Putting theory into practice: Lessons learned from

Antibiotics Smart Use Program

Nithima Sumpradit, Ph.D.1,2 Kanyada Anuwong, Ph.D.3

Pisonthi Chongtrakul, MD.4 Somying Pumthong, Ph.D.3

1. International Health Policy Program, Ministry of Public Health, Thailand2. Food and Drug Administration, Ministry of Public Health, Thailand3. Faculty of Pharmacy, Srinakarintharawiroj University, Thailand4. Faculty of Medicine, Chulalongkorn University, Thailand

The 4th National Health Research Forum to Promote the Health Research Systems Strengthening in Lao PDR

October 8, 2010

Shared issues

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To create societal change on rational use of medicines, we need to find a common area that everybody can work together.

Antibiotic resistance & Global warming

Picture source: http://ale1980italy.wordpress.com/

Similarities:• Burning issue but well- tolerated (no sense of urgency)• Everybody’s matters• Effects on mankind

Difference:Unlike the global warming, antibiotic resistance is not well-recognized among outsiders.

Antibiotics profile, Thailand

• Anti-infective drugs (including antibiotics) are the top value for being imported and manufactured since 2000. – In 2007, this drug group was accounted for approximately

20,000 m. baht (625 m. US$) or 20% of all medicine values.

Drug group Values (million baht)

Anti-infective drugs 20,094

Alimentary tract and metabolism 15,747

Central nervous system 13,719

Cardiovascular system 9,909Source: Drug Control Division, Food and Drug Administration, Thailand (2007).

Adverse Drug Reactions

Source: The 2009 Annual report of Food and Drug Administration, Thailand

Antibiotics are the

top of ADR reports.-In 2007, antibiotics are accounted for 54% of ADR reports from all medicines.

Top ten of medicines reported with ADR (2009)

Reports

Antibiotic resistance crisis

Source: http://www.weizmann.ac.il/molgen/Sorek/antimicrobials.html

In Thailand, Acinetobacter baumannii – resistance to Cabapenam increases from 2.1% in 1998 to 61% in 2010.

We cannot outrun bacteria. So, we must stop creating selective pressure on them.

unnecessary use of antibiotics

STOP

Bacteria/Microbes

Picture source: http://www.geology.wisc.edu/homepages/g100s2/public_html/Geologic_Time/Time_Clock.gif

Purposes of ASU1. To reduce unnecessary antibiotic use in three

common diseases:– Upper Respiratory Infection (URI) –cold with sore throat– Acute diarrhea e.g., food poisoning– Simple woundInclusion criteria: OPD patients, 2 years and older with overall good

health. Exclusion criteria: IPD patients, patients who are seriously ill or diabetic, or people with low or compromised immune system.

2. To create the decentralized, collaborative networks between national and local stakeholders.

- Well-accepted national policy on antibiotics- Social norms

Goal: To test the effectiveness of interventions in changing antibiotics prescribing behaviorSettings: 1 province (Saraburi) involving all 10 community hospitals and 87 primary health centers

Phase 1: Pilot project (2007 – 2008)

Goal: To test feasibility of program expansion and develop decentralized, collaborative networks.Settings: 3 provinces (large, medium & small provinces) and 2 hospital networks (public & private hospitals)

Phase 2: Scaling up feasibility (2008 – 2009)

Phase 3: Program sustainability (2009 – 2012)

Goal: To integrate ASU into national agenda on antibiotics and create social norms on proper use of antibioticsStrategy: Policy advocacy, Network strengthening & empowerment, Public communication & campaign

Diffusion update: Dec 2009

Antibiotics Smart Use Program (5 year)

First policy support was from the National Health Security Office (NHSO) in March 2009.

Conceptual framework

Versiom June 19, 2010 /Nithima Sumpradit

PatientsQuality of life

Prescribing behavior

Hospital / healthcare setting context

Intention

Knowledge, perception & attitude toward

disease & antibiotics

Subjective norm, perception of patients’

expectation

Enabling factors

Hospital formulary, Medical devices

Perceived behavioral control & Self-efficacy

Hospital networking context

Community context

National context

Indicator 1: Knowledge, attitude, self-efficacy, and intention

Indicator 3: Percent of targeted patients who were not prescribed with antibiotics

Indicator 4: Patients’ knowledge, perceived health and satisfaction

Reinforcing factors

Directive policyFinancial incentives

Predisposing factors

Cost

Indicator 2: Amount of antibiotics being prescribed

ASU Conceptual framework

Based on:PRECEDE-PROCEED planning modelTheory of Planned BehaviorSocial Cognitive Theory

Intervention Implementation

Intervention implementation• ASU is a voluntary program with an incentive policy support

from NHSO. – 10 good reasons to join ASU

• Local healthcare team (LHT) in each province or setting plans their own ASU project and can name their own project (sense of ownership).

