ASSESSING THE EFFECT OF TWO POLICY INTERVENTIONS ON TREATMENT COSTS AND DRUG USE PATTERNS IN A PRIVATE SELF
FUNDING HEALTHCARE INSTITUTION; THE CASE OF GENERIC PRESCRIBING AND GENERIC SUBSTITUTION
Ojoo MMA1, Waning B2, Maina M3
1-Gertrude’s Garden Children’s Hospital, Kenya, 2-Boston University, USA, Kenyatta National Hospital, Kenya
OVERALL AIM
This study aims to determine whether well-proven interventions aimed at improving drug use yield positive outcomes in private sector healthcare
institutions. These interventions are; prescribing by use of generic names and Generic substitution at pharmacy level
SPECIFIC OBJECTIVES
1.
To implement two specific policy interventions on generic prescribing and generic substitution (dispensing)
2.
To measure the effect of each of these policies on drug use patterns and treatment costs
3.
To compare and contrast the two policies
SIGNIFICANCE OF THE STUDY
This study will provide data that can be used by policy makers in private healthcare institution in similar settings to improve drug use
STUDY DESIGN
This is a before and after intervention type study covering a total of 2 ½ years with an equivalent control group
1.
Generic prescribing policy: August 2001- July 2002
2.
Generic substitution Policy: February 2002 and December 2003
Descriptive and inferential statistical analysis will be used. Logistical regression analysis will be done to control for confounders
THE SETTING
A private, not-for-profit 80-bed hospital in the suburbs of Nairobi treating both outpatients and in patients. The hospital’s main source of income is
fees paid by patients for services rendered. 10% of income is spent on giving free treatment to needy patients who cannot afford to pay for
services. The control private health facility
INTERVENTIONS
1.
A policy requiring all prescribers in the out patient department to use the recommended International Nonproprietary Names (rINN) or
British Approved Names (BAN) when prescribing medications. Using a “brand name” of a cost effective multisource product currently in
stock is considered acceptable. This was implemented in August 2001
2.
A Policy permitting the Pharmacy to dispense the most cost effective Multisource medicine irrespective of what name of the medicine the
prescriber has used on the prescription. This was implemented in August 2002
STUDY POPULATION
Random sampling of 100 cases each per month for children less than 6 years of age for a diagnosis of Acute Respiratory Infection and Diarrhoea will
be entered into the predesigned forms. Similar data will be collected from the control Healthcare institution (AAR)
OUTCOME MEASURES
% number of drugs prescribed as generic
% number of drugs prescribed as antibiotic
% reduction in cost per prescription
% injection use in outpatient set up
Note: Since the study population is derived from those with specific disease states, it is possible to look at disease specific outcomes as well.
RESULTS AND CONCLUSION
Study still in progress
Funding Sources: ARCH project, USA
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THE SETTING-Gertrude’s
Garden Children’s Hospital
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•
•
•
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OPD- A&E and General paed Practice
Average 4500 patients seen in OPD per month
Ave 200 patients admitted from OPD per month
17 Doctors (14 general, 3 paediatricians) in OPD
90% of patients pay, 10% treated free
2 Pharmacists , 8 pharmacy Technicians
84 In Patient beds, 63-75% occupancy rate (2003)
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THE INTERVENTIONS
PROBLEM
STATEMENT
Can RDU intervention
strategies be
implemented
successfully in
private sector
healthcare in a
developing country?
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1.
2.
3.
4.
