WHO EML Research Articles

Use of Essential Medicines for Pain Relief and Palliative Care: a global consensus process

BackgroundThe WHO Model List of Essential Medicines includes 24 medications under the section Medicines for Pain and Palliative Care (EML). The Lancet Commission on Pain and Palliative Care developed the Lancet Essential Package (LEP), including 35 medications designed to alleviate serious health-related suffering worldwide. AimThis study aims to provide recommendations on the appropriate use of essential of medicines in palliative care. MethodsThe global palliative care community was invited to submit guidelines, of which 19/22 were selected. Data was extracted on initial dose, frequency, and maximum daily dose for medications in the LEP and in the WHO EML. For medications where guidance was not available or information differed, a 2-round Delphi process was conducted with 70 experts across regions and income levels. Consensus was set to ≥70% agreement. ResultsConsensus in the guidelines was identified for 24 medications on three parameters. Open questions (mostly on maximum daily dose) were included in the Delphi. 63 experts from 49 countries responded (RR=90%). No consensus was achieved for the maximum daily dose for nine medications. Significant disparities in medication availability were noted between high-income and low/middle-income countries. ConclusionWe were able to partly achieve our goal, with limited evidence and a wide range of clinical practice described by the experts. This highlights an important gap in critical information which affects mostly the provision of palliative care at the primary care. Both limited availability and lack of training on the adequate use of essential medications may affect how clinicians manage symptoms, possibly relying on personal experience or trial and error, rather than evidence-based information.

A quantitative comparison between the essential medicines for rheumatic diseases in children and young people in Africa and the WHO model list

BackgroundThe World Health Organisation Essential Medicines List (WHO EML) guides National Essential Medicines Lists and Standard Treatment Guidelines for clearly identified disease priorities especially in low- and middle-income countries. This study compares the degree to which the basket of medicines recommended for rheumatic diseases in children and young people in National Essential Medicines Lists of countries in the WHO Africa region, corresponds to the 2021 WHO EML and WHO EML for children, as a proxy of availability.MethodsAn online search of the WHO medicines and health technology portal, the Health Ministry websites of the 54 African countries, PUBMED and Google Scholar, with search terms for ‘National Essential Medicines List’, AND/OR ‘standard treatment guidelines’ AND/OR ‘Lista Nacional de Medicamentos Essenciais’ AND/ OR ‘Liste Nationale de Medicaments Essentiels’ AND Africa AND/OR < Name of African country > was conducted. The number of medicines on the national lists were compared according to a predefined template of medicines; and the percentage similarity calculated. Descriptive statistics were derived using STATA.ResultsForty-seven countries in the WHO Africa region have developed a National Essential Medicines List. Eleven countries do not have any medicines listed for rheumatic diseases.The majority of countries had less than or equal to 50% similarity with the WHO EML for rheumatic disease in children and young people, median 3 medicines (IQR 1— 4). The most common medicines on the national lists from Africa were methotrexate, sulfasalazine and azathioprine, with etanercept available in 6 countries. Seven countries had only one medicine, acetylsalicylic acid listed in the section ‘Juvenile Joint diseases’.A multiple linear regression model for the predictors of the number of medicines on the national lists established that 20% of the variability was predicted by health expenditure per capita, socio-demographic index and the availability of rheumatology services (adult and/or paediatric) p = 0.006, with socio-demographic index (p = 0.035, 95% CI 0.64—16.16) and the availability of rheumatology services (p = 0.033, 95% CI 0.13 – 2.90) significant.ConclusionFour countries (8.5%) in Africa have updated their National Essential Medicines Lists to reflect adequate care for children and young people with rheumatic diseases. Moving forward, efforts should focus on aligning available medicines with the WHO EML, and strengthening healthcare policy for rheumatology and pharmaceutical services, for affordable access to care and medicines.

A quantitative comparison of essential cardiovascular medicines from countries in the Southern African Development Community to the WHO model essential medicines list.

