An Intervention To Improve Antibiotic Prescribing Habits of Doctors in a Teaching Hospital

2. An Intervention To Improve Antibiotic Prescribing Habits of Doctors in a Teaching Hospital Ofei F, Forson A, Tetteh R, Ofori-Adjei D University of Ghana Medical School, Korle-Bu Teaching Hospital and Noguchi Memorial Institute for Medical Research, Accra, Ghana.

3. Summary of the study aims and results • Objectives • Establish the magnitude of inappropriate prescribing for treatment of community-acquired lower respiratory tract infections (LRTI) • Implement a managerial and educational intervention selected by hospital consultants • Assess the effect of the intervention on the antibiotic prescribing habits of house officers for LRTI • Results • No change in behaviour observed

4. Study Design 1 Pre- Intervention Intervention Development Post- Intervention • 6 mo. • Batch • Baseline • # all drugs and AB • prescribed per patient • % by generic name • % on EDL • Therapeutic classes • Outcomes (duration, • clinical, cost) Discuss baseline data KAP by Questionnaire 6 mo. 6 mo. 6 mo. Batch Batch Batch 1 2 3  Focus Group Discussions Pre- house job KAP Questionnaire  Results of baseline data Talk on RDU New treatment guidelines In-depth Interviews  New treatment guidelines Post house job- KAP Questionnaire

5. Study Design 2 • Intervention directed at • Specific prescriber - house officer • First contact with patients • Least experienced • Specific problem – community acquired LRTI • common • ‘easy to diagnose’ • requiring antibiotics • Intervention • selected, accepted and supervised by their consultants • documented decision making by category of prescriber

6. Evaluation • Planned before the intervention implemented • Resources for evaluation planned alongside intervention • Parameters evaluated • KAP in antibiotic use pre-/post house job • Antibiotics prescribed • number per patient • by generic name • from EDL • % in accordance with guidelines • Quality of care • duration of admission • clinical outcome • cost

7. Challenging methodological issues • Regular change of house officers (and residents) • Unable to properly assess long-term improvement • Some groups were ‘freshmen’ others on a 2nd rotation • Prescribing experiences may be different • Study cost vs. study duration • Shorter duration would not allow proper assessment of sustainability of the intervention • Use of control group at separate hospital with ?different managerial and regulatory systems and other possible influences • The chances of “contamination” would be high if the study and control group were in the same hospital. • Better compromise

8. Strengths of this design • Prospective • Time series • better assesses sustainability of intervention in view of inevitable change of HO • ‘Double’ Control • Baseline data • Control site data • Allowed identification of problems intrinsic to the health facility

9. Weaknesses of this design • ‘Hawthorne’ effect cannot be fully excluded • Retrospective study not feasible • Pre-intervention data inadequate • Short pre-intervention data collection

10. Lessons learnt • Implement and evaluate on a • longer pre-intervention phase • ?varying experiences of 1st and 2nd rotation house officers • larger scale in different settings of similar standards • Establish on-going evaluation published as ‘league table’ • WHO/INRUD indicators per ward or consultant • Adherence to guidelines • ?more effective feedback

11. Questions for future research • Assessment of factors other than physician knowledge on prescribing • Influence of sales representatives on all categories of prescriber • Influence of national and hospital regulatory controls on prescribing • Patient access to unrestricted range of medicines • Patient pressure

12. Conclusion • There is no ‘gold standard’ • The multiple influences on prescribing require multiple interventional approaches and evaluations