Rational prescribing in the Caribbean

Inappropriate, wasteful and, often, irrational drug use has long been recognised worldwide. Overuse of antibiotics, especially for influenza, overuse of injections in primary care, use of unproven remedies, use of multiple drugs for self-limiting illness and inappropriate dosing are but a few of the recognised problems. Wastefulness on the one hand and patient dissatisfaction with service and outcome on the other are some of the recognised consequences. In the Caribbean the relative availability of a fairly wide range of drugs has created a laissez faire approach to drug use in many countries. The private sector is dominated by influential drugs companies, whose representatives provide the majority of drug education updating for many primary care physicians. As a result newly marketed drugs feature strongly in the prescribing patterns of the private sector. In the public sector drugs supply systems vary considerably across the Caribbean, from highly sophisticated annual international tendering in some countries (e.g. Barbados) and common tendering by the Eastern Caribbean Drug Service for the eight countries of the Organisation of Eastern Caribbean States (OECS) to be more ad hoc, traditional patterns of purchasing of other countries. Only Barbados publishes an annually updated National Formulary; OECS does so every two or three years, and other countries at intervals of 5 to 10 years. Thus prescribers often lack up to date, locally relevant guidelines, and there is no mandatory, even minimum continuing education in therapeutics for doctors. Government expenditures on drugs vary from US$2.00 in Guyana to US$40.00 in Barbados (1996/97 figures). In spite of the emphasis of the World Health Organisation Drug Action Programme on essential drug list, rational prescribing and the formulary process, it can not be said that satisfactory progress has been made in the Caribbean. Cultural factors ("champagne tastes and mauby pockets"), politics, commercial interests and marketing pressures, and the lack of appropriately trained personnel to promote better therapeutic practices, may all play a part. An effective, participatory formulary process with an up-to-date, user-friendly formulary, treatment guidelines, interactive education and prescription audit are techniques shown to improve prescribing practices. Both medical education and medical services should be paying more attention to "better value for money".(AU)

A drug utilization review on asthma in three OECS Countries: St Lucia, Grenada and St Kitts/Nevis - abstract

The Drug Utilization Review (DUR) of asthma treatment comprises simultaneous cross-sectional studies conducted in the OECS countries of St. Lucia, St. Kitts/Nevis and Grenada. The review sought to assess prescribing behaviour in order to devise intervention strategies for enhanced prescribing practice. 1412 prescriptions written for asthmatic patients were drawn for public and private pharmacies on a quota basis. Despite certain inherent constraints in a prescription audit, some meaningful observations and conclusions can be made and drawn. The study revealed that the pattern of prescribing was similar among the countries under review. The top ranking drug was the beta agonist, salbutamol, in tablet form, which was prescribed for 92 percent of patients. Inhaled salbutamol was sparingly used. Experts agree that oral inhalation is the preferred delivery system and is best given on an as-needed basis. Inhaled glucocorticoids, the most effective available drug for controlling asthma, were used in only 6 percent of patients, a gross underutilization of the inhaled steriod. Oral prednisolone emerged as the second most popular drug but was given in multiple daily doses and unecessarily tapered for short one-week courses. The survey showed that the following drugs were frequently prescribed for asthmatic patients despite their dubious efficacy: antibiotics, cough mixtures, decongestants and antihistamines. NSAIDs which are contraindicated in asthma, were prescribed in 3 percent of patients. The DUR pointed to areas of inappropriate prescribing with respect to low use of an inhaled beta agonist and glucocorticoids and concurrent use of supplementary agents of doubtful efficacy(AU)

The dispensing function of the pharmacist in health care delivery from the perspectives of the consumers and suppliers of pharmaceuticals

