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Effectiveness of Quality Use of Medicines (QUM) Programs and Strategies in Saudi Arabia: A Narrative Review
Authors Aldhafeeri F , Wilson A, Larkin S, Aldhafeeri FM
Received 29 October 2024
Accepted for publication 8 February 2025
Published 24 March 2025 Volume 2025:17 Pages 87—96
DOI https://doi.org/10.2147/DHPS.S503383
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 4
Editor who approved publication: Dr Rajender Aparasu
Fahad Aldhafeeri,1 Andrew Wilson,1 Shaun Larkin,1 Faisal Murayh Aldhafeeri2
1Leeder Centre for Health Policy, Economics and Data, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; 2Hafer Al Batin Health Cluster, Ministry of Health, Hafer Al Batin, Saudi Arabia
Correspondence: Fahad Aldhafeeri, Email [email protected]
Background: The high prevalence of chronic diseases, workforce challenges, and growing polypharmacy adversely impact the quality use of medicines (QUM) and health outcomes in Saudi Arabia (SA). The SA Ministry of Health (MOH) has initiated several programs and policies to enhance QUM including a National Medication Safety Program, national clinical guidelines, and technology-based strategies.
Objective: To assess the published literature on the range, quality, and effectiveness of QUM methods in the SA health system.
Methods: Comprehensive search of electronic databases Scopus, Medline, and PubMed for papers reporting evaluation of QUM interventions or programs in SA.
Results: QUM programs involving medication reconciliation, interventions by hospital pharmacists, antibiotics stewardship, technology and staff training are the most commonly used programs reported in SA. Evaluations of several QUM interventions found a significant positive impact on health outcomes, prescribing patterns, chronic disease management, medication safety, and healthcare costs. Medication reconciliation programs reduced discrepancies by up to 20% in some studies. Hospital pharmacist interventions showed high acceptance rates (up to 92%) and improved medication safety. Antibiotic stewardship programs effectively reduced antimicrobial use and costs. Health information technology implementations like electronic health records (EHR), and computerized physician order entry (CPOE) showed mixed results but generally improved medication safety and efficiency. Staff training initiatives enhanced healthcare professionals’ knowledge and skills in medication management.
Conclusion: While SA has national QUM policies and programs, and evidence that individual QUM interventions have significant positive local impact, more large-scale, multi-center studies are needed to provide a comprehensive view of QUM practices. More rigorous evaluations of existing programs and expansion of the range of QUM programs to align with international ones could further improve medication safety and patient outcomes in Saudi Arabia.
Keywords: quality use of medicines, QUM, medication safety, rational use of medicines, Saudi Arabia, medication reconciliation, stewardship programs, technology
Introduction
The healthcare system and other sectors in Saudi Arabia (SA) have made significant progress particularly since a national transformation program was launched in 2016.1 A revision process commenced in 2019 to update and modify the national medicines policy (NMP), aiming at ensuring a secure supply of quality medicines, reshaping prescribing, and procurement habits, and promoting the pharmaceutical industry.2 One of the key features of the NMP is to create a cohesive structured regulatory framework to manage the provision of effective healthcare including quality use of medicines (QUM). There are different regulatory bodies responsible for developing and evaluating the implementation of medication management and pharmaceutical policies, and one of the aims of the NMP is to follow a well-coordinated approach and avoid duplication of efforts. Saudi Food and Drug Authority (SFDA) has been the main regulator ensuring that safe, and effective pharmaceutical products are marketed, while the Ministry of Health (MOH) is responsible for regulating and licensing providers of healthcare. Other regulatory bodies are involved in the training and practice policies of pharmacists and in regulating the pharmaceutical industry. Table 1 describes the responsibilities of seven institutions as defined in the NMP.2
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Table 1 Regulatory Institutions in SA and Their Responsibilities to Medication Management and QUM |
SA is also experiencing growing challenges due to the increasing prevalence of chronic diseases including diabetes, cardiovascular diseases, and obesity. Chronic diseases account for 74% of deaths in SA, with associated morbidity and economic burden.10 Clinical management of chronic diseases impacts QUM with polypharmacy, particularly among older adults, increasing the risk of adverse drug reactions, drug interactions, inappropriate treatment, and medication non-adherence.11 Poor knowledge among patients about their conditions and the proper use of their medications has been reported by some researchers. For example, a survey of people with diabetes mellitus found that more than half had insufficient knowledge about diabetic retinopathy contributing to sub-optimal self-management.12
