roup 1: Prescribing indicators

The indicators of prescribing practices measure the performance of

health care providers in several key dimensions related to the
appropriate use of drugs. The indicators are based on the practices
observed in a sample of clinical encounters taking place at outpatient
health facilities for the treatment of acute or chronic illness. These
encounters can be observed retrospectively, from data recorded in
historical medical records, or they can be observed prospectively,
from a group of patients attending the clinic on the day the data are
collected. Details of how to draw a sample of health facilities and how
to sample clinical encounters are discussed in Chapter 3.
The core prescribing indicators do not require the collection of any
information on signs and symptoms. Because the samples of clinical
encounters cover a broad spectrum of health problems, the core
prescribing indicators measure general prescribing tendencies within a
given setting, independent of specific diagnoses. Admittedly, many
critical questions in drug use have to do with whether health care
providers follow appropriate diagnostic procedures and whether they
select products and dosage schedules to fit underlying health
problems. However, determining the quality of diagnosis and
evaluating the adequacy of drug choices is a complex undertaking in
practice, and beyond the scope of the core indicators. After a first
drug use study with selected indicators has been carried out to
determine overall prescribing performance, it will usually be
necessary to undertake more health problem-specific investigations
and make an assessment of the quality of diagnosis and treatment.
The data to measure the prescribing indicators can be recorded on
forms that are reproduced in Annex 2. The detailed prescriber
indicator form requires recording the names and amounts prescribed
for each drug, from which the values for each prescribing indicator
can later be entered. The form also allows other information on
patients, prescribers and health problems to be recorded. The
advantages of the detailed form are that data can be collected by
persons with less sophisticated knowledge about drugs, and also that
later follow-up health problem-specific or drug-specific analyses can
be carried out on the same data. The ordinary prescriber indicator
form requires that each indicator be entered directly by data collectors
in the field. This assumes that data collectors know enough about
drugs to evaluate the indicators. Its main advantage is that it allows
immediate summaries of the indicators to be produced and discussed
with staff from the health facility; its disadvantage is that fewer
possibilities exist to later validate the data. The detailed form can be
used for secondary analysis of specific diagnoses or drugs.

The ability to prescribe drugs rationally is

influenced by many features of the working
environment. Two particularly important
components are an adequate supply of
essential drugs and access to unbiased
information about these drugs. Without these
it is difficult for health personnel to function
effectively.

The data for the health facility indicators can

be recorded on the facility summary
form included in Annex 2. The same form
can be used to record information on the
data collection process at each health
facility, such as the names of the primary
contact people at the facility, whether
retrospective or prospective data were
collected, how many cases were recorded for
the prescribing and patient care indicators,
and any problems that occurred during the
visit.

Surveys with drug use indicators may have

different objectives: to describe current
treatment practices; to compare the
performance of individual facilities or
prescribers; to monitor or supervise specific
drug use behaviours; or to assess the impact
of an intervention. This chapter discusses
some important study design and sampling
issues.

The best design for a particular study

depends not only on statistical theory but
also on the objective(s) of the study and on
the practical aspects of collecting the data.
Guidelines for the sample size for each of the
different types of study are therefore
included and are based on extensive field
testing. They are summarized in Table 4. By
following these recommendations the results
of the drug use studies will be valid and
comparable.

The methodological issues are discussed in

full in a separate document, in which
theoretical and empirical support for the
recommendations made in this section are
presented. If it is essential that study results
be highly accurate and reliable, for example
when the effects of an expensive
intervention have to be tested, it is
recommended that a sampling expert be
consulted before the study is undertaken.