Behavioural research is urgently needed to improve the way that pharmaceuticals are prescribed, dispensed and used. The level of satisfaction of the providers and consumers of pharmaceuticals with several aspects of the delivery of pharmaceutical health care, may provide information about the standards of pharmaceutical services and its limitations. Such information may be the basis on which the functions of the pharmacist are expanded and improved. The population studied was the pharmacy personnel in private retail pharmacies and public pharmacies, as well as the consumers that receive prescribed medications at these pharmacies. The results revealed that the criteria of provision of additional information and counselling was most popular among consumers and supplier in determing the efficiency of the pharmacist. A higher proportion of consumers in the public sector reportedly received this service all of the time, than consumers in private sector, and the majority of consumers and suppliers in the private and public sectors are satisfied with the amount of patient counselling that is given by pharmacist with regard to prescribed medications. There is significant association between the consumers' level of satisfaction with waiting time for prescription filling and the sector of the pharmacy. Most suppliers were satisfied with the waiting time of consumers at the pharmacies. However, most consumers and suppliers ares satisfied with the dispensing function of the pharmacist in the provision of health care and there is no significant difference in the level of satisfaction among these groups in private and public sectors. Convenient location of the pharmacy, the facilites or equipment available and their maintenance, and the courtesy and positive attitude of the pharmacist ranked high among the reasons that consumers visit the pharmacies that they do visit. The vast majority of consumers and suppliers were satisfied with the dispensing role of the pharmacist in the provision of health care. A prescription window designed specifically for patients that are interested in the availability and price of prescribed drugs, and patient counselling regarding proper use of drugs were the most popular services that consumers believe should be performed routinely by a pharmacist. The suppliers of pharmaceuticals that work in the public sector appear to be more satisfied with management than those working in the private sector. (AU)

The prescribing patterns of doctors in the Kingston Metropolitan region of Jamaica

Rising inflation and the instability of the Jamaican dollar have impacted negatively on the health care of the Jamaican people. Prescription drugs constitute a major component of this health care expenditure. The Generic Act was introduced to promote the dispensing of generic drugs as affordable alternatives to brand-name drugs and seminars targeted doctors to practise rational prescribing of drugs. This study examined the current prescribing patterns of medical doctors with special regard to drug cost and generic prescribing. Six pharmacies were randomly selected from a list from the Pharmaceutical Association of Jamaica, stratified according to three locations. A total of 1020 prescriptions were analyzed for number of items, generics, antibiotics, analgesics, antihypertensives, antidiabetics and whether generic substituiton or repeat was allowed. A self administered questionnaire was also delivered to 170 physicians practising in the Kingston Metropolitan Region who were chosen randomly from a list supplied by the Medical Association of Jamamica. The questionnaire elicited information on demographic charcteristics, factors influencing prescribing decision, prescribing paractice and attitude to generic law and generic prescribing, knowledge of 10 commonly used drugs and sources of information on drug costs. Analysis of prescriptions showed the mean number of drugs prescribed was 1.2 per patient, antibiotics accounted for 30.9 percent of the components of prescriptions, 0.5 percent had substitution and 6 percent were repeat prescriptions. The percentage of drugs prescribed by generic name was 22.1 accounting for 34 per cent of prescriptions. There was no significant difference found by location of pharmacies (chi-squared+2.86, d.f=2, p=0.24). Doctors indicated that drug cost was the third most influential factor determining their prescribing decisions. There were no significant difference found in the prescribing of generics between public and private doctors (chi-squared=2.42, d.f.=2, p>0.05). Most were ignorant about the Generic law as well as the estimated costs of drugs. The respondents agreed that generics were clinically equivalent and more affordable than brand-name drugs. This survey reaffirms the importance of continued medical education being made available and accessible to doctors on relevant health care issues so as to provide better service through more cost effective means. (AU)

Drug utilization review on high blood pressure and diabetes mellitus in St. Vincent and the Grenadines - abstract

The Eastern Caribbean Drug Service (ECDS) conducted a Drug Utilization Review (DUR) of patients with hypertension and diabetes mellitus in St. Vincent and the Grenadines between August, 1993 and August, 1994. The goal of this study was to assess prescribing practices and initiate appropriate education intervention aimed at enhancing prescribing behaviour. One thousand and sixty-two (1062) prescriptions were collected from both public and private sector pharmacies on a patient quota basis. Four (4) times as many patients were treated with antihypertensives (66 percent) as were treated with antidiabetics (15 percent), while 18 percent of subjects were treated with both. The most commonly used anti-hypertensive drug, bendrofluazide, was most often prescribed at the conventional 5 mg daily dose; however, almost one-third of prescriptions were for the recommended daily dose of 2.5 mg. Methyldopa and chlorpropamide were often used in higher than recommended doses. Few drug incompatibles were documented, as evidenced by the occasional concomitant use of two (2) sulphonylureas. Physicians in St. Vincent appeared to be very conservative in their drug choices and are moving towards currently recommended low doses. They also appear to be cost-conscious, for very few of the newer, higher-cost drugs were used, even in private practice. Significant cost savings could, however, be realised by educating patients in the multiple use of insulin syringes (AU)

