Improving Primary Care Pharmaceutical Use
studies at least one major outcome was improved. Combining multiple interventions, for example CME with audit and feedback, improved results. Strategies found to be effective included reminders, patient-mediated interventions, outreach visits, and use of opinion leaders. Audit systems and educational materials on their own were found to be less effective, while traditional CME conferences had little effect.
Recent published reviews by Freemantle, Bloor, and colleagues summarize international experience from Europe, North America, and Australia/New Zealand in controlling pharmaceutical expenditures by interventions directed at patients, doctors, and industry.(Freemantle 1996, Bloor 1996a, 1996b) Increases in direct or indirect patient costs were shown to reduce both essential and non-essential drug consumption with potential adverse consequences. Some studies suggest that doctors will change their prescribing of generic drugs or older established drugs, or their compliance with treatment guidelines, if there are financial incentives to do so. Information and feedback to physicians of comparative prescribing cost information is widely used but has limited effect. Various countries have positive and negative lists of drugs for reimbursement, but the authors did not find any studies of how these lists affected quality of prescribing. The use of reference pricing in Europe is widely used though its effects may be mixed.
Unfortunately, none of these review papers has included experiences from developing countries. The reasons for this may be three-fold: no papers met study inclusion criteria; electronic referencing systems like Medline may systematically exclude sources of developing country literature; reviewers may judge that developing country situations are so different that their experiences may not be relevant. For these reasons, there is need for a review with a specific focus on developing countries to examine similarities and differences in intervention experiences and conclusions about their effectiveness.
Aims of This Review
This review will survey published and unpublished interventions to improve drug use in primary care in developing countries. We will assess the research designs used to evaluate these interventions, and highlight key methodological weaknesses. The experiences from interventions that meet minimum methodological criteria for