807. USING DEFINED DAILY DOSES, PIVOT TABLES & CHARTS AS A MEANS OF MEASURING MEDICINE UTILISATION TRENDS

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1 807. USING DEFINED DAILY DOSES, PIVOT TABLES & CHARTS AS A MEANS OF MEASURING MEDICINE UTILISATION TRENDS Gunn, Brian Conroy; Suleiman, Batool Jaffer Directorate of Rational Use of Medicine, Ministry of Health, Oman Problem statement: Measuring the trends in medicine utilisation is a vital means of control for ensuring the rational use of medicines. The defined daily dose (DDD) is a relatively underused and poorly understood tool for assessing medicine use and comparing trends. Objectives: To set up a relatively simple and on-going medicine utilisation trend analysis using DDDs and Excel pivot tables and charts Resources: National data on medicine consumption in the public sector was obtained from the Director General of Medical Supplies and the Director of Information Technology at the autonomous Royal Hospital, Muscat, Oman. DDDs were obtained from the WHO Collaborating Centre for Drug Statistics Methodology using their ATC/DDD index. Excel 2003 or Excel 2007 spreadsheets were used to create the database and pivot tables for analyses. Methods: Using raw consumption data from the above sources (manual or computerised), an Excel database was designed to permit the rapid generation of the most useful information. Total DDDs for the majority of medicines were calculated and then the internationally recognised standard formula DDD per 1000 population per day was calculated. The methodology is flexible enough to be adapted for other useful formulae to be calculated, such as DDD per 100 bed days, or DDD per 100 admissions for hospital inpatient use, or DDDs per inhabitant per year. Results: Trends in medicine use have now been calculated for the public sector in Oman since 1999 with the most comprehensive results for The results are best displayed as a series of column or stacked column pivot charts for each therapeutic group. Also, pivot tables showing the top 10 or 20 medicines used or the top 10 antibiotics are rapidly generated. An annual report with the most significant charts is produced highlighting positive and negative results. The trends can be looked at from several viewpoints. Positive trends are generally indicative of good prescribing rather than a decline in morbidity. In many cases there may be an increase in morbidity but the prescriber s choice of therapy is considered rational and appropriate. A negative trend sometimes indicates an increased use of a drug pointing to an increase in morbidity, which is bad by itself rather than bad prescribing or it could be due to a poor choice of therapy. The relative results are usually more significant for comparison than the absolute values. Conclusions: The methods used have enabled the rapid assessment of the trends in medicine use in the public sector of Oman over several years. Excel pivot tables and charts can produce an almost infinite number of views of the data with a few keystrokes. The results can be used by policy makers, planners, and researchers. It is hoped that as many as possible of the neighbouring countries can adopt similar methodology for reporting so that regional comparisons can be made. Funding sources: MoH General Budget

2 Background & Setting Measuring trends in medicine utilisation is a vital means of control for ensuring the rational use of medicines. The defined daily dose (DDD) is a relatively underused and poorly understood tool for assessing medicine use and comparing trends. DDD per 1000 population per day is one of the most widely accepted parameters used internationally for outpatient prescriptions DDD per 100 bed days is also widely used to measure medicine use in a hospital in-patient setting

3 Aims & Objectives To gather medicines consumption data throughout the MoH in Oman To design a relatively simple system for the storage, rapid retrieval and display of the data To present highlights to policy makers about the underlying trends Positive and negative trends will be presented

4 Methods Raw consumption data was obtained from the medical supplies section A data base was constructed using Microsoft Excel The design took in to account the varying ways of filtering retrieving and displaying the data Pivot tables were designed to rapidly display reports, tables and charts

5 The Main Database (1)

6 The Main Database (2)

7 Pivot Table

8 Pivot Table (2007 & 2010)

9 3.00 Antiasthmatic Drugs DDD per 1000 Population Per Day MDI Preventers & Relievers Salbutamol - Reliever Beclometasone - Preventer Salmeterol - Reliever Ipratropium - Reliever Fluticasone - Preventer

10 DDD per 1000 Population Per Day Top 10 Medicines Consumed in Oman All Statins Acetylsalicylic acid Atenolol Hydrochlorothiazide Lisinopril Iron (II) Glibenclamide Amoxicillin Chlorpheniramine Metformin

11 Positive & Negative Trends The trends can be analysed from several viewpoints. The positive trends are generally indicative of good prescribing rather than a decline in morbidity. In many cases there may be an increase in morbidity but the prescriber s choice of therapy is considered rational and appropriate. A negative trend usually indicates an increased use of a drug pointing to an increase in morbidity, which is bad by itself rather than bad prescribing or poor choice of therapy per se. o Compare this with the under-prescribing of beclometasone MDI and combining of hyoscine and metoclopramide which are considered as examples of bad prescribing.

12 Positive trends The ratio of hyoscine : metoclopramide has reduced in 2010 from a peak of 1.6:1 to 1.4:1. At RH the ratio favours metoclopramide LMW Heparins have now overtaken heparin use and more so at RH. Ratio of 3:1 in all institutions Aspirin (low dose) use is increasing in line with global trends for primary prevention of cardiovascular events, At RH there is a decline in low dose aspirin consumption Clopidogrel use has been increasing in specialist cases and dipyridamole use remains steady. Ratio of use is about (2.5:1) in MoH and >11:1 at RH Atenolol use is decreasing relatively as an antihypertensive. Lisinopril is now the highest use member of the group. This reflects the priority of renal protection in HTN Negative trends There is an increase in antihistamine use again and especially the traditional drowsy variety except at RH. Antihistamine use is still too high (1% of total population treated every day!) Ratio of reliever inhalers (salbutamol) to preventers (beclometasone) has not improved overall except that it has improved at RH There is an increase in salbutamol syrup again perhaps due to the deletion of cough mixtures There is an overall increase in the cephalosporin group usage with the largest change in the use of 2 nd generation cefuroxime. 3 rd and 4 th generations remain about the same

13 Conclusions Advantages Using Excel as a medicine utilisation database gives a relatively simple platform for trend analysis The database is stable and easy to maintain and monitor for duplicate records The use of Excel pivot tables and charts provides an almost limitless way of viewing and displaying the data from the database Defined Daily Dose per 1000 population per day is an excellent parameter for summarising the data and allows international and regional comparisons if required All medicine forms can be included

14 Conclusions Disadvantages Cannot be used for medicines that do not have an assigned DDD This includes vaccines, topical medicines and some combination drugs

15 Reference: DDDs were obtained from: WHO Collaborating Centre for Drug Statistics Methodology