Advances in Human Biology

INVITED COMMENTARY
Year
: 2020  |  Volume : 10  |  Issue : 3  |  Page : 85--89

Ongoing initiatives to improve the prescribing of medicines across sectors and the implications


Brian Godman 
 Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom; Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden; Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga.Rankuwa, Pretoria, South Africa; School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia

Correspondence Address:
Brian Godman
Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE




How to cite this article:
Godman B. Ongoing initiatives to improve the prescribing of medicines across sectors and the implications.Adv Hum Biol 2020;10:85-89


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Godman B. Ongoing initiatives to improve the prescribing of medicines across sectors and the implications. Adv Hum Biol [serial online] 2020 [cited 2021 Mar 1 ];10:85-89
Available from: https://www.aihbonline.com/text.asp?2020/10/3/85/295848


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We believe medicines including vaccines are a critical component in the management of both infectious diseases and non-communicable diseases (NCDs),[1],[2],[3],[4],[5] and this is reflected in global sales of medicines likely to exceed $1.5 trillion by 2023 with compounded annual growth rates of 3%–6%.[6] Medicines also play a critical role in low- and middle-income countries (LMICs) where their expenditure can account for over 60% of the total health-care expenditure.[7] Because typically these costs are out of pocket, there can be catastrophic consequences for families when members become ill.[8],[9],[10],[11] These consequences and concerns are exacerbated by the World Health Organization (WHO) estimating that more than half of all medicines are prescribed or dispensed inappropriately, with approximately half of all patients failing to take them correctly.[12],[13] Inappropriate prescribing can also increase the number of adverse drug reactions, increasing morbidity and mortality as well as costs.[12],[14],[15],[16],[17] Consequently, inappropriate prescribing should be avoided where possible.

Improving the rational use of medicines (RUM), which has been defined as prescribing the right drug, in the most appropriate dose, for the right duration, in the optimal formulation, route, timing and frequency, to meet the clinical needs of patients at the least cost,[12],[18],[19],[20] is one way forward. A recent example of the consequences of inappropriate prescribing and dispensing surrounds hydroxychloroquine to prevent and treat patients with COVID-19. There was considerable interest and endorsement for its use with or without antibiotics following the initial studies despite concerns with their quality, which resulted in shortages, price hikes and suicides across countries.[11],[21],[22],[23],[24] However, later studies typically failed to show any clinical benefit in patients with COVID-19, leading to the WHO dropping hydroxychloroquine from the Solidarity study.[25],[26],[27] Having said this, hydroxychloroquine is still endorsed in India for the prevention of COVID-19 following the study of Chatterjee et al. despite concerns.[28],[29]

There are many examples of ways to improve the quality of prescribing in both ambulatory care and hospitals, with typically multiple initiatives more effective than single ones.[30],[31] These include educational initiatives incorporating quality indicators as well as drug and therapeutic committees (DTCs) and antimicrobial stewardship programmes (ASPs) in hospitals. We are aware that the WHO has introduced a range of indicators in ambulatory care to assess the quality of prescribing, which are widely used. These include the average number of prescriptions per patient encounter as well as the average number of antibiotics and injections per encounter, the extent of generic name prescribing (international non-proprietary name [INN]) and the percentage of medicines prescribed from the country's essential medicine list.[32] However, there are concerns whether the WHO criteria actually measure the quality of prescribing in reality, especially in countries with high prevalence rates of both infectious and non-infectious diseases. This has resulted in calls to introduce more pertinent quality indicators locally.[33],[34] This subject is likely to grow with increasing awareness that adherence to well-thought-out and easily accessible prescribing guidance is a more appropriate quality measure.[33],[35],[36]

An effective strategy to improve the quality of prescribing in ambulatory care can be seen with the introduction of the 'Wise List' in Stockholm County Council in Sweden, with the first version published in 2001.[37] The Wise List contains a list of suggested first- and second-line treatments covering over 95% of the needs of patients in ambulatory care, which equates to approximately 200 medicines, rising to 250 medicines when suggested medicines for hospital outpatients are included.[37],[38] The concept behind the 'Wise List' is that most ambulatory care physicians only know a limited number of medicines well, with adherence to any suggested list enhanced if the prescribing physicians believe that the suggested medicines are selected using robust evidence-based principles and they have the opportunity to question those compiling the list. This is the situation with the 'Wise List' with strong conflict of interest statements and a comprehensive communication strategy including a patient version, resulting in high adherence rates in practice.[37],[38],[39] Educational initiatives starting in medical school and continuing post-qualification are used in the UK to enhance INN prescribing, with rates routinely over 97% in non-controversial areas.[40],[41] INN prescribing helps address concerns with branded generics where patients may be dispensed different branded generics with different names on different occasions, potentially leading to confusion and possibly underdosing or overdosing unless addressed by either the physician or a pharmacist.[42],[43]

