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1d. Chronic Care: Cross-National or National Analysis of Access to Medicines and Quality of Care of Chronic Diseases in LMIC
Evidence on the Use of Medicines to Treat Chronic Diseases from Household Surveys in Seven Low- and Middle-Income Countries
1University of Nottingham, United Kingdom; 2Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Healthcare Institute, USA; 3Alliance for Health Policy and Systems Research, World Health Organization, Switzerland
Problem statement: Evidence about treatment of chronic diseases in the community is lacking in most low- and middle-income countries.
Objectives: To generate reliable and standardized evidence about the use of medicines for chronic diseases at the community level. Specific aims are to describe patterns of use and costs of medicines for chronic diseases in households and to identify key predictors of adherence to treatment. A secondary objective is to compare the age-specific prevalence of chronic diseases reported by households with published rates.
Design: Descriptive, cross-sectional analysis of survey data
Setting: Household surveys conducted in Gambia, Ghana, Jordan, Kenya, Nigeria, Philippines, and Uganda between 2007 and 2009 using a survey instrument developed by the World Health Organization (WHO) to monitor country pharmaceutical situations at the community level.
Study population: Households were selected by multistage cluster sampling (900 to 1,080 households per country). Study population consisted of 2,457 household members reporting a chronic disease; data were collected on all members in the household reporting a chronic illness in five surveys (Ghana, Jordan, Kenya, Philippines, Uganda) and only on the oldest sick member in two surveys (Nigeria and Gambia).
Outcome measure(s): Prescription of medicines for chronic diseases (overall, and for subgroups reporting hypertension and diabetes), use of medicines as recommended.
Results: 2,457 households reported at least one chronic disease; 40.5% of persons with chronic disease had hypertension, 18.1% diabetes, 12.4% asthma or chronic respiratory disease, and 15.3% arthritis or chronic body pain. The percentage of households keeping some medicines at home was higher for households reporting a chronic disease (66.5% vs. 30.3%). 43.6% of individuals with hypertension and 59.8% of individuals with diabetes had been told to take medicines, but only 31.1% and 45.1% took them as directed. The median number of medications received by chronically ill individuals was 2 (interquartile range 1). The most frequently prescribed medicines were bendrofluazide for hypertension and glibenclamide for diabetes. Monthly out-of-pocket cost to treat hypertension and diabetes varied widely across countries (from $1.50 to $116.60 for hypertension and $4.00 to $204.60 for diabetes). Adjusted multivariate analyses are under way to identify predictors of adherence to treatment for hypertension and diabetes.
Conclusions: Our results provide direct evidence about use of medicines for chronic diseases in the community in low- and middle-income countries.
Funding source(s): The WHO Department of Essential Medicines in Geneva organized and funded data collection, with support from the Medicines Transparency Alliance. The Alliance for Health Policy and Systems funded the analysis.
Genital Ulcer Disease Treatment Policies and Access to Acyclovir in Eight Sub-Saharan African Countries
1Department of Pharmacy, University of Washington, Seattle, WA, USA; 2Department of Global Health, University of Washington, Seattle, WA, USA; 3Department of Epidemiology, University of Washington, Seattle, WA, USA; 4Department of Reproductive Health & Research, World Health Organization, Geneva, Switzerland; 5Department of Medicine, University of Washington, Seattle, WA, USA
Problem statement: World Health Organization 2003 guidelines for sexually transmitted infections (STIs) recommend acyclovir as first-line syndromic treatment of genital ulcer disease (GUD) in countries with high herpes simplex virus-2 (HSV-2) prevalence (i.e., ≥30%). Surveys conducted between 2004 and 2006 suggested that the recommendations for use of acyclovir in GUD had not been implemented in public sectors of low-income countries.
Objective: To assess the extent of adoption of acyclovir as syndromic treatment in countries with high HSV-2 prevalence and to describe procurement, distribution, and cost of acyclovir in the public and private sectors.
Design: This was a descriptive study using structured interviews.
