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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
• Discuss strategies and interventions to
promote rational use of medicines
• 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
D D D per 1000 inh. per day
30
25
20
15
10
5
0
FR G R LU PT
IT
BE SK HR PL
IS
IE
ES
FI
BG CZ
SI
SE H U N O U K D K D E LV
Source: Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.
Department of Essential Medicines and Pharmaceutical Policy
TBS 2011
AT
EE NL
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
Impact of enforcing Prescription-only policy
for antibiotics on consumption in Chile
0.4
DDD/1000 inhabitants/day
0.3
0.25
1996
1997
1998
1999
2000
Source: Bavestrello & Cabello, ICIUM 2004
Department of Essential Medicines and Pharmaceutical Policy
TBS 2011
2001
0.2
2002
a
0.35
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
1995-7
1998-00
2001-3
2004-6
Africa
L.America
E.Mediterr
Europe
SE.Asia
W.Pacific
Data from EMP Pharmaceuticals Database
Department of Essential Medicines and Pharmaceutical Policy
TBS 2011
2007-9
% diarrhoea cases treated
Treatment of diarrhoea in private and public
sectors
70
60
50
40
30
20
10
0
ORS use
Antibiotic use
Private-for-profit (n=43,33,35,4)
Antidiarrhoeal
use
STG compliance
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
Department of Essential Medicines and Pharmaceutical Policy
TBS 2011
PUB
Treatment of ARI by prescriber type
% ARI cases treated
80
70
60
50
40
30
20
10
0
Cough syrup use
Approp.ABs in
pneumonia
Doctor (n=20,18,40,12)
Inapprop.ABs in
viral URTI
STG compliance
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
1. EXAMINE
Measure Existing
Practices
(Descriptive
Quantitative Studies)
4. FOLLOW UP
Measure Changes
in Outcomes
(Quantitative and Qualitative
Evaluation)
improve
diagnosis
improve
intervention
3. TREAT
Design and Implement
Interventions
(Collect Data to
Measure Outcomes)
Department of Essential Medicines and Pharmaceutical Policy
TBS 2011
2. DIAGNOSE
Identify Specific
Problems and Causes
(In-depth Quantitative
and Qualitative Studies)
Many Factors Influence Use of Medicines
Information
Scientific
Information
Influence
of Drug
Industry
Habits
Social &
Cultural
Factors
Treatment
Choices
Workload &
Staffing
Workplace
Intrinsic
Prior
Knowledge
Infrastructure
Relationships
With Peers
Societal
Economic &
Legal Factors
Authority &
Supervision
Workgroup
Department of Essential Medicines and Pharmaceutical Policy
TBS 2011
Strategies to Improve Use of Drugs
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
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
Department of Essential Medicines and Pharmaceutical Policy
TBS 2011
100
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
Department of Essential Medicines and Pharmaceutical Policy
TBS 2011
100
Making a list of Medicines – how it affects Rational Use
Department of Essential Medicines and Pharmaceutical Policy
TBS 2011
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 costeffectiveness 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
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