Framework for Changing Drug Use Practices

1. Framework for Changing Drug Use Practices

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

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

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

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

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

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

8. Educational StrategiesGOAL: to inform or persuade • Training for Prescribers • 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, television Framework for Changing Drug Use Practices

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

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

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

12. Yogyakarta Diarrhea StudyA 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

13. Yogyakarta Diarrhea StudyA 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

14. Impact of Targeted Training on Health Worker Knowledge Significant increase pre vs. post Knowledge Score 10 8 6 Pre Post 4 2 0 Seminar Face-to-Face Yogyakarta Diarrhea StudyImpact of Targeted Training on Health Worker Knowledge Framework for Changing Drug Use Practices

15. % Cases Receiving ORS Differences from controls not significant 100 80 Pre 60 Post 40 20 0 Face-to-Face Seminar Control Yogyakarta Diarrhea StudyImpact of Targeted Training on Prescribing of ORS Framework for Changing Drug Use Practices

16. Pre Post Yogyakarta Diarrhea StudyImpact of Targeted Training on Prescribing of Antibiotics % Cases Receiving Antibiotics Significantly different from controls, p<0.001 100 80 60 40 20 0 Face-to-Face Seminar Control Framework for Changing Drug Use Practices

17. % Cases Receiving Antidiarrheals Significantly different from controls, p<0.001 100 80 60 Pre Post 40 20 0 Face-to-Face Seminar Control Yogyakarta Diarrhea StudyImpact of Targeted Training on Prescribing of Antidiarrheals Framework for Changing Drug Use Practices

18. % Prescribing ORS 100 Phase 1 Nairobi 80 Phase 2 Other Cities 60 Intervention Control 40 20 0 Pre Post Pre Post Impact of Small Group Training on ORS Sales in Kenyan Retail Pharmacies Framework for Changing Drug Use Practices

19. Pre Post Impact of Patient-Provider Discussion Groups on Injection Use in Indonesian PHC Facilities % Prescribing Injections 80 60 40 20 0 Intervention Control Framework for Changing Drug Use Practices

20. Discussion with Chief of Obstetrics % of all C-sections 0.7 ! ! ! ! 0.6 ! -- Cefazolin recommended , ! , 0.5 ! ! ! ! ! ! , ! , ! , ! ! , 0.4 , , ! ! — Cefoxitin not recommended , ! ! , 0.3 ! , ! ! , , 0.2 , ! ! , , 0.1 , , , ! , , , ! , , , , , ! ! ! ! ! ! ! , , , , , , , 0 Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct 84 85 86 Effects of Opinion Leader on Choice Antibiotic for Prophylaxis in a Teaching Hospital Framework for Changing Drug Use Practices

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

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

23. Standard Treatment Guidelines • STGs 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

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

25. Regulatory StrategiesGOAL: 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

26. % cases treated in line with algorithm Study Physicians Control Physicians 100 After Peer Review (n = 20) After Workshop 37/52 80 79/115 BaselineStage (n = 20) 18-months Follow-up 42/82 60 40 31/110 11/46 25/102 20/84 16/70 20 0 Combined Intervention StrategyPrescribing for Acute Diarrhea in Mexico City Framework for Changing Drug Use Practices

27. Prescribers Baseline Post Change % % % 31 24.5 71.2 +46.7 65 17.7 43.4 + 25.6 157 24.7 31.2 + 6.5 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) Source: Munoz, et al, unpublished (1993) Framework for Changing Drug Use Practices

28. Conclusion: Interventions to Change Drug Use (1) • 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

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

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

31. Activity 1 Correcting Antibiotic Misuse in a South American City Framework for Changing Drug Use Practices

32. Activity 2 Which strategies target different types of underlying motivation? Framework for Changing Drug Use Practices