Setting: The study was conducted in Botswana, Kenya, Malawi, South Africa, Tanzania, Uganda, Zambia and Zimbabwe. Organizations and entities included were ministries of health, central and regional medical stores, regional and district hospitals, private pharmacies, and private health institutions including for-profit and non-profit organizations.
Methods: A convenience sample of ministry of health (MoH) officials, pharmacists, and other pharmacy workers based in the public and private sectors was selected for interviews. A 26-item standardized questionnaire with questions regarding (1) the extent of implementation of the 2003 WHO STI treatment guidelines about acyclovir in country-specific essential medicines lists (EMLs) and national STI guidelines and (2) acyclovir procurement, cost, and distribution was administered to MoH officials. We also administered to pharmacists and other pharmacy workers in public and private health facilities a 27-item questionnaire on the availability and retail cost of acyclovir. Acyclovir price data were collected in local currencies and converted to US dollars using the 2007 exchange rate. Price comparisons were conducted using the 2007 median international reference price (IRP) for acyclovir.
Results: In total 100 interviews were conducted with MoH officials and pharmacy personnel. Four of the eight African countries surveyed had adopted acyclovir as first-line syndromic GUD treatment in both their EMLs and STI guidelines. With the exception of Zambia, acyclovir was routinely procured for the public sector in countries where acyclovir was first-line treatment for GUD in the EML. Public health facilities faced cost and regulatory barriers, however, that impeded the requisitioning of acyclovir from the central medical stores. Acyclovir was available in private pharmacies and health institutions but at a median retail cost ranging from 5.85 to 9.76 times the median IRP.
Conclusions: Systems for drug procurement, distribution and access in sub-Saharan African countries need strengthening for a GUD treatment policy using acyclovir to be effective.
Funding source(s): World Health Organization
Working Together for Mental Health: The Nouadhibou Pilot Experience
1Sanofi-aventis, France; 2Neuropsychiatric center, Nouakchott, Mauritania
Problem statement: Although mental disorders are a major contributor to the Global Burden of Diseases, mental health care in many developing countries is accessible only to a minority of patients. With the creation of the Global Fund, dramatic progress has been made in ensuring access to medicines in HIV, TB, and malaria. Major pharmaceutical companies have played a crucial role in this positive evolution through public-private partnerships (PPP). However, psychiatric diseases do not benefit from PPPs that could be decisive levers in improving access to care and promoting psychosocial rehabilitation. In 2005, an international conference held in Nouakchott underlined that improving mental health care in Mauritania, as in other low-income countries, will require changing legislation and policies, setting up services, getting funding, training health care professionals, and making medicines accessible. Through its Access to Medicines department, Sanofi has launched initiatives to improve access to medicines in certain therapeutic domains including mental health. These initiatives consist of both the development of adapted information, education, and communication tools and the implementation of a preferential pricing policy for Sanofi’s antipsychotic medicines.
Intervention: A PPP between the Mauritanian Ministry of Health and Sanofi was set up in October 2008 for developing access to mental health care. It was decided to pilot in the Nouadhibou province and to focus on schizophrenia as a first step.
Objective: The Nouadhibou Pilot Experience is a demonstration project which is intended to prove that access to care for schizophrenic patients could be improved drastically by simple, assessable, and adaptable programs.
Design: The program combines actions dedicated to advocacy efforts toward political and administrative decision makers; increased awareness in communities of mental health issues; development of users’ associations; education of patients and families; training health care professionals; and organizing a sustainable supply of high-quality antipsychotics. These actions are conducted in liaison with local NGOs, patients, families, and the Nouadhibou city civil services with the goal of finally promoting rehabilitation.
Results: In May 2009 the baseline assessment indicated a treatment gap of 93% in psychosis. From May 2009 to May 2010, outpatient facilities have been progressively opened in 7 centers. After 18 months, in October 2010, the treatment gap has already been decreased by 28%. The results after 2 years will be presented, including the burden of the disease on the families through the involvement evaluation questionnaire.
Conclusion: This program is a model of PPP serving the “Make Mental Health a Global Priority” objective at the country level. Lessons drawn from the Nouadhibou Pilot Experience will be useful to the expansion of such approaches to other locations.
