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ABSTRACT
Problem Statement: Low quality of care, including poor case
management of major diseases, has been reported. Standard Treatment
Guidelines (STG) were introduced to all prescribers at provincial hospitals
to improve the situation, but the impact appeared to be insufficient.
Objectives: To evaluate the effects of an educational intervention to
improve treatment practices for malaria, diarrhea, and pneumonia.
Design: Randomized controlled trial.
Setting and Study Population: Eight provincial hospitals, matched into
four pairs, with prescribers in 24 departments. The internal medicine,
pediatrics, and outpatient departments in each pair were randomized into
the intervention or control group.
Intervention: A six-month intervention carried out by members of the
Drug and Therapeutics Committees at the hospitals, comprised of monthly
audit sessions in the form of outcome feedback using indicator scores on
recorded treatment of malaria, diarrhea, and pneumonia.
Outcome Measures: Change of treatment indicator scores for all three
diseases (primary outcome) and for each disease (secondary outcome) six
months after the end of the intervention compared to baseline.
Results: The total mean score for all three diseases increased significantly
more in the intervention group (from 6.48 to 7.94), compared with the
control group (from 6.16 to 7.38). The scores for malaria and diarrhea also
increased significantly more in the intervention group (from 6.44 to 8.66,
and from 5.91 to 7.73, respectively). For pneumonia, the improvement was
the same in both groups. Specific improvements in record keeping were
seen for all three diseases. For malaria, there were improvements in
recording patients’ history, and in frequency of microscope testing. For
diarrhea, there were improvements regarding weight measurements,
palpation of the fontanel for children under two years old, and reduction of
irrational use of antidiarrheals. For pneumonia, there were improvements in
recording respiratory count and in reducing irrational use of antihistamines
and anti-cough medications.
Conclusions: Audit-feedback systems to improve quality of care can be
feasible and effective in hospital settings in low-income countries.
Study funding: Swedish International Development and Co-operation
Agency, Ministry of Health, Lao P.D.R.
BACKGROUND
• Low quality of care, including
poor case management of major
diseases at provincial hospitals
(malaria, diarrhoea, pneumonia)
• Limited opportunity for
prescribers to be trained and to
learn about new treatment
options and new technologies.
• Standard Treatment Guidelines
(STGs) were developed within
the NDP program
• The first STGs covered seven of
the most common and burdening
diseases (malaria, pneumonia,
diarrhoea, parasitosis, dengue
fever, tuberculosis, leprosy)
BACKGROUND
• STGs were introduced to all
prescribers at provincial
hospitals
• Drug and Therapeutics
Committees (DTCs), were
established to be instrumental
for Rational Use of Drugs
(RUD), including use of
practice guidelines
• To facilitate implementation of
an audit-based system,
performance indicators were
developed for RUD and the new
STGs
OBJECTIVES
• To assess the effects of an
educational intervention on
management of three
common diseases (malaria,
pneumonia, and diarrhea)
using performance
indicators and an auditfeedback approach
• The hypothesis was that
the overall treatment score
(primary) and treatment
scores for each disease
(secondary) will be
improved
METHODS
• RANDOMIZED
CONTROLLED TRIAL
• 8 provincial hospitals (with
functioning DTC)
• 24 selected Departments (12
intervention & 12 control)
• OPD, pediatric, internal
medicine
• Pair-wise balanced block
design (4 pairs)
• Participants (n=122): doctors
& medical assistants
• Duration: June 1999 to
August 2000
ASSESSMENT OF
CLINICAL PERFORMANCE
• Using existing STG indicators
• selected aspects of the
diagnostic and treatment
components for case
management
• Source of information: record
keeping book
• 30 selected patients per disease
• Data collectors: DTC members
• The STG indicator scores
measured with three months
intervals per disease
• Maximum score for each
indicator: 10
INTERVENTION
• Pre-intervention period:
Introduction of STG (JuneSeptember 1999), monthly
measurement of indicators
• Regular feedback session
with interactive discussions
(September 1999 to February
2000)
• One disease per month to be
addressed
• Content of Feedback
session: reflection on the
feedback & discussions on
how to improve performance
RESULTS: Comparison of regular
introduction of STG with intensive
feedback discussions
Primary outcome:
• Total mean score for all three diseases
increased from 6.16 to 7.38 (control) and
from 6.48 to 7.94 (intervention)
Secondary outcome:
• Treatment indicators scores of each
disease increased in both control and
intervention
• The difference in improvement for the
mean score for all three diseases was
statistically significant in favor of the
intervention group
Typical Case Management: Improved in
some diagnostic components of the
treatment indicator
• Malaria patient: weight, history,
microscopy testing
• Diarrhea: weight, history, palpating the
fontanel in children <2, not using AB, Info
on how to use ORS
• Pneumonia: history, recording RC, less
anti-histamine & anti-cough medication,
better follow up
Malaria
Diarrhea
Pneumona
Intervention group
10
9
8
7
6
5
4
3
2
1
0
Pre-intevention
intervention
After 3 months
intervention
After 6 months
post intervention post intervention
3 months
6 months
Tim e
Control group
9
8
7
6
scores
Scores
RESULTS
5
4
3
2
1
0
Pre-intevention
intervention
After 3 months
intervention
After 6 months
Time
post intervention
3 months
post intervention
6 months
CONCLUSION &
RECOMMENDATIONS
• A systematically organized
education program with
repeated feedback meetings
improved the performance of
prescribers
• The record keeping system
was improved and became a
good source for calculating
scores
• The audit-feedback model
can be used systematically &
become integrated into
routine work
Key lessons
• Indicators are a useful tool to get
relevant material for feedback to
prescribers related to STGs
• The effect is probably enhanced
through analysis of the
indicators and identification of
messages for change
• Group discussions with
prescribers, facilitated by DTC
members, is an essential part of
an educational intervention
• This audit-feedback procedure
should be used on a routine
basis
• Indicators should be constantly
monitored and changed if
reaching high scores
Implications for implementing
policy and programs to
improve use of medicines
Short term
• Time and resources are needed
to support DTC work of this kind
• Time is also needed for staff to
participate in group discussions
on feedback
Long term
• STGs should be developed for
most important clinical problems
• Indicators should be developed
in connection with the STGs