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RATIONAL DRUG USE
ROLE OF PHARMACIST
Submitted to:
V.Rajini M.Pharm
Submitted by:
K.Likhita
Y13PHD1111
1M.A.M.College of Pharmacy
Contents
• Definition of RDU
• Factors that raised the RDU
• Factors influencing use of medicines
• Types of irrational use
 Diagnosis
 Prescription
 Dispensing
• Hazards of irrational use of drugs
• Role of pharmacist in RDU
• Methods for development of RDU
 Drug use indicators
 Drug and therapeutics committee
 Standard treatment guidelines
 Pharmacovigilance
 Pharmaceutical care
• Reference
2M.A.M.College of Pharmacy
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
DEFINITION OF RDU
3M.A.M.College of Pharmacy
FACTORS THAT RAISED THE
RDU
 Drug explosion
 Efforts to prevent the development of resistance
 Growing awareness
 Increased cost of the treatment
 Consumer protection act (CPA)
4M.A.M.College of Pharmacy
FACTORS INFLUENCING USE
OF MEDICINES
RATIONAL
DRUG USE
Policy,
Legal and
Regulatory
framework
Patient &
community
Drug
Supply
System
Prescriber,
Dispenser
& their
workplaces
5M.A.M.College of Pharmacy
TYPES OF IRRATIONAL USE
DIAGNOSIS
PRESCRIPTION
DISPENSING
6M.A.M.College of Pharmacy
DIAGNOSIS- IRRATIONAL
USE
 Inadequate examination of patient
 Incomplete communication between patient and doctor
 Lack of documented medical history
 Inadequate laboratory Resources
7M.A.M.College of Pharmacy
PRESCRIPTION- IRRATIONAL
USE
 Under-prescribing
 Incorrect prescribing
 Extravagant prescribing
 Over-prescribing
 Multiple prescribing
8M.A.M.College of Pharmacy
DISPENSING- IRRATIONAL
USE
 Incorrect interpretation of the prescription
 Retrieval of wrong ingredients
 Inaccurate counting, compounding, or pouring
 Inadequate labeling
 Unsanitary procedures
 Packaging:
 Poor-quality packaging materials
 Odd package size, which may require repackaging
 Unappealing package
9M.A.M.College of Pharmacy
HAZARDS OF IRRATIONAL
USE OF DRUGS
 Ineffective & unsafe treatment
 Exacerbation or prolongation of illness.
 Distress & harm to patient
 Increase the cost of treatment
10M.A.M.College of Pharmacy
11M.A.M.College of Pharmacy
METHODS FOR DEVELOPMENT
OF RDU
 Drug use indicators
- prescribing indicators
- patient care indicators
- facility indicators
 Drug and Therapeutics Committee
 Standard Treatment Guidelines
 Pharmacovigilance
 Pharmaceutical care
12M.A.M.College of Pharmacy
DRUG USE INDICATORS
• used as measures of performance in three general areas
related to the rational use of drugs in primary care:
- Prescribing practices
- Patient care
- Facility specific factors
13M.A.M.College of Pharmacy
DRUG USE INDICATORS
Continued
Prescribing indicators
1. Average number of drugs per encounter
2. Percentage of drugs prescribed by generic name
3. Percentage of encounters with an antibiotic prescribed
4. Percentage of encounters with an injection prescribed
5. Percentage of drugs prescribed from essential drugs list
or formulary
14M.A.M.College of Pharmacy
DRUG USE INDICATORS
Continued
Patient care indicators
6. Average consultation time
7. Average dispensing time
8. Percentage of drugs actually dispensed
9. Percentage of drugs adequately labelled
10. Patients' knowledge of correct dosage
15M.A.M.College of Pharmacy
DRUG USE INDICATORS
Continued
Facility indicators
11. Availability of copy of essential drugs list or formulary
12. Availability of key drugs
16M.A.M.College of Pharmacy
DRUG AND THERAPEUTICS
COMMITTEE
* providing advice on all aspects of drug management
• developing drug policies
• evaluating and selecting drugs for the formulary list
• developing (or adapting) and implementing STGs
• assessing drug use to identify problems
• conducting interventions to improve drug use
• managing adverse drug reactions and medication errors
• informing all staff members about drug use issues,
policies and decisions.
