Standard Treatment Guidelines.

DefinitionStandard Treatment Guideline —A systematically developed statement designed to assistpractitioners and patients in making decisions about appropriate health care for specific clinicalcircumstances.

The need: a solution to therapeutic anarchy

In modern medicine, there is the concept that there may be more than one treatment modality available for many medical conditions. This leads to confusion and in many cases incorrect treatment. Doctors, nurses, pharmacists, community health workers, and other health care providers learn about all of the treatments that could be used, instead of focusing on the best treatment that should be used.

Casual observation, as well as more systematic study of prescribing practices, frequently reveals a pattern of tremendous diversity among prescribers in the treatment of even the most common conditions.

Polypharmacy is also a problem

Other common problems are incorrect drug choices, overdosing, underdosing, and choice of more expensive drugs when less expensive drugs would be equally or more effective.

Features of STG

Standard treatment guidelines—also known as standard treatment schedules, standard treatment protocols, therapeutic guidelines, and so forth—list the preferred drug and nondrug treatments for common health problems experienced by people in a specific health system.

Each drug treatment should include for each health problem the name, dosage form, strength, average dose(pediatric and adult), number of doses per day, and number of days of treatment.

Other information on diagnosis and advice to the patient may also be included.

Standard treatments are used at different points of the therapeutic process. They may be used to diagnose, decide on treatment and drug supply, and assist with adherence to the prescribed treatment.

Experience shows that even the shortest essential drug list or formulary list offers ample opportunity to misuse drugs by improper treatment of common problems. Thus, essential drug programs are finding that the development of standard treatments is necessary for therapeutically effective and economically efficient use of drugs.

AdvantagesFor health care providersProvides standardized guidance to practitioners

Dictates the most appropriate drugs for useProduces the best quality of care since patients are receiving optimal therapyUtilizes only formulary drugs or essential drugs, so the system need only provide thedrugs in the guideline.Provides invaluable assistance to all practitioners, especially those with lower skilllevels, as it provides the guidelines necessary to ensure good-quality careEnables providers to concentrate on making the correct diagnosis because treatmentoptions will be provided for them.

For health care officialsProvides a system for controlling cost by using funds more efficientlyProvides the most effective therapy in terms of qualityProvides a basis for evaluating quality of care provided by the health careprofessionalsProvides information for practitioners to give to patients concerning the institution’sstandards of careCan be a vehicle for integrating special programs (diarrhea disease control, acuterespiratory infection, tuberculosis control, malaria) at the primary health carefacilities

For supply managementProvides information for forecasting and ordering (drugs and quantities for commondiseases will be known)Provides information for purchase of prepackaged drugs

For patientsPatients receive optimal drug therapyEnables consistent and predictable treatment from all levels of providers and at alllocations within the health care systemAllows for improved availability of drugs because of more consistent use andorderingEnables improved outcomes because patients are receiving the best treatmentregimens availableLowers cost

Disadvantages

Inaccurate or incomplete guidelines will provide the wrong information for providers andtherefore do more harm than good. Guidelines may not be based on the most reliableinformation.Updating guidelines is difficult and time-consuming and must be done on a regularschedule or they will become obsolete very quickly.Guidelines have been referred to as “cook book” medicine. They provide information totreat the population, but not necessarily the individual patient.Guidelines provide a false sense of security, i.e., many providers will limit theirevaluation of a particular patient as soon as it fits into a particular standard treatment.

Disadvantages of treatment guidelines do exist, but seldom are they proven to have any serious effects on overall patient outcomes.

ESTABLISHING THE GUIDELINE

1. Establish a committee to address the development of the guidelines.2. Develop an overall plan for guidelines.3. Identify the diseases that the STG will cover.4. Determine appropriate treatment options.

