Anticancer medicines in Pakistan: An analysis of essential medicines lists.

OBJECTIVE: The lack of anticancer drugs for curative and supportive purposes is the critical reason for the low survival rate in low-and-middle-income countries. This study aims to analyze whether the National Essential Medicines List (NEML) and Registered Essential Medicines List (REML) are in concordance with the World Health Organization (WHO) Essential Medicines List (EML) and whether the formularies prevalent in the country are parallel to each other and to the NEML. METHOD: An observational study design was used in which antineoplastic drugs from the 2021 NEML and REML were compared with 2021 WHO EML to evaluate their availability in Pakistan. Market access was determined. Moreover, the formularies of six different hospital types were compared with each other and with the NEML, and REML to estimate the availability within hospitals. RESULTS: There were 66 anticancer drugs in 2021 WHO EML and all were found in Pakistan's 2021 NEML but only 48 drugs (73%) were found in the REML. Hydroxycarbamide and dasatinib were two registered drugs absent in all hospitals' formularies. The market access for anticancer medicines was 73% (48 of 66). Semigovernment hospital (86%) has the highest availability, followed by the government hospital (80%). All the hospitals have unregistered drugs including bortezomib, lenalidomide, and mesna. CONCLUSION: Pakistan's NEML adopts WHO EML abruptly but all medicines are not registered. The hospitals are trying their best to increase availability but optimum drug regulations to revise NEML based on the country's requirements and emphasizing registration of anticancer medicines are needed to improve the country's availability of antineoplastic agents.

Two Dimensional Heterostructures for Optoelectronics: Current Status and Future Perspective.

Researchers have found various families of two-dimensional (2D) materials and associated heterostructures through detailed theoretical work and experimental efforts. Such primitive studies provide a framework to investigate novel physical/chemical characteristics and technological aspects from micro to nano and pico scale. Two-dimensional van der Waals (vdW) materials and their heterostructures can be obtained to enable high-frequency broadband through a sophisticated combination of stacking order, orientation, and interlayer interactions. These heterostructures have been the focus of much recent research due to their potential applications in optoelectronics. Growing the layers of one kind of 2D material over the other, controlling absorption spectra via external bias, and external doping proposes an additional degree of freedom to modulate the properties of such materials. This mini review focuses on current state-of-the-art material design, manufacturing techniques, and strategies to design novel heterostructures. In addition to a discussion of fabrication techniques, it includes a comprehensive analysis of the electrical and optical properties of vdW heterostructures (vdWHs), particularly emphasizing the energy-band alignment. In the following sections, we discuss specific optoelectronic devices, such as light-emitting diodes (LEDs), photovoltaics, acoustic cavities, and biomedical photodetectors. Furthermore, this also includes a discussion of four different 2D-based photodetector configurations according to their stacking order. Moreover, we discuss the challenges that remain to be addressed in order to realize the full potential of these materials for optoelectronics applications. Finally, as future perspectives, we present some key directions and express our subjective assessment of upcoming trends in the field.

Procurement of medicines to treat cancer, 2015-2020, China.

Objective: To assess the procurement of medicines to treat cancer in China. Methods: We conducted a descriptive analysis of the national procurement data for 20 anti-cancer medicines in China from 2015 to 2020. We estimated the number of defined daily doses procured per year in three areas of China for essential medicines and medicines for targeted therapies. We adjusted the data by the number of cancer patients in each region for each year. Findings: Between 2015 and 2020, the number of defined daily doses per patient decreased from 40.87 to 35.86 (-12.27%) for essential medicines, while the number increased from 0.85 to 12.52 (1381.15%) for target medicines. The procurement of three out of 10 essential medicines decreased, whereas procurement of all 10 targeted medicines increased. In 2020, the eastern area procured the most essential medicines (44.98 doses per patient) and targeted medicines (16.55 doses per patient), but had the smallest relative change in procurement of both essential medicines (-22.76%) and targeted medicines (978.16%). The central area had the largest increase in procurement of both essential medicines (9.64%; from 25.25 to 27.68 doses per patient) and targeted medicines (4587.81%; from 0.23 to 10.64 doses per patient). Conclusion: Procurement of anti-cancer medicines varied across regions. Specific policies are needed at the national level to eliminate inequalities in access to these medicines. Two issues that need attention are the lower access to many essential anti-cancer medicines in some provinces and the increase in use of targeted medicines.

