Drug and Therapeutics
Committee
Session 9. Strategies to Improve
Medicine Use—Overview
1
Objectives
 Identify effective strategies to improve medicine
use
 Choose an appropriate strategy for improving
medicine use based on an identified problem
 Understand the importance of educational,
managerial, and regulatory interventions in
promoting rational use of medicines
Outline
 Key definitions
 Introduction
 Methods to improve medicine use
 Educational
 Managerial
 Regulatory
 Activity 1
 Summary
Key Definitions
 Standard treatment guideline (STG)—Systematically developed
statement that assists practitioners and patients in making decisions
about appropriate health care for specific clinical circumstances
 Formulary manual—Document that describes medicines that are
available for use in hospitals or clinics (provides information on
indications, dosage, length of treatment, interactions, precautions,
contraindications)
 Drug use evaluation (DUE)—Ongoing, systematic, criteria-based
program of medicine evaluations that helps ensure appropriate
medicine use; if therapy is determined appropriate, interventions
with providers or patients will be necessary to optimize
pharmaceutical therapy
Introduction
 Drug and Therapeutic Committee (DTC)
responsibilities—
 Selecting medicines for the formulary
 Identifying medicine use problems
 Developing and implementing strategies to improve
medicine use
Consequences of Irrational Use of
Medicines (1)
 Waste of resources
Up to half the value of all medicines may be wasted
through inappropriate use
 Morbidity due to adverse drug reactions (ADRs)
In the United States, ADRs cost 30–130 billion U.S.
dollars per year and causes significant morbidity
and mortality
Consequences of Irrational Use of
Medicines (2)
 Antimicrobial resistance through misuse and
overuse
 2–4% multidrug resistance in TB, 12–55% resistance to
penicillin in N. Gonorrhoea and S. Pneumonia, 10–90%
resistance to ampicillin or co-trimoxazole in Shigella
 Increased disease due to dirty or unnecessary
injections
 2.3–4.7 million hepatitis B and C infections and up to
160,000 HIV infections per year
Changing a Medicine 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)
2. DIAGNOSE
Identify specific
problems and causes
(in-depth quantitative
and qualitative studies)
Strategies to Improve Medicine Use
Educational:
to inform or
persuade
Managerial:
to structure or guide
decisions
Regulatory:
to restrict or limit
decisions
Educational Methods: To Inform and
Persuade
 Printed materials
 Pharmaceutical bulletins and newsletters
 Formulary manuals and STGs
 Face-to-face activities
 Group: in-service education, workshops, seminars
 Individual: face-to-face (academic detailing)
Printed Educational Materials (1)
 Newsletters and bulletins
 International newsletters
 Local newsletters
 Brief, to the point, articles of interest to medical staff
 Tailor to problems seen at hospitals and clinics
 Produce regularly
 Need to be coupled with other approaches
Printed Educational Materials (2)
 Pharmaceutical newsletters are more likely to be
effective in improving rational use of medicines if they
do the following—
 Describe the reasons for prescribing behavior
 Offer concise, up-to-date information that can be used
immediately
 Provide limited information and repetition of key points
 Have attractive graphics
 Provide references in the newsletter to information derived from
reputable journals and services
 Provide information oriented toward actions and decisions
 Obtain feedback from the professional staff on the
value of newsletter and institute changes as
necessary
Printed Educational Materials (3)
 Formulary manuals
 Reference source for education and training for all
providers
 Provide a listing of medicines available and information
on the formulary medicines
 Source of price information
 STGs
 Reference source for education and for prescription
audit
 Lists the preferred pharmaceutical and
nonpharmaceutical treatments
Face-to-Face Educational Methods (1)
 In-service education, workshops, seminars
 Focuses on information of local relevance
 Is kept brief (i.e., messages are few and clear,
descriptions of what to do are concise)
 Supports the repetitive information needed for
individuals to learn
 Is run by a presenter who has in-depth knowledge
and an effective teaching style
Face-to-Face Educational Methods (2)
 Person-to-person educational outreach
(academic detailing)—most effective form of
education
 Focuses on specific problems and targets the
prescribers
 Addresses the underlying causes of prescribing
errors such as inadequate knowledge
Face-to-Face Educational Methods (3)
 Person-to-person educational outreach
(continued)
 Allows for interactive discussion with targeted
audience
 Uses concise and authoritative materials to augment
presentations
 Gives sufficient attention to solving practical
problems encountered by prescribers in real settings
Face-to-Face Educational Methods (4)
 Influencing opinion leaders
 Chiefs of service
 Dominant and experienced physicians in
community settings
 University professors
