Transcript IMPACT OF TRAINING IN EFFECTIVE PRESCRIBING IN PRIMARY CARE Summers RS

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IMPACT OF TRAINING IN EFFECTIVE
PRESCRIBING IN PRIMARY CARE
Summers RS1, Meyer JC1, Möller H2
(1) School of Pharmacy, Medical University of Southern Africa (MEDUNSA)
(2) South African Drug Action Programme (SADAP)
Abstract
Problem statement: An in-service training programme in Effective Prescribing,
adapted from the World Health Organization’s “Guide to Good Prescribing”, was
presented to Primary Health Care (PHC) clinic staff.
Objectives: To assess the impact of the training programme on prescribing
patterns.
Design: Randomised, controlled, pre-and post-intervention study.
Setting and Study Population: Twenty-four PHC clinics in Region 5 (Lowveld) of
the Northern Province, now Limpopo Province, each allocated to a study group or
a control group by a combination of stratified and random sampling (12 clinics in
each group).
Intervention: Effective prescribing training for primary health care prescribers. The
study consisted of four phases: pre-intervention survey, four-day training
workshop for staff from the study group clinics, first post-intervention survey one
month after the workshop and second post-intervention survey three months after
the work-shop. During each survey, at each clinic 30 prescriptions were analysed
for each of two target conditions, namely upper respiratory tract infections (URTI)
and diarrhoea and vomiting (DV).
Outcome Measures: Number of items per prescription, generic prescribing,
antibiotic prescribing, treatment with ORS, correct choice of treatment according
to the national Standard Treatment Guidelines (STG). Other measures of
prescribing and patient care were investigated, but are not presented here.
Results: Improvements were found both for the target condition addressed by the
workshop (URTI) and for a condition which was not covered in the workshop
(diarrhoea and vomiting). Improvements were sustained to the second postintervention survey.
Conclusions: Improvements in prescribing for both an example and a nonexample condition showed that the principles of effective prescribing were
internalised during the training and then applied in everyday practice. In the World
Health Organization’s “Teacher’s Guide to Good Prescribing” this training
programme has been described in Chapter 6, “Application in Primary Care
Settings”, and examples of patient cases are presented in Annex 1.
Funding sources: Operating budgets of the MEDUNSA School of Pharmacy and
provincial pharmaceutical services of Limpopo Province. Health Systems Trust
(HST).
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Introduction
Prescribing practices impact greatly on
drug use and expenditure. The situation
in developing countries is often
compounded by a limited health budget.
Furthermore, due to role substitution in
these countries, prescribers are often not
formally trained in rational prescribing.
As a result of a study carried out in the
Northern Province of South Africa (1),
the provincial Department of Health
implemented a training cascade in 1997,
with an initial focus on the improvement
of prescribing practices at primary care
level.
Objectives of the study
To assess the effect of a prescribing
training intervention for primary health
care nurses.
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Method
An Effective Prescribing training cascade
was implemented in the Northern Province
(now Limpopo Province) of South Africa.
This study investigated the impact of the
training on prescribing for two target
conditions (see Study Plan). WHOrecommended indicators and supplementary
“drug use” indicators for the target conditions
were used.
Data were collected by patient interviews
and prescription reviews.
Data collector interviewing patients
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Training course
Effective prescribing training was based
on two major sources.
1. The WHO’s “Guide to Good
Prescribing” (2), which describes six
steps in rational pharmacotherapy:
2. A problem-based learning approach,
adapted from the Problem-Based
Pharmacotherapy Teaching course of the
Department of Clinical Pharmacology of
Groningen University in the Netherlands.
Trainers also introduced the participants
to some key aspects of the National Drug
Policy of South Africa, as well as to the
underlying principles of Standard
Treatment Guidelines (STGs) and the
Essential Drugs List (EDL) .
Between 1997 and 2000, 946
prescribers, mostly nurses, were trained
in this way.
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Training cascade
Regional and district trainers attended a oneweek generic Training of Trainers’ course, and
a one-week trainers’ workshop on Effective
Prescribing. They subsequently conducted
similar 4-day Effective Prescribing courses for
approximately twenty Primary Health Care
workers per workshop under MEDUNSA’s
supervision.
Effective
Prescribing
course
Trainers of the
Lowveld region
Training of
trainers
course
Effective
prescribing
training in
districts
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Study plan
Apr-Sep 97
47 clinics considered
23 clinics excluded
24 clinics selected and randomised
Control group
Study group
Pre-intervention evaluation
12 clinics
12 clinics
2 clinics excluded:
prescribers transferred to
study group clinics
11 clinics
11 clinics
11 clinics
No
training
1 clinic to control group,
prescriber could not attend
training
4-day workshop
11 clinics
Post-intervention
evaluation 1
Post-intervention
evaluation 2
11 clinics
11 clinics
= 1 month
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Results
We found numerous significant differences
within and between groups (see figures). The
comparison between pre-test and post-test 1
results (one month after training) showed
similar patterns to those between pre-test and
post-test 2 (three months after training). Only
results of the latter comparison are shown.
Indicators:
A Average items per prescription
B % encounters with no drugs
C % items prescribed by generic name
D % items from National Essential Drugs List
E % prescriptions with antibiotic(s)
F % prescription with injection(s)
G % prescriptions with antidiarrhoeal(s)
H % prescriptions with antimicrobial(s)
I % prescriptions without Oral Rehydration Solution
J % prescriptions with only Oral Rehydrat. Solution
K % items according to Standard Treatm’t Guidelines
Key to tables and figures
Significant differences (p<0.05) are shown as follows:
1.95 1.71 within groups (paired T-test)
2.40 1.71 between groups (T-test for independent means)

