper drugs
Factors Influencing the Rational Use of Medicines Health Systems 1

Prescribers that sell drugs usually:
prescribe more drugs and less appropriately
Increased cost sharing is associated with:

reduced patient access to drugs and health care reduced appropriate and inappropriate drug use with higher
fees reduced inappropriate use only with lower fees
Increased drug availability associated with increased
use
availability of non-essential drugs leads to their use
Factors Influencing the Rational Use of Medicines Health Systems 2

Flat fees per prescription are associated with drug
overuse and polypharmacy Charging per drug item is associated with prescription of fewer drug items Charging variable fees may lead to:
reduced use of expensive drugs, and increased use of cheaper drugs
Strategies to promote rational use can be built into
insurance systems and reimbursement

Factors Influencing the Rational Use of Medicines Clients/Patients and Community

Misinformation about medications Misleading beliefs Client/patient demands or expectations Complex diseases or problems No labeling or labels clients/patients cannot understand Inadequate oral instructions Clients /patients misunderstanding of medicines and their use Conflict between cultural values and therapy Lack of client/patient trust Poor client/patient doctor communication

Conclusions
y The promotion of RUM generally is crucial to maximize the
impact of health care delivery

y There are many challenges to RUM at the diagnosis, prescribing,
dispensing, and client/patient-use levels.

y All stakeholders have key roles to play in promoting RUM at all
levels.
PM604-Session Two: Investigating Drug Use In Health Facilities

Session Objectives
y Describe a model for defining and changing drug use
patterns y Identify the importance of drug use indicators y Know steps to implement an indicator study y Understand different methods of sampling and data collection y Understand how to analyze a situation using indicators y Identify & evaluate sources of data for indicator study y Introduce qualitative research methods
An Overview of the Process of Changing Drug Use

1. EXAMINE Measure Practices (Descriptive Quantitative Studies) 4. FOLLOW UP Assess Changes in Outcomes (Quantitative & Qualitative) Qualitative) Im rove diagnosis 2. DIAGNOSE Identify Problems & Causes (In(In-depth Quantitative & Qualitative Studies) Studies)
Im rove Intervention 3. TREAT Design and Implement Interventions (Collect Data to Measure Outcomes)
Changing Drug Use Problems:

1. Examine
y Identify drug use issue of interest
Highest clinical risk? y Widely used or expensive drugs? y Easiest to correct?
y
y Collect data to describe practices

In all groups of interest y Most important prescribers? y High-risk patients?
y
Changing Drug Use Problems: 2. Diagnose (dii)

y Describe problem in detail y Specific problem behavior y Define important providers or patients y Identify determinants of the problem y Knowledge and beliefs y Cultural factors or peer practices y Patient demand and expectations y Identify constraints to change y Economic constraints y Drug supply y Work environment
Changing Drug Use Problems: 3. Treat

y Select target and design intervention
Which behaviors can be changed? y Feasible interventions? y Cost-effectiveness? y Personnel required?
y
y Pilot test
Acceptability y Effectiveness
y
y Implement in stages
y y
Collect process and outcome data Evaluate impacts
Changing Drug Use Problems: 4. Follow Up

y Evaluate success in relation to intended outcomes
y y y
Was the intervention implemented as planned? What changes occurred Was the intervention cost-effective? Transferable?
y Consider unintended negative outcomes y Feed back results

y y y
To managers and policymakers To staff To providers and consumers
y Use results to plan future activities

Selecting Methods to Study Drug Use

y Depends on y Nature of the problem y Objectives of collecting data y Resource availability y Time available
Methods to Study Drug Use .

y Quantitative Methods
y What? or How much? y Counts y Rates y Classifications
y Qualitative Methods
y Why? or How strong? y Opinions y Descriptions y Observations
DRUG USE INDICATOR STUDY
Purpose of Drug Use Indicator Studies

y Measure current medicines use practices y Comparing the performance of individual facilities or
prescribers.
y Periodic monitoring of specific medicine use behavior to
assess change over time.

y To evaluate impact of intervention impact
Implementing a Drug Use OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY Indicators Study
MUHIMBILI UNIVERSITY
57
Types of Indicators
y Prescribing y Patient Care y Facility Indicators
58
Prescribing Indicators
Measure performance of prescribers in the several key dimensions of appropriate use as per indicators listed below: 1. Average number of medicines prescribed per patient encounter 2. Average number of medicines prescribed by generic name 3. Percentage of encounters with antibiotic prescribed 4. Percentage encounters with injections prescribed
59
Patient Care Indicators

1. These measure what patients experience in the HF and how long it takes to be prepared to take the prescribed pharmaceuticals 2. They do not capture quality of examination or RX
Example 1. Average consultation time 2. Average dispensing time 3. Percentage of prescribed medicines actually dispensed 4. Percent adequately labeled 5. Percentage of patients who could correctly explain on how to take the prescribed medicines. Implementing a Drug Use
MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY Indicators Study
60
Facility Indicators
y Availability of national standard treatment guidelines y Availability of key medicines
Complimentary indicators Percentage of medicines prescribed in consistence with standard treatment guideline
61
Steps in an Indicator Study (oim gst pcff)

y Specify objectives y Define indicators to be used y Develop Methods for measuring indicators y Select geographic area y Select sample of facilities
Select and train personnel Pilot test and revise procedures Collect data Feedback to facilities and managers y Decide on follow-up studies
y y y y
62
Scope of the Indicators Study

y Depends on:
information needs of managers y capabilities of record system y types of providers y resources available
y
y Minimum sample
20 facilities and 30 prescriptions / 30 patients per facility for crosssectional study y 100 prescriptions per facility if facilities will be compared
y
63
Preparing for a Survey (1)

