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Ooms GI, Usman MA, Reed T, van den Ham HA, Mantel-Teeuwisse AK. The impact of scheduling ketamine as an internationally controlled substance on anaesthesia care in Sub-Saharan Africa: a case study and key informant interviews. BMC Health Serv Res 2024; 24:598. [PMID: 38715038 PMCID: PMC11077710 DOI: 10.1186/s12913-024-11040-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Access to anaesthesia and surgical care is a major problem for people living in Sub-Saharan Africa. In this region, ketamine is critical for the provision of anaesthesia care. However, efforts to control ketamine internationally as a controlled substance may significantly impact its accessibility. This research therefore aims to estimate the importance of ketamine for anaesthesia and surgical care in Sub-Saharan Africa and assess the potential impact on access to ketamine if it were to be scheduled. METHODS This research is a mixed-methods study, comprising of a cross-sectional survey at the hospital level in Rwanda, and key informant interviews with experts on anaesthesia care in Sub-Saharan Africa. Data on availability of four anaesthetic agents were collected from hospitals (n = 54) in Rwanda. Semi-structured interviews with 10 key informants were conducted, collecting information on the importance of ketamine, the potential impact of scheduling ketamine internationally, and opinions on misuse of ketamine. Interviews were transcribed verbatim and analysed using a thematic analysis approach. RESULTS The survey conducted in Rwanda found that availability of ketamine and propofol was comparable at around 80%, while thiopental and inhalational agents were available at only about half of the hospitals. Significant barriers impeding access to anaesthesia care were identified, including a general lack of attention given to the specialty by governments, a shortage of anaesthesiologists and migration of trained anaesthesiologists, and a scarcity of medicines and equipment. Ketamine was described as critical for the provision of anaesthesia care as a consequence of these barriers. Misuse of ketamine was not believed to be an issue by the informants. CONCLUSION Ketamine is critical for the provision of anaesthesia care in Sub-Saharan Africa, and its scheduling would have a significantly negative impact on its availability for anaesthesia care.
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Affiliation(s)
- Gaby I Ooms
- Health Action International, Overtoom 60-2, 1054HK, Amsterdam, The Netherlands.
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
| | - Mohammed A Usman
- Federal University of Dutse, Dutse, Jigawa State, Nigeria
- Rasheed Shekoni Teaching Hospital, Dutse, Jigawa State, Nigeria
| | - Tim Reed
- Health Action International, Overtoom 60-2, 1054HK, Amsterdam, The Netherlands
| | - Hendrika A van den Ham
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
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Costa E, Moja L, Wirtz VJ, van den Ham HA, Huttner B, Magrini N, Leufkens HGM. Uptake of orphan drugs in the WHO essential medicines lists. Bull World Health Organ 2024; 102:22-31. [PMID: 38164340 PMCID: PMC10753278 DOI: 10.2471/blt.23.289731] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/31/2023] [Accepted: 09/13/2023] [Indexed: 01/03/2024] Open
Abstract
Objective We evaluated the uptake of medicines licensed as orphan drugs by the United States Food and Drug Administration (FDA) or European Medicines Agency (EMA) into the WHO Model list of essential medicines and the WHO Model list of essential medicines for children from 1977 to 2021. Methods We collated and analysed data on drug characteristics, reasons for adding or rejecting medicines, and time between regulatory approval and inclusion in the lists. We compared trends in listing orphan drugs before and after revisions to the inclusion criteria of the essential medicines lists in 2001, as well as differences in trends for listing orphan and non-orphan drugs, respectively. Findings The proportion of orphan drugs in the essential medicines lists increased from 1.9% (4/208) in 1977 to 14.6% (70/478) in 2021. While orphan drugs for communicable diseases have remained stable over time, we observed a considerable shift towards more orphan drugs for noncommunicable diseases, particularly for cancer. The median period for inclusion in the essential medicines lists after either FDA or EMA first approval was 13.5 years (range: 1-28 years). Limited clinical evidence base and uncertainty about the magnitude of net benefit were the most frequent reasons to reject proposals to add new orphan drugs to the essential medicines lists. Conclusion Despite lack of a global definition of rare diseases, the essential medicines lists have broadened their scope to include medicines for rare conditions. However, the high costs of many listed orphan drugs pose accessibility and reimbursement challenges in resource-constrained settings.
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Affiliation(s)
- Enrico Costa
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Department of Pharmacoepidemiology, Utrecht University, Utrecht, Kingdom of the Netherlands
| | - Lorenzo Moja
- Secretariat of the Expert Committee on the Selection and Use of Essential Medicines, Department of Health Products Policy and Standards, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
| | - Veronika J Wirtz
- WHO Collaborating Centre in Pharmaceutical Policy, Department of Global Health, Boston University, Boston, United States of America
| | - Hendrika A van den Ham
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Department of Pharmacoepidemiology, Utrecht University, Utrecht, Kingdom of the Netherlands
| | - Benedikt Huttner
- Secretariat of the Expert Committee on the Selection and Use of Essential Medicines, Department of Health Products Policy and Standards, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
| | - Nicola Magrini
- WHO Collaborating Centre for Evidence-Based Research Synthesis and Guideline Development, Emilia-Romagna Health Authority, Bologna, Italy
| | - Hubert GM Leufkens
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Department of Pharmacoepidemiology, Utrecht University, Utrecht, Kingdom of the Netherlands
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Joosse IR, Tordrup D, Glanville J, Mantel-Teeuwisse AK, van den Ham HA. A systematic review of policies regulating or removing mark-ups in the pharmaceutical supply and distribution chain. Health Policy 2023; 138:104919. [PMID: 37788559 DOI: 10.1016/j.healthpol.2023.104919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 08/09/2023] [Accepted: 09/21/2023] [Indexed: 10/05/2023]
Abstract
The regulation of mark-ups throughout the pharmaceutical supply and distribution chain may be a valuable approach to control prices of medicines and to achieve broader access to medicines. As part of a wider review, we aimed to systematically determine whether policies regulating mark-ups are effective in managing the prices of pharmaceutical products. We searched for studies published between January 1, 2004 and October 10, 2019, comparing policies on regulating mark-ups against other interventions or a counterfactual. Eligible study designs included randomized trials, and non-randomized or quasi-experimental studies such as interrupted time-series (ITS), repeated measures (RM), and controlled before-after studies. Studies were eligible if they included at least one of the following outcomes: price (or expenditure as a proxy for price and volume), volume, availability or affordability of pharmaceutical products. The quality of the evidence was assessed using the GRADE methodology. A total of 32,011 records were retrieved, seven of which were eligible for inclusion for this review. The limited body of evidence cautiously suggests that policies regulating mark-ups may be effective in reducing medicine prices and pharmaceutical expenditures. However, the design of mark-up regulations is a critical factor for their potential success. Additional research is required to confirm the effects of these policies on the availability, affordability or usage patterns of medicines and in low- and middle-income countries.
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Affiliation(s)
- Iris R Joosse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, CG, 3584 Utrecht, the Netherlands
| | - David Tordrup
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, CG, 3584 Utrecht, the Netherlands
| | - Julie Glanville
- York Health Economics Consortium (YHEC), York YO10 5NQ, United Kingdom
| | - Aukje K Mantel-Teeuwisse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, CG, 3584 Utrecht, the Netherlands
| | - Hendrika A van den Ham
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, CG, 3584 Utrecht, the Netherlands.
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Costa E, Girotti S, van den Ham HA, Cipolli M, van der Ent CK, Taylor-Cousar JL, Leufkens HGM. Traits, trends and hits of orphan drug designations in cystic fibrosis. J Cyst Fibros 2023; 22:949-957. [PMID: 37507282 DOI: 10.1016/j.jcf.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/06/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND In the United States (US) and in Europe, cystic fibrosis (CF) qualifies as a rare disease, thus positioning the field to benefit from regulatory incentives provided by orphan drug designation (ODD) to boost pharmaceutical research and development. In this study, we analyzed the pool of products for the treatment of CF that received such incentives from the US Food and Drug Administration (FDA) and/or the European Medicines Agency (EMA) over the past two decades. We describe the characteristics and trends in ODDs over time and explore factors that might be determinants of successful drug development. METHODS We collected the products that received the ODD from the registries of the FDA and the EMA from 2000 to 2021, characterizing their nature, development stage, and type of sponsor. We categorized the study drugs according to the therapeutic target addressed and described trends of drug development over the study period. A logistic regression analysis was done to assess how ODD characteristics were associated with the approval for market authorization. RESULTS From 2000-2021, 107 ODDs were collectively granted by the FDA and the EMA for products developed for the treatment of CF. Although the trends of the number of ODDs granted remained stable over time, those targeting the CF basic protein defect increased from 6 out of 54 (11.1%) in the first half of the study period up to 20 out of 54 (37.7%) in the second half, while those treating symptoms decreased from 48/54 (88.9%) to 33/53 (62.3%). Overall, 10 products obtained marketing approval: 7 in both the US and Europe, 3 only in Europe. All the approved ODDs were chemical products for chronic use. No statistically significant difference was found across the examinated variables, but we observed possible drivers of successful drug development for ODDs targeting CFTR, as well as for those with active substances previously marketed, and for those developed by large companies and companies with experience in developing orphan drugs. By contrast, our findings suggest that financial issues most hamper the development of ODDs sponsored by small-medium enterprises. CONCLUSIONS Although ODDs for treating infection and other CF sequelae accounted for the majority, we observed a shift of ODDs toward mechanism-based products over the study period. In line with other rare diseases, we found that approximately 1/10 ODDs for CF reached the status of marketing approval. Advances in disease genetics paved the way for a shift in CF drug development; however, we described how the convergence of pharmaceutical technology, the financial environment, and the regulatory ecosystem played a crucial role in successful marketing authorization in CF.
