Transcript Poster presentation

MTP Approach Is Effective in
Reducing
Inappropriate Medicines Use in
Hospitals
Sri Suryawati1 & Budiono Santoso2
1Center
for Clinical Pharmacology & Medicines Policy
Studies, Gadjah Mada University, Yogyakarta
2WHO – Western Pacific Regional Office, Manila
Abstract
Problem Statement: ICIUM 1997 recommended that a successful intervention should focus on a
specific problem, address the underlying factors, use a problem-solving approach, repeat the intervention,
be interactive, provide feedback to prescribers, and be followed by monitoring and supervision.
Considering the active roles of clinicians, an approach to changing prescribing practices in hospitals should
ideally be self-initiated, self-executed, and self-evaluated.
Objective: To develop, field-test, and implement a monitoring-training-planning (MTP) approach to reduce
inappropriate use of medicines for specific disease problems as defined by each hospital.
Indicators: Percentage of patients receiving particular medicines under investigation (e.g., intravenous
[IV] fluids in normal delivery, IV fluids in cranial trauma, antibiotics in normal delivery), after the hospital
has undergone several MTP meetings.
Design: The MTP approach focuses on the quality improvement process. Therefore, its effectiveness in
improving prescribing is evaluated by a before-and-after intervention without control design, in each
activity site.
Study Population: Patients with specific disease problems as defined by each hospital.
Intervention: An MTP team is set up in each hospital; each team identifies a priority problem and then
plans a series of MTP meetings involving managers and prescribers who contribute to the problem. As
there are routine technical meetings in hospitals, the MTP meetings can be easily slipped in. In brief, the
monitoring component is identifying and defining the severity of a problem; the training component is
solving the problem; and the planning component is setting the target of improvement. One problem
usually requires 3–5 MTP meetings. When the problem has been solved, the team may address another
problem.
Outcome Measures: Reduction of the percentage of patients receiving inappropriate medicines, and if
data are available, reduction of medicine costs.
Results: Following a successful field test in Indonesia involving 6 hospitals, Cambodia (13 hospitals) and
Laos (28 hospitals) have implemented the approach with good results. The use of inappropriate medicines
has been significantly reduced in both countries, including the overuse of IV fluids.
Conclusions: This experience showed that an MTP approach is effective for reducing inappropriate
medicine use in hospitals, especially among hospitalized patients. Moreover, such an approach can be
Improving drug use in hospital?
 Inappropriate prescribing practices in hospitals
 Improve prescribing in hospitalized patients is more
complicated
 Ideal mechanism:
self-initiative, self-conduct, self-assessment
by Hospital Drugs & Therapeutics Committees or
Technical Committees
 Activities should be incorporated in the existing
management system
What is MTP?
Monitoring Training
M
Planning
Description of the
recent situation
P
Setting the target
of improvement
Reflection of
previous experience
Adult learning
process
Problem solving &
scientific/reality testing
T
What is Monitoring-Training-Planning?
 Monitoring (problem identification and
measurement)
Identify the specific drug use problem, select a priority problem, determine
drug use indicator(s) and data source, identify the target of intervention.
When MTP has been running: follow up commitments from the previous
session, evaluate the result of improvement, conclude the achievement
 Training (problem solving)
Discuss the problem: why, what are the motivation, underlying factors,
etc., collect scientific information, collect supporting information, discuss
how to solve the problem, experience in the past, solve the problem,
agreements to make changes
 Planning (setting target for improvement)
Set a target of improvement, set measures to achieve target, assign who
is responsible for executing the plan, set the date for the next MTP
session, assign person(s) to collect data and present it in the next MTP
session
Flow of MTP activities
 3-4 cycles for each problem
 Simultaneous or parallel
activities
P
T
M
P
T
M
P
T
M
MTP meeting
P
T
M
P
T
M
MTP cycle
MTP implementation in hospital?
 Set up the hospital core MTP team, with supports





from Managers
Plans for MTP activities, assign MTP Group(s)
involving the targets of intervention
Plan activities in MTP Groups
Identification and involvement of internal
resources
Conducting MTP sessions
Periodic evaluations
Distribution of activities (examples)
Approach
the Director
Provide
articles
MTP team
at hospital level
MTP teams
at ward/unit
level
Provide
microbial
culture
Collect
indicators
Approach
the professor
MTP reduces inappropriate use of medicines
Some examples of achievement:
Hospital
Battambang, Cam
Kandal, Cam
Siem Reap, Cam
Kampong Cham,
Cam
Bokeo, Lao
Xayaboury, Lao
Saravane, Lao
Sleman, Indo
Panti Rapih, Indo
Karyadi, Indo
Drug use problem Achievement
Overuse of iv fluids in normal delivery in Maternity
Ward
Overuse of antibiotics in normal delivery in
Maternity Ward
Overuse of antibiotics in Traumatology Ward
Overuse of antibiotics in post-Caesarean surgery
Overuse of antibiotics in post- scrotal hernia surgery
Overuse of IV fluids in Emergency Department
Overuse of injection in malaria treatment
Overuse of antibiotics in diarrhea
Overuse of antibiotics in diarrhea in Adult &
Pediatric OPDs
Overuse of antibiotics in outpatient ARI
Overuse of antibiotics in pre- scrotal hernia surgery
70% to 59% to 0%
100% to 15%
100% to 63%
100% to 36%
100% to 33%
78% to 29% to 23%
96% to 10%
83% to 23% to 13%
67 to 12% and 33 to
2%
94% to 45%
85% to 8%
Sleman experience (Yudatiningsih et al., 2004)
1
00
80
MTP
at 24 HCs
60
Feedback
in month-14
Feedback
in month-30
Feedback
in month-45
Feedback
40
20
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 Sleman started MTP in 1999 for overuse of antibiotics in ARI, with
good results
 Skills in conducting MTP was well-adopted by health center staff
 Since then MTP has also been used for other drug use problems
 Less-frequent feedback is needed, after adopting MTP people are
responsive to feedbacks
Cambodia Experience
(Srun
& Sokhan, 2004)
 Beginning August 2001, MOH-Cambodia pilot-tested the




MTP implementation in 6 referral hospitals, focused on
drug use problems in hospitalized patients
A National Evaluation Workshop was conducted in March
2002, showing good results, 4 hospitals succeeded, 2
faced problems
Beginning October 2002, the second pilot-test was
conducted, involving the previous 6 hospitals and 6 more
hospitals.
The 2nd National Evaluation Workshop in October 2003
showed good results, most hospitals succeeded
Cambodia plans to implement MTP nation wide, as an
approach to improve the appropriate use of drugs
Discussions
 Some hospitals failed, due to: weak support frm
hospital directors, wrong selection of core MTP
Team, too many problems to solve at the same time,
or confused with other on-going projects
 Training in conducting MTP is transferring the skills
to initiate, execute, and evaluate activities in
improving drug use. In other words, it sets up
capacity building in improving drug use problems in
health facilities
 Although data are limited, it is reported that lessfrequent feedback is needed to make the
improvement sustainable. This will lessen the
workload of supervision in the health care system.
Conclusions
 MTP approach is effective for reducing
inappropriate medicine use in hospitals,
including drug use problems in hospitalized
patients.
 MTP approach is feasible to implement at
minimum cost, and feasible to be
incorporated in the existing hospital
managerial activities.
 MTP approach is promising for a nation-wide
implementation