Pengobatan rasional

Pengantar: Pengobatan Rasional Rustamaji

Sleman, 10 April 2012 Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Tujuan • Difinisi Pengobatan Rasional dan mengidentifikasi besarnya masalah yang ditimbulkan

• Memahami mengapa terjadi pengobatan yang tidak rasional • Mendiskusikan strategi intervensi unutk memperbaiki masalah • Mendiskusikan pedoman pengobatan

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Definisi The rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and at the lowest cost to them and their community. WHO conference of experts Nairobi 1985


Ciri pengobatan rasional • Tepat dalam pemilihan obat • Obat digunakan sesuai indikasi • Obat memenuhi kriteria kemanfaatan klinkk, keamanan, kecocokan dengan kondisi pasien, dan biaya • Tepat dosis, cara pemberian, dan lama terapi • Tidak ada kontraindikasi pada pasien • Pemberian obat yang tepat (termasuk informasi yang cukup agar pasien dapat mengikuti program pengobatan dengan benar)


Ketepatan dalam diagnosis

Pakistan Bangladesh Burkino Faso Senegal Angola Tanzania 0

10

20

30

40

50

% observed consultations where the diagnostic process was adequate Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

60

5-55% pasien di PHC menerima injeksi90% tidak perlu secara medis Quick et al, 1997, Managing Drug Supply Ghana Cameroon Nigeria Sudan Tanzania Zimbabwe

Yemen Indonesia Nepal

 15

juta injeksi/tahun secara global  50% tidak menggunakan jarum steril  2.3-4.7 juta infeksi hepatitis B/C dan sekitar 160,000 infeksi HIV/tahun

Ecuador Guatemala El Salvador Jamaica Eastern Caribean

0%

10%

20%

30%

40%

% pasien di PHC yang mendapatkan injeksi Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

50%

60%

Pola pemakaian antibiotika di 26 negara Eropa tahun 2002 35

DDD per 1000 inh. per day

30

25

20

15

10

5

0 FR GR LU PT IT

BE SK HR PL IS

IE ES FI BG CZ SI SE HU NO UK DK DE LV AT EE NL

Goosens et al, Lancet, 2005; 365: 579-587; ESAC project. Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

% Ketaan terhadap Pedoman Pengobatan 60 50 40 30 20 10 0 1982-1994

1995-2000

2001-2006

Sub-Saharan Africa (n=29-48)

Lat. America & Carrib (n=5-13)

Middle East & C. Asia (n=4-8)

East Asia & Pacific (n=7-11)

South Asia (n=6-12) Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Pola Pengobatan Diare Akut oleh Dokter, Perawat, dan paramedis 80 70 60 50 40 30 20 10 0 % antibiotika

% antidiare

Public (n=54-90)

% larutan rehabilitasi oral

Private-for-profit (n=5-10)


Pola Pengobatan ISPA Berdasarkan Tenaga 80 70 60 50 40 30 20 10 0 % Antibiotika pada ISPA viral Dokterr (n=26-62)

% pneumonia yang mendapatkan antibiotika

Perawat/paramedis (n=12-86)


% ISAP yang diobati dengan sirup obat batuk Staf Farmasif (n=9-17)

Penggunaan antimikroba dan Pengaruhnya terhadap resistensi WHO country data 2000-3

• • • •

• • •

Malaria – choroquine resistance pada 81/92 negara Tuberculosis – 0-17 % multi-drug resistance primer HIV/AIDS – 0-25 % resistance primer (minimal 1 antiretroviral) Gonorrhoea – 5-98 % penisillin resistance terhadap N. gonorrhoeae Pneumonia and bacterial meningitis – 0-70 % penicillin resistance terhadap S. pneumoniae Diarrhoea: shigellosis – 10-90% ampisillin resistance, 5-95% cotrimoxazole resistance Hospital infections – 0-70% S. Aureus resistance terhadap seluruh penisillin & cephalosporins


Community surveillance Resistensi dan Penggunaan antimikroba • Antimicrobial resistance – E.Coli patogen pada wanita hamil di India • Cotrim 46-65%; Ampi 52-85%; Cipro 32-59%; Cefalex 16-50% – S.Pneumoniae & H.influenzae sputum di afrika Selatan • Cotrim > 50% (both organisms); Ampi >70% (H.influenzae)

• Penggunaan antibiotika – Sekitar 50% pasien di India dan <25% di AfrikaSelatan menerima antibiotika – Penggunaan fluoroquinolones unutk common cold di India terutama di sektor private