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Affiliation(s)
- Enrico Costa
- World Health Organization Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, the Netherlands.
| | - Silvia Girotti
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Hendrika A van den Ham
- World Health Organization Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, the Netherlands
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Cornelis K van der Ent
- Department of Pediatric Pulmonology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Hubert G M Leufkens
- Emeritus Professor Regulatory Science and Pharmaceutical Policy, Utrecht University, Utrecht, the Netherlands
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Joosse IR, van den Ham HA, Mantel-Teeuwisse AK, Suleman F. Alignment in the registration, selection, procurement and reimbursement of essential medicines for childhood cancers in South Africa. BMJ Glob Health 2023; 8:e012309. [PMID: 37730243 PMCID: PMC10846849 DOI: 10.1136/bmjgh-2023-012309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/30/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION The effectiveness of a health system in providing access to medicines is in part determined by the alignment of several core pharmaceutical processes. For South Africa's public health sector, these include the registration of medicines, selection and subsequent procurement through national tenders. Registration, selection and reimbursement are key processes in the private sector. This study assessed the alignment of forementioned processes for essential paediatric oncology medicines in South Africa. METHODS A selection of priority chemotherapeutics, antiemetics and analgesics in the treatment of five prevalent childhood cancers in South Africa was compared with those listed in 1) the WHO Essential Medicines List for Children (WHO EMLc) 2021, 2) the registered health products database of South Africa, 3) the relevant South African National Essential Medicines Lists (NEML), 4) bid packs and awarded tenders for oncology medicines for 2020 and 2022 and 5) oncology formularies from the leading Independent Clinical Oncology Network (ICON) and two private sector medical aid schemes. Consistency between these sources was assessed descriptively. RESULTS There was full alignment for 25 priority chemotherapeutics for children between the NEML, the products registered in South Africa and those included on tender. Due to unsuccessful procurement, access to seven chemotherapeutics was potentially constrained. For antiemetics and analgesics, eight of nine active ingredients included on the WHO EMLc were also registered in South Africa and on its NEML. An exploratory assessment of private sector formularies showed many gaps in ICON's formulary and two medical scheme formularies (listing 33% and 24% of the chemotherapeutics, respectively). CONCLUSION Despite good alignment in public sector pharmaceutical processes, access constraints to essential chemotherapeutics for children may stem from unsuccessful tenders. Private sector formularies show major gaps; however, it is unclear how this translates to access in clinical practice.
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Affiliation(s)
- Iris R Joosse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Hendrika A van den Ham
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Fatima Suleman
- WHO Collaborating Centre for Pharmaceutical Policy and Evidence Based Practice, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Joosse IR, Tordrup D, Glanville J, Kotas E, Mantel-Teeuwisse AK, van den Ham HA. Evidence on the effectiveness of policies promoting price transparency - A systematic review. Health Policy 2023; 134:104681. [PMID: 36372608 PMCID: PMC10357344 DOI: 10.1016/j.healthpol.2022.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/16/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022]
Abstract
Policies promoting price transparency may be an important approach to control medicine prices and achieve better access to medicines. As part of a wider review, we aimed to systematically determine whether policies promoting price transparency are effective in managing the prices of pharmaceutical products. We searched for studies published between January 1, 2004 and October 10, 2019, comparing policies promoting price transparency against other interventions or a counterfactual. Eligible study designs included randomized trials, and non-randomized or quasi-experimental studies such as interrupted time-series (ITS), repeated measures (RM), and controlled before-after studies. Studies were eligible if they included at least one of the following outcomes: price (or expenditure as a proxy for price and volume), volume, availability or affordability of pharmaceutical products. The quality of the evidence was assessed using the GRADE methodology. A total of 32011 records were retrieved, two of which were eligible for inclusion. Although based on evidence from a single study, public disclosure of medicine prices may be effective in reducing prices of medicines short-term, with benefits possibly sustained long-term. Evidence on the impact of a cost-feedback approach to prescribers was inconclusive. No evidence was found for impact on the outcomes volume, availability or affordability. The overall lack of evidence on policies promoting price transparency is a clear call for further research.
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Affiliation(s)
- Iris R Joosse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, the Netherlands
| | - David Tordrup
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, the Netherlands
| | - Julie Glanville
- York Health Economics Consortium (YHEC), York, YO10 5NQ, United Kingdom
| | - Eleanor Kotas
- York Health Economics Consortium (YHEC), York, YO10 5NQ, United Kingdom
| | - Aukje K Mantel-Teeuwisse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, the Netherlands
| | - Hendrika A van den Ham
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, the Netherlands.
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Ooms GI, van Oirschot J, de Kant D, van den Ham HA, Mantel-Teeuwisse AK, Reed T. Barriers to accessing internationally controlled essential medicines in sub-saharan Africa: A scoping review. Int J Drug Policy 2023; 118:104078. [PMID: 37276779 DOI: 10.1016/j.drugpo.2023.104078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/14/2023] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Access to internationally controlled essential medicines (ICEMs), medicines that are listed on both the World Health Organization's Essential Medicines List and one of three international drug control conventions, remains problematic in Sub-Saharan Africa (SSA). Previous reviews have focused only on specific ICEMs or ICEM-related healthcare fields, but none have focused on all ICEMs as a distinct class. This scoping review therefore aims to identify the barriers to accessing ICEMs across all relevant healthcare fields in SSA. METHODS A scoping review was conducted across indexing platforms Embase, PubMed, Scopus and Web of Science of studies published between January 1 2012 and February 1 2022. Articles were eligible if they mentioned barriers to accessing ICEMs and/or ICEM-related healthcare fields, if studies were conducted in SSA, or included data on an SSA country within a multi-country study. The review was guided by the Access to Medicines from a Health System Perspective framework. RESULTS The search identified 5519 articles, of which 97 met the inclusion criteria. Many barriers to access were reported and were common across the ICEMs drug class. Main barriers were: at the individual level, the lack of knowledge about ICEMs; at the health service delivery level, low availability, stockouts, affordability, long distances to health facilities, insufficient infrastructure to store and distribute ICEMs, and lack of ICEM knowledge and training among healthcare workers; at the health sector level, lack of prioritisation of ICEM-related healthcare fields by governments and subsequent insufficient budget allocation. Cross-cutting, governance-related barriers pertained to lack of proper quantification systems, cumbersome procurement processes, and strict national laws controlling ICEMs, leading to overly restrictive prescription practices. CONCLUSION This review showed that there are a multitude of barriers to accessing ICEMs in SSA across all health system levels. Many of the barriers identified are applicable to all ICEMs, highlighting the importance of tackling barriers for this entire class of drugs together.
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Affiliation(s)
- Gaby I Ooms
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands; Health Action International, Amsterdam, the Netherlands.
| | | | | | - Hendrika A van den Ham
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, the Netherlands
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Joosse IR, Mantel-Teeuwisse AK, Suleman F, van den Ham HA. Sustainable Development Goal indicator for measuring availability and affordability of medicines for children: a proof-of-concept study. BMJ Open 2023; 13:e065929. [PMID: 37041064 PMCID: PMC10106062 DOI: 10.1136/bmjopen-2022-065929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
OBJECTIVES To complement Sustainable Development Goal (SDG) indicator 3.b.3 that monitors access to medicines for all, a corresponding child-specific methodology was developed tailored to the health needs of children. This methodology could aid countries in monitoring accessibility to paediatric medicines in a validated manner and on a longitudinal basis. We aimed to provide proof of concept of this adapted methodology by applying the method to historical datasets. METHOD A core set of child-appropriate medicines was selected for two groups of children: children aged 1-59 months and children aged 5-12 years. To enable calculation of affordability of medicines for children, the number of units needed for treatment was created, incorporating the recommended dosage and duration of treatment for the specific age group. The adapted methodology was applied to health facility survey data from Burundi (2013), China (2012) and Haiti (2011) for one age group. SDG indicator 3.b.3 scores and (mean) individual facility scores were calculated per country and sector. RESULTS We were able to calculate SDG indicator 3.b.3 based on historical data from Burundi, China and Haiti with the adapted methodology. In this case study, all individual facilities failed to reach the 80% benchmark of accessible medicines, resulting in SDG indicator 3.b.3 scores of 0% for all 3 countries. Mean facility scores ranged from 22.2% in Haiti to 40.3% in Burundi for lowest-price generic medicines. Mean facility scores for originator brands were 0%, 16.5% and 9.9% for Burundi, China and Haiti, respectively. The low scores seemed to stem from the low availability of medicines. CONCLUSION The child-specific methodology was successfully applied to historical data from Burundi, China and Haiti, providing proof of concept of this methodology. The proposed validation steps and sensitivity analyses will help determine its robustness and could lead to further improvements.
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Affiliation(s)
- Iris R Joosse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Fatima Suleman
- WHO Collaborating Centre for Pharmaceutical Policy and Evidence Based Practice, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Hendrika A van den Ham
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
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9
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van den Dries CJ, Pajouheshnia R, van den Ham HA, Souverein P, Moons KGM, Hoes AW, Geersing GJ, van Doorn S. Safety of off-label dose reduction of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Br J Clin Pharmacol 2023; 89:751-761. [PMID: 36102068 PMCID: PMC10091743 DOI: 10.1111/bcp.15534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 01/18/2023] Open
Abstract
AIM To investigate the effects of off-label non-vitamin K oral anticoagulant (NOAC) dose reduction compared with on-label standard dosing in atrial fibrillation (AF) patients in routine care. METHODS Population-based cohort study using data from the United Kingdom Clinical Practice Research Datalink, comparing adults with non-valvular AF receiving an off-label reduced NOAC dose to patients receiving an on-label standard dose. Outcomes were ischaemic stroke, major/non-major bleeding and mortality. Inverse probability of treatment weighting and inverse probability of censoring weighting on the propensity score were applied to adjust for confounding and informative censoring. RESULTS Off-label dose reduction occurred in 2466 patients (8.0%), compared with 18 108 (58.5%) on-label standard-dose users. Median age was 80 years (interquartile range [IQR] 73.0-86.0) versus 72 years (IQR 66-78), respectively. Incidence rates were higher in the off-label dose reduction group compared to the on-label standard dose group, for ischaemic stroke (0.94 vs 0.70 per 100 person years), major bleeding (1.48 vs 0.83), non-major bleeding (6.78 vs 6.16) and mortality (10.12 vs 3.72). Adjusted analyses resulted in a hazard ratio of 0.95 (95% confidence interval [CI] 0.57-1.60) for ischaemic stroke, 0.88 (95% CI 0.57-1.35) for major bleeding, 0.81 (95% CI 0.67-0.98) for non-major bleeding and 1.34 (95% CI 1.12-1.61) for mortality. CONCLUSION In this large population-based study, the hazards for ischaemic stroke and major bleeding were low, and similar in AF patients receiving an off-label reduced NOAC dose compared with on-label standard dose users, while non-major bleeding risk appeared to be lower and mortality risk higher. Caution towards prescribing an off-label reduced NOAC dose is therefore required.
