Drug Prescribing Practices in Children under 5 with Acute Respiratory Infection in Family Group Practices in Central Kazakhstan Nurgozhin Talgat ZdravPlus/USAID

Abstract ID: 406 Author Name: Talgat Nurgozhin Presenter Name: Talgat Nurgozhin Authors: Nurgozhin T Use last name and initials only as in: Laing RL, Foster S, Waning B, Levison L Institution: ZdravPlus Project Title: Drug Prescribing Practices in Children under 5 with Acute Respiratory Infection in Family Group Practices (FGPs) in Central Kazakhstan Problem Statement: For children under 5 in central Kazakhstan, 70% of morbidity and visits to health care facilities is caused by respiratory disease. Given that antibiotic prescription for acute respiratory tract infections (ARIs) is often irrational, it is possible to assume that the high percentage of antibiotic prescriptions for ARI in central Kazakhstan is largely irrational. Objective: To identify the major patterns of drug prescribing practices in children under 5 with ARI. Design: Randomized retrospective chart analysis. Setting and Population: Twenty-nine outpatient primary health care facilities in central Kazakhstan were selected (out of total a total of 36 FGPs). The information was obtained from 359 patient charts in the year 2000 and 328 patient charts in 2001–2002. Intervention: From May 2001 to August 2002, 8 IMCI trainings were held for 40 physicians from the pilot sites. The intermediate study covered the period from October 2001 to September The control study is planned for Outcome Measures: The average number of drugs prescribed per patient/visit; percentage of prescribed generics and essential drugs; percentage of prescribed injections and antibiotics. Results: According to the 2000 study, a patient with ARI was prescribed 3.3 drugs on average, whereas in 2001–2002 this number was 2.7 drugs per patient. In 2000, 84.4% of children with ARI were prescribed 3 or more drugs. As shown in the intermediate study, between 2000 and 2002 this number fell 27.4%, to 57%. Less than 10% of drugs prescribed were injections. Generics were used in no more than 40% of cases. Essential drugs were prescribed in 44.8% of cases. The percentage of patients who were prescribed antibiotics decreased 16.5% (from 42 % to 25.5%). The most significant decrease in antibiotic prescribing was registered in Zhezkazgan city where antibiotic prescribing fell by 31%. Additionaly in the central district of Karaganda and in the suburban districts of Yugo-Vostok and Maikuduk, decreases of 14.8%, 16.9%, and 18.8% were seen, respectively. At the same time, a high rate of antibiotic prescribing was reported in Satpaev city: 56%. Conclusions: The intermediate study results revealed favorable trends in drug prescribing practices. The WHO IMCI training program covers all aspects of clinical practice; however, some corrections as to the improvement of family physicians’ practices in relation to generic and essential drug use need to be introduced. Study Funding: U.S. Agency for International Developmen/ZdravPlus Project

Introduction 1 In Kazakhstan, as in most countries, trends in the general drug prescription practices of family physicians usually reflect the way the healthcare system functions. Study of these patterns will allow selection of interventions to improve the situation. The prescribing pattern of physicians will reflect the level and status of the entire primary healthcare system. ZdravPlus is actively engaged in training primary health care physicians and pharmacists in rational drug use, especially through drug information centers, one of which is located in Karaganda. The activities of the centers collectively aim to reduce the inappropriate prescription of antibiotics for children, specifically among acute respiratory infectioncases. Primary care physicians also complain that they are undermined by the narrow specialty and academic medical communities.

Their patients are told by consultants that the primary care physician’s new prescribing methods demonstrate that she/he does not know how to prescribe properly. Financial incentives in the health care system also sometimes work against rational prescribing practice. If injections result in a fee for the practitioner, but oral medications do not, there is an incentive to provide injections. The economy of providing generics compared to brand name medications is also not so clear in Kazakhstan as in many cultures with a long established pharmaceutical industry. For children under 5 in central Kazakhstan, 70% of morbidity and visits to health care facilities is caused by respiratory disease. Given that antibiotic prescription for acute respiratory tract infections is often irrational, it is possible to assume that the high percentage of antibiotic prescriptions for ARI in Kazakhstan is largely irrational. Introduction 2

The Objectives of the Survey: To compare the medications prescribed in the FGPs of Central Kazakhstan over two time periods of one year each. To identify the possible impact of the interventions by ZdravPlus’ programs on FGP physician drug prescribing practices. To formulate further objectives designed to improve the clinical practice of drug prescribing. To identify possible modifications of existing programs or new programs to be implemented by the ZdravPlus Project for promotion of rational pharmaceutical practices.

