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4a. Access: Interventions to Improve Prescribing Practices in LMIC
Impact of the WHO Guide to Good Prescribing on Medical Students
Centre National de Pharmacovigilance et de Matériovigilance, Algeria
Problem statement: Pharmacotherapy teaching in medicine is characterized by transfer of knowledge about medicines rather than training students to treat methodically and using structured approach. Recently, a six-step problem-solving approach in pharmacotherapy using normative model was suggested by WHO and based on the following steps: (1) define the patient’s problem; (2) specify the therapeutic objective; (3) verify the suitability of the P-drug for the individual patient; (4) write a prescription; (5) inform and instruct the patient; and (6) monitor and/or stop the treatment.
Objectives: To measure the impact of the WHO Guide of Good Prescribing in short-term pharmacotherapy teaching (a 10-week study)
Intervention: A randomized controlled trial was conducted among students divided into two groups: a control group with 65 students and a study group with 133 students. The two groups were assessed through 3 successive tests, each containing open and structured questions about drug treatment of different type of pain. The assessing tests are taken before the training period (T0), six weeks after problem-based training period and at the end of teaching pharmacotherapy (T1), and finally 4 weeks later to assess if they remembered the method studied (T2). The study was conducted over 3 years for controlling the reproducibility of observed data. The scores of control and study groups are compared by using Student’s t-test, p<0.05 is considered as significant.
Study population: Students at 6th year of graduate medicine in Algiers, at the clerkship period
Results: Data show that students from the study group performed significantly better than those in the control group at all six steps. The students in the study group showed good problem-solving capabilities at T1, and they remembered the method to solve the health problems 4 weeks later at T2. The results confirm the data previously obtained by other authors. Moreover, in our study, the impact of fundamental sciences such as physiopathology to specify the therapeutic objective and pharmacology to verify the suitability of medicine for individual patient constitute a solid bridge between fundamental and clinical knowledge in prescribing and solving problems. The method described in Guide to Good Prescribing reinforce the understanding of the students and the transfer of knowledge to new capabilities improving rational use of medicines (p<0.05).
Conclusion: The WHO method of good prescribing is effective and efficient for pharmacotherapy teaching in developing countries and also not expensive as pointed out by certain studies. The method is flexible and adaptable to every country.
Funding source(s): Centre National de Pharmacovigilance et de Matériovigilance, NIPA, Dely Brahim Algiers (Algeria)
Drug and Therapeutics Committees in Africa and Asia: From Training to Implementation
1Strengthening Pharmaceutical Systems (SPS) Program, Management Sciences for Health (MSH), Arlington, VA, USA; 2World Health Organization, SEARO, New Delhi, India
Problem statement: The World Health Organization (WHO) and ICIUM recommend the establishment of drug and therapeutics committees (DTCs) to improve medicine use and contain antimicrobial resistance. However, many low-resource countries lack DTCs or face challenges to manage them efficiently.
Objective: To show how in-country stakeholders can be capacitated to implement DTCs and how DTCs can implement medicine use activities in low-resource countries
Setting and population: Pharmacists, physicians, nurses, hospital managers, and policy-makers in hospitals in low-resource countries in Africa and Asia
Interventions: Since 2001, MSH’s SPS Program and its predecessor, RPM Plus, collaborated with ministries of health (MoH), WHO, and other in-country organizations to conduct DTC training courses, including training of trainers, for 945 participants from 70 countries. After the trainings, SPS/RPM Plus provided follow-up technical assistance to implement DTC activities in the participants’ respective settings.
Outcome measures: Number of DTCs established and number of DTC-led activities that contribute to improving the use of medicine and cost savings
Results: Data show DTC course participants have developed and implemented 209 DTCs. These DTCs developed 49 hospital formularies, 23 standard treatment guidelines, and 13 adverse medicine reaction reporting systems. They conducted 35 medicine use studies, 21 medicine use evaluations, 17 training programs on rational medicine use, and 57 DTC trainings provided by participants. Specific results include a DTC in a large private hospital in Nairobi reducing the use of three injection products, saving $4,091 over six months and deleting 20 pediatric cough and cold medicines from the formulary. Based on a medicine use evaluation, another DTC established a protocol for cesarean section antibiotic prophylaxis that is projected to save the hospital $23,970 a year. In China, a course participant collaborated with the MoH to organize three regional DTC courses resulting in a pool of trainers. In one hospital, prescription review by clinical pharmacists decreased major prescription errors and irrational use. As a result of advocacy and local evidence, MoHs in Afghanistan, Ethiopia, and Rwanda have institutionalized DTCs by including them in guidelines or policies.
