Transcript Poster presentation

AN EDUCATIONAL INTERVENTION
ON RATIONAL PRESCRIBING OF
CHLOROQUINE IN THE
MANAGEMENT OF
UNCOMPLICATED MALARIA IN
LAGOS STATE GENERAL
HOSPITALS, NIGERIA
ABSTRACT
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Title: An Educational Intervention on Rational Prescribing of Chloroquine in the
Management of Uncomplicated Malaria in Lagos State General Hospitals, Nigeria
Authors:Aina BA, Tayo F and Taylor O
Institution: Department of Clinical Pharmacy and Biopharmacy, Faculty of Pharmacy of
the University of Lagos, Idi-Araba,Lagos, Nigeria.
Objective: To determine the impact of two modes of educational intervention on the
chloroquine prescribing pattern of prescribers in Lagos State General Hospitals
Design: Retrospective, cross sectional, before and after study with control group
Setting and Population: Ten Government General Hospitals under Lagos State
Hospitals Management Board. 100 prescriptions each for adults and children for
January-December 2000 were systematically sampled. Where there were fewer than
100 prescriptions all the prescriptions available were sampled for quantitative analysis.
Questionnaires were distributed to the prescribers in November - December 2001 for
quantitative and qualitative analysis.
Intervention: An educational intervention took place in January-February 2002.
Educational Seminar was presented in 8 out of the 10 hospitals. Among the 8 that had
seminars , 4 hospitals had educational posters while the other 4 had plastic board
describing correct doses of chloroquine left behind . Two hospitals served as control.
Result: There was significant increase in the percentage of prescriptions with correct
dose of chloroquine post intervention.There was association between intervention and
dose of chloroquine prescribed (X2 = 1276.02 and p<0.001). There was also association
between the mode of intervention and dose of chloroquine prescribed. The group with
plastic board had a significantly higher percentage of correct prescriptions than the
group with poster(paired t = 15.00, p = 0.04238 1 month post intervention)
Conclusion: Educational intervention improved the prescribing pattern of chloroquine.
Introduction/Background I
 Malaria is a preventable,treatable and curable infection. It is a
major public health problem in Nigeria. Malaria may present
as uncomplicated (non-severe) malaria or severe malaria.
Uncomplicated malaria is not life-threatening while severe
malaria is life-threatening. Treating uncomplicated malaria
promptly and correctly will prevent progression to severe
malaria.
 There are several strategies for the control of malaria but one
strategy that has been consistently used is chemotherapy.
Drugs for treating malaria in Nigeria include Chloroquine,
Amodiaquine, Sulphadoxine-pyrimethamine, Quinine,
Artemether, Artesunate, Dihydroartemisinin,
Halofantrine,Mefloquine and other combination drugs.
Chloroquine is still the cheapest and safest antimalarial and it
is still a first line drug of treatment in Nigeria.
Introduction/Background II
 Rational use of antimalaria drugs involves the appropriate
use of antimalarials at the correct/adequate dosages,
availability of good quality drugs and patient compliance
 Rational use of antimalarials can be determined by
measuring the existing practices and identifying if any
problem exists. If any problem is identified,there is need to
identify the reasons for the problem(s) and then suggest
possible actions to correct the problem(s).
 Inappropriate prescribing, the failure to prescribe drugs in
accordance with guidelines based on scientific evidence to
ensure safe, effective and economic use, is an irrational drug
use behaviour.
 Increased benefits from chloroquine or a slowdown of
progression to resistance could be achieved by improving
prescribing practice, drug quality and patient compliance
Objectives/Study Questions
 To determine the prescribing pattern of
chloroquine in the management of non
severe malaria in Lagos State General
Hospitals.
 To determine the factors that influence the
observed prescribing pattern of chloroquine
in Lagos State General Hospitals.
 To determine the impact of two modes of
educational intervention on chloroquine
prescribing pattern of prescribers in Lagos
State General Hospitals.