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Affiliation(s)
- Carline J van den Dries
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Romin Pajouheshnia
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Patrick Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sander van Doorn
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Kusynová Z, Bais Y, van den Ham HA, Mantel-Teeuwisse AK, Etame-Loe G, Kaale E, Sarr SO, Guiet-Mati F, Bourdillon-Esteve P. Improved knowledge on substandard and falsified (SF) medical products through a dedicated course for pharmacy students at three universities in sub-Saharan Africa. BMJ Glob Health 2023; 6:bmjgh-2022-009367. [PMID: 36731919 PMCID: PMC10175941 DOI: 10.1136/bmjgh-2022-009367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 11/07/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Too few pharmacists receive formal training on substandard and falsified (SF) medical products. Strengthening knowledge across pharmacists is considered a moral and ethical duty of academia, that is, to build the health systems' capacities to combat this global health threat these poor-quality products represent. This study therefore aimed to evaluate whether a dedicated educational course for undergraduate pharmacy students can improve their knowledge on these products. METHODS A survey was conducted at three sub-Saharan universities. Knowledge was assessed through scores on a 20-point questionnaire with questions related to the course content. Scores were compared before and after the course, and a linear mixed-effects model analysis was used to analyse score differences. Students were furthermore asked for feedback and self-assessment. In addition, teachers were interviewed on the context of the course introduction. These data were analysed descriptively. RESULTS Among 335 out of 355 students who completed the survey (n=41/53 in Cameroon, n=244/252 in Senegal and n=50/50 in Tanzania), knowledge of SF medical products was enhanced, with increase in all countries, overall, by 3.5 (95% CI 3.1 to 3.9) score points. Students improved in all offered modules in each country. Students confirmed their improvement through self-assessment.The course was well received among students and teachers. Barriers included time constraints and access to practical means (equipment availability, room allocation, internet accessibility and affordability). These barriers can be overcome by key enablers such as the support from university leadership and early involvement of the university in the course design. CONCLUSIONS The course improved students' knowledge on SF medical products. These findings encourage further full implementation of this course in existing curricula beyond the pilot and can inform possible future scale-up. This has a potential for reinforcing the capacity of health systems to protect communities from SF medicines, by empowering all pharmacist across the health systems to intervene.
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Affiliation(s)
- Zuzana Kusynová
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.,International Pharmaceutical Federation, The Hague, The Netherlands
| | - Youssra Bais
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.,International Pharmaceutical Federation, The Hague, The Netherlands
| | - Hendrika A van den Ham
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | | | - Eliangiringa Kaale
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | | | - Fatima Guiet-Mati
- Access to medicines and health products, World Health Organization, Geneva, Switzerland
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11
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Kusynová Z, van den Ham HA, Leufkens HGM, Mantel-Teeuwisse AK. Longitudinal study of Good Pharmacy Practice roles covered at the annual world pharmacy congresses 2003-2019. J Pharm Policy Pract 2022; 15:94. [PMID: 36443800 PMCID: PMC9706975 DOI: 10.1186/s40545-022-00482-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/03/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Globally accepted roles of pharmacists are described in the Good Pharmacy Practice (GPP) standards, published by the World Health Organization (WHO) and the International Pharmaceutical Federation (FIP) in 2011. These standards provide a wide-ranging description of four main roles pharmacists fulfil. The global platform, where pertinent discussions around excellence and innovation in various pharmacy roles take place, is the annual congress of the pharmacy organisation representing the profession globally, FIP. OBJECTIVES Given the world pharmacy congresses present and reflect on the most topical and contemporary matters, this longitudinal study aimed at creating a historical overview of the frequency of appearance of the different GPP roles in the programmes of the past 17 congresses (2003-2019). This is to distinguish the dominance of different roles over time and thus their relevance for the profession. METHODS The GPP standards served as a framework to create a set of keywords that were analysed for their frequencies of appearance in the programmes through text analysis. Trends in the four overarching GPP roles and at individual keyword level were analysed descriptively over time. RESULTS The study found that all four GPP roles appeared in the programme each year and none of them was significantly missing, neither in the decade preceding the publication of the GPP standards nor in the decade thereafter. Role 3 "Maintain and improve professional performance" was most frequently represented, also demonstrating an upward trend in appearance, together with Role 4: "Contribute to improve effectiveness of the health-care system and public health". Trends emerged towards patient-centred clinical focus and positioning pharmacy as an important player in the health-care system-observed also at individual keywords level in areas such as health promotion-away from the more traditional product-centred practice roles such as compounding. CONCLUSIONS GPP roles have been already covered by the FIP annual congresses (long) before 2011, when the GPP roles were formally adopted, and they stayed relevant in the decade after. The more pronounced dominance toward the roles related to improving professional performance and positioning pharmacy are in line with the trend that the rather technical topics in pharmacy are increasingly covered by specialised meetings and that the FIP annual congresses have moved toward more general, scholarly platforms for dialogue and conversation.
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Affiliation(s)
- Zuzana Kusynová
- International Pharmaceutical Federation (FIP), The Hague, The Netherlands.,Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, PO Box 80082, 3508 TB, Utrecht, The Netherlands
| | - Hendrika A van den Ham
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, PO Box 80082, 3508 TB, Utrecht, The Netherlands.
| | - Hubert G M Leufkens
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, PO Box 80082, 3508 TB, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, PO Box 80082, 3508 TB, Utrecht, The Netherlands
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Joosse IR, Mantel-Teeuwisse AK, Wirtz VJ, Suleman F, van den Ham HA. Missing data on accessibility of children's medicines. Bull World Health Organ 2022; 100:636-642. [PMID: 36188021 PMCID: PMC9511669 DOI: 10.2471/blt.22.288137] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022] Open
Abstract
Child-appropriate medicines are essential for the safe and effective treatment of children, yet we have observed a large gap in the data required to adequately monitor access to these medicines. We have examined data on the availability and pricing of child-appropriate medicines across 50 surveys. Child-appropriate medicines for nine out of 12 priority diseases in children were infrequently surveyed or not at all. A similar data deficit on age-appropriate medicines is detectable in the broader scientific literature. We also note that existing instruments for collecting data on the availability or prices of medicines are limited in their ability to generate the required data for children. We have identified four priorities as key for improved monitoring of access to medicines for children: (i) dedicated child medicine surveys are needed on availability and prices of child-appropriate medicines; (ii) standardized survey instruments should include age-appropriate medicines and dosages; (iii) health facility service readiness survey tools should include the collection of data on the price of child-appropriate medicines in addition to the availability of medicines; and (iv) sustainable development goal indicator 3.b.3 should be modified to enable the monitoring of access to medicines for children. These deficiencies need to be addressed to ensure the monitoring of access to child medicines as part of the sustainable development goal agenda for 2030 and to implement appropriate interventions for improving access for this vulnerable population.
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Affiliation(s)
- Iris R Joosse
- Utrecht World Health Organization Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht World Health Organization Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, Netherlands
| | - Veronika J Wirtz
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | - Fatima Suleman
- World Health Organization Collaborating Centre for Pharmaceutical Policy and Evidence Based Practice, University of KwaZulu-Natal, Durban, South Africa
| | - Hendrika A van den Ham
- Utrecht World Health Organization Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, Netherlands
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13
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Ooms GI, van Oirschot J, Okemo D, Reed T, van den Ham HA, Mantel-Teeuwisse AK. Healthcare workers' perspectives on access to sexual and reproductive health services in the public, private and private not-for-profit sectors: insights from Kenya, Tanzania, Uganda and Zambia. BMC Health Serv Res 2022; 22:873. [PMID: 35794551 PMCID: PMC9261038 DOI: 10.1186/s12913-022-08249-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 06/16/2022] [Indexed: 11/18/2022] Open
Abstract
Background Access to sexual and reproductive health services remains a challenge for many in Kenya, Tanzania, Uganda and Zambia. Health service delivery in the four countries is decentralised and provided by the public, private and private not-for-profit sectors. When accessing sexual and reproductive health services, clients encounter numerous challenges, which might differ per sector. Healthcare workers have first-hand insight into what impediments to access exist at their health facility. The aim of this study was to identify differences and commonalities in barriers to access to sexual and reproductive health services across the public, private and private not-for-profit sectors. Methods A cross-sectional survey was conducted among healthcare workers working in health facilities offering sexual and reproductive health services in Kenya (n = 212), Tanzania (n = 371), Uganda (n = 145) and Zambia (n = 243). Data were collected in July 2019. Descriptive statistics were used to describe the data, while binary logistic regression analyses were used to test for significant differences in access barriers and recommendations between sectors. Results According to healthcare workers, the most common barrier to accessing sexual and reproductive health services was poor patient knowledge (37.1%). Following, issues with supply of commodities (42.5%) and frequent stockouts (36.0%) were most often raised in the public sector; in the other sectors these were also raised as an issue. Patient costs were a more significant barrier in the private (33.3%) and private not-for-profit sectors (21.1%) compared to the public sector (4.6%), and religious beliefs were a significant barrier in the private not-for-profit sector compared to the public sector (odds ratio = 2.46, 95% confidence interval = 1.69–3.56). In all sectors delays in the delivery of supplies (37.4-63.9%) was given as main stockout cause. Healthcare workers further believed that it was common that clients were reluctant to access sexual and reproductive health services, due to fear of stigmatisation, their lack of knowledge, myths/superstitions, religious beliefs, and fear of side effects. Healthcare workers recommended client education to tackle this. Conclusions Demand and supply side barriers were manifold across the public, private and private not-for-profit sectors, with some sector-specific, but mostly cross-cutting barriers. To improve access to sexual and reproductive health services, a multi-pronged approach is needed, targeting client knowledge, the weak supply chain system, high costs in the private and private not-for-profit sectors, and religious beliefs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08249-y.
