MTP Approach Is Effective in MTP Approach Is Effective in Reducing Reducing Inappropriate Medicines Use Inappropriate Medicines Use

in Hospitalsin Hospitals

Sri SuryawatiSri Suryawati11 & Budiono& Budiono SantosoSantoso22

11Center for Clinical Pharmacology & Medicines Center for Clinical Pharmacology & Medicines Policy Studies, Gadjah Mada University, Policy Studies, Gadjah Mada University,

YogyakartaYogyakarta22WHO – Western Pacific Regional Office, ManilaWHO – Western Pacific Regional Office, Manila

Problem Statement:Problem Statement: ICIUM 1997 recommended that a successful intervention should focus on ICIUM 1997 recommended that a successful intervention should focus on a specific problem, address the underlying factors, use a problem-solving approach, repeat the 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 intervention, be interactive, provide feedback to prescribers, and be followed by monitoring and supervision. Considering the active roles of clinicians, an approach to changing prescribing supervision. Considering the active roles of clinicians, an approach to changing prescribing practices in hospitals should ideally be self-initiated, self-executed, and self-evaluated. practices in hospitals should ideally be self-initiated, self-executed, and self-evaluated. Objective:Objective: To develop, field-test, and implement a monitoring-training-planning (MTP) approach To develop, field-test, and implement a monitoring-training-planning (MTP) approach to reduce inappropriate use of medicines for specific disease problems as defined by each to reduce inappropriate use of medicines for specific disease problems as defined by each hospital.hospital.Indicators:Indicators: Percentage of patients receiving particular medicines under investigation (e.g., Percentage of patients receiving particular medicines under investigation (e.g., intravenous [IV] fluids in normal delivery, IV fluids in cranial trauma, antibiotics in normal intravenous [IV] fluids in normal delivery, IV fluids in cranial trauma, antibiotics in normal delivery), after the hospital has undergone several MTP meetings.delivery), after the hospital has undergone several MTP meetings.Design:Design: TheThe MTP approach focuses on the quality improvement process. Therefore, its MTP approach focuses on the quality improvement process. Therefore, its effectiveness in improving prescribing is evaluated by a before-and-after intervention without effectiveness in improving prescribing is evaluated by a before-and-after intervention without control design, in each activity site.control design, in each activity site.Study Population:Study Population: Patients with specific disease problems as defined by each hospital. Patients with specific disease problems as defined by each hospital.Intervention:Intervention: An MTP team is set up in each hospital; each team identifies a priority problem An MTP team is set up in each hospital; each team identifies a priority problem and then plans a series of MTP meetings involving managers and prescribers who contribute to and then plans a series of MTP meetings involving managers and prescribers who contribute to the problem. As there are routine technical meetings in hospitals, the MTP meetings can be easily the problem. As there are routine technical meetings in hospitals, the MTP meetings can be easily slipped in. In brief, the monitoring component is identifying and defining the severity of a slipped in. In brief, the monitoring component is identifying and defining the severity of a problem; the training component is solving the problem; and the planning component is setting problem; the training component is solving the problem; and the planning component is setting the target of improvement. One problem usually requires 3–5 MTP meetings. When the problem the target of improvement. One problem usually requires 3–5 MTP meetings. When the problem has been solved, the team may address another problem. has been solved, the team may address another problem. Outcome Measures:Outcome Measures: Reduction of the percentage of patients receiving inappropriate medicines, Reduction of the percentage of patients receiving inappropriate medicines, and if data are available, reduction of medicine costs.and if data are available, reduction of medicine costs.Results:Results: Following a successful field test in Indonesia involving 6 hospitals, Cambodia (13 Following a successful field test in Indonesia involving 6 hospitals, Cambodia (13 hospitals) and Laos (28 hospitals) have implemented the approach with good results. The use of hospitals) and Laos (28 hospitals) have implemented the approach with good results. The use of inappropriate medicines has been significantly reduced in both countries, including the overuse of inappropriate medicines has been significantly reduced in both countries, including the overuse of IV fluids.IV fluids.Conclusions:Conclusions: This experience showed that an MTP approach is effective for reducing This experience showed that an MTP approach is effective for reducing inappropriate medicine use in hospitals, especially among hospitalized patients. Moreover, such inappropriate medicine use in hospitals, especially among hospitalized patients. Moreover, such an approach can be implemented at minimum cost, and can be incorporated into existing hospital an approach can be implemented at minimum cost, and can be incorporated into existing hospital managerial activities. managerial activities.

