Framework for Changing Drug Use Practices

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

Components of the Drug Use System Drug Imports Local Manufacture Hospital or Health Center Private Physician or Other Practitioner Pharmacist or Drug Trader The Drug Supply Process Provider and Consumer Behavior Illness Patterns + Public Framework for Changing Drug Use Practices

Some Factors Influencing Drug Use Cultural Beliefs Knowledge Deficits Unbiased Information Relation With Peers Authority & Supervision Influence of Industry Workload & Staffing Infra- structure Acquired Habits Patient Demand Interpersonal Workplace Workgroup Personal Informational Framework for Changing Drug Use Practices

Learning about Factors Underlying Drug Use Use qualitative methods to identify motivations and incentives of prescribers and patients Framework for Changing Drug Use Practices

Changing a Drug Use Problem: An Overview of the Process 1. EXAMINE Measure Existing Practices (Descriptive Quantitative Studies) 2. DIAGNOSE Identify Specific Problems and Causes (In-depth Quantitative and Qualitative Studies) 3. TREAT Design and Implement Interventions (Collect Data to Measure Outcomes) 4. FOLLOW UP Measure Changes in Outcomes (Quantitative and Qualitative Evaluation) improve intervention diagnosis Framework for Changing Drug Use Practices

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

Educational Strategies GOAL: to inform or persuade Training for Prescribers 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, television Framework for Changing Drug Use Practices

Training for Prescribers WHO has produced a Guide for Good Prescribing Developed in Groningen Field tested in 7 sites Suitable for medical students, post grads, and nurses Framework for Changing Drug Use Practices

Printed Materials Cover range of materials including journals, newsletters, ads, STGs, etc. Most useful when combined with other methods Should include key messages and have attractive graphics Framework for Changing Drug Use Practices

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

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

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

Yogyakarta Diarrhea Study Impact of Targeted Training on Health Worker Knowledge Face-to-Face Seminar 2 4 6 8 10 Knowledge Score Pre Post Significant increase pre vs. post Impact of Targeted Training on Health Worker Knowledge Framework for Changing Drug Use Practices

Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of ORS Face-to-Face Seminar Control 20 40 60 80 100 % Cases Receiving ORS Pre Post Differences from controls not significant Framework for Changing Drug Use Practices

Significantly different 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 Face-to-Face Seminar Control Framework for Changing Drug Use Practices

Significantly different Yogyakarta Diarrhea Study Impact of Targeted Training on Prescribing of Antidiarrheals Significantly different from controls, p<0.001 Face-to-Face Seminar Control 20 40 60 80 100 % Cases Receiving Antidiarrheals Pre Post Framework for Changing Drug Use Practices

Impact of Small Group Training on ORS Sales in Kenyan Retail Pharmacies Pre Post 20 40 60 80 100 % Prescribing ORS Phase 1 Nairobi Intervention Control Phase 2 Other Cities Framework for Changing Drug Use Practices

Impact of Patient-Provider Discussion Groups on Injection Use in Indonesian PHC Facilities % Prescribing Injections 80 60 Pre Post 40 20 Intervention Control Framework for Changing Drug Use Practices

Effects of Opinion Leader on Choice Antibiotic for Prophylaxis in a Teaching Hospital , ! Jan Apr Jul Oct 84 85 86 0.1 0.2 0.3 0.4 0.5 0.6 0.7 % of all C-sections Discussion with Chief of Obstetrics -- Cefazolin recommended — Cefoxitin not recommended Framework for Changing Drug Use Practices

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

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

Standard Treatment Guidelines STGs 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

Prescribing Audits plus "Feedback" to Prescriber Establish Criteria and Guidelines for Review AUDIT (COLLECT DATA ON) PRESCRIBING · Comparison with Guidelines · Comparison with Peers NOTIFY PRESCRIBERS OF RESULTS · Individuals or Groups · Letters or Patient Notes or in Person Framework for Changing Drug Use Practices

Regulatory Strategies 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

Combined Intervention Strategy Prescribing for Acute Diarrhea in Mexico City 20 40 60 80 100 % cases treated in line with algorithm Study Physicians Control Physicians 37/52 79/115 20/84 BaselineStage (n = 20) After Workshop After Peer Review 18-months Follow-up 11/46 31/110 16/70 25/102 42/82 Framework for Changing Drug Use Practices

Impact of Training on Use of Diarrhea Treatment Algorithm in Three Mexico Settings Intervention Prescribers 31 65 157 Baseline % 24.5 17.7 24.7 Post % 71.2 43.4 31.2 Change % +46.7 + 25.6 + 6.5 given by: "Experts" in 2 clinics (San Jeronimo) "Leaders" in 18 clinics (Coyoacan) "Coordinators" in 124 clinics (Tlaxcala) Source: Munoz, et al, unpublished (1993) Framework for Changing Drug Use Practices

Conclusion: Interventions to Change Drug Use (1) 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

Conclusion: Interventions to Change Drug Use (2) Few interventions in hospitals in developing countries but great potential exists Consumers need to be involved. Experience is lacking, but interactive, context-specific programs with a mix of communication channels likely to be effective Framework for Changing Drug Use Practices

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

Correcting Antibiotic Misuse in a South American City Activity 1 Correcting Antibiotic Misuse in a South American City Framework for Changing Drug Use Practices

Which strategies target different types of underlying motivation? Activity 2 Which strategies target different types of underlying motivation? Framework for Changing Drug Use Practices