Rational Use of Medication And Patient Compliance Presented by Dr. Wadha AlFarwan

RATIONAL means “prescribing right drug, in adequate dose for the sufficient duration & appropriate to the clinical needs of the patient at lowest cost”

WHO conference of experts Nairobi 1985 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

Criteria for Using Medicines: Appropriate indication. Appropriate drug considering efficacy, safety, suitability for the patient, and cost . Appropriate dosage, administration, duration Affordable Appropriate patient Appropriate patient information

Objectives To Understand: Concept of rational use of medicines Factors influencing the irrational use of medicines Adverse impact of irrational use of medicines Role of doctors and pharmacist in promoting the rational use of medicines. Importance of patient education .

Many Factors Influence Use of Medicines Treatment Choices Prior Knowledge Habits Scientific Information Relationships With Peers Influence of Drug Industry Workload & Staffing Infra- structure Authority & Supervision Societal Information Intrinsic Workplace Workgroup Social & Cultural Factors Economic & Legal Factors

FACTORS THAT RAISED THE RDU : Drug explosion: Increase in the number of drugs available has incredibly complicated the choice of appropriate drug Efforts to prevent the development of resistance Growing awareness: Today, the information about drug development Increased cost of the treatment Consumer protection Act. (CPA):- Extension of CPA in medical profession may restrict the irrational use of drugs.

Reason for Irrational Use Lack of information Role model – Teachers or seniors Poor communication between health professional & patient Lack of diagnostic facilities/Uncertainty of diagnosis Demand from the patient Defective drug supply system & ineffective drug regulation Promotional activities of pharmaceutical industries

Common patterns of irrational prescribing : The use of drugs when no drug therapy is indicated, e.g. antibiotics for viral upper respiratory infections. The use of the wrong drug for a specific condition requiring drug therapy, e.g. tetracycline in childhood diarrhea requiring ORS. The use of drugs with doubtful or unproven efficacy, e.g. the use of antimotility agents in acute diarrhea

cont. Failure to provide available, safe and effective drugs, e.g. failure to vaccinate for measles or tetanus, or failure to prescribe ORS for acute diarrhea. The use of correct drugs with incorrect administration, dosage and duration, e.g. using intravenous route where oral or suppository routes would be appropriate. The use of unnecessarily expensive drugs, e.g. the use of a third generation, broad-spectrum antimicrobial when a first line, narrow spectrum agent is indicated. Antibiotics misuse

Hazards of Irrational Use Ineffective & unsafe treatment * over-treatment of mild illness * inadequate treatment of serious illness Exacerbation or prolongation of illness Distress & harm to patient Increase the cost of treatment Increased morbidity and mortality Increased Adverse drug reactions and drug Resistance Loss of patient confidence in health system

Obstacles exist in RDU : Lack of objective information & of continuing education & training programs. Lack of well organized drug regulatory authority & supply of drugs. Presence of large number of drugs in the market & the lucrative methods of promotion of drugs employed by pharmaceutical industries. The prevalent belief that “every ill has a pill.”

Steps To Improve Rational Drug Prescribing : Make a specific diagnosis Consider the pathophysiology of diagnosis selected : If the disorder is well understood the prescriber is in a better position to select effective therapy. Select a specific therapeutic objective or goal and medications should be selected based on it. Select a drug of choice .

Determine the appropriate dosing regimen to obtain desired therapeutic levels and the drug must be inexpensive, easily available and should be prescribed in generic name. Drug interaction and adverse effects must be taken into account before initiating combination of drugs. Device a plan for monitoring the drugs action and determine an end point for the therapy. Plan a program for patient education.

Strategies to Improve Use of Drugs Economic: Offer incentives Institutions Providers and patients Managerial: Guide clinical practice Information systems/STGs Drug supply / lab capacity Regulatory: Restrict choices Market or practice controls Enforcement Educational: Inform or persuade Health providers Consumers Use of Medicines

Educational Strategies 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

Managerial strategies 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

Avoid perverse financial incentives Economic strategies: 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

Regulatory strategies 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

Role of Doctors and Pharmacist They can establish a common approach to the rational use of drugs by giving advice and information to patient regarding the proper use of drugs. They have more opportunity to interact closely with the prescriber and therefore, to promote the rational prescribing and use of drugs.

By having access to medical records, they are in a position to influence the selection of drugs, dosage regimens, to monitor patient compliance and therapeutics, response to drugs and to recognize and report adverse drug reactions. They can control hospital manufacture and procurement of drugs to ensure the supply of high quality products.

