Improving Primary Care Pharmaceutical Use
Problem Statement: Pharmaceuticals play a critical role in health systems, but many studies have demonstrated that medicines are often used in ways that are not clinically efficacious or cost-effective. A number of reviews have examined the effectiveness of interventions to improve problems in primary care prescribing in developed countries, but there is as yet no systematic summary of the impacts of similar interventions in the developing world.
Objectives: To summarize the methodologies and reported impacts of interventions to improve use of medicines in primary care settings in developing countries, and to identify the critical drug use issues and promising interventions in these settings in need of further research.
Design: Systematic review of published and unpublished intervention studies.
Methods: Relevant studies were identified using a computerized literature search, a review of key institutional archives, and personal requests to researchers. Studies were categorized by type of intervention, by health problem addressed, and on the basis of the adequacy of research design, using commonly accepted criteria for ranking quality of research evidence. A method was developed for comparing the magnitude of effects across studies, based on the largest reported improvement in a key drug use outcome targeted by individual authors.
Results: We identified 59 studies that met the criteria for the review, 36 of which had study designs of acceptable quality, either randomized controlled trials (n=13), pre-post with comparison group (n=12), or time series (n=11). Nearly three-fourths of these 59 studies (72.9%) were reported after 1990; most were from Asian countries (59.3%), with one-third from Africa (31.3%), and the rest (11.9%) from Latin America. Educational interventions in the form of workshops or training courses (33.9%) or community case management interventions aimed at community health workers (30.5%) were the most frequent types of interventions; the remaining interventions tested some form of administrative or managerial strategy for improving drug use, either group process in norm setting or performance review (10.2%), supervision or audit and feedback (13.6%), or the impacts of a national essential drugs program (11.9%).
Most interventions targeted prescribing for ARI (44.1%), diarrhea (35.6%), or less frequently, malaria (10.2%), usually in children. Inappropriate antibiotic use was by far the dominant prescribing issue addressed, in 76.3% of studies, with polypharmacy (23.7%) and injection use (20.3%) receiving some attention. Treatment