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ASSESSING THE EFFECT OF TWO POLICY INTERVENTIONS ON TREATMENT COSTS AND DRUG USE PATTERNS IN A PRIVATE SELF FUNDING HEALTHCARE INSTITUTION; THE CASE OF GENERIC PRESCRIBING AND GENERIC SUBSTITUTION
Ojoo MMA1, Waning B2, Maina M3
1-Gertrude’s Garden Children’s Hospital, Kenya, 2-Boston University, USA, Kenyatta National Hospital, KenyaOVERALL AIMThis study aims to determine whether well-proven interventions aimed at improving drug use yield positive outcomes in private
sector healthcare institutions. These interventions are; prescribing by use of generic names and Generic substitution at pharmacy level
SPECIFIC OBJECTIVES1. To implement two specific policy interventions on generic prescribing and generic substitution (dispensing)2. To measure the effect of each of these policies on drug use patterns and treatment costs3. To compare and contrast the two policies SIGNIFICANCE OF THE STUDYThis study will provide data that can be used by policy makers in private healthcare institution in similar settings to improve drug
useSTUDY DESIGNThis is a before and after intervention type study covering a total of 2 ½ years with an equivalent control group1. Generic prescribing policy: August 2001- July 2002 2. Generic substitution Policy: February 2002 and December 2003 Descriptive and inferential statistical analysis will be used. Logistical regression analysis will be done to control for confoundersTHE SETTINGA private, not-for-profit 80-bed hospital in the suburbs of Nairobi treating both outpatients and in patients. The hospital’s main
source of income is fees paid by patients for services rendered. 10% of income is spent on giving free treatment to needy patients who cannot afford to pay for services. The control private health facility
INTERVENTIONS1. A policy requiring all prescribers in the out patient department to use the recommended International Nonproprietary Names
(rINN) or British Approved Names (BAN) when prescribing medications. Using a “brand name” of a cost effective multisource product currently in stock is considered acceptable. This was implemented in August 2001
2. A Policy permitting the Pharmacy to dispense the most cost effective Multisource medicine irrespective of what name of the medicine the prescriber has used on the prescription. This was implemented in August 2002
STUDY POPULATIONRandom sampling of 100 cases each per month for children less than 6 years of age for a diagnosis of Acute Respiratory Infection
and Diarrhoea will be entered into the predesigned forms. Similar data will be collected from the control Healthcare institution (AAR)
OUTCOME MEASURES% number of drugs prescribed as generic% number of drugs prescribed as antibiotic% reduction in cost per prescription% injection use in outpatient set upNote: Since the study population is derived from those with specific disease states, it is possible to look at disease specific outcomes
as well.RESULTS AND CONCLUSIONStudy still in progress Funding Sources: ARCH project, USA
THE SETTING-THE SETTING-Gertrude’s Garden Gertrude’s Garden Children’s HospitalChildren’s Hospital
• OPD- A&E and General paed Practice• Average 4500 patients seen in OPD per month• Ave 200 patients admitted from OPD per month• 17 Doctors (14 general, 3 paediatricians) in OPD• 90% of patients pay, 10% treated free • 2 Pharmacists , 8 pharmacy Technicians• 84 In Patient beds, 63-75% occupancy rate (2003)
THE INTERVENTIONSPROBLEM STATEMENT
Can RDU intervention strategies be implemented successfully in private sector healthcare in a developing country?
