Rationality of drug prescriptions in rural health centres in Burkina Faso.
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The objective of this study is to investigate the quality of drug prescriptions in nine health centres of three districts in rural Burkina Faso. 313 outpatient consultations were studied by methods of guided observation. Additionally interviews were held with the health care workers involved in the study. A total of 793 drugs prescribed by 15 health care workers during the observation period and 2815 prescribed drugs copied from the patient register were analyzed. An average of 2.3 drugs were prescribed per visit. 88.0% of the prescribed drugs were on the essential drug list. 88.4% were indicated according to the national treatment guidelines. 79.4% had a correct dosage. The study revealed serious deficiencies in drug prescribing that could not be detected by assessing selected quantitative drug-use indicators as recommended by the WHO. In two-thirds of the cases the patients received no information on how long the drug had to be taken. Errors in dosage occurred significantly more often in children under 5 years. The combined analysis of choice and dosage of drugs showed that 59.3% of all the patients received a correct prescription. Seven out of 21 pregnant women received drugs contraindicated in pregnancy. We conclude that assessment of quantitative drug-use indicators alone does not suffice in identifying specific needs for improvement in treatment quality. We recommend that prescribing for children under 5 and for pregnant women should be targeted in future interventions and that the lay-out, content and distribution of treatment guidelines must be improved. (+info)
GPs' treatment of uncomplicated urinary tract infections--a clinical judgement analysis in four European countries. DEP group. Drug Education Project.
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BACKGROUND: Non-adherence to recommendations for treatment of uncomplicated urinary tract infections (UTI) is common, but the reasons are not sufficiently understood. OBJECTIVES: We aimed to assess and compare the influence of specific patient characteristics on GPs' treatment decisions for UTI in four European countries. METHODS: GPs in The Netherlands, Norway, Sweden and Germany were presented 18-26 case vignettes of UTI. Linear regression models were used to determine which patient characteristics predicted non-optimal decisions. RESULTS: Adherence to national recommendations varied both within and between countries, but there were remarkable similarities in the case characteristics predicting non-optimal decisions: a history of UTI and the patient's age were strongly related to prescription of second-choice antibiotics and longer treatment courses. CONCLUSION: In all countries many GPs were reluctant to follow the recommendations in UTI cases that they might perceive as being more complicated. (+info)
The association between physician reimbursement in the US and use of hematopoietic colony stimulating factors as adjunct therapy for older patients with acute myeloid leukemia: results from the 1997 American Society of Clinical Oncology survey. Health Services Research Committee of the American Society of Clinical Oncology.
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BACKGROUND/OBJECTIVES: Financial considerations play an important role in the delivery of medical care in the US. In 1996, revised guidelines from the American Society of Clinical Oncology (ASCO) indicated that granulocyte colony-stimulating factor (G-CSF) and granulocyte macrophage-colony stimulating factor (GM-CSF) were unlikely to be harmful for older acute myeloid leukemia (AML) patients and suggested that physicians could consider their use in this setting. In 1997, the ASCO health services research committee evaluated whether physician reimbursement was a primary determinant in the decision to use G-CSF and GM-CSF in this clinical situation. PATIENTS AND METHODS: A questionnaire describing clinical scenarios for a 67-year-old man with newly diagnosed de novo AML was mailed to 1500 ASCO members who practiced medical oncology and hematology. Physicians were queried about their preferences for adjunctive CSF use following induction and consolidation chemotherapy. RESULTS: Of 1020 potentially eligible respondents, returned surveys were received from 672. Following induction chemotherapy, support for CSF use was 40%, similar in magnitude for that for non-use of these agents. The most important determinant of support for CSF use was being in a fee-for-service practice (P < 0.001). CONCLUSIONS: Physicians in the US are mixed in their support for CSFs for older AML patients. Support was high in settings where CSF use was accompanied by financial profit to the physician practice, and support was low otherwise. (+info)
Undertreatment of hyperlipidemia in the secondary prevention of coronary artery disease.
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OBJECTIVES: To determine adherence to national guidelines for the secondary prevention of coronary artery disease (CAD) using lipid-lowering drugs (LLDs), by studying the rate of use of LLDs, predictors of use, and the rate of achieving lipid goals, among eligible patients recently hospitalized with acute myocardial infarction. DESIGN: Cross-sectional analysis of 2,938 medical records, collected from July 1995 to May 1996. SETTING: Thirty-seven community-based hospitals in Minnesota. PATIENTS: The 622 patients had previously established CAD and hyperlipidemia (total cholesterol> 200 mg/dL or currently using LLDs), and were eligible for LLDs according to the National Cholesterol Education Program II (NCEP II) Guidelines. MEASUREMENTS: The use of LLDs in eligible patients (primary outcome) and successful achievement of NCEP II goals (total cholesterol <160 mg/dL) among treated patients (secondary outcome). MAIN RESULTS: Only 230 (37%) of 622 eligible patients received LLDs. In multivariate logistic regression, factors independently related to LLD use included age greater than 74 years (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.35, 0.88) and severe comorbidity (AOR 0.60; 95% CI 0.38, 0.95), managed care enrollee (AOR 1.56; 95% CI 1.02, 2.39), past smoker (AOR 1.72; 95% CI 0.98, 3.01), prior revascularization (AOR 2.31; 95% CI 1.51, 3.53), and the use of aspirin (AOR 1.59; 95% CI 1.07, 2.38) or >/=4 medications (AOR 2.89; 95% CI 2.19, 3.84). Of the treated patients who had lipid levels measured (n = 149), 15% achieved the recommended goal of a total cholesterol below 160 mg/dL. Of the untreated patients (n = 392), 89% were discharged from hospital without a LLD prescription. CONCLUSIONS: Lipid-lowering drugs, although proven effective for the secondary prevention of CAD, were used by only one third of eligible patients. Among patients receiving LLDs, few achieved recommended lipid goals. Directed quality improvement interventions, such as starting LLDs during hospitalization, may have the potential to substantially reduce CAD morbidity and mortality in this vulnerable population. (+info)
Physicians' perceptions about managed care restrictions on antibiotic prescribing.
