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DRUG USE 08/16/2024 Drug use 1 Drug use is the process of: Prescribing Dispensing Patient use Adherenc Diagnosis/ e Follow up Dispensing Prescribing 08/16/2024 Drug use 2...
DRUG USE 08/16/2024 Drug use 1 Drug use is the process of: Prescribing Dispensing Patient use Adherenc Diagnosis/ e Follow up Dispensing Prescribing 08/16/2024 Drug use 2 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 to their community 08/16/2024 Drug use 3 Rational drug use involves: Appropriate indication Appropriate drug Appropriate dosage regimen Appropriate patient Correct dispensing Patient adherence 08/16/2024 Drug use 4 a. Rational Prescribing Requires: – Making accurate diagnosis – Deciding whether or not the diagnosis requires drug treatment – Selecting the best drug among available – Prescribing in accordance with the standard course of treatment – Following correct prescription writing – Counseling the patient 08/16/2024 Drug use 5 What roles can you play as a pharmacist to promote rational prescribing? 08/16/2024 Drug use 6 b. Rational dispensing Dispensing: refers to the process of preparing drugs and distributing them to their users with provision of appropriate information. It may be based on a prescription or an oral request of users (patients or care providers) depending on the type of drugs to be dispensed 08/16/2024 Drug use 7 1. Dispensing a prescription – Receiving and validation of a prescription – Interpreting a prescription – Preparing medication/s to be dispensed – Issuing medication/s with the provision of appropriate and complete instruction 08/16/2024 Drug use 8 Dispensing a prescription…. A label must contain the following information: Patient name Generic name, strength, and dosage form of medicine Dosage regimen information (dose, frequency and duration of treatment) quantity dispensed How to administer medicine Storage condition Date dispensed Name of dispenser 08/16/2024 Drug use 9 2. Dispensing OTC medications/responding to symptoms – The following information are relevant before dispensing Age, sex, pregnancy status if female, history of allergic reaction, history of renal or hepatic disease and any history of other disease Nature, site and severity of symptom/s For how long the symptom/s persist Whether the patient is taking any medication to relief from the existing complication or for any other purpose 08/16/2024 Drug use 10 – Based on the above information decide whether the symptom/s are minor or are indication of major illness – Decide whether the patient need non- drug management, OTC drug or referring – If the decision is to give OTC drug/s select an appropriate OTC drug considering the above relevant information 08/16/2024 Drug use 11 c. Appropriate patient use Proper handling of medications Adherence to treatment 08/16/2024 Drug use 12 Irrational drug use Common types?????? 08/16/2024 Drug use 13 Impact of irrational drug use ??????? 08/16/2024 Drug use 14 Factors underlying irrational drug use a. Health care provider (prescriber and dispenser) – Inadequate pre-service training – Lack of continuing education – Financial interest – Lack of role models who practice rationally – Patient load and pressure on treatment choice – Unethical promotional activities by pharmaceutical companies 08/16/2024 Drug use 15 b. Health system – Pharmaceutical supply system and availability of facilities Poor quantification and forecasting Inadequate inventory management Unreliable supplies Inadequate distribution system Inefficient management of procurement process Lack of adequate laboratory facilities Lack of facilities for dispensing 08/16/2024 Drug use 16 – Legal and regulatory framework Non-formal prescribers/dispensers Out of date or no-existent standard treatment guideline (STG), drug list, formulary… No drug and therapeutics committee (DTC) encouragement No pharmacovigilance program Inadequate medicine registration and quality assurance system 08/16/2024 Drug use 17 Lack of system for continuing medical education Lack of financing and reimbursement mechanisms Lack of regulation on drug promotion Even in the presence of regulations, there may be lack of enforcement 08/16/2024 Drug use 18 c. Patient/client and community – Perceived need for medicines – Perceived need for consulting health workers – Ideas about efficacy and safety – Uncertainty resulting in polytherapy – Cost of medicines – Absence of social support 08/16/2024 Drug use 19 – Inability to take time off work – Low literacy level – Medicine use culture – Medicine supply system – Quality of prescribing and dispensing – Therapy related factors 08/16/2024 Drug use 20 Stepwise approach for promotion of rational drug use Assess current patterns of drug use, identify any problem and recognize the need for action Identify underlying causes and motivating factors List possible interventions Assess resources available for action Choose and carryout interventions Monitor the impact and restructure the intervention 08/16/2024 Drug use 21 Examine Diagnosis (identify (measure problems and existing causes practice) Follow up Treat (design and (measure implement outcomes) intervention) 08/16/2024 Drug use 22 Interventions/strategies to improve drug use They can be classified in to three major strategies: – Educational – Regulatory – Managerial Educational: Is intended to persuade individuals by providing information It may include training, provision of printed materials and education 08/16/2024 Drug use 23 Managerial: Is used to guide action (decision making) Example: – Drug list, STG – Drug utilization review and