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Rational prescription. C H Chen Nov., 2001. Mr. Wong, 65 years old, attended for follow up . Ex-smoker, non drinker Come for medications 2-monthly as usual Good tolerance to med. Apart from on and off dizziness, but no history of syncope Problem lists : HT, IHD, AF, Dizziness.

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rational prescription

Rational prescription

C H Chen

Nov., 2001

mr wong 65 years old attended for follow up
Mr. Wong, 65 years old, attended for follow up

Ex-smoker, non drinker

Come for medications 2-monthly as usual

Good tolerance to med. Apart from on and off dizziness, but no history of syncope

Problem lists : HT, IHD, AF, Dizziness

con t case 1
Con’t ( case 1 )
  • Drug lists ( total 8 weeks of med.)
  • isordil 10mg tds po
  • Digoxin 0.25mg qd po
  • Adalat retard 40mg bd po
  • Natrilix 2.5mg om po
  • Stemetil 1 tab tds po prn
  • Panadol 500mg qid po prn
what will you do case 1
What will you do ? (case 1 )
  • Continue current regime for 8 weeks more ?
  • Any things do you want to know ?
case 1
Case 1
  • BP this time > 102/78
  • Pulse 68 regular
  • Physical exam revealed no sign of acute heart failure, but mild pitting ankle edema only
  • No evidence of GIB, no pallor
  • HS dual , no definite murmur heard
  • Clinically not in distress
case 16
Case 1
  • Previous BP : range from 98 to 180 systolic and 60 to 100 diastolic
  • No ECG available in the old files
  • Digoxin and isordil was prescribed by one of his private physician previously as he was told that he got IHD and arrthymia.
  • Latest elecrolyte in Sept., 1999 > K 3.3 with normal creatinine, corresponding notes reviewed encourage fruit intake.
discussion case 1
Discussion (Case 1 )
  • Blood pressure control
  • Diagnosis of AF and IHD
  • Dizziness
good prescribing
Good prescribing
  • What do patients want and need?
    • Advice
    • Cure: symptom relief
    • Prognosis
    • Certificates
4 aims to achieve for prescribers
4 aims to achieve for prescribers
  • Maximize effectiveness
  • Minimize risks
  • Minimize costs
  • Respect the patient’s choice
maximize effectiveness
Maximize effectiveness
  • Pharmacological manipulation of the body to improve or remove a condition
  • Use some objective, numerical measurement to assess effect ( eg., BP measurement for BP control )
minimize risks
Minimize risks
  • Reduce probability of an untoward happening resulting from drug treatment
  • Include transient, minor side effect and adverse drug reaction
respect the patient s choice
Respect the patient’s choice
  • Ethical/practical choice behind patient
  • Informed choice
  • Ironically, complying with patient’s choice of treatment means poor prescriber
  • Patients are more satisfied if doctors listen to their views, negotiating the details of drug treatment may improves compliance
conflicts
conflicts
  • Effectiveness and risks
  • Cost effectiveness and patient’s choice
rational prescribing
Rational prescribing
  • Correct diagnosis
  • Appropriate drug, dose, route and duration
  • Simple regimen
  • Avoid drugs if therapeutic advantage not supported by independent evidence
  • Avoid drugs with poor risk/benefit ratios
  • Review regularly and terminate if no longer needed
the most powerful drug doctor
The most powerful drug: doctor
  • Understanding
  • Explanation
  • Reassurance and prognosis
  • Placebo effect
adverse drug reaction adr
Adverse drug reaction (ADR)
  • Generally under-reported
  • A threat to patient’s health and quality of care
  • Generates significant expenses
slide17
ADR
  • Unwanted or unintended effects of a medicine which occur during its proper use
  • Extrinsic and intrinsic factors
slide18
Extrinsic
  • > Errors in manufacturing, supplying, prescribling, giving or taking medicine
  • Intrinsic
  • > inherent properties of the medicine itself may cause unwanted effects
medication related problems
Medication related problems
  • Prescription cascade
    • Misinterpretation of an adverse drug event as another medical condition

Prescription of additional medications

  • Non-adherence
    • poor therapeutic outcomes

higher dosages or more potent therapies

slide20
ADR
  • Survey done at one of the university hospital in Switzerland
  • 6 months of surveying to all primary admissions to medical emergency department
  • Total about 7% of admissions related to ADR
  • Most common being of GIB, follow by febrile neutropenia
  • Anti-cancer drugs in 22.7% of cases
slide21
ADR

