Pengobatan Rasional

Pengantar:
Pengobatan Rasional
Rustamaji
Sleman, 10 April 2012

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM
2012
Tujuan
Difinisi Pengobatan Rasional dan mengidentifikasi
besarnya masalah yang ditimbulkan
Memahami mengapa terjadi pengobatan yang

tidak rasional
Mendiskusikan strategi intervensi unutk
memperbaiki masalah
Mendiskusikan pedoman pengobatan
Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012
Definisi
The rational use of drugs requires that patients
receive medications appropriate to their clinical
needs, in doses that meet their own individual
requirements for an adequate period of time, and
at the lowest cost to them and their community.
WHO conference of experts Nairobi 1985
Ciri pengobatan rasional

Tepat dalam pemilihan obat
Obat digunakan sesuai indikasi
Obat memenuhi kriteria kemanfaatan klinkk, keamanan,
kecocokan dengan kondisi pasien, dan biaya
Tepat dosis, cara pemberian, dan lama terapi
Tidak ada kontraindikasi pada pasien
Pemberian obat yang tepat (termasuk informasi yang cukup agar
pasien dapat mengikuti program pengobatan dengan benar)
Ketepatan dalam diagnosis
Pakistan
Bangladesh
Burkino Faso
Senegal
Angola
Tanzania
0
10
20
30
40
50
% observed consultations where the diagnostic process was adequate

60
5-55% pasien di PHC menerima injeksi90% tidak perlu secara medis

Quick et al, 1997, Managing Drug Supply
Ghana
Cameroon
Nigeria
Sudan
Tanzania
Zimbabwe
Yemen
Indonesia
Nepal
15
juta injeksi/tahun secara global

50% tidak menggunakan jarum steril
2.3-4.7 juta infeksi hepatitis B/C dan
sekitar 160,000 infeksi HIV/tahun
Ecuador
Guatemala
El Salvador
Jamaica
Eastern Caribean
0%
10%
20%
30%
40%
% pasien di PHC yang mendapatkan injeksi

50%
60%
Pola pemakaian antibiotika di 26

negara Eropa tahun 2002
35
DDD per 1000 inh. per day
30
25
20
15
10
0
FR GR LU PT IT
BE SK HR PL IS
IE ES FI BG CZ SI SE HU NO UK DK DE LV AT EE NL
Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.

% Ketaan terhadap Pedoman Pengobatan

60
50
40
30
20
10
0
1982-1994
1995-2000
2001-2006
Sub-Saharan Africa (n=29-48)
Lat. America & Carrib (n=5-13)
Middle East & C. Asia (n=4-8)
East Asia & Pacific (n=7-11)
South Asia (n=6-12)

Pola Pengobatan Diare Akut oleh Dokter,

Perawat, dan paramedis
80
70
60
50
40
30
20
10
0
% antibiotika
% antidiare
Public (n=54-90)
% larutan rehabilitasi oral
Private-for-profit (n=5-10)
Pola Pengobatan ISPA Berdasarkan Tenaga

80
70
60
50
40
30
20
10
0
% Antibiotika pada ISPA
viral
Dokterr (n=26-62)
% pneumonia yang
mendapatkan antibiotika
Perawat/paramedis (n=12-86)
% ISAP yang diobati

dengan sirup obat batuk
Staf Farmasif (n=9-17)
Penggunaan antimikroba dan

Pengaruhnya terhadap resistensi
WHO country data 2000-3
Malaria
choroquine resistance pada 81/92 negara
Tuberculosis
0-17 % multi-drug resistance primer
HIV/AIDS
0-25 % resistance primer (minimal 1 antiretroviral)
Gonorrhoea
5-98 % penisillin resistance terhadap N. gonorrhoeae
Pneumonia and bacterial meningitis
0-70 % penicillin resistance terhadap S. pneumoniae
Diarrhoea: shigellosis
10-90% ampisillin resistance, 5-95% cotrimoxazole resistance
Hospital infections
0-70% S. Aureus resistance terhadap seluruh penisillin &
cephalosporins
Community surveillance Resistensi dan