Catastrophic pharmaceutical expenditure in patients with type 2 diabetes in Iran.

OBJECTIVES: This study aimed to assess the financial burden of out-of-pocket (OOP) payments to purchase antidiabetic medicines for type 2 patients in Iran. METHOD: The "budget share" and "capacity to pay" approaches were employed to assess the catastrophic pharmaceutical expenditures of antidiabetic medication therapies. The catastrophic thresholds were adjusted for pharmaceutical sectors. The data was 2019 monthly household expenditures in rural and urban areas, insurance coverages of antidiabetic medicines and patients' out-of-pocket (OOP) payments in 30-day treatment schedules. RESULTS: The results show that expenditure on diabetes medication therapies in the form of mono-dual therapy and some cases triple oral therapies were not catastrophic even for rural households. Insulin puts patients at risk of catastrophic pharmaceutical expenditures when added to the treatment schedules, and lack of financial protection intensifies it. In general, the poorer households and those resistant to first-line treatments were at increased risk of catastrophic pharmaceutical expenditures. The number of treatments that put patients at risk of catastrophic pharmaceutical expenditure in "budget share" was higher than the "capacity to pay" approach. CONCLUSIONS: Assessing medication treatment affordability instead of a single medicine assessment is needed. Assessment could be done by utilizing a macro-level data approach and applying adjusted pharmaceutical sector threshold values. Considering the variation between treatment schedules that put patients at risk of catastrophic pharmaceutical expenditures, targeted pharmaceutical policies and reimbursement decisions are recommended to promote Universal Health Coverage (UHC) and to protect vulnerable populations from hardship.

Antibiotic stewardship program in Pakistan: a multicenter qualitative study exploring medical doctors' knowledge, perception and practices.

BACKGROUND: The emerging threat of antibiotic resistance is growing exponentially and antibiotic stewardship programs are cornerstone to fight against this global threat. The study aimed to explore the knowledge, perspectives and practices of physicians regarding various aspects of antibiotic stewardship program including antibiotic stewardship activities, rational use of antibiotics, antibiotic resistance, prescribing practices and factors associated with these practices. METHODS: In this qualitative study, a total of 17 semi-structured, in-depth interviews with doctors of three tertiary care public sector hospitals in Bahawalpur and Rahim Yar Khan were conducted. The convenient sampling method was adopted to collect the data and the saturation point criterion was applied to determine the sample size. Thematic analysis approach was used to draw conclusions from the data. RESULTS: The analysis of data yielded five themes, 12 subthemes and 26 categories. The themes included, (i) perception about antibiotic use and antibiotic stewardship, (ii) antibiotic prescription practices, (iii) antibiotic resistance, (iv) limited strategies adopted by hospital administration to ensure quality and safe distribution of antibiotics, (v) implementation of antibiotic stewardship program: barriers, suggestion and future benefits. Doctors had misconceptions about the rational use of antibiotics. The perception regarding antibiotic stewardship programs was poor. Moreover, very few activities related to ASP existed. The participants gave many suggestions for successful implementation of ASP in order to reduce the burden of antibiotic resistance, including development of guidelines for the use of antibiotics, strict legislation regarding use of antibiotics, active participation of healthcare professionals and awareness program among general public about the use of antibiotics. CONCLUSION: This study concluded that poor knowledge of doctors regarding ASP, non-existence of antibiogram of hospital and lack of rules for the safe use of antibiotics were the main driving factors associated with irrational antibiotic prescription practices and development of AR.

WHO key access antibiotics price, availability and affordability in private sector pharmacies in Pakistan.