Anticoagulants, analgesic and non-steroidal anti-inflammatory drugs in 8 % of cases each

case 2
Case 2
  • Mr. Chan, 60 years old, attended for follow up as usual
  • Chronic smoker, social drinker
  • Presented with exertional dysneoa and wheezing
  • Associated with chronic dry cough
  • No recent hospitalization
case 223
Case 2
  • Claimed good drug compliance with regular usage of puffer
  • ET > level ground only
  • Problem list : COAD, HT
drugs list
Drugs list
  • Ventolin puff 2 puffs qid prn
  • Atrovent puff 2 puffs qid prn
  • Theodur 100mg tds po
  • Bricanyl durule 7.5mg bd po
  • Ventolin 4mg tds po
  • Inderal 40mg tds po
  • Betaloc 50mg bd po
case 225
Case 2
  • Clinically not in distress with occ. Coughing only
  • Chest occ. Rhonchi with poor expansion of lung and hence poor air entry
  • BP 155/90, P 66 with occ. Ectopic heart beat
  • PFR 130/150
discussion case 2
Discussion (case 2 )
  • Coad control
  • BP control
  • Side effect profiles
  • Alternative choice of agents
  • Treatment other than drugs
are hong kong doctors over prescribing
Are Hong Kong doctors over-prescribing?
  • Expenditure on drugs per capita in HK 2-3X that of UK
  • Items prescribed:
    • HK Government OPD:just under 3
    • UK:just over 1
slide28
Regional/international standards (national library of med. )
  • 2 for the average of the drug
  • 17% for injection
  • 50% for antibiotics
a pill for every ill
A pill for every ill??

Random sample of 1068 HK Chinese interviewed by telephone done in 1995

results
results
  • 40% thought illnesses always needed drug treatment
  • 76% expected prescription
  • Almost 100% got prescription in their last consultation
  • 85% prescription > 3 or more drugs
  • < 50% finished all the medication
result
result
  • Younger age and higher education associated with less likelihood of expecting prescription
conclusion
conclusion
  • Chinese do not expect a pill for every ill but doctors prescribe in nearly 100% of consultations
  • Doctors created high expectation for a prescription in every consultation through their own prescribing habit
bmj vol 315 6 dec 97

The influence of patients’ hopes of receiving a prescription on doctors’ perceptions and the decision to prescribe: a questionnaire survey

BMJ Vol 315 6 Dec 97

design
Design
  • Questionnaires to patients waiting to see GP and to doctors immediately after their consultations
subjects
Subjects
  • 544 unselected patients consulting 15 GP
results36
Results
  • 67% patient hope for prescription
  • Doctors perceived 56% patients wanted prescriptions
  • 59% doctors prescribed
  • 25% of patients hoped for a prescription did not receive one
conclusion37
Conclusion
  • Decision to prescribe was closely related to actual and perceived expectations, the latter being more significant
over prescription of antibiotics in primary care
Over-prescription of antibiotics in primary care
  • 20-50% believed to be unnecessary
factors responsible for inappropriate antibiotic use
Factors responsible for inappropriate antibiotic use
  • Patient factors
    • Misconception about what antibiotics do
    • Misconception about healing power of antibiotics
factors responsible for inappropriate antibiotic use40
Factors responsible for inappropriate antibiotic use
  • Physician factors
    • Real or perceived patient pressure
    • Economic concern for self e.g. loss of clients
    • Physician fallibility:inadequate knowledge
    • Uncertainty of the diagnosis
    • Easing himself ( something done )
factors responsible for inappropriate antibiotic use41
Factors responsible for inappropriate antibiotic use
  • Other factors
    • Cost saving pressures to substitute therapy for diagnostic test
    • Reduce appointment time per patient
    • Misleading advertisement
    • Cultural factor
final comments
Final comments
  • Do he needs prescriptions
  • Is it indicated
  • Adverse drug reactions
  • Risk and benefits ratio
  • Polypharmacy
  • Always review drug lists
review drug regimen
Review drug regimen
  • All new medication should started as a trial
  • Substitute instead of adding on new medications
  • Look for signs of adverse reactions and drug induced problems
improving rational prescription
Improving rational prescription
  • Physician training

>more training to communicate with patients about risk and benefit

>training in decision analysis

>undergraduate/continuing education in therapeutics

improving rational prescription45
Improving rational prescription
  • Patient education
  • Public need to be educated about the risks and benefits of medical interventions

Government

Pharmacist

media

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