MTP Approach Is Effective in Reducing Inappropriate Medicines Use in Hospitals Sri Suryawati 1 & Budiono Santoso 2 1 Center for Clinical Pharmacology & Medicines Policy Studies, Gadjah Mada University, Yogyakarta 2 WHO – Western Pacific Regional Office, Manila

Problem Statement: ICIUM 1997 recommended that a successful intervention should focus on a specific problem, address the underlying factors, use a problem-solving approach, repeat the intervention, be interactive, provide feedback to prescribers, and be followed by monitoring and supervision. Considering the active roles of clinicians, an approach to changing prescribing practices in hospitals should ideally be self-initiated, self- executed, and self-evaluated. Objective: To develop, field-test, and implement a monitoring-training-planning (MTP) approach to reduce inappropriate use of medicines for specific disease problems as defined by each hospital. Indicators: Percentage of patients receiving particular medicines under investigation (e.g., intravenous [IV] fluids in normal delivery, IV fluids in cranial trauma, antibiotics in normal delivery), after the hospital has undergone several MTP meetings. Design: The MTP approach focuses on the quality improvement process. Therefore, its effectiveness in improving prescribing is evaluated by a before-and-after intervention without control design, in each activity site. Study Population: Patients with specific disease problems as defined by each hospital. Intervention: An MTP team is set up in each hospital; each team identifies a priority problem and then plans a series of MTP meetings involving managers and prescribers who contribute to the problem. As there are routine technical meetings in hospitals, the MTP meetings can be easily slipped in. In brief, the monitoring component is identifying and defining the severity of a problem; the training component is solving the problem; and the planning component is setting the target of improvement. One problem usually requires 3–5 MTP meetings. When the problem has been solved, the team may address another problem. Outcome Measures: Reduction of the percentage of patients receiving inappropriate medicines, and if data are available, reduction of medicine costs. Results: Following a successful field test in Indonesia involving 6 hospitals, Cambodia (13 hospitals) and Laos (28 hospitals) have implemented the approach with good results. The use of inappropriate medicines has been significantly reduced in both countries, including the overuse of IV fluids. Conclusions: This experience showed that an MTP approach is effective for reducing inappropriate medicine use in hospitals, especially among hospitalized patients. Moreover, such an approach can be implemented at minimum cost, and can be incorporated into existing hospital managerial activities. Abstract

Improving drug use in hospital?  Inappropriate prescribing practices in hospitals  Improve prescribing in hospitalized patients is more complicated  Ideal mechanism: self-initiative, self-conduct, self-assessment by Hospital Drugs & Therapeutics Committees or Technical Committees  Activities should be incorporated in the existing management system

What is MTP? | Monitoring - Training - Planning | Adult learning process 80% 20% Setting the target of improvement Description of the recent situation Problem solving & scientific/reality testing P M Reflection of previous experience T

What is Monitoring-Training-Planning?  Monitoring (problem identification and measurement) Identify the specific drug use problem, select a priority problem, determine drug use indicator(s) and data source, identify the target of intervention. When MTP has been running: follow up commitments from the previous session, evaluate the result of improvement, conclude the achievement  Training (problem solving) Discuss the problem: why, what are the motivation, underlying factors, etc., collect scientific information, collect supporting information, discuss how to solve the problem, experience in the past, solve the problem, agreements to make changes  Planning (setting target for improvement) Set a target of improvement, set measures to achieve target, assign who is responsible for executing the plan, set the date for the next MTP session, assign person(s) to collect data and present it in the next MTP session

Flow of MTP activities  3-4 cycles for each problem  Simultaneous or parallel activities T M P T M P T M P T M P T M P MTP meeting MTP cycle

MTP implementation in hospital?  Set up the hospital core MTP team, with supports from Managers  Plans for MTP activities, assign MTP Group(s) involving the targets of intervention  Plan activities in MTP Groups  Identification and involvement of internal resources  Conducting MTP sessions  Periodic evaluations

Distribution of activities (examples) Approach the professor Provide microbial culture Provide articles Approach the Director Collect indicators MTP teams at ward/unit level MTP team at hospital level

MTP reduces inappropriate use of medicines Hospital Drug use problem Achievement Battambang, Cam Kandal, Cam Siem Reap, Cam Kampong Cham, Cam Bokeo, Lao Xayaboury, Lao Saravane, Lao Sleman, Indo Panti Rapih, Indo Karyadi, Indo Overuse of iv fluids in normal delivery in Maternity Ward Overuse of antibiotics in normal delivery in Maternity Ward Overuse of antibiotics in Traumatology Ward Overuse of antibiotics in post-Caesarean surgery Overuse of antibiotics in post- scrotal hernia surgery Overuse of IV fluids in Emergency Department Overuse of injection in malaria treatment Overuse of antibiotics in diarrhea Overuse of antibiotics in diarrhea in Adult & Pediatric OPDs Overuse of antibiotics in outpatient ARI Overuse of antibiotics in pre- scrotal hernia surgery 70% to 59% to 0% 100% to 15% 100% to 63% 100% to 36% 100% to 33% 78% to 29% to 23% 96% to 10% 83% to 23% to 13% 67 to 12% and 33 to 2% 94% to 45% 85% to 8% Some examples of achievement:

Sleman experience Sleman experience (Yudatiningsih et al., 2004) Feedback % patient receiving antibiotics MTP at 24 HCs Feedback in month-14 Feedback in month-30 Feedback in month-45  Sleman started MTP in 1999 for overuse of antibiotics in ARI, with good results  Skills in conducting MTP was well-adopted by health center staff  Since then MTP has also been used for other drug use problems  Less-frequent feedback is needed, after adopting MTP people are responsive to feedbacks

Cambodia Experience Cambodia Experience (Srun & Sokhan, 2004)  Beginning August 2001, MOH-Cambodia pilot-tested the MTP implementation in 6 referral hospitals, focused on drug use problems in hospitalized patients  A National Evaluation Workshop was conducted in March 2002, showing good results, 4 hospitals succeeded, 2 faced problems  Beginning October 2002, the second pilot-test was conducted, involving the previous 6 hospitals and 6 more hospitals.  The 2 nd National Evaluation Workshop in October 2003 showed good results, most hospitals succeeded  Cambodia plans to implement MTP nation wide, as an approach to improve the appropriate use of drugs

Discussions  Some hospitals failed, due to: weak support frm hospital directors, wrong selection of core MTP Team, too many problems to solve at the same time, or confused with other on-going projects  Training in conducting MTP is transferring the skills to initiate, execute, and evaluate activities in improving drug use. In other words, it sets up capacity building in improving drug use problems in health facilities  Although data are limited, it is reported that less- frequent feedback is needed to make the improvement sustainable. This will lessen the workload of supervision in the health care system.

Conclusions  MTP approach is effective for reducing inappropriate medicine use in hospitals, including drug use problems in hospitalized patients.  MTP approach is feasible to implement at minimum cost, and feasible to be incorporated in the existing hospital managerial activities.  MTP approach is promising for a nation-wide implementation