Medication errors (MEs) continue to occur in healthcare settings in SA at an unacceptable level. A recent systematic review and meta-analysis estimated the total rate of MEs in SA hospitals to be 44 per 100 prescriptions, which is considered high and raises patient safety concerns.13 Reviews indicate that MEs occur in diverse healthcare settings, with most errors happening due to factors such as high workload, fatigue, and inadequate staffing.14 The aging of the population and rapid population growth both contribute to pressure on the health system capacity.15 In addition to a specific shortage of trained pharmacy professionals, QUM is also impacted by healthcare practitioners not consistently following evidence-based guidelines for medication use.16
The Saudi MOH has recognized the need for improved health outcomes and patient safety and has increased its efforts to promote QUM. The MOH launched a National Medication Safety Program in 2013, which aims to improve medication safety in all pharmacy institutions thereby by decreasing medicine-related harms, improving morbidity and mortality, and reducing adverse event-related healthcare costs.17 The Saudi Center for Evidence-Based Healthcare has developed national clinical guidelines to provide information on pharmacological treatments for specific diseases and conditions.18 Generic medicines prescribing is still not common in SA, and is relatively low in comparison to other countries.19 Another MOH measure allows pharmacists to perform generic substitution which could help promote the cost-effective use of medications. The MOH also introduced the use of information systems to support medication management and use processes.20 Other medication therapy management programs like medication reconciliation and medication review are used in some SA healthcare settings, to help avoid polypharmacy and drug-related problems (DRPs) among patients.21,22 In addition, the “Choosing Wisely” campaign was launched to support healthcare providers and patients in discussing their options about healthcare services and diagnostic tests with the aim of reducing the risk of harm and service duplication.23
However, while there are strong policy and program settings, there is limited literature on the implementation and effectiveness of the QUM policies and program limitations that could affect their implementation in the Saudi healthcare system.18
A QUM initiative or program is deemed useful and successful when it results in improved health outcomes and quality care, aids healthcare professionals in decision-making, and acknowledges the community’s diversity. A better understanding of these programs, their effectiveness, and their limitations would help to identify whether the SA medication management system incorporates the most effective QUM programs implemented internationally. In this review, we summarize the published studies evaluating QUM strategies in Saudi hospitals to provide insights into the overall effectiveness of the SA’s QUM programs, identify any gaps, and consider areas for improvement.
Materials and Methods
A comprehensive search for relevant studies was done using the following electronic databases: Scopus, Medline, and PubMed. The search strategy combined the keywords: “quality use of medicines” OR “QUM” OR “rational use of medicines” OR “appropriate use of medicines” OR “medication safety” OR “medication reconciliation” OR “medication review” OR “stewardship” AND “strategy” OR “initiative” OR “programs” AND “Saudi Arabia”. The search was limited to peer-reviewed articles written in English and Arabic. The search results showed 616 articles out of which 93 were included after reading the abstract. The total number of articles eventually included in this review after reading the full texts was 17 articles and they are those reporting measurable outcomes and a clear methodology to evaluate the impact of a program or initiative implemented in an SA healthcare setting to achieve QUM and safe use of medications. A formal systematic review was not undertaken as the intent was to describe the range and scope of evaluation activity rather than a quantitative estimate for a specific topic.
Findings and Discussion
Saudi QUM programs share similarities with QUM programs implemented internationally but exhibit some unique characteristics and areas for improvement. International QUM programs include medication reconciliation,24–28 hospital pharmacist interventions,29–36 transition of care programs,37–40 staff education,41–43 interprofessional collaboration,44–47 antibiotics programs48–50 and the adoption of electronic systems and technologies.51–61 Consistent with international experience, these initiatives in SA have shown promising results in improving patient safety and medication use. This review of published studies evaluating the impact of programs and initiatives in Saudi healthcare settings on QUM, and it indicates the range includes medication reconciliation, hospital pharmacist interventions, antibiotic stewardship programs, implementing health information technology (IT) systems and staff training.
