1. REDUCING ANTIBIOTIC OVERUSE for ARIs with SMALL- GROUP EDUCATIONAL INTERVENTION Munawaroh S 1, Sunartono H 2, Suryawati S 3 1 INRUD Yogya/Indonesia; 2 Sleman District Health Office; 3 Department of Clinical Pharmacology, Gadjah Mada University, Indonesia 3 Department of Clinical Pharmacology, Gadjah Mada University, Indonesia

2. ABSTRACT Problem Statement: Standard Treatment Guidelines (STG) and a diagnosis flow chart for acute respiratory tract infections (ARIs) for the health centre (HC) level were developed and distributed by the Ministry of Health of Indonesia in 1983 and 1991 respectively. However, the excessive use of antibiotics in treating ARI in HCs demonstrate that the STG and flow chart are not followed. Objectives: To reduce antibiotic overuse by paramedics for treating ARI at the HC level utilizing a small group educational intervention. Design: Randomized pre-post study. Setting and Population: In the Bantul District, 18 HCs were randomly assigned as follows: 6 HCs were assigned to undergo Small-Group Discussions (SGDs) about the ARI STGs and feedback (FB) meetings in 2 consecutive months to discuss problems with implementing the recommended changes in prescribing (Group A); 6 HCs were assigned to undergo SGDs without FB meetings (Group B); and 6 HCs acted as controls (Group C). SGDs were conducted in each HC in the two intervention groups and participated in by 7-9 paramedics, with one paramedic acting as facilitator and the HC doctor invited as resource person. Prescribing practices were measured by surveys of 100 paramedics’ prescriptions per HC per month for 3 months before the intervention, 1 month post-SGD, and 1 month after each FB session (post-FB1 and FB2). Prescriptions were required to have ARI as a single diagnosis; both under-five and adult patients were sampled. Without doctors’ awareness, doctors’ prescriptions were also sampled by the same method. Outcome measures: Percentage of antibiotic use in patients with ARI. Results: Comparing prescribing at baseline to post-FB2, paramedics in Group A showed a reduction in antibiotic use for ARI from 49.5% to 29.2% (-20.3%). In Group B, antibiotic use was reduced from 75.1% at baseline to 53.9% (-21.2%). In Group C, paramedics’ antibiotic use did not change (56.6% to 60.0%). Doctors’ antibiotic use in Group A was reduced from 49.7% to 30.0% (-19.7%) and in group B from 63.6% to 54.7% (-8.9%). In group C, doctors’ antibiotic use also did not change (58.6% to 57.3%). Conclusion: An intervention using SGDs either with or without FB can decrease antibiotic prescribing by paramedics in ARI treatment, bringing it more in accordance with national STGs. There was also a change in the prescribing of doctors who attended the SGDs as resource persons, despite the fact that paramedics were the targets of the intervention. Further studies must demonstrate that this reduced antibiotic use in ARI treatment can be sustained. Study Funding: Applied Research for Child Health (ARCH) Project No. 012/1999 (65%), WHO fellowship (20%), and Self- funding (15%).

3. BACKGROUND  MOH of Indonesia has developed STG and a diagnosis flow chart for ARIs for HC level in 1983 and 1991, respectively.  The excessive use of antibiotics in treating simple ARI in HCs demonstrates that the STG and flow chart are not followed.  Many evidences showed inappropriate drug treatment for ARI, including indiscriminate use of antibiotics.  Special efforts are needed to reduce the overuse of antibiotics.

4. OBJECTIVES General Objective To improve the quality of care of ARI patients (adult and child) in HCs Specific Objectives  To improve specific prescribing practices in the treatment of ARI, including:  reducing the overuse of antibiotics  reducing the overuse of antihistamine  reducing the number of drugs per encounter  To compare the effectiveness of SGD, with-and without feedback, in improving ARI treatment.