BACKGROUND: Poor availability and unaffordability of key access antibiotics may increase antimicrobial resistance in the community by promoting inappropriate antibiotic selection and abridged therapy compliance. OBJECTIVE: To check the prices, availability, and affordability of the World Health Organization (WHO) key access antibiotics in private sector pharmacies of Lahore, Pakistan. METHODOLOGY: A survey of WHO key access antibiotics from WHO essential medicine list 2017 was conducted in private sector pharmacies of 4 different regions of Lahore employing adapted WHO/HAI methodology. The comparison of prices and availability between originator brands (OB) and lowest price generics (LPG) were conducted followed by the effect of medicine price differences on patient's affordability. The data were analyzed using a preprogrammed WHO Microsoft excel workbook. RESULTS: The mean availability of OB products was 45.20% and the availability of LPGs was 40.40%. The OBs of co-amoxiclav, clarithromycin and metronidazole and LPGs of azithromycin and ciprofloxacin were easily available (100%) in all private sector pharmacies. Whereas, antibiotics like chloramphenicol, cloxacillin, nitrofurantoin, spectinomycin, and cefazolin were totally unavailable in all the surveyed pharmacies. The OBs and LPGs with high MPRs were ceftriaxone (OB; 15.31, LPG; 6.38) and ciprofloxacin (OB; 12.42, LPG; 5.77). The median of brand premium obtained was 38.7%, which varied between the lowest brand premium of 3.97% for metronidazole and highest for ceftriaxone i.e. 140%. The cost of standard treatment was 0.5 day's wage (median) if using OB and 0.4 day's wage (median) for LPG, for a lowest paid unskilled government worker. Treatment with OB and LPG was unaffordable for ciprofloxacin (OB; 2.4, LPG; 1.1) & cefotaxime (OB; 12.7, LPG; 8.1). CONCLUSION: There is dire need to properly implement price control policies to better regulate fragile antibiotic supply system so that the availability of both OB and LPG of key access antibiotics should be increased. The prices could be reduced by improving purchasing efficiency, excluding taxes and regulating mark-ups. This could increase the affordability of patients to complete their antibiotic therapy with subsequent reduction in antimicrobial resistance.

Prescribing trends of oral anticoagulants in England over the last decade: a focus on new and old drugs and adverse events reporting.

Direct-acting oral anticoagulants (DOACs) are replacing conventional VKA (vitamin K antagonist, i.e., warfarin) for various indications where a therapeutic anticoagulant effect is desired. We evaluated the prescribing patterns of the DOACs and warfarin, cost implications of the increasing DOACs prescribing, and deduce the reporting of serious and fatal events, during 2009-2019 in primary care England. Prescriptions and fatal or serious adverse events reporting data, between 2009 and 2019 were analysed, using linear regression to examine the trends in prescriptions, costs, and serious and fatal events reporting. We also compared the prescribing trends of four direct-acting oral anticoagulants and warfarin, normalised to per 1000 clinical commissioning group (CCG) patient population for the year 2019 to better understand the regional differences in DOACs prescribing. The overall use of any DOACs (as a proportion of total anticoagulants) increased from 16% in 2015 to 62% in 2019 with an average increase of 87% (95% CI 83.1, 90.5) per year. The reporting of serious and fatal events associated with DOACs decreased by 6% (95% CI 12.5, - 0.1) per year. Apixaban is by far the most prescribed with an average drug cost increasing to 156% (95% CI 140, 172) per year. In England, the lowest anticoagulant prescribing region was Greater London whereas the highest prescribing regions were Yorkshire and Humber for DOACs and the East Midlands for warfarin. Interestingly, Lancashire, Merseyside, and Cheshire showed a higher usage for warfarin over DOACs. The differing prescription patterns could be a result of changes in national guidelines and increasing population. Nevertheless, DOACs appear to make an increasing contribution to total anticoagulant prescription items and costs.

Assessing the prices and affordability of oncology medicines for three common cancers within the private sector of South Africa.

