急性呼吸道疾病抗生素的超量使用的预防-(英文)REDUCING-ANTIBIOTIC-OVERUSE.ppt

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1、REDUCING ANTIBIOTIC OVERUSE for ARIs with SMALL-GROUP EDUCATIONAL INTERVENTIONMunawaroh S1,Sunartono H2,Suryawati S31INRUD Yogya/Indonesia;2Sleman District Health Office;3Department of Clinical Pharmacology,Gadjah Mada University,IndonesiaABSTRACTProblem Statement:Problem Statement:Standard Treatmen

2、t Guidelines(STG)and a diagnosis flow chart for acute respiratory tract infections Standard Treatment Guidelines(STG)and a diagnosis flow chart for acute respiratory tract infections(ARIs)for the health centre(HC)level were developed and distributed by the Ministry of Health of Indonesia in 1983 and

3、 1991(ARIs)for the health centre(HC)level were developed and distributed by the Ministry of Health of Indonesia in 1983 and 1991 respectively.However,the excessive use of antibiotics in treating ARI in HCs demonstrate that the STG and flow chart are not respectively.However,the excessive use of anti

4、biotics in treating ARI in HCs demonstrate that the STG and flow chart are not followed.followed.Objectives:Objectives:To reduce antibiotic overuse by paramedics for treating ARI at the HC level utilizing a small group educational To reduce antibiotic overuse by paramedics for treating ARI at the HC

5、 level utilizing a small group educational intervention.intervention.Design:Design:Randomized pre-post study.Randomized pre-post study.Setting and Population:Setting and Population:In the Bantul District,18 HCs were randomly assigned as follows:6 HCs were assigned to undergo In the Bantul District,1

6、8 HCs were randomly assigned as follows:6 HCs were assigned to undergo Small-Group Discussions(SGDs)about the ARI STGs and feedback(FB)meetings in 2 consecutive months to discuss Small-Group Discussions(SGDs)about the ARI STGs and feedback(FB)meetings in 2 consecutive months to discuss problems with

7、 implementing the recommended changes in prescribing(Group A);6 HCs were assigned to undergo SGDs problems with implementing the recommended changes in prescribing(Group A);6 HCs were assigned to undergo SGDs without FB meetings(Group B);and 6 HCs acted as controls(Group C).SGDs were conducted in ea

8、ch HC in the two without FB meetings(Group B);and 6 HCs acted as controls(Group C).SGDs were conducted in each HC in the two intervention groups and participated in by 7-9 paramedics,with one paramedic acting as facilitator and the HC doctor invited intervention groups and participated in by 7-9 par

9、amedics,with one paramedic acting as facilitator and the HC doctor invited as resource person.Prescribing practices were measured by surveys of 100 paramedics prescriptions per HC per month for 3 as resource person.Prescribing practices were measured by surveys of 100 paramedics prescriptions per HC

10、 per month for 3 months before the intervention,1 month post-SGD,and 1 month after each FB session(post-FB1months before the intervention,1 month post-SGD,and 1 month after each FB session(post-FB1 and FB2).Prescriptions and FB2).Prescriptions were required to have ARI as a single diagnosis;both und

11、er-five and adult patients were sampled.Without doctors were required to have ARI as a single diagnosis;both under-five and adult patients were sampled.Without doctors awareness,doctors prescriptions were also sampled by the same method.awareness,doctors prescriptions were also sampled by the same m

12、ethod.Outcome measures:Outcome measures:Percentage of antibiotic use in patients with ARI.Percentage of antibiotic use in patients with ARI.Results:Results:Comparing prescribing at baseline to post-FB2,paramedics in Group A showed a reduction in antibiotic use for ARI Comparing prescribing at baseli

13、ne to post-FB2,paramedics in Group A showed a reduction in antibiotic use for ARI from 49.5%to 29.2%(-20.3%).In Group B,antibiotic use was reduced from 75.1%at baseline to 53.9%(-21.2%).In Group C,from 49.5%to 29.2%(-20.3%).In Group B,antibiotic use was reduced from 75.1%at baseline to 53.9%(-21.2%)

14、.In Group C,paramedics antibiotic use did not change(56.6%paramedics antibiotic use did not change(56.6%to 60.0%).Doctors antibiotic use in Group A was reduced from 49.7%to to 60.0%).Doctors antibiotic use in Group A was reduced from 49.7%to 30.0%(-19.7%)and in group B from 63.6%to 54.7%(-8.9%).In g

