Hostname: page-component-586b7cd67f-r5fsc Total loading time: 0 Render date: 2024-11-23T01:13:50.890Z Has data issue: false hasContentIssue false
  • English
  • Français

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
Get access Rights & Permissions [Opens in a new window]

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

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. Birks, J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev. 2006;1:CD005593.Google Scholar
2. Birks, J, Grimley Evans, J, Iakovidou, V, Tsolaki, M. Rivastigmine for Alzheimer's disease. Cochrane Database Syst Rev. 2000;4:CD001191.Google Scholar
3. Birks, J, Harvey, RJ. Donepezil for dementia due to Alzheimer's disease. Cochrane Database Syst Rev. 2006;1:CD001190.Google Scholar
4. Caltagirone, C, Bianchetti, A, Di Luca, M, et al. Guidelines for the treatment of Alzheimer's disease from the Italian Association of Psychogeriatrics. Drugs Aging. 2005;22 (Suppl 1):1–26.CrossRefGoogle ScholarPubMed
5. Costa, AF, Picon, PD, Amaral, KM, Chaves, MLF. Doença de Alzheimer. In: Picon, PD, Beltrame, A, eds. Protocolos Clínicos e Diretrizes Terapêuticas: Medicamentos Excepcionais. Brasília: Ministério da Saúde; 2002:167–180.Google Scholar
6. Dartigues, JF, Douet, C, Rey, M, et al. Prescription of cholinesterase inhibitors in Alzheimer's disease in France in 2000–2001: An assessment of compliance with national guidelines for diagnosis and follow-up. Rev Neurol (Paris). 2005;161:957–962.CrossRefGoogle ScholarPubMed
7. Doody, RS, Stevens, JC, Beck, C, et al. Practice parameter: Management of dementia (an evidence-based review) Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001 56:1154–1166.CrossRefGoogle Scholar
8. Galvin, JE, Pollack, J, Morris, JC. Clinical phenotype of Parkinson disease dementia. Neurology. 2006;67:1605–1611.CrossRefGoogle ScholarPubMed
9. Kavirajan, H, Schneider, LS. Efficacy and adverse effects of cholinesterase inhibitors and memantine in vascular dementia: A meta-analysis of randomised controlled trials. Lancet Neurol. 2007;6:782–792.CrossRefGoogle ScholarPubMed
10. Knopman, DS. Dementia and cerebrovascular disease. Mayo Clin Proc. 2006;81:223–230.CrossRefGoogle ScholarPubMed
11. Krug, BC, Schwartz, IVD, de Oliveira, FL, et al. The management of Gaucher disease in developing countries: A successful experience in Southern Brazil. Public Health Genomics. 2009 [Epub ahead of print].CrossRefGoogle Scholar
12. Loy, C, Schneider, L. Galantamine for Alzheimer's disease and mild cognitive impairment. Cochrane Database Syst Rev. 2006;1:CD001747.Google Scholar
13. Malone, DM, Lindesay, J. Cholinesterase inhibitors and cardiovascular disease: A survey of old age psychiatrists’ practice. Age Ageing. 2007;36:331–333.CrossRefGoogle ScholarPubMed
14. Nakamura, S. A guideline for the treatment of dementia in Japan. Intern Med. 2004;43:18–29.CrossRefGoogle ScholarPubMed
15. National Institute for Clinical Excellence. Guidance on the use of Donepezil, Rivastigmine and Galantamine for the treatment of Alzheimer's disease. London: NICE; 2001.Google Scholar
16. NICE Technology Appraisal. Donepezil, galantamine, rivastigmine (review) and memantine for the treatment of Alzheimer's disease. NICE technology appraisal no. 111. 2006. www.nice.org.uk/TA111.Google Scholar
17. Purandare, N, Swarbrick, C, Fischer, A, Burns, A. Cholinesterase inhibitors for Alzheimer's disease: Variations in clinical practice in the north-west of England. Int J Geriatr Psychiatry. 2006;21:961–964.CrossRefGoogle ScholarPubMed
18. Raina, P, Santaguida, P, Ismaila, A, et al. Effectiveness of cholinesterase inhibitors and memantine for treating dementia: Evidence review for a clinical practice guideline. Ann Intern Med. 2008;148:379–397.CrossRefGoogle ScholarPubMed
19. Sauer, J, Howard, R. The impact of journal advertisements on prescribers of cholinesterase inhibitors. Int J Geriatr Psychiatry. 2002;17:976–978.CrossRefGoogle ScholarPubMed