BACKGROUND: Prices of cancer medicines are a major contributor to the cost of treatment for cancer patients and the comparison of these cost needs to be assessed. OBJECTIVES: To assess the prices of cancer medicines for the three most common cancers ((breast, prostate and colorectal) in the private healthcare sector of South Africa. METHODS: The methodology was adapted from the World Health Organization (WHO)/ Health Action International (HAI) methodology for measuring medicine prices. The Single Exit Price (SEP) variations between product types of the same medicine between the highest- and lowest-priced product and between Originator Brand (OB) and its Lowest Priced Generic (LPG) of the same medicine brand was compared, as of March 2020. The affordability of those medicines for cancer usage based on treatment affordability in relation to the daily wage of the unskilled Lowest-Paid Government Worker (LPGW) was also determined. Also, a comparison of the proportion of the population below the poverty line (PL) before (Ipre) and after (Ipost) procurement of the cancer medicines was determined. RESULTS: SEP Price differences ranged from 25.46 to 97.33% between highest- and lowest-priced products and a price variation of 72.09% more for the OB than the LPG medicine, except for one LPG that was more expensive than the OB. Affordability calculations showed that All OB treatments for all three cancers (breast, prostate and colorectal), except for paclitaxel 300 mg (0.2 days wage) and Fluorouracil (Fluroblastin) 500 mg (0.3 days wage) costs respectively were more than 1 day's wage, with patients diagnosed with colorectal cancer needing 32.5 days wages in order to afford a standard course of treatment for a month. CONCLUSION: There was a considerable variation in the price of different brands of cancer medicines available in the South African private sector.

What impact does medicines shortages have on patients? A qualitative study exploring patients' experience and views of healthcare professionals.

BACKGROUND: The shortage of medicines represents a complex global phenomenon that triggers patient care and safety issues. The study was undertaken to explore the impact of medicines shortages on patients in Pakistan. The study also identified barriers which hinder the solutions of medicines shortages issue. METHODS: A qualitative study design was adopted and the data was collected in stages between July and September 2019using an in-depth interview approach. The purposive and convenient sampling strategy was used to recruit the study participants. Sample size was limited by using the saturation point criteria. All interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis. RESULTS: A total of 35 stakeholders including 13 physicians, 12 pharmacists and 10 patients participated in the study. The findings of the study were classified into five key themes and seven subthemes. The five themes included, 'impact of medicine shortages on patients', 'patients' practices in response to medicine shortages', 'influence of medicines shortages on medical practice or pharmaceutical business', 'barriers to solutions for medicines shortages', and 'suggestions to assuage the impact of medicine shortages.'This study showed that the medicine shortages had significant clinical and financial impact on patients. Patients' opted for a number of risk-prone practices to avoid treatment disruption during shortages. An array of pharmaceutical market, medicines quality and patient related factors refrain physicians to switch from brand name medicine to generics and lead to ineffective management of medicines shortages. Promotion of generic prescription, implementation of punitive policies and proper patient consultation was advised to assuage the impact of medicine shortages on patients. CONCLUSION: The adverse clinical, economic and humanistic impact affirmed in this study demand the introduction of risk-management strategies for medicines shortages in hospital and community settings in accordance with the international standards. Promotion of effective patient counselling by the healthcare professionals to deter risk-prone practices associated with medicines shortages is mandatory.

How medicines sales staff is responding to presumptive COVID-19 patients attending drug retail outlets: An exploratory qualitative study.

The objective of this qualitative study was to explore how the medicine sales staff responded to presumptive COVID-19 patients in Pakistan. The data were obtained from the medicine sales staff working at drug retail outlets of Bahawalpur, Punjab, Pakistan, through in-depth face-to-face interviews using a semi-structured interview guide. A two-step sampling strategy was used, including purposive and convenient sampling techniques. Sample size was determined by applying the saturation point criteria. A total of 17 interviews were audio-recorded, transcribed verbatim and analysed using the thematic analysis. Analysis of data yielded six themes and seven sub-themes. The themes included (1) knowledge about various aspects of COVID-19, (2) practices of sales staff in response to COVID-19 pandemic, (3) attitude of sales staff towards COVID-19 pandemic, (4) services offered to presumptive COVID-19 patients, (5) challenges encountered during pandemic and (6) suggestions to improve delivery of pharmacy services by sales staff. In Pakistan, non-pharmacist sales staff had superficial knowledge about COVID-19. Presumptive COVID-19 patients were provided with only basic pharmacy services. Professional training is advised among pharmacy sales staff as a short-term solution to improve their knowledge. As a long-term goal, the availability of pharmacists at drug retail outlets is warranted.

The effects of pricing policy on the prices and supply of low-cost medicines in Shandong, China: evidence from an interrupted time series analysis.

