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Improving the performance of Drug and Therapeutics Committees in hospitals – a quasi-experimental study in Laos

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Background and objectives Drug and Therapeutics Committees (DTCs), which are essential for ensuring the rational use of drugs (RUD) in hospitals, have recently been established in Laos. Sub-optimal performance had been reported. The aims of this
  Eur J Clin Pharmacol (2006) 62: 57  –  63DOI 10.1007/s00228-005-0069-8 PHARMACOEPIDEMIOLOGY AND PRESCRIPTION Chu Vang .Goran Tomson .Sengchan Kounnavong .Thanakhanh Southammavong .Amphayvanh Phanyanouvong .Rolf Johansson .Bo Eriksson .Rolf Wahlstrom Improving the performance of Drug and Therapeutics Committeesin hospitals  –  a quasi-experimental study in Laos Received: 25 September 2005 / Accepted: 14 November 2005 / Published online: 22 December 2005 # Springer-Verlag 2005 Abstract  Background and objectives:  Drug and Thera- peutics Committees (DTCs), which are essential for ensuring the rational use of drugs (RUD) in hospitals,have recently been established in Laos. Sub-optimal per-formance had been reported. The aims of this study wereto determine those factors in the working environment that relate to DTC performance in Lao hospitals and evaluatewhether DTC performance could be improved through aneducational intervention utilizing auditing and feedback targeted towards DTC members.  Methods:  This was aquasi-experimental (before and after) study. Two centraland seven provincial hospitals and the DTC members fromthese hospitals participated in the study. Performance of the DTCs was assessed by means of specifically devel-oped indicators on structure and process combined withindicators for RUD and adherence to Standard Treatment Guidelines (STG). Data were collected for a 3-month period at baseline and for three consecutive periodsthereafter. The results of the first three data collectionswere shared and discussed with the DTC members duringfeedback sessions. The DTC members were also inter-viewed in order to identify factors they thought may havean impact on DTC performance.  Results:  Following theintervention, there was a significant improvement in theoverall score for DTC performance (  p <0.001) and, in par-ticular, in general activity and feedback and drug infor-mation to staff. The STG scores also improved (  p <0.01).Interviews indicated that one negative factor was theexperience of the DTC members being overloaded withother work, resulting in DTC meetings being held ir-regularly and drawing poor attendance.  Conclusion:  Con-tinuous self-monitoring of performance by means of indicators, followed by feedback discussions, is sug-gested the means of improving the work of the DTC. Keywords  Drug and Therapeutics Committee .Standard Treatment Guidelines .Rational use of drug .Health systems research .Lao PDR  Introduction The problems associated with the irrational use of drugsand self-medication are international and have been re- ported to be widespread [11, 20]. The Lao People ’ sDemocratic Republic (Laos) is no exception [12, 15  –  17].Laos is one of the world ’ s poorest countries with a GDP per capita of about 310 USD per year. Health indicators are C. Vang ( * )Department of Cardiology, Mahosot Hospital,Vientiane, P.O. Box 5202,Lao People ’ s Democratic Republic (Laos)e-mail: wachuvang@yahoo.comTel.: +856-21-214026Fax: +856-21-450002 G. Tomson .R. Johansson .R. Wahlstrom ( * )Division of International Health (IHCAR),Karolinska Institutet,Stockholm, Swedene-mail: rolf.wahlstrom@ki.seTel.: +46-8-52483355Fax: +46-8-311590 G. TomsonMedical Management Center,Karolinska Institutet,Stockholm, SwedenT. SouthammavongOut-patient Department,Mahosot Hospital,Vientiane, LaosS. Kounnavong National Institute of Public Health (NIOPH),Vientiane, LaosA. PhanyanouvongCurative Department,Ministry of Health,Vientiane, LaosB. Eriksson Nordic School of Public Health,Goteborg, Sweden   poor with an infant mortality rate of 82 per 1000 live birthsand a maternal mortality rate of 530 per 100,000 live births.Life expectancy is oneof the lowest in the region  –  57 yearsfor men and 61 years