Project for Promotion of Appropriate Use of Medicines with Medication Support Tools via Clinical Pharmacists in Vietnam

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The Access Group of the Global Health Subcommittee of the International Committee of the Pharmaceutical Manufacturers Association of Japan (hereinafter referred to as "the Group") is working with the Pharmacy Department of the National Center for Global Medical Research (NCGM) and Bac Mai Hospital (BMH) in Hanoi, Vietnam, to improve access to medicines in low and middle income countries through activities to promote the appropriate use of medicines. This activity is being carried out in collaboration with the National Center for Health Promotion (NCGM) Pharmacy Department and Bac Mai Hospital (BMH) in Hanoi, Vietnam. This activity was also adopted as one of the projects for promoting international deployment of medical technology by the Ministry of Health, Labour and Welfare (MHLW) in FY2019, and we plan to continue to promote local deployment in Vietnam in FY2020 and beyond. In this report, we will focus on the activities that have been carried out so far and also provide an overview of future activity plans.

At the main gate of BMH

Background of Activities

In developing countries, there is an overwhelming shortage of "health human resources" such as doctors, nurses, pharmacists, and midwives, which is one of the reasons why adequate medical services are not provided. In the area of medicines, access to medicines due to income disparity and inappropriate use of medicines, such as incorrect prescribing, provision, and use, are also major issues. In 2017, the National Center for Global Medical Research (NCGM) Pharmaceutical Department launched a clinical trial in Vietnam. When we learned that the National Center for Global Medical Research (NCGM) Pharmacy Department was focusing on education and training for clinical pharmacists in Vietnam, we learned about their efforts, which highlighted the issue that clinical pharmacist services in Vietnam are limited to routine drug dispensing and provision of drug information to physicians, with little or no direct medication guidance for patients. This is an issue that has come to light. Furthermore, after exchanging opinions with various stakeholders, we realized that in order for drugs to be used correctly, it is important to provide appropriate information to patients and to strengthen the job function of clinical pharmacists as the people who lead this process, and that it is also the mission of pharmaceutical companies to take concrete actions to meet these needs, so we decided to establish the NCGM We decided to work together with the Pharmaceutical Department as a partner in this project.

Preliminary survey

In order to confirm that the content conceived by our group for local activities will actually benefit local patients, we have decided to conduct a preliminary survey starting in 2018. For the selection of the region and country of implementation, we considered Asia, which is a priority region for the Pharmaceutical Cooperative Association, but it was difficult to identify a specific country because we had absolutely no experience in this activity, so we decided to conduct the activity in Vietnam, where the NCGM Pharmaceutical Department had laid the foundation for the activity. We received a lot of valuable advice from Mitsuhiro Ushio, who was stationed in Vietnam from Japan as an advisor to the Vietnamese Ministry of Health, and his words especially stuck in my mind: "In order to expand our activities widely, it is important to first gradually build up a solid track record and experience.

The preliminary survey includes observing how patients are prescribed medicines and interviewing each patient to find out what his or her needs are and how he or she feels about the current situation. Bac Mai Hospital (BMH), where the survey was conducted, is one of the three major central hospitals in Hanoi, the capital of Vietnam, and is a large hospital with more than 2,000 beds, with which NCGM has a long cooperative relationship. In these large hospitals, there are many patients with relatively severe illnesses, but even patients with moderate illnesses come to receive better medical care, so the hospital is full of patients and their families. The number of patients to medical staff is too large. It was obvious that the medical staff could not spend enough time with each patient because there were too many patients for the staff to care for. The results of an interview survey of nearly 160 outpatients conducted by the Group in cooperation with the NCGM Pharmacy Department revealed that about 30% of the patients had surplus or shortage of prescribed medication, more than half of the patients did not understand the "efficacy," "dosage," and "side effects" of their medications, and more than half of the patients were not aware of their medication's "efficacy," "dosage regimen," "side effects," etc. The survey also revealed that more than half of the patients do not understand the "indications," "how to take," "side effects," etc. of the medicines they are taking, that 2/3 of the patients surveyed would like more guidance on taking their medicines, and that the 1/3 of patients who did not want this guidance did not necessarily have a high level of understanding of their medicines.

Preliminary survey

Full-scale operation of promotion of appropriate use of medicines through clinical pharmacists (activities in 2019)

Based on the results of this preliminary survey and discussions with the Vietnamese Ministry of Health, the World Health Organization (WHO) Vietnam Office, the Japan International Cooperation Agency (JICA) Vietnam Office, and others, we recognized the significance of activities to promote the proper use of medicines through training of clinical pharmacists. However, the budget of the Pharmaceutical Manufacturers Association of Japan (PMAJ) Global Health Subcommittee was not sufficient for more meaningful activities. Therefore, we investigated national and other support systems, and based on our previous experience that the "Project for Supporting Human Resource Development for Promoting Regulatory Science Research" was approved and funded by the "Project for Promoting International Development of Medical Technology" under the auspices of the Ministry of Health, Labor and Welfare, we applied for this project in FY2019, and fortunately it was adopted and we were able to conduct full-scale activities. We are very happy to announce that our application was accepted and we will be able to start full-fledged activities.