17M.A.M.College of Pharmacy
SUCCESS OF DTC
 A multidisciplinary approach sensitive to local politics
 Transparency and commitment to good service
 Technical competency
 Administrative support
18M.A.M.College of Pharmacy
STANDARD TREATMENT
GUIDELINES
STGs may be defined as ‘systematically developed
statements to help practitioners or prescribers make
decisions about appropriate treatments for specific clinical
conditions.
19M.A.M.College of Pharmacy
USES OF STGs
• providing guidance to health professionals on the diagnosis
and treatment of specific clinical conditions
• orienting new staff about accepted norms in treatment
• providing prescribers with justification for prescribing
decisions made in accordance with STGs
• providing a reference point by which to judge the quality of
prescribing
• aiding efficient estimation of drug needs and setting
priorities for procuring and stocking drugs.
20M.A.M.College of Pharmacy
PHARMACOVIGILANCE
• Relating to the collection, detection, assessment,
monitoring, and prevention of adverse effects with
pharmaceutical products.
• The 4 elements of an AE case are
(1) an identifiable patient,
(2) an identifiable reporter,
(3) a suspect drug, and
(4) an adverse event.
Its study is necessary to prevent ADR to promote RDU. 21M.A.M.College of Pharmacy
PHARMACEUTICAL CARE
Definition
The mission of the pharmacist is to provide pharmaceutical
care. Pharmaceutical care is the direct, responsible
provision of medication-related care for the purpose of
achieving definite outcomes that improve a patient’s
quality of life.
22M.A.M.College of Pharmacy
Reference
• The rational use of drugs, Report on the conference of
experts Nairobi, 25-29 Nov.1985 sponsored by W.H.O.
Geneva.
• RATIONAL DRUG USE by Dr Sneha Ambwani* Dr A K
Mathur **, Health Administrator Vol : XIX Number 1: 5-7
23M.A.M.College of Pharmacy
24M.A.M.College of Pharmacy
25M.A.M.College of Pharmacy

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Rational drug use

  • 1. RATIONAL DRUG USE ROLE OF PHARMACIST Submitted to: V.Rajini M.Pharm Submitted by: K.Likhita Y13PHD1111 1M.A.M.College of Pharmacy
  • 2. Contents • Definition of RDU • Factors that raised the RDU • Factors influencing use of medicines • Types of irrational use  Diagnosis  Prescription  Dispensing • Hazards of irrational use of drugs • Role of pharmacist in RDU • Methods for development of RDU  Drug use indicators  Drug and therapeutics committee  Standard treatment guidelines  Pharmacovigilance  Pharmaceutical care • Reference 2M.A.M.College of Pharmacy
  • 3. 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 DEFINITION OF RDU 3M.A.M.College of Pharmacy
  • 4. FACTORS THAT RAISED THE RDU  Drug explosion  Efforts to prevent the development of resistance  Growing awareness  Increased cost of the treatment  Consumer protection act (CPA) 4M.A.M.College of Pharmacy
  • 5. FACTORS INFLUENCING USE OF MEDICINES RATIONAL DRUG USE Policy, Legal and Regulatory framework Patient & community Drug Supply System Prescriber, Dispenser & their workplaces 5M.A.M.College of Pharmacy
  • 6. TYPES OF IRRATIONAL USE DIAGNOSIS PRESCRIPTION DISPENSING 6M.A.M.College of Pharmacy
  • 7. DIAGNOSIS- IRRATIONAL USE  Inadequate examination of patient  Incomplete communication between patient and doctor  Lack of documented medical history  Inadequate laboratory Resources 7M.A.M.College of Pharmacy
  • 8. PRESCRIPTION- IRRATIONAL USE  Under-prescribing  Incorrect prescribing  Extravagant prescribing  Over-prescribing  Multiple prescribing 8M.A.M.College of Pharmacy
  • 9. DISPENSING- IRRATIONAL USE  Incorrect interpretation of the prescription  Retrieval of wrong ingredients  Inaccurate counting, compounding, or pouring  Inadequate labeling  Unsanitary procedures  Packaging:  Poor-quality packaging materials  Odd package size, which may require repackaging  Unappealing package 9M.A.M.College of Pharmacy
  • 10. HAZARDS OF IRRATIONAL USE OF DRUGS  Ineffective & unsafe treatment  Exacerbation or prolongation of illness.  Distress & harm to patient  Increase the cost of treatment 10M.A.M.College of Pharmacy
  • 12. METHODS FOR DEVELOPMENT OF RDU  Drug use indicators - prescribing indicators - patient care indicators - facility indicators  Drug and Therapeutics Committee  Standard Treatment Guidelines  Pharmacovigilance  Pharmaceutical care 12M.A.M.College of Pharmacy
  • 13. DRUG USE INDICATORS • used as measures of performance in three general areas related to the rational use of drugs in primary care: - Prescribing practices - Patient care - Facility specific factors 13M.A.M.College of Pharmacy
