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Session GuideImplementing a Drug Use

Indicators Study

IMPLEMENTING A DRUG USE INDICATORS STUDY SESSION GUIDE

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Implementing a Drug Use Indicators Study

SESSION GUIDE

PURPOSE AND CONTENT

The purpose of this session is to train participants how to describe the drug use situationin a particular setting. Experience from many countries has encouraged the developmentof a standard method of measuring drug use practices, based on drug use indicators. This unit will expose you to the process of implementing a drug use indicator study.

The three activities will help you to gain experience in carrying out the basic steps of a realstudy through simulation exercises.

[VA1]OBJECTIVES

By the end of the session, you will be able to:

1. Identify the importance of drug use indicators.

2. Identify steps to be taken in preparing and implementing a drug use indicators study.

3. Understand the strengths and weaknesses of different methods of sampling and datacollection.

4. Understand how to analyze drug use practice in a given setting using the drug useindicators.

5. Present the results of a drug use indicator study.

PREPARATION AND MATERIALS

1. Read the Session Notes.

2. Become familiar with the WHO Manual, "How to Investigate Drug Use in HealthFacilities." WHO/DAP 93.1

3. Read Hogerzeil H.V., et al. Field tests for rational drug use in twelve developingcountries. The Lancet, 4 December 1993; pp 1408-1410. (See Annex)


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Implementing a Drug Use Indicators Study

SESSION NOTES

A. OVERVIEW

Researchers and need to understand drug use problemsso that they can work to improve performance. (seeIntroduction to "How to Investigate Drug Use in HealthFacilities").

"Drug Use" involves not only the actual prescribing ofdrugs but also a wide range of behaviors that occur duringthe drug use encounter, the interaction between theprescriber (provider) and the patient. These behaviorsinclude the processes of making a diagnosis, prescribing,dispensing, and use of drugs by the patient.

[VA 2]Drug use indicator studies can be used for four main purposes. (See Table 4, P. 26 of theWHO Manual). These purposes are:

1. A descriptive cross-sectional study -- this measures drug use in a representativegroup of facilities.

2. A comparative cross-sectional study -- this compares facilities, providers, orgroups at a single time.

3. Supervision (monitoring) -- to identify whether a facility is above or below a setnorm of practice.

4. An assessment of the impact of an intervention (evaluation) -- to assess theimpact of an intervention in an intervention group and a control group, bymeasuring indicators before and after.

For each different purpose, different sampling methods may be required.

In assessing drug use, you would ideally want to know about the whole process of care,but unfortunately this is not always possible. A set of limited indicators, namely the DrugUse Study Indicators, has been developed to assist in such an assessment. Theseindicators have been selected through a process of discussion, field testing, and revision,involving a wide range of people coordinated by INRUD, with support from WHO/DAP.


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Other indicators may be used when different needs arise.

[VA 3]The WHO/DAP indicators are divided into three groups: Prescribing Indicators; PatientCare Indicators; and Facility Indicators. The list of the indicators follows:

PRESCRIBING INDICATORS

1. Average Number of Drugsper Encounter

2. Percentage of DrugsPrescribed by GenericName

3. Percentage of Encounters

with an AntibioticPrescribed

4. Percentage of Encounters with an Injection Prescribed

5. Percentage of Drugs Prescribed from Essential Drugs List or Formulary

[VA4]PATIENT CARE INDICATORS

6. Average Consultation Time

7. Average Dispensing Time

8. Percentage of Drugs Actually Dispensed

9. Percentage of Drugs Adequately Labeled

10. Patients' Knowledge of Correct Dosage

[VA 5]FACILITY INDICATORS

11. Availability of Copy of Essential Drugs List or Formulary


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12. Availability of Key Drugs

[VA 6]B. DESIGNING A DRUG USE INDICATORS STUDY

The design of a drug use indicators study will vary from setting to setting. The nature andscope will depend on many factors, such as:

• the information needs of health managers• the capabilities of the record systems• the types of providers whose behavior is to be described• the resources available to carry out the work

The purpose of the study will determine which indicators to use and how the study shouldbe designed. Possible purposes of drug use indicators studies are:

• Describe current treatment practicesUseful for problem identification or for collecting baseline information at thebeginning of a project. Usually more general/basic indicators are used todescribe the situation.