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Affiliation(s)
- Gaby I Ooms
- Health Action International, Overtoom 60-2, 1054 HK, Amsterdam, The Netherlands. .,Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
| | | | | | - Tim Reed
- Health Action International, Overtoom 60-2, 1054 HK, Amsterdam, The Netherlands
| | - Hendrika A van den Ham
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
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14
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Perehudoff K, Kibira D, Wuyts E, Pericas C, Omwoha J, van den Ham HA, Mantel-Teeuwisse AK, Michielsen K. A comparative human rights analysis of laws and policies for adolescent contraception in Uganda and Kenya. Reprod Health 2022; 19:37. [PMID: 35130932 PMCID: PMC8822716 DOI: 10.1186/s12978-021-01303-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background Improving access to adolescent contraception information and services is essential to reduce unplanned adolescent pregnancies and maternal mortality in Uganda and Kenya, and attain the SDGs on health and gender equality. This research studies to what degree national laws and policies for adolescent contraception in Uganda and Kenya are consistent with WHO standards and human rights law. Methods This is a comparative content analysis of law and policy documents in force between 2010 and 2018 governing adolescent (age 10–19 years) contraception. Between and within country differences were analysed using WHO’s guidelines “Ensuring human rights in the provision of contraceptive information and services”. Results Of the 93 laws and policies screened, 26 documents were included (13 policies in Uganda, 13 policies in Kenya). Ugandan policies include a median of 1 WHO recommendation for adolescent contraception per policy (range 0–4) that most frequently concerns contraception accessibility. Ugandan policies have 6/9 WHO recommendations (14/24 sub-recommendations) and miss entirely WHO’s recommendations for adolescent contraception availability, quality, and accountability. On the other hand, most Kenyan policies consistently address multiple WHO recommendations (median 2 recommendations/policy, range 0–6), most frequently for contraception availability and accessibility for adolescents. Kenyan policies cover 8/9 WHO recommendations (16/24 sub-recommendations) except for accountability. Conclusions The current policy landscapes for adolescent contraception in Uganda and Kenya include important references to human rights and evidence-based practice (in WHO’s recommendations); however, there is still room for improvement. Aligning national laws and policies with WHO’s recommendations on contraceptive information and services for adolescents may support interventions to improve health outcomes, provided these frameworks are effectively implemented. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01303-8. The unmet need for contraception among adolescents is high in Uganda and Kenya, and has many negative consequences, including unwanted pregnancy, exposure to unsafe abortion, and maternal morbidity and mortality. National laws and policies play an important role in determining adolescents’ access to contraception. For example, national laws and policies can shape the government programs that provide (or withhold) contraception, and the social norms influencing adolescents’ access to contraception. Therefore, this research compares national laws and policies that determine access to contraception services and information for adolescents in Uganda and Kenya with WHO’s recommendations for access to contraception. This is an analysis of the content of Ugandan and Kenyan laws and policies in force between 2010 and 2018. The content of these documents was analyzed using WHO’s nine recommendations for how contraception information and services should be provided: non-discrimination, availability, accessibility, acceptability, quality, informed decision-making, confidentiality, participation, accountability. Ninety-three documents were screened and 26 documents were included in the analysis: 13 policies from Uganda and 13 policies from Kenya. On average, Ugandan policies include one WHO recommendation for adolescent contraception per policy and Kenyan policies include two WHO recommendations. This recommendation most frequently mentioned in all policies is the accessibility of contraception (for example, for adolescents living remotely, integrated in adolescent HIV or pre-/post-natal care, etc.). Together, all Ugandan policies mentioned 6/9 WHO recommendations whereas all Kenyan policies cover 8/9 WHO recommendations. In conclusion, Ugandan and Kenyan policies are consistent with many of WHO’s recommendations for access to contraception, however, there is still room for improvement.
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15
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Ooms GI, van Oirschot J, Okemo D, Waldmann B, Erulu E, Mantel-Teeuwisse AK, van den Ham HA, Reed T. Availability, affordability and stock-outs of commodities for the treatment of snakebite in Kenya. PLoS Negl Trop Dis 2021; 15:e0009702. [PMID: 34398889 PMCID: PMC8389522 DOI: 10.1371/journal.pntd.0009702] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/26/2021] [Accepted: 08/03/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Annually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya. METHODOLOGY/PRINCIPAL FINDINGS This study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day's wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days' wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible. CONCLUSIONS Access to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.
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Affiliation(s)
- Gaby Isabelle Ooms
- Health Action International, Amsterdam, The Netherlands
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | | | | | | | | | - Aukje K Mantel-Teeuwisse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Hendrika A van den Ham
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, The Netherlands
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van den Ham HA, Souverein PC, Klungel OH, Platt RW, Ernst P, Dell'Aniello S, Schmiedl S, Grave B, Rottenkolber M, Huerta C, Martín Merino E, León-Muñoz LM, Montero D, Andersen M, Aakjaer M, De Bruin ML, Gardarsdottir H. Major bleeding in users of direct oral anticoagulants in atrial fibrillation: A pooled analysis of results from multiple population-based cohort studies. Pharmacoepidemiol Drug Saf 2021; 30:1339-1352. [PMID: 34173286 PMCID: PMC8456818 DOI: 10.1002/pds.5317] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 06/07/2021] [Accepted: 06/21/2021] [Indexed: 11/24/2022]
Abstract
Objective To establish the risk of major bleeding in direct oral anticoagulant (DOAC) users (overall and by class) versus vitamin K antagonist (VKA) users, using health care databases from four European countries and six provinces in Canada. Methods A retrospective cohort study was performed according to a similar protocol. First‐users of VKAs or DOACs with a diagnosis of non‐valvular atrial fibrillation (NVAF) were included. The main outcome of interest was major bleeding and secondary outcomes included gastrointestinal (GI) bleeding and intracranial haemorrhage (ICH). Incidence rates of events per 1000 person years were calculated. Hazard ratios (HRs) and 95% confidence intervals (95% CI) were estimated using a Cox proportional hazard regression model. Exposure and confounders were measured and analysed in a time‐dependant way. Risk estimates were pooled using a random effect model. Results 421 523 patients were included. The risk of major bleeding for the group of DOACs compared to VKAs showed a pooled HR of 0.94 (95% CI: 0.87–1.02). Rivaroxaban showed a modestly increased risk (HR 1.11, 95% CI: 1.06–1.16). Apixaban and dabigatran showed a decreased risk of respectively HR 0.76 (95% CI: 0.69–0.84) and HR 0.85 (95% CI: 0.75–0.96). Conclusions This study confirms that the risk of major bleeding of DOACs compared to VKAs is not increased when combining all DOACs. However, we observed a modest higher risk of major bleeding for rivaroxaban, whereas for apixaban and dabigatran lower risks of major bleeding were observed compared to VKAs.
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Affiliation(s)
- Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Robert W Platt
- Canada and Canadian Network for Observational Drug Effect Studies (CNODES), Lady Davis Institute of the Jewish General Hospital, Montreal, Canada
| | - Pierre Ernst
- Canada and Canadian Network for Observational Drug Effect Studies (CNODES), Lady Davis Institute of the Jewish General Hospital, Montreal, Canada
| | - Sophie Dell'Aniello
- Canada and Canadian Network for Observational Drug Effect Studies (CNODES), Lady Davis Institute of the Jewish General Hospital, Montreal, Canada
| | - Sven Schmiedl
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University (UW/H), Witten, Germany.,Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | | | - Marietta Rottenkolber
- Diabetes Research Group, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Consuelo Huerta
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Elisa Martín Merino
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Luz M León-Muñoz
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Dolores Montero
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Morten Andersen
- Pharmacovigilance Research Group, Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mia Aakjaer
- Pharmacovigilance Research Group, Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marie L De Bruin
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacy, Division Laboratory and Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
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Ooms GI, van Oirschot J, Waldmann B, Okemo D, Mantel-Teeuwisse AK, van den Ham HA, Reed T. The Burden of Snakebite in Rural Communities in Kenya: A Household Survey. Am J Trop Med Hyg 2021; 105:828-836. [PMID: 34280130 PMCID: PMC8592359 DOI: 10.4269/ajtmh.21-0266] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/25/2021] [Indexed: 11/07/2022] Open
Abstract
Annually, about 2.7 million snakebite envenomings occur worldwide, primarily affecting those living in rural regions. Effective treatment exists but is scarce, and traditional treatments are commonly used. To inform context-specific policies in Kenya, this study aimed to determine the health-seeking behavior and the health, social, and economic burden of snakebites in rural communities. Nonprobability sampling was used to survey 382 respondents from four snakebite-endemic counties, from February to August 2020, using a structured questionnaire. Descriptive statistics, Fisher's exact tests, binary logistic regressions, and Mantel-Haenszel tests were used for analysis. Life-time experience with snakebites included 13.1% of respondents who reported being personally bitten and 37.4% who reported knowing of a community member being bitten. Respondents reported death after a snakebite in 9.1% of bitten community members and in 14.6% of bitten family members. Risk of snakebite was not significantly associated with sex, educational level, or occupation. Snakebite victims were most often walking (38%) or farming (24%) when bitten. Of those bitten, 58% went to a health facility, 30% sought traditional treatment, and 12% first went to a traditional healer before visiting a facility. Significant differences existed in perceptions on the financial consequences of snakebites among those who had been personally bitten and those who had observed a snakebite. Most commonly mentioned preventive measures were wearing shoes and carrying a light in the dark. Community engagement, including engagement with traditional healers, is needed to reduce snakebites. This should be done through education and sensitization to improve used preventive measures and effective health-seeking behavior.
