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Does Drug Use Evaluation
Required by National Policy
Improve Use of Medicines?
Akaleephan C*, Muenpa R**, Sittitanyakit B***, Treesak C#,
Cheawchanwattana A$, Limwattananon S$, Limwattananon C$,
Tangcharoensathien V*
*International Health Policy Programme
Abstract
Akaleephan C*, Muenpa R**, Sittitanyakit B***, Treesak C#, Cheawchanwattana A$, Limwattananon S$, Limwattananon C$,
Tangcharoensathien V*
*International Health Policy Programme-Thailand, **Lumpang Hospital, ***KhonKaen Hospital, Srinakharinwirot
University#, $KhonKaen University
Problem Statement: Drug Use Evaluation(DUE) was first introduced to Thailand’s Ministry of Public Health (MoPH)
hospitals in 1991. Annual surveys of pharmacy activities in 92 MoPH hospitals during 1995-1999, indicated that DUE
existed in 30-50% of them, however only 7.5% was continuous DUE monitoring. DUE was strengthened by the policy
statement in the 1999 National Essential Drug List (NEDL) and the 1998 MoPH post-economic crisis drug management
reforms under Good Health at Low Cost Policy.
Objectives: To assess the DUE situation in Thailand regarding policy implementation and outcomes on rational drug use; to
assess health professionals’ perspectives towards and experience on DUE and its constraints since the program was
strengthened in 2000.
Design: Prospective, time-series design
Setting: 100 MoPH hospitals, 1 university hospital, and 4 defense hospitals.
Intervention: Four antimicrobials and two cardiovascular drugs were selected as tracers. DUE package for the 6 drugs,
(consist of evaluation criteria of 6 drugs use, guideline on DUE procedure, drug order forms, data collection forms and
report forms) were developed by researcher. A national meeting of the chairpersons and secretariat of hospitals’ DTC
was organized to disseminate the policy messages and DUE package for the 6 drugs in 2000. A self administered
questionnaires survey of hospital pharmacists’ perspective, experience and constraints was conducted and another
survey of physicians’ perspective in 2 regional hospitals with 10-year experiences in DUE was also conducted at the
end of 2002.
Outcome Measures: %hospitals having DUE in pre- and post-policy implementation; %appropriateness of indication and
dosage regimen; incidence of adverse events; %self evaluation competency of hospital pharmacists; and %DUE
perspective of physicians.
Results: The survey of pharmacy activities showed increasing proportion among 92 MoPH hospitals having a qualitative or
quantitative DUE program, from 19.7% in 1999 to 82% in 2000. Qualitative DUE data were spontaneously reported
with an average 30% reporting rate. The rate decreased over the 3 six-monthly period during June 2000 to December
2001. The rates of appropriate indication for using pentoxiphylline and statin (primary prevention) tablets were 3057%, higher rates of 44-90% were found among other drugs. A questionnaire survey of 450 hospital pharmacists
indicated that 32% had insufficient knowledge to set up DUE criteria, while 47% was able to analyse data. The
constraints in conducting DUE were described. It was found that 94% and 44% of physicians in hospital 1 and 2,
respectively, misunderstood that DUE is the compulsory use of drug order forms for restricted drugs.
Conclusions: The national policy was effective in encouraging DUE; however, there is room for improvement. Therapeutic
outcomes of drug use should be assessed. Current lack of proper understandings on DUE illustrated existing problems.
Background

Drug Use Evaluation(DUE) was first introduced to Thailand
Ministry of Public Health (MoPH) hospitals as a component of
clinical pharmacy package in 1991. In 1995-1999 annual surveys
of pharmacy activities of all 92 provincial and regional hospitals
indicated that DUE was existing in 30-50% of these hospitals,
however, 7.5% had a continuous DUE program. During 1992 to
2002, most (74%) DUE conducted were qualitative studies,
focusing on antimicrobials and the rest were quantitative
evaluation and prescribing pattern review.

Since 1998, DUE has been addressed within the framework of two
key policies.