  • 14. DRUG USE INDICATORS Continued Prescribing indicators 1. Average number of drugs per encounter 2. Percentage of drugs prescribed by generic name 3. Percentage of encounters with an antibiotic prescribed 4. Percentage of encounters with an injection prescribed 5. Percentage of drugs prescribed from essential drugs list or formulary 14M.A.M.College of Pharmacy
  • 15. DRUG USE INDICATORS Continued Patient care indicators 6. Average consultation time 7. Average dispensing time 8. Percentage of drugs actually dispensed 9. Percentage of drugs adequately labelled 10. Patients' knowledge of correct dosage 15M.A.M.College of Pharmacy
  • 16. DRUG USE INDICATORS Continued Facility indicators 11. Availability of copy of essential drugs list or formulary 12. Availability of key drugs 16M.A.M.College of Pharmacy
  • 17. DRUG AND THERAPEUTICS COMMITTEE * providing advice on all aspects of drug management • developing drug policies • evaluating and selecting drugs for the formulary list • developing (or adapting) and implementing STGs • assessing drug use to identify problems • conducting interventions to improve drug use • managing adverse drug reactions and medication errors • informing all staff members about drug use issues, policies and decisions. 17M.A.M.College of Pharmacy
  • 18. SUCCESS OF DTC  A multidisciplinary approach sensitive to local politics  Transparency and commitment to good service  Technical competency  Administrative support 18M.A.M.College of Pharmacy
  • 19. STANDARD TREATMENT GUIDELINES STGs may be defined as ‘systematically developed statements to help practitioners or prescribers make decisions about appropriate treatments for specific clinical conditions. 19M.A.M.College of Pharmacy
  • 20. USES OF STGs • providing guidance to health professionals on the diagnosis and treatment of specific clinical conditions • orienting new staff about accepted norms in treatment • providing prescribers with justification for prescribing decisions made in accordance with STGs • providing a reference point by which to judge the quality of prescribing • aiding efficient estimation of drug needs and setting priorities for procuring and stocking drugs. 20M.A.M.College of Pharmacy
  • 21. PHARMACOVIGILANCE • Relating to the collection, detection, assessment, monitoring, and prevention of adverse effects with pharmaceutical products. • The 4 elements of an AE case are (1) an identifiable patient, (2) an identifiable reporter, (3) a suspect drug, and (4) an adverse event. Its study is necessary to prevent ADR to promote RDU. 21M.A.M.College of Pharmacy
  • 22. PHARMACEUTICAL CARE Definition The mission of the pharmacist is to provide pharmaceutical care. Pharmaceutical care is the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient’s quality of life. 22M.A.M.College of Pharmacy
  • 23. Reference • The rational use of drugs, Report on the conference of experts Nairobi, 25-29 Nov.1985 sponsored by W.H.O. Geneva. • RATIONAL DRUG USE by Dr Sneha Ambwani* Dr A K Mathur **, Health Administrator Vol : XIX Number 1: 5-7 23M.A.M.College of Pharmacy

Notas del editor

  1. This statement was agreed by the WHO conference of experts in Nairobi in 1985 and is still the accepted definition of Rational Drug Use. It highlights the fact that rational use of medicines has many components, all of which must be in place before we can say that a drug has been rationally used. Rational use of drugs should ensure: 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
  2. Rational drug use attained more significance nowadays in terms of medical, socio economical and legal aspect. Factors that have led sudden realization for rational drug use are. 1. Drug explosion:- Increase in the number of drugs available has incredibly complicated the choice of appropriate drug for particular indication. 2. Efforts to prevent the development of resistance – Irrational use of drugs may lead to the premature demise of highly efficacious & life saving new antimicrobial drug due to development of resistance. 3. Growing awareness:- Today, the information about drug development, it’s uses & adverse effects travel from one end of the planet to the other end with amazing speed through various media. 4. Increased cost of the treatment:- Increase in cost of the drug increases economic burden on the public as well as on the government. This can be reduced by rational drug use. 5. Consumer protection Act. (CPA):- Extension of CPA in medical profession may restrict the irrational use of drugs.