feedback Regulatory: Aimed to enforce decisions Example: – Drug registration regulation – Generic policy – Prescribing and dispensing restrictions – Level of use restrictions 08/16/2024 Drug use 24 Characteristics of effective interventions: Identify key influence factors Target individuals or groups with the worst practice Use credible information sources Use credible communication channels Use personal contact whenever possible Limit the number of messages using different media Provide better alternatives 08/16/2024 Drug use 25 INVESTIGATING DRUG USE 08/16/2024 investigating drug use 26 objectives Explain the need to investigate drug use Describe methods of investigating drug use 08/16/2024 investigating drug use 27 Outline The need for investigating medicine use Quantitative methods: – WHO drug use indicators – Drug use studies based on aggregate data (DDD, ABC, VEN) – Other drug use studies Qualitative methods: – Focused Group Discussion (FGD) – In-depth Interview – Structured Observation 08/16/2024 investigating drug use 28 Major reasons for investigating drug use: – To describe current patterns of drug use – To identify drug use problems and underlying problems – To monitor drug use over time Methods for assessing drug use – Quantitative methods – Qualitative methods 08/16/2024 investigating drug use 29 A. Quantitative Methods Are used to describe how often certain drug use practices occur 08/16/2024 investigating drug use 30 1. WHO drug use indicators A. Core drug use indicators I. Prescribing indicators II. Patient-care indicators III. Health facility indicators B. Complementary drug use indicators 08/16/2024 investigating drug use 31 A. Core drug use indicators I. Prescribing indicators Average number of drugs per encounter % of drugs prescribed by generic name % of encounters with an antibiotic prescribed % of encounters with an injection 08/16/2024 investigating drug use 32 II. Patient-care indicators Average consultation time Average dispensing time % of drugs actually dispensed % of drugs adequately labelled Patients’ knowledge of correct dosage 08/16/2024 investigating drug use 33 III. Facility indicators Availability of copy of essential drug list or formulary Availability of key drugs 08/16/2024 investigating drug use 34 B. Complementary drug use indicators % of patients treated without drugs Average drug cost per encounter % of drug cost spent on antibiotics % of drug cost spent on injections Prescription in accordance with treatment guidelines % of patients satisfied with the care they received % of health facilities with access to impartial drug information 08/16/2024 investigating drug use 35 2. Aggregate data Defined Daily Dose (DDD) methodology ABC analysis VEN analysis 08/16/2024 investigating drug use 36 1. Defined Daily Dose (DDD) methodology Defined daily dose: Is the assumed average maintenance dose for the medication’s main indication. It converts and standardizes readily available product quantity data such as packages, tablets, injections vials etc in to number of daily doses. It is used to directly compare consumption of drugs irrespective of price and type of formulation 08/16/2024 investigating drug use 37 3. Other drug use studies Health-problem based Drug-specific studies 08/16/2024 investigating drug use 38 B. Qualitative Methods Used to determine why things are the way they are or why people behave as they do Used to find out more about – People’s ideas – The reasons why problems occur – What people see as possible solutions and constrains 08/16/2024 investigating drug use 39 The methods include: – FGD (Focused Group Discussion) – In-depth interview – Structured observation 08/16/2024 investigating drug use 40 Thank you 08/16/2024 investigating drug use 41 DRUG DISTRIBUTION 08/16/2024 42 Objectives Explain drug distribution cycle Describe visual inspection Discuss stock management principles Identify inventory control system types Describe stock levels Explain stock status assessment Identify inventory control/logistics records Explain physical inventory Describe logistic management information system 08/16/2024 43 Drug distribution is a continuous process of receiving drugs from the supplier and moving them safely/securely, expeditiously to the many point in the health care system at which the drugs will be dispensed to patients. A well-run distribution system should: – Maintain a constant supply of drugs – Keep drugs in good condition 08/16/2024 44 – Minimize drug loses due to spoilage and expiry – Rationalize drug storage costs – Use available transport as efficiently as possible – Reduce theft and fraud – Provide information for forecasting drug needs 08/16/2024 45 The distribution cycle 08/16/2024 46 A. Visual inspection Visual inspection is the process of examining products and their packaging to look for obvious problems with product quality. When to conduct visual inspection Visual inspection can be conducted during the following circumstances: Receiving products Issuing products from one level to another Dispensing products to patients Storage 08/16/2024 47 Visual inspection… Conducting physical inventory Receiving complaints from lower levels or customers Products are to expire Products show signs of damage Products have been kept under improper storage conditions 08/16/2024 48 Visual inspection… What to look for in a visual inspection Mechanical damage Chemical damage Packaging Labeling (product identity, expiry date, lot number…..) Quantity of products 08/16/2024 49 B. Stock management (storage, handling, arrangement….) Storage of pharmaceuticals Proper storage practice is the safe keeping of products until ultimately reaches the consumer Generally pharmaceuticals should be protected from: – Moisture – Heat – Sunlight – Physical damage – Dirt…. 