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The purpose of this study was to compare physicians' perceptions about managed care restrictions on drug prescribing with objective measures of the restrictions' effects. When asked a general question, 17 emergency medicine physicians in one urban, university hospital answered that they had to prescribe an antibiotic that was not their first choice because of managed care restrictions 32% of the time. The actual frequency of prescribing other than first-choice antibiotics, which was determined by asking the same physicians about the prescription of specific antibiotics for specific patients seen recently in the emergency department, was 6% ( p <.0001). We conclude that emergency medicine physicians treating patients in one managed care system significantly overestimated the restrictions imposed by managed care formularies on their antibiotic prescribing practices. Additional studies are warranted to measure the extent of this bias. (+info)
Changing pattern of end-stage renal disease in central and eastern Europe.
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BACKGROUND: The epidemiology of end-stage renal disease (ESRD) is changing all over the world. Particularly dramatic changes of the epidemiology of ESRD have occurred in central and eastern Europe (CEE). The aim of the present study was (i) to document the further expansion of renal replacement therapy (RRT) noted in recent years in CEE and (ii) to analyse in some detail treatment modalities and underlying renal conditions. METHODS: Three independent surveys were performed in 1995, 1997 and 1998. Fifteen CEE countries participated. The data were mainly obtained from national registries which are based on centre and patient questionnaires. RESULTS: The data collected from 15 CEE countries document further expansion of RRT in this region. The report includes data on the availability of RRT in Byelorussia, Estonia, and Russia which have become available for the first time. The epidemiology of dialysed patients has changed remarkably. In the majority of countries the number of diabetic patients has increased, most dramatically so in the Czech Republic (31% of all dialysed patients), in the majority of the other countries 10-14%. The number of ESRD patients with the diagnosis of hypertensive nephropathy has also increased and this was accompanied by an increase in proportion of elderly (>65 years) patients, i.e. 46% in the Czech Republic and 12-25% in most other countries. CONCLUSION: Dramatic changes of the availability of RRT treatment have occurred in central and eastern Europe. The proportion of diabetic nephropathy and elderly patients has risen. Large differences in RRT exist between individual CEE countries and this appears mainly dependent on the level of economic development. (+info)
The public health implications of the 1995 'pill scare'.
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The warning issued by the UK Committee on Safety Medicines in October 1995, followed by their 'Dear Doctor' letter of October 18, 1995, that oral contraceptive pills containing gestodene or desogestrel were associated with a higher risk of venous thromboembolism has had a negative impact on public heath. A significant number of women either switched brands or ceased contraception altogether following the announcement. National data suggest a strong association between the pill scare and a substantial increase in the number of unintended pregnancies, particularly significant among younger women, with use of oral contraception falling from 40 to 27% of under 16s between 1995-1996 and 1996-1997. The resulting cost of the increase in births and abortions to the National Health Service has been estimated at about Pound Sterling 21 million for maternity care and from Pound Sterling 46 million for abortion provision. The level of risk should, in future, be more carefully assessed and advice more carefully presented in the interests of public health. (+info)
Antibiotic use in Dutch hospitals 1991-1996.
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The use of antibiotics in Dutch hospitals between 1991 and 1996 was investigated. A total of 54 hospitals responded to the enquiry, representing over 70% of all hospital beds in The Netherlands. The use of antibiotics in Dutch hospitals, expressed as defined daily doses (DDD) per hundred bed days, gradually increased from 37.2 DDD per 100 bed days in 1991 to 42.5 DDD per 100 bed days in 1996. The antibiotic that showed the largest increase in use was co-amoxiclav. Its use increased more than three-fold from 3.93 DDD per 100 bed days in 1991 to 12.5 DDD per 100 bed days in 1996. The increase in use of co-amoxiclav exceeded the increase in total antibiotic consumption. The use of cephalosporins remained fairly constant during the study period, but there were changes in the relative use of the different cephalosporin groups. The use of earlier cephalosporins gradually decreased, whereas the use of the more recently developed cephalosporins increased between 1991 and 1996. Ciprofloxacin and norfloxacin were the most commonly used fluoroquinolones throughout the study period. The use of ofloxacin increased significantly between 1991 and 1996, approaching the levels of use of ciprofloxacin and norfloxacin. There may be complex reasons for the increases, which need further analysis, but they mirror those few data available from elsewhere in the world. Possible explanations include more intensive treatment to expedite patient discharges, sicker patients with more serious infections and more resistant organisms. (+info)