First, the high cost or high risk drugs in sub-list D in the 1999
National List of Essential Drug (NLED) enforced a mandatory DUE
program if a hospital adopt this list.
 Second, DUE was advocated in the MoPH post-economic crisis drug
management reforms under Good Health at Low Cost Policy banner.
Objectives


To assess the DUE situation in Thailand regarding policy
implementation and outcomes in term of rational drug use
To assess health professionals’ perspectives towards and
experiences on DUE and programmatic constraints since its
strengthening in 2000
Methodology
1. Six drugs, namely, ceftazidime injection, imipenem plus cilastatin
injection, ciprofloxacin injection and tablet, statins tablet and
pentoxiphylline tablet were selected as tracers.
Selection criteria of tracers included in:
 The sublist D classification in the 1999 NLED
 The top 50 drug expenditure of MoPH hospitals
(latest figures in 1998, 1999)
 The list of top 100 drug manufactured
domestically and imported value
(latest figure in 1997, 1998)
Methodology (cont.)
2. DUE package: Drug use criteria were set up mainly based on
NLED recommended indication. Guideline on DUE procedure,
drug order forms, data collection form and report forms were also
developed.
3. A national meeting of chairpersons and secretariats of hospital
drug and therapeutic committee(DTC) was organized to
disseminate the policy messages and DUE package of tracers in
March 2000.
4. The voluntary reports of qualitative DUE of tracer drugs (June
2000 to December 2001) were analyzed.
5. Self administered questionnaire survey of hospital pharmacists’
perspectives, experience and constraints were conducted in a
national academic meeting on pharmaceutical care in November
2002.
6. Self administered questionnaire survey of physicians’ perspectives
in two regional hospitals with 10-year experiences in DUE was
conducted in December 2002.
Discussion
1. Average voluntary reporting rate was 30%, with a decreasing
trend over 3 six-monthly periods during June 2000 to December
2001.
2. The high percentage of appropriateness in most tracers in this
study, does not represent a national picture. Voluntary reporting
may biased towards good performance hospitals. Thus, there is
room for strengthen DUE program to cover more hospitals.
3. According to NLED 1999 recommended indication,
pentoxiphylline tablet had the lowest appropriateness. It needs
further verification and specific intervention.
4. Therapeutic outcomes of drug use should be assessed and
strengthened, for example adverse drug reactions in general and
lipid blood level for lipid lowering drug.
Conclusion & recommendation
1. The national policy encourages DUE in hospitals, however,
continual enforcement and concomitant monitoring and technical
support are recommended.
2. Current lack of proper understandings on DUE concept illustrated
existing problem. Insufficient knowledge and skill in clinical
pharmacy or pharmaceutical care, and coordination among
pharmacists and physicians were also found. This prompts to
increase awareness and training needs to strengthen DUE.
Result
1. Percentage of regional and provincial
hospitals responded to DUE policies
%
100
regional
80
prov.>300 beds
Policy introduction
60
prov.<300 beds
total
40
20
0
1996
1997
1998
1999
2000
year
2. Percentage of indication appropriateness
%
100
80
60
40
20
drugs
ifi
c
im
ip
-e
m
pi
ri
c
im
ip
-s
pe
ci
fic
ci
pr
oem
pi
ri
ci
c
pr
osp
ec
ifi
c
ftsp
ec
ce
ce
ftem
pi
r
ic
0
Jun.-Dec.2000
Jan.-Jun.2001
Jul.-Dec.2001
2. Percentage of indication appropriateness
%
100
80
60
40
20
drugs
-2
st
at
in
-1
st
at
in
pe
nt
ox
.
ci
p
ro
ta
b.
0
Jun.-Dec.2000
Jan.-Jun.2001
Jul.-Dec.2001
statin-1 = statin primary prevention, statin-2 = statin secondary prevention
3. Appropriateness in dosage regimen
Dose appropriateness: more than 70% in
patients without renal problem but 27-78% in
patients with renal insufficiency due to lack of
confidence to adjust dose in severe and serious
infection
 Dosage interval appropriateness: more than
90%

4. Incidence of adverse drug reaction
unable to estimate because of insufficient data
5. Hospital pharmacists’ self evaluation
(n = 450, 64% response rate)
 32% had insufficient knowledge to set up drug
use criteria
 48% was able to modify the MoPH standard
criteria
 47% was able to analyze data
 constraints in conducting DUE were described:
difficulty in patient profile evaluation,
inadequate skill in clinical pharmacy, lack of
coordination among physicians and pharmacists
6. Physicians’ perspectives in 2 regional
hospitals (n = 110)
Issues
Hospital 1 Hospital 2
 Knowing about DUE in
hospital
76%
40%
 DUE refers to
compulsory use of drug
order form for restricted
drug
94%
55%
 Agreed that writing
drug order form can help
prescribing review
60%
67%