ABSTRACT

1. ABSTRACT Problem Statement: Low quality of care, including poor case management of major diseases, has been reported. Standard Treatment Guidelines (STG) were introduced to all prescribers at provincial hospitals to improve the situation, but the impact appeared to be insufficient. Objectives: To evaluate the effects of an educational intervention to improve treatment practices for malaria, diarrhea, and pneumonia. Design: Randomized controlled trial. Setting and Study Population: Eight provincial hospitals, matched into four pairs, with prescribers in 24 departments. The internal medicine, pediatrics, and outpatient departments in each pair were randomized into the intervention or control group. Intervention: A six-month intervention carried out by members of the Drug and Therapeutics Committees at the hospitals, comprised of monthly audit sessions in the form of outcome feedback using indicator scores on recorded treatment of malaria, diarrhea, and pneumonia. Outcome Measures: Change of treatment indicator scores for all three diseases (primary outcome) and for each disease (secondary outcome) six months after the end of the intervention compared to baseline. Results: The total mean score for all three diseases increased significantly more in the intervention group (from 6.48 to 7.94), compared with the control group (from 6.16 to 7.38). The scores for malaria and diarrhea also increased significantly more in the intervention group (from 6.44 to 8.66, and from 5.91 to 7.73, respectively). For pneumonia, the improvement was the same in both groups. Specific improvements in record keeping were seen for all three diseases. For malaria, there were improvements in recording patients’ history, and in frequency of microscope testing. For diarrhea, there were improvements regarding weight measurements, palpation of the fontanel for children under two years old, and reduction of irrational use of antidiarrheals. For pneumonia, there were improvements in recording respiratory count and in reducing irrational use of antihistamines and anti-cough medications. Conclusions: Audit-feedback systems to improve quality of care can be feasible and effective in hospital settings in low-income countries. Study funding: Swedish International Development and Co-operation Agency, Ministry of Health, Lao P.D.R.

2. 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 • The first STGs covered seven of the most common and burdening diseases (malaria, pneumonia, diarrhoea, parasitosis, dengue fever, tuberculosis, leprosy)

3. BACKGROUND • 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

4. 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

5. 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

6. 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

7. 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

8. 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 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

9. RESULTS

10. 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

11. 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

12. 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