  3. Patient& Community Beliefs and (mis)information available in the Community including cultural values on therapy, patient demands& expectations, Prescriber, Dispenser Lack of drug information, limited experience and skills, fear induced prescribing (uncertain diagnosis) Incorrect generalization from experience, inability to read or interpret prescriptions, inadequately trained dispensers, poor attitude about dispensing and packaging Workplace Lack of equipment, facilities, packaging materials, lab capacity, continuing education, pressure to prescribe and dispense, insufficient staffing, inadequate supervision of practitioners. Drug Supply System: Drug Quality Problems unreliable suppliers Bad forecasting/bad quantifications Bad Inventory Management (expired drugs, Shortages, etc.) Pressure and lobbying from Industry (promotional activities and misleading claims) Drug Regulation non-essential drugs available: non-formal prescribers lack of regulation enforcement
  4. Diagnosis: Inadequate examination of patient Incomplete communication between patient and doctor Lack of full medical and medication history e.g. Rifampicin in Tb treatment and Stavudine (d4t), EFV potential for teratogenicity
  5. Prescribing: Extravagant prescribing: Expensive drugs are used when less expensive equivalents are available. Over-prescribing: Prescribed drugs are not needed, or the dosage is too high. Patient has gained weight after ART and dosage is not changed. Incorrect prescribing: The wrong drugs are selected for the patient’s condition. Under-prescribing: Needed medications are not prescribed, or the dosage is inadequate. Multiple prescribing; Many drugs are used when fewer would have the same effect.
  6. Dispensing: Incorrect interpretation of the prescription Retrieval of wrong ingredients Inaccurate counting, compounding, or pouring: lack of Pediatric ARV formulations Inadequate labeling Unsanitary procedures Packaging: Poor-quality packaging materials Odd package size, which may require repackaging Unappealing package
  7. Studies to measure drug use will vary from setting to setting. The nature and design of such studies will depend on many factors, which include: the specific information needs of health managers; the types of record-keeping systems available in health facilities; the types of providers whose behaviour is to be characterized; and the resources available to carry out the work. In general, however, drug use studies by means of indicators will fall into four broad categories: • Describing current treatment practices: Such a cross-sectional survey is done by taking specific measures of treatment practices from carefully selected groups of facilities and patients. • Comparing the performance of individual facilities or prescribers: Rather than being primarily concerned with summarizing the treatment practices of the group as a whole, such a study seeks to compare practices between individual facilities or prescribers, or between groups. • Periodic monitoring and supervision of specific drug use behaviours: After the broad outlines of drug use behaviour are known, the indicators can be used to identify facilities or providers whose performance falls below a specific standard of quality, so that they can be targeted for intensive supervision. • Assessing the impact of an intervention: Specific indicators can be used to evaluate the effectiveness of an intervention designed to change prescribing practices, by providing the capability for reliably measuring practices both before and after the intervention, and in both an intervention and a control group. The first step in designing a drug use study is to specify the objectives clearly. The size of the samples required, the design of the sampling process and the complexity of data analysis will vary greatly depending on the specific objectives. This manual will focus primarily on the design and implementation of a basic indicators study to describe treatment practices, and on how this basic design should be changed to allow for a comparison of regions or facilities. Ideas for using the indicators for supervision will also be presented briefly.