Globally, cardiovascular disease (CVD) is a leading cause of death and disproportionately affects low- and middle-income countries (LMICs). The WHO Model List of Essential Medicines (WHO EML) is a tool for improving accessibility and availability of medicines. This study compared the 2021 WHO EML CVDs basket of medicines with latest available national essential medicines list (NEMLs) for South Africa and 15 Southern African Development Community (SADC) countries to assess consistency in CVDs medicine listing. This descriptive, desktop review study compared SADC NEMLs. A comparator list was extracted by combining cardiovascular medicines listed in the 2021 WHO EML for adults and children. SADC country NEMLs were obtained from the WHO Essential Medicines and Health Products Information Portal. Consistency of NEMLs was calculated as a percentage coverage of CVD medicines listed in the 2021 WHO EML. SA hospital and primary health care (PHC) level NEMLs were included as separate formularies. The SA hospital level NEML scored 70% consistency with the 2021 WHO EML. Tanzania (84%), Namibia (81%) and Angola (79%) scored the highest consistency. The mean consistency for SADC NEMLs was 66%. The lowest scoring country was Eswatini at 26%. The SA PHC NEML scored 35%. The least listed medicines were beta-blockers, angiotensin receptor blockers (ARBs), clopidogrel (43%) and paediatric formulations (furosemide (21%); digoxin (43%)). Individual antihypertensive medicines were most commonly listed. Botswana and Lesotho were the only countries to list a single pill combination (SPC) for the treatment of hypertension. This comparison indicates that South Africa and most SADC countries are aligned with 2021 WHO EML recommendations. The inclusion of age-appropriate formulations for children as well as ARBs and SPC for the treatment of hypertension may improve patient adherence and cardiovascular outcomes in these countries. More frequent updates to NEMLs should improve consistency. NEMLs were not available for two countries, and these therefore did not form part of this study. Country health expenditure in ranking the consistency of NEMLs was not accounted for. LMICs adopting the essential medicine list strategy should consider imposing minimum consistency thresholds to the WHO EML to improve accessibility and availability of CVD medicines. Not applicable.

Abstract 11314: Essential and Evidence-Based Cardiovascular Disease Medicine Availability in Low-Cost Generic Drug Plans

Introduction: Patients’ lack of access to affordable cardiovascular disease (CVD) medicines poses a crucial barrier to achieving desired cardiovascular outcomes. Many pharmacies have launched low-cost generic programs (LCGP) to expand medication accessibility. It is uncertain whether LCGPs include CVD drugs recommended by World Health Organization Essential Medicines List (WHO EML) and promote evidence-based prescribing. Our study aimed to estimate the availability of essential and guideline-recommended CVD medicines on LCGP in the United States (US). Methods: We selected 6 CVD conditions: atrial fibrillation (AF), heart failure (HF), hyperlipidemia (HLD), hypertension (HTN), stable angina (SA), and secondary prevention (SPX). LCGPs in the US with publicly available formularies were identified in February 2022. We used the 22 nd WHO EML edition and Class 1A recommendations (1ARec) from current CVD guidelines as reference standards. Availability was estimated using the proportion of coverage for each LCGP overall, and by condition. Results: Nineteen LCGPs were included. There were 122 WHO EML and 155 1ARec CVD drugs. No LCGPs offered at least 50% of WHO EML and 1ARec. Both WHO EML and 1ARec analyses showed that 9 of 19 LCGPs covered at least 30% of listed medications. Out of the 19 LCGPs, the proportion of essential and evidence-based CVD medicine availability was highest at Kroger (46.3% and 47.9%) and lowest at Costco (5.0% and 6.1%), respectively. Higher availability was observed for HLD medications: only TOPS and the Mark Cuban Plan had at least 80% of WHO EML available, and only the Mark Cuban Plan had at least 80% of 1ARec medications covered. HTN drugs were least available for both. Conclusion: The accessibility of CVD medicines is low in LCGP formularies with variation in availability by pharmacy and condition. To optimize the accessibility of CVD medicines and health outcomes, pharmacies with LCGPs should offer more essential and evidence-based CVD medicines.

Access to and Affordability of World Health Organization Essential Medicines for Cancer in Sub-Saharan Africa: Examples from Kenya, Rwanda, and Uganda.