• Compare performance among health facilities or regionsMore specific indicators usually are used; the choice of which indicators to use ismade on the basis of previous findings or knowledge of the practices in an area.

• Assess the impact of an interventionIn this case certain key outcome indicators have been determined at thebeginning of an intervention project. This study is meant to measure whether theobjectives of the intervention have been met by measuring changes in theseindicators.

• Periodic monitoring of drug use.Supervisors can select important performance indicators to monitor over time ina set of health facilities, so that their supervision can be more focussed andtargeted at specific improvements.

[VA 7]C. SAMPLING ISSUES

A great deal of work has been done to determine the optimum sampling arrangement toassess a drug use situation. (See Session Guide, Sampling for Drug Use Studies and theAnnex to the WHO Manual)]


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When an assessment of the drug use situation in a region or a set of health facilities isrequired, a sample of 30 prescriptions from each of 20 sites is the optimal arrangement. Ifthe number of sites can be increased this should be done.

When a survey is undertaken to measure impact of an intervention or to assess practicesin individual facilities, at least 100 prescriptions per site should be studied.

The basic design for an indicator study carried out to characterize drug use practices in aregion would call for a sample of at least 20 health facilities, with at least 30 encountersbeing recorded in each facility. Studying 20 facilities, or more if possible, will increase thereliability and generalizability of indicators.

If you have identified fewer that 20 health facilities of interest, clearly all facilities should beincluded, and the number of encounters studied in each facility should be increased toensure that 600 observations or prescriptions are included. However in this case,because the number of facilities studied is low, conclusions about practices in otherfacilities that were not studied should be advanced cautiously.

If there are more than 20 facilities in the study areas that will be included in the prescribingsurvey, it may be necessary to draw a sample of facilities for the study from the largerpopulation. There is danger of introducing error into the results of the prescribing analysisat this step by selecting facilities for the sample which share a certain bias that mightinfluence their prescribing patterns. One example would be only selecting and collectingdata from facilities that are easier to reach; because they are more accessible, suchfacilities might also have more reliable drug supply and because of this, their prescribingpractices might be different.

[VA 8]D. PRESCRIBING INDICATORS

The first five indicators record information about how many and what type of drugsare prescribed. These indicators include:


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Average number of Drugs Prescribed

Percent Prescribed by Generic Name

Percent of Patients Receiving Antibiotics

Percent of Patients Receiving Injections

Percent of Drugs Prescribed on the EDL

Two forms for collecting these indicators (the Simple Prescribing Indictors Form andDetailed Prescribing Indicators Form) included in Annex 1. The following steps describethe process for measuring the prescribing indicators.

1. Decide on Source of Data for Prescribing EncountersOne of the basic decisions to be made in designing an indicators study is whether to useretrospective data extracted from historical records, or prospective data collected fromcurrent patients as they are treated. There are advantages and disadvantages to bothtypes of data collection.

Retrospective treatment records exist in many facilities, although often in different forms. These records are typically kept as part of the normal morbidity or drug consumptionrecording and reporting systems, or else as part of a facility-based system of medical orpharmacy records.

Retrospective data are usually easier to collect than prospective data, and suffer fewerpotential biases. If they are well-maintained, it is often possible to define a retrospectivestudy period of a year or longer, and spread cases throughout this period. This serves tominimize any possible bias due to seasonal variations in health problems. It also meansthat treatment is observed at many points in the drug supply cycle. If practices tend tochange during periods of drug shortage, this will be reflected in the data sampled fromthese different periods. The major weakness of retrospective data is that they are oftenincomplete. Individual or entire series of records can be missing, either because theywere misplaced or because they were simply not recorded in the first place. The validity ofretrospective data is often difficult to verify. Since retrospective records are usually keptfor a different purpose than prescription analysis, key data elements such as an exactidentification of the pharmaceutical prescribed, health problem, or even whether a drugwas dispensed as prescribed, can be consistently missing or of uncertain accuracy.

