1. MTP Approach to Reduce Inappropriate Use of Antibiotics in Hospitals: Results of the Field Test Suryawati S, Setiyawati E, Saleh-Danu S, Rustamaji A, Santoso B Center for Clinical Pharmacology and Medicine Policy Studies Gadjah Mada University, Yogyakarta.

2. Problem Statement: Experience showed 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. Moreover, indicator-based monitoring strategies with feedback were found to be effective in improving drug use practices. Unfortunately, few data have been compiled from hospitals. Objective: To develop and field-test an innovative MTP (Monitoring-Training-Planning) approach to reducing inappropriate prescribing in hospitals. Indicators: Percentage of patients receiving antibiotics (AB) after hernia surgery and cesarean surgery, percentage of patients with diarrhea receiving AB, percentage of patients with acute respiratory tract infection (ARI) receiving AB, etc. Design: Field tests were conducted in 6 hospitals: 2 public hospitals (Sleman and Yogyakarta), 2 private hospitals (PKU and Pantirapih), and 2 teaching hospitals (Sardjito and Karyadi). These hospitals were selected based on convenient sampling. The field test included 3 consecutive MTP meetings in each hospital. The impact of MTP was evaluated by comparing the indicators prior to the implementation of MTP (baseline) and after, for each specific drug use problem identified in each hospital. Process evaluation was also undertaken at each hospital. Study Population: Patients with specific disease problems as defined by each hospital. Intervention: An MTP team was set up in each hospital. Each team chose a priority problem and planned 3 consecutive MTP meetings involving managers and prescribers. Each meeting was about 2–3 hours. Outcome Measures: Reduction of percentage of patients receiving AB. Results: All facilities reported that MTP reduced inappropriate AB use. Sleman reduced AB use for adult diarrhea from 67% to 8%, and for children’s diarrhea from 33% to 0. Yogyakarta reduced AB use postcesarean from 100% to 0. PKU reduced AB use for nonspecific diarrhea from 21% to 4%, and Pantirapih reduced AB use for adults with ARI from 94% to 45%. Sardjito reduced AB use post–hernia surgery from 100% to 13%, and Karyadi reduced AB use post–scrotal hernia surgery from 85% to 8%. Most participants expressed the feeling that the MTP approach was easy to conduct. Participants were optimistic that MTP could be implemented or used in combination with other approaches. Conclusions: The MTP approach is a combination of educational and managerial strategies. Because the MTP activity is self-initiated, self-planned, self-executed, and self-evaluated by the hospital team, this approach will be more acceptable to hospital managers. ABSTRACT

3. Background  Inappropriate prescribing practices in health facilities  Intervention to improve prescribing is uneasy to conduct, especially in private health facilities  Needs of self-initiative, self-conduct, self- assessment, self-decision making  Interventions needs to be encorporated in the existing management system

4. Indicator-based monitoring strategy  Self-monitoring approach to improve drug use practices (Sunartono & Darminto, 1996)  MTP (Monitoring - Training -Planning) approach to improve efficiency in drug management (MSH, 1998) MTP to improve drug use practices?

5. Objectives  To measure the effectiveness and usefulness of indicator-based MTP to improve prescribing practices:  general teaching hospitals  private hospitals  public hospitals

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

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

8. Priority problem -Overuse of ABs in hernia surgery -Overuse of ABs in scrotal hernia surgery - Overuse of ABs in acute diarrhea -Overuse of ABs in Caesarian surgery -Overuse of ABs in ARI -Overuse of ABs in diarrhea Priority problem -Overuse of ABs in hernia surgery -Overuse of ABs in scrotal hernia surgery - Overuse of ABs in acute diarrhea -Overuse of ABs in Caesarian surgery -Overuse of ABs in ARI -Overuse of ABs in diarrhea Site of intervention -Operation theatre -Operation theatre -Pediatric & Internal OPDs -Operation theatre -General OPD -General OPD Site of intervention -Operation theatre -Operation theatre -Pediatric & Internal OPDs -Operation theatre -General OPD -General OPD Health facility Teaching Hospital: - Sardjito - Karyadi Public Hospital: - Sleman - Yogya Private Hospital: - Panti Rapih - PKU Drug use problems

9. MTP at General Teaching Hospitals Problem: Pre- and post surgery ABs in elective hernia surgery Indicator: - % patients receiving antibiotics Result 1: Sardjito Teaching Hospital Revision of STG Karyadi Teaching Hospital

10. MTP at Public Hospitals Problem: - Overuse of AB in acute diarrhea (Sleman) - Pre- and post-surgery ABs in Caesarian surgery (Yogya) Indicator: - % patients receiving antibiotics Result 2: Sleman District Hospital Yogya District Hospital Discussion on STG and diagnosis

11. MTP at Private Hospitals Problem: - Overuse of antibiotics in acute respiratory tract infections - Overuse of antibiotics in acute diarrhea Indicator: - % patients receiving antibiotics Result 3: Panti Rapih HospitalPKU Hospital Clinicians refused the data Development of STG Impact of data collection?

12. Hospitals’ comments on MTP approach  Flexible approach, not time-consuming, not costly  A comprehensive approach, a combination of adult learning and managerial strategies  Encourage DTC to initiate activities  Encourage internal experts to contribute  Involved stakeholders in hospital  Good approach for sensitive issues, the “negative impacts” of promoting rational drug use can be discussed internally

13. Lessons learnt  Factors of success: Self-initiated and self-planned: idea for improvements was developed and decided within the group Self-initiated and self-planned: idea for improvements was developed and decided within the group Self-executed and self evaluated: empowerment of internal actors Self-executed and self evaluated: empowerment of internal actors  Comprehensive approach: educational & managerial  MTP can be conducted at low cost, using the existing mechanism and routine meetings in hospitals  MTP is promising for use in groups with high resistance