for women [9].Drug and Therapeutics Committees (DTCs) wereintroduced into a number of high-income countries decadesago as a means to improve the use of medicines, and theyhave gradually spread into low-income countries as well[14]. The establishment of DTCs has been reported toimprove drug use and reduce costs in hospitals and asso-ciated health care facilities [4, 22]. The tasks of a DTC relate to all aspects of drug management, including de-veloping locally adapted drug policies, evaluating andselecting drugs for the formulary list, developing, adaptingand implementing standard treatment guidelines, assessingdrug use to identify problems, conducting interventions toimprove drug use, managing adverse drug reactions andrectifying medication errors [4]. The establishment of committees bearing the responsibility for carrying out thesetasks has been encouraged and promoted in developingcountries through a combination of training and follow-upsupport [3]. However, very little information is available onthe effectiveness of DTCs in developing countries.The hospital system in Laos is almost exclusively publicwith a few central hospitals and 18 provincial hospitals.Government expenditure on health is only about 4 USD per  person per year, and out-of-pocket expenditure on drugsand hospital services is high.Indicators for   “ Rational Use of Drugs ”  (RUD) andStandard Treatment Guidelines (STG) were developedwithin the Lao National Drug Policy Programme, andDTCs were established in all provincial hospitals in Laosduring 1999  –  2000, with specified tasks (Appendix 1).Treatment indicator scores for three major diseases im- proved with the introduction of STGs and regular feedback interventions to the prescribers by members of the DTCs ineight provincial hospitals [21]. However, problems withsustainability were detected during supervisory visits [5].The aims of this study were to determine factors in theworking environment that relate to DTC performance andto conduct an educational intervention to improve DTC performance by means of feedback of indicator scores andinterview information targeted toward DTC members. Materials and methods Study design and samplesThis was a quasi-experimental (before and after) study(Fig. 1). Drug and Therapeutics Committees at central and provincial hospitals were included if they had beenestablished at least one year before the start of the studyand could be considered as functioning according to theguidelines set up for DTCs in Lao PDR by the Ministry of Health (MoH). Two central and seven provincial hospitalswere thus recruited to the study, including the ninety-four committee members from these hospitals.The study was performed in three phases during 2002. A pre-intervention phase with baseline data collection wasfollowed by an intervention phase with three feedback ses-sionseveryothermonthandathirdphasewithdatacollection3 months after the last feedback session. Data were alsocollected before the second and third intervention session.Data collection tools  DTC indicators Eight indicators were developed and tested by the researchteam as a means of reflecting most of the 13 tasks(Appendix 1) assigned to DTCs in Laotian hospitals. Theindicators (Appendix 2) were aimed at assessing details bearing on the DTC ’ s structure (1), reporting system (2),activities (3), feedback to prescribers (4), drug information(5), adverse drug reaction control (6), monitoring of drugcosts cost and consumption using DDD (defined dailydose) (7) and management of hospital medical routines (8)(details about this last indicator are not reported). Eachcomponent of the indicator was weighted (only positiveweights) according to assessments agreed to by the re-searchers, comprising medical doctors, pharmacists andhealth-systems ’  researchers. Each indicator could give amaximum score of 10. After training to ensure intra- andinter-rater reliability, data were collected by a field im- plementation team consisting of the four Laotian authorsand three other experienced staff from the Ministry of Health (MoH; see Acknowledgements). For each hospital,two team members were assigned to perform all four datacollections. STG indicators STG scores on