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Increasing rational use of cholinesterase inhibitors for Alzheimer's disease in Brazil: Public health strategy combining guideline with peer-review of prescriptions

Published online by Cambridge University Press:  15 April 2010

Paulo Dornelles Picon ,
Ana Luiza Camozzato ,
Elaine A. Lapporte ,
Rafael V. Picon ,
Humberto Moser Filho ,
Maria Otília Cerveira  and
Márcia L. F. Chaves
Paulo Dornelles Picon
Affiliation:
Universidade Federal do Rio Grande do Sul and Secretaria da Saúde do Estado do Rio Grande do Sul
Ana Luiza Camozzato
Affiliation:
Fundação Faculdade Federal de Ciências Médicas e da Saúde and Secretaria Estadual da Saúde do Rio Grande do Sul
Elaine A. Lapporte
Affiliation:
Secretaria Estadual da Saúde do Estado do Rio Grande do Sul
Rafael V. Picon
Affiliation:
Universidade Federal do Rio Grande do Sul
Humberto Moser Filho
Affiliation:
Universidade Federal do Rio Grande do Sul
Maria Otília Cerveira
Affiliation:
Hospital de Clínicas de Porto Alegre
Márcia L. F. Chaves
Affiliation:
Universidade Federal do Rio Grande do Sul and Hospital de Clínicas de Porto Alegre
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Abstract

Objectives: Since 2002, the treatment with cholinesterase inhibitors (CHEIs) for Alzheimer's disease (AD) has been paid for by the public health system of the Brazilian Ministry of Health for any patient that fulfills clinical criteria established by an evidence-based guideline developed and published by the Ministry. The aim of this study was to evaluate compliance of prescription patterns to the national guideline for use of CHEIs’ in the southern Brazilian state of Rio Grande do Sul.

Methods: We created a regional expert-committee reference center to review all prescriptions of CHEIs and to send feedback to physicians whenever prescriptions without compliance to the guideline were noted. One thousand three hundred ninety-nine (1,399) CHEI prescriptions presented to the public health system from 2005 to 2007 were evaluated by an expert team of neurologists and psychiatrists. Clinical history, performance on mental status screening by Mini Mental State Examination (MMSE), Clinical Dementia Rating scale (CDR), laboratory results, and neuroimaging findings were evaluated in relation to the adherence to the national guideline's recommendations. If the prescription was rejected because of lack of adherence to the criteria of the guideline, a written response was sent by the expert committee to physicians concerning the request.

Results: The majority of the requests (n = 1,044; 75 percent) did not meet the AD guideline's criteria, either for diagnosis or for treatment, and were not granted. A diagnostic mistake was evident in 64.3 percent of cases. Findings of vascular or Parkinson's dementia or severe AD were the main reasons for rejection. Rivastigmine was the most prescribed cholinesterase inhibitor, used in 86 percent of cases. Of note was the reduction in the number of CHEIs prescriptions in the years following this intervention.

Conclusions: The public health strategy of using expert-review of prescriptions and their compliance to national guideline revealed a low rate of rational use of CHEIs for dementia. Such a strategy is relevant for protecting patients from unproven medical interventions and for reducing waste of resources.

Keywords

Brazilian guidelineCholinesterase inhibitorsAlzheimer's disease treatmentRational use of technology
Type
POLICIES
Information
International Journal of Technology Assessment in Health Care , Volume 26 , Issue 2 , April 2010 , pp. 205 - 210
Copyright
Copyright © Cambridge University Press 2010

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