MTP Approach to Reduce MTP Approach to Reduce Inappropriate Use of Inappropriate Use of Antibiotics in Hospitals: Antibiotics in Hospitals: Results of the Field Test Results of the Field Test

Suryawati S, Setiyawati E, Saleh-Suryawati S, Setiyawati E, Saleh-Danu S, Rustamaji A, Santoso BDanu S, Rustamaji A, Santoso B

Center for Clinical Pharmacology and Center for Clinical Pharmacology and Medicine Policy StudiesMedicine Policy Studies

Gadjah Mada University, Yogyakarta.Gadjah Mada University, Yogyakarta.

Problem Statement: Experience showed 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. Moreover, indicator-based monitoring strategies with feedback were found to be effective in improving drug use practices. Unfortunately, few data have been compiled from hospitals.Objective: To develop and field-test an innovative MTP (Monitoring-Training-Planning) approach to reducing inappropriate prescribing in hospitals.Indicators: Percentage of patients receiving antibiotics (AB) after hernia surgery and cesarean surgery, percentage of patients with diarrhea receiving AB, percentage of patients with acute respiratory tract infection (ARI) receiving AB, etc. Design: Field tests were conducted in 6 hospitals: 2 public hospitals (Sleman and Yogyakarta), 2 private hospitals (PKU and Pantirapih), and 2 teaching hospitals (Sardjito and Karyadi). These hospitals were selected based on convenient sampling. The field test included 3 consecutive MTP meetings in each hospital. The impact of MTP was evaluated by comparing the indicators prior to the implementation of MTP (baseline) and after, for each specific drug use problem identified in each hospital. Process evaluation was also undertaken at each hospital.Study Population: Patients with specific disease problems as defined by each hospital.Intervention: An MTP team was set up in each hospital. Each team chose a priority problem and planned 3 consecutive MTP meetings involving managers and prescribers. Each meeting was about 2–3 hours. Outcome Measures: Reduction of percentage of patients receiving AB.Results: All facilities reported that MTP reduced inappropriate AB use. Sleman reduced AB use for adult diarrhea from 67% to 8%, and for children’s diarrhea from 33% to 0. Yogyakarta reduced AB use postcesarean from 100% to 0. PKU reduced AB use for nonspecific diarrhea from 21% to 4%, and Pantirapih reduced AB use for adults with ARI from 94% to 45%. Sardjito reduced AB use post–hernia surgery from 100% to 13%, and Karyadi reduced AB use post–scrotal hernia surgery from 85% to 8%. Most participants expressed the feeling that the MTP approach was easy to conduct. Participants were optimistic that MTP could be implemented or used in combination with other approaches.Conclusions: The MTP approach is a combination of educational and managerial strategies. Because the MTP activity is self-initiated, self-planned, self-executed, and self-evaluated by the hospital team, this approach will be more acceptable to hospital managers.

ABSTRACTABSTRACT

BackgroundBackground Inappropriate prescribing practices in Inappropriate prescribing practices in

health facilitieshealth facilities Intervention to improve prescribing is Intervention to improve prescribing is

uneasy to conduct, especially in private uneasy to conduct, especially in private health facilitieshealth facilities

Needs of self-initiative, self-conduct, self-Needs of self-initiative, self-conduct, self-assessment, self-decision making assessment, self-decision making

Interventions needs to be encorporated in Interventions needs to be encorporated in the existing management systemthe existing management system

Indicator-based monitoring Indicator-based monitoring strategystrategy

Self-monitoring Self-monitoring approach to improve drug approach to improve drug use practices (Sunartono use practices (Sunartono & Darminto, 1996)& Darminto, 1996)

MTP MTP (Monitoring - (Monitoring - Training -Planning)Training -Planning) approach to improve approach to improve efficiency in drug efficiency in drug management (MSH, management (MSH, 1998)1998)

0%

20%

40%

60%

80%

100%

1 3 5 7 9 11 13 15 17 19 21 23 25Control (12 HCs)

IGD (12 HCs)

MTP to improve drug use MTP to improve drug use practices?practices?

MTP to improve drug use MTP to improve drug use practices?practices?

