Transcript Poster presentation

SMALL GROUP DISCUSSION AMONG
PARAMEDICS AT HEALTH CENTER LEVEL TO
IMPROVE ADHERENCE TO STANDARD
TREATMENT GUIDELINES OF ACUTE
RESPIRATORY TRACT INFECTIONS
Sri Hidayati, Siti Munawaroh
INRUD Yogya/INDONESIA
ABSTRACT








Problem Statement: Acute respiratory infection (ARI) is the leading cause of morbidity and mortality of
children under five years old in Indonesia, despite the availability of standard treatment guidelines
(STGs) and a flow chart of diagnosis and treatment of ARI in health centers in Indonesia. Previous
studies showed that treatment of ARI at the health center level did not always comply with the STGs, as
indicated by the use of nonstandard drugs such as antibiotics, antihistamines, corticosteroids, and
phenobarbital.
Objective: To reduce the use of nonstandard drugs for under-five ARI patients.
Design: Randomized controlled study.
Setting and Study Population: Twelve health centers from two districts were randomly assigned to
receive the intervention (Group A), and another 12 from these districts acted as controls (Group B).
Interventions: A two-hour small group discussion (SGD) on the ARI STGs was conducted in each health
center in Group A, facilitated by a senior paramedic who was trained by the study team to facilitate such
a discussion. Agreement on how to treat ARI in each health center was reached in this discussion. Selfassessment discussions (SA1 after one month and SA2 after two months) were conducted at each health
center to discuss the results of prescribing in the previous month and problems faced by paramedics in
treating ARI. A feedback seminar (FBS) in which the results of the study were presented to both groups
was conducted four months after SA2. Prescribing surveys were conducted at baseline, post-SGD, postSA1, post-SA2, four months post-SA2, and monthly for three months post-FBS. Thirty prescriptions
with ARI as a single diagnosis were collected from each health center each month.
Outcome Measures: Average number of drugs prescribed/encounter, percentage with an antibiotic
prescribed, percentage with an antihistamine prescribed, percentage with a corticosteroid prescribed,
and average drug cost/encounter.
Results: Comparing baseline to four months post-SA2, the average number of drugs prescribed/encounter
decreased from 4.0 to 3.1 in Group A and increased slightly in Group B (3.8–4.0). Group A had a 41% drop
in percentage receiving antibiotics (from 63–22%) compared to no change (stable at 67%) in Group B.
Antihistamine use was reduced by 56% (79–23%) compared to 9% (75–64%), and corticosteroid use fell
by 15% (21–6%) in Group A compared to a 2% increase (22–24%) in Group B. Average drug cost was
reduced by 373 rupiahs (1,123 to 750) in Group A compared to 145 rupiahs (1,296 to 1,151) in Group B.
Following the FBS, there were significant improvements in all outcomes in Group B of about one-third to
one-half the levels observed in Group A during the intervention.
Conclusions: Small group interactive seminars conducted by senior paramedics followed by two selfassessment meetings are effective in reducing the use of nonstandard drugs for under-five ARI patients
by health center paramedics. Providing feedback after an intervention can result in significant
BACKGROUND
 Standard Treatment Guidelines (STG) and flow
chart of diagnosis and treatment of Acute
Respiratory Infection (ARI) have been available in
health centres all over Indonesia
 Previous studies showed that treatment of ARI at
health centre level did not always comply to the
guideline, as indicated by the indiscriminate use of
nonstandard drugs such as antibiotics,
antihistamines, corticosteroids, phenobarbital,etc.
 Efforts have been done to reduce antibiotics in
ARI, but the use of nonstandard drugs was still
practiced.
 Innovative Strategies are needed to improve
adherence to ARI treatment guidelines in health
OBJECTIVES
General:
To improve adherence to STG of
ARI
Specific :
 To reduce the number of drugs per
encounter for ARI patients
 To reduce unnecessary drugs such as
antibiotics, antihistamines,
corticosteroids, and phenobarbitals
in ARI in health centers
 To reduce cost of drugs in ARI
METHODS (1)



Location: Bantul and Magelang
Districts, Indonesia
Target Intervention: Health center
paramedics
Design:
 Randomized pre-post study
 24 HCs were randomly assigned:
 12 HCs to underwent series of
intervention (SGD-SA1-SA2)
 12 HCs acted as control
Methods(2):
STUDY DESIGN: Randomized Pre – Post Study
12 HCs underwent series of intervention
Small Group
Discussion
24 HCs in 2
districts
Self
Assessment-1
Self Assessment-2
Feedback
Seminar (FBS)
Randomization
FGD
12 HCs acted as control
FGD
Prescribing survey:
Number of sample: 30 prescriptions per HC X 12
time points X 24 Hcs = 8640 prescriptions
PRE
INTERVENTIO
Post Post Post POST
SGD SA1 SA2 INTERVENTIO
POST FBS
Methods(3):
OUTCOME MEASURES
Data Collection
Prescribing
survey was conducted before the intervention (3
months), Post SGD, Post SA1, Post SA2, and 4 months after
SA2, 1 after FBS, 2 months after FBS, and 3 months after FBS
 Number of sample: 30 prescriptions per HC per month
 Total amount of sample: 8640 prescriptions
Outcome measures