  8. The indicators of prescribing practices measure the performance of health care providers in several key dimensions related to the appropriate use of drugs. The indicators are based on the practices observed in a sample of clinical encounters taking place at outpatient health facilities for the treatment of acute or chronic illness. These encounters can be observed retrospectively, from data recorded in historical medical records, or they can be observed prospectively, from a group of patients attending the clinic on the day the data are collected. Details of how to draw a sample of health facilities and how to sample clinical encounters are discussed in Chapter 3. The core prescribing indicators do not require the collection of any information on signs and symptoms. Because the samples of clinical encounters cover a broad spectrum of health problems, the core prescribing indicators measure general prescribing tendencies within a given setting, independent of specific diagnoses. Admittedly, many critical questions in drug use have to do with whether health care providers follow appropriate diagnostic procedures and whether they select products and dosage schedules to fit underlying health problems. However, determining the quality of diagnosis and evaluating the adequacy of drugchoices is a complex undertaking in practice, and beyond the scope of the core indicators. After a first drug use study with selected indicators has been carried out to determine overall prescribing performance, it will usually be necessary to undertake more health problem-specific investigations and make an assessment of the quality of diagnosis and treatment. The data to measure the prescribing indicators can be recorded on forms that are reproduced in Annex 2. The detailed prescriber indicator form requires recording the names and amounts prescribed for each drug, from which the values for each prescribing indicator can later be entered. The form also allows other information on patients, prescribers and health problems to be recorded. The advantages of the detailed form are that data can be collected by persons with less sophisticated knowledge about drugs, and also that later follow-up health problem-specific or drug-specific analyses can be carried out on the same data. The ordinaryprescriber indicator form requires that each indicator be entered directly by data collectors in the field. This assumes that data collectors know enough about drugs to evaluate the indicators. Its main advantage is that it allows immediate summaries of theindicators to be produced and discussed with staff from the health facility; its disadvantage is that fewer possibilities exist to later validate the data. The detailed form can be used for secondary analysis of specific diagnoses or drugs. 1 Average number of drugs per encounter   Purpose To measure the degree of polypharmacy. Prerequisites Combination drugs are counted as one. Guidelines are needed on how to count certain ambiguous prescribing practices (e.g. some standardized sequential therapies). Calculation Average, calculated by dividing the total number of different drug products prescribed, by the number of encounters surveyed. It is not relevant whether the patient actually received the drugs. Example In health centers in Indonesia patients are prescribed an average of 3.3 drugs per consultation.   2 Percentage of drugs prescribed by generic name   Purpose To measure the tendency to prescribe by generic name. Prerequisites Investigators must be able to observe the actual names used in the prescription rather than only having access to the names of the products dispensed, since these may be different; a list must be available of specific product names to be counted as generic drugs. Calculation Percentage, calculated by dividing the number of drugs prescribed by generic name by the total number of drugs prescribed, multiplied by 100. Example In health units in Nepal an average of 44% of drugs are prescribed by generic name.   3 Percentage of encounters with an antibiotic prescribed   4 Percentage of encounters with an injection prescribed   Purpose To measure the overall level of use of two important, but commonly overused and costly forms of drug therapy. Prerequisites A list must be available of all the drug products which are to be counted as antibiotics; investigators must be instructed about which immunizations are not to be counted as injections. Calculation Percentages, calculated by dividing the number of patient encounters during which an antibiotic or an injection are prescribed, by the total number of encounters surveyed, multiplied by 100. Example In dispensaries in Nigeria 48% of all outpatient encounters were prescribed one or more antibiotics, while an injection was prescribed during 37% of all consultations.   5 Percentage of drugs prescribed from essential drugs list or formulary   Purpose To measure the degree to which practices conform to a national drug policy, as indicated by prescribing from the national essential drugs list or formulary for the type of facility surveyed. Prerequisites Copies of a published national essential drugs list or local institutional formulary to which data on prescribed drugs can be compared; procedures are needed for determining whether or not brand name products are equivalent to ones appearing in generic form on the drug list or formulary. Calculation Percentage, calculated by dividing the number of products prescribed which are listed on the essential drugs list or local formulary (or which are equivalent to drugs on the list) by the total number of products prescribed, multiplied by 100. Example In dispensaries in Tanzania on average 88% of drugs prescribed appeared on the national essential drugs list. Required tasks for measuring prescribing indicators All prescribing indicators are based on behaviour observed in small samples of patient encounters which are collected retrospectively or prospectively from a group of health facilities. Therefore, the first two tasks for measuring any of the prescribing indicators are to select a group of health facilities and to define how the clinical encounters will be sampled at these facilities. Once the samples of facilities and encounters have been selected, specific types of data necessary to measure theindicators will be recorded for each encounter. In order to record these data in a consistent and reproducible way, certain other activities have to take place before the data collection can start. The sequence of activities for measuring the prescribingindicators in a standardized way is detailed below.