Conclusion : The demands of rational drug use are: Availability of essential & life saving drugs and unbiased drug information with generic name. Adequate quality control & drug control. Withdrawal of hazardous & irrational drugs. Drug legislation reform.

Policy implementation at the national level 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.

Definition of compliance Compliance, simply defined as “agreement.” With regard to medicine, compliance means agreeing to take medicine(s) as directed, and then following through with that agreement…..accepting the responsibility of taking medicine(s) as agreed8

Definition of Adherence Adherence is defined as the extent to which a patient’s health behavior coincides with their physician’s recommendations, whether taking medications or following advice for some type of behavioral change.

Adherence vs. Compliance Adherence is a more accurate term than compliance. Compliance suggests a process in which dutiful patients passively follow the advice of their physicians Adherence, in contrast, better fits how most patients actively participate in their care and decide for themselves when and whether to follow their doctor’s advice.

Non compliance can be caused by: Failure to understand instructions Non comprehension Volitional non compliance How big a problem is medication non compliance? Up to 60% of all medication prescribed is taken incorrectly or not taken at all!

Medication noncompliance includes: Not filling a prescription Over medication Taking wrong medication Taking right medication in a wrong time Forgetting to take medication Deliberately under dosing or not taking medication

Overall Rates Of Noncompliance 90% of elderly patients make some medication errors. 35% of elderly patients make potentially serious errors. 50% of all long term medications are abandoned in the first year. 75% of chronic care patients prescribed drugs either stop taking their medication at some point or don’t take them as directed. Only 75% of patients who understand and agree with treatment are compliant.

Noncompliance in medication taking can be classified as: Noncompliance causes admission of 380,000 patients to nursing homes (23% of all admissions) and is the key factors in admissions. Noncompliance in medication taking can be classified as: Errors of omission Errors of commission Dosage errors Scheduling errors

Patient’s noncompliance is important from at least 4 perceptions: Individual patient care. Public health efforts. Interpretation of the medical literature. Economic consequences.

Exacerbation of disease Increases frequent physician visits Health Effects: Increase morbidity Treatment failure Exacerbation of disease Increases frequent physician visits Increases hospitalization Death

Increases absenteeism Lost productivity at work Economic Effects Increases absenteeism Lost productivity at work Lost revenues to pharmacies Lost revenues to pharmaceutical manufacturers

Measurements of Compliance Approaches to assessing compliance behavior in patients by Asking Medication counting Assay Supervision Often necessary to use more than one method to arrive at a reasonably valid estimate of compliance in the individual patient.

1. Asking: Ability to predict compliance Methods of measurement: Sometimes no better than would be expected by chance Methods of measurement: 1. Asking: Simplest and most practical method of assessing compliance behavior. Self-reports of noncompliance are valid, but often result in underestimation of the degree of noncompliance. Only 40%-80% of patients admit their noncompliance . Self-reported compliance over estimate true compliance rates. Manner of asking influences the accuracy of patient response.

2. Medication Counting : 3. Assays : More objective but it has problems: Overestimation Underestimation 3. Assays : Limitations: Assays can be expensive. Multiple measurements are required over extended period of time. Patient may take medicine immediately before the collection of specimen but not at other time.

Differences in drug absorption, distribution, metabolism, excretion Differences in drug absorption, distribution, metabolism, excretion.(whether a low level represents noncompliance or inadequate dosage in patient???). Collection of specimens has to be timed correctly, at appropriate times, absence of any drugs in the specimen suggests noncompliance. Assays are not available for many medications.

Patient Considerations Factors believed to affect compliance: Patient knowledge. Prior compliance behavior Ability to integrate into daily life / Complexity of the particular drug regimen. Health beliefs and perceptions of possible benefits of treatment (self efficiency) Social support (including practitioner relationships)

Factors which NOT believed to be associated with compliance: Age, race, gender, income or education. Patient intelligence. Actual seriousness of the disease or the efficiency of the treatment.

Patients in Higher Risk: Asymptomatic conditions Hypertension. Chronic conditions Hypertension, arthritis, diabetes. Cognitive impairment Dementia, Alzheimer. Complex regimens Poly pharmacy.

5. Multiple daily dosing 6. Patient perceptions 7. Poor communication Effectiveness, side effects, cost. 7. Poor communication Patient practitioner rapport 8. Psychiatric illness Less likely to comply.

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