Considerations for implementing an antibiotic policy in hospital practice

An antibiotic policy should aim for the safe, effective and economical use of antimicrobial drugs, and to prevent their indiscriminate use and development of resistant bacterial strains. The term 'antibiotic' is used as a general term for all antimicrobial drugs. Antibiotics prescriptions should be based on clinical evidence of bacterial infection, preferably substantiated by appropriate laboratory culture and sensitivity tests. Viral infections are not an indication for antibiotic prescriptions. Patient factors to be considered for choice and dose of an antibiotic are age, pregnancy, lactation, renal and hepatic impairment. Immunodeficient patients should receive only bactericidal drugs. Severity of infection determines the route of administration. Duration of therapy should not exceed five days, unless specifically prescribed by the physician. An antibiotic should, if started as an empirical therapy not be changed before a minimum of three days trial. Prescriptions of drugs such as aztreonam, imipenem, vancomycin, piperacillin and amphotericin are to be restricted due to cost and toxicity and should be reviewed by the microbiologist (AU)

Trinidad and Tobago Ministry of Health drug formulary: a guide to rational drug prescribing

A document listing drugs, which may be purchased by the Ministry of Health, and containing information on the indications, contraindications, side effects, dosage, and any other special information related to the drug.(AU)

Pharmacy dispensing practices for children with diarrhoea in Trinidad and Tobago - abstract

A survey was conducted among 81 pharmacies randomly selected from among 253 pharmacies in Trinidad and Tobago. The aim of the study was to investigate the pharmacy dispensing practices for children with diarrhoea in Trinidad and Tobago. Two local women representing a low-income mother (LIM) and a middle-income mother (MIM) were trained to present the pharmacies with a brief fictitious description of their infant with diarrhoea. Pharmacists' history and advice were noted and the drugs dispensed were bought. Forty-two (51.8 percent) pharmacies gave appropriate treatment and 39 (48.2 percent) dispensed drugs to MIM., where as 54 (66.7 percent) pharmacies dispensed drugs and 27 (33.3 percent) gave appropriate treatment to LIM. Discontinuation of milk feed was advised by 60 (74.1 percent) pharmacies to the LIM and 52 (62.4 percent) pharmacies to the MIM. In order to improve pharmacists' dispensing practices and quality of advice offered, appropriate training programmes should be set up. A national diarrhoeal disease control policy should be formulated and implemented. This would serve as an instrument for rationalizing drug usage. Oral rehydration therapy (ORT) should be established in health centres throughout the country and public awareness of ORT should be enhanced (AU)

Prescribers' formularies and rational drug use - abstract

Traditional formularies were comprehensive "recipe books". As a result of initiatives of the Pan American Health Organisation, five Caribbean countries created National Formularies which were merely limited lists of from 400 (St. Vincent) to 850 (Jamaica) chemical entities. These lists often bore little relation to drugs available, and initially had little impact on prescribing. In 1989, Barbados established an effective Formulary Committee, with mechanisms for annual revision of a National Formulary. The third edition was a "Prescribers' Formulary", with guidance on selection and prescribing of drugs; a twelfth edition appeared in 1990. The Eastern Caribbean Drug Service produces a similar formulary for the members of the OECS (Organisation of Eastern Caribbean States). The impact of both formularies on local prescribing has been increasing steadily. A Drug Utilisation Review (DUR) Pilot Study was carried out at major private Bridgetown pharmacies early in 1991, to assess the extent of use of formulary drugs and Benefit Service schemes. Fifty-one percent of all scripts were for benefit Service items (free for patients of certain ages, under 16 or over 65, or with certain chronic diseases or cancer). Seventy-four per cent of all prescribed items were for formulary drugs. Of the remaining 26 per cent, 6 per cent were the same generic name but a different brand from the formulary drug. These figures show that the Barbados National Formulary markedly influences prescribing practices, including use of generic names and the learning of new brand names associated with lower cost and locally manufactured drugs. The promotion of rational drug use at lower cost depends on an effective formulary process, and a respected prescribers' formulary. The essential components are: a restricted list (never more than 500 drugs), use of generic names, rigorous testing of quality (there is a Caribbean Regional Drug Testing Laboratory in Jamaica), continuity of selection of drugs for chronic diseases, a "cost effective" approach, participation of health professionals in drug selection and protocols and, above all, recognition by all of the formulary as a national guide to rational drug use. The failure of most Caribbean countries to develop national drug policies or effective formularies is due both to the lack of appropriately trained professionals and to the failure of Governments and health planners to recognise these principles (AU)