5. METHODS (1)  Location:  HCs in Bantul District, Indonesia  Subject:  Paramedics (target intervention) and doctors (as resource person) in HCs  Design:  Randomized controlled study with pre and post evaluation  18 HCs were randomly assigned into:  6 HCs underwent SGDs and FB meetings in 2 consecutive months (group A)  6 HCs underwent SGDs without FB meetings (group B)  6 HCs acted as controls (group C)

6. METHODS (2) 18 HCs Group A (6 HCs) Group B (6 HCs) Group C (6 HCs) SGD FB1 FB2 -- C O N T R O L FGD Baseline Post SGD Post FB1 Post FB2 FGD = Focus Group Discussion SGD = Small Group Discussion FB = Feedback Design Rando mized Analysis Para

7. METHODS (3)  Prescribing Survey  100 paramedics’ and 100 doctors’ prescriptions per HC per month at each time point (total 7 time points)  Pre-1, pre-2, pre-3 (3, 2, and 1 months before the intervention)  Para (preparation, 1 month)  post SGD (1 month after the intervention)  post FB1 (2 months after the intervention)  post FB2 (3 months after the intervention)  Total amount of sample: 100 prescriptions x 7 time points x 2 providers x 18 HCs = 25.200 prescriptions  Data presentation  Percentage of patients with ARI receiving antibiotics  Percentage of patients with ARI receiving antihistamines  Average number of drugs per prescription  Statistical analysis  t-test is used to compare reduction of pre vs post intervention  anova is used to compare reduction of Group A vs Group B vs Group C

8. RESULT (1), REDUCTION OF ANTIBIOTICS USE Paramedics’ prescriptions Doctors’ prescriptions SGDSGD FB1FB1 FB 2 SGDSGD FB1FB1

9. RESULT (2), REDUCTION OF ANTIHISTAMINE USE Paramedics’ prescriptionsDoctors’ prescriptions SGDSGD FB1FB1 FB 2 SGDSGD FB1FB1

10. RESULT (3), NUMBER OF DRUGS PER ENCOUNTER Paramedics’ prescriptions Doctors’ prescriptions SGDSGD FB1FB1 FB 2 SGDSGD FB1FB1

11. DISCUSSIONS (1)  Printed material for Small-Group Discussions Besides the existing STG and flowchart of ARI treatment, the research team also prepared booklet on how to treat ARI in HCs. Findings from FGD, also incorporated in this booklet. This printed material were distributed few days before the SGD, so all paramedics had time to read them.  Small-Group Discussion SGD was conducted in all HC is intervention group. Besides printed material, result of baseline prescription survey was also presented in this forum. Confronting their prescribing practice shown by the result of baseline prescribing survey to the STG became a trigger for the lively discussion. At the end, all paramedics reached an agreement on how to treat ARI in daily practice. This agreement proven to be important as it served as a group pressure for all paramedics.  Feedback In group A, feedbacks were given twice, in the form of monthly prescribing survey of respective HC after the SGD. The main topics of discussion were comparing the feedback with the baseline prescribing survey and problems faced in implementing the STG in daily practice. At the end, paramedics reached agreement on how to solve the problems in treating ARI in their HC. It showed in the result that group A had more sustainable improvements compared to group B which did not receive feedbacks.

12. DISCUSSIONS (2)  Facilitators The facilitator in each SGD was one of the paramedics who had undergone a training. The fact that the facilitator and participants are all paramedics reduce the resistance of participants to new ideas. It also allowed the participants to act more freely in giving ideas and arguments in the discussions.  Resource Person HC doctor became the resource person during FGD and feedbacks in each HC, who gave input or comments when they was a disagreements among paramedic.  Key factors of intervention The printed material specially design for FGD, the interactive process of SGD, feedback, internal facilitators, and internal resource person are the key factors to the success of the intervention.  Other interesting finding Although the target of intervention was paramedics, surprisingly the doctors’ prescriptions also improved. It means that there were double impacts of placing the doctors as resource persons.

13. CONCLUSIONS  Small Group Discussions followed by Feedbacks reduced the overuse of antibiotics and other unnecessary drugs in the treatment of ARI in adult and children in Health Center level.  Small Group Discussions among paramedics with a trained paramedic facilitator and a doctor as a resource person provided fora for paramedics to discuss and solve problems in ARI treatment. Such forum would be also ideal for other medical problems.  Repeating intervention is necessary to reinforce the agreement reached in previous discussions to maintain the impact of the intervention.