Funding source: Sanofi
The Evaluation of Compliance to an Essential Medicine Programme: Use of Standard Treatment Guidelines in South Africa’s State Health Facilities of eThekwini
1Independent Pharmacist, South Africa; 2University of KwaZulu-Natal, South Africa
Problem statement: To promote the rational use of medicines (RUM), the KZN Department of Health, South Africa, adopted the national standard treatment guidelines (STGs) and essential medicine lists in May 1999. The evaluation of this intervention on prescribers had not been done.
Objectives: To determine compliance to the STGs in terms of (1) the percentage of RUM, (2) the differences in prescribing and dispensing antihypertensive medicines among practitioners, and (3) the impact of practitioner variables
Design: A two-arm study was concurrently conducted: the (A) arm used WHO prescribing indicators and a purposive retrospective sampling of antihypertensive prescriptions, and the (B) arm used a structured questionnaire.
Setting: State health facilities in the district of eThekwini, KZN, South Africa
Population: In the (A) arm, 2,100 antihypertensive prescriptions were collected across three levels of the health care system. In the B arm, 260 qualifying health care prescribers were interviewed.
Outcome measure(s): Percentages of (1) overall compliance to the STGs, (2) compliance to the STGs per category of practitioner, and (3) the impact of practitioner variable(s) on the overall compliance to the STGs
Results: Hypertension featured as 57.5% of the diagnoses. For the correct use of the STGs, the diagnosis was identified for 99.9 % of the prescriptions at the primary health care, 91.1% at the community health care centres, 99.0 % at the district hospitals, and 81.7% at the regional hospitals. Of the prescriptions with a diagnosis, the medicines prescribed did not correlate with the condition on 77.9% of the prescriptions. The overall mean result of compliance to the STGs was 22% (±20.0). The multiple linear regression equation (MLRE) suggested that the variables selected explained 86.8% of the impact on STG adherence. The mean STG compliance scores were 19.4% (19.0), 19.2% (18.9), and 18.7 (17.9) for nurses, medical doctors, and pharmacists, respectively. The MLRE analysis for the practitioner variables suggested that the impact on compliance to the STGs was only 8.58%, of which knowledge of the STGs had a significant impact, Χ2 (7, N =257)=19.03, p<0.008, as with a greater knowledge, compliance increased. Chi square analyses on practitioner type and exposure to private sector experience indicated that there were significant differences between the type of practitioners and experience in private sector, Χ2(2, N=257)=19.73, p< 0.0001.
Conclusions: The low mean overall results for compliance to the STGs were due to the absence or incomplete diagnoses with additions of medicines for each symptom without due consideration to the RUM. Only three of the eight practitioner variables had an impact on adherence to the STGs. For the correct use of STGs in EDPs, the format and continuity of education need promotion. Implementation strategies must include interventions for each health professional cadre. Diagnoses or diagnosis codes on prescriptions should be mandatory.
Funding source(s): Study grant from the University of KwaZulu-Natal, South Africa
Evaluating the Quality of Care for Patients with Type 2 Diabetes Using Electronic Medical Record Information in Mexico
1Epidemiology and Health Services Research Unit at Instituto Mexicano del Seguro Social, Mexico; 2Centre for Health Services and Policy Research The University of British Columbia, Canada; 3Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute, USA; 4Hospital Infantil de México Federico Gómez, Mexico.
Problem Statement: Affecting 10.6% of the Mexican population, type 2 diabetes (T2D) is the most common chronic condition seen at Mexican Institute of Social Security (IMSS) family medicine clinics (FMC), and among the top causes of hospital admissions and death. In 2003, IMSS introduced an electronic medical record (EMR) system in its 1,400 FMC that serve 48 million people. This is the first study to evaluate quality of care (QC) using data from the IMSS EMR and associated electronic pharmacy and laboratory databases.
Objectives: (1) To validate data in the IMSS EMR and to test the feasibility of structuring extracted medical records and other electronic data according to data specifications used for large health system research collaborations in the United States; and (2) to develop indicators and evaluate the quality of diabetes care provided in IMSS clinics based on electronic EMR and other data.
