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Transcript
Rational prescription C H Chen Nov., 2001 Mr. Wong, 65 years old, attended for follow up Ex-smoker, non drinker Come for medications 2-monthly as usual Good tolerance to med. Apart from on and off dizziness, but no history of syncope Problem lists : HT, IHD, AF, Dizziness Con’t ( case 1 ) Drug lists ( total 8 weeks of med.) isordil 10mg tds po Digoxin 0.25mg qd po Adalat retard 40mg bd po Natrilix 2.5mg om po Stemetil 1 tab tds po prn Panadol 500mg qid po prn What will you do ? (case 1 ) Continue current regime for 8 weeks more ? Any things do you want to know ? Case 1 BP this time > 102/78 Pulse 68 regular Physical exam revealed no sign of acute heart failure, but mild pitting ankle edema only No evidence of GIB, no pallor HS dual , no definite murmur heard Clinically not in distress Case 1 Previous BP : range from 98 to 180 systolic and 60 to 100 diastolic No ECG available in the old files Digoxin and isordil was prescribed by one of his private physician previously as he was told that he got IHD and arrthymia. Latest elecrolyte in Sept., 1999 > K 3.3 with normal creatinine, corresponding notes reviewed encourage fruit intake. Discussion (Case 1 ) Blood pressure control Diagnosis of AF and IHD Dizziness Good prescribing What do patients want and need? Advice Cure: symptom relief Prognosis Certificates 4 aims to achieve for prescribers Maximize effectiveness Minimize risks Minimize costs Respect the patient’s choice Maximize effectiveness Pharmacological manipulation of the body to improve or remove a condition Use some objective, numerical measurement to assess effect ( eg., BP measurement for BP control ) Minimize risks Reduce probability of an untoward happening resulting from drug treatment Include transient, minor side effect and adverse drug reaction Respect the patient’s choice Ethical/practical choice behind patient Informed choice Ironically, complying with patient’s choice of treatment means poor prescriber Patients are more satisfied if doctors listen to their views, negotiating the details of drug treatment may improves compliance conflicts Effectiveness and risks Cost effectiveness and patient’s choice Rational prescribing Correct diagnosis Appropriate drug, dose, route and duration Simple regimen Avoid drugs if therapeutic advantage not supported by independent evidence Avoid drugs with poor risk/benefit ratios Review regularly and terminate if no longer needed The most powerful drug: doctor Understanding Explanation Reassurance and prognosis Placebo effect Adverse drug reaction (ADR) Generally under-reported A threat to patient’s health and quality of care Generates significant expenses ADR Unwanted or unintended effects of a medicine which occur during its proper use Extrinsic and intrinsic factors Extrinsic > Errors in manufacturing, supplying, prescribling, giving or taking medicine Intrinsic > inherent properties of the medicine itself may cause unwanted effects Medication related problems Prescription cascade Misinterpretation of an adverse drug event as another medical condition Prescription of additional medications Non-adherence poor therapeutic outcomes higher dosages or more potent therapies ADR Survey done at one of the university hospital in Switzerland 6 months of surveying to all primary admissions to medical emergency department Total about 7% of admissions related to ADR Most common being of GIB, follow by febrile neutropenia Anti-cancer drugs in 22.7% of cases ADR Anticoagulants, analgesic and nonsteroidal anti-inflammatory drugs in 8 % of cases each Case 2 Mr. Chan, 60 years old, attended for follow up as usual Chronic smoker, social drinker Presented with exertional dysneoa and wheezing Associated with chronic dry cough No recent hospitalization Case 2 Claimed good drug compliance with regular usage of puffer ET > level ground only Problem list : COAD, HT Drugs list Ventolin puff 2 puffs qid prn Atrovent puff 2 puffs qid prn Theodur 100mg tds po Bricanyl durule 7.5mg bd po Ventolin 4mg tds po Inderal 40mg tds po Betaloc 50mg bd po Case 2 Clinically not in distress with occ. Coughing only Chest occ. Rhonchi with poor expansion of lung and hence poor air entry BP 155/90, P 66 with occ. Ectopic heart beat PFR 130/150 Discussion (case 2 ) Coad control BP control Side effect profiles Alternative choice of agents Treatment other than drugs Are Hong Kong doctors overprescribing? Expenditure on drugs per capita in HK 2-3X that of UK Items prescribed: HK Government OPD:just under 3 UK:just over 1 Regional/international standards (national library of med. ) 2 for the average of the drug 17% for injection 50% for antibiotics A pill for every ill?? Random sample of 1068 HK Chinese interviewed by telephone done in 1995 results 40% thought illnesses always needed drug treatment 76% expected prescription Almost 100% got prescription in their last consultation 85% prescription > 3 or more drugs < 50% finished all the medication result Younger age and higher education associated with less likelihood of expecting prescription conclusion Chinese do not expect a pill for every ill but doctors prescribe in nearly 100% of consultations Doctors created high expectation for a prescription in every consultation through their own prescribing habit The influence of patients’ hopes of receiving a prescription on doctors’ perceptions and the decision to prescribe: a questionnaire survey BMJ Vol 315 6 Dec 97 Design Questionnaires to patients waiting to see GP and to doctors immediately after their consultations Subjects 544 unselected patients consulting 15 GP Results 67% patient hope for prescription Doctors perceived 56% patients wanted prescriptions 59% doctors prescribed 25% of patients hoped for a prescription did not receive one Conclusion Decision to prescribe was closely related to actual and perceived expectations, the latter being more significant Over-prescription of antibiotics in primary care 20-50% believed to be unnecessary Factors responsible for inappropriate antibiotic use Patient factors Misconception about what antibiotics do Misconception about healing power of antibiotics Factors responsible for inappropriate antibiotic use Physician factors Real or perceived patient pressure Economic concern for self e.g. loss of clients Physician fallibility:inadequate knowledge Uncertainty of the diagnosis Easing himself ( something done ) Factors responsible for inappropriate antibiotic use Other factors Cost saving pressures to substitute therapy for diagnostic test Reduce appointment time per patient Misleading advertisement Cultural factor Final comments Do he needs prescriptions Is it indicated Adverse drug reactions Risk and benefits ratio Polypharmacy Always review drug lists Review drug regimen All new medication should started as a trial Substitute instead of adding on new medications Look for signs of adverse reactions and drug induced problems Improving rational prescription Physician training >more training to communicate with patients about risk and benefit >training in decision analysis >undergraduate/continuing education in therapeutics Improving rational prescription Patient education Public need to be educated about the risks and benefits of medical interventions Government Pharmacist media