Rational Use of Drugs in the Public and Private SectorsPengantar:
2012
Tujuan
Memahami mengapa terjadi pengobatan yang tidak rasional
Mendiskusikan strategi intervensi unutk memperbaiki masalah
Mendiskusikan pedoman pengobatan
Definisi
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
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Tepat dalam pemilihan obat
Obat digunakan sesuai indikasi
Tepat dosis, cara pemberian, dan lama terapi
Tidak ada kontraindikasi pada pasien
Pemberian obat yang tepat (termasuk informasi yang cukup agar pasien dapat mengikuti program pengobatan dengan benar)
Ciri pengobatan rasional
Ketepatan dalam diagnosis
5-55% pasien di PHC menerima injeksi-
90% tidak perlu secara medis
% pasien di PHC yang mendapatkan injeksi
Quick et al, 1997, Managing Drug Supply
15 juta injeksi/tahun secara global
50% tidak menggunakan jarum steril
2.3-4.7 juta infeksi hepatitis B/C dan sekitar 160,000 infeksi HIV/tahun
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Pola pemakaian antibiotika di 26 negara Eropa tahun 2002
Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.
*
Total outpatient antibiotic use in 26 European countries in 2002 (WHO ATC/DDD version 2003).
This are ESAC data to position Belgium among other European countries…
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
% Ketaan terhadap Pedoman Pengobatan
Pola Pengobatan ISPA Berdasarkan Tenaga
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Penggunaan antimikroba dan Pengaruhnya terhadap resistensi
Malaria
Tuberculosis
Gonorrhoea
Pneumonia and bacterial meningitis
Diarrhoea: shigellosis
Hospital infections
WHO country data 2000-3
Community surveillance Resistensi dan Penggunaan antimikroba
Antimicrobial resistance
Cotrim 46-65%; Ampi 52-85%; Cipro 32-59%; Cefalex 16-50%
S.Pneumoniae & H.influenzae sputum di afrika Selatan
Cotrim > 50% (both organisms); Ampi >70% (H.influenzae)
Penggunaan antibiotika
Sekitar 50% pasien di India dan <25% di AfrikaSelatan menerima antibiotika
Penggunaan fluoroquinolones unutk common cold di India terutama di sektor private
Motivasi provider dan konsumen
Promosi obat yang tidak terkontrol dan alasan finasial
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Adverse drug events
Penyebab ke- 4-6 kematian di USA
Biaya yang dikeluarkan sekitar 30 ribu -130 juta US$ in the USA
4-6% kasus yang memerlukan perawatan di rumah sakit di USA & Australia
Sering ditemukan, penyebab kasus yang memerlukan biaya perawatan : pendarahan, cardiac arrhythmia, gangguan jiwa, diare, demam, hipotensi, itching, mual, rash, gangguan ginjal
White et al, Pharmacoeconomics, 1999, 15(5):445-458
*
Upaya mengatasi masalah
Banyak Faktor Yang Mempengaruhi Penggunaan Obat
Treatment Choices
Prior Knowledge
Strategi untuk memperbaiki
Use of Medicines
Educational Strategies
Training for Providers
Clinical supervision or consultation
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Impact of Patient-Provider Discussion Groups on Injection Use in Indonesian PHC Facilities
Intervention
Control
0
20
40
60
80
Pre
Post
Training for prescribers
The 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
Changes in selection, procurement, distribution to ensure availability of essential drugs
Essential Drug Lists, morbidity-based quantification, kit systems
Strategies aimed at prescribers
Dispensing strategies
*
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
RCT in Uganda of the effects of STGs, training and supervision on % of Px conforming to guidelines
Source: Kafuko et al, UNICEF, 1996.
Randomised group
14
21.4%
55.2%
+33.8%
Economic strategies:
Avoid perverse financial incentives
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
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Pre-post with control study of an economic intervention (user fees) on prescribing quality in Nepal
Holloway, Gautam & Reeves, HPP, 2001
Fees (complete drug courses)
2.9 2.9
Source: Scuzochukwu et al, HPP, 2002
*
Regulatory strategies
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
*
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Intervention impact: largest % change in any medicines use outcome measured in each study
Database on medicines use 2009
Intervention type
No. studies
Median impact
25,75th centiles
Printed materials
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Impact of multiple interventions on injection use in Indonesia
Source: Long-term impact of small group interventions, Santoso et al., 1996
Interactive group discussion (IGC group only)
Seminar (both groups)
What national policies do countries have to promote rational use?
