Improving Patient Outcomes and Reducing Expenditures through increased compliance with Standard Treatment Guidelines (STGs) for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in Ilembe District, KZN

Vani Naidoo Manager :Pharmaceutical Services ILembe District Office Sushila Reddy Stanger Hospital Pharmacy Manager Vimal Singh Montebello Hospital Pharmacy Manager

HST Conference 5 May 2016

Outline of Presentation Background

Current Situation

Policies and Legislation

Stakeholder Analysis

Monitoring and Evaluation plan

Root Cause Analysis

Methodology

Findings/Results

Cost Considerations

Impact of project on work environment

Lessons learnt

Way forward

Conclusion

References

Acknowledgements

Background

POPULATION

662 413

Sundumbili CHC

Stanger Regional Hospital

Montebello District Hospital

No of Regional Hospitals 1

No of District Hospitals 3

No of Community Health Centre's

2

No of PHC Clinics 31

Background cont…

• NSAIDS widely used for management of pain &

inflammation

• Rational prescribing imperative

• Extensive range of side effects ( gastric, renal,

cardiovascular)

• Different levels of care provided at selected sites

• Common problem: non-adherence to STG /Essential Medicines List (EML)

• KZN and facility ABC analyses 2012-2013: Indomethacin suppositories was an A category item

Background cont…

Facility Annual Usage (units)

2012/2013

Annual Expenditure

in Rands

ABC Category

Stanger 15 624 R 312 480 A

Montebello 3 880 R 77 600 A

Sundumbili 6 552 R 131 040 A

PPSD 707 613 R 13 275 845 A

Background cont…

Rational Prescribing

STG audits for Compliance

Improving Patient Outcomes

Current Situation

Cu

rre

nt

Situ

atio

n

Ass

ess

me

nt Knowledge of STG/EML

Prescription compliance with STG/EML on NSAIDS

Baseline Audit 2013– Knowledge of STG/EML

• Pharmacy and Therapeutics Committee (PTC) meetings were not held or did not address relevant STG issues

• Doctors and pharmacists did not have a clear understanding of role of EML and National Drug Policy (NDP)

Pharmacy Department Quality Evaluation Survey on EML and STGs Instructions to respondents: Please place a cross in the appropriate box for each of the questions 1. Have you heard of EML and STG? Yes No 2. What do EML and STG stand for? EML: ______________________________________________________ STG: ______________________________________________________ 3. Have you had formal training on EML and STG? (Formal = trained in undergraduate curriculum or attended a workshop training programme) Yes No 4. How would you rate your current knowledge of EML and STG on a scale of 1 to 5? 1= poor I do not understand EML/STG and do not use it 2= marginal I have a vague understanding of it and use it sometimes 3= satisfactory I have a fair understanding and use it sometimes 4= good I have a good knowledge on EML/STG and use it often 5= excellent I have an excellent knowledge base about EML/STG and use it. 5. Would you like to have regular training on EML/STG?

Yes No If yes, what aspects of EML/ STG training will you like to receive? _________________________________________________________ Thank you for your participation.

Baseline Assessment Tool – Doctors and Pharmacists

Doctors and pharmacists self rating of STG /EML knowledge and training audit - August 2013

67% 70%

20%

85%

100%

10%

98% 90% 90%

0102030405060708090

100

Stanger[n=55] Montebello [n=10] Sundumbili [n=10]

Per

cen

tage

of

do

cto

rs a

nd

ph

arm

acis

ts

% Less than Good Knowledge

% No Formal training

% Requested Training

Name of Institution

Baseline Audit : Prescription compliance with STG/EML on NSAIDS

• No institutional policy regarding NSAID use

• KZN PTC 2010 NSAID policy was not yet aligned with 2012 STG/EML

Baseline Results of Prescription Audit

Stanger Montebello Sundumbili

Prescriptions

Number of Acute Prescriptions 100 50 27

Number of Chronic Prescriptions 100 50 73

Total Number of Prescriptions 200 100 100

% Prescriptions with Multiple NSAIDs 1.5 0 0

Compliance % Compliance with Prescriber Level

98 95 100

% Compliance with STG/EML/KZN PTC/Institution Policy

57 60 37

Impact of Current Situation Poor knowledge of current policy and guidelines

Non-compliance with STG/EML

Irrational prescribing

Increased risk of side effects

Increased risk of co-morbidities

Increased burden of disease

Erratic stock quantification

Inappropriate use of medicines

budget

Inefficient Service Delivery

Challenge

How can we improve the percentage compliance with STG/EML for NSAIDS, in adult prescriptions at the three