Prospectively collected data have the advantage that they are usually complete. However,since prospective treatment data are often collected over a very short period of time, theycan suffer biases due to seasonality, peculiarities in staffing, inconsistencies in the supplycycle, or most importantly, due to the fact that providers are aware that their behavior isbeing observed. Of course, in the absence of retrospective sources of data, study


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planners have little choice but to collect data prospectively, and try to guard against thesepossible sources of bias. Both sources of data have been validated in INRUD studies.

The principle question to answer in deciding to use retrospective or prospective encounterdata is whether adequate sources of retrospective data exist. The useful elements fordesigning a retrospective sample that these historical data provide include:

• the ability to link specific health problems diagnosed with specific drugsprescribed for individual patient encounters;

• a method of selecting a random sample of patient encounters that took placewithin a defined period of time.

Whenever possible, use retrospective data spread over the past year. Draw a sample ofrecords using one of the techniques described in the sampling module (usually systematicor multistage sampling.)

2. Define Types of Encounters to be IncludedThere are many different types of prescribingencounters that take place in an outpatient healthfacility. There are sometimes separate clinics foradult and pediatric cases, and even when thesecases are mixed in the same clinic, prescribingpractices for them will be quite different. Newpatients are frequently separated from re-attendances for an existing health problem, both ina record-keeping system and also in the type of care they receive. Similarly, casespresenting for curative care are managed differently from those who attend to receivepreventive services such as vaccinations, prenatal or postnatal care, or child healthservices. The usual indicator study includes new patients attending for curativecomplaints.

EXCLUDE REPEAT ATTENDANCES AND PREVENTIVE OR PROMOTIVE CASES.

3. Define Drugs to be Included as Antibiotics

There are a number of different ways in which antimicrobial agents are classified indifferent settings. Sometimes drugs such as antiprotozoals, antihelminthics, orantituberculosis agents will be placed in a separate category from other antibiotics, whileother systems organize all of these products under a single category of antiinfectives orantimicrobials. The indicators of antibiotic use are quite sensitive to whether or not certaingroups of drugs are included as antibiotics, especially in environments where problemssuch as parasitic infestation or tuberculosis are common.


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Another issue in the definition of antibiotics for an indicators study is whether to includeantibiotic topical preparations, such as skin creams, ophthalmic ointments, or ophthalmicdrops. In areas where trachoma, bacterial conjunctivitis, or bacterial skin infections arecommon, these products may be widely used.

Metronidazole is a problem to classify. At primary level it is used as an antiparasitic agent,though it can be effective against anaerobic bacteria. For purposes of indicator studies,we recommend that metronidazole NOT be classified as an antibiotic. See Page 15 ofManual for further explanation and for the recommended list of drug groups to include asantibiotics..

4. List Drugs to be Classed as Generic

Data collectors and coders will need to have specific lists of drugs they are to class asgeneric in order to be able to compute the proportion of drugs prescribed as genericproducts. Often an essential drug list or national formulary will be written in generic termsand can be used as the basis for such a list of generic products supplied in a healthsystem.

There are certain drugs that are difficult to class as generic or branded. For someproducts, such as aspirin, it makes sense to include all generic and branded forms asgeneric, since they are used interchangeably and tend to have similar costs. Althoughmost combination drugs would not be classed as generic, there are some combinations incommon use that would qualify, such as co-trimoxazole (trimethoprim-sulfamethoxazole). Panadol is often thought to be a generic name though it is not. Abbreviations (e.g. CQ aschloroquin or HCT as hydrochlorthiazide may be counted as generics.)