Use the fewest drugs necessary to treat the medical conditionChoose cost-effective treatmentUse formulary drugs (from local and national formularies)Give first-, second-, and third-line drugs when appropriateProvide dose and duration, contraindications, side effects

5. Determine what information should be included in the STG.Clinical condition, pathophysiology, diagnostic criteria, laboratory tests etcTreatment objectives (e.g., elimination of plasmodium from a blood smear)Nondrug treatmentDrugs of choice (and alternatives) for the medical conditionImportant prescribing information—dose, duration, contraindications, side

effects,warnings, drug interactionsReferral criteriaPatient education information

6. Draft the STGs for comments and pilot testing.7. Publish and disseminate.8. Revise and update.

Key features of a successful guide

SimplicityCredibility.Same standards for all levels—Doctors and other health care providers use the samestandard treatments. The referral criteria differ, but the first-choice treatment for a patientdepends on the patient’s diagnosis and condition, not on the prescriber. Drug supply based on standardsIntroduced in preservice trainingDynamic (regular updatesDurable pocket manuals

In terms of selection of health problems to be addressed, standard treatment falls into threecategories—

Individual—Standard treatments are prepared for only one problem or set of problems,such as only diarrheal disease, only ARI, or only malaria.

Selective—Standard treatments are prepared for a small number of high-priorityproblems, perhaps 6 to 12, for example, a “package” of treatments for diarrheal disease,ARI, antenatal care, immunization screening, malaria, and tuberculosis.Comprehensive—Standard treatments are prepared for 30, 50, 100, or even morecommon health problems. When published, such standard treatments become more liketextbooks than basic references.

IMPLEMENTING THE GUIDELINE

In terms of impact on prescribing and drug use patterns, the greatest weakness in past efforts tointroduce standard treatments has probably not been in the development of reasonable standards,but in the effective implementation of the standards once they have been developed. Prescribingpatterns change slowly; consequently, practitioners must be educated in the use and importanceof the guidelines. Marketing of the guideline will be very important.

The following are important elements for a plan to implement standard treatments:

Printed reference materialsOfficial launchInitial trainingReinforcement trainingMonitoringSupervision

In India

Standard treatments are currently in use in parts of the United States, Europe, Latin America,Asia(including India , Nepal , Bangladesh etc), Africa, and the Western Pacific.In India :Many states have already adopted Stg and successfully implemented at different levels.Eg Tamil Nadu , Andhra Pradesh , West Bengal etc have govt circulated stgs.Also many corporate and teaching hospitals have their own institutional stg which are close accordance with the recommended standards.

West Bengal

In pursuance to the decision of the Department of Health and Family Welfare, Government of West Bengal the IHFW Kolkata guided the development of a Standard Treatment Guidelines and an Operational Manual to streamline its implementation at the Basic/Primary level health care facilities. The aim is to standardize treatment, referral, prescribing habit, infrastructure, supplies, providing skilled manpower, monitoring and evaluation and maintenance and use of data. The process will lead to increased client, provider and management satisfaction; ensure quality of service and increased output.

Activities taken up : The document was piloted for a period of six months from July to December 2009 in the districts of North and South 24 Paraganas.

Following preparatory activities were taken up :

1. Printing of the STG

2. Printing of an Operational Manual to guide the implementation and evaluation of the effectiveness of the programme.

3. Training of the facility heads of the pilot districts by faculty members from Medical Colleges who prepared the STG.

4. Orientation of State and District Nodal Officers, State Level Monitoring Officers, faculty members of Kolkata based medical colleges and district and subdivision level monitoring officers. They were oriented on the use of tools for facility assessment including exit interview of clients, prescription auditing, identifying the gaps and adopting corrective actions at the local, district and state level.

5. Training of the data entry operators to capture the data generated during the facility assessment and its follow up actions.

The following documents have been developed for the above activities and will be available in the website :

1. Standard Treatment Guidelines

2. Operational Manual

3. Presentations use by the trainers while training on STG. The contact numbers of the trainers have been shown. These faculty members may be approached for any clarification on their subject. Presentation on Prescription Audit

4. Presentation on the training on facility assessment.

5. Presentation on the training on prescription audit

Etc etc etc