Methods I
 Antimalarial prescriptions under the “Eko Free Malaria
Programme” were studied using the WHO 1993 guidelines on
‘How to investigate drug use in health facilities’. Certain core
prescribing indicators, complimentary drug use indicators and
specific chloroquine indicators were analysed.
 These indicators include
 Average number of drugs per encounter
 Average number of injections per encounter
 Percentage of encounters with injections
 Percentage of encounters with dipyrone
 Average drug cost per encounter
 Percentage of encounters with the different antimalarials
and other drugs prescribed with the antimalarials
 Percentage of encounters with the different chloroquine
dosage forms
Methods II
 Percentage of encounters with either correct, overdose
or underdose of chloroquine
 100 prescriptions each for adults and children were
systematically sampled retrospectively in all the ten
General Hospitals in Lagos State for the month of
January to December 2000. Where there were a fewer
than 100 prescriptions in a particular month, all the
prescriptions available were sampled for quantitative
analysis.
 Questionnaires were designed and distributed from
November to December 2001 to the prescribers that
manned the Out Patient (OPD) section of these
hospitals to corroborate the baseline data from the
prescription survey and to address the KAP of the
prescribers which influenced their prescribing pattern
and this information was used to design intervention
Methods III
 Educational intervention took place in January to February
2002. Educational seminars were presented in 8 out of the
10 hospitals. 2 Hospitals served as control.Among the 8
hospitals that had the seminars, 4 hospitals had
educational posters describing the correct doses of
chloroquine for the different age groups and having
pictures left behind whereas the other 4 had a plastic
board printed with the correct doses.
 Post intervention prescribing pattern was carried out
retrospectively after 1, 3, 6 and 12 months to determine
short, intermediate and long term impact of the
intervention.
 Chi square distribution, ANOVA , Kruskal-Wallis test and
Paired t test were used to test for association or
independence or differences of some indicators. Results
were considered to be statistically significant if p < 0.05
 Data were analysed using Epi6 Info statistical software
Results I
 Chloroquine was widely prescribed and it was the first
choice of most prescribers not just because it is a first line
drug or the drug that is available in the hospital but
because it was believed to be effective (73.1 %)
 Underdose was predominant when injection chloroquine
only was prescribed (prescriptions & questionnaires).
 Correct dose was predominant when tablet chloroquine
only was prescribed (prescriptions & questionnaires).
 Underdose prescribing was more common for children
than for adults probably due to different age groups(about
4) for children (prescriptions & questionnaires).. It may not
be easy to recall the different doses for these different age
groups. There is only one dose for adults.
 There was association between intervention and dose of
chloroquine prescribed (X2 = 1276.02 , p< 0.001). There
was association between the mode of intervention and
dose of chloroquine prescribed (X2 = 429.08 and p<
0.001).
Results II
 There was significant increase in the percentage of
prescriptions with correct dose of chloroquine post
intervention, 45.3%, 72.3%, 70.4%, 65.3% and
68.6 % at pre-intervention, 1month, 3 months, 6
months and 12 months post intervention
respectively
 The group with plastic board had a significantly
higher percentage of prescription with correct dose
than the group with poster
 There was no statistically significant difference in
percentage of correct prescriptions between 1
month post intervention and throughout the
duration of study post intervention hence it is
hereby implied that the intervention was sustained
Implication/Conclusion
 Educational intervention improved the prescribing pattern of
chloroquine in Lagos State General Hospitals.
 There is still room for improvement since 100% correct dose
was not achieved.
 There is need to stress on limiting the use of injection to
patients that can not swallow or that are vomiting
 In order to sustain/maintain correct prescribing habit there
may be need to
 reward prescribers or health facilities that have higher
correct prescribing habit
 have a managerial intervention such as structured drug
order forms and /or course-of-therapy packaging
 have reminders sent to prescribers and pharmacists
 have a prescriber and a pharmacist as facilitators or
monitoring team in each health facility