VA 9]E. PATIENT CARE INDICATORS

The second major category of INRUD indicators measures the adequacy of the patientcare process according to certain minimum standards of performance. These indicatorsinclude:

Average Consultation Time

Average Dispensing Time

Percentage of Drugs ActuallyDispensed


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Percentage of Drugs Adequately Labeled

Patients' Knowledge of Correct Dosage

The length of time that a health worker spends with a patient and the type of examinationperformed set important limits to the adequacy of diagnosis and treatment from both aclinical and social perspective. Patients who emerge from the clinical process withprescribed pharmaceuticals should, at a minimum, understand the timing and amount ofeach oral and topical medication.

The following activities are recommended to plan data collection for the patient careindicators.

1. Observe the Logistics of thePatient Care Process

To determine how and when the datarequired to measure the indicators ofpatient care will be collected, it isnecessary to become familiar with theorganization of services at samplehealth facilities. In particular, datamust be collected about both theclinical examination and drugdispensing procedures. In addition, anon-disruptive way must be found tointercept and interview patients at some convenient point after their drugs have beendispensed.It may be impractical to observe in advance the clinic activities in all facilities in thesample. However, health facilities in a region are often organized in a similar way, soobservations in a few facilities should be sufficient to design efficient data collectionprocesses for the patient care indicators. However, if there are different types of facilitiesto be studied, for example, large multi-provider polyclinics and smaller, single-providerhealth centers, a few facilities of each type should be observed to ensure that datacollection can be organized in all. Training of data collector should prepare them fordifferent situations.

2. Determine How Consultation and

Dispensing Times will be MeasuredTo measure the length of time the patients areseen in the treatment and dispensing process, itis necessary to develop a method for observing


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the starting and ending times of these processes for individual patients. To smooth someof the variations in time that occur with different diagnoses, it is recommended that thepatient care process be timed for at least ten individual patients.

Based on the logistics of care at health facilities, you will need to describe the proceduresto be used to record times for ten patients. There are two basic alternatives:

• Record beginning and ending times for ten individual consultations betweenpatients and health workers, then follow the same patients to the dispensary,and again record the beginning and ending times of their interactions withpharmacists or dispensers. This method is preferred if it is possible to observethese interactions on an individual patient basis, or if there are only a few casesawaiting treatment.

• Record the beginning time of an index patient, and keep a cumulative record ofthe time it takes for health workers to see ten consecutive patients; repeat thisprocess as these ten patients see drug dispensers. This procedure is preferredif it is impossible to observe individual episodes, or if there are many patients inthe queue.

An example of a form in which to enter this information is included in Annex 1. Whichever method is selected, it is resting the beginning of observations takes place at arandom point in the middle of a clinic day. This way, the results will not be overlyinfluenced by the rush to see patients at the beginning or end of a clinic, or by freshnessor fatigue on the part of health workers.3. Define Criteria for Adequate Patient Knowledge about Medicines

At some point during the examination or dispensing process, medications prescribed for apatient should be explained. Ideally, this explanation would include the reasons why eachparticular medication is being given, how each drug should be taken, and any precautionsor possible side effects explained.

AT A MINIMUM, PATIENTS SHOULD BE ABLE TO DESCRIBE WHEN AND IN WHATQUANTITY EACH SELF-ADMINISTERED DRUG IS TO BE USED.

Because of the difficulty in reliably evaluating other factors, it is recommended that theminimum criteria of timing of administration and dose be used. These criteria should beevaluated for each oral or topical medication received by the patient during the visit. Failure to know about any of the drugs prescribed should result in patient knowledgebeing scored as inadequate.

4. Describe the Procedures for Evaluating Patient Knowledge about Medications

A procedure must be defined for intercepting and interviewing patients after they have


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received their medications from the dispensary. Because such a process can disruptpatient flow as well as intimidate health workers, an effort should be made to find an areato do this that is removed from the main clinic area.

