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Intervention study to reduce prescription cost in the Lagos University Teaching Hospital

Mabadeje AFB , Taylor O, Abiose AK

Lagos University Teaching Hospital & College of Medicine, University of Lagos, Nigeria

 

The components of the Nigerian National Drug Policy include the selection and procurement of essential drugs at affordable cost and of established good quality. A preliminary survey of prescribing habits of 60 doctors in medical outpatient clinics and medical wards of the Lagos University Teaching Hospital showed that there was a tendency to prescribe the expensive alternatives of drugs. They were subdivided into control and test groups by stratified random sampling. The controls were allowed to continue with their usual prescribing habits while the test subjects were given regular counselling by one of us (AFBM). Test group 1 had only weekly counselling for 4 weeks using the WHO Guide to Good Prescribing manual, Test group 2 had only printed handouts, and Test group 3 had counselling reinforced with handouts. The handouts showed the correct treatment for the chosen diseases, the comparative costs of different indicated drugs and the amount of money to be saved by the patient if cheaper and equally effective alternative drugs are prescribed. The diseases chosen were hypertension, diabetes and chest infection (upper and lower respiratory). In surveys repeated after 4 weeks using these modified WHO indicators (% generic, number of drugs per prescription per single diagnosis, daily cost per prescription per single diagnosis) the control group showed no change; Test group 1 showed better improvement than Test group 2, but Test group 3 showed the greatest improvement of all in the indicators surveyed. The three months post intervention survey will be performed without further reinforcement of the intervention in half of the group 3 subjects to see if the improvement can be maintained without reinforcement. Face-to-face counselling reinforced with printed materials is the most effective way of changing bad prescribing habits.

 

Introduction

In 1975, after the essential drugs concept was introduced in the WHO Director General's report to the 28th World Health Assembly, Resolution WHA28.66 requested that the proposals contained in this report be implemented and advice to WHO Member States on the selection, procurement at reasonable cost of essential drugs of established quality, corresponding to their national health needs be given. The first Nigerian National Formulary and Essential Drugs List was published in 1986 and has been revised three times, although the third revision (done in 1993) is yet to be published. The Nigerian National Health Policy and Nigerian National Drug Policy were launched in 1988 and 1991 respectively, but although drugs are now more readily available, the prevailing prices are exorbitant. Consequently there has been a considerable decline in the utilisation of public health facilities. Patients only patronise the secondary and tertiary health care centres when they are terminally ill. They prefer to seek the services of the traditional and alternative medicine practitioners, the efficacy of whose remedies is still largely in doubt. The University Teaching Hospitals are tertiary health care facilities where the academic medical practitioners are concentrated. One would expect that they would blaze the trail in rational drug use, but a close look at the prescription pattern of doctors in these hospitals shows that there is overprescribing as well as expensive prescribing. The result is that despite the establishment of a drug revolving fund scheme in these facilities there is still a considerable occurrence of drug shortages. The hypothesis is that if doctors in these hospitals are properly instructed in the method of rational prescribing, there will be a reduction in prescription cost.

 

Objectives

  • To carry out a prescription survey of doctors in the medical units of the Lagos University Teaching Hospital.
  • To find out if doctors have precise knowledge of the active components of the brand name drugs which they prescribe.
  • To find out doctors' sources of drug information .
  • To find out if intervention using printed materials only produces an improvement in prescribing habits.
  • To find out if intervention using both printed materials and face-to-face instructions produces a greater improvement in prescribing habits than using printed materials only.
  • To find out if the reduction in overprescribing is translated into a reduction in cost of prescriptions.

 

Methods

A preliminary survey of the prescribing habits of doctors in the department of medicine of the Lagos University Teaching Hospital was carried out using outpatient prescription forms and inpatient treatment sheets. Questions were also asked about their knowledge of the active components of brand name drugs like "septrin", "augmentin", "brinerdin", "moduretic", "daonil" and "glucophage". They were also asked about their four main sources of drug information and education. The subjects were then divided into four groups by stratifying them according to their status and randomly selecting three groups from each grade. Group 1 acted as the control and was allowed to continue usual prescribing habits. Test group 1 had only weekly counselling session during 4 weeks using the WHO "Guide to Good Prescribing" manual. Test group 2 only had printed handouts stating the correct drug treatment for the chosen index diseases, while Test group 3 had counselling reinforced with printed handouts. The index diseases were hypertension, diabetes and chest infection (upper and lower respiratory tract). The printed handouts showed the correct treatment for the chosen diseases, the comparative costs of different indicated drugs, and the amount of money to be saved by the patient if cheaper and equally effective alternative drugs are prescribed. Surveys were repeated after 4 weeks for all four groups. The results were analysed using EPIINFO Version 6. Students' t-tests were used to compare the difference between the groups. A value of P<0.05 was regarded as significant difference.

 

Results

Table 1 shows the result for the control group

Period

Hypertension

 

Diabetes

 

Chest infection

 

 

 

 

Number of drugs

Percent generic

Number of drugs

Percent generic

Number of drugs

Percent generic

Baseline

4.1 0.4

348.1

3.50.5

1710

3.00.7

3215

4 weeks

5.0 0.4

31 7.9

3.80.4

227.6

3.30.6

3911

P

NS

NS

NS

NS

NS

NS

 

Table 2 shows the result for Test Group 1

Period

Hypertension

 

Diabetes

 

Chest infection

 

 

 

 

Number of drugs

Percent generic

Number of drugs

Percent generic

Number of drugs

Percent generic

Baseline

5.11.1

402.5

4.3O.3

426.4

4.40.2

423.7

4 weeks

3.80.3

766.2

3.60.2

709.1

3.70.2

787.2

P

<0.005

<0.001

NS

<0.001

NS

<0.001

 

Table 3 shows the result for Test Group 2

Period

Hypertension

 

Diabetes

 

Chest infection

 

 

 

 

Number of drugs

Percent generic

Number of drugs

Percent generic

Number of drugs

Percent generic

Baseline

4.10.3

208.5

3.80.3

3815.1

4.5O.3

526.1

4 weeks

3.80.3

687.8

3.40.3

658.8

4.00.2

605.2

P

NS

<0.001

<0.005

NS

 

Table 4 shows the result for Test Group 3

Period

Hypertension

 

  Diabetes

 

  Chest infection

 

 
 

 

 

Number of drugs

Percent generic

Number of drugs

Percent generic

Number of drugs

Percent generic

Baseline

3.70.2

415.4

3.90.5

3515.8

3.50.5

0.00

4 weeks

3.40.1

9210

2.30.1

1000

2.50.2

885.8

P

<0.05

<0.001

<0.0001

<0.0001

<0.001

<0.0001

 

Table 5 shows the change in daily prescription cost

Period

Control

 

Test group 1

 

Test group 2

 

Test group 3

 

 

 

Cost of drugs

Percent change

Cost of drugs

Percent change

Cost of drugs

Percent change

Cost of drugs

Percent change

Baseline

N18850

582180

15687

11527

4 weeks

15422

-18.00

35072

-40.00

11465

-27.00

5214

-55.00

P

NS

<0.05

NS

<0.05

Conclusions 

  • The control group showed no change in their prescription habits.
  • Those with weekly counselling only showed considerable improvement.
  • Those with printed handouts only showed less improvement than those counselled.
  • Those whose counselling was reinforced with printed handouts demonstrated the greatest improvement.
  • Face-to-face counselling reinforced with printed materials is the most effective way of changing bad prescribing habits.
  • Proper instruction in the method of rational prescribing produces a reduction in prescription cost.