Prescribing Indicators
y Select a sample of facilities y Decide on a source of data for prescribing encounters y Define types of encounters to include y Define drugs to be counted as antibiotics y List drugs to be classified as generic
64
Preparing for a Survey (2):

Patient Care Indicators
y Observe logistics of patient care y Determine how consulting and dispensing times will be measured y Define criteria for adequate patient knowledge y Describe procedure for evaluating patient knowledge
65
Preparing for a Survey (3):

Facility Indicators
y Determine if national EDL
or STG exists
y Prepare a short list of key
drugs to test availability
66
Indicator Sampling Methods

y Selection of Facilities y Simple Random / Systematic y Useful to Stratify -Government / Mission y Retrospective Prescribing Data y Systematic y Random sampling y Prospective Patient Encounters y Convenience
67
Where Can We Find Useful Data for calculating Indicators?

y Administrative offices, medical stores y Clinical treatment areas and medical record departments y Health facility pharmacies y Private pharmacies and retail outlets y Households?
Where Can We Find Useful Data for calculating Indicators? Data Available at Health Facilities
y Retrospective
y Patient registers y Treatment logs y Pharmacy records y Medical records
y Prospective
y Observation of clinical encounters y Patient exit interview y Inpatient surveys
Data from Drug Encounters

y FACILITY y PATIENT y PROVIDER y INTERACTION y DRUGS
y ID, characteristics, equipment, drugs y y
available ID, date, age, gender, symptoms knowledge, beliefs, attitudes qualification, training, access to information, knowledge, beliefs, attitudes exams, history, diagnosis, time spent, explanation about illness, explanation about drugs brand, generic, strength, form, quantity, duration, if dispensed, how labeled, cost, patient charge
Undertaking the Survey: Field Activities

y Select a sample of encounters y Fill in encounter forms y Observe consultation and dispensing times y Collect patient knowledge and dispensing
information
y Fill in facility summary forms y Present results to staff
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10 11
Simple Prescribing Indicators Form

1 1 1 1 1 1 1 1 0 1
PRESCRIBING INDICATOR FORM

Date:
Location: Investigator:
Seq. # 1 2 3 0 4 5 6 7 8 9 10 11 12 13
Type (R/P)
Date of Rx
Age (yrs)
# Drugs
# Generics
Antib. (0/1)
Injec. (0/1)
# on EDL
Diagnosis (Optional)
Tot
XXXXXXXX
XXXXXXXXXXXXXX XXXXXXXX XXXXXXXX XXXXXXXX XXXXXXXX XXXXXXXXXXXXXX % of tota l drugs of ca se s % % of tota l ca se s % XXXXXXXXXXXXXX of tota l drugs
Av
g nt g
XXXXXXXX XXXXXXXX
* 0=No 1=Yes
Implementing a Drug14 Use OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY Indicators Study 15
16
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Detailed Prescribing Indicators Form

Detailed rescribing Indicators orm
Loca ion: Inves i a or: Da e:
ID# Heal h roblems 1 2 3 Dr s 1 2 3 4 5 6 7 8, 9
Da e Heal h
ame roblem Descri ion
e Code
ex
rescri er
ame and
rength
Code
Q antity
73
Prescription 1
74
Prescription 2
75
Prescription 3
76
Prescription 4
77
Prescription 5
78
Prescription 6
79
Patient Care Indicators Form

PATIENT CARE FORM
Locat on: Invest ator Pat ent Identifier (if needed) Consult ng D spensing # Drugs Time Time Pre(mins) (secs) scribed Date: # Drugs # AdeKnows Disquately Dosage pensed Labelled ( )
Seq. #
Count Total Average Percentage
XXXXXX XXXXXX XXXXXX XXXXXX XXXXXXXX XXXXXXXX XXXXXX % % %
* 0=No 1= es
80
Health Facility Summary Form

Loca ion

In es iga or
ontact
Proble s or o plaint
# Cases
Essential Drug Li t/For ular a ailable at facilit ? (0/1
e Drug in Stock to Treat I portant Condition
81
% in tock thi facilit
Retro pecti e Pro pecti e Patient Care

co ering dates co ering dates co ering dates
In Stock (0/1
Fro

F CILITY SU

RY F RM
ae
To
Facility Indicator Reporting Form

F
Lo In ti n tig t r te
ility Indi
t r
rting For
mments
Signatures
82
!
A e rage u ber drugs rescribed Percentage drugs rescribed by generic names enc unters with an antibi tic rescribed Percentage Percentage enc unters with an injecti n rescribed Percentage drugs rescribed n ssential rug List nsulting Time A e rage A e rage i spensing Time Percentage drugs actually dispensed Percentage drugs adequately labelled d sage Percent c rrect patient nowledge A a ilability essential drug List r Formulary Percentage a a ilability e y indicat r drugs
' % % ! ! ! ! "! & ! ! ( "! % ( % % ! ! "! $ "! "! "! "! "! "! "! !# ! ' ) $ $ $ $
# "!
u ber
a ses
Prescribing Patient a re % % % % mins secs % % % Yes / % % % % % mins secs % % % % %