Cancer mortality is high in sub-Saharan Africa (SSA), partly due to inadequate treatment access. We explored access to and affordability of cancer treatment regimens for the top 10 cancers utilizing examples from Kenya, Uganda, and Rwanda. Population, healthcare financing, minimum wage, and cancer incidence and mortality data were obtained from the WHO, World Bank, public sources, and GLOBOCAN. National Essential Medicines List (NEML) alignment with 2019 WHO EML was assessed as a proportion. Cancer regimen pricing was calculated using public and proprietary sources and methods from prior studies. Affordability through universal healthcare coverage (UHC) was assessed as 1-year cost <3× gross national income per capita; and to patients out-of-pocket (OOP), as 30-day treatment course cost <1 day of minimum wage work. A total of 93.4% of the WHO EML cancer medicines were listed on the 2019 Kenya NEML, and 70.5% and 41.1% on Uganda (2016) and Rwanda (2015) NEMLs, respectively. Generic chemotherapies were available and affordable to governments through UHC to treat non-Hodgkin's lymphoma, cervical, breast, prostate, colorectal, ovarian cancers, and select leukemias. Newer targeted agents were not affordable through government UHC purchasing, while some capecitabine-based regimens were not affordable in Uganda and Rwanda. All therapies were not affordable OOP. All cancer treatment regimens were not affordable OOP and some were not covered by governments. Newer targeted drugs were not affordable to all 3 governments. UHC of cancer drugs and improving targeted therapy affordability to LMIC governments in SSA are key to improving treatment access and health outcomes.

National adaptation and implementation of WHO Model List of Essential Medicines: A qualitative evidence synthesis.

The World Health Organization Model List of Essential Medicines (WHO EML) has played a critical role in guiding the country-level selection and financing of medicines for more than 4 decades. It continues to be a relevant evidence-based policy that can support universal health coverage (UHC) and access to essential medicines. The objective of this review was to identify factors affecting adaptation and implementation of WHO EML at the national level. We conducted a qualitative evidence synthesis by searching 10 databases (including CINAHL, Embase, Ovid MEDLINE, Scopus, and Web of Science) through October 2021. Primary qualitative studies focused on country-level implementation of WHO EML were included. The qualitative findings were populated in the Supporting the Use of Research Evidence (SURE) framework, and key themes were identified through an iterative process. We appraised the papers using the Critical Appraisal Skills Programme (CASP) tool and assessed our confidence in the findings using the Grading of Recommendations Assessment, Development and Evaluation working group-Confidence in Evidence from Reviews of Qualitative research (GRADE-CERQual). We screened 1,567 unique citations, reviewed 183 full texts, and included 23 studies, from 30 settings. Non-English studies and experiences and perceptions of stakeholders published in gray literature were not collected. Our findings centered around 3 main ideas pertaining to national adaptation and implementation of WHO EML: (1) the importance of designing institutions, governance, and leadership for national medicines lists (NMLs), particularly the consideration of transparency, coordination capacity, legislative mechanisms, managing regional differences, and clinical guidance; (2) the capacity to manage evidence to inform NML updates, including processes for contextualizing global evidence, utilizing local data and expert knowledge, and assessing budget impact, to which locally relevant cost-effectiveness information plays an important role; and (3) the influence of NML on purchasing and prescribing by altering provider incentives, through linkages to systems for financing and procurement and donor influence. This qualitative evidence synthesis underscores the complexity and interdependencies inherent to implementation of WHO EML. To maximize the value of NMLs, greater investments should be made in processes and institutions that are needed to support various stages of the implementation pathway from global norms to adjusting prescribed behavior. Moreover, further research on linkages between NMLs, procurement, and the availability of medicines will provide additional insight into optimal NML implementation. PROSPERO CRD42018104112.

Antibiotic procurement and ABC analysis for a comprehensive primary health care clinic in the Eastern Cape province, South Africa.