08/16/2024 50 Characteristics of a well managed stores operation and good storage guidelines Clearly defined management structure Staffs appropriately qualified, trained, disciplined and rewarded Store divided into zones Stocks arranged within each zone in some order system Stocks stored on pallets on the floor or pallet racks or on shelves Store products based on manufacturer’ specification 08/16/2024 51 Storage…. Good housekeeping- regular cleaning and inspection Store pharmaceuticals in a dry, well-lit, well- ventilated store room-out of direct sun light Protect storeroom from water penetration Keep fire safety equipment available, accessible, and functional, and train employees to use it Store latex products away from electric motors and fluorescent lights Maintain cold storage, including a cold chain, as required 08/16/2024 52 Storage…. Limit storage area access to authorized personnel and lock up controlled substances Stack cartons at least 10 cm off the floor and, 30cm away from the wall and other stacks, and no more than 2.5m high Store medical supplies away from insecticides, chemicals, old files, office supplies and other materials Arrange cartons with arrows pointing up, and 08/16/2024 53 Storage…. Liquid and heavy products kept at the lower shelves Products arranged to facilitate first expiry first out Damaged/expired products stored separately Store flammable products separately from other products Report products with near expiry 08/16/2024 54 Location and design of store Location Design – Size – Height of the wall – Roof 08/16/2024 55 Storage conditions There are two main types of storage conditions: – Normal storage condition – Special storage condition Cold storage condition Separate storage 08/16/2024 56 Storage temperature and environment – Dry place ……………………. 30oC – At room temperature ………… 15oC – 30oC – Cool place …………………… 8oC – 15oC – Cold place (refrigeration)-not >8oC (usually 2-8 oC) – In deep freezer ………………. -20oC – 0oC 08/16/2024 57 Arrangement of drugs Arranging drugs properly enables to control shelf life and simplify accessibility. Types: – Pharmaco-therapeutic – Alphabetic – Pharmaceutic order/dosage form 08/16/2024 58 Stock rotation First Expiry First Out (FEFO): – Involves arranging drugs with the earliest expiration date in front/on top and drugs with the latest expiration date in the back/below so that drugs with near expiry will be issued and/or dispensed first. Other approaches: First In First Out(FIFO), Last In First Out (LIFO) 08/16/2024 59 C. Inventory Control and Logistic Management Information System( LMIS) Inventory is the stock on hand at any given time. Inventory control is the process of maintaining of stock properly at all times. It is a process of assuring that the right volume and movement are secured in order to ensure that the obtained drugs have reached to the final consumer correctly. 08/16/2024 60 Inventory control system…… Inventory control helps to: – Maintain appropriate stock – Avoid over-stocking – Monitor shortage of drugs – Check the movement of stocks – Prevent expiry of drug before being used – Balance the merits and demerits of inventory keeping 08/16/2024 61 Inventory control system…… An inventory control system informs personnel when to order or issue, how much to order or issue and how to maintain an appropriate stock level to meet the needs of patients. The most important inventory control systems for health commodities are max-min inventory control systems. 08/16/2024 62 Inventory control system…… Key terms: Maximum Stock Level: is the level of stock above which inventory levels should not rise, under normal condition. Minimum Stock Level: is the level of stock at which actions to replenish inventory occur under normal condition. – It can also be considered as reorder stock level. 08/16/2024 63 Review Period: this is the interval of time Inventory control system…… Safety/reserve stock level: is the additional buffer or reserve kept on hand to protect against stockouts caused by delayed deliveries, markedly increased demand, or other unexpected events. Lead time: is the time between ordering a supply up to receiving and availing it for use. Lead time stock level: is the level of stock used within the lead time period Emergency order point (EOP): this is the level of stock that triggers an emergency order. The EOP must be less than the min. 08/16/2024 64 Inventory control system…… There are three types of a max-min inventory control systems that are applicable to health commodity logistic system: 1. Forced ordering system 2. Continuous review system 3. Standard system 08/16/2024 65 Inventory control system…… No matter which inventory control system is used, the formula for calculating the order or issue quantity is the same. – i.e order/issue quantity= (Maximum stock level/quantity)- (stock on hand) – if there is stock on order which is not yet received: order/issue quantity= (Maximum stock level/quantity)- (stock on order)-(stock on hand The difference between the above three inventory control systems is the trigger for placing an order or issuing resupply. 