Transcript Poster presentation

IMPROVING COMMUNITY DRUG USE
FOCUSING ON HOSPITAL OUT-PATIENT
THROUGH PEER REVIEW AND
IMPLEMENTATION OF GUIDELINES FOR
ARI TREATMENT
PH Dung, NTK Chuc and Dennis Ross Degan
Funding by ARCH (Harvard University)
ABSTRACT
IMPROVING COMMUNITY DRUG USE FOCUSING ON HOSPITAL OUT-PATIENT THROUGH PEER REVIEW AND
IMPLEMENTATION OF GUIDELINES FOR ARI TREATMENT
Pham Huy Dung, Nguyen Thi Kim Chuc, Dennis Ross Degan and al.
Hanoi Medical University
Problem Statement: Medical prescription for ARI has been observed not in accordance to guidelines in various
outpatient clinics of various community (district) hospitals. This situation makes community drug use for the
treatment of ARI irrational. Some previous study suggests that such irrational medical prescription for ARI is
closely linked to unhealthy behavior of physicians
Objectives: The study aims at changing the behavior of physicians in their prescription practice for more rational
treatment of ARI
Design: Pre post evaluation of the intervention with matched pairs intervention-control
Setting and Population: Three provinces (Ha Tay, Hai Duong and Nam Dinh) were selected for the study. All district
of these 3 provinces were matched into pairs and 9 matched pairs were chosen randomly. From these pairs half
was for the intervention group and half was for the control group.
Intervention: (1) Involving physicians in a process of guideline development to be used later by them (2) Peer
review and supervision of guideline implementation (3) Involving ARI program officers and health/ drug
inspectors in the intervention and evaluation
Outcome measures: KAP of involved physicians (Knowledge: % of interviewed physicians giving the right answer to
tested questions for their knowledge; attitude: % of interviewed physicians stating that they prescribe
according the guidelines; and practice: % of encounters to be prescribed according to guidelines)
Results: (1) Knowledge: from 62% to 70% in the intervention group versus from 78% to 42% in the control group (2)
Attitude: from 60% to 80% in the intervention group versus from 73% to 32% in the control group (3) Practice:
The rate of encounters with right indication increased from 49.5% (731/1,438) to 65.8% (1,064/1,618) in the
intervention group versus a decrease from 64.2% (771/1,201) to 52.6% (562/1,089) in the control group; the
rate of encounters with right kinds of antibiotics increased from 52.1% (381/731) to 86.8% (923/1,064) the
intervention group versus an increased rate only from 58.5% (450/771) to 68.3% (385/562) in the control group
Conclusions: Intervention involving physicians in a process of local guideline development and peer supervision
with the assistance from the National ARI project and drug administrators could improve the prescription
practice for more rational treatment of ARI. This result could be a research evidence for drug/ health policy
makers and the National ARI project to encourage the process for more rational drug use in ARI treatment
Study funded by: ARCH (Harvard Universty)
BACKGROUND & SETTING
 Low compliance to guidelines for the treatment of ARI at
district outpatient wards -> irrational community drug
use
 Intervention for changing prescription behavior in 9
(randomly) selected district outpatient wards of 3
representative provinces (Hai Duong, Ha Tay and Nam
Dinh) of the rural agricultural region -> improving
compliance to guidelines
 Average district population: 200,000/ Population under 5:
about 12,3%/ of the population/ ARI incidence: 6
episodes / child / year/ Number of ARI cases attending
one outpatient ward per month: around 60-90 (2-3 cases
per day)/ Average number of physician in each outpatient
ward: 3-4 physicians/ Almost all physicians had some
retraining in ARI diagnosis and treatment
STUDY AIMS
 To enhance awareness of
physicians about ARI treatment
guidelines
 To make them more confident for
them to use the guidelines
 To improve their practice on
analysis of prescription encounters
from their clinics
METHODS 1: INTERVENTION
• Involving physicians in a process of
guideline development to be used
later by them (on the study of national
guidelines)
• Peer review and supervision of
guideline implementation
• Involving ARI program officers and
health/ drug inspectors in the
intervention and evaluation
METHODS 2: EVALUATION
• Pre-post intervention evaluation with randomly
selected matched pair controls
• Indicators for evaluation: Knowledge: % of
interviewed physicians giving the right answer to
tested questions for their knowledge/ Attitude: %
of interviewed physicians stating that they
prescribe according the guidelines/ Practice: % of
encounters to be prescribed according to
guidelines)
• Matched-pair control and intervention districts on
indicators: % of right prescription according to
diagnosis/ % of right antibiotic prescription/
Number of drug items per prescribed encounter/
Cost per prescribed encounter VN$
RESULTS 1: Knowledge scores
 Intervention group
 Before intervention:
 After intervention:
47.7 + 13.3
73.1 + 22.3
 Control group
 Before intervention:
 After intervention :
69.0 + 22.6
68.0 + 18.4
RESULTS 2: Attitude (% of interviewees expressing
the willingness to use guidelines)
 Intervention
 Before intervention:
 After intervention:
60%
80%
 Control
 Before intervention:
 After intervention:
73.9%
32.0%
RESULTS 3: Practice (% antibiotics in
non-pneumonia)
 Intervention
 Before intervention:
 After intervention:
99.7
66.2
 Control
 Before intervention:
 After intervention:
99.2
99.1
RESULTS 4: Practice (% right
antibiotics)
 Intervention
 Before intervention:
 After intervention:
25.0
56.9
 Control
 Before intervention:
 After intervention:
36.6
35.2
RESULTS 5: Average cost per
encounter
 Intervention
 Before intervention:
 After intervention:
9441 VN$
6868 VN$
 Control
 Before intervention:
 After intervention:
8368 VN$
11642 VN$
SUMMARY
Intervention Control
BI
AI
BI
AI
Knowledge (scores)
47
73 69
68
Attitude (% acceptance) 60
80 73
32
Practice
 Antibiotics in non pneumonia%
97
66 99
99
 Right antibiotics%
25
57 36
35
 Cost (VN$)
9441
6868 8368 11642
CONCLUSION AND POLICY IMPLICATIONS
Intervention involving physicians in a process of
(1) Local guideline development
(2) Peer supervision with the assistance of the
National ARI project and drug administrators
could improve the prescription practice for more rational
treatment of ARI.
This result would be a research evidence for drug/ health policy
makers and the National ARI project to encourage this
process for more rational drug use in ARI treatment