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Sabaydee

Sabaydee. 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.

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Sabaydee

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  1. Sabaydee

  2. 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 diseasesat 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 !

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