This project for promoting the international deployment of medical technology is a training program that aims to bring about a virtuous cycle for both Japan and developing countries by contributing to the improvement of medical standards in partner countries while taking advantage of the strengths of Japanese medical care and businesses. First, the Group will re-tailor explanatory materials on drugs and diseases prepared by pharmaceutical companies and related organizations for Japanese patients, and second, clinical pharmacists will use the materials to provide patients with medication guidance, and ask patients to evaluate their level of understanding of the drugs and their satisfaction with the medication guidance. This is a two-step activity plan.

The medication guidance was to be inspired by the patient classes that NCGM conducts in Japan, and we hoped that the group-type patient guidance would reduce the burden on busy physicians and nurses. In addition, since it is difficult to target all diseases from the beginning, we decided to target diabetes, taking into account that the increase in non-communicable diseases (NCDs) has become an international priority, therapeutic areas of focus on the part of BMH, and the opinions of the NCGM Pharmacy Department.

Thus, in August 2019, the Group, together with the NCGM Pharmacy Department, visited BMH again.

Meeting with BMH executives

Initially, we were considering a training program for clinical pharmacists only, but after discussing the details of the project plan with BMH executives, we realized that the advice of physicians is essential for improving materials, and since medication instruction to patients is provided only by physicians and nurses, not pharmacists, the involvement of physicians in medication instruction education is We found that it is necessary to involve physicians as well, and decided to change our activity plan for FY 2019 to include their cooperation. This has resulted in better materials and smoother cooperation within BMH, which has led to very positive outcomes. We also had the opportunity to interview several people, including front-line staff (doctors and nurses) and patients engaged in diabetes treatment, and obtained a variety of opinions and expectations. The participants were also able to reconfirm that BMH does not provide materials related to medications for both inpatients and outpatients and that Japanese-style materials with rich illustrations are useful. Furthermore, it was a very valuable opportunity for us to see firsthand the group instruction by nurses in the corridor of the BMH, to get an idea of what we were looking for. During the visit, we exchanged opinions on the type, structure, and content of patient materials to be developed, as well as briefly discussed outcome measures, and agreed to finalize them at the next training session to be held in Japan.

Patient group guidance at BMH

From September 30, Dr. Nguyen Thi Thuc Hien, a diabetes specialist from BMH, and Dr. Bui Thi Ngoc Thuc, a clinical pharmacist, attended a 5-day training course in Japan. The following is a summary of the training.

Training in Japan

The five days flew by, and we created three tools: two patient medication support tools ("Basic Guide to Diabetes Care" and "General Knowledge about Medications") ( Figure 1) and one slide material for group patient instruction by clinical pharmacists.

Fig. 1 Two types of medication support tools for patients

For the materials on diabetes treatment, we added innovations such as incorporating the use of insulin, which is widely used, and adding elements of the medicine handbook, which has become commonplace in Japan. The general knowledge of drugs is based on materials provided by the Council for the Proper Use of Drugs. These support tools will be validated by Hien and Thuc using them in actual medical practice and medication guidance at BMH, and patients will be asked to judge them through questionnaires.

In January 2020, we visited BMH to review the results of this patient survey. When asked how they would like to use the medication support tools "Basic Guide for Diabetes Treatment" and "General Knowledge about Medication" in the future, more than 80% of the patients selected "Always carry with me," "Keep in a bag with my medication," or "Keep in a designated place in my house. The results showed that more than 80% of the respondents selected "Always carry it with me," "Keep it in a bag with the medicine," or "Keep it in a designated place at home. In addition, the satisfaction level of clinical pharmacists with medication instruction was very high at 98%, and with regard to patients' understanding of the effects and side effects of medications, more than 85% of the respondents answered that they "understood more than before the instruction" in all items.

Group patient guidance by BMH and pharmacists

In conjunction with this training, a diabetes sub-seminar was held for medical professionals from BMH and its related institutions. The content of the training program was introduced along with the current status of diabetes treatment in Japan, and the importance of medication guidance by clinical pharmacists was emphasized. The fact that the patients appreciated the medication guidance by clinical pharmacists and the BMH confirmed its intention to continue the group patient guidance by clinical pharmacists is a great encouragement for our group to continue this activity.

Small seminar on diabetes

Future activities

In order to continue our activities after April 2020, we plan to apply again to the Project for Promotion of International Development of Medical Technology and receive approval. During our visit in January, we visited two regional hospitals in northern Vietnam to discuss the possibility of continuing the project. As a result of the visit, we first met with the hospital directors and pharmacy directors, who expressed high expectations for the role clinical pharmacists play in healthcare and a strong desire to improve hospital functions through training with Japan.

On the other hand, we also learned that clinical pharmacists, who are currently limited in number, do not provide direct medication guidance to patients, and that there are significant differences in the types and number of anti-diabetic drugs employed at BMH and at regional hospitals. Therefore, it is our future task to consider the best implementation method for rural hospitals, taking these findings into consideration.

The Group will continue its activities to improve access to medicines and to contribute to the health of the local population.

At a local hospital

( Toshihiko Tsunenari, Access Group Leader, Global Health Subcommittee, International Committee)

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