Source: MOH Pharmaceutical policy surveys 2003 and 2007
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
For Iceland, total data (including hospitals) are used
Increase
Decrease
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
For Iceland, total data (including hospitals) are used
Co-ordination programs and national campaigns
Slide courtesy of Otto Cars, STRAMA, Sweden
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Why does irrational use continue?
Very few 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?
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
What are we spending to promote rational use of medicines ?
Global sales of medicines 2002-3 (IMS): US$ 867 billion
Drug promotion costs in USA 2002-3: US$ >30 billion
Global WHO expenditure in 2002-3: US$ 2.3 billion
Essential Medicines expenditure 2% (of 2.3 billion)
Essential Medicines expenditure on
WHO expenditure on promoting
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
2nd International Conference for Improving Use of Medicines, Chiang Mai, Thailand, 2004
472 participants from 70 countries
Recommendations for countries to:
Scale up successful interventions
http://www.icium.org
Health systems with no national programs:
No coordinated action
Health systems with national programs:
Coordinated action
Develop national plans of action
Situational analysis
Implement & evaluate national action plans using govt & local donor funds
WHO facilitating multi-stakeholder action in countries
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Global monitoring and identifying effective strategies to promote rational use of medicines
WHO/EMP databases on drug use and policy
quantitative data on medicines use and interventions to improve medicines use from 1990 to present day
data from MOHs on pharmaceutical policies every 4 years – 1999, 2003, 2007
ICIUM3 in 2011
3rd international conference on improving the use of medicines (ICIUM3)
Surveillance of antimicrobial use & resistance
method for community-based surveillance in poor settings
interventional approach for improving use in private sector
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Pembekalan MTP (STG) kepada staf Puskesmas mengurangi penggunaan antibiotika
Yudatiningsih, ICIUM, 2004
% patient receiving antibiotics
Standard Pengobatan
Tujuan pembahasan :
Pemahaman tahap pengembangan standard pengobatan
Menyiapkan pembuatan standard pengobatan
Pengantar
3. Dampak pedoman pengobatan
4. Pengembangan pedoman pengobatan
5. Penerapan pedoman pengobatan
Pedoman Pengobatan
Tatacara diagnosis
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Pedoman pengobatan harus mencakup tatacara diagnosis yang esensial
Health Problem =
symptom - “headache”
diagnosis - “malaria”
Pedoman Pengobatan dan Proses Terapi
Rx
Rx
Rx
Rx
Diagnosis
Advantages of Standard Treatments
Quality of care standard
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Supply Management Staff
Drug demand more predictable
Therapeutic integration of special programs
Advantages of Standard Treatments
Key Features
1. Simplicity
2. Credibility
5. Introduced in pre-service training
6. Dynamic—regular updates
7. Durable pocket manuals
Developing Standard Treatment Guidelines
1. Target priority conditions
3. Coordinate with special programs
4. Use fewest drugs necessary
5. Choose cost-effective treatments
7. Involve respected clinicians
8. Consider patient perspective
Approaches to Standard Treatment Guidelines
Individual
Selective
Comprehensive
Implementing Standard Treatments
1. Printed reference
2. Official launch
3. Initial training
4. Reinforcement training
Conclusion
Standard treatment guidelines can have considerable impact if they are developed and used in a sensible fashion
They can also be an expensive waste of effort
With standard treatment guidelines, the process of production and use is more important than the product
0102030405060
Tanzania
Angola
Senegal
0%10%20%30%40%50%60%
Eastern Caribean
Middle East & C. Asia (n=4-8)East Asia & Pacific (n=7-11)
South Asia (n=6-12)
0
10
20
30
40
50
60
70
80
Randomised
group
0%
20%
40%
60%
80%
100%
135791113151719212325
Months
UG doctors trained on EML/STGs
Obligatory CME for doctors
Antibiotic OTC non-availability
Drug use audit in last 2 years
% countries implementing policies
0
20
40
60
80
100
Agust-99Nop99Feb-00Mei00Agust-00Des00Mrt01Jun01.Sep01.Des01.Apr02.Jul02.Oct02.Jan03.Apr03.Aug03.
0
5
10
15
20
25
30
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
Percent change in antibiotic consumption,
out-patient care in 25 European countries 1997-2003
Data from ESAC