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3d. Chronic Care: Improving Prescription Practices in Treating Chronic Diseases in LMIC with Particular Focus on Hypertension and Diabetes
Effects of Two Educational Programs Aimed at Improving the Utilization of Non-opioid Analgesics in Family Medicine Clinics in Mexico
1Mexican Institute of Social Security, Mexico; 2Instituto de Geriatría, SSA, México; 3Instituto Nacional de Salud Pública, México
Problem statement: There is a high frequency of prescription of non-opioid analgesics (NOAs), second only to cardiovascular drugs. Several studies have reported that medical doctors do not prescribe properly, and patients do not use the NOAs appropriately. This finding is evidenced by overutilization rates of up to 41% and by the frequent appearance of preventable adverse events. As many as 42% of the medical doctors are unaware of the adverse events that NOAs cause. Regarding the patient’s side, 34% are unsure about the proper method of taking NOAs, despite the fact that these are among the most common self-medicated drugs.
Objectives: To develop and test two educational programs (interactive and passive) aimed at improving family doctors’ (FDs) prescribing practices and patient’s knowledge and use of NOAs.
Methods: The educational programs were conducted in two family medicine clinics belonging to the Mexican Institute of Social Security in Mexico City. The study was performed in three stages: (1) baseline evaluation, (2) design and implementation of educational activities, and (3) post-program evaluation. An interactive educational program (IEP) was compared with a passive educational program (PEP); both were attended by FDs and patients. The IEP for FDs comprised of workshops, discussion groups, in-service training, and guidelines, whereas for patients, the IEP consisted of an interactive session with a video, leaflets, and a discussion. The PEP consisted of delivering the guidelines to the FDs and the leaflets to patients. All FDs working at the clinics were invited to participate in the programs, and most (99%) of them accepted the invitation. There were 58 FDs in the IEP group and 52 FDs in the PEP group. The eligibility criteria for patients were as follows: age ≥ 50 years, suffered from non-malignant pain syndrome, had received at least one NOA prescription for a period of ≥7 days, were under the care of the participating FDs, and were able to answer the questions posed during the interview. The baseline and post-program evaluations included 300 patients by group. The effect of the programs on the FDs was measured through the appropriateness of prescriptions of NOA and analyzed using the differences-in-differences estimator (D-in-D), and on patients through changes in self-medication and in their knowledge about the proper use and adverse events by analyzing the inter- and intra-group differences before and after the programs.
Results: The IEP obtained better results to improve appropriate FDs prescription of NOA than PEP (D-in-D=15%). Regarding the patients, the PEP group reached higher reduction of self-medication than the IEP group (13.4 vs. 9.1%); the knowledge of proper NOA use increased by 8.5% in both groups, whereas knowledge of NOA-related adverse events was better in the IEP (39.6%) than in the PEP group (9.2%).
Conclusions: The IEP was better to improve the doctors’ abilities to prescribe NOAs, and both programs improved patients’ knowledge. Our findings suggest that programs aimed at improving medication use should focus on interactive educational activities.
Funding source(s): The study was supported by grants from the Research Promotion Fund of the Mexican Institute of Social Security (FOFOI IMSS-2005/1/I/201).
Prevalence and Predictors of Potentially Inappropriate Medication Use in Elderly Patients in Two Indian Teaching Hospitals
1JSS College of Pharmacy, JSS University, Mysore, India; 2JSS Medical College Hospital, JSS University, Mysore, India; 3St Johns Medical College, Bangalore, Bangalore, India
Problem statement: Geriatrics is an emerging clinical specialty in India. Information about the appropriateness of prescription medication use among the elderly in India is limited.
Objectives: To determine the prevalence and predictors of potentially inappropriate medication (PIM) use and assess the relationship between PIM use and adverse drug reactions (ADRs) in hospitalized elderly.
Methods: Patients aged > 60 years admitted to medicine wards at 2 medical college hospitals in southern India between January 2008 and June 2009 were included randomly (convenience sample collected opportunistically). These patients were reviewed by the clinical pharmacist for PIM use according to the Beers criteria 2003; severity of PIM use was classified as high or low. ADRs observed in the study patients were also recorded.
Statistical analysis: Association between ADRs and PIM use was assessed using chi square test. Bivariate analysis and subsequently multivariate logistic regression was used to identify predictors of PIM use.
Results: PIM use was observed in 191 of 814 enrolled patients. At least one PIM was received by 2.4% (20) and 22.1% (180) of patients at admission and during hospital stay, respectively. Highly severe PIM use showed a higher prevalence [26.8% (218) compared to low severity 5.5% (45)]. Among the patients who received polypharmacy (> 5 concurrent medications), 1.4% (5/362) and 22.1% (163/736) of patients received PIMs correspondingly at admission and during hospital stay, respectively. Use of aspirin/clopidogrel/diclofenac in the presence of blood clotting disorder or anticoagulant therapy (8.3%) was the most commonly observed PIM use. Compared to medications listed in Beers criteria, medications not listed were associated with increased occurrence of ADRs (349 vs. 11) (χ2 = 98.4, p < 0.001). Use of > 9 medications during the stay in medicine wards was identified as an influential predictor of PIM use (odds ratio: 1.9, 95% confidence interval: 1.34-2.69, p < 0.001) in hospitalized elderly.
Conclusion: PIM use was common (23.5%) among the elderly patients during their stay in medicine wards in 2 tertiary care hospitals. Focus of measures targeted to reduce the risk of ADRs in elderly should not be limited to Beers criteria medications.
Key lessons and implications: PIM prescribing is highly prevalent in hospitalized Indian elderly patients. The number of medications used can predict PIM prescribing in the elderly. Interventions targeted only at Beers criteria medications may do little to change the risk of ADRs in the elderly.