facilities identified, given that

There are poorly functioning institutional PTCs with regard to the National Drug Policy

and Standard Treatment Guidelines

There is poor compliance of prescriptions with STG/EML

National Drug Policy of South Africa (1996)

Rational Drug Prescribing

Cost-effective Drug usage

Public Finance Management Act 1 (1999)

Effective budget utilisation

STG/EML Hospital Level (2006, 2012)

Reference for previous and current guidelines

KZN PTC Policy on NSAIDS (2010)

Current provincial guidelines

Relevant Policies & Legislation

Stakeholder Analysis

Rational use of

NSAIDs

Medical Officers

Dentists

Pharmacists

Pharmacy Manager

Medical Manager

PTC Members

Monitoring and Evaluation Plan

Indicator Definition Data Source

Data Collection method

Frequency of data collection

1. Percentage prescriptions compliant with STG for NSAID’s

No of doctor’s prescriptions compliant with STG(NSAIDS)/ Total prescriptions for NSAIDS audited NSAID, EML, STG, compliance= appropriate prescribing as per STG/EML : dose, frequency, duration, prescriber level

Patient files and prescriptions

Record Review

Baseline: daily for 2 weeks in August 2013 and January 2014

2. No. of health care workers (HCW) trained on STG/EML

HCW = doctors and pharmacists at hospitals and CHC; Trained: attended an in-house workshop on STG/

Tool - Individual Register

Presentation October 2013

MISSION

To enable accessible, co-ordinated, integrated pharmaceutical services based on principles of rational drug use to

provide cost-effective quality care to all stakeholders in Ilembe

VISION

Quality pharmaceutical services for a happy healthy Ilembe

Measurable Result

To improve % of prescriptions for adult patients compliant with EML/STG to NSAIDS by 20% in 1 Regional Hospital [Stanger] 1 District Hospital [Montebello] and 1 CHC [Sundumbili ] by Jan

2014

Current Situation

There is 57%, 60% and 37% prescription compliance to STG/ EML on NSAIDS at Stanger, Montebello and Sundumbili respectively

Obstacles and Root Causes

• Provincial / Institutional Policy on use of NSAIDS not clear and updated as per hospital EML 2012 .

• Institutional PTCs not optimally functional • EML not a standing item on the agenda • Lack of in-service training and orientation on STG • Poor translation of KZN PTC decisions into

policy/practice

Challenge

How can we improve percentage prescriptions compliant with STG/EML for NSAIDS by 20% ,considering there is a poor functioning of institutional PTC with regard to NDP, STG and EML and health care workers’ orientation

Priority Actions

Train and orientate all prescribers and pharmacists on compliance with STGs

Strengthen PTC with NDP and EML Focus

Strengthen communication between provincial and district/institutional PTCs

Root Cause Analysis

POLICIES

PEOPLE

PROCESSES AND PROCEDURES

Policies • Provincial / Institutional PTC Policy

on use of NSAIDS not clear and updated as per Hospital EML 2012

Processes and procedures • Institutional PTCs not optimally functional • EML not a standing item on institutional PTC

agenda • Lack of training and orientation on STGs/EML • Poor translation of KZN PTC decisions into

policy/practice

People • Lack of knowledge • Resistance to comply

Poor compliance with NSAIDS prescribing, in accordance with STG/EML, resulting in irrational medicine usage and poor patient management.