Numerous educational and other strategies have also been introduced to reduce inappropriate prescribing of antimicrobials across countries including LMICs given concerns with rising resistance rates, with multiple strategies again typically more effective than single strategies.[31],[44],[45] Potential educational initiatives to improve antibiotic prescribing in ambulatory care have been described by Dyar et al.,[46] and more recently by Godman et al. (2020) for upper respiratory tract infections.[44] Potential quality indicators for antimicrobials in ambulatory care include assessing the extent of prescribing of broad versus narrow antibiotics as well as the extent of prescribing of suggested treatments from the 'Access' group in the WHO AWaRe list as opposed to 'Watch' and 'Reserve' antibiotics.[47],[48],[49]

Quality indicators for NCDs in ambulatory care include the extent of doses of medicines prescribed according to agreed guidance, for example, high versus low doses of statins, adherence to current national or regional guidelines, the extent of co-prescriptions of statins for patients with established coronary vascular disease including diabetes and adherence rates to prescribed medicines in practice.[40],[50],[51] The prescribing of patented or originator medicines rather than lower cost, multiple sourced medicines where pertinent is now less of an issue in ambulatory care with many standard treatments available as low-cost generics. However, the quality of generics can be a concern in some LMICs, limiting their use, which needs addressing to enhance their prescribing first line where indicated.[52],[53] Adherence to medicines is a particular issue for NCDs, with rates depending on a number of issues including the perceived seriousness of the disease, the extent of family member support, affordability and understanding of the instructions given.[54],[55],[56] Addressing these issues and challenges will help improve adherence rates in the future.

The WHO and others see the instigation of DTCs involving all key stakeholder groups as one of the pivotal ways to enhance the quality of prescribing of medicines in hospitals and reduce any inappropriate influence of pharmaceutical companies.[57],[58],[59],[60],[61] DTCs can provide leadership and structure in hospitals to help select the most appropriate medicines for any given situation, provide guidance on subsequent medicine use and monitor use in practice, educate physicians on evidence-based medicine approaches, suggest alternative medicines when shortages occur and generally help improve resource use and the quality of care in hospitals.[39],[59],[62],[63],[64],[65],[66] DTCs can also be proactive and instigate a number of activities in advance using appropriate methodologies to reduce the impact of any medicine shortages, particularly in priority disease areas.[67] DTC personnel can also enhance the appropriate use of medicines by documenting current utilisation and expenditure patterns across disease areas as a first step to assess whether undue resources are being spent on high-cost/high-expenditure non-vital or non-essential medicines,[68] with the findings directing future activities. DTC personnel can also encourage the reporting of adverse drug reactions given the current concerns with low rates, particularly in LMICs to improve the future use of medicines.[69],[70],[71],[72] However, a concern across a number of LMICs is the current lack of DTCs even among tertiary hospitals, which urgently needs addressing to improve the quality of future prescribing.[73]

There are also concerns regarding antimicrobial prescribing in hospitals especially among LMICs, driving up resistance rates and costs. Concerns include a lack of documentation of the rationale for the initial selection, in lack of any formal review of antibiotic choices during patient management including reviews against agreed hospital guidelines, prolonged use of antimicrobials to prevent surgical-site infections and a lack of intravenous to oral switching.[74],[75],[76] These issues can be addressed through having active ASPs within hospitals, which includes encouraging empiric prescribing based on the current resistance patterns reducing inappropriate antimicrobial prescribing and costs.[77],[78],[79],[80],[81] However, there are concerns with the extent of ASPs in practice among LMICs and the knowledge of physicians regarding their potential use, which also needs addressing to improve future antimicrobial prescribing in hospitals.[82],[83],[84]

In conclusion, there are multiple activities that can be conducted across countries in both ambulatory and hospital care to improve prescribing. Such activities become increasingly important with the growing prevalence of both infectious and non-infectious diseases across countries and the resultant implications on medicine use. In the next editorial, we will examine the range of activities that health authorities and governments can instigate to enhance appropriate medicine use and their outcomes especially in ambulatory care to also provide guidance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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