BackgroundAntimicrobial resistance (AMR), a major threat to global public health, can be addressed using a managed care approach. This includes timely analysis of antibiotic consumption and procurement data to drive evidence-based policies and practices in healthcare facilities. ‘ABC analysis’ presents an opportunity for this.MethodsABC analysis data for a comprehensive Primary Health Care (PHC) clinic in the Eastern Cape province of South Africa was obtained from the Provincial Department of Health for 01 April 2015 to 31 March 2018. Procured antibiotics were analysed on the quantities purchased, total cost, route of administration and spectrum of activity. Antibiotic categorization was also carried out according to the World Health Organization Model List of Essential Medicines (WHO EML) 2017.ResultsAntibiotics made up approximately 7% of the total annual pharmaceutical expenditure. A total of 31, 35 and 34 antibiotics were procured in the first, second and third years, respectively. The most procured antibiotics were: (1) isoniazid, (2) flucloxacillin, (3) azithromycin, (4) a combination of rifampicin, isoniazid, pyrazinamide, and ethambutol and (5) amoxicillin. Overall, 55%, 2% and 15% of antibiotics accounted for the ‘Access’, ‘Watch’ and ‘Access and Watch’ categories, respectively, of the WHO EML. No ‘Reserve’ antibiotics were procured. The remaining 28% were antituberculosis medicines. Altogether, 89%, 8% and 3% of the antibiotics were respectively administered orally, systemically, and topically. A total of 58% were broad-spectrum and 42% were narrow-spectrum antibiotics.ConclusionOral antibiotics in the ‘Access’ category presented favourable usage of antibiotics. Decreasing the use of broad-spectrum antibiotics requires consideration.

Inclusion in the World Health Organization Model List of Essential Medicines of Non-Vitamin K Anticoagulants for Treatment of Non-Valvular Atrial Fibrillation: A Step Towards Reducing the Burden of Cardiovascular Morbidity and Mortality.

Non-vitamin K antagonist oral anticoagulants (NOACs) represent a paradigm shift in the treatment of non-valvular atrial fibrillation (AF) with major practice guidelines around the world recommending NOACs over vitamin K antagonist oral anticoagulants for initial treatment of AF for stroke prevention. Here we describe the evidence collated and the process followed for the successful inclusion of NOACs into the 21st WHO Model List of Essential Medicines (EML).Individual NOACs have been reported to be non-inferior or superior to warfarin in preventing stroke and systemic embolism in eligible AF patients with a reduction in the risk of stroke and systemic embolism and a lower risk of major bleeding in patients with non-valvular AF compared with warfarin in both RCTs and real-world data.The successful inclusion of NOACs in the WHO EML is an important step forward in the global fight against cardiovascular morbidity and mortality, especially in low- and middle-income countries, where the burden of disease is high and limited access to diagnosis and treatment translates into a higher burden of morbidity, mortality, and economic costs.

Differences in reimbursement listing of anticancer therapies in China: an observational study

ObjectiveAccess to highly priced anticancer medications usually requires insurance coverage. A first step towards coverage of such medications is their inclusion in reimbursement lists. We assessed listing for reimbursement in...

Estimation of cost-based prices for injectable medicines in the WHO Essential Medicines List

ObjectivesChallenges remain in ensuring universal access to affordable essential medicines. We previously estimated the expected generic prices based on cost of production for medicines in solid oral formulations (ie, capsules...

Essential medicines for emergency care in Africa

ObjectivesEssential medicines lists (EMLs) are efficient means to ensure access to safe and effective medications. The WHO has led this initiative, generating a biannual EML since 1977. Nearly all countries...

ESMO International Consortium Study on the availability, out-of-pocket costs and accessibility of antineoplastic medicines in countries outside of Europe