Conclusions: In-country stakeholders in resource-limited countries have made progress in establishing DTCs and implementation of interventions to improve the use of medicines, including antimicrobials. Although initial trainings are important to help jump-start the process, ongoing technical support is critical to ensure continuing motivation and effective implementation.
Funding sources: MSH/SPS and RPM Plus through US Agency for International Development, WHO
Evaluation of Prescribing Practices by Assistant Medical Officers at Malaysian Public Health Care Facilities
1Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia; 2School of Pharmacy, Division of Medicine, Pharmacy & HealthSciences
Background: Prescribing is one of the primary stages at which errors occur. Prescribing errors occur when the probability that the treatment will be timely and effective is reduced or when the risk of harm, when compared with generally accepted practice, is increased. Prescribing errors can be classified into omission errors and decision errors. Omission errors include incomplete prescriptions, inappropriate use of abbreviations, and illegible hand writing. Decision errors are wrong indications, contraindications, drug-drug interactions, polypharmacy, inappropriate dosing, inappropriate duration of treatment, and inappropriate dosing frequency. In Malaysia, assistant medical officers (AMOs) play an important role in the health setting because of the shortage of medical officials, especially at government health clinics. According to the Malaysia Poison Act of 1952, medical assistants are authorized to prescribe but are limited to certain items at certain premises. It was noted that the medical assistants prescribe medications that are out of their allowed authority.
Objectives: To identify the frequency and nature of various types of prescription errors made by AMOs at a government health clinic and a government hospital at Kampar district, to study the prescribing patterns of AMOs, and to determine whether there is an association between prescribing errors and patients’ demographics and disease stages
Methods: 1,612 prescriptions that were generated within 1 week were screened retrospectively, and 421 prescriptions that met the inclusion criteria were evaluated. During screening, prescribing errors were classified into either omission errors or decision errors. The British National Formulary (edition 56), Lexi-Comp, and other relevant references were used to evaluate prescription errors. Out of the 421 prescriptions being studied, only 13 prescriptions were totally free of errors. All the prescribing errors made were recorded on a data collection form. The data was then analyzed using SPSS (version 12).
Results: 1,169 prescribing errors were noted, and about 2.78 prescribing errors were made by AMOs for each prescription generated; 67% were omission errors and 33% were decision errors. Illnesses for which the medication was being prescribed varied from general medical conditions such as the common cold and flu to specialty diseases, such as those involving the cardiovascular or respiratory system, and infections. Most of the errors made were related to anti-infective medications prescribed, and there was a significant association between prescribing errors and the patient’s disease stage. Among the 421 prescriptions generated by AMOs, 39% were prescribed with at least one medication categorized as a Group B poison under the First Schedule Poison List of Malaysia Laws on Poison and Sale of Drugs.
Conclusions: Prescribing errors are common and frequent at government health settings in Kampar District. A much wider appreciation is required of the value of focusing on the root causes of errors. Designing initiatives targeting the causes of errors that are most likely to occur would be helpful in reducing them.
Funding source(s): Self-funded
Use of Prophylactic Oxytocin by Health Care Providers in Northeast Argentina as Part of Active Management of the Third Stage of Labor
1Tulane School of Public Health & Tropical Medicine, United States of America; 2Institute for Clinical Effectiveness and Health Policy-Buenos Aires, Argentina
Problem statement: Postpartum hemorrhage (PPH) is the second leading cause of maternal deaths in Latin America and the primary cause throughout the world. To reduce the incidence of PPH, active management of the third stage of labor (AMTSL) has been widely recommended and accepted as standard care. In many countries, however, particularly in Latin America, AMTSL is not being routinely practiced. In particular, birth attendants are not routinely administrating prophylactic uterotonics to mothers in labor as a result of lack of knowledge among health care providers and limited access to drugs, among other reasons.
Objectives: The primary objective was to measure and compare birth attendants’ knowledge, use, and opinion regarding prophylactic uterotonics, controlled cord traction, and uterine massage from before and after the intervention was administered. The secondary objective was to assess the availability and storage conditions of prophylactic uterotonics, as well as the existence of clinical guidelines regarding labor and delivery, at each of the participating hospitals.
Design: This was a prospective before-and-after study without a control group. We evaluate the efficacy of an intervention through pre- and post-surveys distributed among medical workers in 5 maternity hospitals in Corrientes Province.
Setting: The study took place in 5 hospitals located throughout the province of Corrientes, located in northeastern Argentina. Corrientes Province is an economically underdeveloped region that depends mostly on agriculture for subsistence and growth. The participating hospitals were either primary or secondary and are part of the public sector.
Study population: We invited all birth attendants, including physicians, midwives, and nurses who work in the participating hospitals to take part in the study. During the baseline period, 30 providers participated in the survey. During the follow-up period, 32 providers participated. For both phases, the mean age was approximately 40. One-third of them were male, and the overwhelming majority were physicians.