INTERVENTIONS

Action Time Period

1. Strengthened communication with prescribers and pharmacists by including STG on monthly PTC agendas

August 2013

2. Aligned institutional NSAID Policy with that of KZN PTC Policy at Stanger Hospital

August 2013

3. Conducted training on National Drug Policy, STGs/ EML on NSAIDS

October 2013

4. Monitored prescriptions and provided additional support to prescribers

November-December 2013

5. Re-audited prescriptions for compliance January 2014

FINDINGS/ RESULTS

Results : No of Doctors & Pharmacists trained on STG/EML/NDP/NSAIDs

FACILITY DOCTORS TRAINED PHARMACISTS TRAINED

STANGER HOSPITAL 45 11

MONTEBELLO HOSPITAL 8 2

SUNDUMBILI CHC 8 4

TOTAL 61 17

% Compliance with STG/EML for NSAIDS

57 60

37

94

68 67

0

20

40

60

80

100

Stanger(n=200) Montebello(n=100) Sundumbili(n=100)

Pe

rce

nta

ge P

resc

rip

tio

ns

com

plia

nt

wit

h

STG

/EM

L

Facility Baseline Compliance to STG/EML 2013

Post-intervention Compliance to STG/EML 2014

Results cont…

• More requests received from doctors for copies of EML/ STG.

• More discussion on other STG by doctors and pharmacists.

• Increased referencing of EML by both doctors and pharmacists.

Example of Potential Cost Savings (2013)

Treatment Arm Prescription Cost/patient per month

Annualised Cost per 1000 patients

Non-compliant NSAID usage for treatment of Osteoarthritis

Indomethacin 100mg suppository 1 nocte x 1/12 (30)

R60 per patient/month (R20/10 supps)

R720 000/1000 patients per annum

Compliant NSAID usage for treatment of Osteoarthritis

Ibuprofen 400mg tds x 1/12 (84)

R7.71 per patient/month (R7.71/ 84 tabs)

R92 520/1000 patients per annum

Difference

R627 480/1000 patients per annum

Discussion

• All facilities showed improvement in compliance of prescriptions with STG for NSAIDs

• Sundumbili CHC and Stanger Hospital achieved greater than the targeted 20% improvement in compliance

• Stanger Hospital attained the highest improvement (37%) due to a functional PTC, improved communication between prescribers and pharmacists and consistent monitoring and intervention by pharmacists.

Discussion

• Montebello achieved an 8% improvement in compliance:

• Although all stakeholders were trained , monitoring and intervention by pharmacists was poor

• Peer review showed that Stanger and Sundumbili had greater success than Montebello due to active intervention by pharmacists, post-training

• The work climate in this facility still needed to be analysed further

Impact of project on work environment

• Attitudes and Relationships across teams

• The Pharmacist in Multi Disciplinary Team was recognized as integral member in promoting rational drug use

Impact of project on work environment cont……

• Less resistance to change due to increased awareness of current policy and legislation.

• As understanding of NDP and EML became clearer there was commitment and improved communication.

Lessons learnt

• Imparting knowledge effects change on a larger scale.

Lessons learnt- leading & managing principles Changing work environment requires constant use of leading and managing principles.

Leading principles:

• Inspire and motivate relevant stakeholders to work towards common goals.

• Projects can be completed with commitment.

• Commitment versus Compliance

• TEAM - Together Everyone Achieves More

Managing principles

• Importance of Policy Implementation

• Monitoring and Evaluation

Way forward 1. Continue with PTC having STG/EML as standing item on the

agenda.

2. Monitor prescriptions on a daily basis for compliance to STGs across many diseases and present to management at clinical forums

3. Address deviations and non compliance with relevant prescribers and Medical Managers

4. Provide feedback to prescribers and pharmacists

5. Introduce STG/EML training as part of the annual orientation programme for new doctors and pharmacists

Inspiration……

The

journey of a

1000 miles

Begins

with a

single step…. Chinese philosopher-Lao-tzu

References

• National Drug Policy, 1996, National Department of Health

• Essential Medicines Lists- Hospital Level, 2006 and 2012

• Minutes of KZN PTC, 2010 to 2013

• Public Finance Management Act 1 of 1999

Acknowledgements

• KZN Pharmaceutical Services

• SIAPS/MSH /USAID (this work was presented previously at the final PLDP Presentation to USAID)

• Institutional Management and Pharmacy Staff at Stanger , Montebello, Sundumbili CHC

• Pharmacy Manager Sundumbili CHC

• Doctors and Pharmacists

• Our team members

The End Thank You Siyabonga Siyabulela