Framework for Changing Drug Use Practices 1 Framework
- Slides: 32
Framework for Changing Drug Use Practices 1
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
Components of the Drug Use System Local Manufacture Drug Imports The Drug Supply Process Provider and Consumer Behavior + Hospital or Health Center Illness Patterns Private Physician or Other Practitioner Pharmacist or Drug Trader Public Framework for Changing Drug Use Practices 3
Some Factors Influencing Drug Use Informational Unbiased Information Knowledge Deficits Influence of Industry Personal Acquired Habits Cultural Beliefs DRUG USE Patient Demand Workload & Staffing Workplace Infrastructure Interpersonal Relation With Peers Authority & Supervision Workgroup Framework for Changing Drug Use Practices 4
Learning About Factors Underlying Drug Use qualitative methods to identify motivations and incentives of prescribers and patients Framework for Changing Drug Use Practices 5
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
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
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
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
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
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
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
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
Yogyakarta Diarrhea Study Impact of Targeted Training on Health Worker Knowledge 10 Knowledge Score Significant increase pre vs. post 8 6 Pre Post 4 2 0 Face to Face Seminar Framework for Changing Drug Use Practices 14
Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of ORS % Cases Receiving ORS Differences from controls not significant 100 80 Pre Post 60 40 20 0 Face to Face Seminar Control Framework for Changing Drug Use Practices 15
Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of Antibiotics % Cases Receiving Antibiotics Significantly different from controls, p<0. 001 100 80 Pre Post 60 40 20 0 Face to Face* Seminar* Control Framework for Changing Drug Use Practices 16
Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of Antidiarrheals % Cases Receiving Antidiarrheals Significantly different from controls, p<0. 001 100 80 60 Pre Post 40 20 0 Face to Face* Seminar* Control Framework for Changing Drug Use Practices 17
Impact of Small Group Training on ORS Sales in Kenyan Retail Pharmacies Percentage Prescribing ORS 100 Phase 1 Nairobi 80 Phase 2 Other Cities 60 40 20 0 Intervention Control Pre Post Framework for Changing Drug Use Practices 18
Impact of Patient-Provider Discussion Groups on Injection Use in Indonesia PHC facilities Percentage Prescribing Injections 80 60 Pre Post 40 20 0 Intervention Control Framework for Changing Drug Use Practices 19
Effects of Opinion Leader on Choice Antibiotic for Prophylaxis in a Teaching Hospital Discussion with Chief of Obstetrics Percent of all C-sections 0. 7 0. 6 0. 4 , , 0. 5 ! , , , !!, , , 0. 3 0. 2 !! !!!! -- Cefazolin recommended !! ! ! — Cefoxitin not recommended ! , , , , , 0. 1 0 ! ! ! !!!! !! Jan Apr Jul 84 Oct Jan Apr Jul 85 Oct Jan Apr 86 Jul Oct Framework for Changing Drug Use Practices 20
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
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
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
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
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
Combined Intervention Strategy Prescribing for Acute Diarrhea in Mexico City % cases treated in line with algorithm 100 After Workshop 80 60 After Peer Review (n = 20) 37/52 Study Physicians Control Physicians 79/115 Baseline Stage (n = 20) 42/82 18 -months Follow-up 40 31/110 25/102 20/84 16/70 11/46 20 0 Framework for Changing Drug Use Practices 26
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) 31 24. 5% 71. 2% +46. 7% "Leaders" in 18 clinics (Coyoacan) 65 17. 7% 43. 4% + 25. 6% "Coordinators" in 124 clinics (Tlaxcala) 157 24. 7% 31. 2% + 6. 5% Source: Munoz, et al, unpublished (1993) Framework for Changing Drug Use Practices 27
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
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
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
Activity One Correcting Antibiotic Misuse in a South American City Framework for Changing Drug Use Practices 31
Activity Two Which strategies target different types of underlying motivation Framework for Changing Drug Use Practices 32
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