PH Dung, NTK Chuc and Dennis Ross Degan 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: 47.7 + 13.3 After intervention: 73.1 + 22.3 Control group Before intervention: 69.0 + 22.6 After intervention : 68.0 + 18.4

Intervention Control Before intervention: 60% After intervention: 80% RESULTS 2: Attitude (% of interviewees expressing the willingness to use guidelines) Intervention Before intervention: 60% After intervention: 80% Control Before intervention: 73.9% After intervention: 32.0%

RESULTS 3: Practice (% antibiotics in non-pneumonia) Intervention Before intervention: 99.7 After intervention: 66.2 Control Before intervention: 99.2 After intervention: 99.1

RESULTS 4: Practice (% right antibiotics) Intervention Before intervention: 25.0 After intervention: 56.9 Control Before intervention: 36.6 After intervention: 35.2

RESULTS 5: Average cost per encounter Intervention Before intervention: 9441 VN$ After intervention: 6868 VN$ Control Before intervention: 8368 VN$ After intervention: 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