• Motivasi provider dan konsumen – Permintaan pasien – menganggap lebih cepat menyembuhkan – Tidak ada CME & takut kehilangan klien – Promosi obat yang tidak terkontrol dan alasan finasial Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Adverse drug events White et al, Pharmacoeconomics, 1999, 15(5):445-458

• Penyebab ke- 4-6 kematian di USA • Biaya yang dikeluarkan sekitar 30 ribu -130 juta US$ in the USA

• 4-6% kasus yang memerlukan perawatan di rumah sakit di USA & Australia • Sering ditemukan, penyebab kasus yang memerlukan biaya perawatan : pendarahan, cardiac arrhythmia, gangguan jiwa, diare, demam, hipotensi, itching, mual, rash, gangguan ginjal Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Upaya mengatasi masalah 1. EXAMINE Measure Existing Practices (Descriptive Quantitative Studies) 4. FOLLOW UP Measure Changes in Outcomes (Quantitative and Qualitative Evaluation)

improve diagnosis

improve intervention 3. TREAT Design and Implement Interventions (Collect Data to Measure Outcomes)


2. DIAGNOSE Identify Specific Problems and Causes (In-depth Quantitative and Qualitative Studies)

Banyak Faktor Yang Mempengaruhi Penggunaan Obat Information

Scientific Information

Influence of Drug Industry

Habits Social & Cultural Factors

Treatment Choices

Workload & Staffing

Workplace

Intrinsic

Prior Knowledge

Infrastructure

Relationships With Peers

Societal Economic & Legal Factors

Authority & Supervision

Workgroup


Strategi untuk memperbaiki Educational:  Inform or persuade – Health providers – Consumers

Managerial:  Guide clinical practice – Information systems/STGs – Drug supply / lab capacity

Use of Medicines Economic:  Offer incentives – Institutions – Providers and patients

Regulatory:  Restrict choices – Market or practice controls – Enforcement


Educational Strategies Goal: to inform or persuade • Training for Providers – – – –

Undergraduate education Continuing in-service medical education (seminars, workshops) Face-to-face persuasive outreach e.g. academic detailing Clinical supervision or consultation

• Printed Materials – Clinical literature and newsletters – Formularies or therapeutics manuals – Persuasive print materials

• Media-Based Approaches – Posters – Audio tapes, plays – Radio, television Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Impact of Patient-Provider Discussion Groups on Injection Use in Indonesian PHC Facilities Source: Hadiyono et al, SSM, 1996, 42:1185 % Prescribing Injections 80

60 Pre Post

40

20

0 Intervention

Control


Training for prescribers The Guide to Good Prescribing

• WHO has produced a Guide for Good Prescribing - a problem-based method • Developed by Groningen University in collaboration with 15 WHO offices and professionals from 30 countries • Field tested in 7 sites • Suitable for medical students, post grads, and nurses

• widely translated and available on the WHO medicines website Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Managerial strategies Goal: to structure or guide decisions • Changes in selection, procurement, distribution to ensure availability of essential drugs – Essential Drug Lists, morbidity-based quantification, kit systems

• Strategies aimed at prescribers – targeted face-to-face supervision with audit, peer group monitoring, structured order forms, evidence-based standard treatment guidelines

• Dispensing strategies – course of treatment packaging, labelling, generic substitution


RCT in Uganda of the effects of STGs, training and supervision on % of Px conforming to guidelines Source: Kafuko et al, UNICEF, 1996.

Randomised group

No. health PrePostfacilities intervention intervention

Change

Control group

42

24.8%

29.9%

+5.1%

Dissemination of guidelines

42

24.8%

32.3%

+7.5%

Guidelines + onsite training

29

24.0%

52.0%

+28.0%

14

21.4%

55.2%

+33.8%

Guidelines + onsite training + 4 supervisory visits


Economic strategies: Goal: to offer incentives to providers an consumers

• Avoid perverse financial incentives – prescribers’ salaries from drug sales – insurance policies that reimburse non-essential drugs or incorrect doses – flat prescription fees that encourage polypharmacy by charging the same amount irrespective of number of drug items or quantity of each item


Pre-post with control study of an economic intervention (user fees) on prescribing quality in Nepal Holloway, Gautam & Reeves, HPP, 2001

Fees (complete drug courses)

control fee / Px 1-band item fee 2-band item fee n=12 n=10 n=11

Av. no. items per prescription

2.9 2.9 (+/- 0)

2.9 2.0 (-0.9)

2.8 2.2 (-0.6)