BACKGROUND: In China, some medicines had a supply problem. In 2015, to address this problem, the Chinese government issued a policy to raise the price cap for some shorted low-cost medicines (LCMs). The objective was to assess the effects on medicine prices and supply of medicines from a medicine pricing policy reform point of view. METHODS: This study was conducted in Shandong, an eastern province of China with a population of 99.4 million. We collected procurement data of all (n = 1494) LCM medicines available between April 2014 and February 2017 from the web-based Provincial Drug Centralized Bidding Procurement System. This study used the Drug Price index and the average price to reveal the price change of LCMs and used the interrupted time series to evaluate the effects of LCM policy on medicine supply by measuring the change of monthly procurement volume, the number of products, and the average delivery time of LCMs. RESULTS: After the policy implementation in October 2015, the quarterly average price of all LCM products, especially traditional Chinese medicines, showed a sudden growth trend. Then after two-quarter implementation of policy, the price recovered to the same trend before policy intervention, which is consistent with the trend of the Drug price index. There were 466 of LCM products available in October 2015. After the policy intervention, the number of products available increased by 109.87% (n = 978) in February 2017, at a growth rate of 6.44% per month (Value = 30.02, P < 0.001). Besides after the intervention in October 2015, the monthly procurement volumes of LCMs increased rapidly, on average, at a rate of 28.93% per month (Value = 474,000, P < 0.001) for all LCMs. The average delivery time of LCMs kept on decreasing from 33.37 days to 10.69 days at a reduced rate of 3.63% (Value = - 1.21, P < 0.001) per month before the policy, while no significant changes were noted. Also, average monthly delivery time was stable at 9 days after the intervention. CONCLUSIONS: The policy promoted the supply of low-cost medicines, which is beneficial for the Universal Health Coverage. However, future policies should focus on monitoring price change and reducing the delivery time of generic medicines.

Interventions to improve insulin prescribing practice for people with diabetes in hospital: a systematic review.

AIM: To conduct a systematic review of literature to identify interventions that are effective in improving insulin prescribing for people with diabetes in the hospital setting. METHODS: Computerized bibliographic databases were searched for studies published in English that described the effectiveness of interventions to improve insulin prescribing within the hospital setting. Studies were eligible for inclusion if they reported data that compared insulin prescribing practice after an intervention or compared with a control group. Studies were not excluded on the basis of publication date, geographical location or risk of bias assessment. RESULTS: We identified 35 studies for inclusion in the review, including two cluster randomized controlled trials, two cohort studies, and 31 uncontrolled before-after studies. Studies reported a variety of interventions that aimed to increase insulin prescribing accuracy or completeness or decrease the use of discouraged subcutaneous sliding scale insulin regimens. Differences in definition of insulin prescribing error, terminology and common practice based on geographical location was evident, and quality issues with respect to study design and reporting somewhat limited the interpretation of conclusions. CONCLUSIONS: Implementing strategies that are sensitive to local context and designed to increase adherence to insulin prescribing guidelines are associated with a reduction in prescribing errors. Future implementation should build on effective approaches including multifaceted interventions involving multiple stakeholders at various institutional levels. Future studies in insulin prescribing errors would benefit from the use of standardized approaches, terminology and outcome measures to enable greater comparison.

Editorial: Medicines pricing, access and safety in Morocco.

Unregulated supply of medicines compromises quality assurance and risks patient safety. The emergence of illegal medicines trafficking in Morocco presents a major health threat, which highlights the need for region-wide alignment in policies to drive stringent regulatory enforcement and robust health systems that ensure population- wide access to safe medicines. Herein, we draw on insights from a situational analysis in Morocco, as a lower- middle income setting, to present access to medicines through regulated supply procedures as a vital prerequisite for quality assurance and patient safety.

L'approvisionnement non réglementé en médicaments compromet l'assurance qualité et la sécurité des patients. L'émergence du trafic illégal de médicaments au Maroc constitue une menace majeure pour la santé, ce qui souligne la nécessité d'un alignement régional des politiques pour une application stricte de la réglementation et des systèmes de santé robustes garantissant l'accès de la population à des médicaments sûrs. Nous nous inspirons d'une analyse situationnelle menée au Maroc, en tant que pays à revenu moyen-inférieur, pour présenter l'accès aux médicaments par le biais de procédures d'approvisionnement réglementées, prérequis indispensable à l'assurance qualité et à la sécurité des patients.

