1. Drug and Therapeutics Committee Session 7A. Identifying Problems with Medicine Use: Indicator Studies

2. Objectives  Describe how indicators can be used to identify medicine use problems  Perform a prescribing indicator study on a sample of prescriptions and explain how it can be used to identify medicine use problems

3. Outline—Part A  Introduction  WHO/INRUD indicators in primary health care  Prescribing indicators  Patient care indicators  Facility indicators  Hospital indicators  Activities  Summary

4. Introduction  Irrational medicine use is widespread and results in—  Poor patient outcome  High cost of inappropriate medicine use  Increased risk of ADRs  Emergence of antimicrobial resistance  Measuring medicine use problems is the first step to improving use

5. Methods to Investigate Medicine Use Indicator study methods  Use data collected at the individual level—patient, health facility  Data insufficient to judge appropriateness of a medicine for a specific diagnosis Aggregate data methods  Use routine data (e.g., stock records) not collected at the individual patient level  Give an overview of medicine use and can highlight problem areas In-depth investigation of medicine use  Prescription audit, patient record review  Drug use evaluation (DUE)  Qualitative methods to understand causes of a medicine use problem

6. Indicators for Health Care Facilities (1)  Measure specific aspects of medicine use and health provider activities in a hospital or health center  Provide information to health care managers concerning medicine use, prescribing habits, and important aspects of patient care to compare or monitor facilities over time

7. Indicators for Health Care Facilities (2)  Characteristics of sound indicators  Relevant  Easily generated and measured  Reliable  Valid  Action-oriented

8. Indicators for Health Care Facilities (3)  Use of indicators  Determine where medicine use problems may exist—when an indicator study shows an extreme result, the DTC can investigate and, as necessary, take action to improve the situation.  Provide a monitoring mechanism  Motivate health care providers to improve and follow established standards

9. WHO Indicators for PHC  Developed by INRUD and WHO  Used for assessing health care and medicine use for primary health care (PHC) in dispensaries, clinics or hospitals  Prescribing indicators  Patient care Indicators  Facility indicators  Complementary medicine use indicators

10. Prescribing Indicators—PHC  WHO/INRUD health facility prescribing indicators  Average number of medicines per encounter  % of medicines prescribed by generic name  % of encounters with an antibiotic prescribed  % of encounters with an injection prescribed  % of medicines prescribed which are from the essential medicines list or formulary list

11. Prescription 1

12. Prescription 2

13. Prescription 3

14. Prescription 4

15. Prescription 5

16. Prescription 6

17. Patient Care Indicators—PHC  WHO/INRUD health facility patient care indicators  Average consultation time  Average dispensing times  % of medicines actually dispensed  % of medicines that are adequately labeled  % of patients who know how to take their medicines

18. Health Facility Indicators—PHC  WHO/INRUD health facility indicators  Availability of essential medicine list or formulary  Availability of key set of indicator medicines  Availability of standard treatment guideline (STG)

19. Complementary Indicators—PHC  WHO/INRUD medicine use indicators with less standardization and less experience in actual use  % of patients treated without medicines  Average medicine costs per encounter  % of medicine cost spent on antibiotics  % of medicine cost spent on injections  % of prescriptions in accordance with STG  % of patients satisfied with care provided  % of facilities with access to impartial information

20. Performing an Indicator Study (1)  Determine objectives, priorities, and indicators  Determine study design according to objectives  Monitoring over time, comparing facilities  Cross-sectional survey, time series  Evaluating interventions  Randomized controlled trial, pre/post with control, time series  Define indicators and data collection procedures  Pilot-test procedures

21. Performing an Indicator Study (2)  Train data collectors  Randomly select facilities (at least 20 if possible) in the region from which to collect data  Obtain approximately 30 medicine use encounters for each facility (100 if only one facility is chosen)  Analyze data  Provide results to DTC for evaluation and follow- up

22. Results of Indicator Studies  Results can be used as follows—  Describing current treatment practices  Comparing the performance of individual facilities or practitioners  Periodic monitoring and supervision of specific medicine use behaviors  Identifying potential medicine problems that affect patient care  Assessing the impact of an intervention

23. Graphs of Indicator Data (1) Facility-Specific Antibiotic Use Percentage of Patients

24. Graphs of Indicator Data (2) Facility-Specific Consultation Times Average Time (minutes)

25. Hospital Antimicrobial Indicators (1) (Developed and being field-tested by MSH) Designed to evaluate and improve antimicrobial use  Facility indicators (four indicators)  Existence of STG and a formulary with approved antimicrobials  Availability of a key set of antimicrobials  Average number of days that this key set of antimicrobials are out of stock over 12 months  Expenditure on antimicrobial medicines as a percentage of total hospital medicine costs

26. Hospital Antimicrobial Indicators (2)  Prescribing indicators (eight indicators) 1.% of hospitalizations with one or more antimicrobials prescribed 2.Average number of antimicrobial medicines prescribed per hospitalization with antimicrobials prescribed 3.% of antimicrobials prescribed consistent with formulary 4.Average cost of antimicrobials prescribed from hospitalizations with one or more antimicrobial prescribed

27. Hospital Antimicrobial Indicators (3)  Prescribing indicators (continued) 5.Average duration of prescribed antimicrobial treatment 6.% of surgical patients who receive antimicrobial prophylaxis 7.% of pneumonia patients who are prescribed antimicrobials in accordance with STG 8.% of antimicrobials prescribed by generic name

28. Hospital Antimicrobial Indicators (4)  Patient care indicators  % of doses of prescribed antimicrobial medicines actually administered  Average duration of stay of patients who receive antimicrobials  Supplemental indicator  Number of antimicrobial medicine sensitivity tests reported

29. Hospital Indicators Developed and Used in Australia and Zimbabwe Designed to evaluate and improve medicine use and health care  Average number of days per hospital admission  Average number of medicines prescribed per hospital admission  % prescribed medicines consistent with hospital formulary list  Average medicine cost per inpatient day  % patients with morbidity due to a preventable ADR  % inpatient deaths due to a preventable ADR  % patients reporting adequate post-operative pain control  % surgical patients receiving appropriate antimicrobial prophylaxis  Average number of antimicrobial sensitivity tests per hospital admission

30. Activities 1 and 2  Activity 1  Calculating prescribing indicators from prescription records  Activity 2  Calculating patient care indicators from observing role-play consultations

31. Summary  A major function of a DTC is to identify medicine use problems and to implement corrective measures  Performing an indicator study is useful method to—  Identify medicine use problems at the individual patient level  Monitor medicine use by prescribers  Evaluate the impact of interventions