1. REDUCING ANTIBIOTIC OVERUSE FOR ACUTE RESPIRATORY TRACT INFECTIONS WITH SMALL- GROUP EDUCATIONAL INTERVENTION
Munawaroh S1, Sunartono H2, Suryawati S3
1Yogyakarta Provincial Health Office;
2Sleman District Health Office;
3Department of Clinical Pharmacology, Gadjah Mada University, Indonesia

2. BACKGROUND
MOH of Indonesia has developed Standard Treatment Guidelines (STG) in 1983, and a diagnosis flow chart for ARIs for Health Center (HC) level in 1991.
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 treatment for ARI, including indiscriminate use of antibiotics.
Previous studies showed that Small-Group Educational and Feedback are effective in improving drug use.
Special efforts are needed to reduce the overuse of antibiotics

3. OBJECTIVES General Specific
To improve the quality of care of ARI patients (adult and child) in HCs by applying Small-Group Discussion (SGD).
Specific
To improve specific prescribing practices in ARI, including:
reducing the overuse of antibiotics
reducing the overuse of antihistamine
reducing the number of drugs per encounter
To compare the effectiveness of Small-Group Discussion, with-and without feedback (FB), in improving ARI treatment.

4. METHODS (1) Location Subject Design HCs in Bantul District, Indonesia
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 followed by FB meetings in 2 consecutive months (group A)
6 HCs underwent SGDs without FB meetings (group B)
6 HCs acted as controls (group C)

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

6. METHODS (3) Prescribing Survey Data presentation Statistical analysis
100 paramedics’ & 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, post FB1, post FB2 (1 month, 2 months, 3 months after the intervention, respectively)
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 to compare reduction of pre vs post intervention
Anova to compare reductions of Group A vs Group B vs Group C

7. Paramedics’ prescriptions Doctors’ prescriptions
RESULT (1): REDUCTION OF ANTIBIOTICS USE
% patients receiving
antibiotics
% patients receiving
antibiotics
Paramedics’ prescriptions
Doctors’ prescriptions
SGD
FB1
FB2
SGD
FB1
FB2

8. Paramedics’ prescriptions Doctors’ prescriptions
RESULT (2): REDUCTION OF ANTIHISTAMINE USE
% patients receiving
antihistamine
% patients receiving
antihistamine
Paramedics’ prescriptions
Doctors’ prescriptions
SGD
FB1
FB2
SGD
FB1
FB2

9. Paramedics’ prescriptions Doctors’ prescriptions
RESULT (3): NUMBER OF DRUGS PER ENCOUNTER
Paramedics’ prescriptions
Doctors’ prescriptions
SGD
SGD
FB1
FB1
FB2
FB2

10. DISCUSSIONS (1) Interesting finding
Although the target of intervention was paramedics, surprisingly the doctors’ prescriptions also improved.
It means that there were double impacts of posing the doctors as resource persons.

11. DISCUSSIONS (2)
The key factors to the success of the intervention are:
Handy printed material, question & answer format, problem-based
Interactive, problem-solving Small-Group Discussion
Feedbacks showing individual achievement
Facilitators are recruited from the target of intervention
Doctor as resource person is a strategy in improving doctor’s behavior

12. CONCLUSIONS
SGD followed by FBs reduced the overuse of antibiotics and other unnecessary drugs in the treatment of ARI in adult & children in HC level.
SGDs 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.
Further studies are needed to find out sustainability of long term impact.

13. “Terima Kasih” Thank you