ABSTRACT THE IMPACT OF CONTINUOUS MEDICAL EDUCATION ON PRESCRIBING HABITS IN MISSION HOSPITALS IN KENYA By John Kiambuthi Mission for essential drugs and supplies Problem statement :The mission for essential drugs and supplies conducts institutional training interventions in mission hospitals. These consist of three phases: a baseline survey using the international network for rational use of drugs (INRUD) indicators, the training intervention and a follow-up evaluation one year later. Some hospitals then start their own in-house continuous medical education (CME) program. Objectives: To assess the impact of training interventions on prescribing habits in hospitals and the impact of complementing this with an in-house CME program. Design: Retrospective before/after with a comparison. Setting and population :Three mission hospitals in Kenya, using patient records. In each,a hundred prescriptions sampled out. Intervention: Institutional training interventions were conducted in each hospital. In one hospital, this was complemented by a regular in-house CME program organized by the drugs and therapeutics committee (DTC ).The staff are fully involved in the CME as facilitators, and the treatment protocol is updated after each CME session. Outcome measures: Average number of drugs per case, percentage of generic drugs prescribed, percentage of cases prescribed antibiotics, and percentage of cases prescribed injections. Results: In one hospital, 3 of 4 indicators showed improvement, and 1 of 4 deteriorated. In the second hospital, 1 of 4 indicators showed improvement, 1 of 4 did not change and 2 of 4 deteriorated. In the third hospital, which had the CME program, all 4 indicators showed dramatic improvement, especially antibiotic and injection use. Conclusions: Training by external facilitators has mixed success in improving prescribing habits. When complemented by a CME program, it is much more successful. Additional studies would be helpful in assessing these two forms of educational intervention in drug use.

STUDY SETTING The mission for essential drugs and supplies (MEDS) is an ecumenical organization based in Kenya in East Africa Has two main mandates : - To source, stock and supply quality but affordable essential drugs to not-for-profit organizations - To organize and conduct training for workers in these organizations.

TRAINING STYLES Conducted either in a central location for nearby facilities or in a health facility for the staff working there. When conducted in a health facility, has three phases: - training needs assessment - training intervention - post-training evaluation(one year after training intervention) During training, facilities are encouraged to start their own continuous medical education(CME) programs to continually address drug use issues.

QUESTION Does a training intervention by an outside team have any impact on prescribing habits in health facilities ? What effect does complementing this with an own CME program have ??

METHODOLOGY (1) The study is retrospective, using data collected in three hospitals all of which received training over a period of one year. In each, all phases of the facility-based training were conducted. In phase one a hundred prescriptions were sampled out in the out-patient department. Analysis was done using the INRUD indicators.

METHODOLOGY (2) The analysis covered the average number of drugs per prescription, percentage of drugs prescribed in generic names, percentage of prescriptions with an antibiotic prescribed and percentage of prescriptions with an injection

INTERVENTION (1 ) A training intervention was conducted in all three hospitals soon after the training needs assessment. This was done by a team of external facilitators (MEDS). The areas addressed were the ones identified during phase one in order to improve prescribing behavior.

INTERVENTION (2) In one hospital a continuous medical education (CME) program was started soon after the training intervention. The staff members were fully involved in the program as facilitators. No such program was started in the other two hospitals. Hospitals A,B,C hospitalA Training intervention hospitalB Training intervention hospitalC Training intervention+CME programme

RESULTS (1) In one hospital three of the four indicators improved while one deteriorated. In another, one improved, one did not change while two deteriorated. In the third hospital which had a CME program, all four indicators showed remarkable improvement.

RESULTS (2) IndicatorBeforeAfterBeforeAfterBeforeAfter Number of drugs per prescription % of prescriptions with antibiotic % of prescriptions with injection % of drugs in generic name Facility AFacility BFacility C

RESULTS (3) IndicatorFacility AFacility BFacility C Number of drugs per prescription 2%2.94%28.8% % at prescription with antibiotic -39.6%-8.70%50.8% % of prescription with injection 79%-36.1%80.7% % of drugs in generic name 30.23%0%40.38% Percentage Improvement

CONCLUSION From the results above, the following conclusions can be made :  The study presents comparative results from studies on two forms of the training intervention in improving the use of medicines  Training intervention by external facilitators is helpful in improving drug use  When the training intervention is combined with an own CME program the improvement is much greater. To get a better insight into the relative effectiveness of these two forms of training intervention in improving drug use, more studies are needed.