 Important and respected traditional healers
Effects of an Opinion Leader
on Choice Opinion Antibiotic for Prophylaxis in a U.S. Teaching Hospital
0.7
0.6
0.5
0.4
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0.2
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Jul
84
Oct
-- Cefazolin
recommended
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— Cefoxitin
not recommended
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Apr
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0.1
Jan
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0.3
0
Percentage of all cesarean sections
Discussion
with
Chief of
Obstetrics
Jan
Apr
Jul
85
Oct
Jan
Apr
Jul
86
Oct
Face-to-Face Educational Methods (5)
 Patient education
 Patients provided with education will—
 Have fewer demands for medicines
 Show improved compliance with pharmaceutical
therapy
 Have improved quality of care and outcomes
 Must be provided by authoritative persons, such
as physicians, pharmacists, and nurses in an
organized, systematic approach
Impact of Patient-Provider Discussion Groups
on Injection Use in Indonesian PHC Facilities*
% Prescribing Injections
80
60
Pre
Post
40
20
0
Intervention
Control
*Hadiyono, J.E., S. Suryawati, S.S. Danu, et al. 1996. Interactional Group Discussion: Results of a Controlled Trial Using a Behavioral
Intervention to Reduce the Use of Injections in Public Health Facilities. Social Science Medicine 42:1177–83.
Sites for Face-to-Face Education
 Health centers
 Hospitals
 Pharmacies
 Universities
 District-level education
Strategies to Improve Medicine Use
Educational:
to inform or
persuade
Managerial:
to structure or guide
decisions
Regulatory:
to restrict or limit
decisions
Managerial Methods: To Structure
and Guide Decisions
 STGs
 DUEs
 Clinical pharmacy programs
 Medicine restrictions and control
Standard Treatment Guidelines
 Advantages
 Standardized treatment guidance to all practitioners
 Dictates the most appropriate medicines
 Provides basis for evaluating quality of care
 Disadvantages
 Difficult to produce accurately
 Inaccurate or incomplete guidelines will provide the
wrong information and do more harm than good
 Guidelines may not be based on the most reliable
information
Randomized Controlled Trial In Uganda—
Effects of Treatment Guidelines, Training, and Supervision
on the Percentage of Prescriptions Conforming to STGs*
Randomised
group
PostPreNo. health
facilities intervention intervention
Change
Control group
42
24.8%
29.9%
+5.1%
Dissemination of
guidelines
42
24.8%
32.3%
+7.5%
Guidelines + onsite training
29
24.0%
52.0%
+28.0%
14
21.4%
55.2%
+33.8%
Guidelines + onsite training + 4
supervisory visits
*Kafuko, J.M., C. Zirabumuzaale, and D. Bagenda. 1996. Rational Drug Use in Rural Health Units
of Uganda: Effect of National Standard Treatment Guidelines on Rational Drug Use. Final report
UNICEF/Uganda.
Audit and Feedback
 DUE
 Program of ongoing, systematic, criteria-based
evaluations of pharmaceutical therapy
Clinical Pharmacy Programs
Last check on correct use, doses, side effects
 Medicine information and patient education
 Correct labeling and course of treatment packaging
 Generic substitution programs—bioequivalence issues
 Therapeutic substitution (interchange)—substitution of
medicines that differ in active ingredients but have
similar therapeutic activities in terms of efficacy and
safety (e.g., lisinopril for enalapril)
Pharmaceutical Restrictions and
Control
 Formulary list (essential medicine list)
 Structured order forms
 Automatic stop orders
Controlling Pharmaceutical
Promotion
 All promotional claims concerning medicines should
be reliable, accurate, truthful, informative, balanced,
capable of substantiation, and in good taste
 Control access of medical representatives to
prescribers in the hospital during working hours
 Organize meetings of discussion between medical
representatives and prescribers to allow DTC to
evaluate the medicine of interest
Avoiding Perverse Economic
Incentives
 Separation of the prescribing and dispensing functions
 Avoidance of flat prescription fees that encourage
polypharmacy
 Avoidance of percentage dispensing fees that encourage
the sale of more expensive medicines
 Avoidance of polypharmacy where prescribers earn part
of their income from the sale of medicines (including the
use of expensive medicines where cheaper one would
be just as good)
Improving Prescribing by Changing
Financial Incentives from User Fees*
 Pre- and post-study with control
 1992: All three areas used flat fee covering all medicines in
whatever quantities (perverse financial incentive)
 1993–94: Two areas changed to a fee per pharmaceutical
item (positive incentive)
 1992–95: One area continued with the flat fee covering all
medicines (control)
 Prescription (Px) surveys done in pre-intervention (1992) and
post-intervention (1995)
 10–12 health facilities per area, > 30 prescriptions per facility
*Holloway, K.A., B.R. Gautam, and B.C. Reeves. 2001. The Effects of Different Kinds of User Fees
on Prescribing Quality in Rural Nepal. Journal of Clinical Epidemiology 54(10):1065–71.
