1 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 MMA 1, Waning B 2, Maina M 3 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 July 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 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

2 THE SETTING-Gertrude’s Garden Children’s Hospital 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)

3 THE INTERVENTIONS PROBLEM STATEMENT Can RDU intervention strategies be implemented successfully in private sector healthcare in a developing country? INTERVENTION STRATEGIES 1.Policy Interventions 2.Information & clinical Decision Support 3.Education & training 4.Audit & feedback

4 1: POLICY INTERVENTIONS Generic prescribing & substitution Drug stocking and purchasing policy Antibiotic use restrictions in OPD Regulation of Medical representatives 2: INFORMATION & DECISION SUPPORT 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

5 Doctors resource room-Computer & Tea facilities on site

6 3: EDUCATION &TRAINING 4: AUDIT & FEEDBACK 3. Education & Training Journal club CMEs based on need Internships locally and abroad PALS, HIV/AIDs, UTI, URTI, IMCI 4. Audit & Feedback DURs & feedback PMR audit & feedback Focus groups Opinion leaders Incentives for change (Resource allocation)

7 METHODOLOGY INRUD/WHO DUIs at baseline & every 3 months till Dec 2003 Systematic sampling (Doctor, Day, wk/end) Pxrs per month Baseline data Sept-Nov 01

8 RESULTS: TABLE 1 MonthAv Drug% Gen% A/B% Inj Sept-Nov Dec01-Feb Mar-May Jul-Sept Oct-Dec Jan-Mar Apr-Jun Jul-Sept Oct-Dec

9 Results 1: Ave No. of Drugs per Rx

10 Results 2: % A/B, % Drugs prescribed as generic,% Inj

11 Results 3: Av Cost per Prescription

12 Changes in Brand drug sales- Ceftriaxone & CoAmoxiclav

13 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 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

14 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