Promoting Rational Use of Drugs Krisantha Weerasuriya MD

Promoting Rational Use of Drugs

Krisantha Weerasuriya MD

Department of Essential Medicines and Health Products TBS 2012

Objectives

• Define rational use of medicines and identify the magnitude of the problem

• Understand the reasons underlying irrational use

• Discuss strategies and interventions to promote rational use of medicines

• Some questions to ponder


The rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and at the lowest cost to them and their community.

WHO conference of experts Nairobi 1985

• correct drug• appropriate indication• appropriate drug considering efficacy, safety, suitability for the

patient, and cost• appropriate dosage, administration, duration• no contraindications• correct dispensing, including appropriate information for patients• patient adherence to treatment

Could there have been a better term than "Rational" ?


Treatment of diarrhoea in private and public sectors

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10

20

30

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50

60

70

ORS use Antibiotic use Antidiarrhoealuse

STG compliance

% d

iarr

ho

ea c

ases t

reate

d

Private-for-profit (n=43,33,35,4) Public (n=119, 100, 67, 80)

Snapshots in Low and Middle Income Countries


% STG compliance

05

1015202530354045

PR_NOPROF PR_PROF PUB

% STG compliance


Treatment of ARI by prescriber type

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10

20

30

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50

60

70

80

Cough syrup use Approp.ABs inpneumonia

Inapprop.ABs inviral URTI

STG compliance

% A

RI c

ases

tre

ated

Doctor (n=20,18,40,12) Paramedic/nurse (n=13,94,69,61)


% Compliance w ith STGs over time

010203040506070

<1992 1992-4 1995-7 1998-00 2001-3 2004-6 2007-9

Africa L.America E.Mediterr

Europe SE.Asia W.Pacific

Data from EMP Pharmaceuticals Database


Overuse and misuse of antimicrobials contributes to antimicrobial resistance

• Malaria– choroquine resistance in 81/92 countries

• Tuberculosis– 0-17 % primary multi-drug resistance

• HIV/AIDS– 0-25 % primary resistance to at least one anti-retroviral

• Gonorrhoea – 5-98 % penicillin resistance in N. gonorrhoeae

• Pneumonia and bacterial meningitis – 0-70 % penicillin resistance in S. pneumoniae

• Diarrhoea: shigellosis– 10-90% ampicillin resistance, 5-95% cotrimoxazole resistance

• Hospital infections– 0-70% S. Aureus resistance to all penicillins & cephalosporins

Source: WHO country data 2000-3


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35

FR GR LU PT IT BE SK HR PL IS IE ES FI BG CZ SI SE HU NO UK DK DE LV AT EE NL

DD

D p

er 1

000 in

h. p

er d

ay

Variation in outpatient antibiotic use in 26 European countries in 2002

Source: Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.

Snapshots High Income Countries


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35

FR GR LU PT IT BE SK HR PL IS IE ES FI BG CZ SI SE HU NO UK DK DE LV AT EE NL

DD

D p

er

1000 in

h. p

er

day

How many LMICs can provide this data?

This provides antibiotics by class and total; how many of your countries can provide even the total?

Whose responsibility is it to collect the data?

Are health systems in LMICs comprehensive enough to collect this data?


Top 10 drugs by Prescription counts in Australia 2009-2010

Source: Australian Prescriber | 2010; 33: 181

1. atorvastatin 2. esomeprazole3. simvastatin 4. rosuvastatin5. paracetamol6. perindopril7. pantoprazole8. metformin9. atenelol 10. irbesartan

Snapshots High Income Countries


2008 Generic Uptake after Patent Expiry in 2000

Unprotected market segmentation volume (SU) 2000

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Vo

lum

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ark

et

share

% S

U

ORIGINAL & LICENSED OTHER BRANDS UNBRANDED

Data Source IMS Health 2009

Expensive access with potential for enormous savings – Policy?


Changing a Drug Use Problem:An Overview of the Process

1. EXAMINEMeasure Existing

Practices(Descriptive

Quantitative Studies)

2. DIAGNOSEIdentify Specific

Problems and Causes(In-depth Quantitative and Qualitative Studies)

3. TREATDesign and Implement

Interventions (Collect Data to

Measure Outcomes)

4. FOLLOW UPMeasure Changes

in Outcomes (Quantitative and Qualitative

Evaluation)

improveintervention

improvediagnosis


Treatment Choices

Prior Knowledge

HabitsScientific Information

RelationshipsWith Peers

Influenceof DrugIndustry

Workload & Staffing

Infra-structure

Authority & Supervision

Societal

Information

Intrinsic

Workplace

Workgroup

Social &CulturalFactors

Economic &Legal Factors

Many Factors Influence Use of Medicines


Strategies to Improve Use of Drugs

Economic: Offer incentives

– Institutions– Providers and patients

Managerial: Guide clinical practice

– Information systems/STGs– Drug supply / lab capacity

Regulatory: Restrict choices

– Market or practice controls– Enforcement

Educational: Inform or persuade

– Health providers– Consumers

Use of Medicines


Educational StrategiesGoal: to inform or persuade

• Training for Providers– Undergraduate education– Continuing in-service medical education (seminars, workshops)– Face-to-face persuasive outreach e.g. academic detailing– 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