  9. In order to understand the way drugs are used it is important to consider what takes place at health facilities from both the provider's and the patient's perspectives. Patients enter facilities with a set of symptoms and complaints, and with expectations about the care they will receive; they typically leave with a package of drugs or with a prescription to obtain them in the private market. The patient care indicators address key aspects of what patients experience at health facilities, and how well they have been prepared to deal with the pharmaceuticals that have been prescribed and dispensed. The time that prescribers and dispensers spend with each patient sets important limits on the potential quality of diagnosis and treatment. Patients for whom pharmaceuticals are prescribed should, at a minimum, receive well-labelled medications, and should understand how to take each drug. Like the prescribing indicators, the patient care indicators do not capture many fundamental issues related to the quality of examination and treatment. A proper evaluation of quality of care should assess the content of interactions between patients and health workers. However, this is both practically and technically beyond the scope of a limited set of core indicators. As with the prescribing indicators, it may be necessary to examine the patient-provider interactions in more detail and to explore the beliefs and motivations regarding the use of drugs in more depth, after an initial survey has identified one or more specific problems. All the data needed to measure the patient care indicators for each facility can be recorded and summarized on the patient care form included in Annex 2. 6 Average consultation time   Purpose To measure the time that medical personnel spend with patients in the process of consultation and prescribing. Prerequisites Procedures for accurately recording the time spent during the consultation, that is, the time between entering and leaving the consultation room. Waiting time is not included. Calculation Average, calculated by dividing the total time for a series of consultations, by the number of consultations. Example In Malawi patients spend an average of 2.3 minutes with health workers in the consultation room.   7 Average dispensing time   Purpose To measure the average time that personnel dispensing drugs spend with patients. Prerequisites Procedures for accurately recording the average time patients spent with pharmacists or drug dispensers, that is, the time between arriving at the dispensary counter and leaving. Waiting time is not included. Calculation Average, calculated by dividing the total time for dispensing drugs to a series of patients, by the number of encounters. Example In health centres in Tanzania patients spend an average of 78 seconds receiving their drugs.   8 Percentage of drugs actually dispensed   Purpose To measure the degree to which health facilities are able to provide the drugs which were prescribed. Prerequisites Information on which drugs were prescribed, and whether these drugs were actually dispensed at the health facility. Calculation Percentage, calculated by dividing the number of drugs actually dispensed at the health facility by the total number of drugs prescribed, multiplied by 100. Example In health facilities in Nepal, 73% of prescribed drugs were actually dispensed at the health facility.   9 Percentage of drugs adequately labelled   Purpose To measure the degree to which dispensers record essential information on the drug packages they dispense. Prerequisites Investigators must be able to examine the drug packages as they are actually dispensed at the health facility. Calculation Percentage, calculated by dividing the number of drug packages containing at least patient name, drug name and when the drug should be taken, by the total number of drug packages dispensed, multiplied by 100. Example In Region A only 10.2% of drugs dispensed were adequately labelled.   10 Patients' knowledge of correct dosage   Purpose To measure the effectiveness of the information given to patients on the dosage schedule of the drugs they receive. Prerequisites Access to a written prescription or to a patient card against which patients' knowledge on the dosage schedule can be checked, or access to standards for how each common drug is supposed to be used; investigators must be trained to evaluate patient knowledge during the interview, or to record patient responses for later evaluation. Calculation Percentage, calculated by dividing the number of patients who can adequately report the dosage schedule for all drugs, by the total number of patients interviewed, multiplied by 100. Example In 23 health facilities in Bangladesh 63% of patients were able to repeat the correct dosage schedule of the drugs they had received. Required tasks In a simple drug use indicator study the adequacy of patient care is measured by observing a sample of patient encounters as they normally occur, and by interviewing patients as they leave the facilities. In addition to those described for the prescribingindicators, the following tasks are required to measure the patient care indicators.