F

Thi ility

ti n l tandard
Indicators Consolidation Form

Indicator
ocation:
01
onsolidation For
Date:
Av . dr Date Facility
0
Percent
Percent
Percent
Percent on EDL
Consult tim e
Dispense tim e
% Drugs dispensed
% Adequate label
%Adequate know ledge
Im partial
% Drugs
Prescribed
generics antibiotics Injections
Inform ation in stock
Mean Maximum MUHIMBILI UNIVERSITY Implementing a Drug Use Minimum OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY Indicators Study
83
Graphs of Indicators Data (1)

Sample-Wide Distribution of Antibiotic Use
NUMBER OF FACILITIES
12 10 8 6 4 2 0
Under 30% 30% - 40% 40% - 60% Over 60%
Percentage Antibiotic Use

84

Sample-Wide Distribution of Consulting Times
NUMBER OF FACILITIES
8 7 6 5 4 3 2 1 0
Under 2 2-3 3-4 Over 4
Average Consulting Time (mins)

85

Facility-Specific Antibiotic Use
Percentage of Patients
80 70 60 50 40 30 20 10 0
U0 U1 U3 U3 U5 U6 U7 U8 U9 R0 R1 R2 R3 R4 R5 R6 R7 R8 R9
Urban Rural
Health Facility
86

Facility-Specific Consultation Times
AVERAGE TIME (MINS)
7 6 5 4 3 2 1 0
U0 U1 U3 U3 U5 U6 U7 U8 U9 R0 R1 R2 R3 R4 R5 R6 R7 R8 R9
Urban Rural
Health Facility
87
Conclusion
y Undertaking a Drug Use
Indicators Study is possible in nearly all environments y The more attention to detail the greater the value and accuracy of the survey.
88
PM604: Session Three: Qualitative Methods
Session Objectives (2)

y Identify four methods used to investigate reasons
underlying drug use and prescribing behavior

y Understand use of qualitative methods to identify why
documented drug use problems occur
Session Outline (2)

y Introduction y Applying qualitative methods to drug use studies y Qualitative methods
y Focus group discussions y In-depth interviews y Structured observations y Structured questionnaires
y Activities y Summary
Introduction
y Quantitative study methods identify presence of drug
use problems
y Indicator studies y Aggregate data: DDD, ABC, VEN y Record review and DUE
y What else do we need to plan an intervention? y We need to know why the problem exists: i.e.,
qualitative methods
Introduction (2)
y Four qualitative study methods:
y Focus group discussions y In-depth interviews y Structured observations y Questionnaires
Applying Qualitative Methods

y Complement results of a quantitative study y Explore a topic about which little is known y Provide background data prior to developing training
materials for a planned educational intervention and for developing managerial and regulatory interventions.
Applying Qualitative Methods (2)

y Example of the use of qualitative methods
y Prescribing by brand name was very popular at the district
hospital. Despite numerous interventions including face-toface discussions, in-service education, policy and procedures changes, physicians continued to prescribe by brand name.
y Utilizing qualitative methods it was discovered that physicians
were receiving educational benefits from drug companies in exchange for their prescribing of branded products. This problem was then corrected once the reasons for the drug use behavior became known.
Focus Group Discussions (1)

y A short discussion (1-2 hours) led by a moderator in which a small groups of respondents (6-10) talk in depth about a list of topics of interest. y A trained moderator leads the discussion and encourages participants to reveal underlying opinions, attitudes, and reasons for the problem being studied y The discussion is recorded and analyzed to identify key themes and issues

y 6-10 homogeneous participants i.e. they should share similar characteristics (e.g., age, gender, type of work) y Local convenience to participants y Number of focus groups discussions should be sufficient to gain the views of all the various target groups involved in the drug use problem
y Moderator and recorder must be skilled and trained

y Advantages
y Relatively cheap and easy to organize y Identifies a range of beliefs and ideas
y Disadvantages y Group may not represent the larger population y Success depends on the skill of the moderator
In-depth Interview (1)

y An extended discussion between a respondent and an trained interviewer (who is knowledgeable about the topic) based on a brief interview guide that usually covers 10-20 topics y The interview is flexible and often unstructured y The questions are open ended to encourage the interviewee to talk at length on the topic of interest y 5-10 interviews with each important subgroup, often opinion leaders and key informants
In-depth Interview (2)

y Advantages y Can develop trust between interviewer and interviewee y Possible to probe deeper and therefore gain unexpected insights or new ideas y Disadvantages
y Generates lots of data and analysis may be difficult y Interviewees may give answers they think the
interviewer wants to hear y time consuming
Structured Observation (1)