BackgroundThe availability and affordability of safe, effective, high-quality, affordable anticancer therapies are a core requirement for effective national cancer control plans. MethodOnline survey based on a previously validated approach. The aims of the study were to evaluate (i) the availability on national formulary of licensed antineoplastic medicines across the globe, (ii) patient out-of-pocket costs for the medications, (iii) the actual availability of the medication for a patient with a valid prescription, (iv) information relating to possible factors adversely impacting the availability of antineoplastic agents and (v) the impact of the country’s level of economic development on these parameters. A total of 304 field reporters from 97 countries were invited to participate. The preliminary set of data was posted on the ESMO website for open peer review and amendments have been incorporated into the final report. ResultsSurveys were submitted by 135 reporters from 63 countries and additional peer-review data were submitted by 54 reporters from 19 countries. There are substantial differences in the formulary availability, out-of-pocket costs and actual availability for many anticancer medicines. The most substantial issues are in lower-middle- and low-income countries. Even among medications on the WHO Model List of Essential Medicines (EML) the discrepancies are profound and these relate to high out-of-pocket costs (in low-middle-income countries 32.0% of EML medicines are available only at full cost and 5.2% are not available at all, and for low-income countries, the corresponding figures are even worse at 57.7% and 8.3%, respectively). ConclusionsThere is wide global variation in formulary availability, out-of-pocket expenditures and actual availability for most licensed anticancer medicines. Low- and low-middle-income countries have significant lack of availability and high out-of-pocket expenditures for cancer medicines on the WHO EML, with much less availability of new, more expensive targeted agents compared with high-income countries.

Treatment of acute migraine attacks in children with analgesics on the World Health Organization Essential Medicines List: A systematic review and GRADE evidence synthesis.

Background The World Health Organization Essential Medicines List (WHO EML) contains two analgesics for treatment of acute migraine attacks in children, ibuprofen and paracetamol. Methods The Embase, CDSR, CENTRAL, DARE and MEDLINE databases were searched up to 18 April 2017. We analyzed randomized controlled trials (RCTs) and systematic reviews (SRs) that investigate the efficacy and safety of ibuprofen or paracetamol for treatment of acute migraine attacks in children. We conducted meta-analysis and assessments of evidence with GRADE, Cochrane risk of bias tool, and AMSTAR. Results Three RCTs (201 children) and 10 SRs on ibuprofen and/or paracetamol for acute migraine attacks in children were included. Meta-analysis indicated that ibuprofen was superior to placebo for pain-free at 2 h or pain relief at 2 h, without difference in adverse events. There were no differences between paracetamol and placebo, or ibuprofen and paracetamol. Ten SRs that analyzed various therapies for migraine in children were published between 2004 and 2016, with discordant conclusions. Conclusion Limited data from poor quality RCTs indicate that ibuprofen and paracetamol might be effective analgesics for treating migraine attacks in children. Inclusion of ibuprofen and paracetamol as antimigraine medicines for children in the WHO EML is supported by indirect evidence from studies in adults.

Access to cancer drugs: Are we meeting the needs of Malaysian?

ObjectiveProviding access to essential cancer drugs is a mounting challenge in low- and middle income countries (LMICs). There is variability in inclusion of these drugs into the national essential medicines list (NEML) of LMICs including Malaysia. Therefore, the primary objective of this study was to determine the current status of access to essential cancer drugs in the Ministry of Health Malaysia. The overall access to cancer drugs was also assessed as a secondary objective. MethodsThe Malaysia NEML (4th edition), Ministry of Health Medicines Formulary (MOHMF) and the WHO Model List of Essential Medicines (WHO EML) 2013 and 2015 was obtained. The total number of cancer drugs under the Anatomical Therapeutic Chemical classification of L01 available in the NEML and the MOHMF in comparison to WHO EML was analysed. Total number of cancer drugs available in MOHMF was also analysed. ResultsMalaysia NEML has 20 cancer drugs which corresponds to 90.9% and 58.8% of the cancer drugs in WHO EML 2013 and 2015 respectively. Comparison with MOHMF found that all cancer drugs recommended in the WHO EML are listed in the formulary. DiscussionBased on the NEML, results indicate limited access to essential cancer drugs in MOH. However, since access to treatment in Ministry of Health is dependent on drugs listed in the MOHMF, access to essential cancer drugs was found to be good. Nevertheless, there is still concerns regarding overall access to cancer treatment in the Ministry of Health Malaysia considering the limited adoption of new innovative cancer therapies.