The method for recording results will differ depending on the pharmaceutical knowledge ofdata collectors. If data are being collected by pharmacists or physicians who are familiarwith each drug, it will be possible for them to evaluate adequacy of knowledge in the fieldand simply record each patient interviewed as having adequate or inadequate knowledge. If this system is used, the proper dosing of all major medications should be reviewedduring the training of data collectors, and the data collectors should be provided with adrug list containing this information to refer to in the field.

If data collectors are less experienced, they may simply record the information on eachdrug and the patient's knowledge about it during the interview, and allow these records tobe evaluated for adequacy later by a single experienced person on the study team. If thismethod is chosen, the data collector should record, for each oral and topical drugprescribed to the patient, the drug name, strength, number of units (pills, tubes, etc)dispensed, and the patient's explanation of how and when the drug is to be taken.

As with the other two patient care indicators, it is best to sample patients from the middleof a clinic day.

[VA 10]F. FACILITY INDICATORS

The ability of prescribers to use drugs rationally is influenced by many features of theenvironment in which they practice. These features include access to relevant, impartialpharmaceutical information; adequate supply of products needed to treat common healthproblems; and a regulatory climate that encourages the proper use of drugs in the privatesector.

There are two core drug use indicators aimed at measuring factors at the facility level,including:

Availability of Copy of Essential Drugs List or Formulary

Availability of Key Drugs

The activities needed to plan for measuring these indicators aredescribed below.

1. Determine If There is a National Essential Drug List orFormulary


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One sign of the acceptance of the concept of essential drugs by national authorities andthe basis for rational drug use in the public sector is the development of a nationalessential drug list. In order for such a list to be most effective, it should be disseminatedto all health facilities at the local level to guide decisions about the purchase andtherapeutic use of drugs. It should be determined before the study whether there is anational essential drug list, when the list underwent its most recent revision, and in whatform the list has been distributed to health facilities. While in the field, data collectors areexpected to ask prescribers in each facility to show them a copy of the list in some form. The list must be in the facility.

2. List the Key Pharmaceuticals Recommended

For prescribers to treat effectively the recommended products must be available infacilities on a regular basis.

Identify key products (name and formulation) to survey for availability in facility stores. It isimportant for data collectors to know all common proprietary names as well as generic names for these drugs, since from a therapeutic perspective branded and generic drugsare equivalent. Choose between 10 and 15 drugs. [See page 23 of WHO/DAP manual.]

On a summary form for each facility, data collectors should check the products on each listthat are found in any amount in health facility stores. An example of such a form appearsin Annex 1.

[VA 11]

G. UNDERTAKING THE SURVEY

1. Preparation

Careful preparation for the survey is essential. After the steps listed above have beencompleted, the next stages in doing the survey are:

1. Select and train personnel and conduct pilot tests -- Try to recruit people whoknow drug names.

2. Select and inform sample sites. It may be necessary to get permission lettersfrom local authorities.

3. Plan the schedule of data collection visits -- In general, it is possible for two data


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collectors to survey one facility per day.

2. Data Collection[VA12]When collecting data in the field, follow these steps:

1. Select a sample of encounters to record. If adequate records exist, use theserecords (retrospective data collection). If the data are inadequate, use directobservation (prospective data collection).

2. Fill in prescribing encounter forms (see Annex 1). If the field workers are skilledand you do not require diagnosis-specific data, use the short [VA 13] SimplePrescribing Indicator Form If the field workers are unskilled, or you want detailedinformation, use the Detailed Indicators Encounter Form.

[VA 14] [VA 15 - 20]

3. Observe patient care indicators for at least 30 patients. You can observedifferent patients for consultation and dispensing indicators. Fill in the data onthe Patient Care Indicators Form. [VA 21]

4. Fill in the Health Facility Summary Form. [VA 22]

It is most important that the quality of data collection is supervised in the field.

[VA23]

H. ANALYZING THE DATA

There are two levels of analysis that are done. First, at the facility itself a report should bemade to the staff about the survey. Second, the data for the twenty facilities should beaggregated to produce a combined result.