Medication Reconciliation
Medication reconciliation entails the comprehensive review of patients’ medications at different levels of patient care.62 It involves preparing a complete list of the patient’s current medications which should be updated whenever there is an addition or change to medications.63 Medication reconciliation programs in SA have been evaluated in major hospitals in some studies (Table 2). These programs have demonstrated effectiveness in reducing medication discrepancies and improving patient safety. While studies varied methodologically (retrospective or prospective) and sizes (single-center or multi-center), all studies indicate the value of medication reconciliation for improving patient safety by identifying medication discrepancies and reducing their incidence. Pharmacist involvement in medication reconciliation, standardized processes, multidisciplinary teams, and follow-up after transitions of care appeared to be among the most impactful interventions for reducing medication discrepancies and related problems in the Saudi healthcare settings. In addition, the combination of multiple interventions as part of a comprehensive program seemed to yield the best results.
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Table 2 Studies Evaluated Medication Reconciliation Programs in SA Healthcare Settings |
These results align with international findings that highlight the importance of medication reconciliation in improving patient safety. Recent international studies have examined medication reconciliation conducted at different stages or transitions in care, including admission,24,25 discharge,25–27 and outpatient settings.28 However, Saudi studies appear more limited in scope and number, suggesting implementation is not yet widespread across the healthcare system. The reported SA’s programs appear more general compared to more standardized procedures in the international programs, which cover a broader range of outcomes like medication adherence26 and clinical outcomes.25 QUM in SA may benefit from expanding its medication reconciliation initiatives and conducting more comprehensive studies on their effectiveness across various healthcare settings.
Hospital Pharmacist Interventions
The impact on MEs and QUM of hospital pharmacist services in SA has been evaluated in some studies (Table 3). The published research suggests that involving hospital pharmacists in all aspects of medication use and patient care could help improve patient safety and achieve QUM. Saudi pharmacists are involved in various aspects of patient care, including medication reconciliation, clinical interventions, and transition of care services. Significant positive impacts of pharmacist interventions on medication appropriateness, dosing, and clinical outcomes have been demonstrated in all studies, despite using different approaches. The broadest impact on reducing inappropriate prescribing was seen by Najjar et al (2018) in which the combined educational and clinical interventions were used.66 The results of the studies reviewed are comparable to international studies that consistently demonstrate the value of pharmacist involvement in patient care. For example, such interventions in other countries have been also associated with a high acceptance rate of pharmacists’ interventions, resulting in a substantial improvement in medication use among cancer patients undergoing pain management therapy,29 and patients admitted to general surgical wards.30 However, international literature describes more specialized pharmacist-led programs, such as comprehensive medication management for specific disease states, while Saudi studies mention fewer such specialized interventions. Adoption of more comprehensive pharmacist care models, such as those targeting patients with multiple chronic conditions or high-risk medications, could enhance Saudi programs.
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Table 3 Studies Evaluating Hospital Pharmacist’s Interventions on QUM Parameters in SA |
Antibiotics Stewardship
Some studies have evaluated the implementation and effectiveness of antibiotic stewardship programs (ASPs) in SA hospitals (Table 4). The effectiveness of ASPs in reducing antibiotic use has been demonstrated in these studies in hospital and ICU settings. ASPs in Saudi hospitals have shown promising results in reducing antibiotic use, costs, and healthcare-associated infections, but the impacts on costs and clinical outcomes were more variable. All studies used pre-post designs, but there were key differences in the study setting, duration, and measured outcomes. The multidisciplinary approach that involves leadership was highlighted as important for successful ASP implementation across the studies.