Penggunaan antimikroba
Antimicrobial resistance
E.Coli patogen pada wanita hamil di India
Cotrim 46-65%; Ampi 52-85%; Cipro 32-59%; Cefalex 16-50%
S.Pneumoniae & H.influenzae sputum di afrika Selatan
Cotrim > 50% (both organisms); Ampi >70% (H.influenzae)
Penggunaan antibiotika
Sekitar 50% pasien di India dan <25% di AfrikaSelatan menerima
antibiotika
Penggunaan fluoroquinolones unutk common cold di India terutama di
sektor private
Motivasi provider dan konsumen

Permintaan pasien menganggap lebih cepat menyembuhkan
Tidak ada CME & takut kehilangan klien
Promosi obat yang tidak terkontrol dan alasan finasial
Adverse drug events

White et al, Pharmacoeconomics, 1999,
15(5):445-458
Penyebab ke- 4-6 kematian di USA

Biaya yang dikeluarkan sekitar 30 ribu -130 juta US$
in the USA
4-6% kasus yang memerlukan perawatan di rumah

sakit di USA & Australia
Sering ditemukan, penyebab kasus yang
memerlukan biaya perawatan : pendarahan, cardiac
arrhythmia, gangguan jiwa, diare, demam, hipotensi,
itching, mual, rash, gangguan ginjal
Upaya mengatasi masalah

1. EXAMINE
Measure Existing
Practices
(Descriptive
Quantitative Studies)
4. FOLLOW UP
Measure Changes
in Outcomes
(Quantitative and Qualitative
Evaluation)
improve
diagnosis
improve
intervention
3. TREAT
Design and Implement
Interventions
(Collect Data to
Measure Outcomes)
2. DIAGNOSE
Identify Specific
Problems and Causes
(In-depth Quantitative
and Qualitative Studies)
Banyak Faktor Yang Mempengaruhi

Penggunaan Obat
Information
Scientific
Information
Influence
of Drug
Industry
Habits
Social &
Cultural
Factors
Treatment
Choices
Workload &
Staffing
Workplace
Intrinsic
Prior
Knowledge
Infrastructure
Relationships
With Peers
Societal
Economic &
Legal Factors
Authority &
Supervision
Workgroup
Strategi untuk memperbaiki

Educational:
Inform or persuade
Health providers
Consumers
Managerial:
Guide clinical practice
Information systems/STGs
Drug supply / lab capacity
Use of
Medicines
Economic:
Offer incentives
Institutions
Providers and patients
Regulatory:
Restrict choices
Market or practice controls
Enforcement
Educational Strategies
Goal: to inform or persuade
Training for Providers
Undergraduate education
Continuing in-service medical education (seminars, workshops)
Face-to-face persuasive outreach e.g. academic detailing
Clinical supervision or consultation
Printed Materials
Clinical literature and newsletters
Formularies or therapeutics manuals
Persuasive print materials
Media-Based Approaches
Posters
Audio tapes, plays
Radio, television
Impact of Patient-Provider Discussion Groups

on Injection Use in Indonesian PHC Facilities
Source: Hadiyono et al, SSM, 1996, 42:1185
% Prescribing Injections
80
60
Pre
Post
40
20
0
Intervention
Control
Training for prescribers

The Guide to Good Prescribing
WHO has produced a Guide for Good

Prescribing - a problem-based method
Developed by Groningen University in
collaboration with 15 WHO offices and
professionals from 30 countries
Field tested in 7 sites
Suitable for medical students, post grads,
and nurses
widely translated and available on the WHO

medicines website
Managerial strategies
Goal: to structure or guide decisions
Changes in selection, procurement, distribution to
ensure availability of essential drugs
Essential Drug Lists, morbidity-based quantification, kit systems
Strategies aimed at prescribers

targeted face-to-face supervision with audit, peer group
monitoring, structured order forms, evidence-based standard
treatment guidelines
Dispensing strategies
course of treatment packaging, labelling, generic substitution
RCT in Uganda of the effects of STGs, training and