AbstractAbstract

Improving drug use in Improving drug use in hospital?hospital?

Inappropriate prescribing practices in hospitalsInappropriate prescribing practices in hospitals Improve prescribing in hospitalized patients is Improve prescribing in hospitalized patients is

more complicatedmore complicated

Ideal mechanism: Ideal mechanism: self-initiative, self-conduct, self-assessmentself-initiative, self-conduct, self-assessmentby Hospital Drugs & Therapeutics Committees by Hospital Drugs & Therapeutics Committees or or Technical CommitteesTechnical Committees

Activities should be incorporated in the existing Activities should be incorporated in the existing management systemmanagement system

What is What is MTP?MTP? Monitoring - Monitoring -

Training - Training - PlanningPlanning

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

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

PP

MM

Reflection of Reflection of previous experienceprevious experience

TT

What is Monitoring-Training-What is Monitoring-Training-Planning?Planning? Monitoring Monitoring (problem identification and (problem identification and

measurement)measurement)Identify the specific drug use problem, select a priority problem, Identify the specific drug use problem, select a priority problem, determine drug use indicator(s) and data source, identify the target of determine drug use indicator(s) and data source, identify the target of intervention. When MTP has been running: follow up commitments from intervention. When MTP has been running: follow up commitments from the previous session, evaluate the result of improvement, conclude the the previous session, evaluate the result of improvement, conclude the achievement achievement

TrainingTraining (problem solving) (problem solving)Discuss the problem: why, what are the motivation, underlying factors, Discuss the problem: why, what are the motivation, underlying factors, etc., collect scientific information, collect supporting information, etc., collect scientific information, collect supporting information, discuss how to solve the problem, experience in the past, solve the discuss how to solve the problem, experience in the past, solve the problem, agreements to make changesproblem, agreements to make changes

PlanningPlanning (setting target for improvement) (setting target for improvement)Set a target of improvement, set measures to achieve target, assign Set a target of improvement, set measures to achieve target, assign who is responsible for executing the plan, set the date for the next MTP who is responsible for executing the plan, set the date for the next MTP session, assign person(s) to collect data and present it in the next MTP session, assign person(s) to collect data and present it in the next MTP sessionsession

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

MTP implementation in MTP implementation in hospital?hospital?

Set up the hospital core MTP team, with Set up the hospital core MTP team, with supports from Managerssupports from Managers

Plans for MTP activities, assign MTP Group(s) Plans for MTP activities, assign MTP Group(s) involving the targets of interventioninvolving the targets of intervention

Plan activities in MTP GroupsPlan activities in MTP Groups Identification and involvement of internal Identification and involvement of internal

resources resources Conducting MTP sessionsConducting MTP sessions Periodic evaluationsPeriodic evaluations

Distribution of activities Distribution of activities (examples)(examples)

Approachthe

professor

Providemicrobial culture

Provide articles

Approach the Director

Collect indicators

MTP teamsat ward/unit

level

MTP teamMTP teamat hospital levelat hospital level

MTP reduces inappropriate use of MTP reduces inappropriate use of medicinesmedicines

Hospital Drug use problem AchievementHospital Drug use problem Achievement

Battambang, CamKandal, CamSiem Reap, Cam Kampong Cham, Cam

Bokeo, LaoXayaboury, LaoSaravane, LaoSleman, IndoPanti Rapih, IndoKaryadi, Indo

Overuse of iv fluids in normal delivery in Maternity WardOveruse of antibiotics in normal delivery in Maternity WardOveruse of antibiotics in Traumatology WardOveruse of antibiotics in post-Caesarean surgeryOveruse of antibiotics in post- scrotal hernia surgeryOveruse of IV fluids in Emergency DepartmentOveruse of injection in malaria treatmentOveruse of antibiotics in diarrheaOveruse of antibiotics in diarrhea in Adult & Pediatric OPDsOveruse of antibiotics in outpatient ARIOveruse of antibiotics in pre- scrotal hernia surgery