% prescriptions conforming to STGs

23.5 26.3 (+2.7%)

31.5 45.0 (+13.5%)

31.2 47.7 (+16.5%)

Av.cost (NRs) per prescription

24.3 33.0 (+8.7)

27.7 28.0 (+0.3)

25.6 24.0 (-1.6)


PHC prescribing with and without Bamako initiative in Nigeria Source: Scuzochukwu et al, HPP, 2002

15.3

no.EDL drugs avail

35.4

21

% pres EDL drugs

93

25.6

% Px with antibiotics

64.7 38

% Px with injections

72.8

2.1 5.3

no.drug items/Px 0

20

21 Bamako PHCs

40

60

12 non-Bamako PHCs


80

100

Regulatory strategies Goal: to restrict or limit decisions • Drug registration • Banning unsafe drugs - but beware unexpected results – substitution of a second inappropriate drug after banning a first inappropriate or unsafe drug

• Regulating the use of different drugs to different levels of the health sector e.g. – licensing prescribers and drug outlets – scheduling drugs into prescription-only & over-the-counter

• Regulating pharmaceutical promotional activities

Only work if the regulations are enforced Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Intervention impact: largest % change in any medicines use outcome measured in each study Database on medicines use 2009

Intervention type

No. studies Median impact

25,75th centiles

Printed materials

5

8%

7%, 18%

National policy

6

15%

14%, 24%

Economic strategies

7

15%

14%, 31%

Provider education

25

18%

11%, 24%

Consumer education

3

26%

13%, 27%

Provider+consumer education

12

18%

8%, 21%

Provider supervision

25

22%

16%, 40%

Provider group process

8

37%

21%, 59%

Essential drug program

5

28%

26%, 50%

Community case mgt

5

28%

28%, 37%

Providr+consumr ed & supervis 7

40%

18%, 54%


Proportion of visits with injection

Impact of multiple interventions on injection use in Indonesia Interactive group discussion (IGC group only)

100%

Seminar (both groups) 80%

District-wide monitoring (both groups)

60% 40% 20% 0% 1

3

5

7

9

11

13 15

17 19

21 23

25

Months Comparison group

Interactive group discussion

Source: Long-term impact of small group interventions, Santoso et al., 1996 Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

What national policies do countries have to promote rational use? Source: MOH Pharmaceutical policy surveys 2003 and 2007 Drug use audit in last 2 years National strategy to contain AMR Antibiotic OTC non-availability Public education on antibiotic use DTCs in >half general hospitals Drug Info Centre for prescribers Obligatory CME for doctors UG doctors trained on EML/STGs STGs updated in last 2 years EML updated in last 2 years

2007 (n>85)

0 2003 (n>90)

20 40 60 80 % countries implementing policies


100

Percent change in antibiotic consumption, out-patient care in 25 European countries 1997-2003 Data from ESAC 25 20

Increase

Percent change

15 10 5 0 -5

Decrease

-10 -15

For Iceland, total data (including hospitals) are used

U Fr K an ce

Po la n C d ro at G ia re ec Ire e la Po nd rtu D ga e l Lu nm xe ar m k bo ur H un g ga ry It Sl aly ov ak ia Is ra N el or w Sw ay ed e Au n s Sl tria ov en Es ia to n Fi ia nl an Th d e Sp N et he ain rla G nds er m a Be ny lg iu m C ze Ic ch ela R nd ep ub lic

-20

Slide courtesy of Otto Cars, STRAMA, Sweden


Percent change in antibiotic consumption, out-patient care in 25 European countries 1997-2003 Data from ESAC 25 20

Co-ordination programs

and national campaigns

Percent change

15 10 5 0 -5 -10 -15

For Iceland, total data (including hospitals) are used

U Fr K an ce

Po la n C d ro at G ia re ec Ire e la Po nd rtu D ga e l Lu nm xe ar m k bo ur H un g ga ry It Sl aly ov ak ia Is ra N el or w Sw ay ed e Au n s Sl tria ov en Es ia to n Fi ia nl an Th d e Sp N et he ain rla G nds er m a Be ny lg iu m C ze Ic ch ela R nd ep ub lic

-20

Slide courtesy of Otto Cars, STRAMA, Sweden


Why does irrational use continue?

Very few countries regularly monitor drug use and implement effective nation-wide interventions - because… • they have insufficient funds or personnel? • they lack of awareness about the funds wasted through irrational use? • there is insufficient knowledge of concerning the costeffectiveness of interventions?