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Affiliation(s)
- Gaby I. Ooms
- Health Action International, Amsterdam, The Netherlands
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | | | | | | | - Aukje K. Mantel-Teeuwisse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Hendrika A. van den Ham
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, The Netherlands
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Kibira D, Asiimwe C, Muwonge M, van den Ham HA, Reed T, Leufkens HG, Mantel-Teeuwisse AK. Donor Commitments and Disbursements for Sexual and Reproductive Health Aid in Kenya, Tanzania, Uganda and Zambia. Front Public Health 2021; 9:645499. [PMID: 33959580 PMCID: PMC8093629 DOI: 10.3389/fpubh.2021.645499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/05/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Sexual and Reproductive Health and Rights (SRHR) investments are critical to people's well-being. However, despite the demonstrated returns on investments, underfunding of SRHR still persists. The objective of this study was to characterize donor commitments and disbursements to SRH aid in four sub-Saharan countries of Kenya, Tanzania, Uganda and Zambia and to compare trends in donor aids with SRH outcome and impact indicators for each of these countries. Methods: The study is a secondary analysis of data from the Organization for Economic Co-operation and Development's Assistance creditor reporting system and SRH indicator data from the Global Health Observatory and country demographic health surveys for a 16-year period (2002-2017). We downloaded and compared commitments to disbursements of all donors for population policies, programs and reproductive health for the four African countries. SRH indicators were stratified into health facility level process/outcome indicators (modern contraceptive prevalence rate, unmet need for family planning, antenatal care coverage and skilled birth attendance) and health impact level indicators (maternal mortality ratio, newborn mortality rate, infant mortality rate and under five mortality rate). Results: Donor commitments for SRH aid grew on average by 20% while disbursements grew by 21% annually between 2002 and 2017. The overall disbursement rate was 93%. Development Assistance Cooperation (DAC) countries donated the largest proportion (79%) of aid. Kenya took 33% of total aid, followed by Tanzania 26%, Uganda 23% and then Zambia (18%). There was improvement in all SRH outcome and impact indicators, but not enough to meet targets. Conclusion: Donor aid to SRH grew over time and in the same period indicators improved, but improvement remained slow. Unpredictability and insufficiency of aid may be disruptive to recipient country planning. Donors and low- and middle-income countries should increase funding in order to meet global SRHR targets.
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Affiliation(s)
- Denis Kibira
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
- Coalition for Health Promotion and Social Development (HEPS-Uganda), Kampala, Uganda
| | | | | | - Hendrika A. van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, Netherlands
| | - Hubert G. Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Aukje K. Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
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19
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Kibira D, Ssebagereka A, van den Ham HA, Opigo J, Katamba H, Seru M, Reed T, Leufkens HG, Mantel-Teeuwisse AK. Trends in access to anti-malarial treatment in the formal private sector in Uganda: an assessment of availability and affordability of first-line anti-malarials and diagnostics between 2007 and 2018. Malar J 2021; 20:142. [PMID: 33691704 PMCID: PMC7944888 DOI: 10.1186/s12936-021-03680-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Malaria is the single largest cause of illness in Uganda. Since the year 2008, the Global Fund has rolled out several funding streams for malaria control in Uganda. Among these are mechanisms aimed at increasing the availability and affordability of artemisinin-based combination therapy (ACT). This paper examines the availability and affordability of first-line malaria treatment and diagnostics in the private sector, which is the preferred first point of contact for 61% of households in Uganda between 2007 and 2018. Methods Cross-sectional surveys were conducted between 2007 and 2018, based on a standardized World Health Organization/Health Action International (WHO/HAI) methodology adapted to assess availability, patient prices, and affordability of ACT medicines in private retail outlets. A minimum of 30 outlets were surveyed per year as prescribed by the standardized methodology co-developed by the WHO and Health Action International. Availability, patient prices, and affordability of malaria rapid diagnostic tests (RDTs) was also tracked from 2012 following the rollout of the test and treat policy in 2010. The median patient prices for the artemisinin-based combinations and RDTs was calculated in US dollars (USD). Affordability was assessed by computing the number of days’ wages the lowest-paid government worker (LPGW) had to pay to purchase a treatment course for acute malaria. Results Availability of artemether/lumefantrine (A/L), the first-line ACT medicine, increased from 85 to100% in the private sector facilities during the study period. However, there was low availability of diagnostic tests in private sector facilities ranging between 13% (2012) and 37% (2018). There was a large reduction in patient prices for an adult treatment course of A/L from USD 8.8 in 2007 to USD 1.1 in 2018, while the price of diagnostics remained mostly stagnant at USD 0.5. The affordability of ACT medicines and RDTs was below one day’s wages for LPGW. Conclusions Availability of ACT medicines in the private sector medicines retail outlets increased to 100% while the availability of diagnostics remained low. Although malaria treatment was affordable, the price of diagnostics remained stagnant and increased the cumulative cost of malaria management. Malaria stakeholders should consolidate the gains made and consider the inclusion of diagnostic kits in the subsidy programme.
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Affiliation(s)
- Denis Kibira
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands. .,Coalition for Health Promotion and Social Development (HEPS-Uganda), Plot 351A, Balintuma Road, Namirembe Hill, Kampala, Uganda.
| | - Anthony Ssebagereka
- Coalition for Health Promotion and Social Development (HEPS-Uganda), Plot 351A, Balintuma Road, Namirembe Hill, Kampala, Uganda
| | - Hendrika A van den Ham
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
| | - Jimmy Opigo
- National Malaria Control Division, Ministry of Health, Uganda, Plot 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Henry Katamba
- National Malaria Control Division, Ministry of Health, Uganda, Plot 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Morries Seru
- National Malaria Control Division, Ministry of Health, Uganda, Plot 6 Lourdel Road, Wandegeya, Kampala, Uganda
| | - Tim Reed
- Health Action International, Overtoom 60, 1054 HK, Amsterdam, The Netherlands
| | - Hubert G Leufkens
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
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20
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Kibira D, Ooms GI, van den Ham HA, Namugambe JS, Reed T, Leufkens HG, Mantel-Teeuwisse A. Access to oxytocin and misoprostol for management of postpartum haemorrhage in Kenya, Uganda and Zambia: a cross-sectional assessment of availability, prices and affordability. BMJ Open 2021; 11:e042948. [PMID: 33414148 PMCID: PMC7797249 DOI: 10.1136/bmjopen-2020-042948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess access (availability and affordability) to oxytocin and misoprostol at health facilities in Kenya, Uganda and Zambia to improve prevention and management of postpartum haemorrhage (PPH). DESIGN The assessment was undertaken using data from Health Action International (HAI) research on sexual and reproductive health commodities based on a cross-sectional design adapted from the standardised WHO/HAI methodology. SETTING Data were collected from 376 health facilities in in Kenya, Uganda and Zambia in July and August 2017. OUTCOME MEASURES Availability was calculated as mean percentage of sampled medicine outlets where medicine was found on the day of data collection. Medicine prices were compared with international reference prices (IRP) and expressed as median price ratios. Affordability was calculated using number of days required to pay for a standard treatment based on the daily income of the lowest paid government worker. RESULTS Availability of either oxytocin or misoprostol at health facilities was high; 81% in Kenya, 82% in Uganda and 76% in Zambia. Oxytocin was more available than misoprostol, and it was most available in the public sector in the three countries. Availability of misoprostol was highest in the public sector in Uganda (88%). Oxytocin and misoprostol were purchased by patients at prices above IRP, but both medicines cost less than a day's wages and were therefore affordable. Availability of misoprostol was poor in rural settings where it would be more preferred due to lack of trained personnel and cold storage facilities required for oxytocin. CONCLUSION Availability and affordability of either oxytocin or misoprostol at health facilities met the WHO benchmark of 80%. However, countries with limited resources should explore mechanisms to optimise management of PPH by improving access to misoprostol especially in rural areas.
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Affiliation(s)
- Denis Kibira
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Coalition for Health Promotion and Social Development (HEPS-Uganda), Kampala, Uganda
| | - Gaby Isabelle Ooms
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Health Action International, Amsterdam, The Netherlands
| | - Hendrika A van den Ham
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Juliet Sanyu Namugambe
- Department of Pharmacy, Mbarara University of Science and Technology Mbarara, Mbarara, Uganda
| | - Tim Reed
- Health Action International, Amsterdam, The Netherlands
| | - Hubert Gm Leufkens
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Aukje Mantel-Teeuwisse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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21
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van den Dries CJ, van Doorn S, Souverein P, Pajouheshnia R, Moons KGM, Hoes AW, Geersing GJ, van den Ham HA. The Number of Concomitant Drugs and the Safety of Direct Oral Anticoagulants in Routine Care Patients with Atrial Fibrillation. TH Open 2020; 4:e417-e426. [PMID: 33376941 PMCID: PMC7758151 DOI: 10.1055/s-0040-1721499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 10/22/2020] [Indexed: 12/13/2022] Open
Abstract
Background
The benefit of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) on major bleeding was less prominent among atrial fibrillation (AF) patients with polypharmacy in post-hoc randomized controlled trials analyses. Whether this phenomenon also exists in routine care is unknown. The aim of the study is to investigate whether the number of concomitant drugs prescribed modifies safety and effectiveness of DOACs compared with VKAs in AF patients treated in general practice.
Study Design
Adult, nonvalvular AF patients with a first DOAC or VKA prescription between January 2010 and July 2018 were included, using data from the United Kingdom Clinical Practice Research Datalink. Primary outcome was major bleeding, secondary outcomes included types of major bleeding, nonmajor bleeding, ischemic stroke, and all-cause mortality. Effect modification was assessed using Cox proportional hazard regression, stratified for the number of concomitant drugs into three strata (0–5, 6–8, ≥9 drugs), and by including the continuous variable in an interaction term with the exposure (DOAC vs. VKA).
