1. Sabaydee

2. Ministry of Health, Lao P.D.R.
Effectiveness of Feedback for Improving Case Management of Malaria, Diarrhea, and Pneumonia: A Randomized Controlled Trial at Provincial Hospitals in Lao P.D.R.
Kounnavong S, Wahlstrom R, Sisounthone B, Panyanouvong A, Southammavong T
Ministry of Health, Lao P.D.R.
International Health Care Research, Karolinska Institute, Sweden

3. BACKGROUND
Low quality of care, including poor case management of major diseases at provincial hospitals (malaria, diarrhoea, pneumonia)
Limited opportunity for prescribers to be trained and to learn about new treatment options and new technologies.
Standard Treatment Guidelines (STGs) were developed within the NDP program

4. The first STGs covered seven of the most common and burdening diseases (malaria, pneumonia, diarrhoea, parasitosis, dengue fever, tuberculosis, leprosy).
The STGs were introduced to all prescribers at provincial hospitals
Drug and Therapeutics Committees (DTCs), were established to be instrumental for Rational Use of Drugs (RUD), including use of practice guidelines
To facilitate implementation of an audit-based system, performance indicators were developed for RUD and the new STGs

5. OBJECTIVES
To assess the effects of an educational intervention on management of three common diseases (malaria, pneumonia, and diarrhea) using performance indicators and an audit-feedback approach
The hypothesis was that the overall treatment score (primary) and treatment scores for each disease (secondary) will be improved

6. METHODS RANDOMIZED CONTROLLED TRIAL
8 provincial hospitals (with functioning DTC)
24 selected Departments (12 intervention & 12 control)
OPD, Pediatric, Internal Medicine
Pair-wise balanced block design (4 pairs)
Participants (n=122): doctors & medical assistants
Duration: June 1999 to August 2000

7. ASSESSMENT OF CLINICAL PERFORMANCE
Using existing STG indicators
Selected aspects of the diagnostic and treatment components for case management
Source of information: record keeping book
30 selected patients per disease
Data collectors: DTC members
The STG indicator scores measured with three months intervals per disease
Maximum score for each indicator: 10

8. INTERVENTION
Pre-intervention period: Introduction of STG (June-September 1999), monthly measurement of indicators
Regular feedback session with interactive discussions (September 1999 to February 2000)
One disease per month to be addressed
Content of Feedback session: reflection on the feedback & discussions on how to improve performance

9. RESULTS: Comparison of regular introduction of STG with intensive feedback discussions
Primary outcome:
Total mean score for all three diseases increased from 6.16 to 7.38 (control) and
from 6.48 to 7.94 (intervention)
Secondary outcome:
Treatment indicators scores of each disease increased in both control and intervention
The difference in improvement for the mean score for all three diseases was statistically significant in favor of the intervention group

10. RESULTS

11. RESULTS

12. Typical Case Management:
Improved in some diagnostic components of the treatment indicator
Malaria patient: weight, history, microscopy testing
Diarrhea: weight, history, palpating the fontanel in children <2, not using AB, Info on how to use ORS
Pneumonia: history, recording RC, less anti-histamine & anti-cough medication, better follow up

13. CONCLUSION & RECOMMENDATIONS
A systematically organized education program with repeated feedback meetings improved the performance of prescribers
The record keeping system was improved and became a good source for calculating scores
The audit-feedback model can be used systematically & become integrated into routine work

14. Key lessons
Indicators are a useful tool to get relevant material for feedback to prescribers related to STGs
The effect is probably enhanced through analysis of the indicators and identification of messages for change
Group discussions with prescribers, facilitated by DTC members, is an essential part of an educational intervention
This audit-feedback procedure should be used on a routine basis
Indicators should be constantly monitored and changed if reaching high scores

15. Implications for implementing policy and programs to improve use of medicines
Short term
Time and resources are needed to support DTC work of this kind
Time is also needed for staff to participate in group discussions on feedback
Long term
STGs should be developed for most important clinical problems
Indicators should be developed in connection with the STGs

16. Specific studies in a Future research agenda
on finding most efficient ways of feedback in a particular context
on finding most appropriate methods to develop indicators
on how to sustain impact of educational interventions (when there is no project)

17. Thank you very much for your kind attention !