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CITATION: Presented at the International Conference on Improving Use of - page 16 / 51





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Improving Primary Care Pharmaceutical Use

prescribing practices, such as the selection of an appropriate drug within a therapeutic class, correct dosing or duration of therapy, or cost-effectiveness of prescribing have been infrequently studied.

Outcomes measured

Not surprisingly, the prescribing practices have been the principal outcomes of interest in most of the interventions to improve drug use in primary care.  In 36 interventions with acceptable study designs, improvement in prescribing was the major targeted outcome in nearly three-fourths (72.2%) of studies (Table 3).  Excluding the community case management studies, which often focused on reducing child mortality, drug prescribing practice was the predominant target in 21 of 24 interventions.

Despite the fact that interventions which involve education or training implicitly are directed at improving knowledge, specific gains in knowledge resulting from interventions have been rarely measured; only 7 methodologically sound studies (19.4%) reported data on this easily collectable intermediate outcome.  Like increased knowledge, improved diagnostic skill is another crucial intermediate factor that precedes quality prescribing.  However, unlike knowledge - which can be measured with simple questionnaires - measuring gains in diagnostic performance is much more methodologically challenging.  Usually validation of diagnostic accuracy requires some form of concurrent measurement by a Astandard@ observer.  Only three of the 36 well-designed studies attempted this type of outcome measurement.

Once drugs have been prescribed, their use depends in large part on the knowledge and motivation of patients.  Special opportunities for educating patients and motivating them to use drugs in a clinically effective way occur during dispensing encounters.  In addition, the way drugs are packaged and labeled by dispensers can also contribute to their correct or incorrect use.  Only three studies have attempted to evaluate these types of patient-oriented outcome measure (Kafuko 1995, Kafle 1995b, ZEDAP 1995).  These studies all used patient exit interviews to determine their knowledge about how to take the drugs they received, and also whether the drug packages contained essential items of information such as patient name, drug name, and dosing schedule.

All 6 high quality ARI CCM interventions, two of the 5 diarrhea CCM studies, and the single malaria


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