Results
A total of 63,600 patients with 146,059 person-years of follow-up were analyzed (39,840 person-years of DOAC follow-up). The median age was 76 years in both groups, the median number of concomitant drugs prescribed was 7. Overall, the hazard of major bleeding was similar between VKA-users and DOAC-users (hazard ratio [HR] 0.98; 95% confidence interval [CI] 0.87–1.11), though for apixaban a reduction in major bleeding was observed (HR 0.81; 95% CI 0.68–0.98). Risk of stroke was comparable, while risk of nonmajor bleeding was lower in DOAC users compared with VKA users (HR 0.92; 95% CI 0.88–0.97). We did not observe any evidence for an impact of polypharmacy on the relative risk of major bleeding between VKA and DOAC across our predefined three strata of concomitant drug use (
p
-value for interaction = 0.65). For mortality, however, risk of mortality was highest among DOAC users, increasing with polypharmacy and independent of the type of DOAC prescribed (
p
-value for interaction <0.01).
Conclusion
In this large observational, population-wide study of AF patients, risk of bleeding, and ischemic stroke were comparable between DOACs and VKAs, irrespective of the number of concomitant drugs prescribed. In AF patients with increasing polypharmacy, our data appeared to suggest an unexplained yet increased risk of mortality in DOAC-treated patients, compared with VKA recipients.
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Affiliation(s)
- Carline J van den Dries
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Sander van Doorn
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Patrick Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Romin Pajouheshnia
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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22
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Rustem Gulluoglu F, Souverein PC, van den Ham HA, de Boer A, Komen J. Comparative effectiveness and safety of direct oral anticoagulants versus warfarin in UK patients with atrial fibrillation and type 2 diabetes: A retrospective cohort study. Pharmacoepidemiol Drug Saf 2020; 30:1293-1320. [PMID: 33314401 PMCID: PMC8451809 DOI: 10.1002/pds.5181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/09/2020] [Accepted: 12/07/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE To estimate the effectiveness and safety of direct oral anticoagulants (DOACs) compared with warfarin in AF patients with type 2 diabetes (T2DM). METHODS A retrospective cohort study was designed, using the UK Clinical Practice Research Datalink (August 2011-June 2018). Participants were 1-year naïve users of DOACs or warfarin, followed from the date of first prescription of an oral anticoagulant until the end of the study period, death, discontinuation of treatment, switching to another anticoagulant, or an outcome of interest, whichever came first. Cox regression analysis was performed to estimate the hazard ratio (HR) adjusted for potential confounders. RESULTS A total of 8555 patients were identified. No significant differences were found between DOACs and warfarin in the risk of stroke (adjusted HR 1.15; 95% CI 0.82-1.60), ischemic and unspecified stroke (adjusted HR 1.23; 95% CI 0.86-1.76) or haemorrhagic stroke (adjusted HR 0.75; 95% CI 0.30-1.85), and myocardial infarction (adjusted HR 1.39;95% CI 0.99-1.97). DOAC and warfarin users were comparable with respect to risk of major bleed (adjusted HR 0.83; 95% CI 0.68-1.03), intracranial bleeding (HR 0.66; 95% CI 0.34-1.30), gastrointestinal bleeding (HR 0.88; 95% CI 0.60-1.30), and bleeding on other clinically relevant sites (HR 0.89; 95% CI 0.60-1.31). In the subgroup analyses stratified by gender and diabetes severity, the risk for stroke and bleeding remained consistent. CONCLUSION DOACs are effective and safe alternatives to warfarin for the prevention of stroke in AF patients with T2DM.
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Affiliation(s)
- Fatma Rustem Gulluoglu
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Joris Komen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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23
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Ooms GI, van Oirschot J, Waldmann B, von Bernus S, van den Ham HA, Mantel-Teeuwisse AK, Reed T. The Current State of Snakebite Care in Kenya, Uganda, and Zambia: Healthcare Workers' Perspectives and Knowledge, and Health Facilities' Treatment Capacity. Am J Trop Med Hyg 2020; 104:774-782. [PMID: 33236717 DOI: 10.4269/ajtmh.20-1078] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/08/2020] [Indexed: 11/07/2022] Open
Abstract
Snakebites continue to be a public health concern in sub-Saharan Africa, where availability of appropriate medical treatment is rare, even though death and disability can be prevented with timely intervention. A challenge is the lack of sociopolitical studies to inform health policies. This study aimed to identify snakebite patient profiles, healthcare workers' (HCWs) knowledge of snakebite, and facilities' snakebite treatment capacity in Kenya, Uganda, and Zambia to inform interventions to improve access to appropriate treatment. The research comprised a cross-sectional key informant survey among HCWs from health facilities in Kenya (n = 145), Uganda (n = 144), and Zambia (n = 108). Data were collected between March 2018 and November 2019. Most of the HCWs suggested that the number of snakebite incidents was similar between the genders, that most patients were aged 21-30 years, and most people were bitten when farming or walking. Overall, only 12% of HCWs had received formal training in snakebite management. Only about 20% of HCWs in each country said their health facility had the medicines needed to treat snakebites, with antivenom available in 0-34% of facilities across the sectors and countries, and snakebites were not systematically recorded. This research shows that an integrative approach through policies to increase resource allocation for health system strengthening, including community education, HCW training, and improved access to snakebite treatment, is needed. Part of this approach should include regulations that ensure antivenoms available in health facilities meet quality control standards and that snakebites are accommodated into routine reporting systems to assess progress.
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Affiliation(s)
- Gaby I Ooms
- Health Action International, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | | | | | | | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, The Netherlands
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Tordrup D, van den Ham HA, Glanville J, Mantel-Teeuwisse AK. Systematic reviews of ten pharmaceutical pricing policies - a research protocol. J Pharm Policy Pract 2020; 13:22. [PMID: 32695425 PMCID: PMC7366307 DOI: 10.1186/s40545-020-00228-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 02/07/2023] Open
Abstract
Background High prices of pharmaceutical products are an increasing challenge in high- and low-income countries. Governments in many countries have implemented pricing policies to ensure affordability of medicines to patients and healthcare systems. The World Health Organization published in 2015 the Guideline on Country Pharmaceutical Pricing Policies, which was based on a series of evidence reviews in the preceding years. As part of the ongoing update of this guideline, we present a protocol for 10 systematic literature reviews on pharmaceutical pricing policies to be covered by the updated guideline. Methods The systematic literature reviews will be undertaken according to the principles embodied in the Cochrane Handbook and Centre for Reviews and Dissemination. The interventions studied are pharmaceutical pricing policies implemented by public institutions or a group of purchasing organizations/individuals (e.g. health services). Studies reporting price, volume, availability and/or affordability as the primary outcomes will be eligible for inclusion. Studies in any country or jurisdiction, in any language and in any setting published in 2004 or later are eligible. Eligible study designs are randomized and non-randomized trials, and observational studies including cohort studies, panel data analyses, comparative time series design (including interrupted time-series and repeated measures studies), and controlled before-after studies. A list of 21 databases of peer-reviewed and grey literature will be searched, along with supplementary searches of relevant national and international organizational and governmental websites. Risk of bias will be assessed according to the Cochrane Effective Practice and Organisation of Care (EPOC) guidelines. A summary table according to the EPOC Worksheets for preparing a Summary of Findings table (SoF) using GRADE will be provided. Discussion The results of the review will be used as part of the update of the WHO Guideline on Country Pharmaceutical Pricing Policies. The current protocol may serve as an example for performing systematic literature reviews to inform policy makers.
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Affiliation(s)
- David Tordrup
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Hendrika A van den Ham
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | | | - Aukje K Mantel-Teeuwisse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
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25
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Souverein PC, van den Ham HA, Huerta C, Merino EM, Montero D, León-Muñoz LM, Schmiedl S, Heeke A, Rottenkolber M, Andersen M, Aakjaer M, De Bruin ML, Klungel OH, Gardarsdottir H. Comparing risk of major bleeding between users of different oral anticoagulants in patients with nonvalvular atrial fibrillation. Br J Clin Pharmacol 2020; 87:988-1000. [PMID: 32627222 PMCID: PMC9328267 DOI: 10.1111/bcp.14450] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/11/2020] [Accepted: 06/11/2020] [Indexed: 12/13/2022] Open
Abstract
AIMS The introduction of direct oral anticoagulants (DOACs) has broadened the treatment arsenal for nonvalvular atrial fibrillation, but observational studies on the benefit-risk balance of DOACs compared to vitamin K antagonists (VKAs) are needed. The aim of this study was to characterize the risk of major bleeding in DOAC users using longitudinal data collected from electronic health care databases from 4 different EU-countries analysed with a common study protocol. METHODS A cohort study was conducted among new users (≥18 years) of DOACs or VKAs with nonvalvular atrial fibrillation using data from the UK, Spain, Germany and Denmark. The incidence of major bleeding events (overall and by bleeding site) was compared between current use of DOACs and VKAs. Cox regression analysis was used to calculate hazard ratios and 95% confidence intervals (CI) and adjust for confounders. RESULTS/CONCLUSION Overall, 251 719 patients were included across the 4 study cohorts (mean age ~75 years, % females between 41.3 and 54.3%), with overall hazard ratios of major bleeding risk for DOACs vs VKAs ranging between 0.84 (95% CI: 0.79-0.90) in Denmark and 1.13 (95% CI 1.02-1.25) in the UK. When stratifying according to the bleeding site, risk of gastrointestinal bleeding was increased by 48-67% in dabigatran users and 30-50% for rivaroxaban users compared to VKA users in all data sources except Denmark. Compared to VKAs, apixaban was not associated with an increased risk of gastrointestinal bleeding in all data sources and seemed to be associated with the lowest risk of major bleeding events compared to dabigatran and rivaroxaban.