• LHT can request support from the ASU program e.g., materials, speakers and technical support. Example of materials to be shown.

• LHT implements the program. Activities are for example:– Training or group discussion– Herbal medicine substitution– Local/Provincial policy– Positive competition / Campaign– Reminder (e.g., salary pay slip) – etc.

• The ASU program monitor progress from LHT and provide support to LHT.

Tools for prescribers (to educate and increase confidence)

Tools for patients (to lower expectation on antibiotics)

Examples of ASU tools

All supportive materials can be download from

http://newsser.fda.moph.go.th/rumthai/

RESULTS

Indicator 3: Percent of targeted patients who did not receive ABO (Goal: 20% increase)

0

10

20

30

40

50

60

70

80

Before After

Saraburi

Ayuthaya (control)

45.5

74.6

44.242.3

Intervention, N 8,099 Control, N 5,865

Sample: Two community hospitals and 4 primary health centers from an intervention province and the control provinceData analysis: Chi-square (before - after) (May–Oct 07 vs. Dec 07–May 08)

Source: Kunyada Anuwong & Somying Pumtong

Effects on prescribing behavior

% of patients not receiving antibiotics

Indicator 2: Change in antibiotics use (Goal: 10% reduction)

Data collection: Before (Dec 06–Oct 07) vs. After (Dec 07–Oct 08)Sample: All 10 community hospitals and 87 primary health

centers in Saraburi (RR = 50%)

Source: Kunyada Anuwong & Somying Pumtong

0

1

2

3

4

5

6

7

Before After

Amount of ABO (Capsules/Tablets)

0

2

4

6

8

10

12

Before After

Primary health centers

Community hospitals

-39%

-18%

-46%

-23%

Amount of ABO (Bottles)

• Result: antibiotics reduction is accounted for approximately 34,000 US$/year

Indication 4: Patients’ perception of health status and satisfaction despite no antibiotics prescription (Goal: 70%)

Source: Kunyada Anuwong & Somying Pumtong

Data collection: Telephone interviews targeted patients after their hospital visit for 7-10 daysSample: 3 settings (N = 2,286): Sarabuti province (n=1,200), Samutsongkarn province (n = 151), Srivichai private hospital (n = 917)

• Almost all patients (97.1%, 96% and 99.3%, respectively) were fully recovered or felt better.

• Over 80-90% were satisfied with medical services and treatment outcome and intended to return to this healthcare setting for the next medical visit.

Effects on patients’ health and satisfaction

Conclusion

• Purpose 1: Reduction of antibiotics use

– Based on a theoretically-guided, multifaceted interventions, ASU is successful in changing antibiotic prescribing behavior.

• Purpose 2: Developing decentralized, collaborative network between national and local stakeholders

• At the end of 2nd year, more than 10,000 people/ health professionals was trained and involved in this program

• Some local teams start to apply the ASU framework to irrational use of other medicines e.g., NSAIDs

• Local materials and media were initiated.

• Strengthening research capacity of local teams via their own ASU program (22 local projects on ASU in 2010)

• International collaboration opportunity e.g., exchange program and joined project

Saraburi province team“R2R Outstanding Award”

Ayutthaya province team “Excellence Poster Award”

Decentralized ASU networks

Local community leaders

ASU team @ community hospitalTraining session

ASU & partners

Villagers learning about ASU

Home visit

Primary health center

Project’s grand opening

Singing contest

Strengths and limitations• Strengths:

– Characteristics of the program • ASU concept is not complex and it is part of their routine work• Relatively advantage e.g., cost saving• Compatible with health professionals’ values e.g., patient safety• Observable outcomes e.g., patients’ recovery

– Multisectoral partners– Supportive mechanism for local healthcare teams – Autonomy “decentralization – sense of ownership”

• Limitations:– Limited resources– Resistance to change– Application to big hospitals or private healthcare setting

Thank you for your attention.Thank you for ASU partners and network.• Thai Food and Drug Administration• World Health Organization • Health Systems Research Institution• National Health Security Office• Drug System Monitoring and Development Center• Faculty of Medicine at Chulalongkorn University, Konkean

University and Thammasart University • Faculty of Pharmacy at Srinakarintharawiroj University,

Chulalongkorn University, Maha Sarakram University• Health professionals and participants in

• Saraburi, Ayutthaya, Samutsongkhram and Ubonratchathani • Kantang community hospital network • Srivichai private hospital network• many other provinces and settings

• International Health Policy Program, Thailand