Introducing management principles into the supply and distribution of medicines in Tunisia.
(25/2434)
A number of strategies have been proposed by various organizations and governments for rationalizing the use of drugs in developing countries. Such strategies include the use of essential drug lists, generic prescribing, and training in rational prescribing. None of these require doctors to become actively involved in the management of the drug supply to their health centres. In 1997, in the Kasserine region of Tunisia, the regional health authorities piloted a radically different strategy. This involved the theoretical allocation of a proportion of the regional drug budget to each district and subsequently to each health centre according to estimated demand. Medical staff were given responsibility for the management of these budgets, allowing them to control the nature and quantities of drugs supplied to the health centres in which they worked. This paper outlines the process by which this strategy was successfully implemented in the Foussana district of Kasserine region, and explores the problems encountered. It describes now the theoretical budgets were allocated to each district and how the costs of individual drugs and the consumption of drugs in the previous year were calculated. It then continues by giving an account of the training of the staff of the health centres, the preparation of a drug order form and the method of allocation of the theoretical budgets to each of the health centres. The results give an account of how the prescribing habits of doctors were changed as a result of the strategy, in order to take into account the costs of the drugs that they prescribed. They show how the health centres were able to manage their budgets, spending overall 99.8% of the budget allocated to the district. They outline some of the changes in the prescribing habits that took place, demonstrating a greater use of appropriate and essential drugs. The paper concludes that doctors and paramedical staff can successfully manage a theoretical drug budget, and that their involvement in this process leads to more rational prescribing within existing resource constraints. This has a consequence of benefiting patients, satisfying doctors and pleasing administrators. (+info)
Antibiotic prescribing for Canadian preschool children: evidence of overprescribing for viral respiratory infections.
(26/2434)
Antibiotic resistance is associated with prior receipt of antibiotics. An analysis of linked computerized databases for physician visits and antibiotic prescriptions was used to examine antibiotic prescribing for different respiratory infections in preschool children in Canada. In 1995, 64% of 61,165 children aged <5 years made 140,892 visits (mean, 3.6 visits per child) for respiratory infections; 74% of children who made visits received antibiotic prescriptions. Antibiotics were prescribed to 49% of children with upper respiratory tract infection, 18% with nasopharyngitis, 78% with pharyngitis or tonsillitis, 32% with serous otitis media, 80% with acute otitis media, 61% with sinusitis, 44% with acute laryngitis or tracheitis, and 24% with influenza. Acute otitis media accounted for 33% of all visits and 39% of all antibiotic prescriptions. The estimated Canadian-dollar cost of overprescribing was $423,693, or 49% of the total cost of antibiotics ($859,893) used in this group. This population-based study confirms antibiotic overprescribing in Canada. (+info)
Effects of perceived patient demand on prescribing anti-infective drugs.
(27/2434)
BACKGROUND: Although patient demand is frequently cited by physicians as a reason for inappropriate prescribing, the phenomenon has not been adequately studied. The objectives of this study were to determine the prevalence of perceived patient demand in physician-patient encounters; to identify characteristics of the patient, physician and prescribing situation that are associated with perceived demand; and to determine the influence of perceived demand on physicians' prescribing behaviour. METHODS: An observational study using 2 survey approaches was conducted in February and March 1996. Over a 2-day period 20 family physicians in the Toronto area completed a brief questionnaire for each patient encounter related to suspected infectious disease. Physicians were later asked in an interview to select and describe 1 or 2 incidents from these encounters during which perceived patient demand influenced their prescribing (critical incident technique). RESULTS: Perceived patient demand was reported in 124 (48%) of the 260 physician-patient encounters; however, in almost 80% of these encounters physicians did not think that the demand had much influence on their decision to prescribe an anti-infective. When clinical need was uncertain, 28 (82%) of 34 patients seeking an anti-infective were prescribed one, and physicians reported that they were influenced either "moderately" or "quite a bit" by perceived patient demand in over 50% of these cases. Of the 35 critical prescribing incidents identified during the interviews, anti-infectives were prescribed in 17 (49%); the reasons for prescribing in these situations were categorized. INTERPRETATION: This study provides preliminary data on the prevalence and influence of perceived patient demand in prescribing anti-infectives. Patient demand had more influence on prescribing when physicians were uncertain of the need for an anti-infective. (+info)
Prescribing psychotropic medication for elderly patients: some physicians' perspectives.
(28/2434)
BACKGROUND: The inappropriate use of psychotropic medication is widespread and has potential consequences for the autonomy of elderly people. This study explored physicians' perceptions and attitudes and the decision-making process associated with prescribing psychotropic medications for elderly patients. METHODS: In this qualitative study conducted between February and April 1996, 9 of 12 physicians who offered consultation services for elderly people in private apartment buildings in a suburban region of Montreal were interviewed. The transcripts of the interviews were analysed quantitatively using an iterative process. The authors assessed the physicians' perceptions of the elderly patient population, the decision-making process leading to the prescription of psychotropic medication and the nature of follow-up. RESULTS: All of the physicians interviewed perceived the aging process as a negative experience and stated that the long-term use of psychotropic medication is justified by the distress of their aging patients and the few negative side effects that are noticed. Most said that, when they re-prescribe, they see their role as a "gatekeeper" to monitor and control the type and quantity of medication prescribed. Most physicians felt that the solutions to the inappropriate prescribing of psychotropic medication were beyond the scope of the individual physician. INTERPRETATION: Physicians interviewed in this study had a patient-centered perspective. From a public health viewpoint this calls for an innovative approach to involve physicians in a multidisciplinary intervention strategy to examine the inappropriate use of psychotropic medication among elderly patients. (+info)
GPs' perceptions of patient influence on prescribing.