What are we spending to promote rational use of medicines ? • Global sales of medicines 2002-3 (IMS):

US$ 867 billion

• Drug promotion costs in USA 2002-3:

US$ >30 billion

• Global WHO expenditure in 2002-3:

US$ 2.3 billion

– Essential Medicines expenditure

2% (of 2.3 billion)

– Essential Medicines expenditure on promoting rational use of medicines

10% (of 2%)

– WHO expenditure on promoting rational use of medicines

0.2% (of 2.3 billion)


2nd International Conference for Improving Use of Medicines, Chiang Mai, Thailand, 2004 472 participants from 70 countries

http://www.icium.org

Recommendations for countries to: • Implement national medicines programmes to improve medicines use • Scale up successful interventions • Implement interventions to address community medicines use


Health systems with no national programs: •No coordinated action •No monitoring of use of medicines Situational analysis

Modify action plans

WHO facilitating multi-stakeholder action in countries

Implement & evaluate national action plans using govt & local donor funds

Health systems with national programs: •Coordinated action •Regular monitoring of use of medicine Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Develop national plans of action

Global monitoring and identifying effective strategies to promote rational use of medicines • WHO/EMP databases on drug use and policy – quantitative data on medicines use and interventions to improve medicines use from 1990 to present day – data from MOHs on pharmaceutical policies every 4 years – 1999, 2003, 2007

• ICIUM3 in 2011 – 3rd international conference on improving the use of medicines (ICIUM3)

• Surveillance of antimicrobial use & resistance – method for community-based surveillance in poor settings – interventional approach for improving use in private sector Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Pembekalan MTP (STG) kepada staf Puskesmas mengurangi penggunaan antibiotika Yudatiningsih, ICIUM, 2004 100 80

MTP

60

Feedback Month 14

Feedback Month 30

Feedback Month 45

40 20 0 Agust-99 Nop99 Feb-00

Mei00 Agust-00 Des00

Mrt01

Jun01. Sep01. Des01.


Apr02.

Jul02.

Oct02.

Jan03.

Apr03. Aug03.

Standard Pengobatan • Tujuan pembahasan : – Menilai manfaat dan kerugian penerapan standard pengobatan – Pemahaman tahap pengembangan standard pengobatan – Menyiapkan pembuatan standard pengobatan


Pengantar 1. 2. 3. 4. 5.

Therapeutic Anarchy Keuntungan penerapan pedoman pengobatan Dampak pedoman pengobatan Pengembangan pedoman pengobatan Penerapan pedoman pengobatan


Pedoman Pengobatan

Tatacara diagnosis

Pilihan intervensi (non obat dan obat)


Pedoman pengobatan harus mencakup tatacara diagnosis yang esensial

• Health Problem = – symptom - “headache” – diagnosis - “malaria” – health service “antenatal care”


Pedoman Pengobatan dan Proses Terapi Signs and Symptoms

Diagnosis (Health Problems)

Rx Drug Supply

Treatment (Responses) Adherence (Compliance)

Rx Rx

Rx Clinical Outcome Rx = focus of standard treatments Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Advantages of Standard Treatments • Patients – Consistency among prescribers – Most effective treatments prescribed – Improved drug supply

• Providers – – – –

Provides expert consensus Provider can concentrate on diagnosis Quality of care standard Basis for monitoring and supervision


Advantages of Standard Treatments

• Supply Management Staff – Performance standard for drug supply – Allows pre-packs of common items – Drug demand more predictable

• Health Policy Makers – Funds used more efficiently – Assess and compare quality of care – Therapeutic integration of special programs


Key Features 1. 2. 3. 4. 5. 6. 7.

Simplicity Credibility Same standards for all levels Drug supply based on standards Introduced in pre-service training Dynamic—regular updates Durable pocket manuals


Developing Standard Treatment Guidelines

1. Target priority conditions 2. Base on local disease factors 3. Coordinate with special programs 4. Use fewest drugs necessary 5. Choose cost-effective treatments 6. Use essential drug list drugs only 7. Involve respected clinicians 8. Consider patient perspective


Approaches to Standard Treatment Guidelines • Individual • Selective • Comprehensive


Implementing Standard Treatments

1. Printed reference 2. Official launch 3. Initial training 4. Reinforcement training 5. Monitoring 6. Supervision Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Conclusion • Standard treatment guidelines can have considerable impact if they are developed and used in a sensible fashion • They can also be an expensive waste of effort • With standard treatment guidelines, the process of production and use is more important than the product


Pengobatan rasional

Recommend Documents