supervision on % of Px conforming to guidelines
Source: Kafuko et al, UNICEF, 1996.
Randomised
group
No. health
PrePostfacilities intervention intervention
Change
Control group
42
24.8%
29.9%
+5.1%
Dissemination of
guidelines
42
24.8%
32.3%
+7.5%
Guidelines + onsite training
29
24.0%
52.0%
+28.0%
14
21.4%
55.2%
+33.8%
Guidelines + onsite training + 4

supervisory visits
Economic strategies:
Goal: to offer incentives to providers an consumers
Avoid perverse financial incentives

prescribers salaries from drug sales
insurance policies that reimburse non-essential
drugs or incorrect doses
flat prescription fees that encourage
polypharmacy by charging the same amount
irrespective of number of drug items or quantity
of each item
Pre-post with control study of an economic

intervention (user fees) on prescribing quality in Nepal
Holloway, Gautam & Reeves, HPP, 2001
Fees (complete
drug courses)
control fee / Px 1-band item fee 2-band item fee

n=12
n=10
n=11
Av. no. items

per prescription
2.9 2.9
(+/- 0)
2.9 2.0
(-0.9)
2.8 2.2
(-0.6)
% prescriptions
conforming to
STGs
23.5 26.3
(+2.7%)
31.5 45.0
(+13.5%)
31.2 47.7
(+16.5%)
Av.cost (NRs)
per prescription
24.3 33.0
(+8.7)
27.7 28.0
(+0.3)
25.6 24.0
(-1.6)
PHC prescribing with and without Bamako

initiative in Nigeria
Source: Scuzochukwu et al, HPP, 2002
15.3
no.EDL drugs avail
35.4
21
% pres EDL drugs
93
25.6
% Px with antibiotics
64.7
38
% Px with injections
72.8
2.1
5.3
no.drug items/Px
0
20
21 Bamako PHCs
40
60
12 non-Bamako PHCs
80
100
Regulatory strategies
Goal: to restrict or limit decisions
Drug registration
Banning unsafe drugs - but beware unexpected results
substitution of a second inappropriate drug after banning a first
inappropriate or unsafe drug
Regulating the use of different drugs to different

levels of the health sector e.g.
licensing prescribers and drug outlets
scheduling drugs into prescription-only & over-the-counter
Regulating pharmaceutical promotional activities
Only work if the regulations are enforced

Intervention impact: largest % change in any

medicines use outcome measured in each study
Database on medicines use 2009
Intervention type
No. studies Median impact
25,75th centiles
Printed materials
8%
7%, 18%
National policy
15%
14%, 24%
Economic strategies
15%
14%, 31%
Provider education
25
18%
11%, 24%
Consumer education
26%
13%, 27%
Provider+consumer education
12
18%
8%, 21%
Provider supervision
25
22%
16%, 40%
Provider group process
37%
21%, 59%
Essential drug program
28%
26%, 50%
Community case mgt
28%
28%, 37%
Providr+consumr ed & supervis 7
40%
18%, 54%
Proportion of visits
with injection
Impact of multiple interventions on injection

use in Indonesia
Interactive group discussion (IGC group only)
100%
Seminar (both groups)

80%
District-wide monitoring
(both groups)
60%
40%
20%
0%
1
11
13 15
17 19
21 23
25
Months
Comparison group
Interactive group discussion
Source: Long-term impact of small group interventions, Santoso et al., 1996

What national policies do countries have to promote rational use?

Source: MOH Pharmaceutical policy surveys 2003 and 2007
Drug use audit in last 2 years
National strategy to contain AMR
Antibiotic OTC non-availability
Public education on antibiotic use
DTCs in >half general hospitals
Drug Info Centre for prescribers
Obligatory CME for doctors
UG doctors trained on EML/STGs
STGs updated in last 2 years
EML updated in last 2 years
2007 (n>85)
0
2003 (n>90)
20
40
60
80
% countries implementing policies
100
Percent change in antibiotic consumption,