the management of malaria, diarrhoea and pneumonia, the three most common infectious diseases inLaos, were collected using the STG indicator charts de-veloped by the MoH [21]. The indicators reflect infor-mation on the diagnosis, treatment and follow-up of thesediseases and used information that had been stored in thehospital record-keeping system. A task force comprisingDTC members collected data on 30 cases for each disease(encompassing the Departments of Infectious Diseases,Internal Medicine and Paediatrics). For easy comparisonthe maximum score was 10. These data had already beenroutinely collected before the start of the study.  RUD indicators Indicators related to the RUD had previously been de-veloped by the MoH [5] based on World Health Organi-zation (WHO) indicators and had also been routinelycollected for some time by the DTCs. The maximum scorewas 10. 58  Self-administered questionnaire To identify factors which could impact on DTC perfor-mance, the DTC members were interviewed before andafter the intervention using a self-administered question-naire [1] presented by the field implementation team. Theinformants were asked about their views on predefinedfactors that may influence, prevent or facilitate a successful performance of their DTC. They could also give opencomments. All eligible DTC members responded in boththe pre-intervention period ( n =90) and in the post-intervention period ( n =94). Data were analysed in detailto explore both the factors that were perceived to impact onthe performance of the DTCs and the informants ’  sug-gestions for better DTC performance.InterventionFeedback was based on the indicator scores (DTC, STG,RUD) recorded at baseline and at two consecutive times of data collection. The main aim of the feedback sessions wasto encourage DTCs to perform the 13 tasks evaluated in anappropriate manner. The members of the implementationteam assisted the DTCs in planning the feedback sessions,whichwereconductedafter eachofthethreedatacollection periods to ensure the continued influence of the evalua-tions. TheHead of the DTC at eachhospital led the meeting by introducing the session and stimulating the discussion.TheDTCtaskforcefirstpresentedthemainmessagesoftheSTG and RUD scores and subsequently highlighted thoseaspectswhichcouldbeimproved.Theintention oftheDTCtask force was that these messages should subsequently be discussed with prescribers at the different depart-ments in the hospital. Following the presentation, two of the members of the implementation team presented theDTC indicator scores that had been recorded andsuggested areas where improvement could be con-sidered. These suggestions were discussed among theDTC members before any decisions were taken. Thefeedback sessions were performed in a similar manner inall hospitals.Data analysisAll data from the scoring of indicators were entered andanalysed using the  EPI info  and  SPSS   (SPSS Inc, Chicago,Ill.) statistical programmes. The Pearson chi-squared test was used to evaluate the potential association of DTCmembers ’  tasks and their performance. The one-wayanalysis of variance test was used to assess the degree of statistical significance of the difference in mean scores of the DTC, STG and RUD indicators collected during thefour rounds of data collection. The Scheffe test was used toassess the statistical significance between two groups of means in post hoc comparisons. Results Performance of DTC UnitsThe successive changes in the overall mean scores re-corded in the four periods of data collection are shown inTable 1. Following the educational feedback sessionsattended by the DTC members, the total mean score of allDTC indicators for all hospitals improved significantly  –  Pre-intervention period (3 months)Intervention period(4 months)Post-intervention period (3 months)1 st  DTC members interviewwith 1 st  round of collection of DTC, STG and RUD scores 2 nd  DTC members interview with 4 th  round of collection of DTC, RUDand STG scores2 nd  and 3 rd rounds of collection of DTC, STG and RUD scores 3 educational feedback intervention sessions to DTC members Comparison Feedback IFeedback IIFeedback III Fig. 1  Process of interventionand data