y Systematic observations by trained observers of a series of encounters between health providers and patients y Observers record behaviors and impressions they witness during the encounters in structured manner or they record a score for each observed interaction y Data may be recorded as coded indicators and scales or lists of behaviours and events, and then frequency of behaviours may be calculated

y To prepare for the study the observer should
introduce a non-threatening explanation and spend time blending in

y At least 30 encounters should be observed to
calculate the frequency of behaviours

y At least 10 sites should be visited to observe
behaviour

y Advantages
y Best way to study the complex provider-patient interactions,
including patient demand and quality of communication y Can learn about provider behaviour in natural setting
y Disadvantages
y Observed providers may modify their behavior because of
observer s presence y requires skilled patient observers y inappropriate for infrequent behaviours
Structured Questionnaire (1)

y A fixed set of questions asked to a large sample of respondents selected according to strict rules to represent a larger population y The questions have a fixed set of responses or options in order to collect the desired information in a standard way from all respondents y The questionnaire may be administered by an interviewer or filled out alone by the respondent

y At least 50-75 respondents from each target group y Respondents should be chosen randomly y Training and supervision of interviewers required y Questions always asked in a standardized way, with no leading questions y Useful for attitudes, beliefs and opinions as well as facts

y Advantages
y Best for measuring strength & frequency of attitudes,
beliefs, knowledge, and population characteristics y Can generalize to a wider population

y Disadvantages
y Do not uncover the unexpected y Sensitive to the way questions are phrased leading to
possible bias and respondents may answer even when they have no true opinion y Large surveys are expensive
Summary
y Before an intervention can be designed to correct poor practice or irrational use of drugs, we need to know why that behavior is occurring y Qualitative methods should be used to investigate the behaviour from different perspectives and with regard to different actors (patients, staff, etc.) y Triangulation of results using different methods should be done to identify the major reasons underlying a particular behaviour.
PM604-Session IV: Drug Use Evaluation
Session Objectives 1 (DUE)

y Understand the concept of drug use evaluation (DUE) y Understand the process for implementing and
performing a DUE
y Discuss the use of a DUE program for improving drug
therapy
ey Definition:
Drug use evaluation (DUE)

y Ongoing, systematic, criteria-based program of drug criteriaevaluations that will ensure appropriate drug use. Interventions are necessary when inappropriate therapy is identified. y A DUE will:
y Define appropriate drug use (by establishing criteria) y Audit criteria against what is being prescribed y Give feedback to prescribers on all identified problems y Monitor to see if criteria are followed and prescribing is
improved
Drug Use Evaluation (DUE)

y When drug use problems are identified, corrective
action with providers will be necessary and required to optimize drug therapy
Objectives of a DUE
y Ensure that drug therapy meets current standards y Promote optimal medication therapy y Prevent medication-related problems y Identify areas in which further evaluation is needed y Create criteria for drug use y Define thresholds for quality of drug use below which corrective action will be undertaken y Enhance accountability in drug use y Control drug costs
Indicators suggesting need for DUE

y Over-use or under-use of medications y Problems indicated from WHO/MSH indicator studies y High number of adverse drug reactions y Signs of treatment failures y Excessive non-formulary medications used y Use of high-cost drugs where less expensive alternatives exist y Excessive number of drugs within a therapeutic category
Stepwise Approach to DUE

1. Establish responsibility
2. Develop scope of activities 3. Establish criteria and Thresholds for the DUE 4. Collect data and organize results 5. Analyze data 6. Develop recommendations and plan of action 7. DUE follow-up
Step 1 Establish Responsibility

y Drug and Therapeutics Committee is a logical choice y Multidisciplinary committee dealing with all facets of drug therapy has the necessary expertise y Subcommittees of the DTC y Must include representation of practitioners whose drug prescribing will be assessed
Step 2 Develop Scope of Activities

y Identify drug therapy problems to be addressed
y
Using ABC/VEN analysis, ADR reports, AMR reports
y Concentrate on drugs with highest potential for problems

y y y y y y y y y
High volume Low therapeutic index High ADR rate Expensive drugs Critically important drugs Antimicrobials Injections Drugs used for non-labeled indications Drugs used for high-risk patients
Step 3 Establish Criteria and thresholds defining correct drug use (using evidence-based medicine)
y y y y y y y y y y y
Appropriate drug for medical condition Correct dose Quantity to be dispensed Preparation for administration Monitoring is appropriate (e.g. lab test) Contraindications Drug interactions Drug administration (especially for injections) Patient education (written and oral instructions) Patient outcomes (e.g., blood glucose, Glyosyl.Haem.) Pharmacy administrative indicators (correct cost, billing)
Step 3 Establish Criteria and Thresholds (2)

y Define and establish thresholds or benchmarks for
quality of drug use below which corrective action will be undertaken
y Thresholds define the expectations or goals for
complying with the criteria (e.g. 90% of prescriptions for 3rd generation cephalosporins are for predefined serious infections).
Example: Ciprofloxacin DUE criteria & thresholds (1)

Criteria Use
y y y y y y
Threshold 90%
Complicated, chronic, or relapsing UTI, Gonorrhea Resistant respiratory tract infections Bone and joint infections Prostatitis GI infections
Dose
y y y y
95%
Complicated or recurring. infections: 500-750mg bid GI infections: 500mg bid Gonorrhea: 250mg in 1 dose renal disease decrease as follows:
Creatine Clearance 30-50ml/min 5-29ml/min Hemodialysis

250-500 q 12 h 250-500 q 18 h 500mg q 24 h
Ciprofloxacin DUE criteria & thresholds (contd.)