Future research agenda: Assess the usefulness of tools other than Beers criteria to arrive at a gold standard to assess PIM use. Health-related adverse consequences of PIM prescribing in the Indian elderly population should be evaluated.
Funding source: None
Improving Diabetes Management in Primary Care
NPS: Better Choices, Better Health, Australia
Problem statement: Diabetes has been an Australian national health priority. Metformin is a cost-effective first-line therapy for type 2 diabetes; however, uptake has not been optimal.
Objectives: To demonstrate the impact of a national program to improve management of diabetes in primary care
Design: NPS: Better Choices, Better Health implemented 3 national programs to improve management of type 2 diabetes: 2001–03 (#1), 2005–06 (#2), and 2007–08 (#3). Key messages focused on encouraging lifestyle interventions, management of risk factors, and first-line use of metformin. Programs were evaluated to measure changes in knowledge and prescribing practice. Computer simulation modelling, based on risk reductions achieved through use of metformin in overweight patients in the UKPDS study, was used to evaluate the likely impact of increased use of metformin on progression of diabetes and its complications.
Setting: Primary care
Study population: General practitioners (GPs) and their patients
Intervention: For each program, NPS deployed a range of activities to deliver key program messages. NPS facilitators based in local areas conducted face-to-face visits with practitioners and small group case study discussions. Clinical audits with feedback were available to help clinicians reflect on their practice. Information resources on the management of diabetes were distributed to support good decisions by health professionals and consumers.
Outcome measure(s): Prescribing rate change, knowledge of health professionals
Results: The numbers of GPs who participated were 6,704 (#1); 6,965 (#2); and 8,746 (#3)—approximately a third of the Australian GP population. Between 2001 and 2007, the mean prescribing rate increased from <20 to >25 metformin prescriptions per 1,000 consultations per month on the national Pharmaceutical Benefits Scheme. Time-series analysis did not confirm a statistically significant increase associated with NPS active program interventions. A random sample of 2,000 GPs was surveyed before and after the implementation of program #2. The proportion of respondents who selected metformin correctly in the management of a hypothetical patient was significantly higher in the post-survey (42% vs. 55%). Based on the survey and clinical audit results of program #2, it was estimated 3,000 additional patients were prescribed metformin. Computer simulation modelling projected that the additional use would result in 231 myocardial infarctions prevented, 370 premature deaths averted, and 1,719 life years saved.
Conclusions: National use of metformin has increased substantially and is likely to have major benefits for patients. Although the impact of NPS programs was not able to be demonstrated using available nationally aggregated data, audit and survey data demonstrated an impact. NPS experience should be of benefit to other countries to promote better diabetes care.
Funding source(s): NPS is funded by Australian Government Department of Health and Ageing.
Editor Training Program
Therapeutic Guidelines Ltd, Australia
Problem statement: Locally produced, independent, high-quality therapeutic information, such as drug bulletins and treatment guidelines, is an essential tool for activities to improve the use of medicines. The production of such information needs to be undertaken by health professionals with appropriate editorial training. Such training, however, is not usually available in developing countries. Therapeutic Guidelines Limited (TGL) is fortunate in that it is financially secure; this has allowed TGL to make a commitment to allocate some of its funds each year to share its expertise in this area and provide training for editors from developing countries.
Objective: To provide customised editorial training for health professionals who are currently working as editors in developing countries
Design: An editor from a developing country is selected each year to spend two to four weeks at TGL learning about the development of guidelines and associated activities.
Setting: TGL is a not-for-profit organisation that writes and publishes therapeutic guidelines. The guidelines provide independent and evidence-based recommendations for patient management for community practitioners. They are based on the latest international literature, interpreted by some of Australia’s most eminent and respected experts, with each statement having been examined, subjected to challenge and discussed over a series of day-long meetings. TGL is totally independent. All revenue is derived from sales, and no funding is received from either government or industry. Its strict policy on conflict of interest protects its intellectual independence. TGL employs 20 people, including 8 medical editors, a medical librarian, a senior medical advisor, IT officers, and an electronic publishing staff. The TGL editors have extensive experience in medical writing and editing both for hard copy and electronic publications.
Intervention: The editors from developing countries already have some editorial experience so the training program is tailored to suit the specific needs of each visiting editor and to focus on the gaps in their skills. TGL staff members make themselves available for one-on-one personal tuition and supervision.
Outcome measure(s): At the conclusion of each training program, the visiting editor is asked to provide TGL with an assessment of the usefulness and value of the training program. This evaluation has taken the form of informal communications immediately after program completion and follow-up e-mails in subsequent months. More formal measures, such as questionnaires to evaluate training, are being developed.
Results: Areas that the visiting editors have highlighted as being particularly useful are computer software training, design and layout of text, and marketing techniques. Attending interviews with users of therapeutic guidelines gives the editors an insight into the value of seeking feedback to improve the usability of guidelines. Although the aim of the program is to provide training for visiting editors, TGL staff also benefit by gaining an increased understanding of health systems in countries as diverse as India, Cuba, and Tonga.
Conclusion: The visiting editors have all left TGL with an enthusiasm to make use of their new knowledge in their own countries. It is hoped that the training will support the production of clear, concise information to help to improve use of medicines and health outcomes in those countries.
Funding source(s): TGL is totally independent. All revenue is derived from sales, and no funding is received from either government or industry. With regard to funding the TGL Editor Training Program, in 2010 and 2011, TGL provided 100% of funding; in 2008 and 2009, TGL provided 60% funding and the International Society of Drug Bulletins provided 40% funding.