  10. The ability to prescribe drugs rationally is influenced by many features of the working environment. Two particularly important components are an adequate supply of essential drugs and access to unbiased information about these drugs. Without these it is difficult for health personnel to function effectively. The data for the health facility indicators can be recorded on the facility summary form included in Annex 2. The same form can be used to record information on the data collection process at each health facility, such as the names of the primary contact people at the facility, whether retrospective or prospective data were collected, how many cases were recorded for the prescribing and patient care indicators, and any problems that occurred during the visit. 11 Availability of copy of essential drugs list or formulary   Purpose To indicate the extent to which copies of the national essential drugs list or local formulary are available at health facilities. Prerequisites A national essential drugs list or a local formulary must exist for that level of care; if not, the indicator would always be scored “no”. Calculation Yes or no, per facility. Example In Country A only 28% of health facilities had a copy of the national list of essential drugs.   12 Availability of key drugs   Purpose To measure the availability at health facilities of key drugs recommended for the treatment of some common health problems. Prerequisites A short list of 10-15 essential drugs must be compiled that should always be available (suggested list in Table 3). Calculation Percentage, calculated by dividing the number of specified products actually in stock by the total number of drugs on the checklist, multiplied by 100. Example In health centers in Nigeria, on average 62% of 14 key essential drugs were actually in stock. Required Tasks Determine whether a national essential drugs list or local formulary exists One sign that the concept of essential drugs has been accepted is the development, dissemination and use of a national essential drugs list, a local essential drugs formulary, or equivalent reference material on essential drugs, such as druginformation sheets. The availability of such drug information is one cornerstone for rational prescribing. In order to be most effective, information must be widely disseminated to all health facilities to guide decisions about the purchase, distribution and therapeutic use of drugs. The investigators should determine whether a national essential drugs list, local formulary, or equivalent reference material exists, when this material underwent its most recent revision, and in what form it has been distributed to health facilities. To score this indicator in the field, data collectors should ask the prescribers in each facility to produce an up-to-date copy of the list or formulary. Develop a short list of essential drugs to test availability Prescribers can only treat patients in a rational way if essential drugs are available on a regular basis. One way of indicating the overall availability of essential drugs is to identify a short list of specific drugs (less than 15) that are essential to treat common health problems, and to examine their availability in the facility on the day of the survey. A suggested list of drugs that might be used for this purpose is presented in Table 3. Investigators should modify this list, or develop a new list, to apply to a few important health problems in the local environment. Data collectors will then check the drugs on this list for availability in the facility. For the purposes of this indicator brand name and generic drugs are chemically equivalent, and the presence of any such chemically-equivalent form of the listed drug should therefore be counted. If there are questions about whether or not a particular drug qualifies, data collectors should be trained to record questions on the facility summary form so that a final decision can be made by the principal investigators. The quantity in stock should not be considered. Even if only one bottle or a few tablets are available, the drug should be recorded as being in stock.  
  11. Changing the use of medicines to ensure that they are used in the most effective way is the overall aim of a drug andtherapeutics committee (DTC). There are three overall types of strategy to change the use of medicines: • educational strategies that aim to inform prescribers • managerial strategies that aim to guide the decisions of prescribers • regulatory strategies that aim to restrict the decisions of prescribers. A comprehensive approach with a combination of interventions (preferably of different types) is always more effective than single interventions. It is critical to assess the impact of interventions using adequate study design in order either to discontinue those that have no impact, or to gain sufficient support to continue implementation of those that do have impact.