1. Presenting at the Health Facility

At the end of the survey activities in each facility, add up and calculate the percentage oraverage results.

Then ask all the staff involved, including the registration clerk, the dispenser, and thedispensary assistant, to sit down to review the results. Always start off positively --


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identifying something good that has been observed . Fill in the Facility IndicatorReporting Form(see Annex 1) and leave it with the staff.

Start with the prescribing indicators and discuss how their average drugs per consultation,percentage antibiotics, injections, and generics compare with what should be, what occursin other facilities in their country, and other countries.

Then discuss the patient care form. Start by discussing the diagnostic process. Talkabout history, examination, diagnosis, prescription, dispensing, and patient education. Point out how each of these activities takes time, and how important physical examinationis, both for making a diagnosis and for patient satisfaction. Then describe their resultsand talk about how their results compare with other studies. A table of results fromdifferent studies is available in the WHO manual.

Finally, discuss the facility form, examining the availability of drugs, and the presence orabsence of the essential drugs list.

[VA24]

2. Aggregating Facility Results

As each facility is studied, enter the summary results into the Drug Use IndicatorsConsolidation Form (Annex 1). Add up and average these results. These resultswill then be the summary results for the survey.

It is always interesting to look at the individual facilities, but with asmall sample size of prescriptions, it is not possible to makeabsolute comparisons. The differences may be interesting, but arenot conclusive and would need to be followed up with furtherstudies.

The data from the consolidation form can be graphed, as shown in the examples below.

EXAMPLES OF GRAPHS FROM FACILITY DATA

[VA 25, 26, 27, 28]


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Sample-wide Distribution of Antibiotic Use

0

2

4

6

8

10

12

Un d er 30 % 3 0% - 40 % 4 0% - 60 % O ve r 6 0%

Percen tage An tib io tic Use

NUMBER OF FACILITIESNUMBER OF FACILITIES


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Sample-wide Distribution of Consulting Times

Facility Specific Antibiotic Use

0

1

2

3

4

5

6

7

8

Un d er 2 2 - 3 3 - 4 O ve r 4

Average Consu lting T im e (m ins)

NUMBER OF FACILITIESNUMBER OF FACILITIES

0

10

20

30

40

50

60

70

80

U0 U1 U3 U3 U5 U6 U7 U8 U9 R0 R1 R2 R3 R4 R5 R6 R7 R8 R9

Health Facility

U rban

Rural

Percentage of PatientsPercentage of Patients


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Facility Specific Consultation Times

[VA29]CONCLUSION

It is possible to undertake a Drug Use Indicators study in nearly all possible environments.Members of the INRUD network have done a great deal of work with support from WHO tostandardize the methods and to make the process as easy as possible.

When undertaking such a survey the more attention which can be paid to detail thegreater the value and the accuracy of the survey. Once reliable data are available it areoften possible to identify the priority problems and to decide which problem to address firstwith an intervention.

0

1

2

3

4

5

6

7

U0 U1 U3 U3 U5 U6 U7 U8 U9 R0 R1 R2 R3 R4 R5 R6 R7 R8 R9

Health Facility

U rban

Rural


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ACTIVITY ONEData Collection and Entry

RATIONALE

In this activity you will process the data collected from a prescribing study and docalculations and tabulations.

INSTRUCTIONS

1. Read the directions to complete the Simple Prescribing Indicator Form as provided inthe WHO Drug Use Indicators Manual.

2. Fill in the data collection form using the data presented. Each member of the groupshould fill in the data from one of the six prescriptions on the following pages. Inaddition, the group should work together to draw a systematic sample of 24prescriptions from the consultation logs (to be distributed during this exercise). Usethe random number table to select these prescriptions randomly. Remember to fill inonly new cases!

3. Complete the calculation of the indicators by filling in the appropriate cells in the form.

WORKSHEETS TO BE USED :

The Simple Prescribing Indicator Form will be used. In addition to the sixprescriptions which follow, you will be shown pages from consultation logs from whichyou will select prescriptions.