A systematic review of patient-reported outcomes associated with the use of direct-acting oral anticoagulants.

AIMS: Patient-reported outcomes (PROs) are a distinctive method of evaluating patient response to health care or treatment. This systematic review aimed to analyse the impact of PROs in patients on direct oral anticoagulant (DOAC) treatment, prescribed for any indication (e.g. venous thromboembolism treatment or atrial fibrillation) using controlled trials (CT) and real-world observational studies (OS). METHODS: A systematic search of articles was conducted according to PRISMA guidelines using databases, with the last update in November 2018. The Cochrane Collaboration tool for assessing bias in randomized CTs and the Newcastle-Ottawa Scale adapted for cross-sectional studies were used. Outcomes evaluated were related to health-related quality of life (HRQoL), satisfaction, adherence and compliance. RESULTS: Twenty-one original studies (6 CT, 15 OS) were included. HRQoL was assessed by 6 (1 CT, 5 OS) studies and reported that HRQoL scores were similar in patients on DOACs and warfarin. Patients prescribed DOACs presented higher HRQoL scores which were attributed to lack of intense monitoring required compared with warfarin but this was not statistically significant. The majority of studies (5 CT, 9 OS) investigated patient-reported satisfaction, indicating greater satisfaction with DOACs with significantly lower burden and increased benefit scores for patients on DOACs. Patient-reported expectations, compliance and adherence were similar for patients on DOACs and warfarin. CONCLUSION: Patients appear to prefer treatment with DOACs vs warfarin. This is shown by the higher quality of life, satisfaction and adherence described in the studies. However, heterogeneity in the analysed studies does not allow firm conclusions.

Evaluating medicine prices, availability and affordability in Bangladesh using World Health Organisation and Health Action International methodology.

BACKGROUND: Previous studies have shown limited availability of medicines in health facilities in Bangladesh. While medicines are dispensed for free in public facilities, they are paid out-of-pocket in private pharmacies. Availability, price and affordability are key concerns for access to medicines in Bangladesh. METHODS: The World Health Organization/Health Action International survey methodology was used to determine price, availability and affordability of 61 lowest price generic (LPG) and originator branded medicines in public facilities, private retail pharmacies and private clinics across 6 regions of Bangladesh. Medicines for non-communicable and infectious diseases, and both on and off the national Essential Medicines List were included. Prices were compared internationally using Median Price Ratio (MPR). RESULTS: Mean LPG (originator brand) availability in the public sector, private retail pharmacies, and private clinics was 37%, 63 (4) percent, and 54 (2) percent, respectively. Medicines for Non-Communicable Diseases (NCD) and essential medicines were significantly less available than infectious disease medicines and non-essential medicines, respectively. Mean LPG (originator brand) MPR was 0.977 in the public sector, 1.700 (3.698) in private retail pharmacies and 1.740 (3.758) in private clinics. Six medicines were expensive by international standards across all sectors. The least affordable treatments in both private sectors were bisoprolol (hypertension), metformin (diabetes) and atorvastatin (hypercholesterolemia). CONCLUSION: Availability and affordability of NCD medicines are key concerns where the burden of NCD is rising. These findings show improvement from earlier studies, but room for further advances in availability and affordability of NCD medicines in Bangladesh. A small number of medicines are consistently expensive across sectors in Bangladesh, suggesting the need for strategies to address prices for certain medicines.

Cross verification of prescribing trends through loop evaluation of physicians, patients and medical store personnel.

