ABSTRACT

1. ABSTRACT Problem statement: The Lao PDR National Drug Policy (NDP) Program, implemented by the Ministry of Health supported by the Swedish International Development Agency, has rational use of drug as one component. The NDP aims to improve the prescribing in hospitals through Drug and Therapeutic Committee (DTC), using indicators, regular meeting, and feedback to all prescribers. The MTP approach. implemented in 2001, provided hospitals with a complementary tool for intervening on smaller scale problems and structures. Hospitals focused on solving problems that had not responded well to the previous DTC approach. Objective: To evaluate the effectiveness of the MTP approach in reducing irrational use of drugs for specific diseases, with targets defined by individual departments in study hospitals. Setting: Initially implemented in 11 provincial hospitals then extended to 14 provincial and 14 district hospitals. Study Design: Before and after design Population: Specific problems, and patient populations were defined by each hospital. Intervention: The MTP approach involves a series of small group discussions among prescribers in individual hospital departments. After training in the use of MTP, these groups: defined a problem of interest, selected targets to be achieved, applied a problem solving approach, and monitored indicators to observe response. Outcome measures: Depended on the target problem; examples include % receiving injection, % receiving antibiotics, % receiving IV fluids, waiting time, correct diagnosis. Results: The MTP approach frequently met defined targets in 2-3 monthly meeting cycles; in some hospitals, targets were not met, but decision makers were satisfied enough to move to another problem. Bokeo Hospital aimed to reduce waiting time for ultrasound from 43 minutes to 20 minutes, after 2 cycles, waiting time was 25 minutes. Saravan Hospital increased recording of respiratory rate in pediatric pneuminia from 60% to 80% (3 cycles). Vientiane (Lao-Luxembourg) Hospital aimed to reduce post-operative antibiotic prescription from 60% to 45% and achieved rate of 49% (3 cycles). Mahosoth Central Hospital reduce injections from 78% to 51% of patients, and reduce post-operative antibiotic use from 46% to 29% (3 cycles). Mittaphap Central Hospital reduce IV fluid use for gastritis from 78% to 46% and antibiotic use from 40% to 20% (3 cycles). Oudomxay Hospital reduce antibiotic use in out patients from 60% to 45% (3 cycles). Conclusion: The MTP approach was effective in solving drug use problems in in small setting, especially district hospitals and departments of provincial and central hospitals. Problem defined by the DTC research process (Hospital Medical Routine) were solved by the MTP approach. Therefore, the MTP has been extended to 23 district hospitals and will be to all hospitals in the country.

2. BACKGROUND • Irrational use of drug, including over prescription, prescription of brand name, prescription out of essential drug list, high antibiotic use, high injection use, irrational use IV fluid, the prescription unclear • Limited opportunity prescribers to be trained or trained different institution or project, • National Drug Policy (NDP): Component 2 Rational Use of Drug (RUD) Standard Treatment Guideline (STG) were develop and introduced to all prescribers at central and provincial hospital • Drug and Therapeutic Committee (DTC) established in all provincial and central hospitals to monitored RUD and STG implemented. • Monitoring Training Planning (MTP) team were established in central hospitals, some provincial and district hospitals

3. OBJECTIVES • To evaluate the effectiveness of the MTP approach in reducing irrational use of drugs for specific diseases, with targets defined by individual departments in study hospitals. • To train the MTP technique to the prescribers to solves the drug problem by themselves and to be sustainable

4. MONITORING • Identify the specific drug use problems • Select a priority problem • Determine indicators and data source • Identify the target of intervention When MTP has been running: • Follow up commitments from the previous session • Measure the impact of intervention • Conclude the achievement

5. TRAINING • Discuss the problem agreed in the Monitoring in more details • Collect supporting information • Collect related scientific information to set up the norms or standard reference, e.g., reference books, standard treatment guidelines, etc. • Collect information about the intervention efforts considered effective, and to discuss the suitable intervention strategy to choose. • Agree upon an intervention strategy and to discuss the intervention steps.

6. PLANNING • Set a target of achievement • Set measures to achieve target, including the sequence of activity, the program, and the person responsible for execution. • Agree on who is responsible for the execution of the plan. • Facilitate communication and coordination among MTP team members • Agree upon schedule of the next MTP session.

7. RESULTS • The MTP approach frequently met defined targets in 2-3 monthly meeting cycles; in some hospitals, targets were not met, but decision makers were satisfied enough to move to another problem.

8. ANTIBIOTIC USE

9. Respiratory rate Waiting time

10. IV fluid and Injection

11. CONCLUSION • The MTP approach was effective in solving drug use problems in small setting, especially the specific problem in the departments of hospitals. • The MTP can solve any problems by discussion and agreement in the teamwork • The MTP were useful at the district level

12. Key lessons • Team development • Supports from hospital • Scenario • Distribution of activities within MTP team • Identification of internal resources • Conducting MTP session