CAMBODIA EXPERIENCE ON MTP TO REDUCE INAPPROPRIATE MEDICINE USE IN HOSPITALS Sok Srun & Chroeng Sokhan Ministry of Health, Kingdom of Cambodia

Abstract Problem Statement: An indicator-based supervision and monitoring program had been conducted by the Ministry of Health for years, aimed at improving prescribing practices in hospitals. However, the results did not show significant improvement. A new approach was therefore implemented in 2002, using the Monitoring – Training – Planning (MTP) method, a series of small-group discussions among managers and prescribers in hospitals to solve problems in medicine use. MTP was first implemented in 2 stages, involving 13 pilot hospitals. Objectives: To evaluate the effectiveness of the MTP approach to reduce inappropriate medicine use in specific disease problems as defined by each hospital. Indicators: % patients receiving IV fluids and % patients receiving antibiotics (AB) after prescribers and managers participated in several MTP meetings. Design: Pre and post MTP intervention without control. Study Population: Patients with specific disease problems as defined by each hospital. Intervention: An MTP Team was set up in each hospital, involving the managers and prescribers whose prescribing practices showed a problem. Each team agreed on a priority disease problem, and arranged a series of MTP monthly meetings. Prescribing surveys were conducted based on 30 cases per month, or all cases if the number was <30 per month. Outcome Measures: Reduction of % patients receiving inappropriate medicines, and when data were available, reduction of medicine costs. Indicators: % patients receiving IV fluids and % patients receiving antibiotics (AB) after prescribers and managers participated in several MTP meetings. Results: Most pilot hospitals showed improvement in prescribing practices. Among them, Kandal Hospital reduced AB use in normal delivery from 100% to 15% after 4 meetings. Kampong Cham Hospital reduced AB use in post Caesarean surgery from 100% to 36% after 4 meetings and reduced AB post scrotal hernia surgery from 100% to 33% after 3 meetings. No post-surgery complications were observed, and the hospital reduced the average medicine cost from US$ 15.3 to US$ 6.1 per patient, saving US$ >2,000 per month on medicine expenditure. At Seam Reap Hospital, the use of AB in the Traumatology Ward was reduced from 100% to 63%, and Oddar Meanchey Hospital reduced the use of IV fluids in normal delivery from 27% to zero, and the use of AB from 23% to zero. At Battambang Hospital, the use of IV fluids in the maternity ward was reduced from 70% to 0%, IV fluid use in the traumatology ward decreased from 70% to 0%, and the use of AB in malaria decreased from 30% to 20%. Conclusions: The MTP approach was effective in reducing inappropriate medicine use in hospitals, and the achievements were sustainable. The preparation and evaluation workshops at the national level were relatively costly, but the implementation cost in each hospital was quite low. After the successful implementation in 13 hospitals, the MTP approach will be disseminated country-wide.

1- Background PPrevious indicator-based supervision and monitoring program in Cambodia did not show significant improvement. IInappropriate prescribing practices in health facilities IIntervention to improve prescribing is uneasy to conduct, especially in private facilities IInterventions needs to be incorporated in the existing management system

2- Objective  To discuss the problems of drug use in the health care system  To discuss the efforts in improving drug use carried out so far  To develop the innovative strategy for rational drug use in the health care system.

3-Intervention Method (Stage 1)  Select 6 pilot hospitals  Assign 6 people of each hospital as Hospital MTP Teams  Training of MTP Teams on MTP process  Schedule the meeting to:  define problems on drugs use  develop an innovative strategy to improve drug use  define target  monitor the implementation and evaluate the achievements  National evaluation workshop  Wider implementation (Stage 2) if Stage 1 is successful

3-Self-monitoring vs MTP MTP approach Self- Monitoring strategy MTPMTP MTPMTP MTPMTP MTPMTP MTPMTP MTPMTP MTPMTP MTPMTP MTPMTP MTPMTP Indicato r Periodic evaluation at MOH

Health FacilitiesPriority problemIntervention result 1-Kandal Hospital-Use of AB in normal delivery -Reduction from 100% down to 15%(target 10%) 2-Kanpong Cham Hospital -Use of AB in post- Caesarean surgery -AB use post-scrotal hernia surgery. -Reduction from 100% down 36%(Target 10%) -Reduction from 100% (target 10%)down to 33% in 3 meetings -Average cost per patient reduction from 15.3 to 6.1$ 7- Summary results of Stage 1

Kandal RH: Reduce AB use in normal delivery 4-Result of Stage 1

Kompong Cham: Reduce AB use in post Caesarean surgery 4-Result of Stage 1 % of patients receiving antibiotics Reduction of the average medicine cost per patient from 15.3 to US$ 6.1 (US$ 2000/month)

3-Intervention Method (Stage 2)  Select … pilot hospitals  Assign 6 people of each hospital as Hospital MTP Teams  Training of MTP Teams on MTP process  Schedule the meeting to:  define problems on drugs use  develop an innovative strategy to improve drug use  define target  monitor the implementation and evaluate the achievements  National evaluation workshop involving hospitals from Stage 1  Nation-wide implementation if Stage 2 is successful

Health FacilitiesPriority problemIntervention result 1-Siem Reap Hospital -AB use in Tromatology Ward -Reduction from 100% down to 63% (target 50%) 2-Oddar Mean Chhey Hospital -Use of IV fluid in normal delivery -Reduction from 27% down to 0% (target 0%) 3-Battambang Hospital -IV fluid use in Maternity -IV fluid use in Traumatology -AB use in Malaria -Reduction from 70% down to 0%.(target 0%) -Reduction from 70% down to 0% (target 0%). -Reduction from 30% down to 20%(target 0%) 7- Summary results of Stage 2

8-Conclusion(1)  Flexible approach, not time-consuming, not costly to improve appropriate use of drugs in hospitals  MTP is good for solving sensitive problems  Encourage Hospital Technical Committees to initiate activities in improving appropriate use of drugs  A comprehensive approach, a combination of adult learning and managerial strategies.  Involving stakeholders in hospital, the “negative” consequences of rational drug use could be discussed accordingly

8-Conclusion(2)  MTP can be implemented in both sector public and private. With the supports from PHDs, MTP can be used to solve drug use problems by themselves.  MTP can be extended nationwide. The “right people” should be selected from each hospitals.  If MTP imlementation is conducted with monitoring, supervision, and continuous training, MTP can reduce the health care cost. The community will participate and support this efforts  To reduce the prescribing problems and improve RUD for healthcare workers and patients.