Cisplatin for testicular germ cell tumors: a rapid review

Cisplatin is one of efficacious medicines for TGCT, but is not in 18th WHO EML now. The Union for International Cancer Control recommended cisplatin to the 19th WHO EML for TGCT. To evaluate the effectiveness, safety and cost of cisplatin for TGCT according to the requirements of WHO EML Expert Committee, and to provide the evidence whether cisplatin should be included in WHO EML. We searched The Cochrane Library, PubMed, EMbase, NHS EED, US National Guideline Clearinghouse (NGC) and WHO guidelines. Guidelines and systematic reviews (SRs) on cisplatin for TGCT were included. Two reviewers selected studies and extracted relevant information independently. Quality of SRs was appraised through AMSTAR. Seven guidelines and four SRs were included in this rapid review. Quality of SRs was moderate according to AMSTAR. The results showed that: (a) effectiveness: cisplatin-based chemotherapy significantly improved in response rates and overall survival for more advanced disease (stage II and stage III). Bleomycin, etoposide, and cisplatin (BEP)-one of the most widely used of cisplatin-based chemotherapy regimens should be considered as the standard treatment of good-prognosis patients with survival rates of 90% and as the best option for intermediate- or poor-prognosis patients with survival rates of 75% and 50%, respectively. (b) Safety: nephrotoxicity, ototoxicity and peripheral neuropathy are common adverse effects of cisplatin. (c) Cost: there was no relevant study about cost of cisplatin for TGCT. But the affordability of cispaltin is good for Chinese patients, due to it is in health insurance directory of China. We recommend cisplatin to be listed in 19th WHO EML for TGCT, due to adequate evidence of effectiveness and good affordability.

A Case Study on National List of Essential Medicines(NLEM)in India and WHO EML 2015-Overview

Availability of modern medicine increased all over the world due to huge expansion of the global Pharma market. At the same time misuse as well as accessibility of the most of essential drugs to majority of the population was denied due to cost-effectiveness of healthcare delivery combined with poor procurement policies and poor prescribing practices. During the recent years, the national list of India has assumed immense importance to improve access to medicines in India. It is therefore necessary to understand policies and guidelines followed in developing WHO essential drug list and national list of essential medicines. In this review article history of essential drug list and important inclusions in NLEM 2015 and WHO EML 2015 were highlighted.

Drug utilization pattern of antimicrobial drugs in intensive care unit of a tertiary care hospital attached with a medical college

Background: A number of antimicrobial drugs are prescribed to the patients in Intensive Care Unit (ICU). Drug utilization research was defined by WHO as the study of marketing, distribution, prescription, and use of drugs in a society, with special emphasis on the resulting medical, social and economic consequences. There is lack of information about the use of antimicrobial agents in the ICU at GGGH till date. So we decided to conduct this type of study.Methods: A prospective observational study was carried out for 12 months. Patients of age &gt;18 of both sexes who was admitted in ICU were included in the study while pregnant and lactating women excluded. The prescribing pattern was analyzed by using World Health Organization basic drug indicators. Results: Among 611 patients, 373 (61.04%) were male and 238 (38.95%) were female. The most common emergency was post-operative 204 (33.38%).The most common prescribed antimicrobial drug group and drug was antiamoebic drugs and metronidazole respectively in 437 (24.04%) out of total drugs prescribed. The numbers of antimicrobial drugs prescribed per patient were 2.97. 68% drugs were prescribed from WHO and national EML list. Total 57.26% drugs were prescribed by generic name. Average antimicrobial drug cost per patient was 1805.34 rs.Conclusions: Despite of limitations of present study it gives important conclusion about how antimicrobial drugs are used in GGGH ICU. This information can be used for improvement of current treatment strategies.

Exploration and practice of methods and processes of evidence-based rapid review on peer review of WHO EML application.