Polypharmacy and Antibiotic Use: On
changing from a flat medicine fee to a fee
per medicine item
Average number of medicines per patient
% patients treated with antibiotics
4
80
3
60
2
40
1
20
0
Px fee 1-band item fee 2-band item fee
1992
Holloway et al. (2001).
1995
0
Px fee 1-band item fee 2-band item fee
1992
1995
Injection and Vitamin or Tonic Use:
On changing from a flat medicine fee to a
fee per medicine item
% patients treated with
vitamins/tonics
% patients treated with injections
25
20
15
10
5
0
30
25
20
15
10
5
0
Px fee
1-band item fee
1992
1995
Holloway et al. (2001).
2-band item fee
Px fee 1-band item fee 2-band item fee
1992
1995
Treatment Cost and Compliance with
STGs: On changing from flat medicine fee
to fee per medicine item
Average medicine cost
per patient (NRs)*
% patients treated according to STGs
60
50
40
30
20
10
0
40
30
20
10
0
Px fee
1-band item fee 2-band item fee
1992
Holloway et al. (2001).
1995
Px fee
1-band item fee 2-band item fee
1992
*NR = Nepalese rupees
1995
Strategies to Improve Medicine Use
Educational:
to inform or
persuade
Managerial:
to structure or guide
decisions
Regulatory:
to restrict or limit
decisions
Regulatory Methods: To Restrict or
Limit Decisions
 Country pharmaceutical registration—ensure only
registered medicines are used
 Professional licensing—employ only licensed staff
for the level of prescribing required
 Licensing of pharmaceutical outlets—buy
medicines only from licensed outlets
 Regulation pharmaceutical promotion activities
Choosing an Intervention (1)
 A single educational strategy is usually not too
effective and the impact is not sustainable.
 Printed materials alone are not effective or advisable.
 A combination of strategies, particularly of different
types (e.g., educational and managerial) always
produces better results than a single strategy.
Choosing an Intervention (2)
 Focused small groups and face-to-face interactive
workshops have been shown to be effective.
 Monitoring (audit) and feedback and peer review are
effective strategies to improve medicine use.
 Economic strategies are powerful strategies to change
medicine use but may be difficult to introduce.
 Treatment guidelines are effective when used with
other interventions.
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
Baseline Stage
(n = 20) 42/82
18-months
Follow-up
31/110
25/102
0
Control Physicians
79/115
40
20
Study Physicians
20/84
16/70
11/46
Impact of Training on Using
Diarrhea Treatment Algorithm in
Three Mexican 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)
Review of 30 Studies in Developing Countries—
Medicine Use Improvements with Different
Interventions*
None,
Large
Moderate
minor
Large group training
Small group training
Diarr. community case mgt
ARI community case mgt
Info/guidelines
Group process
Supervision/audit
EDP/medicine supply
Economic strategies
0
10
20
30
40
50
60
Improvement in outcome measure (%)
Source: Ross-Degnan et al. 1997. Plenary Presentation, Conference on Improving the Use
of Medicines. Chiang Mai, Thailand.
Activity 1.
Case Study: Generic and Brand Name Antibiotics
 What are the major pharmaceutical management
problems in this case presentation?
 Clearly define the beliefs and motivations of the
prescribers that may contribute to the observed
behavior.
 Once the problem has been defined, what kinds of
strategies or interventions would you use to improve
pharmaceutical therapy and to lower medicine costs in
this hospital?
Summary (1)
 Strategies to improve medicine use
include the following types of
interventions—
 Educational programs
 In-service education
 Pharmaceutical bulletins and newsletters
 Formulary manuals
 Face-to-face education
Summary (2)
Interventions (continued)—
 Managerial programs
 DUE
 STG
 Clinical pharmacy programs
 Medicine restrictions and control
 Regulatory programs—registration of medicines,
professionals, facilities