Criteria Duration
y y y y
Threshold 95%
Complicated UTI 10-21 days Respiratory 7-14 days Osteomyelitis 4-6 weeks GI 5 days
Contraindications
y y
100% 90% 90%
Pregnancy Children less than 18
Drug interactions
y y
Theophylline, antacids, iron, sucralfate, probenecid Food: decreased absorption with milk
Outcome
y y
Negative cultures Improved symptomatology
Step 4 Collect Data

y Prospective evaluation
y done as drug is prepared or dispensed to the patient y pharmacist can intervene at the time the drug is dispensed
y Retrospective evaluation
y requires access to medical records
y Sources of data
y patient charts, medical records, prescriptions, laboratory files y manual systems versus computerized systems y needs minimum of 50-75 records
Step 5 Analyze Data

y Tabulate results for each indicator y Analyze to see what % of prescribing episodes comply with the criteria and whether the threshold is met, e.g.:
y 70% of patients prescribed 3rd generation cephalosporins
were given it for predefined criteria threshold
20% short of
y Determine why thresholds (benchmarks) are not met y Analyze data quarterly or more frequently
Step 6 Develop Recommendations and Plan of Action

y Recommendations to address
Inappropriate drug use y Unacceptable patient outcomes y Interventions to resolve any drug use problems
y
y Interventions to resolve drug use problems

y y y y y
Education Drug order forms Prescribing restrictions Formulary manual changes STG changes
Step 7 DUE Follow-up

y Check to see that recommendations have been
implemented
y Re-evaluate DUE to see if problems with drug therapy
have been resolved
Problems that can arise in DUEs

y Lack of authority y Poor prioritization of drug use problems y Poor documentation of findings y Inadequate follow-up y Overly intrusive data collection and evaluation y Failure to obtain buy in from medical staff
Summary (1)
y DUE is an audit and feedback intervention where drug use can be reviewed against approved criteria and thresholds y Requires establishing criteria and thresholds and then reviewing drug use to determine if therapy is appropriate y Feedback to prescribers is necessary to improve prescribing (educational, managerial, regulatory interventions may be required)
Summary (2)
DUE will help improve drug use by
y Ensure that drug therapy meets current standards y Promote optimal medication therapy y Prevent medication-related problems y Identify areas in which further evaluation is needed y Create criteria for drug use y Define thresholds for quality of drug use below which corrective action will be undertaken y Enhance accountability in drug use y Control drug costs
INTERVENTIONS STRATEGIES
Decision Making for Rational Use Interventions: Objectives

y To review intervention strategies y Choose between interventions y Develop a plan to undertake an
intervention
Decision Making for RDU OF HEALTH AND ALLIED SCIENCES SCHOOL OF InterventionsPHARMACY
129
Developing Strategy
y Identify the problem & recognize the need for action-
meet consensus about the problem y Identify underlying causes and motivation factors using posters to promote generic prescribing will fail if doctors don t know generic names y List possible interventions educational, managerial and regulatory y Assess resources available for action- who will implement? Do they have enough time? y Choose an intervention or interventions to testeffectiveness, costs, sustainability y Monitor the impact & restructure the intervention
Choosing Strategies
y Expected magnitude of impact y Likelihood of success y Risk of unintended effect y Political and cultural feasibility y Technical feasibility y Cost (economic feasibility) y Potential for donor support
Decision Making for RDU Interventions 131
Framework for Intervention Studies

FORMA IVE S UDIES
. D fin
Drug U ro l rn wi h
lprescribing ldispensing lpatient use linformational leconomic lsocial, cultural lsupply logistics leducational lmanagerial lregulatory lcultural acceptance llikelihood of success lpotential impact lfeasibility
. Id n ify Mo i ing Factors/Und rlying Caus s
IN ERVEN ION S UDIES
. List ossibl Interventions . Choose Intervention s) to test 5. Conduct controlled study of Intervention s)
FOLLOW U
IMPLEMEN
cost effective interventions on a MUHIMBILI UNIVERSITY Decision Making larger scale for RDU OF HEALTH AND ALLIED SCIENCES SCHOOL OF InterventionsPHARMACY 132
Source: Quick et al. 1991.
REVISE & RES UDY

partially effective or costly interventions
DROP
ineffective, uneconomical interventions
Selecting an Intervention
Stage 1: Choosing a Target
y Characterize situation (indicator study) y Clarify problem (follow-up quantitative studies) y Investigate underlying factors (qualitative studies)
motivations of prescribers y patient expectations y constraints of system
y
y Synthesize data to choose targets

key behaviors to change y target group
y
Selecting an Intervention
Stage 2: Choosing an Intervention
y List possible interventions y Consider available resources

y financial y human y administrative structure
y Choose an intervention (or interventions)

y feasibility y likely to change target behaviors y no absolute constraints
Types of Study Design

y Post Only:
y
Not Recommended Not Recommended
after the event before and after

Recommended
y Pre-Post
y
y Randomized Trial
y
random assignment of study & control group

