Many factors, such as patient acuity, number of intensive care beds, and patient demographic characteristics, can confound differences in utilization rates of antimicrobials across different facilities; therefore, comparisons between hospitals and districts should be used only as a guide. There was a nonsignificant trend for small hospitals to have higher use of fluoroquinolones than large hospitals, which suggests overuse of these drugs by some facilities.
Data on patient acuity and outcomes after the use of specific agents were not available for this particular study. Furthermore, information on hospital infection control policies and their implementation was not collected. This study was also limited by the relatively small number of hospitals and districts and the short time frame over which policies might have been introduced and implemented. Although the statistical power to detect a difference in the use of fluoroquinolones between hospitals with no utilization policies and those with more than one policy was low (post hoc power = 0.2434), it is important to note that the geographic region of the study had only a limited number of institutions. Therefore, this pilot study was restricted in the number of institutions available for analysis. Future studies could include additional hospitals outside of Nova Scotia. The year in which policies were instated was requested, but this information was not provided in all cases. Two of the policies were implemented sometime in 1999 and another in 2000. One limitation to interpreting the influence of utilization policies on actual fluoroquinolone use is the assumption that each hospital within a DHA followed the district’s policies as reported by the survey respondent; however, adherence to policies was not verified in this study, nor were changing policies over time examined.
The DDDs for some fluoroquinolones (levofloxacin, ciprofloxacin) are lower than the dosages commonly used for certain infections in Nova Scotia, which might have led to an overestimation of use. Nevertheless, this methodology does provide a way of comparing drug utilization among DHAs and hospitals and provides guidance to improving their use.By comparing drug utilization data from different locations, it is often possible to detect substantial differences requiring further evaluation, and such evaluation may lead to the identification and promotion of best practices, often called benchmarking. Such comparisons will be accurate as long as the data are collected in a uniform way. The ATC/DDD methodology recommended by WHO and the European Drug Utilization Research Group (see http://www.eurodurg.com) allows these comparisons. Bhavnani and others used the WHO ATC/DDD methodology to compare use of fluoro- quinolones and found an insufficient number of hospitals that could provide data on actual antimicrobial use. They concluded that surrogate markers such as expenditures would suffice until more hospitals are able to provide running totals for drug use on a patient-by-patient basis. The current study has shown that the WHO ATC/DDD methodology applied to purchasing data offers a simple and effective method of comparing use between hospitals, in attempts to develop best practices. Additionally, this study had the advantage of investigating all NS hospitals that used fluoroquinolones and thus represented true (or “real”) utilization patterns in the province. This represents valuable information for policy-makers, pharmacists, and clinicians.
This study demonstrated application of the WHO ATC/DDD methodology to compare drug utilization between hospitals and health districts. This tool should be applied more widely to detect trends or signals in utilization patterns that could be investigated in more formal drug use management programs and thereby to improve the appropriate utilization of antimicrobials. In this study, fluoroquinolone use increased significantly over time. These data will provide a useful baseline for examination of future use and its association with antimicrobial susceptibility patterns in Nova Scotia. Although limitations in study design prevented demonstration of statistically significant differences in utilization rates between hospitals with and without utilization policies, further studies of the effectiveness of these strategies are warranted. Lack of resources for education and follow-up may prevent hospitals from gaining full benefit from policy interventions.
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