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Drug and Therapeutics Committee. Session 7A. Identifying Problems with Medicine Use: Indicator Studies. Describe how indicators can be used to identify medicine use problems

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Drug and Therapeutics Committee

Session 7A. Identifying Problems with

Medicine Use: Indicator Studies

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Describe how indicators can be used to identify medicine use problems

Perform a prescribing indicator study on a sample of prescriptions and explain how it can be used to identify medicine use problems


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WHO/INRUD indicators in primary health care

Prescribing indicators

Patient care indicators

Facility indicators

Hospital indicators



Outline—Part A

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Irrational medicine use is widespread and results in—

Poor patient outcome

High cost of inappropriate medicine use

Increased risk of ADRs

Emergence of antimicrobial resistance

Measuring medicine use problems is the first step to improving use


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Indicator study methods

Use data collected at the individual level—patient, health facility

Data insufficient to judge appropriateness of a medicine for a specific diagnosis

Aggregate data methods

Use routine data (e.g., stock records) not collected at the individual patient level

Give an overview of medicine use and can highlight problem areas

In-depth investigation of medicine use

Prescription audit, patient record review

Drug use evaluation (DUE)

Qualitative methods to understand causes of a medicine use problem

Methods to Investigate Medicine Use

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Measure specific aspects of medicine use and health provider activities in a hospital or health center

Provide information to health care managers concerning medicine use, prescribing habits, and important aspects of patient care to compare or monitor facilities over time

Indicators for Health Care Facilities (1)

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Characteristics of sound indicators


Easily generated and measured




Indicators for Health Care Facilities (2)

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Use of indicators

Determine where medicine use problems may exist—when an indicator study shows an extreme result, the DTC can investigate and, as necessary, take action to improve the situation.

Provide a monitoring mechanism

Motivate health care providers to improve and follow established standards

Indicators for Health Care Facilities (3)

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Developed by INRUD and WHO

Used for assessing health care and medicine use for primary health care (PHC) in dispensaries, clinics or hospitals

Prescribing indicators

Patient care Indicators

Facility indicators

Complementary medicine use indicators

WHO Indicators for PHC

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WHO/INRUD health facility prescribing indicators

Average number of medicines per encounter

% of medicines prescribed by generic name

% of encounters with an antibiotic prescribed

% of encounters with an injection prescribed

% of medicines prescribed which are from the essential medicines list or formulary list

Prescribing Indicators—PHC

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Prescription 1

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Prescription 2

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Prescription 3

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Prescription 4

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Prescription 5

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Prescription 6

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WHO/INRUD health facility patient care indicators

Average consultation time

Average dispensing times

% of medicines actually dispensed

% of medicines that are adequately labeled

% of patients who know how to take their medicines

Patient Care Indicators—PHC

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WHO/INRUD health facility indicators

Availability of essential medicine list or formulary

Availability of key set of indicator medicines

Availability of standard treatment guideline (STG)

Health Facility Indicators—PHC

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WHO/INRUD medicine use indicators with less standardization and less experience in actual use

% of patients treated without medicines

Average medicine costs per encounter

% of medicine cost spent on antibiotics

% of medicine cost spent on injections

% of prescriptions in accordance with STG

% of patients satisfied with care provided

% of facilities with access to impartial information

Complementary Indicators—PHC

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Determine objectives, priorities, and indicators

Determine study design according to objectives

Monitoring over time, comparing facilities

Cross-sectional survey, time series

Evaluating interventions

Randomized controlled trial, pre/post with control, time series

Define indicators and data collection procedures

Pilot-test procedures

Performing an Indicator Study (1)

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Train data collectors

Randomly select facilities (at least 20 if possible) in the region from which to collect data

Obtain approximately 30 medicine use encounters for each facility (100 if only one facility is chosen)

Analyze data

Provide results to DTC for evaluation and follow-up

Performing an Indicator Study (2)

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Results can be used as follows—

Describing current treatment practices

Comparing the performance of individual facilities or practitioners

Periodic monitoring and supervision of specific medicine use behaviors

Identifying potential medicine problems that affect patient care

Assessing the impact of an intervention

Results of Indicator Studies

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Percentage of Patients

Graphs of Indicator Data (1)Facility-Specific Antibiotic Use

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Graphs of Indicator Data (2)Facility-Specific Consultation Times

Average Time (minutes)

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Designed to evaluate and improve

antimicrobial use

Facility indicators (four indicators)

Existence of STG and a formulary with approved antimicrobials

Availability of a key set of antimicrobials

Average number of days that this key set of antimicrobials are out of stock over 12 months

Expenditure on antimicrobial medicines as a percentage of total hospital medicine costs

Hospital Antimicrobial Indicators (1)(Developed and being field-tested by MSH)

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Prescribing indicators (eight indicators)

% of hospitalizations with one or more antimicrobials prescribed

Average number of antimicrobial medicines prescribed per hospitalization with antimicrobials prescribed

% of antimicrobials prescribed consistent with formulary

Average cost of antimicrobials prescribed from hospitalizations with one or more antimicrobial prescribed

Hospital Antimicrobial Indicators (2)

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Prescribing indicators (continued)

Average duration of prescribed antimicrobial treatment

% of surgical patients who receive antimicrobial prophylaxis

% of pneumonia patients who are prescribed antimicrobials in accordance with STG

% of antimicrobials prescribed by generic name

Hospital Antimicrobial Indicators (3)

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Patient care indicators

% of doses of prescribed antimicrobial medicines actually administered

Average duration of stay of patients who receive antimicrobials

Supplemental indicator

Number of antimicrobial medicine sensitivity tests reported

Hospital Antimicrobial Indicators (4)

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Designed to evaluate and improve medicine use and health


Average number of days per hospital admission

Average number of medicines prescribed per hospital admission

% prescribed medicines consistent with hospital formulary list

Average medicine cost per inpatient day

% patients with morbidity due to a preventable ADR

% inpatient deaths due to a preventable ADR

% patients reporting adequate post-operative pain control

% surgical patients receiving appropriate antimicrobial prophylaxis

Average number of antimicrobial sensitivity tests per hospital admission

Hospital Indicators Developed and Used in Australia and Zimbabwe

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Activity 1

Calculating prescribing indicators from prescription records

Activity 2

Calculating patient care indicators from observing role-play consultations

Activities 1 and 2

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A major function of a DTC is to identify medicine use problems and to implement corrective measures

Performing an indicator study is useful method to—

Identify medicine use problems at the individual patient level

Monitor medicine use by prescribers

Evaluate the impact of interventions


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