(29/2434)
BACKGROUND: Controlling prescribing costs is an issue of concern to many GPs. OBJECTIVE AND METHODS: This paper is based on interviews with 21 GPs in which they were asked about influences on prescribing budgets. RESULTS: The results presented relate specifically to GPs' perceptions of the influence of patients on prescribing. Perceptions of patient demand were described both in terms of a general demand and demand by patients with specific health beliefs or particular social characteristics. Generally, GPs reported that decisions to prescribe were informed by a concern to maintain a good relationship with their patients, and not to risk the relationship by not prescribing when they believed a prescription was expected. CONCLUSIONS: Although information was available about whether practices had a 'high' or 'low' budget, and whether they were under- or overspent, there did not appear to be any relationship between GPs' beliefs that patient expectations affected their prescribing and whether they were under or over budget. This paper suggests that patient demand for prescriptions may not only be overestimated but also perpetuated by GPs' belief in its existence and a wish to maintain a good doctor-patient relationship. (+info)
'Brown bag' medication reviews as a means of optimizing patients' use of medication and of identifying potential clinical problems.
(30/2434)
BACKGROUND: 'Brown bag' medication reviews carried out by community pharmacists collaborating with GPs have become established, in the USA and elsewhere, as an effective means of helping primary care patients to derive maximum benefit from their medicines, of identifying medication-related problems and of reducing wastage of medicines. OBJECTIVE: We aimed to determine whether 'brown bag' medication review could be used successfully in the UK, and particularly whether it represents an efficient and potentially cost-effective means of identifying medication problems. METHOD: 'Brown bag' medication reviews were carried out on 205 volunteer patients in 23 pharmacies in south-east London. Pharmacists' interventions to improve patients' knowledge and usage of their medicines were analysed. Potential clinical problems identified by pharmacists were analysed in order to identify the drug groups most likely to cause problems. RESULTS: Interventions were made in 87% of reviews; interventions to improve patients' knowledge of the purpose and correct usage of their drugs were made in 65% of reviews. In 12% of reviews, problems were identified that could potentially result in a hospital admission, and the potential for an improved outcome for the patient if drug therapy was changed was identified in a further 34% of cases. Beta-blockers, NSAIDs and verapamil were identified as being associated with potential problems of the highest clinical significance. Patients taking psychoactive medication were at greatest risk of a medication-related problem from any cause. CONCLUSION: Pharmacists could contribute to patients' welfare and reduce health care costs by carrying out 'brown bag' medication reviews on behalf of GPs. (+info)
Reference-based pricing of prescription drugs: exploring the equivalence of angiotensin-converting-enzyme inhibitors.
(31/2434)
BACKGROUND: Reference-based pricing is a cost-containment policy applied to prescription drugs that are in the same class and deemed to be therapeutically equivalent. Recent reference-based pricing measures have targeted several drug classes, including angiotensin-converting-enzyme (ACE) inhibitors. The objective of this study was to assess whether patients treated for hypertension with various ACE inhibitors differed in their utilization of health care services and hence, whether the various ACE inhibitors should be considered therapeutically equivalent. METHODS: A retrospective cohort was formed from 4709 Saskatchewan residents aged 40-79 years who initiated treatment for hypertension with 1 of the 3 most frequently prescribed ACE inhibitors (captopril, enalapril or lisinopril) between Jan. 1, 1991, and Dec. 31, 1993. Information obtained from universal insurance databases included prescription drug use, the number of visits to a general practitioner (GP) or specialist and the number of hospital admissions during the year before treatment was initiated and during a follow-up period of up to 4 years. Rates were statistically adjusted for potential confounding variables and compared across treatment groups. RESULTS: Of the 4709 patients, 529 were prescribed captopril initially, 2939 enalapril and 1241 lisinopril. After treatment was initiated patients prescribed captopril were dispensed more medications on average, with an overall rate of 18.6 prescriptions per patient per year (v. 16.4 and 14.7 for enalapril and lisinopril users respectively); they were admitted to hospital more often, and they made more visits to GPs and specialists. The adjusted rate ratio of the number of visits to a GP for patients receiving enalapril, relative to captopril, was 0.84 (95% confidence interval [CI] 0.80-0.88), and for those receiving lisinopril it was 0.79 (95% CI 0.74-0.83). The adjusted rate ratios for the number of visits to a specialist were similar but lower, and for the number of hospital admissions they were 0.82 for patients prescribed enalapril initially (95% CI 0.73-0.93) and 0.65 (95% CI 0.56-0.75) for those prescribed lisinopril. INTERPRETATION: Patients with hypertension who are initially prescribed captopril used health care services more than those initially prescribed enalapril or lisinopril. This suggests that ACE inhibitors may not be therapeutically equivalent. (+info)
Evaluating reference-based pricing: initial findings and prospects.
(32/2434)
Reference-based pricing is a controversial policy mechanism used to control pharmaceutical expenditures. After its implementation in some European countries, the British Columbia government introduced a version of reference-based pricing in October 1995. The authors reviewed previous studies of reference-based pricing in other countries and conducted a preliminary assessment of the impacts of the BC system by analysing secondary utilization and cost data. After the introduction of reference-based pricing in other jurisdictions within the Organisation for Economic Cooperation and Development, there was a temporary reduction in the rate of growth of total pharmaceutical expenditures, followed by a return to previous growth trends in subsequent years. Similarly, initial data from BC showed dramatic declines in annual expenditures for drugs within referenced categories (from $42.0 million the year before reference-based pricing was introduced to $23.7 million the year after). Although early evidence suggests that reference-based pricing in BC is indeed reducing drug expenditures, much more research is needed to make a final determination of its success. A more comprehensive and longitudinal evaluation of reference-based pricing is needed and should take into account a wide range of non-cost impacts, the most important of which are the effects on health outcomes. (+info)