Implementing a Drug Use Indicators Study

Implementing a Drug Use Indicators Study: Objectives Identify the importance of drug use indicators Know the steps to implement an indicators study Understand different methods of sampling and data collection Understand how to analyze a situation using indicators Present the results of an indicators study Refer to Chapter 1, p3-7 of WHO manual. Implementing a Drug Use Indicators Study

Types of Drug Use Studies Descriptive: Cross-sectional (basic) Comparative: Stratified cross-sectional Monitoring: To assess change over time Evaluation: To evaluate intervention impact Refer to p4 of WHO manual. Implementing a Drug Use Indicators Study

Types of Indicators Prescribing Patient Care Facility Implementing a Drug Use Indicators Study

Prescribing Indicators Average number of drugs Percentage antibiotics Percentage injections Percentage generic Percentage prescribed from Essential Drugs List or Formulary Refer to p13 and 15-antibiotics, 15-generics. Implementing a Drug Use Indicators Study

Patient Care Indicators Average consultation time Average dispensing time Percentage drugs dispensed Percentage drugs adequately labeled Patient's knowledge of correct dosage Refer to p17-20 of WHO manual. Implementing a Drug Use Indicators Study

Facility Indicators Availability of national Essential Drugs List or Formulary Availability of key drugs Refer to p22-24 of WHO manual. Implementing a Drug Use Indicators Study

Steps in an Indicators Study Select geographic area Select sample of facilities Retrospective prescribing data available? Simple vs. detailed data form? Define criteria for core indicators Define complementary indicators Describe study procedures Select and train personnel Pilot test and revise procedures Collect data Feedback to facilities and managers Decide on follow-up studies Implementing a Drug Use Indicators Study

Scope of the Indicators Study Depends on— Information needs of managers Capabilities of record system Types of providers Resources available Minimum sample 20 facilities and 30 prescriptions / 30 patients per facility for cross-sectional study 100 prescriptions per facility if facilities will be compared Refer to p25-31 of WHO manual. Implementing a Drug Use Indicators Study

Indicator Sampling Methods Selection of Facilities Simple Random / Systematic Useful to Stratify Urban / Rural Doctor / Non-doctors Health Center / Dispensary Government / Mission Retrospective Prescribing Data Systematic Stratified by prescriber? Prospective Patient Encounters Convenience Quota by Health Problem? Refer to p25-31 in WHO manual. Implementing a Drug Use Indicators Study

Preparing for a Survey (1) Prescribing Indicators Select a sample of facilities Decide on a source of data for prescribing encounters Define types of encounters to include Define drugs to be counted as antibiotics List drugs to be classified as generic Refer to Chapter 4 p32-38 for the next 7 VA’s. Key Point: Need visit to health facilities in advance to plan logistic aspects and sampling. Implementing a Drug Use Indicators Study

Preparing for a Survey (2) Patient Care Indicators Observe logistics of patient care Determine how consulting and dispensing times will be measured Define criteria for adequate patient knowledge Describe procedure for evaluating patient knowledge Point out that additional complimentary indicators can be used. See p83 of WHO manual. Implementing a Drug Use Indicators Study

Preparing for a Survey (3) Facility Indicators Determine if national EDL or Formulary exists Prepare a short list of key drugs to test availability Note: Be sure to find out if there is more than one version of an EDL or formulary. Decide on which version will be acceptable. Implementing a Drug Use Indicators Study

Undertaking the Survey Preparation Select and train personnel Conduct pilot tests Select and inform sample sites Plan schedule of data collection visits Refer to the Model Training Course for data collectors on p35 of the Manual. Implementing a Drug Use Indicators Study

Undertaking the Survey Field Activities Select a sample of encounters Fill in encounter forms Observe consultation and dispensing times Collect patient knowledge and dispensing information Fill in facility summary forms Present results to staff Implementing a Drug Use Indicators Study

Simple Prescribing Indicators Form Point out which cells are used to calculate each indicator, making clear that in some the denominator is number of drugs, and in others number of cases. Implementing a Drug Use Indicators Study

