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Promoting Rational Use of Drugs

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

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Promoting Rational Use of Drugs

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  1. Promoting Rational Use of Drugs Krisantha Weerasuriya MD

  2. 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

  3. 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" ?

  4. Snapshots in Low and Middle Income Countries

  5. Variation in outpatient antibiotic use in 26 European countries in 2002 Snapshots High Income Countries Source: Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.

  6. 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?

  7. 2008 Generic Uptake after Patent Expiry in 2000 Expensive access with potential for enormous savings – Policy? Data Source IMS Health 2009

  8. AN EXAMPLE FOR FEDBACK SYSTEM AVERAGE COST PER PRESCRIPTION(Country?)

  9. 1. EXAMINE Measure Existing Practices (Descriptive Quantitative Studies) improve diagnosis 4. FOLLOW UP 2. DIAGNOSE Measure Changes Identify Specific in Outcomes Problems and Causes (Quantitative and Qualitative (In-depth Quantitative Evaluation) and Qualitative Studies) improve 3. TREAT intervention Design and Implement Interventions (Collect Data to Measure Outcomes) Changing a Drug Use Problem:An Overview of the Process

  10. NO. OF UNIT-ATC (ITS/2011)(PHARMACY SALE DATA)

  11. ITSDATA FOR JUNE-JULY 2012 Where should the focus of activities be ? Hospitals or Pharmacies?

  12. Intrinsic Prior Knowledge Scientific Information Habits Information Social &Cultural Factors Influenceof Drug Industry Treatment Choices Societal Economic & Legal Factors Workload & Staffing Workplace Infra-structure Authority & Supervision Relationships With Peers Workgroup Many Factors Influence Use of Medicines

  13. 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 Strategies to Improve Use of Drugs

  14. Educational StrategiesGoal: 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

  15. Training for prescribersThe 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 • Needs to be updated

  16. 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

  17. 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)

  18. Regulatory strategiesGoal: 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

  19. What are countries doing to promote the rational use of medicines? national policies Source: EMP pharmaceutical policy database

  20. Basic training and obligatory continuing medical education (CME) available for health professionals Source: EMP pharmaceutical policy database How many of the countries present in TBS teach Essential Medicines concept in undergraduate teaching?

  21. However, is it all Doom and Gloom?Having a Policy does help Comparison of countries with and without specific policies Weighted mean of differences for 12 INRUD/IMCI indicators (bars denote % difference and 95% CI)

  22. Reminder: 10 national strategies to promote RUMneed 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

  23. 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 cost-effectiveness of interventions? • they do not bear the cost of irrational use? (OOP?)

  24. 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!)

  25. Some issues to think about • There are textbook cases of Technical Success in RUMTools 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?

  26. 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?

  27. 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: weerasuriyak@who.int Comments and Questions welcome Some notes in individual slides

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