out-patient care in 25 European countries 1997-2003
Data from ESAC
25
20
Increase
Percent change
15
10
5
0
-5
Decrease
-10
-15
For Iceland, total data (including hospitals) are used
U
Fr K
an
ce
Po
la
n
C d
ro
at
G ia
re
ec
Ire e
la
Po nd
rtu
D ga
e
l
Lu nm
xe ar
m k
bo
ur
H
un g
ga
ry
It
Sl aly
ov
ak
ia
Is
ra
N el
or
w
Sw ay
ed
e
Au n
s
Sl tria
ov
en
Es ia
to
n
Fi ia
nl
an
Th
d
e
Sp
N
et
he ain
rla
G nds
er
m
a
Be ny
lg
iu
m
C
ze Ic
ch ela
R nd
ep
ub
lic
-20
Slide courtesy of Otto Cars, STRAMA, Sweden
Percent change in antibiotic consumption,

out-patient care in 25 European countries 1997-2003
Data from ESAC
25
20
Co-ordination programs
and national campaigns
Percent change
15
10
5
0
-5
-10
-15
For Iceland, total data (including hospitals) are used
U
Fr K
an
ce
Po
la
n
C d
ro
at
G ia
re
ec
Ire e
la
Po nd
rtu
D ga
e
l
Lu nm
xe ar
m k
bo
ur
H
un g
ga
ry
It
Sl aly
ov
ak
ia
Is
ra
N el
or
w
Sw ay
ed
e
Au n
s
Sl tria
ov
en
Es ia
to
n
Fi ia
nl
an
Th
d
e
Sp
N
et
he ain
rla
G nds
er
m
a
Be ny
lg
iu
m
C
ze Ic
ch ela
R nd
ep
ub
lic
-20
Slide courtesy of Otto Cars, STRAMA, Sweden
Why does irrational use continue?
Very few countries regularly monitor drug

use and implement effective nation-wide
interventions - because
they have insufficient funds or personnel?
they lack of awareness about the funds wasted
through irrational use?
there is insufficient knowledge of concerning the costeffectiveness of interventions?
What are we spending to promote rational

use of medicines ?
Global sales of medicines 2002-3 (IMS):
US$ 867 billion
Drug promotion costs in USA 2002-3:
US$ >30 billion
Global WHO expenditure in 2002-3:
US$ 2.3 billion
Essential Medicines expenditure
2% (of 2.3 billion)
Essential Medicines expenditure on

promoting rational use of medicines
10% (of 2%)
WHO expenditure on promoting

rational use of medicines
0.2% (of 2.3 billion)
2nd International Conference for Improving

Use of Medicines, Chiang Mai, Thailand, 2004
472 participants from 70 countries
http://www.icium.org
Recommendations for countries to:

Implement national medicines programmes to
improve medicines use
Scale up successful interventions
Implement interventions to address community
medicines use
Health systems with no national programs:

No coordinated action
No monitoring of use of medicines
Situational analysis
Modify
action plans
WHO facilitating
multi-stakeholder
action in countries
Implement & evaluate

national action plans using
govt & local donor funds
Health systems with national programs:

Coordinated action
Regular monitoring of use of medicine
Develop
national plans
of action
Global monitoring and identifying effective

strategies to promote rational use of medicines
WHO/EMP databases on drug use and policy
quantitative data on medicines use and interventions to
improve medicines use from 1990 to present day
data from MOHs on pharmaceutical policies every 4 years
1999, 2003, 2007
ICIUM3 in 2011
3rd international conference on improving the use of
medicines (ICIUM3)
Surveillance of antimicrobial use & resistance

method for community-based surveillance in poor settings
interventional approach for improving use in private sector
Pembekalan MTP (STG) kepada staf Puskesmas

mengurangi penggunaan antibiotika
Yudatiningsih, ICIUM, 2004
100
80
MTP
60
Feedback
Month 14
Feedback
Month 30
Feedback
Month 45
40
20
0
Agust-99 Nop99 Feb-00
Mei00 Agust-00 Des00
Mrt01
Jun01. Sep01. Des01.
Apr02.
Jul02.
Oct02.
Jan03.
Apr03. Aug03.
Standard Pengobatan
Tujuan pembahasan :
Menilai manfaat dan kerugian penerapan
standard pengobatan
Pemahaman tahap pengembangan standard
pengobatan
Menyiapkan pembuatan standard
pengobatan
Pengantar
1.
2.
3.
4.
5.
Therapeutic Anarchy
Keuntungan penerapan pedoman pengobatan
Dampak pedoman pengobatan
Pengembangan pedoman pengobatan
Penerapan pedoman pengobatan
Pedoman Pengobatan
Tatacara diagnosis
Pilihan intervensi (non

obat dan obat)
Pedoman pengobatan harus mencakup

tatacara diagnosis yang esensial
Health Problem =
symptom - headache
diagnosis - malaria
health service antenatal care
Pedoman Pengobatan dan Proses Terapi

