P1252428582SyRor

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REDUCING ANTIBIOTIC OVERUSE FOR ACUTE RESPIRATORY
TRACT INFECTIONS WITH SMALL- GROUP EDUCATIONAL
INTERVENTION
Munawaroh S1, Sunartono H2, Suryawati
S3 1Yogyakarta Provincial Health Office 2Sleman
District Health Office 3Department of Clinical
Pharmacology, Gadjah Mada University, Indonesia
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BACKGROUND

• MOH of Indonesia has developed Standard Treatment
  Guidelines (STG) in 1983, and a diagnosis flow
  chart for ARIs for Health Center (HC) level in
  1991.
• The excessive use of antibiotics in treating
  simple ARI in HCs demonstrates that the STG and
  flow chart are not followed.
• Many evidences showed inappropriate treatment for
  ARI, including indiscriminate use of antibiotics.
• Previous studies showed that Small-Group
  Educational and Feedback are effective in
  improving drug use.

Special efforts are needed to reduce the overuse
of antibiotics
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OBJECTIVES

• General
• To improve the quality of care of ARI patients
  (adult and child) in HCs by applying Small-Group
  Discussion (SGD).
• Specific
• To improve specific prescribing practices in ARI,
  including
• reducing the overuse of antibiotics
• reducing the overuse of antihistamine
• reducing the number of drugs per encounter
• To compare the effectiveness of Small-Group
  Discussion, with-and without feedback (FB), in
  improving ARI treatment.

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METHODS (1)

• Location
• HCs in Bantul District, Indonesia
• Subject
• Paramedics (target intervention) and doctors (as
  resource person) in HCs
• Design
• Randomized controlled study with pre and post
  evaluation
• 18 HCs were randomly assigned into
• 6 HCs underwent SGDs followed by FB meetings in 2
  consecutive months (group A)
• 6 HCs underwent SGDs without FB meetings (group
  B)
• 6 HCs acted as controls (group C)

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METHODS (2)
Design
Group A (6 HCs)
SGD
FB1
FB2
18 HCs
Group B (6 HCs)
Randomized
Analysis
-
-
SGD
Group C (6 HCs)
C O N T R O L
FGD Focus Group Discussion SGD Small Group
Discussion FB Feedback
Timeline
Post FB2
Post FB1
Post SGD
Para
Baseline
FGD
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METHODS (3)

• Prescribing Survey
• 100 paramedics 100 doctors prescriptions per
  HC per month at each time point (total 7 time
  points)
• Pre-1, pre-2, pre-3 (3, 2, and 1 months before
  the intervention)
• Para (preparation, 1 month)
• post SGD, post FB1, post FB2 (1 month, 2 months,
  3 months after the intervention, respectively)
• Total amount of sample 100 prescriptions x 7
  time points x 2 providers x 18 HCs 25,200
  prescriptions
• Data presentation
• Percentage of patients with ARI receiving
  antibiotics
• Percentage of patients with ARI receiving
  antihistamines
• Average number of drugs per prescription
• Statistical analysis
• t-test to compare reduction of pre vs post
  intervention
• Anova to compare reductions of Group A vs Group B
  vs Group C

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RESULT (1) REDUCTION OF ANTIBIOTICS USE
patients receiving antibiotics
patients receiving antibiotics
Paramedics prescriptions
Doctors prescriptions
SGD
FB1
FB2
SGD
FB1
FB2
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RESULT (2) REDUCTION OF ANTIHISTAMINE USE
patients receiving antihistamine
patients receiving antihistamine
Paramedics prescriptions
Doctors prescriptions
SGD
SGD
FB1
FB2
FB1
FB2
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RESULT (3) NUMBER OF DRUGS PER ENCOUNTER
Paramedics prescriptions
Doctors prescriptions
SGD
SGD
FB1
FB1
FB2
FB2
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DISCUSSIONS (1)

• Interesting finding
• Although the target of intervention was
  paramedics, surprisingly the doctors
  prescriptions also improved.
• It means that there were double impacts of
  posing the doctors as resource persons.

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DISCUSSIONS (2)

• The key factors to the success of the
  intervention are
• Handy printed material, question answer format,
  problem-based
• Interactive, problem-solving Small-Group
  Discussion
• Feedbacks showing individual achievement
• Facilitators are recruited from the target of
  intervention
• Doctor as resource person is a strategy in
  improving doctors behavior

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CONCLUSIONS

• SGD followed by FBs reduced the overuse of
  antibiotics and other unnecessary drugs in the
  treatment of ARI in adult children in HC level.
• SGDs among paramedics with a trained paramedic
  facilitator and a doctor as a resource person
  provided fora for paramedics to discuss and solve
  problems in ARI treatment. Such forum would be
  also ideal for other medical problems.
• Repeating intervention is necessary to reinforce
  the agreement reached in previous discussions to
  maintain the impact of the intervention.
• Further studies are needed to find out
  sustainability of long term impact.

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Terima KasihThank you