Percentage of ARI patient receiving antibiotics
Percentage of ARI patient receiving corticosteroids
Percentage of ARI patient receiving antihistamines
Percentage of ARI patient receiving phenobarbitals
Average cost of drugs per encounter in rupiah
Average number of drug per encounter
Methods(4):
INTERVENTION
SGD
SA1
SA2
FBS
Duration,
time, and
place
2-hour interactive
discussion, conducted in
each HC in group A
2-hour interactive
discussion,
conducted in each
HC in group A, one
month after SGD
2-hour interactive
discussion, conducted
in each HC in group A,
one month after SA1
Half day interactive
seminar, 6 months
after SA2
Participants
8-12 HC paramedics
8-12 HC
paramedics
8-12 HC paramedics
1 paramedics and 1
doctor each HC, from
24 study HCs. Total:
48 participants
Facilitator
Paramedic
Paramedic
Paramedic
Speaker:
researchers, and Hcs
with best and worst
performance
Resource
Person
HC doctor
HC doctor
HC doctor
Experts in ARI and
Clinical Pharmacology
Material
Flow chart and STG of
ARI, booklet prepared by
reseachers on how to
treat ARI in HCs, result
of FGD and baseline
prescribing survey
Result of
prescribing survey:
baseline and 1
month post SGD
Result of prescribing
survey: baseline, 1
month post SGD, 1
month post SA2, and
result from other
HCs
Result of prescribing
survey from all study
Hcs at baseline, 1
month post SGD, 1
month post SA2, and
4 month Post SA2
Focus of
discussion
STG and evidences on its
trustworthiness
Problems faced in
implementing SGD
Problems faced in
implementing SGD,
comparison of
performance with
other HCs
Sharing experience
and knowledge on
implementing STG of
ARI
Result(1):
REDUCTION OF ANTIBIOTICS &
ANTIHISTAMINE
% Patients Receiving Antihistamine
% Patients Receiving Antibiotics
100
100
80
80
60
63
67
64
60
67
44
40
21,5
PRE
21,3
POST INTERVENTION
Intervention
Control
POST FBS
60
40
23
20
20
0
79 75
0
PRE
17,6
POST
INTERVENTION
Intervention
POST FBS
Control
 Paramedics underwent series of intervention
showed dramatic reduction (>50%) in antibiotics
and antihistamine use.
 These improvements were maintained at low
level until after Feedback seminar (FBS)
Result (2):
REDUCTION OF CORTICOSTEROIDS & PHENOBARBITA
% Patients Receiving Antibiotics
% Patients Receiving Antihistamine
100
100
80
80
60
63
67
67
40
0
21,5
21,3
POST INTERVENTION
Intervention
Control
POST FBS
60
40
23
20
0
PRE
64
60
44
20
79 75
PRE
17,6
POST
INTERVENTION
Intervention
POST FBS
Control
 Paramedics underwent series of intervention
showed dramatic reduction (>50%) in antibiotics
and antihistamine use.
 These improvements were maintained at low
level until after Feedback seminar (FBS)
Result (3):
AVERAGE DRUG COST AND POLYPHARMACY
Average Drug Cost per Encounter (rupiah)
4,5
1400
1200
Average Number of Drugs per Encounter
1283
4
1163
1151
1015,6
1000
3,83
3,5
3,72
3,12
3
800
2,96
3,28
2,5
749
621
600
2
1,5
400
1
200
0
4,1
0,5
PRE
POST INTERVENTION
intervention
control
POST FBS
0
PRE
POST
INTERVENTION
Intervention
POST FBS
East
Control
 Marked reduction at drug cost per encounter
(>30% reduction) is also shown by Paramedics
underwent series of intervention.
 Average number of drugs per encounter reduced
from 4.1 to 3.0, meaning that on average, one drug
disappeared from the prescription.
DISCUSSIONS
 Small Group Discussion followed by Self Assessment
discussion have been proven effective in improving prescribing
practices for ARI patients in HCs.
 The opportunities for paramedic to actively share their
opinion and experience in the discussion, and the strength of
the agreement achieved at the end of discussion are the
factors of success to the improvement achieved.
 The mixed intervention, i.e., small group discussion, selfassessment discussion, and feedback given in large group
feedback seminar, contributes to the sustainable
improvement. However, enforcements might be repeated to
maintain long-term impact.
 Previous studies showed that replacement of drugs usually
occurred as the adverse effect of intervention. This study
however, showed that the elimination of nonstandard drugs
was not replaced by others as indicated by the reduction of
the number of drugs per encounter (4.1 – 3.0).
CONCLUSIONS

Repeated Small Group Discussions
reduces the use of nonstandard
drugs in the treatment of ARI in
children in Health Centers.

Small Group Discussions among
paramedics with trained paramedics
acted as a facilitators and doctors
as resource persons are feasible to
organize in health centers.

T0 maintain the impact of
intervention in long term period,
reinforcements are needed.