70% to 59% to 0%100% to 15%100% to 63%100% to 36%100% to 33%78% to 29% to 23%96% to 10%83% to 23% to 13%67 to 12% and 33 to 2%94% to 45%85% to 8%

Some examples of achievement:Some examples of achievement:

Sleman experienceSleman experience (Yudatiningsih et al., 2004)

Feedback

0

20

40

60

80

100

Ags99 Nop99 Feb-00 Mei00 Ags00 Des00 Mrt01 Jun01. Sep01. Des01. Apr02. Jul02. Okt02. Jan03. Apr03. Ags03.

% patient receiving antibiotics

MTP at 24 HCs

Feedbackin month-14

Feedback in month-30 Feedback

in month-45

Sleman started MTP in 1999 for overuse of antibiotics in ARI, Sleman started MTP in 1999 for overuse of antibiotics in ARI, with good resultswith good results

Skills in conducting MTP was well-adopted by health center Skills in conducting MTP was well-adopted by health center staffstaff

Since then MTP has also been used for other drug use Since then MTP has also been used for other drug use problemsproblems

Less-frequent feedback is needed, after adopting MTP Less-frequent feedback is needed, after adopting MTP people are responsive to feedbackspeople are responsive to feedbacks

Cambodia Cambodia Experience Experience (Srun & Sokhan, 2004)

Beginning August 2001, MOH-Cambodia pilot-tested Beginning August 2001, MOH-Cambodia pilot-tested the MTP implementation in 6 referral hospitals, the MTP implementation in 6 referral hospitals, focused on drug use problems in hospitalized patients focused on drug use problems in hospitalized patients

A National Evaluation Workshop was conducted in A National Evaluation Workshop was conducted in March 2002, showing good results, 4 hospitals March 2002, showing good results, 4 hospitals succeeded, 2 faced problemssucceeded, 2 faced problems

Beginning October 2002, the second pilot-test was Beginning October 2002, the second pilot-test was conducted, involving the previous 6 hospitals and 6 conducted, involving the previous 6 hospitals and 6 more hospitals.more hospitals.

The 2The 2ndnd National Evaluation Workshop in October National Evaluation Workshop in October 2003 showed good results, most hospitals succeeded2003 showed good results, most hospitals succeeded

Cambodia plans to implement MTP nation wide, as an Cambodia plans to implement MTP nation wide, as an approach to improve the appropriate use of drugsapproach to improve the appropriate use of drugs

DiscussionsDiscussions Some hospitals failed, due to: weak support frm Some hospitals failed, due to: weak support frm

hospital directors, wrong selection of core MTP hospital directors, wrong selection of core MTP Team, too many problems to solve at the same Team, too many problems to solve at the same time, or confused with other on-going projectstime, or confused with other on-going projects

Training in conducting MTP is transferring the Training in conducting MTP is transferring the skills to initiate, execute, and evaluate activities skills to initiate, execute, and evaluate activities in improving drug use. In other words, it sets up in improving drug use. In other words, it sets up capacity building in improving drug use capacity building in improving drug use problems in health facilitiesproblems in health facilities

Although data are limited, it is reported that Although data are limited, it is reported that less-frequent feedback is needed to make the less-frequent feedback is needed to make the improvement sustainable. This will lessen the improvement sustainable. This will lessen the workload of supervision in the health care workload of supervision in the health care system. system.

ConclusionsConclusions

MTP approach is effective for reducing MTP approach is effective for reducing inappropriate medicine use in hospitals, inappropriate medicine use in hospitals, including drug use problems in including drug use problems in hospitalized patients. hospitalized patients.

MTP approach is feasible to implement MTP approach is feasible to implement at minimum cost, and feasible to be at minimum cost, and feasible to be incorporated in the existing hospital incorporated in the existing hospital managerial activities. managerial activities.

MTP approach is promising for a nation-MTP approach is promising for a nation-wide implementationwide implementation