Framework for Changing Drug Use Practices 1 Framework

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Framework for Changing Drug Use Practices 1

Framework for Changing Drug Use Practices 1

Framework for Changing Drug Use Practices: Objectives • Identify specific drug use problems and

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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,

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

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

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

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

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

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

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,

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

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

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

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

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