ObjectivesObjectivesTo measure the effectiveness To measure the effectiveness

and usefulness of indicator-and usefulness of indicator-based MTP to improve based MTP to improve prescribing practices: prescribing practices:

general teaching hospitalsgeneral teaching hospitals private hospitals private hospitals public hospitalspublic hospitals

What is MTP?What is MTP?Monitoring - Training Monitoring - Training - Planning- Planning

Adult learning Adult learning processprocess

80%80%

20%20%

Setting the target Setting the target of improvementof improvement

Description of the Description of the recent situationrecent situation

Reflection of Reflection of previous experienceprevious experience

Problem solving & Problem solving & scientific/reality testingscientific/reality testing

P

M

T

Flow of MTP Flow of MTP activitiesactivities

• 3-4 cycles for each 3-4 cycles for each problemproblem

• Simultaneous or parallel Simultaneous or parallel activitiesactivities

TTMM

PP

TTMM

PP

TTMM

PP

TTMM

PP

TTMM

PP

MTP meetingMTP meeting MTP cycleMTP cycle

Priority problemPriority problem

-- Overuse of ABs in hernia Overuse of ABs in hernia surgery surgery -- Overuse of ABs in scrotal Overuse of ABs in scrotal hernia surgeryhernia surgery

- - Overuse of ABs in acute Overuse of ABs in acute diarrheadiarrhea-- Overuse of ABs in Caesarian Overuse of ABs in Caesarian surgerysurgery

-- Overuse of ABs in ARIOveruse of ABs in ARI-- Overuse of ABs in diarrheaOveruse of ABs in diarrhea

Site of Site of interventionintervention

--Operation theatre Operation theatre --Operation theatreOperation theatre

--Pediatric & Pediatric & Internal OPDsInternal OPDs--Operation theatre Operation theatre

--General OPDGeneral OPD--General OPDGeneral OPD

Health facilityHealth facility

Teaching Teaching Hospital: Hospital: - Sardjito - Sardjito - Karyadi - Karyadi

Public Hospital: Public Hospital:

- Sleman - Sleman - Yogya - Yogya

Private Hospital:Private Hospital:- Panti Rapih- Panti Rapih

- PKU- PKU

Drug use Drug use problemsproblems

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20%

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80%

100%

1st meeting 2nd meeting 3rd meeting

Pre-surgery

Post-surgery

MTP at General Teaching HospitalsMTP at General Teaching Hospitals

0%

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40%

60%

80%

100%

1st meeting 2nd meeting 3rd meeting

Problem: Pre- and post surgery ABs in elective hernia surgeryIndicator: - % patients receiving antibiotics

Result 1:Result 1:

Sardjito Teaching Hospital Sardjito Teaching Hospital

Revision of STG

Karyadi Teaching Karyadi Teaching Hospital Hospital

MTP at Public MTP at Public HospitalsHospitals

0%

20%

40%

60%

80%

100%

1st 2nd 3rd 4th 5th

Pediatric OPDInternal OPD

0%

20%

40%

60%

80%

100%

1st meeting 2nd meeting 3rd meeting

Pre-surgery

Post-surgery

Problem: - Overuse of AB in acute diarrhea (Sleman) - Pre- and post-surgery ABs in Caesarian surgery (Yogya)

Indicator: - % patients receiving antibiotics

Result 2:Result 2:

Sleman District HospitalSleman District Hospital Yogya District HospitalYogya District Hospital

Discussion on STG

and diagnosis

MTP at Private HospitalsMTP at Private Hospitals

0%

20%

40%

60%

80%

100%

1st meeting 2nd meeting 3rd meeting0%

20%

40%

60%

80%

100%

1st meeting 2nd meeting 3rd meeting

Problem: - Overuse of antibiotics in acute respiratory tract infections - Overuse of antibiotics in acute diarrhea

Indicator: - % patients receiving antibiotics

Result 3:Result 3:

Panti Rapih Hospital

PKU Hospital

Clinicians refused the data

Development of STG

Impact of data collection?

Hospitals’ comments on MTP Hospitals’ comments on MTP approachapproach Flexible approach, not time-consuming, Flexible approach, not time-consuming,

not costly not costly A comprehensive approach, a combination A comprehensive approach, a combination

of adult learning and managerial of adult learning and managerial strategiesstrategies

Encourage DTC to initiate activities Encourage DTC to initiate activities Encourage internal experts to contributeEncourage internal experts to contribute Involved stakeholders in hospitalInvolved stakeholders in hospital Good approach for sensitive issues, the Good approach for sensitive issues, the

“negative impacts” of promoting rational “negative impacts” of promoting rational drug use can be discussed internallydrug use can be discussed internally

Lessons Lessons learntlearnt Factors of success:Factors of success:

Self-initiated and self-planned: idea for Self-initiated and self-planned: idea for improvements was developed and decided within improvements was developed and decided within the groupthe group

Self-executed and self evaluated: empowerment of Self-executed and self evaluated: empowerment of internal actorsinternal actors

Comprehensive approach: educational & managerialComprehensive approach: educational & managerial MTP can be conducted at low cost, using the existing MTP can be conducted at low cost, using the existing

mechanism and routine meetings in hospitals mechanism and routine meetings in hospitals MTP is promising for use in groups with high MTP is promising for use in groups with high

resistanceresistance