Health care delivery in Barbados: utilization of the drug service by the elderly

This thesis on the health care delivery system of Barbados, places special emphasis on the Barbados Drug Service utilization by the elderly. Increased human longevity and changing disease patterns have created the need for community-oriented programmes and community support systems for the elderly in Barbados. The Barbados Drug Service is analysed in the context of the broader national health care system. Historically, the system of health care in Barbados was characterized by institutional care provided at the one government-owned general hospital, one psychiatric hospital and five district hospitals which provided long term care for the aged and indigent. Over the years, Barbados has advanced the kind of health care system reflective of primary health care but with some deficiences. The current thrust is decentralization of health services to make the rich and poor alike to have equal access to good quality health services. A network of eight polyclinics has been strategically located at various points in the island to provide comprehensive care. One of the services provided at the polyclinics is the drug service with special benefits for the elderly. The empirical aspect of this thesis provides a survey on the awareness, perception, knowledge and pattern of utilization of the Barbados Drug Service by the elderly. The study findings reveal a high-level of awareness of the existence of the Barbados Drug Service, limited knowledge of the benefits and the failure of the elderly to make maximum use of the service due to their perception and lack of knowledge of the service. Another finding is that many elderly people view the Barbados Drug Service as dealing with illegal drugs and drug abuse. The study identifies problems encountered by the users of the service and includes some of their suggestions for improvement. Recommendations are made based on the study findings.(AU)

A prescription analysis study of drug utilisation in polyclinics in Barbados - abstract

A drug utilisation review was carried out in three polyclinics in Barbados by analysing prescriptions. The prescribing patterns of seven doctors were assessed with respect to (1) the total number of different drugs prescribed, (2) the therapeutic category of each drug, (3) whether they were prescribed by generic or trade name, (4) the number of drugs per patient visit, (4) the cost of one in five prescriptions and (5) the choices within the three most prescribed categories, i.e. analgesics and anti-inflammatory drugs, antibiotics and diruetics. The number of different drugs used by individual doctors was extremely modest. It ranged from 29 to 60 (mean 47). The number of drugs used correlated positively with the number of items per patient visit. The mean items per patient ranged from 1.82 to 3.12. Eighty-eight per cent of prescriptions were written by trade name. Only one doctor, the most highly trained, showed a noticeable preference for generic prescribing, and in spite of a relatively high score of items per patient visit his prescription costs were below the average. Paracetamol (cost 1.5 cents) and then bendrofluazide (cost 1.1 cents) were the two most frequently prescribed drugs. This illustrates prescriber compliance with formulary recommendations. Some other prescribing practices were much less rational and economical. Prescription analysis is an essential tool for monitoring drug use. It reveals bad prescribing practices and can assess responses to education. It provides a logical and cost-effective means of physician audit with potential for improving prescribing practices and hence health care (AU)

Drug therapy in an isolated rural community - abstract

This study was conducted in Carriacou, one of the Grenadine islands affiliated to Grenada, between October 1985 and Janaury 1986, to determine the extent and pattern of drug-prescribing in the island. Three doctors on the island provided general practitioner services at five clinics. From the case-notes, the name, age, sex, diagnosis, treatment and duration of treatment were collected. The diagnosis and treatment were coded and the information processed by computer. A total of 1,349 patients was seen 2,034 times: 17.1 percent of attending patients received no medication, 54.6 percent received one drug per prescription and only 3.4 percent per cent three or more drugs per prescription; 49.2 percent of prescriptions were for less than 14 days whilst 37.3 percent were for 28 days or more. Penicillins were most commonly prescribed, accounting for 10.1 percent of all prescribed drugs. This was followed by aspirin (8.1 percent) and antacids (7.3 percent). Pencillins were the most frequently prescribed drugs for patients under 45 years of age. Antihypertensives were the most frequently prescribed drugs for patients over 45 years of age. There was not excessive prescribing of psychotropic drugs, antibiotics and analgesics when compared with more developed countries. The most frequently recorded health problems were hypertension (14.2 percent), upper respiratory tract infection (8.7 percent) and dyspepsia (6.5 percent). The high incidence of dyspepsia was related to the high alchohol intake and the use of aspirin to treat osteoarthritis. An examination of prescribing practices, increased community education and patient participation can result in more effective and economical use of drugs (AU)