08/16/2024 66 Inventory control system…… 1. Forced ordering system: Decision rule: the review period is the trigger for ordering. emergency order point is used to place an emergency order Advantage: – Decision rule is simple – Transportation can be scheduled for specific times – Unless there is potential for stock out, assessing stock status constantly is not needed – Every facility orders or is resupplied at the end of every review period Disadvantage: – Orders for some items may be for small quantities 08/16/2024 67 Inventory control system…… Forced-ordering delivery truck system: it is one variation of forced ordering system. It is sometimes called a topping up or bread truck system. In this system, a truck is loaded with supplies at the end of the review period. The truck and delivery team travel to each facility, assess the stock, and leave (top up) an amount of each product that is sufficient to bring stock levels up to the maximum at that location. 08/16/2024 68 Inventory control system…… 2. Continuous review system Decision rule: the trigger for ordering products is the minimum stock level. Advantage: – Decision rule is simple – It is more responsive and flexible – Small orders are eliminated Disadvantage – Transportation resources are harder to schedule – The workload on the store keeper is high 08/16/2024 69 Inventory control system…… 3. Standard max-min system Decision rule: – It combines the decision rules of both forced- ordering and continuous review. – The decision when to make an order or issue new stock is based on the min stock level and the review period. – Review all stock levels at the end of each review period and order quantities up to the maximum level for products that are at or have fallen below the min. – EOP will be needed to ensure that a stockout does not occur between review periods. 08/16/2024 70 Inventory control system…… Advantage: – Small orders are eliminated – There is no need to assess stock status continuously – Reduce the number of calculations as only products that are at or have fallen below the min will be ordered – Transportation can be scheduled Disadvantage: – The min stock level is higher (higher likelihood of expiry, require more storage capacity and increased cost) – Decision rule is complex 08/16/2024 71 Inventory control system…… The decision to choose an appropriate max-min system depends on following factors: Number of items managed Type of products managed Transport availability Level of staff training Level of reporting Whether push or pull system is used Supervision system Storage space 08/16/2024 72 Inventory control system…… LMIS and its linkage with inventory control: An LMIS and the inventory control system have a close relationship: the LMIS provides the data required to maintain the inventory control system. 08/16/2024 73 Inventory control system…… Logistics systems for all commodities should include at least three essential data items Stock on hand: The quantities of usable stock available Consumption: The quantity of stock dispensed to users or used during a particular time period Losses/adjustments 08/16/2024 74 Inventory control system…… There are three types of logistics records to track products. 1. Stock keeping records: Holds information about products in storage. Example: bin card, stock card, inventory control card, stores ledger 2. Transaction records: Holds information about products being moved. Example: Issue and receipt vouchers 3. Consumption records: Holds information about products being consumed or used. Example: daily dispensing registers 08/16/2024 75 Inventory/logistics records Stock records and reports form the foundation of an effective inventory management and overall drug supply management. Information to be included – product name/description including the form and strength – beginning stock balance – receipts – issues – losses/adjustments – closing/ending balance – transaction reference (e.g., issue voucher number or name of supplier or recipient). 08/16/2024 76 – special storage conditions – unit prices – lot numbers/bin locations – item codes – expiry dates – calculated data items: average monthly consumption (AMC), lead times for ordering/requisition, maximum and minimum stock levels, emergency order point 08/16/2024 77 Standard forms used for inventory control: – Stock cards – Bin cards – Requisition/issue vouchers – Expired stock disposal forms – Physical inventory forms – list of approved medicines and prices 08/16/2024 78 Stock cards: Can be used: – As the base for requisition and issuing of products – To know fluctuation of price of drugs – To control shelf life Bin cards – Remain with each item in the store – Filled by the store keeper – Are used as an easy reference on stock levels and expiry dates 08/16/2024 79 Physical inventory It is the process of counting by hand the number of each type of product in a store at any given time It is used to: – Know whether the actual quantity on hand balances the recorded stock on the stock keeping records – Identify surplus, expired and obsolete (outdated) stock – Promote periodic evaluation of storage conditions and the adequacy of storage facilities, layout and stock management. 08/16/2024 80 There are two kinds of physical inventory: Complete physical inventory: – All products are counted at the same time. – A complete inventory should be taken at least once a year. – More frequent inventory (quarterly or monthly) is recommended. – For large warehouses, this may require closing the storage facility for a day or longer. – It is easier to conduct regularly at facilities that manage smaller quantities of products. 08/16/2024 81 Cyclic or random physical inventory: – Selected products are counted and checked against the stock keeping records on a rotating or regular basis throughout the year. – It is usually appropriate at facilities that manage larger quantities of products. 08/16/2024 82 Thank you 08/16/2024 83