Increasing rational use of cholinesterase inhibitors for Alzheimer's disease in Brazil: public health strategy combining guideline with peer-review of prescriptions.
OBJECTIVE
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.
Picon
Paulo Dornelles
PD
Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grand do Sul, Brazil. paulopicon@gmail.com
Camozzato
Ana Luiza
AL
Lapporte
Elaine A
EA
Picon
Rafael V
RV
Moser Filho
Humberto
H
Cerveira
Maria Otília
MO
Chaves
Márcia L F
ML
D000544:Alzheimer Disease / Q000188:drug therapy*; D001938:Brazil; D002800:Cholinesterase Inhibitors / Q000627:therapeutic use*; D019317:Evidence-Based Medicine; D017408:Guidelines as Topic; D006801:Humans; D010380:Peer Review; D011634:Public Health
D002800:Cholinesterase Inhibitors