Design: The study used a mixed method approach consisting of development of quality of care indicators for T2D using the RAND-UCLA method; evaluation of the feasibility to extract and process EMR data and construct QC indicators; and evaluation of QC for T2D.
Setting: 39 FMCs in Mexico City
Study Population: Patients with T2D who received care in 2009
Outcome Measures: We developed and tested 12 QC indicators including prescription drug use (metformin, statins, angiotensin converting enzyme inhibitors [ACEI] and acetylsalicylic acid [ASA]); nutritional counselling; foot evaluation; orders of blood glucose and total cholesterol measurements; outcome indicators were blood glucose, blood pressure, and total cholesterol control and body weight.
Results: Among 7,152 patients in a pilot FMC, 57.5% of overweight or obese (BMI ≥ 25 kg/m2) patients received metformin; 58.9% with known cardiovascular disease and total cholesterol >200 mg/dl were prescribed statins; 46.0% of patients with arterial hypertension received ACEI; and 45.8% of patients over 40 years of age with one or more risk factors (smoking, hypertension, dyslipidemia) received ASA in doses of 75–150 mg/day.
Conclusion: This pilot study demonstrated that it is feasible to evaluate QC using the IMSS EMR data. It highlighted needs for improvement of both QC and the completion of information in the EMR at the IMSS.
Funding Source: Information not available
Antihypertensive Medicines Prescriptions Before and After the Nigeria Hypertension Society Guidelines and Prescriber’s Awareness of the Guideline
Clinical Pharmacology and Therapeutics Unit, Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria
Problem statement: The Nigerian hypertension guideline (2005) was based on 1999 ISH/WHO and the 2003 sub-Saharan Africa hypertension guidelines. The changes in the prescribing pattern of physicians following the introduction of these guidelines in Southern Nigeria are unknown.
Objectives: To assess changes in prescribing of antihypertensives prior to and after the 2005 guideline as well as physicians’ awareness of the guidelines
Design: A policy evaluation and descriptive study and a cross-sectional study of the physicians’ awareness of the guidelines
Setting: The study was carried out at the University of Benin Teaching Hospital (UBTH), a 620-bedded tertiary health facility in Southern Nigeria.
Study population: The study evaluated 3,379 hypertensive patients and 48 post registration doctors working in UBTH. The study reviewed the case records (1999– 2008) of hypertensive patients who had attended the medical outpatient clinic. All cases were selected using a convenience sampling method. A self-administered semi-structured questionnaire was administered to the doctors to assess awareness.
Policies: The Nigerian hypertension guideline (2005) recommended the use of diuretics as first-choice antihypertensives in uncomplicated hypertension.
Outcome Measures: The study’s primary outcome was to determine if diuretics were the most prescribed group of antihypertensives since the release of the guideline; also to determine if diuretics would be the most preferred antihypertensives by doctors.
Results: Annual prescriptions of diuretics increased steadily from 38% in 1999 to a peak of 58% in 2005. The values were sustained in 2006 (57%), 2007 (55%), and 2008 (55%). The calcium channel blockers were the most prescribed class over the entire period (44.7%–69.2%), while the prescriptions for angiotensin converting enzyme inhibitors increased by 327% rising from the 5th most prescribed medicine (1999) to the 3rd (2008). The prescription level for beta blockers changed slightly throughout the study period. The use of 2 or more medicines also increased from 78.9% to 85.9%; however, a decrease (69.1% to 54.0%) in the proportion of patients using fixed-dose combinations was observed. A total of 37/48 returned the filled questionnaire (response rate 77.1%). A high proportion (32/37; 86.5%) of the doctors were aware of the national guidelines but only 13/37 (35.1%) were satisfied with the recommendations. Diuretics were stated as the most preferred class of antihypertensive medicines by 26/37 (70.3%) of respondents.
Conclusions: The findings suggest a less than optimal compliance with the guidelines with preference for newer medicines. There was a disconnect in the prescribers’ knowledge of recommendations in the guidelines, their stated preferences for medicines, and the observed findings in the case records. This may be due in part to the observed dissatisfaction of doctors with the guidelines.
Funding source: Private (self)