collection59  from a pre-intervention score of 4.7 to a post-interventionscore of 6.9 (  p <0.001). The indicators for activity, feedback to prescribers and drug information in particular showedsignificant improvement, with high scores in the post-intervention period. The indicator on DTC structure wasabove nine already at baseline, while the indicator for the Table 1  Means of DTC (Drugand Therapeutics Committees),STG (Standard Treatment Guidelines) and RUD (rationaluse of drugs) scores for thenine hospital DTCs recordedin the four rounds of datacollections*  p <0.05**  p <0.01***  p <0.001 a  Collected before the first intervention  b Collected before the secondintervention c Collected before the thirdintervention d Collected 3 months after thethird interventionIndicators Pre-intervention(mean) a  Intervention 2(mean)  b Intervention 3(mean) c Post-intervention(mean) d DTCStructure 9.11 9.55 9.83 9.77Report 6.55 6.33 7.66 7.55Activity 6.66 7.61 8.75* 8.44*Feedback 5.55 7.00 7.41 7.50*Drug Information 7.11 9.22* 8.33 9.55*Adverse drug reaction(ADR)/side effect (SE)0 1.50 1.75 3.55**Daily defined doses(DDD)/cost 2.11 5.00 4.66 4.00Hospital medical routine (HMR) 0.66 4.00* 4.66* 3.77*Mean DTC 4.67 6.22** 6.56** 6.90***STGMalaria 8.42 8.45 8.86 8.75Diarrhoea 6.71 7.49 7.83 7.64Pneumonia 7.08 7.62 8.06 8.33Mean STG 7.40 7.72 8.25** 8.21**RUD Number of drugs 8.62 9.33 9.11 9.22Essential drugs list (EDL) (%)8.83 8.95 8.83 8.42Generic name 7.37 7.23 8.10 8.09Drug in hospital 9.74 8.62 9.82 9.85Clear writing 9.54 9.37 9.55 9.90Traditional medicine 0 1.00 0.47 0.18Antibiotic 5.81 6.43 6.38 7.16Rational use of antibiotic 9.35 7.90 7.45 6.71Injections 6.54 8.20 5.27 7.47Rational use of injection 8.24 7.98 7.50 8.79Mean RUD 7.68 7.46 7.28 7.63 Table 2  DTC, STG and RUD scores for the nine DTCs a   preceding and following the interventionDTC  b DTC1C DTC2C DTC 3C DTC4P DTC5P DTC6P DTC7P DTC8P DTC9PPre/post  c Pre/post Pre/post Pre/post Pre/post Pre/post Pre/post Pre/post Pre/post Structure 10/10 10/10 10/10 10/10 9/10 9/9 8/10 6/9 10/10Report 7/8 9/8 3/7 5/8 9/7 7/5 6/8 6/8 7/9Activities 6/8 9.5/9 7/7 3.5/9 10/8 6.5/5.5 4.5/9 6.5/10 6.5/10Feedback 4.5/7 7/8.5 4.5/8 6/9 7/7.5 8/4.5 2/7.5 5/9 6/6.5Drug Info 7/10 9/10 7.5/8 9/9 8/9 9/10 2.5/10 8.5/10 3.5/10ADR/SE 0/7 0/6.5 0/0 0/0 0/0 0/0 0/0 0/7 0/5.5DDD/cost 8/8 0/0 4/0 3/0 0/5 4/8 0/10 0/0 0/5HMR 0/7 0/8 0/6 0/4 0/4 6/5 0/8 0/8 0/0M-DTC 4.4/8.2 5.6/7.5 4.5/6.5 4.5/7.5 5.4/6.3 6.8/5.8 2.4/6.8 4/6.6 4.2/6.9M-STG 6.7/7.7 7.3/7.9 8.2/8.4 7.4/8.1 8.2/8.4 9/8.8 7.0/7.2 6.2/8.4 6.67/9.1M-RUD 7.7/7.1 7.5/8.1 7.8/8.2 7.3/7.2 8.3/7.6 7.7/8.4 7.7/7.6 7.6/6.8 8.2/7.6 a  DTC1C  –  3C, Central hospital; DTC4P  –  9P, provincial hospital  b M-DTC, Mean DTC indicator score; M-STG, mean STG indicator score; M-RUD, mean-RUD indicator score; for other indicators,see Table 1 c Pre, Pre-intervention period; post, post-intervention period60  reporting system was lower due to the discovery that meeting summaries were not being sent to DTC members.The mean STG score also improved significantly after the intervention (7.4  –  8.2,  p <0.01), while no significant change was detected in the mean RUD indicator score.The absence of any obvious improvement in the latter could partly be due to quite a high mean score at base-line (7.7) and to the fact that the indicator on use of traditional medicines was zero or very low for allhospitals. None of the DTC units monitored adverse drug reactions(ADR) or side effects (SE) during the pre-intervention period (Table 2). There was a significant improvement inthe mean ADR score compared with baseline (  p <0.01), but the score recorded in the post-intervention was still low.However, during the course of the study four of the DTCsassigned DTC members to be responsible for ADR/SEactivity and subsequently scored between 5.5 and 7, whilethe other DTCs had zero scores. Drug cost monitoring wasnot effective in four of the hospitals (Table 2), while threeDTCs performed well (score: 8  –  10) and two moderatelywell (score: 5).Views of DTC MembersOf the DTC members 64% held the position of Head of Department or Hospital Director. Four out of five DTCmembers had been recruited to the permanent