After 38 years of development, the procedure of selection and evaluation of the World Health Organization Essential Medicine List (WHO EML) is increasingly scientific and formal. However, peer review for the applications of World Health Organization Essential Medicine List is always required in a short period. It is necessary to build up a set of methods and processes for rapid review. We identified the process of evidenced-based rapid review on WHO EML application for peer reviews according to 11 items which were required during reporting of the peer review results of the proposals. The most important items for the rapid review of World Health Organization Essential Medicine List peer reviewers are (1) to confirm the requirements and identify the purposes; (2) to establish the research questions and translate the questions into the 'Participants, Interventions, Comparators, Outcomes, Study design' (PICOS) format; (3) to search and screen available evidence, for which high-level evidence is preferred, such as systematic reviews or meta-analyses, health technology assessment, clinical guidelines; (4) to extract data, where we extract primary information based on the purposes; (5) to synthesize data by qualitative methods, assess the quality of evidence, and compare the results; (6) to provide the answers to the applications, quality of evidences and strength of recommendations. Our study established a set of methods and processes for the rapid review of World Health Organization Essential Medicine List peer review, and our findings were used to guide the reviewers to fulfill the 19(th) World Health Organization Essential Medicine List peer review. The methods and processes were feasible and met the necessary requirements in terms of time and quality. Continuous improvement and evaluation in practice are warranted.

Using the WHO Essential Medicines List to Assess the Appropriateness of Insurance Coverage Decisions: A Case Study of the Croatian National Medicine Reimbursement List

PurposeTo investigate the use of the WHO EML as a tool with which to evaluate the evidence base for the medicines on the national insurance coverage list of the Croatian Institute of Health Insurance (CIHI).MethodsMedicines from 9 ATC categories with highest expenditures from 2012 CIHI Basic List (n = 509) were compared with 2011 WHO EML for adults (n = 359). For medicines with specific indication listed only in CIHI Basic List we assessed whether there was evidence in Cochrane Database of Systematic Reviews questioning their efficacy and safety.ResultsThe two lists shared 188 medicines (52.4% of WHO EML and 32.0% of CIHI list). CIHI Basic List had 254 medicines and 33 combinations of these medicines which were not on the WHO EML, plus 14 medicines rejected and 20 deleted from WHO EML by its Evaluation Committee. For deleted medicines, we could obtain data that showed 2,965,378 prescriptions issued to 617,684 insured patients, and the cost of approximately € 41.2 million for 2012 and the first half of 2013, when the CIHI Basic List was in effect. For CIHI List-only medicines with a specific indication (n = 164 or 57.1% of the analyzed set), fewer benefits or more serious side-effects than other medicines were found for 17 (10.4%) and not enough evidence for recommendations for specific indication for 21 (12.8%) medicines in Cochrane systematic reviews.ConclusionsNational health care policy should use high-quality evidence in deciding on adding new medicines and reassessing those already present on national medicines lists, in order to rationalize expenditures and ensure wider and better access to medicines. The WHO EML and recommendations from its Evaluation Committee may be useful tools in this quality assurance process.

Screening of prescriptions in geriatric population in a tertiary care teaching hospital in north India

The objective of our study was to assess the pattern of prescribing prescriptions and cost analysis among the geriatric patients attending the Medicine Outpatient Department of NIMS Medical College and Hospital, Jaipur. After taking permission from the Institutional Ethical Committee, prescriptions of 235 geriatric patients attending the medicine outpatient department of NIMS Medical College and Hospital, Jaipur, were noted and demographic profile, commonly prescribed drugs as per Anatomical Therapeutic Chemical Classification (ATC) and WHO core indicators were assessed after taking written informed consent from the patients. Out of 235 patients, 130(55.31%) were males and 105(44.68%) were females and most of the patients were in the age group of 81-85 for males 65-70 for females. Maximum number of patients were having cardiovascular diseases (n=196) followed by respiratory disorders (n=172) and musculoskeletal diseases (n=153). 89 patients (38%) were having three comorbid conditions. Average number of drugs per prescription was 5.51(1296/235). Drugs on WHO EML were 546 while on NLEM was779. Drugs prescribed by generic names were 31.94%, is less than that prescribed by their brand names 68.05%. Average cost per prescription was INR 18.75 per day. Drugs prescribed as fixed dose combinations were 324. Drugs acting on cardiovascular system (n=356) were the most commonly used drugs in our study followed by antibiotics (n=127) and bronchodilators (n=126). Thus irrational prescribing and polypharmacy were prevalent among elderly.