Improving the use of prescription medicines : exploration of international comparisons of utilisation and other strategies to influence more rational use of specific medicines

International comparisons of prescription medicine usage represent a valuable strategy to achieve a better understanding about how medicines are being prescribed. Cross-national drug utilization studies can provide comparative information on differences in the effects of access to drug subsidy programs, formulary policies and some influences on physician prescribing (educational interventions, industry and marketing efforts) to explain some of the prescribing variations as well as to plan and improve practices in drug approval, regulation, financing, reimbursement, prescribing and use by patients. However, despite the potential benefits that could be achieved by comparing drug utilization in different jurisdictions, review of the international literature still identified a lack of research regarding cross-national comparisons and lack of a standardized methodology to describe and compare prescribing patterns within and between different countries. The overall aim of this thesis was to perform national and international comparison studies of non-steroidal anti-inflammatory drugs (NSAIDs), cyclo-oxygenase-2 (COX-2) inhibitors, paracetamol, proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) utilization patterns in Australia and Nova Scotia (Canada) to understand, describe and contrast factors influencing the use of those medicines and to identify aspects of relevance for future strategies designed to improve prescribing behaviour. The initial research involved the collection of NSAIDs, COX-2 inhibitors, and paracetamol prescription data both in Australia and in Queensland, over the period 1997-2003, in order to identify and validate a suitable methodology and to determine whether national data could be used for comparative purposes. Subsequently, the analyses of the Australian data were extended to PPIs and H2RAs. Also, the NSAIDs, COX-2 inhibitors data were used to carry out an international comparison with Nova Scotia to determine the relationship between these classes of drugs in the two jurisdictions. Data for each individual drug and total overall NSAID, COX-2 inhibitor, paracetamol, PPI and H2RA use were accessed from the prescription medicine administrative databases. Use of each of the drugs was aggregated at yearly levels and converted to Defined Daily Doses (DDDs), the WHO method for international comparison of drug utilization. DDDs for each of the drugs were calculated per thousand head of the eligible population. The changes in drug use over time at each site were evaluated. To investigate more in depth the qualitative factors driving some of the prescribing patterns quantified, consumers’, pharmacists’ and general practitioners’ (GPs) beliefs and perceptions about the use of NSAIDs, COX-2 inhibitors and paracetamol were explored. This allowed further insight into the rationale behind the prescribing practice for those drugs in Australia. Focus groups with consumers and pharmacists and in-depth semi-structured interviews with pharmacists and GPs were organized. Subsequently, an educational intervention aimed at encouraging a more rational use of therapies for chronic pain control in osteoarthritis was designed, implemented and evaluated. The designed intervention aimed at improving paracetamol prescribing practice and reducing the prescribing of other therapies. Printed educational materials were disseminated to specified geographic areas. Changes in paracetamol prescribing and consumers’ knowledge about use of paracetamol were explored and compared to control groups. To summarise some of the analyses in this thesis, the data for NSAIDs and related medicines showed that COX-2 inhibitor prescribing influenced markedly the overall pattern of NSAID prescribing both in Australia and Nova Scotia, increasing the total NSAIDs use. The total use of NSAIDs changed from approximately 80 to about 105 DDD/1000 concession beneficiaries/day in Australia and from about 55 to 70 DDD/1000 concession beneficiaries/day in Nova Scotia over the study period. In Australia, PPIs use increased between 1997 and 2007 (from 20 to 140 DDD/1000 concession beneficiaries/day). On the other hand, H2RAs decreased, being almost completely replaced by PPIs (from 65 to 20 DDD/1000 concession beneficiaries/day). There were no obvious relationships between population use of NSAIDs and use of gastroprotective agents. From the qualitative analysis, it appeared that consumers had poor knowledge of the appropriate use of paracetamol. In practice, patients seemed to need a better understanding of use of paracetamol as regular treatment for osteoarthritis pain. Also, from the study it became evident that pharmacists and doctors did not appear to be discussing options for pain control well with consumers. However, a small educational intervention targeted towards consumers did not produce measurable changes in paracetamol use. In conclusion, this research has examined and contrasted the utilization pattern of NSAIDs, COX-2 inhibitors, paracetamol, PPIs and H2RAs as well as explored some of the obstacles that surround paracetamol prescribing. Overall, problems were identified with lack of adherence to guidelines and little sharing of information between consumers and health professionals. This research suggests good opportunities to identify ways to progress research in this field. Also, it recognizes the importance of initiatives that may be implemented to educate people to achieve better understanding and more appropriate use of their medications.

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