BACKGROUND: Prescription connects physician, patient and community pharmacy personnel who can help in understanding prescribing pattern. The present study was aimed to get an insight of viewpoints of all members involved in progression of events from prescription to drug purchase, i.e., physician, patient and medical-store personals regarding the prescription pattern in Pakistan. METHODS: Therefore, a cross-sectional study was conducted in four provinces and capital territory (Islamabad) of Pakistan to evaluate the perception of physicians, patients and medical stores/pharmacy personnel of the prescribing trends in Pakistan. RESULTS: Response rate was higher from Punjab and lower in Sindh. Responses of 981 walk-in patients with 393 physicians and 618 medical stores/pharmacies were received and statistically evaluated. The majority of physicians, patients and pharmacists/medical store personnel considered the medicines of multinational manufacturers as more effective. Physicians considered their prescribing cost-effective. However, majority of patients as well as pharmacists/medical store personnel strongly disagreed or disagreed with this notion that physicians prescribe cheap medicines. Furthermore, physicians and patients reported that medicines of local companies were not as effective as the medicines of multinational manufacturers, which were contrary to what pharmacists thought. Majority of physicians disagreed that their prescribing was under the influence of medical stores in their vicinity. The response of most of the patients (40.5%) was in line with that of physicians whereas 32% pharmacist/medical store personnel agreed. Nearly half of the physicians strongly agreed or agreed that patients demand medicines of multinational companies. Contrarily, a majority of patients and medical store personnel denied that patients demand for the medicines of multinational manufacturers. CONCLUSION: The study highlighted that there was a need to develop policy guidelines at the level of Federal Government and Drug Regulatory Authority of Pakistan in connection with prescribing practices to reduce the variation in perception of key stakholders involved in drug use process.

Association between the Vicious Cycle of Diabetes-Associated Complications and Glycemic Control among the Elderly: A Systematic Review.

Background and objectives: Improved quality of life (QoL) and life expectancy of elderly diabetic patients revolves around optimal glycemic control. Inadequate glycemic control may lead to the development of diabetes-associated complications (DAC), which not only complicate the disease, but also affect morbidity and mortality. Based on the available literature, the aim was to elucidate the vicious cycle underpinning the relationship between diabetes complications and glycemic control. Materials and Methods: A comprehensive literature search was performed to find eligible studies published between 1 January 2000 and 22 September 2018 pertaining to diabetes complications and glycemic control. Results: Initially, 261 studies were retrieved. Out of these, 67 were duplicates and therefore were excluded. From the 194 remaining articles, 85 were removed based on irrelevant titles and/or abstracts. Subsequently, the texts of 109 articles were read in full and 71 studies were removed at this stage for failing to provide relevant information. Finally, 38 articles were selected for this review. Depression, impaired cognition, poor physical functioning, frailty, malnutrition, chronic pain, and poor self-care behavior were identified as the major diabetes-associated complications that were associated with poor glycemic control in elderly diabetic patients. Conclusions: This paper proposes that diabetes-associated complications are interrelated, and that impaired glycemic control aggravates diabetes complications; as a result, patient's self-care abilities are compromised. A schema is generated to reflect a synthesis of the literature found through the systematic review process. This not only affects patients' therapeutic goals, but may also hamper their health-related quality of life (HRQoL) and financial status.

Pricing appraisal of anti-cancer drugs in the South East Asian, Western Pacific and East Mediterranean Region.

BACKGROUND: Globally, cancer is one of the leading causes of mortality. High treatment cost, partly owing to higher prices of anti-cancer drugs, presents a significant burden on patients and healthcare systems. The aim of the present study was to survey and compare retail prices of anti-cancer drugs between high, middle and low income countries in the South-East Asia, Western Pacific and Eastern Mediterranean regions. METHODS: Cross-sectional survey design was used for the present study. Pricing data from ten counties including one from South-East Asia, two from Western Pacific and seven from Eastern Mediterranean regions were used in this study. Purchasing power parity (PPP)-adjusted mean unit prices for 26 anti-cancer drug presentations (similar pharmaceutical form, strength, and pack size) were used to compare prices of anti-cancer drugs across three regions. A structured form was used to extract relevant data. Data were entered and analysed using Microsoft Excel®. RESULTS: Overall, Taiwan had the lowest mean unit prices while Oman had the highest prices. Six (23.1%) and nine (34.6%) drug presentations had a mean unit price below US$100 and between US$100 and US$500 respectively. Eight drug presentations (30.7%) had a mean unit price of more than US$1000 including cabazitaxel with a mean unit price of $17,304.9/vial. There was a direct relationship between income category of the countries and their mean unit price; low-income countries had lower mean unit prices. The average PPP-adjusted unit prices for countries based on their income level were as follows: low middle-income countries (LMICs): US$814.07; high middle income countries (HMICs): US$1150.63; and high income countries (HICs): US$1148.19. CONCLUSIONS: There is a great variation in pricing of anticancer drugs in selected countires and within their respective regions. These findings will allow policy makers to compare prices of anti-cancer agents with neighbouring countries and develop policies to ensure accessibility and affordability of anti-cancer drugs.