Training for prescribersThe Guide to Good Prescribing

• WHO has produced a Guide for Good Prescribing - a problem-based method

• Developed by Groningen University in collaboration with 15 WHO offices and professionals from 30 countries

• Field tested in 7 sites

• Suitable for medical students, post grads, and nurses

• widely translated and available on the WHO medicines website


Managerial strategies Goal: to structure or guide decisions

• Changes in selection, procurement, distribution to ensure availability of essential drugs– Essential Drug Lists, morbidity-based quantification, kit systems

• Strategies aimed at prescribers– targeted face-to-face supervision with audit, peer group

monitoring, structured order forms, evidence-based standard treatment guidelines

• Dispensing strategies – course of treatment packaging, labelling, generic substitution


Economic strategies:Goal: to offer incentives to providers an consumers

• Avoid perverse financial incentives – prescribers’ salaries from drug sales

– insurance policies that reimburse non-essential drugs or incorrect doses

– flat prescription fees that encourage polypharmacy by charging the same amount irrespective of number of drug items or quantity of each item

– (reverse – Quebec, dispensing fee is given even if pharmacist does not dispense for good reason)

– Reimburse without treatment guidelines (ceftriaxone as an OPD medicine)


Regulatory strategiesGoal: to restrict or limit decisions

• Drug registration• Banning unsafe drugs - but beware unexpected results

– substitution of a second inappropriate drug after banning a first inappropriate or unsafe drug

• Regulating the use of different drugs to different levels of the health sector e.g.– licensing prescribers and drug outlets– scheduling drugs into prescription-only & over-the-counter

• Regulating pharmaceutical promotional activities

Only work if the regulations are enforced


What are countries doing to promote the rational use of medicines? national policies

0 20 40 60 80 100

EML updated in last 2 years (n=78)

STGs updated in last 2 years (n=42)

EML in insurance reimbursement (n=90)

Drug Info Centre for prescribers (n=118)

DTCs in most referral hospitals (n=92)

Public education on antibiotic use (n=107)

Antibiotic OTC non-availability (n=60)

National strategy to contain AMR (n=102)

Drug use audit in last 2 years (n=87)

% countries implementing policies

Source: EMP pharmaceutical policy database


Basic training and obligatory continuing medical education (CME) available for health professionals

0 20 40 60 80 100

Essential Medicines(n=68-89)

Clinical Guidelines(n=68-80)

Prescribing concepts(n=63-76)

Pharmaco-therapy(n=60-73)

Obligatory CME(n=99-105)

% countries with basic training available

Doctors Nurses and paramedics

Source: EMP pharmaceutical policy database


However, is it all Doom and Gloom?Having a Policy does help

-15

-10

-5

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20

Comparison of countries with and without specific policies Weighted mean of differences for 12 INRUD/IMCI indicators (bars denote % difference and 95% CI)


Source: WHO Policy Perspectives no.5

Reminder: 10 national strategies to promote RUMneed political support, investment and staff

1. Evidence-based standard treatment guidelines2. Essential Medicines Lists based on treatments of choice3. Drug & Therapeutic Committees in hospitals4. Problem-based pharmacotherapy teaching in universities5. Continuing medical education as a licensure requirement6. Independent drug information e.g bulletins, formularies7. Supervision, audit and feedback8. Public education about medicines9. Avoidance of perverse financial incentives10. Appropriate and enforced drug regulation


Why does irrational use continue?

Very few low and middle income countries regularly monitor drug use and implement effective nation-wide interventions - because…

• they have insufficient funds or personnel?• they lack of awareness about the funds wasted

through irrational use?• there is insufficient knowledge of concerning the cost-

effectiveness of interventions?• they do not bear the cost of irrational use? (OOP?)


Conclusions

• Irrational use of medicines is a very serious global public health problem.

• Much is known about how to improve rational use of medicines but much more needs to be done– policy implementation at the national level– implementation and evaluation of more

interventions, particularly managerial, economic and regulatory interventions

• Rational use of medicines could be greatly improved if a fraction of the resources spent on medicines were spent on improving use.

• (WAIT!)


Some issues to think about

• There are textbook cases of Technical Success in RUMTools to identify the problem, design an intervention to measure the effect, feedback and adjust BUT

• What is more important than Technical Excellence?• What maybe the proportion spent for medicines from the

health budget if RUM is implemented?• What role does Universal Health Coverage play in the

success of RUM?• Can single interventions help in RUM in low and middle

income countries?• Can single interventions help in high income countries?


Some issues to think about

• Can we achieve RUM in a health sector dominated by the private sector?

• Is quality of medicines an important issue in RUM? (Does it differ between LMICs and HICs?)

• Is Information Technology important in promoting RUM?Can it accelerate progress or be the "fix" for irrational use?

• What is the most important lessons that we can learn from high income countries in RUM ?

• Would Universal Health Coverage be the driver for RUM?

• What would be stronger for RUM? Health? Cost to Health care systems?


• Dr K Weerasuriya, Medical Officer Medicines Access and Rational Use (MAR) Essential Medicines and Pharmaceutical Policies (EMP) World Health Organization CH-1211 Geneva 27 Switzerland

• email: [email protected] • Comments and Questions welcome• Some notes in individual slides

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Promoting Rational Use of Drugs Krisantha Weerasuriya MD