DTC task forces, and more than one-half of them were Heads of Department.When DTC members were asked about the number of tasks they had to perform daily due to the projects theywere involved in or positions that they held, 70% statedthat they had more than three tasks to perform. A strongassociation was detected between the positions held bythese DTC members and their daily task load (  p =0.001)(Table 3). The data indicate that the current DTC membersare overloaded and that they do not have enough time to perform their DTC tasks appropriately.After the intervention, many DTC members stated that any poor DTC performance could be due to the irregularityat which DTC meetings were held (60%), the many positions held by DTC members (80%) or a lack of interest shown by the Board of Hospital Directors for DTCactivities (48%). Additional proposed causes of poor DTC performance were insufficient knowledge of theDTC members (66%) and the loss of trained DTC membersto other positions/places (63%).When DTC members were asked about how DTCactivities can be improved, many of the DTC memberssuggested training DTC members specifically for carryingout DTC activities (77%), recruiting more dynamic DTCleaders (72%) and improving the reporting system (56%)and meeting techniques (48%). Only a few suggested al-locating funds for DTC activities (13%). Discussion There is a surprising lack of well-designed studies aimed at assessing the effectiveness of DTCs internationally. In our study, the overall performance of the nine DTCs in Laohospitals improved significantly after three feedback sessions despite the fact that DTC members were over-loaded with other work tasks. In particular, the indicatorson DTC activity, feedback to prescribers and drug infor-mation showed major performance improvement. In con-trast, the monitoring of adverse drug reactions and drugconsumption showed an improvement in only four hos- pitals. The scores for the management of major infectiousdiseases in relation to standard treatment guidelines alsoimproved significantly during the same period. Previousstudies conducted on methods to improve prescribing andto solve problems associated with prescribing [8, 21] showed that guidelines combined with feedback audit isone way to support high-quality clinical practice [1, 18]. An overall low mean DTC indicator score (below half of maximum) was detected during the pre-intervention peri-od. Our findings suggest that the inefficient performancerecorded in the pre-intervention period might have beendue to DTC members being overloaded with other work activities such that meetings and STG and RUD feedback sessions were held on irregular bases and the meetingswere poorly attended by the DTC members. Several of thecurrent Lao DTC task force members are busy Heads of Department and as such are probably more useful as prominent members of their profession in providing a one-on-one feedback to members of their medical staffs as ameans of improving the RUD and STG indicator scoresthan as DTC task force members. Improvement can further  be achieved by motivating staff through feedback and byreducing barriers, such as a lack of time, in order toimprove efficiency [10]. Awareness of the quality of one ’ swork could be one such motivating factor.Another possible reason for the sub-optimal DTC performance may be that the Board of Directors of thesehospitals do not understand the role of the DTC and,consequently, may not acknowledge its importance and useit in their daily hospital management. As such, they havenot stimulated DTC activities adequately as required. Inaddition, it may be due to a lack of regular supervision of DTC activities from the MoH. According to recommenda-tions from WHO, the organizational development and performance of the DTC should be monitored continuously Table 3  Association a   between positions held by DTC members andnumber of tasks ( n =94)Positions held in hospital  ≤ Three tasks >Three tasks Total n  (%)  n  (%)  n  (100)Board of Hospital Director 6 (60) 4 (40) 10 (100)Head of Department 28 (56) 22 (44) 50 (100)Staff 32 (94) 2 (5.9) 34 (100) a  Chi-squared = 14.62,  p <0.00161
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