Primary health care delivery in Carriacou, Grenada

The people of Carriacou utilize curative more than preventative services. Over a four month period of study a total of 1349 patients made encounters at the District Medical Officer's clinics. Most of the encounters were for problems which required treatment e.g. circulatory system diseases, respiratory system diseases, musculo-skeletal system diseases. Other clinics, including the chronic disease, dental, dressing clinics and casualty, were also involved in curative work. However, the low percentage of check-ups (2.2 percent), the limited number of Pap smears done (91 or 5.7 percent of females over 15 years old), the poor immunisation status and low contraceptive use all express the need for preventive care. The distribution of health problems in this lesser developed country appears to be similar to more developed countries. Problems which tend to affect developing countries such as infective and parasitic disease are not a cause of significant morbidity on this island. These illnesses rank seventh in the list of most common diseases. Hypertension, upper respiratory tract infections, and dyspepsia are among the three most common health problems. The position dyspepsia occupies is unlike findings in other countries. This may be the result of dietary factors, alcohol abuse or excessive use of aspirin. The problem needs further investigation. There appears to be rational drug prescribing in Carriacou. No prescriptions were written for more than three drugs during the study and 3.4 percent of prescriptions were for three drugs. Poly-pharmacy is avoided. Compared to some more developed countries there is limited use of psychotropic drugs. There is a need for back-up services in instituting health measures. This is brought out by the cessation of clinics at times when the health personnel assigned to certain duties is absent. Immunisation was one such activity that was affected. Carriacou has great potential to become a healthier nation in the Caribbean. One must, therefore alert health planners of the need for: (1) Upgrading the present system of disease reporting (2) Health education programs (3) Cancer screening activities (4) Improved maternal and child health activities (AU)

Barbados national drug formulary: a guide to rational prescribing

The BNDF is intended to be a pocket book for quick reference, of greatest value to young doctors, but also to every prescriber who needs to use a drug for the first time, to check general guidelines, major cautions and side effects or dose ranges; to identify an unfamiliar drug name or seek help with an unusual patient; in short to assist in rational prescribing. It is also an educational tool for pharmacists, nurses and other members of the health care team(AU)

Prescribing practices for hypertension and diabetes mellitus in government and private clinics in Barbados - abstract

A random sample of prescriptions for hypertension (485) and diabetes mellitus (843) was taken from the Queen Elizabeth Hospital dispensary and a large private dispensary. Prescribing practices were compared for Special Benefit Service patients, private patients paying full cost of their prescriptions, hospital "walk-in-clinic" patients and hospital outpatients' clinic patients. The major differences in prescribing for hypertension were: lower use of beta-blockers in the hospital clinics (12 and 16 percent) than in private offices (33 and 28 percent); higher use of methyl dopa by "walk-in" clinic doctors (28 percent); higher use of diruetics in hospital clinics (56 and 49 percent) than in private offices (39 and 47 percent); a surprisingly high use of methyl dopa by "walk-in" clinic doctors (28 percent); higher use of vasodilators in hospital outpatients (11 percent) than in private clinics (5 percent); and higher use of all other drugs by private doctors. The major differences in prescribing for diabetes mellitus were the very low use of insulin in private (4 percent) and "walk-in" clinic (2 percent) patients compared with hospital outpatients (22 percent) and benefit service patients (25 percent); high use of chlorpropamide by private doctors (54 percent); high use of glibenclamide in the "walk-in" clinic (33 percent) and higher metformin use at the hospital (32 and 27 percent) than in private clinics (21 and 20 percent). There was a consistent trend for use of less drugs per patient in private offices, and there was a significantly lower age range of patients attending private offices, compared with those attending hospital clinics and utilising the Drug Benefit Service. Prescription costs were not strikingly different, but private prescription costs appeared to be kept low by using less drugs of greater cost. These data indicate an important place for education/intervention strategies for doctors in therapeutics, to improve prescribing practices, particularly in private and "walk-in" casualty type settings (AU)