1. “SNAP-LOCK” POLYTHENE BAG FOR DISPENSING DRUGS IN GOVERNMENT HOSPITALS IN SRI LANKA SENARATHNA L (1), SAMARANAYAKE A (2), KUMARAGE S (3), SENEVIRATHNA A (4), KAPPAGODA S (5) (1)OX-COL COLABORATION, DEPARTMENT OF CLINICAL MEDICINE, COLOMBO; GOVERNMENT HOSPITALS (2)MATALE, (3)GAMPOLA, (4)MEDAWACHCHIYA, (5)KANDY.

2. ABSTRACT “ SNAP-LOCK” POLYETHYLENE MINI BAGS FOR DISPENSING DRUGS IN SRI LANKA Senarathna L, Samaranayake A, Kumarage S, Senevirathna A, Kappagoda S. Ox-Col Collaboration, Department of Medicine, Colombo; Government Hospitals in Matale, Gampola, Medawachchiya and Kandy. Problem Statement: Outpatient drugs are dispensed free of charge in government hospitals in Sri Lanka, usually as loose capsules or tablets wrapped in paper. Storage is often inappropriate, risking reduced drug potency due to humidity and sunlight and mixing up of tablets with similar appearance. A “snap lock” polyethylene bag (cost, USD 0.02) containing a drug information card was recently introduced for each drug. Objectives: To determine acceptability of and patient attitude toward payment for snap-lock bags. Design: Observational study comparing two hospitals. Setting and Study Population: Two government hospitals in the Central Province of Sri Lanka, one that charged money for the bags and one that did not. We traced pharmacy records and interviewed patients and pharmacists. Two hundred outpatients using bags were randomly selected (100 from each hospital). Pharmacists from clinics answered a questionnaire Outcome Measures: Use of bags initially and after 10 months; percentage of patients coming with the bag to subsequent clinics initially and after 10 months; patient attitude toward payment for bags; acceptability of bag to patients and pharmacists. Results: Payment for bags initially reduced their uptake (73% with payment; 100% without); uptake of bags in paying hospitals increased to 95% after 10 months. Patient acceptance was high - 82% of patients brought the bag to the next clinic; after 10 months, this increased to 91%. There was no difference between hospitals. Opening the bag caused difficulties during the first month in both hospitals; 35% of patients cut or tore the bag to open it. Education by pharmacists reduced this to 5%. An average of 65% of patients (60% in nonpaying hospital, 70% in paying hospital) agreed to pay money and thought an acceptable payment would motivate them to bring the bag back. In both hospitals, 95% of patients liked the bag, particularly since it prevented tablet mix-ups. Fourteen pharmacists in both hospitals agreed that the bags enhanced the quality of their dispensing. Conclusions: Acceptance of the newly introduced bags was good in both hospitals; acceptance was slower but still substantial where patients were charged for the bag. Pharmacist workload increased when the bags were first issued due to patient unfamiliarity and the time spent enclosing the drug information card, but workload subsequently decreased below previous levels with reuse of bag and card. Both patients and pharmacists thought that the bags were an improvement. Our experience suggests that polyethylene bags may be useful to prevent mixing of tablets/capsules; to improve home storage of drugs; and, with the card, to provide appropriate drug information. Proper use of the bags also suggests patients’ willingness to contribute appropriately to their health care.

3. Background Government Hospitals issue outpatient medication as loose tablets or capsules wrapped in paper. –Appropriate storage difficult due to high humidity & temperature. –Possible deterioration in drug potency &/or product formulation (discolouration, loss of tablet coating, capsule melting, loss of potency) e.g. phenytoin, amitriptyline –Tablets with similar appearance may be mixed up –Limited opportunity to provide written drug information with product. To overcome these issues four hospitals recently introduced a “snap lock” polythene bag for dispensing tablets/capsules. –Some hospitals issued for free, others charged per bag

4. Ordinary Paper Wrapping Tablets wrapped in papers Paper bags used to dispense tablets/capsules

5. Newly Introduced Bags Drug information card “Snap-lock” closure

6. Aims We set up an observational study in two hospitals to assess the effect of payment on: 1.Patient compliance –Initial use of “snap lock” bags –Ongoing use of “snap lock” bags at 10 months 2.Feedback by users –Patient’s attitude($, ease of use, dosing errors) –Pharmacists’ attitude (patient education, ease of use, impact on workload).

7. Methodology Two Base hospitals were selected, both serving ~ 100 000 clinic patients per year. –One hospital charged USD$0.02 per bag. –One hospital issued bags free of charge. 100 patients systematically selected from each hospital. –Cross section of all the patients coming to clinics. –Patients requiring ongoing medication therapy and receiving >2 weeks supply per dispensing

8. Methodology cont … Each patient interviewed to assess –Acceptance of bags and the provision of drug information –Compliance/confidence (subjective) Each pharmacist interviewed to assess –Impact of bags on the dispensing process –Opportunities for provision of drug information –Overall effect on work load Statistics analysed using Chi-square test

9. Results Requirement for payment reduced the uptake of the bags initially –73% with payments, 100% free of charge Uptake of bags in the payment hospital increased to 95% after 10 months (p<0.0001) –Initial concerns over payment settled –Pharmacist education (verbal & written on card) –Encouraged use by other patients

10. Patient acceptance During first month, 35% of patients cut or tore the bag to open –↓ to 5% at 10 months due to pharmacist education (p<0.0001) 82% of patients brought the bag to the next clinic after first month. –↑ to 91% at 10 months (p=N/S) No difference in outcome between hospitals

11. Patient and Pharmacist feedback 95% of patients at both hospitals liked the bag. Prevents tablet mix-ups because of separate packaging –Improved patient confidence Prevents spoilage of medication (protection from H 2 O) 100% of pharmacists in both hospitals accepted bag Initially increased time of dispensing (selecting bag, filling drug information sheet, education of patient) Reuse of the bag subsequently reduce their work load. –Less repetition of instructions and drug information Overall, it was felt that he bag improved the quality of dispensing

12. Discussion and Future Directions Our experience suggests that “snap-lock” bags may help prevent mixing of tablets/capsules, improve home storage and to provide drug information. –Should they be introduced Island-wide? –Are further studies needed to measure the impact of the drug information card and to confirm improved compliance? Patients are willing to contribute to the cost of their health care that is currently free of charge. –This may help maintain the provision of quality and affordable health care for patients in Sri Lanka. – The challenge lies in implementation of other programs

13. Discussion and Future Directions cont…. Other dose forms or administration aids (eg. typed labels, blister strips or unit-of-use packs for selected patients) may improve outcomes such as patient compliance and prevent mediation misadventure and waste. –Given restrictions in resources, the practicalities of this in the current health system are not clear –Feasibility of these or other alternatives should be addressed by the Sri Lankan Ministry of Health –This may be in cooperation with WHO, IDA (International Dispensary Association), NGOs, others

14. Acknowledgements We are grateful for the assistance of the following: Prof Krishantha Weerasuriya (WHO SEARO) Dr Michael Eddleston (UK, Sri Lanka) Dr Darren Roberts (Australia, Sri Lanka) Hospital Directors at Matale & Gampola Chief Pharmacists at Matale & Gampola Base Hospitals Pharmacists at Matale and Gampola Base Hospitals