Qualitative Methods of Drug Use
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Qualitative Methods
• In-depth investigation of drug use to
understand causes of a drug use problem
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Types of Qualitative Methods
• In-depth interviews
• Focus Group Discussions
• Structured Observations
• Structured Questionnaires
• Simulated Purchase Visits
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In-Depth Interviews
• Extended discussion between a
respondent and an interviewer
based
• Will use a brief interview guide
• Usually covers 10-30 topics
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Focus Group Discussions
• Short (1 to 2 hours) discussion
• Led by a moderator, topics kept
in focus
• Small group of respondents (6-
10)
• Talk in depth about a defined
list of topics of interest
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Structured Observations
• Systematic observations by
trained observers of a series
of encounters between
health providers and
patients
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Structured Questionnaires
• Fixed set of items asked to a large sample of
respondents selected according to strict rules to
represent a larger population
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Which Method to Use?
• Best method depends on:
– nature of the problem
– objectives of collecting data
– available resources and time
– local capacity and experience
• Use multiple methods
– quantitative + qualitative
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Aggregate data methods
• Daily Defined Dose (DDD)
• Vital-Essential-Nonessential (VEN)
• ABC Analysis
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Aggregate data methods
• Use routine data not collected at the individual
patient level
• Aggregate methods are useful way to gain an
OVERVIEW of drug use problems using
routine data not collected at individual patient
level
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Drug use Aggregate Data
• Data sources: Data that can be retrieved
– Procurement records Drug Consumption
– Warehouse drug Drug availability
records Frequency of use
– Pharmacy stock and Per capita use of specific Product
dispensing records Prevalence of adverse drug
– ADR and medication reactions
error reports Prevalence of medication
– Patient medical errors
records
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Daily Defined Dose (DDD)
• DDD is the assumed average maintenance dose per
day for a drug used for its main indication in adults
• A methodology that allows comparison of
consumption of drug products across hospitals,
regions, and countries
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• Typically expressed as follows
– DDD per 1,000 inhabitant per year, for total drug
consumption
– DDD per 100 beds per day (100 bed-days), for
hospital use
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Example-Methyldopa use
• A hospital and health center with 2,000,000 populations
– methyldopa 250mg, 25,000 tablets yearly and
– methyldopa 500mg, 3,000 tablets yearly
• Quantity of drug used in 1 year multiplied by strength of the
product
– (25,000 X 250mg) + (3,000 X 500mg) = 7,750,000mg
(7,750gm)
• DDD for methyldopa =1gm
• Divide total quantity by DDD = 7,750gm/1gm = 7,750 DDDs
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• Divide total DDD per year by 2,000,000 population
and multiply by
• 1,000 (this is the population denominator for this
method)
= ( 7,750 / 2,000,000 ) x 1,000 inhabitants
= 3.8 DDD Per 1,000 inhabitants Per Year
= 3.8 / 365 days per year
= 0.01 DDD per 1,000 inhabitants per day
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• DDD Exercise 1
• A certain area with a population of 4 million
consumed the following drugs:
– Ampicillin 250 mg, 50, 000 capsules
– Ampicillin 500 mg, 25, 000 capsules
– Assume DDD for Ampicillin is 2 grams
– Calculate the DDD for Ampicillin?
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PDD/CDD
• Prescribed daily dose and consumed daily dose
– PDD is defined as the average dose prescribed according to
a representative sample of prescriptions.
– The PDD can be determined from studies of prescriptions
or medical or pharmacy records.
– It is important to relate the PDD to the diagnosis on which
the dosage is based.
– The PDD will give the average daily amount of a drug that
is actually prescribed.
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• It should be noted that the PDD does not necessarily
reflect actual drug utilization.
• Some prescribed medications are not dispensed, and
• the patient does not always take all the medications
that are dispensed.
• Specially designed studies including patient
interviews are required to measure actual drug intake
at the patient level (i.e. the consumed daily dose).
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VEN Analysis
• Method to prioritize for drug purchase & stock
• V–Vital
– Potentially lifesaving
– Crucial to providing basic health services
• E–Essential
– Effective against less severe but significant
illness, but not vital
• L/N–Non-Essential
– For minor illnesses
– High cost and low therapeutic advantage
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ABC Value Analysis
• “A” drugs
– 70-80% of the budget
– 10-20% of the drugs
• “B” drugs
– 15-20% of the budget
– 10-20% of the drugs
• “C” drugs
– 5-10% of the budget
– 60-80% of the drugs
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Compliance
• This is a term that has been established to describe a patient‟s
degree of conformity with the advice and recommendations
given by health professionals.
