IMPACT OF TRAINING IN RESPIRATORY GUIDELINES ON IMPROVING USE OF DRUGS Naveen Shrestha Department of Community Medicine and Family Health, IoM, Nepal Louis W. Niessen Institute of Health Policy & Management, Erasmus University, The Netherlands AHA Ten Asbroek Institute of Health Policy & Management, Erasmus University, The Netherlands Kumud Kumar Kafle Department of Clinical Pharmacology, IoM, Nepal David B. Bishai Department of Population and Family Health Science, John Hopkins University, USA

2 Problem Statement: Irrational prescribing is a widespread problem in both developed and developing countries, in public health care facilities and among private health care providers, and results in inefficient use of resources. Among the various intervention options, training in clinical guidelines is one potential way to improve prescribing practices. Objectives: To assess the effectiveness of training in improving adherence to Practical Approach to Lung-health (PAL) guidelines as well as adherence to other guidelines (Standard Treatment Schedule [STS] for health workers). Design: A stratified cluster randomized controlled trial. Setting: Primary health care outlets from a terai (flat land) district of Nepal. Study Population: Randomized 21 health facilities in control group and 19 health facilities in intervention group from 76 health facilities in the district. Intervention: Training in PAL guidelines for primary health care workers as adapted from World Health Organization (WHO) guidelines. Outcome Measures: Average number of drugs, percentage of generic drugs prescribed, percentage of prescribed drugs on the Essential Drugs List (EDL), percentage of encounters prescribed at least one antibiotic, percentage of encounters prescribed at least one injection, percentage of asthma cases treated with salbutamol, percentage of Chronic Obstructive Pulmonary Disease (COPD) cases treated with salbutamol, percentage of pneumonia cases treated with co-trimoxazole, amoxicillin, or chloramphenicol, percentage of amoebiasis cases treated with metronidazole, percentage of headache cases treated with aspirin or paracetamol, percentage of scabies cases treated with benzyl benzoate. Results: There has been a significant decrease in the average number of drugs per patient and a significant increase in the cases treated following PAL guidelines. But there has been no significant effect on prescribing practices following other guidelines (STS). Conclusions: Training of primary health care workers in guidelines improves adherence to the guidelines focused on by the study but not to other guidelines. IMPACT OF TRAINING IN RESPIRATORY GUIDELINES ON IMPROVING USE OF DRUGS Naveen Shrestha, Department of Community Medicine and Family Health, IoM, Nepal Louis W. Niessen, Institute of Health Policy & Management, Erasmus University, The Netherlands AHA Ten Asbroek, Institute of Health Policy & Management, Erasmus University, The Netherlands Kumud Kumar Kafle, Department of Clinical Pharmacology, IoM, Nepal David B. Bishai, Department of Population and Family Health Science, John Hopkins University, USA Abstract

3 Back ground Irrational prescribing and under or over prescribing is a common world-wide problem. Clinical protocol, Guidelines, Algorithm are the tools to improve the prescribing practices

4 Back ground (Cont d ) PAL (Practical Approach to Lung Health) WHO project implementing in Nepal to improve the quality of adult lung health care. Generic PAL guidelines after local adaptation implemented in Nawalparasi district. Selected health workers trained in PAL guidelines CCPPs (Carbon Copy Prescription Pads) implementing in selected health facilities.

5 Objectives To assess the effectiveness of training in improving adherence to Practical Approach to Lung-health (PAL) guidelines as well as adherence to other guidelines (Standard Treatment Schedule [STS] for health workers).

6 Methodology Study design Stratified Clustered randomized controlled trial Intervention Training on PAL (Practical Approach to Lung Health) guidelines

7 Study design J F M A MJJAS O N D J Post-test Study Intervention 4 HPs PAL CasesNon PAL 17 SHPs PAL CasesNon PAL Control 3 HPs PAL CasesNon PAL 16 SHPs PAL CasesNon PAL Pre-test Intervention

8 Randomization of Health Facilities Usual Practices 19 PAL Guidelines 21 PAL Cases Non-PAL Cases PAL Cases Non-PAL Cases Study Design Random

9 Data collection PAL cases Asthma COPD Pneumonia But no combination, only single diagnosis Non PAL cases Scabies Headache Amoebiasis But no combination, only single diagnosis By using Carbon Copy Prescription Pads (CCPPs)

10 Data Analysis Using WHO RUD Indicators (WHO, 1995) Using disease specific indicators –% of correct treatment as per PAL guidelines –% of correct treatment as per STS (Standard Treatment Schedule)

11 Results significant decrease in average drugs prescribed per encounter was fewer drugs (95% CI: to ) as compared to the usual practice group. significant increase in the percentage of correct prescriptions for lung disease which was 50% (95% CI: 30.5 to 69.5 CI) compare to pre- intervention, where as in control group slightly increased but not significant.

12 Results no significant changes in essential drug prescribing, percentage of antibiotics or, use of injections

13 Conclusion Disease-targeted training of primary care workers improves disease-specific rational drug use. We recommend inclusion of other managerial strategies, as supervision and peer review, to enhance further impact and retention among health workers with basic training.