Intervention: During a 6-month baseline period, we performed an intervention that consisted of training birth attendants on AMTSL, distributing oxytocin-filled vials of Uniject, and employing hospital reminders to reinforce the practice of AMTSL. For the training process, we conducted a 1-day instructional session at each hospital. During the intervention period, 1-ml Uniject devices containing 10 IU of oxytocin as well as oxytocin vials and syringes were distributed to the participating hospitals. The Prevention of Postpartum Hemorrhage Initiative (POPPHI), sponsored by USAID, constructed posters that instructed how to practice AMTSL. These posters were then placed in conspicuous locations throughout the hospitals.
Outcome measurements: To determine the use of AMTSL, particularly the administration of prophylactic oxytocin, from before and after the intervention, information was collected from the study data forms of 941 women giving vaginal births at the baseline period and 951 at the intervention period.
Results: For the most part, providers’ knowledge and positive attitude about AMTSL increased from the baseline to the follow-up period, with a few exceptions. Fewer respondents answered “yes” in the post-survey regarding what AMTSL consists of. The percentage of providers who felt that prophylactic uterotonics were effective was higher in the pre-survey than post-survey. These differences were not statistically significant.
The follow-up questionnaire contains a series of questions regarding Uniject that are not included in the baseline one, since the latter was administered prior to the intervention. For these questions, nearly 97% of providers responded that they have used Uniject to administer prophylactic uterotonic. 96% answered that Uniject facilitates the use of prophylactics as part of AMTSL. When asked to compare Uniject to ampoules and syringes, all contested that Uniject was easier to use than the rest. 44% replied that if Uniject was not available, the administration of oxytocin would be reduced.
Conclusions: The results from our study indicate an overall increase in the use of AMTSL ensuing the intervention. The area that showed the greatest increase was the administration of prophylactic oxytocin. The percentage of providers who have used controlled cord traction or uterine massage increased as well, although the number was already significantly high prior to the intervention. In conclusion, the intervention yielded mostly positive results. More health care workers in Corrientes Province are aware of AMTSL and how to administer each component. Because the sample size is very small, however, it is recommended that additional surveys be administered on a greater scale, perhaps in other provinces of Argentina to compare if the results remain consistent and to assess the discrepancies from this particular study.
Funding source(s): Minority Health International Research Training, National Center on Minority Health and Health Disparities, and the National Institutes of Health, USA
Gender and Access to Medicines in 15 Low- and Middle-Income Countries: Does Physician Prescribing for Men and Women Differ?
1IMS HEALTH, United Kingdom; 2Harvard Medical School and Harvard Pilgrim Health Care Institute
Problem Statement: Hypotheses of gender differences in access to medicines exist but information about these is lacking.
Objectives: To assess whether gender differences exist in access to medicines for acute (Upper respiratory infections [URI]) and chronic (diabetes, depression) diseases.
Setting: Private sector physicians recruited by IMS HEALTH who recorded patient age, sex, diagnoses, and medicines prescribed.
Study Population: Fifteen countries—1 low-income and 14 middle- income—from six regions: Americas (6);East Mediterranean (3); Europe (2); South East Asia (2); Africa (1) and Western Pacific (1). Between 2007 and 2010, 92,969 consultations for depression (median across countries: 1,758), 143,087 for diabetes (median 6,747), and 251,785 (median 17,224) for URI were included. Diabetes and depression consultations were defined by drug prescribed and physician’s diagnosis, URI consultations by diagnosis only.
Outcomes: Gender differences by age group defined as (1) a statistical difference in the observed number of consultations for men and women for each disease compared to the expected number (estimated based on WHO estimated disability adjusted life years by cause tables); and (2) statistical differences in the observed number of prescriptions for new oral drugs used in diabetes or for medicines in URI compared to that expected from the observed visit numbers.
Results: A significant difference between the observed number of visits for depression and that expected was detected on 36% of 45 comparisons across countries and age groups, for diabetes on 58%, and for URI on 87%. Where a statistical difference was found, the observed number of visits was higher than expected for women on 75% of occasions for depression, on 18% occasions for diabetes, and on 44% of occasions for URIs. A statistical difference between the expected and observed number and type of prescriptions was found in fewer than 26% of comparisons made in URI and diabetes. Where a statistical difference was found in URI, the observed number was higher than expected for women twice as often as for men.
Conclusions: The present results suggest gender differences in access to medicines. Depending on country, disease, and age group, both women and men may have preferential access. These analyses may provide an important basis for addressing equity concerns in medicines policy decision making.
Funding Sources: IMS HEALTH, UK Government