MTP Approach Is Effective in Reducing Inappropriate Medicines Use in Hospitals

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MTP Approach Is Effective in Reducing
Inappropriate Medicines Use in Hospitals

• Sri Suryawati1 Budiono Santoso2
• 1Center for Clinical Pharmacology Medicines
  Policy Studies, Gadjah Mada University,
  Yogyakarta
• 2WHO Western Pacific Regional Office, Manila

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Abstract
Problem Statement ICIUM 1997 recommended 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. Considering the active roles of
clinicians, an approach to changing prescribing
practices in hospitals should ideally be
self-initiated, self-executed, and
self-evaluated. Objective To develop,
field-test, and implement a monitoring-training-pl
anning (MTP) approach to reduce inappropriate use
of medicines for specific disease problems as
defined by each hospital. Indicators Percentage
of patients receiving particular medicines under
investigation (e.g., intravenous IV fluids in
normal delivery, IV fluids in cranial trauma,
antibiotics in normal delivery), after the
hospital has undergone several MTP
meetings. Design The MTP approach focuses on the
quality improvement process. Therefore, its
effectiveness in improving prescribing is
evaluated by a before-and-after intervention
without control design, in each activity
site. Study Population Patients with specific
disease problems as defined by each
hospital. Intervention An MTP team is set up in
each hospital each team identifies a priority
problem and then plans a series of MTP meetings
involving managers and prescribers who contribute
to the problem. As there are routine technical
meetings in hospitals, the MTP meetings can be
easily slipped in. In brief, the monitoring
component is identifying and defining the
severity of a problem the training component is
solving the problem and the planning component
is setting the target of improvement. One problem
usually requires 35 MTP meetings. When the
problem has been solved, the team may address
another problem. Outcome Measures Reduction of
the percentage of patients receiving
inappropriate medicines, and if data are
available, reduction of medicine costs. Results
Following a successful field test in Indonesia
involving 6 hospitals, Cambodia (13 hospitals)
and Laos (28 hospitals) have implemented the
approach with good results. The use of
inappropriate medicines has been significantly
reduced in both countries, including the overuse
of IV fluids. Conclusions This experience showed
that an MTP approach is effective for reducing
inappropriate medicine use in hospitals,
especially among hospitalized patients. Moreover,
such an approach can be implemented at minimum
cost, and can be incorporated into existing
hospital managerial activities.
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Improving drug use in hospital?

• Inappropriate prescribing practices in hospitals
• Improve prescribing in hospitalized patients is
  more complicated
• Ideal mechanism
  
• self-initiative, self-conduct, self-assessment
• by Hospital Drugs Therapeutics Committees or
• Technical Committees
• Activities should be incorporated in the existing
  management system

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What is MTP?

• Monitoring - Training - Planning

Description of the recent situation
Setting the target of improvement
Reflection of previous experience
T

• Adult learning process

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What is Monitoring-Training-Planning?

• Monitoring (problem identification and
  measurement)
• Identify the specific drug use problem, select a
  priority problem, determine drug use indicator(s)
  and data source, identify the target of
  intervention. When MTP has been running follow
  up commitments from the previous session,
  evaluate the result of improvement, conclude the
  achievement
• Training (problem solving)
• Discuss the problem why, what are the
  motivation, underlying factors, etc., collect
  scientific information, collect supporting
  information, discuss how to solve the problem,
  experience in the past, solve the problem,
  agreements to make changes
• Planning (setting target for improvement)
• Set a target of improvement, set measures to
  achieve target, assign who is responsible for
  executing the plan, set the date for the next MTP
  session, assign person(s) to collect data and
  present it in the next MTP session

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Flow of MTP activities

• 3-4 cycles for each problem
• Simultaneous or parallel activities

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MTP implementation in hospital?

• Set up the hospital core MTP team, with supports
  from Managers
• Plans for MTP activities, assign MTP Group(s)
  involving the targets of intervention
• Plan activities in MTP Groups
• Identification and involvement of internal
  resources
• Conducting MTP sessions
• Periodic evaluations

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Distribution of activities (examples)
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MTP reduces inappropriate use of medicines
Some examples of achievement

• Hospital Drug use problem Achievement

Battambang, Cam Kandal, Cam Siem Reap, Cam
Kampong Cham, Cam Bokeo, Lao Xayaboury,
Lao Saravane, Lao Sleman, Indo Panti Rapih,
Indo Karyadi, Indo
70 to 59 to 0 100 to 15 100 to 63 100 to
36 100 to 33 78 to 29 to 23 96 to 10 83
to 23 to 13 67 to 12 and 33 to 2 94 to
45 85 to 8
Overuse of iv fluids in normal delivery in
Maternity Ward Overuse of antibiotics in normal
delivery in Maternity Ward Overuse of antibiotics
in Traumatology Ward Overuse of antibiotics in
post-Caesarean surgery Overuse of antibiotics in
post- scrotal hernia surgery Overuse of IV fluids
in Emergency Department Overuse of injection in
malaria treatment Overuse of antibiotics in
diarrhea Overuse of antibiotics in diarrhea in
Adult Pediatric OPDs Overuse of antibiotics in
outpatient ARI Overuse of antibiotics in pre-
scrotal hernia surgery
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Sleman experience (Yudatiningsih et al., 2004)
patient receiving antibiotics
MTP at 24 HCs
Feedback in month-14
Feedback in month-30
Feedback in month-45
Feedback

• Sleman started MTP in 1999 for overuse of
  antibiotics in ARI, with good results
• Skills in conducting MTP was well-adopted by
  health center staff
• Since then MTP has also been used for other drug
  use problems
• Less-frequent feedback is needed, after adopting
  MTP people are responsive to feedbacks

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Cambodia Experience (Srun Sokhan, 2004)

• Beginning August 2001, MOH-Cambodia pilot-tested
  the MTP implementation in 6 referral hospitals,
  focused on drug use problems in hospitalized
  patients
• A National Evaluation Workshop was conducted in
  March 2002, showing good results, 4 hospitals
  succeeded, 2 faced problems
• Beginning October 2002, the second pilot-test was
  conducted, involving the previous 6 hospitals and
  6 more hospitals.
• The 2nd National Evaluation Workshop in October
  2003 showed good results, most hospitals
  succeeded
• Cambodia plans to implement MTP nation wide, as
  an approach to improve the appropriate use of
  drugs

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Discussions

• Some hospitals failed, due to weak support frm
  hospital directors, wrong selection of core MTP
  Team, too many problems to solve at the same
  time, or confused with other on-going projects
• Training in conducting MTP is transferring the
  skills to initiate, execute, and evaluate
  activities in improving drug use. In other words,
  it sets up capacity building in improving drug
  use problems in health facilities
• Although data are limited, it is reported that
  less-frequent feedback is needed to make the
  improvement sustainable. This will lessen the
  workload of supervision in the health care
  system.

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Conclusions

• MTP approach is effective for reducing
  inappropriate medicine use in hospitals,
  including drug use problems in hospitalized
  patients.
• MTP approach is feasible to implement at minimum
  cost, and feasible to be incorporated in the
  existing hospital managerial activities.
• MTP approach is promising for a nation-wide
  implementation