Detailed Prescribing Indicators Form Implementing a Drug Use Indicators Study

Prescription 1 These prescriptions are examples which can be discussed AND entered in the summary form. This prescription has two forms of the same drug. This should be recorded as one drug. Implementing a Drug Use Indicators Study

Prescription 2 The writing on this prescription is not clear. Discuss how this common problem can be addressed. Implementing a Drug Use Indicators Study

Prescription 3 Implementing a Drug Use Indicators Study

Prescription 4 In this prescription the final line is an instruction to pulverize the tablets and mix into different packages. Implementing a Drug Use Indicators Study

Prescription 5 Implementing a Drug Use Indicators Study

Prescription 6 Implementing a Drug Use Indicators Study

Patient Care Indicators Form Point out which cells are used to calculate each indicator. Implementing a Drug Use Indicators Study

Health Facility Summary Form Note: While this slide is presented, agree on the list of drugs to be used in the Field Visit. Refer to the Model List on p23 of the manual. Point out how the availability indicator is calculated. Implementing a Drug Use Indicators Study

Facility Indicator Reporting Form Implementing a Drug Use Indicators Study

Indicators Consolidation Form This VA refers to Chapter 5 p39-48 of the WHO manual. Point out that impartial information means presence of EDL or formulary. Implementing a Drug Use Indicators Study

Graphs of Indicators Data (1) Sample-Wide Distribution of Antibiotic Use NUMBER OF FACILITIES This graph and the next reports the distribution of data from all facilities. Key Point: Looking at distribution of values for an indicator conveys a sense of the average performance, as well as the importance of outliers. Implementing a Drug Use Indicators Study

Graphs of Indicators Data (2) Sample-Wide Distribution of Consulting Times NUMBER OF FACILITIES Implementing a Drug Use Indicators Study

Graphs of Indicators Data (3) Facility-Specific Antibiotic Use Percentage of Patients This graph reports the individual facility results. Point out that due to the small sample, the 95% confidence intervals are wide (18%) and results may be misleading. Implementing a Drug Use Indicators Study

Graphs of Indicators Data (4) Facility-Specific Consultation Times AVERAGE TIME (MINS) Implementing a Drug Use Indicators Study

Steps in an Indicators Study Summary Select geographic area Select sample of facilities Retrospective prescribing data available? Simple vs. detailed data form? Define criteria for core indicators Define complementary indicators Describe study procedures Select and train personnel Pilot test and revise procedures Collect data Feedback to facilities and managers Decide on follow-up studies Use the VA to summarize the different steps and make decision for the field test of the indicator manual. Implementing a Drug Use Indicators Study

Conclusion Undertaking a Drug Use Indicators Study is possible in nearly all environments The more attention to detail the greater the value and accuracy of the survey Point out that studies have been done in many countries and environments. Implementing a Drug Use Indicators Study

Lot Quality Sampling Procedure Set standard for adequate performance (e.g., antibiotic use = 30%) Choose level to be considered inadequate (e.g., antibiotic use > 60%) Accept error rates - Misclassifying poor facilities as adequate = 5.0% - Misclassifying good facilities as inadequate = 20.0% Find necessary sample size and critical number of "failures" in table (e.g. sample size = 16 and failures = 6) Select random sample and count "failures" If number of failures is equal to or greater than the critical number, facility is inadequate These 2 VA’s (Lot Quality Sampling Procedure and LQAS Sampling Table) are not normally presented, but if participants ? This method of monitoring can be used. See p77-81 of the WHO manual. Implementing a Drug Use Indicators Study

Maximum Number of Encounters to Examine LQAS Sampling Table 20% 30% 40% 50% 60% 70% 80% 90% 10% 83 26 13 8 5 3 2 1 119 33 15 9 143 37 16 153 38 4 151 35 6 137 29 10 109 20 69 Defined Level of Inadequate Performance Adequate Performance Maximum Number of Encounters to Examine Number of Failures for Inadequate Performance 20% 30% 40% 50% 60% 70% 80% 90% 10% 10 3 2 1 27 8 4 47 13 6 66 17 80 19 87 7 15 57 Implementing a Drug Use Indicators Study