  12. It may be easy to establish a DTC, with a list of core and additional members, all with different expertise, objectives andfunctions, but it may be very difficult to ensure that it functions effectively. Success will depend on having strong and visible support from the senior hospital management and abiding by the principles listed below. 2.1.1 A multidisciplinary approach sensitive to local politics DTC activities will involve different cadres of health professional, who will have different experiences, beliefs, skills, practices, motivations and status. Often a DTC must manage conflict arising between clinicians and the pharmacy or administration concerning prescribing restrictions that result from the implementation of agreed guidelines. Such conflicts can be reduced if staff are convinced of the need for, and benefits of, change and there is strong institutional commitment with the support of people in authority. Wide representation on the DTC and documenting and disseminating decisions taken to correct problems in the use of medicines helps to convince health-care workers. Everyone who contributes should be acknowledged. 2.1.2 Transparency and commitment to good service The success of a DTC will depend upon its being active, working regularly in a consistent direction and making sound decisions in a transparent way. This is especially important in medicine selection and procurement policies. The people involved should not be influenced by inappropriate drug advertisements, promotional activities or personal financial interests. All committee members should be required to sign a ‘declaration of interest’ (see annex 2.1). Such a declaration can bind members to the working principles and ethics of the DTC, and to their roles and responsibilities to other health-care staff, the hospital management andthe community. 2.1.3 Technical competency A DTC must have the appropriate technical competence. Members will have different competencies and the DTC process of discussion and appraisal of drug use issues is a good way to educate members in areas outside their expertise. Good scienceand evidence (if possible) must be the basis of all DTC decisions. 2.1.4 Administrative support Administrative support is very important, as otherwise a DTC may not be able to implement its decisions. Administrative support can provide the executive authority needed to gain the cooperation of senior medical staff. The administration can also provided the funds needed to undertake many of the DTC’s activities.
  13. Even with an ideal formulary list, inappropriate use of formulary drugs may occur. STGs or treatment protocols are a proven, effective strategy to promote appropriate prescribing, when used in conjunction with educational strategies to promote their use (Grimshaw and Russell 1993). STGs may be defined as ‘systematically developed statements to help practitioners or prescribers make decisions about appropriate treatments for specific clinical conditions’ (MSH 1997). As a minimum, they should contain information on clinical features, diagnostic criteria, non-drug and drug treatments (first-, second-, third-line), and referral criteria (see step 5, section 3.4.2). Contrary to what is often alleged, STGs do not constrain but advise prescribers, who still retain their responsibility to decide upon appropriate treatments. STGs merely define the boundaries between the accepted norms in treating a disease based on good clinical evidence, and the practice of relying purely on clinical experience. The latter provides a very limited scientific basis and is often subject unknowingly to bias and misinterpretation which may result in expensive, inefficient disease management.
  14. If one or more of these four elements is missing, the case is not a valid AE report. Although there are no exceptions to this rule there may be circumstances that may require a judgment call. For example, the term "identifiable" may not always be clear-cut. If a physician reports that he/she has a patient X taking drug Y who experienced Z (an AE), but refuses to provide any specifics about patient X, the report is still a valid case even though the patient is not specifically identified. This is because the reporter has first-hand information about the patient and is identifiable (i.e. a real person) to the physician. Identifiability is important so as not only to prevent duplicate reporting of the same case, but also to permit follow-up for additional information. The concept of identifiability also applies to the other three elements. Although uncommon, it is not unheard of for fictitious adverse event "cases" to be reported to a company by an anonymous individual (or on behalf of an anonymous patient, disgruntled employee, or former employee) trying to damage the company's reputation or a company's product. In these and all other situations, the source of the report should be ascertained (if possible). But anonymous reporting is also important, as whistle blower protection is not granted in all countries. In general, the drug must also be specifically named. Note that in different countries and regions of the world, drugs are sold under various tradenames. In addition, there are a large number of generics which may be mistaken for the tradeproduct. Finally, there is the problem of counterfeit drugs producing adverse events. If at all possible, it is best to try to obtain the sample which induced the adverse event, and send it to either the EMA, FDA or other government agency responsible for investigating AE reports. If a reporter can't recall the name of the drug they were taking when they experienced an adverse event, this would not be a valid case. This concept also applies to adverse events. If a patient states that they experienced "symptoms", but cannot be more specific, such a report might technically be considered valid, but will be of very limited value to the pharmacovigilance department of the company or to drug regulatory authorities.[3]