15、roup C,doctors antibiotic use also did not change(58.6%30.0%(-19.7%)and in group B from 63.6%to 54.7%(-8.9%).In group C,doctors antibiotic use also did not change(58.6%to to 57.3%).57.3%).Conclusion:Conclusion:An intervention using SGDs either with or without FB can decrease antibiotic prescribing b

16、y paramedics in ARI An intervention using SGDs either with or without FB can decrease antibiotic prescribing by paramedics in ARI treatment,bringing it more in accordance with national STGs.There was also a change in the prescribing of doctors who treatment,bringing it more in accordance with nation

17、al STGs.There was also a change in the prescribing of doctors who attended the SGDs as resource persons,despite the fact that paramedics were the targets of the intervention.Further studies attended the SGDs as resource persons,despite the fact that paramedics were the targets of the intervention.Fu

18、rther studies must demonstrate that this reduced antibiotic use in ARI treatment can be sustained.must demonstrate that this reduced antibiotic use in ARI treatment can be sustained.Study Funding:Study Funding:Applied Research for Child Health(ARCH)Project No.012/1999(65%),WHO fellowship(20%),and Se

19、lf-Applied Research for Child Health(ARCH)Project No.012/1999(65%),WHO fellowship(20%),and Self-funding(15%).funding(15%).BACKGROUNDvvMOH of Indonesia has developed STG and a MOH of Indonesia has developed STG and a diagnosis flow chart for ARIs for HC level in 1983 diagnosis flow chart for ARIs for

20、 HC level in 1983 and 1991,respectively.and 1991,respectively.vvThe excessive use of antibiotics in treating simple The excessive use of antibiotics in treating simple ARI in HCs demonstrates that the STG and flow ARI in HCs demonstrates that the STG and flow chart are not followed.chart are not fol

21、lowed.vvMany evidences showed inappropriate drug Many evidences showed inappropriate drug treatment for ARI,including indiscriminate use of treatment for ARI,including indiscriminate use of antibiotics.antibiotics.vvSpecial efforts are needed to reduce the overuse of Special efforts are needed to re

22、duce the overuse of antibiotics.antibiotics.OBJECTIVESGeneral ObjectiveGeneral ObjectiveTo improve the quality of care of ARI patients(adult To improve the quality of care of ARI patients(adult and child)in HCsand child)in HCsSpecific ObjectivesSpecific ObjectivesvvTo improve specific prescribing pr

23、actices in the To improve specific prescribing practices in the treatment of ARI,including:treatment of ARI,including:vvreducing the overuse of antibioticsreducing the overuse of antibioticsvvreducing the overuse of antihistaminereducing the overuse of antihistaminevvreducing the number of drugs per

24、 encounterreducing the number of drugs per encountervvTo compare the effectiveness of SGD,with-and To compare the effectiveness of SGD,with-and without feedback,in improving ARI treatment.without feedback,in improving ARI treatment.METHODS(2)18 HCsGroup A(6 HCs)Group A(6 HCs)Group B(6 HCs)Group B(6

25、HCs)Group C(6 HCs)Group C(6 HCs)SGDSGDFB1FB2-C O N T R O LC O N T R O LFGDFGDBaselineBaselinePost Post SGDSGDPost Post FB1FB1Post Post FB2FB2FGD=Focus Group FGD=Focus Group DiscussionDiscussionSGD=Small Group SGD=Small Group DiscussionDiscussionFB =FeedbackFB =FeedbackDesignRandomizedAnalysisParaPar

26、aMETHODS(3)vvPrescribing SurveyPrescribing Surveyvv100 paramedics and 100 doctors prescriptions per HC per month at 100 paramedics and 100 doctors prescriptions per HC per month at each time point(total 7 time points)each time point(total 7 time points)vvPre-1,pre-2,pre-3 (3,2,and 1 months before th

27、e intervention)Pre-1,pre-2,pre-3 (3,2,and 1 months before the intervention)vvPara(preparation,1 month)Para(preparation,1 month)vvpost SGD(1 month after the intervention)post SGD(1 month after the intervention)vvpost FB1(2 months after the intervention)post FB1(2 months after the intervention)vvpost