Economic Evaluation of Hospital and Community Pharmacy Services.

OBJECTIVE: To review the international body of literature from 2010 to 2015 concerning methods of economic evaluations used in hospital- and community-based studies of pharmacy services in publicly funded health systems worldwide, their clinical outcomes, and economic effectiveness. DATA SOURCES: The literature search was undertaken between May 2, 2015, and September 4, 2015. Keywords included "health economics" and "evaluation" "assessment" or "appraisal," "methods," "hospital" or "community" or "residential care," "pharmacy" or "pharmacy services" and "cost minimisation analysis" or "cost utility analysis" or "cost effectiveness analysis" or "cost benefit analysis." The databases searched included MEDLINE, PubMed, Google Scholar, Science Direct, Springer Links, and Scopus, and journals searched included PLoS One, PLoS Medicine, Nature, Health Policy, Pharmacoeconomics, The European Journal of Health Economics, Expert Review of Pharmacoeconomics and Outcomes Research, and Journal of Health Economics. STUDY SELECTION AND DATA EXTRACTION: Studies were selected on the basis of study inclusion criteria. These criteria included full-text original research articles undertaking an economic evaluation of hospital- or community-based pharmacy services in peer-reviewed scientific journals and in English, in countries with a publicly funded health system published between 2010 and 2015. DATA SYNTHESIS: 14 articles were included in this review. Cost-utility analysis (CUA) was the most utilized measure. Cost-minimization analysis (CMA) was not used by any studies. The limited use of cost-benefit analyses (CBAs) is likely a result of technical challenges in quantifying the cost of clinical benefits, risks, and outcomes. Hospital pharmacy services provided clinical benefits including improvements in patient health outcomes and reductions in adverse medication use, and all studies were considered cost-effective due to meeting a cost-utility (per quality-adjusted life year) threshold or were cost saving. Community pharmacy services were considered cost-effective in 8 of 10 studies. CONCLUSIONS: Economic evaluations of hospital and community pharmacy services are becoming increasingly commonplace to enable an understanding of which health care services provide value for money and to inform policy makers as to which services will be cost-effective in light of limited health care resources.

A qualitative study exploring perceptions and attitudes of community pharmacists about extended pharmacy services in Lahore, Pakistan.

BACKGROUND: In recent decades, community pharmacies reported a change of business model, whereby a shift from traditional services to the provision of extended roles was observed. However, such delivery of extended pharmacy services (EPS) is reported from the developed world, and there is scarcity of information from the developing nations. Within this context, the present study was aimed to explore knowledge, perception and attitude of community pharmacists (CPs) about EPS and their readiness and acceptance for practice change in the city of Lahore, Pakistan. METHODS: A qualitative approach was used to gain an in-depth knowledge of the issues. By using a semi-structured interview guide, 12 CPs practicing in the city of Lahore, Pakistan were conveniently selected. All interviews were audio-taped, transcribed verbatim, and were then analyzed for thematic contents by the standard content analysis framework. RESULTS: Thematic content analysis yielded five major themes. (1) Familiarity with EPS, (2) current practice of EPS, (3) training needed to provide EPS, (4) acceptance of EPS and (5) barriers toward EPS. Majority of the CPs were unaware of EPS and only a handful had the concept of extended services. Although majority of our study respondents were unaware of pharmaceutical care, they were ready to accept practice change if provided with the required skills and training. Lack of personal knowledge, poor public awareness, inadequate physician-pharmacist collaboration and deprived salary structures were reported as barriers towards the provision of EPS at the practice settings. CONCLUSION: Although the study reported poor awareness towards EPS, the findings indicated a number of key themes that can be used in establishing the concept of EPS in Pakistan. Over all, CPs reported a positive attitude toward practice change provided to the support and facilitation of health and community based agencies in Pakistan.