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PRESCRIPTION 1


20

PRESCRIPTION 2


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PRESCRIPTION 3


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PRESCRIPTION 4


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PRESCRIPTION 5


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PRESCRIPTION 6


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RANDOM NUMBER TABLE7765 6903 7709 9117 1042 7760 921 944 4315 8295

15 4979 2165 227 5929 4407 3593 1717 4118 23882731 496 6192 3601 77 8201 218 6719 450 19879702 5413 5519 247 7546 9919 2836 765 3290 37505127 2965 5046 9322 9716 592 1369 9520 9559 7492891 700 4998 5623 9249 8743 7684 4211 3687 6026

3704 6017 1658 2230 6741 7484 812 1381 8166 84084836 5592 5522 7977 9975 2930 2315 1748 8590 35098048 7182 1668 2826 8076 9747 6210 1739 5322 71147840 1253 6654 2518 4541 2628 6002 7332 1899 48634533 5532 7839 6936 5362 7318 4529 5948 8726 92404365 6135 3561 131 4003 8430 9108 3726 8426 36194400 9581 9011 8680 8480 8065 5520 673 2184 21915172 4919 8216 9005 7557 2434 5085 1434 5013 64354434 9178 1462 6673 6586 6838 6283 1685 4693 49482920 1968 2098 2212 5171 6256 557 3212 1079 37372739 1180 5093 6475 8845 2602 9016 2415 6140 5107121 6564 4817 7292 8004 9997 3888 7036 5053 86862945 9 8688 214 4872 9664 6442 9655 4590 6039638 1499 5281 2291 1379 4649 1570 9276 6163 15487977 2264 8668 8994 1986 3941 7095 4574 5588 21426149 4160 710 1677 791 6636 4708 8539 8594 47584337 4142 1697 3861 7265 2111 4762 6895 6995 86191258 6250 2513 2799 3953 9114 9445 9169 8063 13773345 376 4532 7515 2377 9860 9576 7098 6031 11123611 6840 4213 1894 3949 8241 1357 6343 5087 98233927 6849 8181 312 6990 668 6047 9371 4400 4480897 1212 4996 4297 8256 3698 6740 1283 7411 2990

3619 4710 6979 7311 1258 7221 5769 9614 2183 84645593 164 4336 1123 4693 2631 2992 2535 7464 75915467 411 2223 2514 3311 2016 1178 2832 1767 14667246 6629 3117 6127 4134 6671 7419 5135 8813 45213686 9954 8933 3707 2453 81 3041 5278 4752 5778041 6306 1733 2214 2648 9530 6778 7904 3051 18362155 4748 2707 9513 5785 5939 2411 6374 7475 63721464 9698 667 7100 1547 652 1255 8405 1724 5502103 6923 3476 4972 8850 48 3366 2094 6992 6950

2458 9945 5969 1206 9525 7897 6687 6567 5532 67164222 8772 7900 8718 6979 9794 368 5698 5500 83958628 4325 650 4183 4428 7479 8758 5623 2127 3852487 8658 3775 8587 625 4884 894 5858 7333 100

ACTIVITY TWO


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DATA PRESENTATION

RATIONALE

In this activity you will review the results shown on Worksheet 2.1. You should prepare topresent the results of a facility to the staff members.

INSTRUCTIONS

1.Review the results of the facility allocated to your group.

2.Identify what are good and bad results compared to other facilities and to other countries(Page 74 of the WHO Manual).

3.Decide if you want to show the results using visual aids. If so, prepare them.

4.Start off your presentation with the positive -- the "good" results.

5.Then identify the problem areas -- the "bad" results.

6.Discuss with the facility members the possible reasons for the results.

7.Make an action plan with the participants for what they will do about their problems.

NOTE: Not every group will present. Groups will be randomly selected.