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Affiliation(s)
- Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, The Netherlands
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, The Netherlands
| | - Consuelo Huerta
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Elisa Martín Merino
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Dolores Montero
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Luz M León-Muñoz
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Sven Schmiedl
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Wuppertal, Germany.,Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | | | - Marietta Rottenkolber
- Diabetic Research Group, Medizinische Klinik und Poliklinik IV, Klinikum der Universitaet Muenchen, Munich, Germany
| | - Morten Andersen
- Pharmacovigilance Research Group, Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Mia Aakjaer
- Pharmacovigilance Research Group, Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Marie L De Bruin
- Copenhagen Centre of Regulatory Science, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, The Netherlands
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, The Netherlands
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Ooms GI, Kibira D, Reed T, van den Ham HA, Mantel-Teeuwisse AK, Buckland-Merrett G. Access to sexual and reproductive health commodities in East and Southern Africa: a cross-country comparison of availability, affordability and stock-outs in Kenya, Tanzania, Uganda and Zambia. BMC Public Health 2020; 20:1053. [PMID: 32620159 PMCID: PMC7333276 DOI: 10.1186/s12889-020-09155-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Access to sexual and reproductive health services continues to be a public health concern in Kenya, Tanzania, Uganda and Zambia: use of modern contraceptives is low, and unmet family planning needs and maternal mortality remain high. This study is an assessment of the availability, affordability and stock-outs of essential sexual and reproductive health commodities (SRHC) in these countries to inform interventions to improve access. METHODS The study consisted of an adaptation of the World Health Organization/Health Action International methodology, Measuring Medicine Prices, Availability, Affordability and Price Components. Price, availability and stock-out data was collected in July 2019 for over fifty lowest-priced SRHC from public, private and private not-for-profit health facilities in Kenya (n = 221), Tanzania (n = 373), Uganda (n = 146) and Zambia (n = 245). Affordability was calculated using the wage of a lowest-paid government worker. Accessibility was illustrated by combining the availability (≥ 80%) and affordability (less than 1 day's wage) measures. RESULTS Overall availability of SRHC was low at less than 50% in all sectors, areas and countries, with highest mean availability found in Kenyan public facilities (46.6%). Stock-outs were common; the average number of stock-out days per month ranged from 3 days in Kenya's private and private not-for-profit sectors, to 12 days in Zambia's public sector. In the public sectors of Kenya, Uganda and Zambia, as well as in Zambia's private not-for-profit sector, all SRHC were free for the patient. In the other sectors unaffordability ranged from 2 to 9 SRHC being unaffordable, with magnesium sulphate being especially unaffordable in the countries. Accessibility was low across the countries, with Kenya's and Zambia's public sectors having six SRHC that met the accessibility threshold, while the private sector of Uganda had only one SRHC meeting the threshold. CONCLUSIONS Accessibility of SRHC remains a challenge. Low availability of SRHC in the public sector is compounded by regular stock-outs, forcing patients to seek care in other sectors where there are availability and affordability challenges. Health system strengthening is needed to ensure access, and these findings should be used by national governments to identify the gaps and shortcomings in their supply chains.
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Affiliation(s)
- Gaby I Ooms
- Health Action International, Overtoom 60-2, 1054, HK, Amsterdam, The Netherlands.
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
| | - Denis Kibira
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
- Coalition for Health Promotion and Social Development (HEPS-Uganda), Kampala, Uganda
| | - Tim Reed
- Health Action International, Overtoom 60-2, 1054, HK, Amsterdam, The Netherlands
| | - Hendrika A van den Ham
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
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Zhang Y, Souverein PC, Gardarsdottir H, van den Ham HA, Maitland-van der Zee AH, de Boer A. Risk of major bleeding among users of direct oral anticoagulants combined with interacting drugs: A population-based nested case-control study. Br J Clin Pharmacol 2020; 86:1150-1164. [PMID: 32022295 PMCID: PMC7256117 DOI: 10.1111/bcp.14227] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 12/28/2019] [Accepted: 12/31/2019] [Indexed: 12/11/2022] Open
Abstract
Aims To assess the association between concurrent use of potential pharmacokinetic or pharmacodynamic interacting drugs and major bleeding among direct oral anticoagulant (DOAC) users. Methods We performed a case–control study nested in a cohort of new users of DOACs (dabigatran etexilate, apixaban or rivaroxaban). Data were obtained from the UK Clinical Practice Research Datalink linked to Hospital Episode Statistics (2008–2015). Cases were patients hospitalized having a primary diagnosis of major bleeding. Up to 4 controls were matched on age, sex, index date and region. Odds ratios (ORs) for the risk of major bleeding were assessed by conditional logistic regression analysis and adjusted for well‐known covariates for the risk of bleeding. Results We identified 393 patients with a major bleeding from a total of 23 492 new users of DOACs and 1494 matched controls. Most subjects were users of rivaroxaban (58.8%) on the index date. The concurrent use of pharmacodynamic interacting drugs was associated with an increased risk of major bleeding (21.6% of cases vs 13.5% of controls, adjusted odds ratio [aOR] 1.92; 95% confidence interval [CI], 1.40–2.66). For the antiplatelet drugs the aOR was 2.01 (95% CI, 1.29–3.11) and for the selective serotonin reuptake inhibitors the aOR was 1.68 (95% CI, 1.10–2.59). We found no increased risk of major bleeding for concurrent use of pharmacokinetic interacting drugs vs DOACs alone (45.0 vs 51.2%; aOR: 0.77; 95% CI: 0.53–1.10). Conclusion Among patients taking DOACs the concurrent use of antiplatelet drugs or selective serotonin reuptake inhibitors was associated with increased risk of major bleeding, while pharmacokinetic interacting drugs do not increase this risk.
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Affiliation(s)
- Yumao Zhang
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacy, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Anke-Hilse Maitland-van der Zee
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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Ooms GI, Klatser P, van den Ham HA, Reed T. Barriers to Accessing Internationally Controlled Essential Medicines in Uganda: A Qualitative Study. J Pain Symptom Manage 2019; 58:835-843.e1. [PMID: 31302261 DOI: 10.1016/j.jpainsymman.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/28/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Access to internationally controlled essential medicines is a problem worldwide. More than five billion people cannot access opioids for pain and palliative care or do not have access to surgical care or anesthetics, 25 million people living with epilepsy do not have access to their medicines, and 120,000 women die annually owing to postpartum hemorrhage. In Uganda, access to controlled medicines is also problematic, but a lack of data on factors that influence access exists. OBJECTIVES The objective of this study was to identify the social, cultural, and regulatory barriers that influence access to internationally controlled essential medicines in Uganda. METHODS Semistructured interviews with 15 key stakeholders with knowledge on controlled medicines from relevant institutions in Uganda. Interviews were transcribed verbatim and analyzed using the Access to Medicines from a Health System Perspective framework. RESULTS Barriers in accessing controlled medicines were experienced owing to lack of prioritization, difficulties in finding the balance between access and control, deficiencies in the workings of the estimate and distribution system, lack of knowledge, inadequate human resources, expenses related to use and access, and stigma. It was believed that some abuse of specific controlled medicines occurred. CONCLUSION The findings of this research indicate that to improve access to internationally controlled essential medicines in Uganda, health system strengthening is needed on multiple fronts. Active engagement and concerted efforts are needed from all stakeholders to ensure access and prevent abuse.
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Affiliation(s)
- Gaby Isabelle Ooms
- Health Action International, Amsterdam, The Netherlands; WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
| | | | - Hendrika A van den Ham
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, The Netherlands
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Ibáñez L, Sabaté M, Vidal X, Ballarin E, Rottenkolber M, Schmiedl S, Heeke A, Huerta C, Martin Merino E, Montero D, Leon-Muñoz LM, Gasse C, Moore N, Droz C, Lassalle R, Aakjaer M, Andersen M, De Bruin ML, Groenwold R, van den Ham HA, Souverein P, Klungel O, Gardarsdottir H. Incidence of direct oral anticoagulant use in patients with nonvalvular atrial fibrillation and characteristics of users in 6 European countries (2008-2015): A cross-national drug utilization study. Br J Clin Pharmacol 2019; 85:2524-2539. [PMID: 31318059 PMCID: PMC6848911 DOI: 10.1111/bcp.14071] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/20/2019] [Accepted: 07/05/2019] [Indexed: 11/30/2022] Open
Abstract
Aims To estimate the incidence of direct oral anticoagulant drug (DOAC) use in patients with nonvalvular atrial fibrillation and to describe user and treatment characteristics in 8 European healthcare databases representing 6 European countries. Methods Longitudinal drug utilization study from January 2008 to December 2015. A common protocol approach was applied. Annual period incidences and direct standardisation by age and sex were performed. Dose adjustment related to change in age and by renal function as well as concomitant use of potentially interacting drugs were assessed. Results A total of 186 405 new DOAC users (age ≥18 years) were identified. Standardized incidences varied from 1.93–2.60 and 0.11–8.71 users/10 000 (2011–2015) for dabigatran and rivaroxaban, respectively, and from 0.01–8.12 users/10 000 (2012–2015) for apixaban. In 2015, the DOAC incidence ranged from 9 to 28/10 000 inhabitants in SIDIAP (Spain) and DNR (Denmark) respectively. There were differences in population coverage among the databases. Only 1 database includes the total reference population (DNR) while others are considered a population representative sample (CPRD, BIFAP, SIDIAP, EGB, Mondriaan). They also varied in the type of drug data source (administrative, clinical). Dose adjustment ranged from 4.6% in BIFAP (Spain) to 15.6% in EGB (France). Concomitant use of interacting drugs varied between 16.4% (SIDIAP) and 70.5% (EGB). Cardiovascular comorbidities ranged from 25.4% in Mondriaan (The Netherlands) to 82.9% in AOK Nordwest (Germany). Conclusion Overall, apixaban and rivaroxaban increased its use during the study period while dabigatran decreased. There was variability in patient characteristics such as comorbidities, potentially interacting drugs and dose adjustment. (EMA/2015/27/PH).