Recommended
y Time Series
y
multiple measures before and after

Principles of Good Intervention Testing

y Use a relevant comparison group
y randomly assigned if possible y data collected like study group
y Measure outcomes at multiple time points

y before and after intervention y time series?
y Focus on key outcome measures

y behaviors targeted by intervention y feasible to measure
Choosing Useful Outcome Measures

y Focus on key behaviors to be changed y Consider likely substitute behaviors y Focus on several important outcomes, not all changes y Choose outcomes:
that can be clearly defined y that can be reliably measured
y
y Measure more than one dimension, for example

changes in knowledge y changes in prescribing y changes in patient knowledge
y
Issues and Sampling Methods

Uni S mp n y i m iz m b b n in h b mp in b in . xp h n
y Simple Random Sampling y Systematic Sampling y Stratified Sampling y Cluster Sampling y Multistage Sampling
Using Samples to Collect Data

y A sample should be typical of the overall group of
interest.
y The accuracy of a study depends on the sample size. y If sample units are drawn in clusters, the size of the
clusters should be small, and the number of clusters should be large.

Involving Decision Makers at Design Stage

y By involving decision makers at design stage increases
chances of implementation if the intervention is successful y Opportunities for involving decision maker should be actively sought y Asking for input at the design stage increases chances of cooperation and success
Planning an Intervention
y Decide what kind of study to use to test the intervention y Define study and control groups y Define sampling process and size y Define outcome variables to measure success y Plan how to collect data y Decide who will analyze the data, how, and when* y Plan how to present the data, and to whom y Decide how to monitor the project
* R m mb : i y n n yz by h n , I y n' , mp nym k hin

mp w !
m y h p.
Conclusion
Which Method to Use
y Best method depends on:
nature of the problem y objectives of collecting data y available resources and time y local capacity and experience
y
y Use multiple methods

quantitative + qualitative y triangulate findings y each method can look at different aspects of a problem
y
Decision Making for RDU Interventions

142
Conclusion 2
Points to Consider when Developing Strategy
y Specific intended changes in behavior y Possible unintended outcomes due to the intervention y How both intended and unintended changes will be measured y Choice of intervention (or combination of interventions) y Why this is likely to achieve desired changes y Other information needed to design the intervention
Decision Making for RDU Interventions

143
General Recommendations to Improve the Rational Use of Medicines
Reference:
y TEN RECOMMENDATIONS TO IMPROVE USE OF
MEDICINES IN DEVELOPING COUNTRIES RO LAING,1 HV HOGERZEIL2 AND D ROSS-DEGNAN3

1Boston
University School of Public Health, Boston, USA, 2 World Health Organization Action Programme on Essential Drugs, Geneva, Switzerland and 3Harvard Medical School and Harvard Pilgrim Health Care, Boston, USA
HEALTH POLICY AND PLANNING; 16(1): 13 20 Oxford University Press 2001
-1-
Establish procedures for Developing, Disseminating, Utilizing and Revising National (or hospital-specific) Standard Treatment Guidelines
-2y Establish procedures for developing and revising an
Essential Drug List (or hospital formulary) based on treatments of choice
-3y Require hospitals to establish representative Pharmacy
and Therapeutics Committees with defined responsibilities for monitoring and promoting quality use of medicines
-4y Implement problem-based training in pharmacotherapy
in undergraduate medical and paramedical education based on national STGs
-5y Encourage targeted, problem-based in-service educational
programmes by professional societies, universities and the Ministry of Health

y Require regular continuing education for licensure of health
professionals
-6y Stimulate an interactive group process among health
providers or consumers to review and apply information about appropriate use of medicines
-7y Train pharmacists and drug sellers to be active members
of the health care team and to offer useful advice to consumers about health and drugs
-8y Encourage active involvement by consumer
organizations in public education about drugs, and devote government resources to support these efforts
-9y Develop a strategic approach to improve prescribing in
the private sector through appropriate regulation and long-term collaborations with professional associations
-10y Establish systems to routinely monitor key
pharmaceutical indicators in order to track the impact of health sector reform and regulatory changes
Conclusions
y The promotion of RUM generally and in the context of
Antiretroviral Treatment is crucial to maximize the impact of health care delivery

y There are many challenges to RUM at the diagnosis, prescribing,
dispensing, and client/patient-use levels.

y All stakeholders have key roles to play in promoting RUM at all
levels.
PM 604: Module 2 Intervention to Promote Rational Use of Medicines
Learning About Factors Underlying Drug Use
Use qualitative methods to identify motivations and incentives of prescribers and patients
Framework for Changing Drug Use Practices 159
Components of the Drug Use System

