Transcript Oral Presentation 1

REDUCING ANTIBIOTIC OVERUSE FOR
ACUTE RESPIRATORY TRACT INFECTIONS
WITH SMALL- GROUP EDUCATIONAL
INTERVENTION
Munawaroh S1, Sunartono H2, Suryawati S3
1Yogyakarta Provincial Health Office;
2Sleman District Health Office;
3Department of Clinical Pharmacology, Gadjah Mada University, Indonesia
BACKGROUND
 MOH of Indonesia has developed Standard Treatment
Guidelines (STG) in 1983, and a diagnosis flow chart for ARIs
for Health Center (HC) level in 1991.
 The excessive use of antibiotics in treating simple ARI in HCs
demonstrates that the STG and flow chart are not followed.
 Many evidences showed inappropriate treatment for ARI,
including indiscriminate use of antibiotics.
 Previous studies showed that Small-Group Educational and
Feedback are effective in improving drug use.
Special efforts are needed to reduce the overuse of antibiotics
OBJECTIVES
General
To improve the quality of care of ARI patients (adult and
child) in HCs by applying Small-Group Discussion
(SGD).
Specific
To improve specific prescribing practices in ARI,
including:
 reducing the overuse of antibiotics
 reducing the overuse of antihistamine
 reducing the number of drugs per encounter
To compare the effectiveness of Small-Group
Discussion, with-and without feedback (FB), in
improving ARI treatment.
METHODS (1)
Location
 HCs in Bantul District, Indonesia
Subject
 Paramedics (target intervention) and doctors (as resource
person) in HCs
Design
 Randomized controlled study with pre and post evaluation
 18 HCs were randomly assigned into:
 6 HCs underwent SGDs followed by FB meetings in 2
consecutive months (group A)
 6 HCs underwent SGDs without FB meetings (group B)
 6 HCs acted as controls (group C)
METHODS (2)
Design
Group A (6 HCs)
SGD
18 HCs
FB1
FB2
Group B (6 HCs)
Randomize
d
SGD
-
Analysis
-
Group C (6 HCs)
C O N T R O L
FGD = Focus Group Discussion
SGD = Small Group Discussion
FB = Feedback
Timeline
FGD
Baseline
Para
Post
SGD
Post
FB1
Post
FB2
METHODS (3)
 Prescribing Survey
 100 paramedics’ & 100 doctors’ prescriptions per HC per month at each
time point (total 7 time points):
 Pre-1, pre-2, pre-3 (3, 2, and 1 months before the intervention)
 Para (preparation, 1 month)
 post SGD, post FB1, post FB2 (1 month, 2 months, 3 months after the
intervention, respectively)
 Total amount of sample: 100 prescriptions x 7 time points x 2 providers
x 18 HCs = 25,200 prescriptions
 Data presentation
 Percentage of patients with ARI receiving antibiotics
 Percentage of patients with ARI receiving antihistamines
 Average number of drugs per prescription
 Statistical analysis
 t-test to compare reduction of pre vs post intervention
 Anova to compare reductions of Group A vs Group B vs Group C
RESULT (1): REDUCTION OF ANTIBIOTICS USE
% patients receiving
antibiotics
% patients receiving
antibiotics
Paramedics’ prescriptions
100
SGD FB
1
80
100
FB2
60
40
40
20
20
0
0
Pre-2
Pre-3
para
post 1
SGD FB
1
80
60
Pre-1
Doctors’ prescriptions
post 2
post 3
pre-1
pre-2
Group A (SGD & FB)
pre-3
para
post1
Group B (SGD)
FB2
post 2
post 3
Group C (Control)
RESULT (2): REDUCTION OF ANTIHISTAMINE USE
% patients
receiving
antihistamine
Paramedics’ prescriptions
% patients
receiving
antihistamine
Doctors’ prescriptions
100
100
SGD FB1 FB2
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
Pre-1 Pre-2 Pre-3
para post 1 post 2 post 3
SGD FB1 FB2
90
Pre-1
Pre-2
Pre-3
Group A (SGD & FB)
para
post 1
Group B (SGD)
post 2
post 3
Group C (Control)
RESULT (3):
NUMBER OF DRUG
Doctors’ prescriptions
Paramedics’ prescriptions
3,8
3,8
SGD FB1 FB2
3,6
3,6
3,4
3,4
3,2
3,2
3
3
2,8
2,8
2,6
2,6
Pre-1
Pre-2
Pre-3
para
post 1
post 2
post 3
SGD FB1
Pre-1
Pre-2 Pre-3
Group A (SGD & FB)
Group C (Control)
para
FB2
post 1 post 2 post 3
Group B (SGD)
DISCUSSIONS (1)
Interesting finding
Although the target of intervention was
paramedics, surprisingly the doctors’
prescriptions also improved.
It means that there were double impacts
of posing the doctors as resource
persons.
DISCUSSIONS (2)
The key factors to the success of the
intervention are:
1. Handy printed material, question & answer format,
problem-based
2. Interactive, problem-solving Small-Group Discussion
3. Feedbacks showing individual achievement
4. Facilitators are recruited from the target of intervention
5. Doctor as resource person is a strategy in improving
doctor’s behavior
CONCLUSIONS
 SGD followed by FBs reduced the overuse of
antibiotics and other unnecessary drugs in the
treatment of ARI in adult & children in HC level.
 SGDs among paramedics with a trained paramedic
facilitator and a doctor as a resource person
provided fora for paramedics to discuss and solve
problems in ARI treatment. Such forum would be
also ideal for other medical problems.
 Repeating intervention is necessary to reinforce the
agreement reached in previous discussions to
maintain the impact of the intervention.
 Further studies are needed to find out sustainability
of long term impact.
“Terima Kasih”
Thank you