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Affiliation(s)
- Luisa Ibáñez
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron, Barcelona, Spain.,Department of Clinical Pharmacology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Pharmacology, Toxicology and Therapeutics, Universitat Autònoma de Barcelona, Spain
| | - Mònica Sabaté
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron, Barcelona, Spain.,Department of Clinical Pharmacology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Pharmacology, Toxicology and Therapeutics, Universitat Autònoma de Barcelona, Spain
| | - Xavier Vidal
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron, Barcelona, Spain.,Department of Clinical Pharmacology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Pharmacology, Toxicology and Therapeutics, Universitat Autònoma de Barcelona, Spain
| | - Elena Ballarin
- Fundació Institut Català de Farmacologia (FICF), Hospital Vall d'Hebron, Barcelona, Spain.,Department of Clinical Pharmacology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marietta Rottenkolber
- Diabetes Research Group, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Sven Schmiedl
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany.,Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | | | - Consuelo Huerta
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Elisa Martin Merino
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Dolores Montero
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Luz María Leon-Muñoz
- Pharmacoepidemiology and Pharmacovigilance Division, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | | | - Nicholas Moore
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, Bordeaux, France
| | - Cécile Droz
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, Bordeaux, France
| | - Régis Lassalle
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, Bordeaux, France
| | - Mia Aakjaer
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten Andersen
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marie Louise De Bruin
- Copenhagen Centre for Regulatory Science (CORS), Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rolf Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Universiteit Utrecht, David de Wiedgebouw, Utrecht, The Netherlands
| | - Patrick Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Universiteit Utrecht, David de Wiedgebouw, Utrecht, The Netherlands
| | - Olaf Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Universiteit Utrecht, David de Wiedgebouw, Utrecht, The Netherlands.,Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Helga Gardarsdottir
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
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Jacobs TG, Robertson J, van den Ham HA, Iwamoto K, Bak Pedersen H, Mantel-Teeuwisse AK. Assessing the impact of law enforcement to reduce over-the-counter (OTC) sales of antibiotics in low- and middle-income countries; a systematic literature review. BMC Health Serv Res 2019; 19:536. [PMID: 31366363 PMCID: PMC6670201 DOI: 10.1186/s12913-019-4359-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/18/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Many low- and middle-income countries (LMIC) are moving towards enforcing prescription-only access to antibiotics. This systematic literature review aims to assess the interventions used to enforce existing legislation prohibiting over-the-counter (OTC) sales of antibiotics in LMICs, their impact and examine the methods chosen for impact measurement including their strengths and weaknesses. METHODS Both PubMed and Embase were systematically searched for studies reporting on impact measurement in moving towards prescription only access to antibiotics in LMICs. The PRISMA methodological review framework was used to ensure systematic data collection and analysis of literature. Narrative data synthesis was used due to heterogeneity of study designs. RESULTS In total, 15 studies were included that assessed policy impact in 10 different countries. Strategies employed to enforce regulations prohibiting OTC sales of systemic antibiotics included retention of prescriptions for antibiotics by pharmacies, government inspections, engaging pharmacists in the design of interventions, media campaigns for the general public and educational activities for health care workers. A variety of outcomes was used to assess the policy impact; changes in antimicrobial resistance rates, changes in levels of antibiotic use, changes in trends of antibiotic use, changes in OTC supply of antibiotics, and changes in reported practices and knowledge of pharmacists, medicine sellers and the general public. Differences in methodological approaches and outcome assessment made it difficult to compare the effectiveness of law enforcement activities. Most effective appeared to be multifaceted approaches that involved all stakeholders. Monitoring of the impact on total sales of antibiotics by means of an interrupted time series (ITS) analysis and analysis of pharmacies selling antibiotics OTC using mystery clients were the methodologically strongest designs used. CONCLUSIONS The published literature describing activities to enforce prescription-only access to antibiotics in LMICs is sparse and offers limited guidance. Most likely to be effective are comprehensive multifaceted interventions targeting all stakeholders with regular reinforcement of messages. Policy evaluation should be planned as part of implementation to assess the impact and effectiveness of intervention strategies and to identify targets for further activities. Robust study designs such as ITS analyses and mystery client surveys should be used to monitor policy impact.
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Affiliation(s)
- Tom G. Jacobs
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, David de Wied building, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Jane Robertson
- World Health Organization (WHO) Regional Office for Europe, UN City, Marmorvej 51, 2100 Copenhagen, Denmark
- University of Newcastle Calvary Mater Hospital, Edith St & Platt St, Waratah NSW, Newcastle, 2298 Australia
| | - Hendrika A. van den Ham
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, David de Wied building, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Kotoji Iwamoto
- World Health Organization (WHO) Regional Office for Europe, UN City, Marmorvej 51, 2100 Copenhagen, Denmark
| | - Hanne Bak Pedersen
- World Health Organization (WHO) Regional Office for Europe, UN City, Marmorvej 51, 2100 Copenhagen, Denmark
| | - Aukje K. Mantel-Teeuwisse
- WHO Collaborating Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, David de Wied building, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
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Gieling EM, van den Ham HA, van Onzenoort H, Bos J, Kramers C, de Boer A, de Vries F, Burden AM. Risk of major bleeding and stroke associated with the use of vitamin K antagonists, nonvitamin K antagonist oral anticoagulants and aspirin in patients with atrial fibrillation: a cohort study. Br J Clin Pharmacol 2017; 83:1844-1859. [PMID: 28205318 DOI: 10.1111/bcp.13265] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 01/18/2017] [Accepted: 01/30/2017] [Indexed: 11/30/2022] Open
Abstract
AIMS Nonvitamin K antagonist oral anticoagulants (NOACs) are now available for the prevention of stroke in patients with atrial fibrillation (AF) as an alternative to vitamin K antagonists (VKA) and aspirin. The comparative effectiveness and safety in daily practice of these different drug classes is still unclear. The objective of this study was to evaluate the risk of major bleeding and stroke in AF patients using NOACs, VKAs or aspirin. METHODS A retrospective cohort study was conducted among AF patients using the UK Clinical Practice Research Datalink (March 2008-October 2014). New users of VKAs, NOACs and low dose aspirin were followed from the date of first prescription of an antithrombotic drug until the occurrence of stroke or major bleeding. Analyses were adjusted for a history of comorbidities and drug use with Cox regression analysis. RESULTS A total of 31 497 patients were eligible for the study. The hazard ratio (HR) of major bleeding was 2.07 [95% confidence interval (CI) 1.27-3.38] for NOACs compared with VKAs, which was mainly attributed by the increased risk of gastrointestinal bleeding (HR 2.63, 95% CI 1.50-4.62). This increased bleeding risk was restricted to women (HR 3.14, 95% CI 1.76-5.60). Aspirin showed a similar bleeding risk as VKAs. NOACs showed equal effectiveness as VKA in preventing ischaemic stroke (HR 1.22, 95% CI 0.67-2.19). VKAs were more effective than aspirin (HR 2.18, 95% CI 1.83-2.59). CONCLUSIONS NOACs were associated with a higher risk on gastrointestinal bleeding, particularly in women. The use of NOACs in patients who are vulnerable for this type of bleeding should be carefully considered. NOACs and VKAs are equally effective in preventing stroke. Aspirin was not effective in the prevention of stroke in AF.
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Affiliation(s)
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands
| | | | | | - Cornelis Kramers
- Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.,Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Frank de Vries
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands.,Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, UK
| | - Andrea M Burden
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands.,Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
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van den Ham HA, Klungel OH, Singer DE, Leufkens HG, van Staa TP. Comparative Performance of ATRIA, CHADS2, and CHA2DS2-VASc Risk Scores Predicting Stroke in Patients With Atrial Fibrillation. J Am Coll Cardiol 2015; 66:1851-9. [DOI: 10.1016/j.jacc.2015.08.033] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/28/2015] [Accepted: 08/04/2015] [Indexed: 10/22/2022]
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Hallgreen CE, van den Ham HA, Mt-Isa S, Ashworth S, Hermann R, Hobbiger S, Luciani D, Micaleff A, Thomson A, Wang N, van Staa TP, Downey G, Hirsch I, Hockley K, Juhaeri J, Metcalf M, Mwangi J, Nixon R, Peters R, Stoeckert I, Waddingham E, Tzoulaki I, Ashby D, Wise L. Benefit-risk assessment in a post-market setting: a case study integrating real-life experience into benefit-risk methodology. Pharmacoepidemiol Drug Saf 2014; 23:974-83. [PMID: 25043919 DOI: 10.1002/pds.3676] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 06/02/2014] [Accepted: 06/03/2014] [Indexed: 11/08/2022]
Abstract
PURPOSE Difficulties may be encountered when undertaking a benefit-risk assessment for an older product with well-established use but with a benefit-risk balance that may have changed over time. This case study investigates this specific situation by applying a formal benefit-risk framework to assess the benefit-risk balance of warfarin for primary prevention of patients with atrial fibrillation. METHODS We used the qualitative framework BRAT as the starting point of the benefit-risk analysis, bringing together the relevant available evidence. We explored the use of a quantitative method (stochastic multi-criteria acceptability analysis) to demonstrate how uncertainties and preferences on multiple criteria can be integrated into a single measure to reduce cognitive burden and increase transparency in decision making. RESULTS Our benefit-risk model found that warfarin is favourable compared with placebo for the primary prevention of stroke in patients with atrial fibrillation. This favourable benefit-risk balance is fairly robust to differences in preferences. The probability of a favourable benefit-risk for warfarin against placebo is high (0.99) in our model despite the high uncertainty of randomised clinical trial data. In this case study, we identified major challenges related to the identification of relevant benefit-risk criteria and taking into account the diversity and quality of evidence available to inform the benefit-risk assessment. CONCLUSION The main challenges in applying formal methods for medical benefit-risk assessment for a marketed drug are related to outcome definitions and data availability. Data exist from many different sources (both randomised clinical trials and observational studies), and the variability in the studies is large.
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