Drug Imports Local Manufacture
The Drug Supply Process
Provider and Consumer Behavior
+
Private Physician or Other Practitioner Pharmacist or or Drug rader
Hospital or Health Center
Illness Patterns
Public Public
160
Changing a Drug Use Problem:

An Overview of the Process
1. EXAMINE Measure Existing Practices (D ip iv Q n i iv S i ) 4. FOLLOW UP Measure Changes Changes in Outcomes n i iv & Q i iv Ev i n) improve diagnosis . DIAGNOSE Identify Specific Pro lems & Causes (In- p h Q n i iv In& Q i iv S i )
(Q
improve intervention
3. TREAT Design & Implement Interventions (C D M O m )

161
Strategies to Improve Drug Use

Educational: to inform or persuade inform or persuade
Managerial: to structure or guide decisions
Regulatory: to restrict or limit decisions
162
Educational Interventions
GOAL: to inform or persuade
y Training
changes in formal education in-service training seminars face-to-face persuasive outreach clinical supervision or consultation y Printed Materials y clinical literature and newsletters y formularies or therapeutics manuals y persuasive print materials y Media-Based Approaches y posters y audio tapes, plays y radio, televisions
y y y y
163
Prescriber Training
y WHO has produced a
Guide for Good Prescribing y Developed in Groningen y Field tested in 7 sites y Suitable for medical students, post grads & nurses
Framework for Changing Drug Use Practices
164
Printed Educational Materials

y Cover range of materials including journals, newsletters, adverts, STG s etc y Most useful when combined with other methods y Should include key messages and have attractive graphics
165
Face to Face Education

y Very effective method in both developed and
developing countries
y Need to target prescribers y Have key messages to convey y Should reinforce messages
166
Yogyakarta Diarrhea Study

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

A Comparison of Two Educational Interventions
Data Collection Pre-post knowledge test Pre Retrospective prescribing audit 3 months pre vs. 3 months post Outcome measures Knowledge about diarrhea % receiving ORS % receiving antibiotics % receiving antidiarrheals

Impact of Targeted Training on Health Worker Knowledge
Imp
10
T inin
nH
hW k
Kn w
Knowledge Score
Significant increase pre vs. post
Pre Post
0
MUHIMBILI UNIVERSITY Framework for Changing Drug Use OF HEALTH AND ALLIED SCIENCES SCHOOL Practices OF PHARMACY
Face to Face
Seminar
169

Impact of Targeted Training on Prescribing of ORS
% Cases Receiving ORS 100
Di m n i ni i
n n n
80
60
Pre Post
Face to Face
Seminar
Control
170

Impact of Targeted Training on Prescribing of Antibiotics
% Cases Receiving Antibiotics 100
80
Si ni i n y i n m n , p<0.001
Pre Post
60
40
20
0 Face to Face* Framework for Changing Drug Use OF HEALTH AND ALLIED SCIENCES SCHOOL Practices OF PHARMACY 171
Seminar*
Control

Impact of Targeted Training on Prescribing of Antidiarrheals
% Cases Receiving Antidiarrheals 100
80
Si ni i n y i n m n , p<0.001
60 Pre Post 40
20
0
Face to Face*
172
Seminar*
Control
Impact of Small Group Training on ORS Sales in Kenyan Retail Pharmacies

Percentage Prescribing ORS 100
Phase 1 Nair bi
80
60
Phase 2 Other Cities
40
20
Intervention Control
0 Pre
Post
173
Pre
Post
Impact of Patient-Provider Discussion Groups on Injection Use in Indonesia PHC facilities

Percentage Prescribing Injections 0
60
40
Pre Post
20
0
Framework for Changing Drug Use Practices Intervention Control 174
Effects of Opinion Leader on Choice Antibiotic for Prophylaxis in a Teaching Hospital

Perce t f all 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 -secti s
Discussi with hief f Obstetrics
! ! ! !
! ! ! !
-- Cefaz li rec mme ded
, , , ,
, , , , , , ! , ! , ! , , ! ! ! !
! ! ! ! ! ! ! ! ! !
Cef xiti t rec mme ded
, ! ! ! ! ! !
Jan Apr
, , , ,
Jul 85
!
Jul 84
, ! !
Oct Jan
,
Apr
, , , , , , , , , , , , ,
Oct Jan Apr 86 Jul Oct
Managerial Strategies 1
GOAL: to structure or guide decisions
y Changes in Selection, Procurement, Distribution

essential drugs lists y morbidity-based quantification y kit system distribution
y
y Changes Aimed at Prescribers

utilization review (audit) and feedback y diagnostic and treatment guidelines y structured drug order forms y peer group monitoring
y
Framework for Changing Drug Use OF HEALTH AND ALLIED SCIENCES SCHOOL Practices OF PHARMACY 176
Managerial Strategies 2:
GOAL: to structure or guide decisions
y Changes Aimed at Dispensers y allowing generic substitution y improved labeling y course of therapy packaging y Changes in Economic Incentives y patient cost-sharing y revolving drug funds y cost controls
Standard Treatment Guidelines

y STG s lead prescribers to most cost-effective treatments y Particularly useful for low level workers y Can be used for training, examinations and audit y Used for procurement
178
Prescribing Audits plus "Feedback" to Prescriber

