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.
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.
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.
Table 1 shows the result for the control group
Table 2 shows the result for Test Group 1
Table 3 shows the result for Test Group 2
Table 4 shows the result for Test Group 3
Table 5 shows the change in daily prescription cost