28、FB2(3 months after the intervention)post FB2(3 months after the intervention)vvTotal amount of sample:100 prescriptions x 7 time points x 2 Total amount of sample:100 prescriptions x 7 time points x 2 providers x 18 HCs=25.200 prescriptionsproviders x 18 HCs=25.200 prescriptionsvvData presentationDa

29、ta presentationvvPercentage of patients with ARI receiving antibioticsPercentage of patients with ARI receiving antibioticsvvPercentage of patients with ARI receiving antihistamines Percentage of patients with ARI receiving antihistamines vvAverage number of drugs per prescriptionAverage number of d

30、rugs per prescriptionvvStatistical analysisStatistical analysisvvt-test is used to compare reduction of pre vs post interventiont-test is used to compare reduction of pre vs post interventionvvanova is used to compare reduction of Group A vs Group B vs Group anova is used to compare reduction of Gro

31、up A vs Group B vs Group C CRESULT(1),RESULT(1),REDUCTION OF ANTIBIOTICS USEParamedics prescriptionsDoctors prescriptionsSGDFB1FB2SGDFB1FB2RESULT(3),RESULT(3),NUMBER OF DRUGS PER ENCOUNTERParamedics prescriptionsDoctors prescriptionsSGDFB1FB2SGDFB1FB2DISCUSSIONS(1)1.1.Printed material for Small-Grou

32、p DiscussionsPrinted material for Small-Group DiscussionsBesides the existing STG and flowchart of ARI treatment,the research team also Besides the existing STG and flowchart of ARI treatment,the research team also prepared booklet on how to treat ARI in HCs.Findings from FGD,also incorporated prepa

33、red booklet on how to treat ARI in HCs.Findings from FGD,also incorporated in this booklet.This printed material were distributed few days before the SGD,so in this booklet.This printed material were distributed few days before the SGD,so all paramedics had time to read them.all paramedics had time

34、to read them.2.2.Small-Group Discussion Small-Group Discussion SGD was conducted in all HC is intervention group.Besides printed material,result SGD was conducted in all HC is intervention group.Besides printed material,result of baseline prescription survey was also presented in this forum.Confront

35、ing their of baseline prescription survey was also presented in this forum.Confronting their prescribing practice shown by the result of baseline prescribing survey to the STG prescribing practice shown by the result of baseline prescribing survey to the STG became a trigger for the lively discussio

36、n.At the end,all paramedics reached an became a trigger for the lively discussion.At the end,all paramedics reached an agreement on how to treat ARI in daily practice.This agreement proven to be agreement on how to treat ARI in daily practice.This agreement proven to be important as it served as a g

37、roup pressure for all paramedics.important as it served as a group pressure for all paramedics.3.3.FeedbackFeedbackIn group A,feedbacks were given twice,in the form of monthly prescribing survey In group A,feedbacks were given twice,in the form of monthly prescribing survey of respective HC after th

38、e SGD.The main topics of discussion were comparing the of respective HC after the SGD.The main topics of discussion were comparing the feedback with the baseline prescribing survey and problems faced in implementing feedback with the baseline prescribing survey and problems faced in implementing the

39、 STG in daily practice.At the end,paramedics reached agreement on how to the STG in daily practice.At the end,paramedics reached agreement on how to solve the problems in treating ARI in their HC.It showed in the result that group A solve the problems in treating ARI in their HC.It showed in the res

40、ult that group A had more sustainable improvements compared to group B which did not receive had more sustainable improvements compared to group B which did not receive feedbacks.feedbacks.CONCLUSIONSvvSmall Group Discussions followed by Feedbacks Small Group Discussions followed by Feedbacks reduce

41、d the overuse of antibiotics and other reduced the overuse of antibiotics and other unnecessary drugs in the treatment of ARI in adult unnecessary drugs in the treatment of ARI in adult and children in Health Center level.and children in Health Center level.vvSmall Group Discussions among paramedics

42、 with a Small Group Discussions among paramedics with a trained paramedic facilitator and a doctor as a trained paramedic facilitator and a doctor as a resource person provided fora for paramedics to resource person provided fora for paramedics to discuss and solve problems in ARI treatment.Such dis

43、cuss and solve problems in ARI treatment.Such forum would be also ideal for other medical problems.forum would be also ideal for other medical problems.vvRepeating intervention is necessary to reinforce the Repeating intervention is necessary to reinforce the agreement reached in previous discussions to agreement reached in previous discussions to maintain the impact of the intervention.maintain the impact of the intervention.