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Worksheet #2.1

EXAMPLES OF INDICATOR RESULTS FROM DIFFERENT FACILITIES

INDICATORFACILITIES

AVERAGES

# 1 # 2 # 3 # 4 # 5 # 6

# Drugs 1.5 1.9 4.7 2.7 3.5 2.1 2.7

%Antibiotics 32 64 47 37 100 24 51

%Injectables 6 44 95 54 89 14 50

%Generics 94 61 47 15 100 92 68

%EDL 100 77 84 43 89 86 80

ConsultationTime (mins.) 2:30 3:24 1:40 1:25 4:53 8:12 3:41

DispensingTime (secs.) 75 42 135 34 185 26 83

%CorrectLabeling

62 68 61 35 28 21 46

% PatientKnowledge 62 41 74 16 32 31 43

% Drugsin Stock 60 100 80 70 60 90 77

EDL Present Yes Yes Yes No Yes No Yes

ImpartialInformation No Yes No No No No No


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Annex 1 : Examples of Forms

Examples of Forms (note that there should be 2 copies of the forms in the binder)

Prescribing Indicators Form

Detailed Prescribing Indicators Encounter Form

Patient Care Form

Facility Summary Form

Facility Indicators Reporting Form

Drug Use Indicators Consolidation Form

PRESCRIBING INDICATOR FORMLocation:Investigator: Date:

Seq. Type Date Age # # Gen- Antib. Injec. # on Diagnosis# (R/P) of Rx (yrs) Drugs erics (0/1) (0/1) EDL (Optional)

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30Total XXXXXXX XXXXXXXXXXX

Average XXXXXXX XXXXXXX XXXXXXX XXXXXXX XXXXXXX XXXXXXXXXXX

Percentage XXXXXXX % % % % XXXXXXXXXXX

of total of of total of totaldrugs cases cases drugs

* 0=No 1=Yes

Location:

Investigator: Date:

ID# Date Name Age Sex Prescriber

Health Health Problem Description CodeProblems 1

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Drugs Name and Strength Code Quantity12345678,9

Detailed Prescribin gIndicators form

Location:

Investigator Date:

Patient Consulting Dispensing # Drugs # Drugs # Ade- KnowsSeq. Identifier Time Time Pre- Dis- quately Dosage

# (if needed) (mins) (secs) scribed pensed Labelled (0/1)

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30

Count TotalAverage XXXXXXX XXXXXXX XXXXXXX XXXXXXX

Percentage XXXXXXXX XXXXXXXX XXXXXXX % % %of pre- of dis- of casesscribed pensed asked

* 0=No 1=Yes

PATIENT CARE FORM

Location:

Investigator Date:

Contacts

Problems orComplaints

# Cases From ToRetrospective covering datesProspective covering datesPatient Care covering dates

Essential Drug List/Formulary available at facility? (0/1)

Key Drugs in Stock to Treat Important Conditions In Stock(0/1)

% in stockthis facility

FACILITY SUMMARY FORM

Facility Indicator Reporting Form

Location:

Investigator Date

T his National Facility S tandard

Number of Cases PrescribingPatient Care

Average Number of drugs prescribedPercentage of drugs prescribed by generic names % %Percentage of encounters with an antibiotic prescribed % %Percentage of encounters with an injection prescribed % %Percentage of drugs prescribed on Essential Drug List % %Average Consulting Time mins minsAverage Dispensing Time secs secsPercentage of drugs actually dispensed % %Percentage of drugs adequately labelled % %Percent correct patient knowledge of dosage % %Availability of essential drug List or Formulary Yes / No %Percentage availability of key indicator drugs % %

Comments

S ignatures

Indicators Consolidation Form

Location: Date:

Avg. drugs Percent Percent Percent Percent Consult Dispense % Drugs % Adequate %Adequate Impartial % Drugs

Date Facility Prescribed generics antibiotics Injections on EDL time time dispensed label knowledge Information in stock

Mean MaximumMinimum

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