between groups, changes (T-test for independent
means)
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Results:
Prescribing for Upper Resp. Tract
Infection
Scripts reviewed:
A Ave items/Rx
B % non drug Tx
C % items generic
D % items EDL
E % Rx with AB
F % Rx with inj
K % items STG
Control group
Study group
Pre Post2
Pre Post2
337
320
340
329
2.12
6.1
55.9
87.7
54.6
0.3
51.9
1.95
4.1
39.8
76.3
46.6
0.6
35.6
2.40
0
49.0
83.1
69.6
2.1
47.2
1.71
12.5
73.0
88.8
30.3
1.2
60.6
50
40
30

Improvements

20


%


10
0
-10
-20
A†
B
Deteriorations
C
D
E
†as
F
K
% of baseline
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Prescribing for Diarrhoea and Vomiting
Control group
Scripts reviewed:
A Ave items/Rx
B % non drug Tx
C % items generic
D % items EDL
E % Rx with AB
F % Rx with inj
G % Rx with AD
H % Rx with AM
I % Rx with no ORS
J % Rx w. only ORS
K % items STG
40

Study group
Pre Post2
Pre Post2
307
190
303
202
2.20
4.6
16.2
89.0
80.5
1.9
0.0
11.2
41.1
5.0
35.1
1.99
0.0
15.3
88.7
67.5
4.6
0.0
5.9
47.6
6.1
35.8
2.52
2.0
15.8
79.6
66.4
2.8
8.0
28.1
43.2
3.1
31.2
1.61
21.2
33.2
85.5
44.0
0.6
3.4
8.2
28.0
24.1
47.1
Improvements
30
20


% 10
0
-10
A† B C
D
E
Deteriorations
-20
F G
†as
H
I
J
% of baseline
K
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Discussion
Prescribing practices for the two conditions
examined were improved by the training.
Changed behaviour was not only seen in
prescribing for Upper Respiratory Tract
Infections, used as an example condition, but
also for Diarrhoea and/or Vomiting, which was
not included in the training programme.
Prescribers thus applied their new skills to
other conditions.
The results show that it is not necessary to use
qualified teachers to do the training, as the
people who successfully conducted the
training workshops had never trained before.
Teaching must be conducted in small groups of
four to six people.
This approach, in which the WHO’s “Guide to
Good Prescribing” was adapted to problembased training, has proved successful. The
WHO’s “Teacher’s guide to good prescribing”
(3) describes this training programme in
Chapter 6, “Application in Primary Care
Settings”, and presents examples of patient
cases in Annex 1.
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Limitations
1. The sample was selected from a single
region and may not be fully
representative of the entire Province.
2. To prove a retention effect it would have
been ideal if post-test 2 had been
carried out six months, instead of three
months, after the intervention. However,
if post-test 2 had been postponed to six
months after the initial training took
place, the control group would have
been lost.
A typical scene outside a PHC clinic
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Contributors
Cascade training concept developed by
D Meyer, Pharmaceutical Services, Northern Province,
and H Möller
Training developed, coordinated and supervised by
H Möller, RS Summers, A Joubert and P Jack from the
School of Pharmacy, Medical University of Southern
Africa (MEDUNSA)
Study coordinator: JC Meyer
Investigators: JC Meyer, H Möller, M Rasengane (team
leaders); M Pholoane, I Maakana, E Makoala, F Mosetsa,
SF Maphalle, P Jack, C Nobela, R Hlatswayo
Acknowledgements
This work was supported by Health Systems Trust
(HST), Durban, South Africa, Grant Number 186/97.
Prof H Schoeman provided statistical consultancy.
Monika Zweygarth assisted with this presentation.
References
(1)Möller H, Summers RS, Hlongwane E, Nobela C, Thupana
M. A Study of Pharmaceutical and Related Services in
Northern Province and a Follow-up Action Plan. CHASA
Journal of Comprehensive Health 1997; 8(3/4), 142-148.
(2)De Vries TP, Henning RH, Hogerzeil HV, Fresle DA. Guide to
Good Prescribing. WHO/DAP/95.1. Geneva: World Health
Organization; 1994.
(3)Hogerzeil HV, Barnes KI, Henning RH et al. Teacher’s Guide
to Good Prescribing. WHO/EDM/PAR/2001.2. Geneva: World
Health Organization; 2001.