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Table 4 Studies Evaluating Antibiotic Programs on QUM in SA |
ASPs implemented internationally and in SA share common goals of reducing antimicrobial resistance and improving patient outcomes. However, the literature on ASPs in SA is limited. Internationally, ASPs have been more extensively studied and implemented, with a broader range of interventions and reductions in inappropriate antibiotic prescribing for urinary tract infections,73 decreased antimicrobial use in nursing homes,50 and improvements in the appropriateness of antibiotic prescriptions in teaching hospitals.48 SA may benefit from adopting some of the broader strategies implemented in other countries and conducting more rigorous evaluations of their ASPs to improve antibiotic stewardship practices further.
Information Technology-Based Programs
IT has been part of different initiatives and interventions aimed at improving medication management and achieving QUM in SA. The adoption of electronic health records (EHR), computerized physician order entry (CPOE) and the introduction of Wasfaty service are examples of technology-based QUM programs implemented in SA with evidence they are effective (Table 5). Different parameters were assessed in the studies including medication errors, cost, and DRPs so an overall conclusion is unclear. While generally showing benefits, they also highlight areas for continued improvement, particularly in pediatric care.
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Table 5 Studies Evaluating the Impact of Implementing Different Types of Technologies as Part of SA QUM Programs |
On the other hand, international more diverse technologies have been studied like clinical decision support systems,51,53 mobile applications for emergency situations,56,57,78 telehealth services for medication management,59,60 and bar-code medication administration technologies.79 There would appear to be opportunities and potential benefits for QUM in SA from the trialing of these other decision support tools and mobile applications for medication management. In addition, more studies are required to identify the limitations of the systems and the optimal error prevention strategies using these technologies.
Staff Training
Well-informed and trained professionals play an essential role in improving the QUM. Staff training and continuous education is the key factor in ensuring that healthcare professionals have the requisite knowledge and the skills to practice effectively and safely. The published research showed QUM knowledge among SA’s healthcare practitioners including pharmacists and physicians could be improved through QUM training programs (Table 6).
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Table 6 Studies Evaluating Impact of Training and Educational Programs on QUM in SA |
However, the literature on staff training programs in SA appears limited compared to the staff training programs implemented internationally which tend to be more varied and extensively evaluated. For instance, international studies have demonstrated the effectiveness of training physicians in electronic prescribing systems,41 providing pharmacists with training in motivational interviewing to improve patient adherence,42 and implementing standardized training for pharmacists and pharmacy technicians in gathering admission medication history.43 This suggests that SA could benefit from expanding and systematizing its training initiatives and conducting more comprehensive evaluations to further improve healthcare professionals’ skills and knowledge in medication management.
Limitations
This review included only 17 articles that reported measurable outcomes with most of the studies conducted in single Saudi healthcare settings, which could limit the generalizability of the data to the entire system. As the review included only published studies, other QUM programs may have been overlooked.
Other Areas for Improvement
As noted above, there is a range of areas for potential improvement in QUM measures in SA and specifically there is a need for larger, multi-center studies to provide a more comprehensive view of QUM practices and their implementation, and conducting more rigorous evaluations of existing programs, including cost-effectiveness analyses and long-term outcome studies.
Conclusion
While not extensive, the published research and reports on the implementation of QUM programs in SA indicate a range of QUM strategies were associated with improvements in terms of improving the prescribing quality, enhancing the management of chronic diseases, and most importantly enhancing medication safety. Key initiatives such as medication reconciliation, hospital pharmacist interventions, antibiotic stewardship programs, information technology-based systems, and staff training have all contributed to improvements in patient care. While there is a well-articulated national QUM framework in the Saudi NMP, it is not clear from current published research the extent to which QUM measures have been systematically implemented across the SA healthcare system. The published research suggests there would be significant benefits to patients, quality of care, and health care costs in systematic implementation. Areas where SA’s QUM programs could be enhanced to align more closely with international best practices including implementing more specialized pharmacist-led programs, expanding the range of technology-based interventions, developing more comprehensive staff training programs, and increasing focus on patient education and engagement. In addition, there is a need for more extensive research and monitoring of the effectiveness of programs at a national level.
Disclosure
The author(s) report no conflicts of interest in this work.
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