INTERVENTION STRATEGIES
1. Policy Interventions
2. Information & clinical Decision Support
3. Education & training
4. Audit & feedback
1: POLICY INTERVENTIONS• Generic prescribing & substitution• Drug stocking and purchasing policy• Antibiotic use restrictions in OPD• Regulation of Medical representatives
2: INFORMATION & DECISION SUPPORT• OPD drug list with drug costs indicated• Drug info service-Query answer & Newsletters• Formulary New & Standard treatment guidelines New
• Patient information leaflets-“ a guide to generics”• Articles in GGCH newsletter for the public• Paediatricians in OPD for decision support• Doctors’ Resource room
3: EDUCATION &TRAINING4: AUDIT & FEEDBACK
3.Education & Training
• Journal club• CMEs based on
need• Internships locally
and abroad• PALS, HIV/AIDs,
UTI, URTI, IMCI
4. Audit & Feedback• DURs & feedback• PMR audit &
feedback• Focus groups• Opinion leaders• Incentives for
change (Resource allocation)
METHODOLOGYMETHODOLOGY
INRUD/WHO DUIs at baseline & every 3 months till Dec 2003
• Systematic sampling (Doctor, Day, wk/end)
• 130-170 Pxrs per month
Parameter Rx PMR Threshold
Av No. Drugs 3.32 3.1 2.2
% Generics 6 4 100
% Antibiotics 82.6 83.3 60
% Injection 17.4 19.3 <10
Baseline data Sept-Baseline data Sept-Nov 01Nov 01
RESULTS: TABLE 1RESULTS: TABLE 1Month Av Drug % Gen % A/B % Inj
Sept-Nov 01 3.32 4.0 82.6 17.4
Dec01-Feb02 2.92 13.0 73.0 20.0
Mar-May 02 2.66 10.0 72.0 17.0
Jul-Sept 02 2.5 16.0 67.0 16.0
Oct-Dec 02 2.3 15.3 73.0 6.7
Jan-Mar 03 2.29 13.0 70.0 11.0
Apr-Jun 03 2.25 9.65 52.5 6.5
Jul-Sept 03 2.34 20.36 40.0 7.4
Oct-Dec 03 2.32 23.36 41.5 7.3
Results 1: Ave No. of Drugs Results 1: Ave No. of Drugs per Rxper Rx
Average number of Drugs per prescription
1.5
1.7
1.9
2.1
2.3
2.5
2.7
2.9
3.1
3.3
3.5
Sept-Nov 01 Dec01-Feb02
Mar-May 02 July-Sept 02 Oct-Dec 02 Jan-Mar 03 Apr-Jun 03 Jul-Sept 03 Oct-Dec 03
Months
Nu
mb
er
Ave Drugs
Linear (Ave Drugs)
Results 2: % A/B, % Drugs prescribed as generic,% Inj
Prescribing Indicators Sept 01-Dec 03
0
10
20
30
40
50
60
70
80
90
Sept-Nov01
Dec01-Feb02
Mar-May02
July-Sept02
Oct-Dec 02 Jan-Mar 03 Apr-Jun 03 Jul-Sept 03 Oct-Dec 03
Months
%
% Gen% A/B% InjLinear (% A/B)Linear (% Gen)Linear (% Inj)
Results 3: Av Cost per Results 3: Av Cost per PrescriptionPrescription
Monthly sales Vs Av cost per Rx Aug 01-Dec 03
1,000
1,100
1,200
1,300
1,400
1,500
1,600
1,700
1,800
Aug-0
1
Oct
-01
Dec-0
1
Feb-0
2
Apr-0
2
Jun-
02
Aug-0
2
Oct
-02
Dec-0
2
Feb-0
3
Apr-0
3
Jun-
03
Aug-0
3
Oct
-03
Dec-0
3
Va
lue
in K
sh
Av cost Per Rx per Month
Changes in Brand drug Changes in Brand drug sales-Ceftriaxone & sales-Ceftriaxone &
CoAmoxiclavCoAmoxiclavBranded Drug Changes
0
500
1,000
1,500
2,000
2,500
3,000
3,500
Sales Jun Sales Jul Sales AUg Sales Sept
Th
ou
san
ds
Claritine
Amikin
Mucosolvon
Zinacef
Cefzil
Rocephine
Augmentin
KEY LESSONS LEARNTINTERVENTION RELATEDInterventions a success story
BUT……….• “Loss of drug profits” panic!• Old habits die hard!• Turnover of Prescribers• Poor perception of generic
drugs• Med Reps persist Outside
GGCHSTUDY RELATED• Data sources primarily Manual• Private Hospitals reluctant to
provide “control” data
IMPLICATIONSImmediateWho pays for the
improvements?Longterm-Interventions
must be ongoing -HMO influence;
Formularies & STGs to be more in use
Future research agenda?– Impact of policy
interventions on health outcomes
Selected ReferencesSelected References• WHO/INRUD; How to Investigate drug use in Health
facilities • Limpanasithukul Et Al; Effects of managerial intervention
(Formulary & generic dispensing) on drug utilization pattern at King Chulalongkorn Memorial hospital- Journal of the Medical Ass of Thailand June 2002
• Thompson et Al; Audit & feedback;effects on professional practice & healthcare outcomes-Cochrane collaboration, Nov 1997
• Dartnell JGA; Understanding, Influencing and evaluating drug use, 2001 (Therapeutic Guidelines Ltd,Australia)
• Laing RO & Ross-Degnan D; Ten recommendations to improve use of medicines in developing countries-Health Policy & Planning 2001