Signs and
Symptoms
Diagnosis
(Health Problems)
Rx
Drug
Supply
Treatment
(Responses)
Adherence
(Compliance)
Rx
Rx
Rx
Clinical Outcome
Rx = focus of standard treatments
Advantages of Standard Treatments

Patients
Consistency among prescribers
Most effective treatments prescribed
Improved drug supply
Providers
Provides expert consensus

Provider can concentrate on diagnosis
Quality of care standard
Basis for monitoring and supervision
Advantages of Standard Treatments
Supply Management Staff

Performance standard for drug supply
Allows pre-packs of common items
Drug demand more predictable
Health Policy Makers

Funds used more efficiently
Assess and compare quality of care
Therapeutic integration of special
programs
Key Features
1.
2.
3.
4.
5.
6.
7.
Simplicity
Credibility
Same standards for all levels
Drug supply based on standards
Introduced in pre-service training
Dynamicregular updates
Durable pocket manuals
Developing Standard Treatment Guidelines
1. Target priority conditions

2. Base on local disease factors
3. Coordinate with special programs
4. Use fewest drugs necessary
5. Choose cost-effective treatments
6. Use essential drug list drugs only
7. Involve respected clinicians
8. Consider patient perspective
Approaches to Standard Treatment

Guidelines
Individual
Selective
Comprehensive
Implementing Standard Treatments
1. Printed reference
2. Official launch
3. Initial training
4. Reinforcement
training
5. Monitoring
6. Supervision
Conclusion
Standard treatment guidelines can have
considerable impact if they are
developed and used in a sensible
fashion
They can also be an expensive waste of
effort
With standard treatment guidelines, the
process of production and use is more
important than the product

Pengobatan Rasional

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Pengobatan Rasional

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Pengantar:

Sleman, 10 April 2012

Memahami mengapa terjadi pengobatan yang

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Ciri pengobatan rasional

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Ketepatan dalam diagnosis

% observed consultations where the diagnostic process was adequate

5-55% pasien di PHC menerima injeksi90% tidak perlu secara medis

juta injeksi/tahun secara global

% pasien di PHC yang mendapatkan injeksi

Pola pemakaian antibiotika di 26

DDD per 1000 inh. per day

Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.

% Ketaan terhadap Pedoman Pengobatan

Sub-Saharan Africa (n=29-48)

Lat. America & Carrib (n=5-13)

Middle East & C. Asia (n=4-8)

East Asia & Pacific (n=7-11)

South Asia (n=6-12)

Pola Pengobatan Diare Akut oleh Dokter,

% larutan rehabilitasi oral

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Pola Pengobatan ISPA Berdasarkan Tenaga

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

% ISAP yang diobati

Penggunaan antimikroba dan

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Community surveillance Resistensi dan

Motivasi provider dan konsumen

Adverse drug events

Penyebab ke- 4-6 kematian di USA

4-6% kasus yang memerlukan perawatan di rumah

Upaya mengatasi masalah

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Banyak Faktor Yang Mempengaruhi

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Strategi untuk memperbaiki

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Impact of Patient-Provider Discussion Groups

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Training for prescribers

WHO has produced a Guide for Good

widely translated and available on the WHO

Strategies aimed at prescribers

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

RCT in Uganda of the effects of STGs, training and

Guidelines + onsite training

Guidelines + onsite training + 4

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Avoid perverse financial incentives

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Pre-post with control study of an economic

control fee / Px 1-band item fee 2-band item fee

Av. no. items

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

PHC prescribing with and without Bamako

no.EDL drugs avail

% pres EDL drugs

Pusat Studi Farmakologi Klinik dan Kebijakan Obat UGM 2012

Regulating the use of different drugs to different

Regulating pharmaceutical promotional activities