• The term non-compliance was used to describe significant
failure to conform with the advice and recommendations to an
extent that it interferes with achieving the patient outcomes
planned.
• Since this term has a negative nuance for the patient and
overrides the concept that the patient may have a problem with
the medication or recommendations, the term non-compliance
is not very much supported today.
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• The concept of compliance seems to denote a relationship in
which the patient has:
– a passive role and
– is expected to follow the doctor‟s orders.
• Since the term does not emphasise patient participation, there
has been a shift towards the use of „adherence‟ as a term
instead.
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Adherence
• As opposed to the concept of compliance, adherence seems to
denote a relationship in which the patient has:
– an active role and
– is expected to contribute to the establishment of the
treatment to be followed.
• In the concept of adherence the patient is free to decide
whether or not to adhere to recommendations by health
professionals and failure to do so should not be a reason to
blame the patient.
• Health professionals have a responsibility to facilitate
adherence.
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Concordance
• This term is used to denote the degree to which the patient and
the health practitioner agree about:
– the nature of the illness and
– the need for management, and
– the relative risks and benefits of the proposed line of
treatment.
• In the concept of concordance, the patient‟s views are taken
into account during the prescribing phase in order to increase
the likelihood of better compliance.
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Categories of non-adherence
• Primary non-adherence: patient does not have access to
medicine
• Secondary non-adherence: patient has access to medicine but
does not take it due to:
– accidental non-adherence: forgets to take medication or is
unable to take medication due to lifestyle
– triggered non-adherence: cannot take medication due to
drug-related problem
– intentional non-adherence: decides not to take medication.
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Classification of non-adherence
• The ideal situation – adherence achieved
• Few errors (0–15%) – partial adherence
• Major default (15%) – partial/non-adherence.
• It is still hard to quantify the consequences of poor
adherence to medication.
• There is no consensus as to the quantification of
partial adherence (number of missed doses).
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Measurement of non-adherence
• Direct methods:
– observation of ingestion of the drug or
– by detecting its presence in body fluids
• Indirect methods: assume ingestion based on proxy
evidence such as patient‟s self-reporting, number of
dosages remaining, number of dosages removed from
a container through data recorded in medication
compliance aids
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• These include:
– tablet counts: counting number of units left in container
– patient diary cards: reporting by patient
– electronic monitors: incorporation of electronic devices into
the medicine container recording time and date of usage
– clinicians‟ estimates and therapeutic outcomes
– patient self-reporting on health status and how the
condition has improved.
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Causes of non-adherence
• Therapy-related factors:
– type of dosage form (e.g. large solid oral dosage forms,
inability to use metered dose inhalers),
– problems with handling container (e.g. opening of child-
resistant containers, blister packs),
– polypharmacy (e.g. patient has to handle a number of
different drugs),
– dosage frequency (e.g. multiple daily dosing),
– occurrence of side-effects.
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• Condition-related factors: non-adherence particularly
noted in conditions where patient is not seeing benefit
from drug therapy (e.g. hypertension),
– in conditions that are associated with a social
stigma (e.g. psychiatric disorders, HIV), where
patients may not be ready to accept medications
for the condition (denial of illness or of need for
medications)
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• Patient-related factors: patient’s knowledge, beliefs about and
attitudes towards medicine and disease state
• Health-system factors: relationships with the healthcare team,
ability to get prescription and medicines, inadequate patient
education
• Social and economic factors: social factors such as lack of
patient support and income, problems with living conditions
and problems at home level of education and literacy.
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Strategies to improve patient adherence
• Labelling: large (font size), clean (printed), simple, specific
• Packaging: while taking into account stability of the product,
ensure patient accessibility and acceptance of product
appearance
• Compliance aids: use of devices that can be used to remind
patient to take medication, dispensing medication in blister
pack according to dosage regimen, preparing medicine
reminder charts, administration devices (e.g. eye-drop
applicators)
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• Review patient prescriptions and medications: to reduce
dosing frequency and multiple drug therapy where relevant
• Improve patient–pharmacist–doctor rapport
• Ensure effective patient information
• Maintain patient contact and regular pharmacist follow-ups
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