INTERVENTION
STRATEGIES
Policy Interventions
Information &
clinical Decision
Support
Education & training
Audit & feedback
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1: POLICY INTERVENTIONS
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Generic prescribing & substitution
Drug stocking and purchasing policy
Antibiotic use restrictions in OPD
Regulation of Medical representatives
2: INFORMATION & DECISION SUPPORT
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OPD drug list with drug costs indicated
Drug info service-Query answer & Newsletters
Formulary New & Standard treatment guidelines New
Patient information leaflets-“ a guide to generics”
Articles in GGCH newsletter for the public
Paediatricians in OPD for decision support
Doctors’ Resource room
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Doctors resource room-Computer & Tea
facilities on site
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3: EDUCATION &TRAINING
4: AUDIT & FEEDBACK
3.Education & Training 4. Audit & Feedback
• Journal club
• CMEs based on need
• Internships locally
and abroad
• PALS, HIV/AIDs,
UTI, URTI, IMCI
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•
•
•
•
DURs & feedback
PMR audit & feedback
Focus groups
Opinion leaders
Incentives for change
(Resource allocation)
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METHODOLOGY
INRUD/WHO DUIs
at baseline & every 3
months till Dec 2003
• Systematic sampling
(Doctor, Day,
wk/end)
• 130-170 Pxrs per
month
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Baseline data Sept-Nov 01
Parameter
Av No. Drugs
Rx
PMR Threshold
3.32
3.1
2.2
6
4
100
% Antibiotics
82.6
83.3
60
% Injection
17.4
19.3
<10
% Generics
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RESULTS: TABLE 1
Month
Av Drug
% Gen
% A/B
% Inj
Sept-Nov 01
3.32
4.0
82.6
17.4
Dec01-Feb02
2.92
13.0
73.0
20.0
Mar-May 02
2.66
10.0
72.0
17.0
Jul-Sept 02
2.5
16.0
67.0
16.0
Oct-Dec 02
2.3
15.3
73.0
6.7
Jan-Mar 03
2.29
13.0
70.0
11.0
Apr-Jun 03
2.25
9.65
52.5
6.5
Jul-Sept 03
2.34
20.36
40.0
7.4
Oct-Dec 03
2.32
23.36
41.5
7.3
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Results 1: Ave No. of Drugs per Rx
Average number of Drugs per prescription
Ave Drugs
Linear (Ave Drugs)
3.5
3.3
3.1
2.9
Number
2.7
2.5
2.3
2.1
1.9
1.7
1.5
Sept-Nov 01
Dec01-Feb
02
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Mar-May 02
July-Sept 02
Oct-Dec 02
Jan-Mar 03
Apr-Jun 03
Jul-Sept 03
Oct-Dec 03
Months
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Results 2: % A/B, % Drugs prescribed as
generic,% Inj
Prescribing Indicators Sept 01-Dec 03
90
80
70
60
%
50
40
30
20
10
0
Sept-Nov Dec01-Feb Mar-May
01
02
02
Months
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July-Sept Oct-Dec 02 Jan-Mar 03 Apr-Jun 03 Jul-Sept 03 Oct-Dec 03
02
% Gen
% A/B
% Inj
Linear (% A/B)
Linear (% Gen)
Linear (% Inj)
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Results 3: Av Cost per Prescription
Av cost Per Rx per Month
Monthly sales Vs Av cost per Rx Aug 01-Dec 03
1,800
1,700
Value in Ksh
1,600
1,500
1,400
1,300
1,200
1,100
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ec
-0
3
D
ct
-0
3
O
Ap
r-0
3
Ju
n03
Au
g03
Fe
b03
ec
-0
2
D
ct
-0
2
O
Ap
r-0
2
Ju
n02
Au
g02
Fe
b02
ec
-0
1
D
ct
-0
1
O
Au
g01
1,000
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Changes in Brand drug salesCeftriaxone & CoAmoxiclav
Thousands
Branded Drug Changes
3,500
3,000
2,500
Claritine
Amikin
2,000
Mucosolvon
Zinacef
Cefzil
1,500
Rocephine
Augmentin
1,000
500
0
Sales Jun
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Sales Jul
Sales AUg
Sales Sept
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KEY LESSONS LEARNT
INTERVENTION RELATED
Interventions a success story
BUT……….
• “Loss of drug profits” panic!
• Old habits die hard!
• Turnover of Prescribers
• Poor perception of generic drugs
• Med Reps persist Outside GGCH
STUDY RELATED
• Data sources primarily Manual
• Private Hospitals reluctant to
provide “control” data
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IMPLICATIONS
Immediate
Who pays for the
improvements?
Longterm-Interventions
must be ongoing
-HMO influence;
Formularies & STGs to
be more in use
Future research agenda?
– Impact of policy
interventions on
health outcomes
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Selected References
• WHO/INRUD; How to Investigate drug use in Health facilities
• Limpanasithukul Et Al; Effects of managerial intervention
(Formulary & generic dispensing) on drug utilization pattern
at King Chulalongkorn Memorial hospital- Journal of the
Medical Ass of Thailand June 2002
• Thompson et Al; Audit & feedback;effects on professional
practice & healthcare outcomes-Cochrane collaboration, Nov
1997
• Dartnell JGA; Understanding, Influencing and evaluating drug
use, 2001 (Therapeutic Guidelines Ltd,Australia)
• Laing RO & Ross-Degnan D; Ten recommendations to improve
use of medicines in developing countries-Health Policy &
Planning 2001
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