Methodology 1 The data collection was made in compliance with WHO and MSH guidelines. The indicators used to study the local PHC physicians’ drug prescribing practices were taken from the WHO guideline “How to Investigate Drug Use in Health Facilities” (WHO 1993) and from «Rapid Pharmaceutical Management Assessment: An Indicator- Based Approach» (RPM), developed by MSH (Management Sciences for Health). This material was adapted for use in Karaganda oblast and some variables as to the names of pharmaceuticals and diagnoses were included. The survey did not consider the issues of drug use in hospitals, specialized polyclinics or other city health facilities, neither were data collected concerning the patients nor indices of health facilities.

All the diagnoses were coded in accordance with the International Classification of Diseases (ICD-10) (WHO 1992) and pharmaceuticals were coded using the WHO Anatomical Therapeutic Chemical (ATC) index (WHO Collaborating Center for Drug Statistics Methodology, 1998). For the purpose of analyses and data input the EpilNFO v 6.04b by Dean et al. (Atlanta, the USA 1994 г.) and EpilNFO 2002 were used. The survey presents comparative analyses of the data collected during the period of two years in Karaganda oblast: from January 2000 to December 2000 (Year 1) and from October 2001 to September 2002 (Year2). Methodology 2

Methodology 3 The survey was conducted in the cities of Karaganda, Zhezkazgan, Satpaev and in two suburban pilot raions (districts) of Karaganda city – Maikuduk and Yugo-Vostok. In each city and raion there are approximately 7-9 PHC facilities. Four to 7 PHC facilities were randomly chosen out of all FGPs in each city and raion. 29 out of 36 PHC facilities were chosen: the city of Karaganda (4 FGPs), Maikuduk (7 FGPs), Yugo Vostok (7 FGPs), the city of Satpaev (4 FGPs), the city of Zhezkazgan (7 FGPs) In each FGP we randomly selected 45 patient charts to investigate physicians’ prescribing practices. Data was collected on group: 10 charts of children under 5 with ARI group).

Results and Discussion 1 IMCI training was given to 40 physicians in Karaganda Oblast between May 2001 and August The trainings in Zhezkazgan and Satpaev did not occur until near the end of the Year 2 collection period. Several favorable changes occurred following the training. Prescriptions per visit decreased, most evident in the sites with earlier IMCI training. The percentage of patients for whom more than 4 medications were prescribed dropped from 8.6% to 3.4% overall. The percentage of use of generics increased. Antibiotic usage also decreased quite substantially. However, there was no change in the frequency of selecting EDL drugs. The frequency of injections actually increased (Table 1).

Table 1 Chil dren unde r 2yrs with ARI Prescri ptions per visit % gene rics % EDL % injec tions % antib iotic s Year %45%5%42% Year %45%8%25%

Results and Discussion 2 Prescription for vitamin products to treat ARI dropped from 20% to 14% of prescriptions written, while prescriptions for antipyretics rose from 17% to 23% of prescriptions written. This is consistent with the teaching in the IMCI courses provided for some of these physicians. Overall frequency of measurement of respiratory rate increased from 81% to 94% from Year 1 to Year 2. Measurement of temperature increased from 81% to 96% of patients seen. Satpaev had 100% compliance with both parameters in the latter study period. This excellent compliance with medical examination parameters in Satpaev and Zhezkazgan may be, in part, due to the ZdravPlus chart audit conducted there in June, 2001.

Results and Discussion 3 This audit checked these parameters in ARI cases also. One of the purposes of the audit was to teach the FGP physicians and the medical authorities the effect of well- designed audits, themselves, to generate future improvement in quality of care. Perhaps, the current study is measuring that particular effect.

Conclusions Use of generics and EDL medications remains very low. Many medications are still used for ARI which are not supported by any clinical evidence of effectiveness (as is true in most of the world). The injection rate remains unacceptably high, despite educational efforts. Even though the percentage of area physicians who have received IMCI training is low, there were improvements in numbers of medications, choice of medication, and use of antibiotics.