Esta lish Criteria & Guidelines for Review
AUDIT (COLLECT DATA ON) RESCRIBING
NOTIFY RESCRIBERS OF RESULTS Individuals or Groups Letters or atient Notes or in erson

AUDIT (COLLECT DATA ON) RESCRIBING Comparison with Guidelines Comparison with eers
179Framework for Changing Drug Use Practices
Rational Use of Medicine Indicators: 1--Prescribing indicators

y Average No. drugs per encounter y % drugs prescribed by generic name y % encounters with antibiotic prescribed y % encounters with injection prescribed y % drugs prescribed from EDL or formulary
Regulatory Options
GOAL: To Restrict Decisions
y Market Controls y Limiting Drug Registration y Banning Previously Registered Drugs y Rx - only to OTC y Controlling Content in Drug Advertising y Prescribing and Dispensing Controls y Limiting Drugs Supplied in Public Sector y Restricting Specific Drugs to Higher Levels of Care y Required Generic Prescribing y Allowing Generic Substitution y Limits on Number or Quantity of Drugs per Patient
181
I t rv
ti
Str t gy
Pr scri i g f r Ac t Di rr
i M xic City
% cases treated in line with algorithm 100 After Workshop After Peer Review (n = 20)
37/52 79/115
Stud Ph sicians Control Ph sicians
80
60
Baseline Stage (n = 20) 42/82
1818-months Follow -up Follow-
40
25/102 20/84 16/70 11/46
31/110
20
0 Framework for Changing Drug Use OF HEALTH AND ALLIED SCIENCES SCHOOL Practices OF PHARMACY 182
Impact of Training on Use of Diarrhea Treatment Algorithm in Three Mexico Settings

Intervention given by: "Experts" in 2 clinics (San Jeronimo) "Leaders" in 18 clinics (Coyoacan) "Coordinators" in 124 clinics (Tlaxcala)
S : M n z, , np b i h (1993)
Prescribers
Baseline % 24.5%
Post % 71.2%
Change % +46.7%
31
65
17.7%
43.4%
+ 25.6%
157
24.7%
31.2%
+ 6.5%
Conclusion: Interventions to Change Drug Use

y Best evidence in PHC area y Focused, problem oriented repeated training y Supervision or self monitoring with simple indicators y Peer group oriented guideline development y Evidence lacking for : y Private sector, adults, and chronic diseases
Conclusion: Interventions to Change Drug Use (2)

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

Use (3)
y Drug retailers sales practices can be improved! y Studies on impact of economic and drug sector policy changes sorely lacking y 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
Characteristic of effective intervention

y Identify key influence factors: why people behave the way they do qualitative methods y Target individuals/group with worst practices y Use credible information sources: decision makers, authoritative materials y Use credible communication channel y Use personal contact whenever possible: face to face y Limit the number of messages & repeat key message using different media y Provide better alternative: encourage people to do something: treat diarrhea with ORS. Antidiarrhea not necessary

SESSION ONE MUHAS - PM604-Rational Use of Medicines Recovered)

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MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

PM604: Session 1: Rational Use of Medicines

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Rational Use of Medicines

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Dimensions of Rational Use of Medicines

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Components of the Drug Use System Supply

Provider & Consumer Interaction

Private MDs/ Other Providers

Pharmacies/ Drug Sellers

WHY RATIONAL USE OF MEDICINES?

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Importance of Rational Use of Medicines 1

effective selection, procurement and distribution of drugs.

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Importance of the Rational Use of Medicines 2

in most developing countries

health care is spent on medicines

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Common Patterns of Irrational Use of Medicines

The Medicine Use Process

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Aspects of Irrational Use of Medicines Diagnosis (1)

and doctor y Lack of documented medical history

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Aspects of Irrational Use of Medicines Prescribing 2a

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Aspects of Irrational Use of Medicines Prescribing (2b)

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Aspects of Irrational Use of Medicines Prescribing (2c)

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Aspects of Irrational Use of Medicines

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Aspects of Irrational Use of Medicines Prescribing (2e)

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Aspects of Irrational Use of Medicines (3)

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Aspects of Irrational Use of Medicines (4)

y Poor-quality packaging materials y Odd package size, which may require

repackaging y Unappealing package

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Aspects of Irrational Use of Medicines (5)

Problems with Irrational Drug Use: Poor Compliance

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Problems with Irrational Drug Use: Poor Compliance

Problems with Irrational Drug Use: Poor Compliance

economic and cultural aspects of the patient

Some Examples of Drug Use Studies

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Impact of Inappropriate Use of Medicines

Risk of unwanted effects

Psychosocial impacts patients rely on unnecessary drugs

reduced availability increased cost

adverse reactions bacterial resistance

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES SCHOOL OF PHARMACY

Factors Influencing the Use of Medicines

Prescriber, dispenser, and their workplaces

Rational use of medicines

Lack of regulation enforcement Non-essential drugs available

Patient preference to pay less for drugs

Increased cost sharing is associated with:

fees reduced inappropriate use only with lower fees

Increased drug availability associated with increased

Strategies to promote rational use can be built into