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					THE IMPORTANCE OF FEEDBACK TO
    ENHANCE THE IMPACT OF
  EFFECTIVE INTERVENTIONS TO
  REDUCE ANTIBIOTICS IN ACUTE
 RESPIRATORY-TRACT INFECTION



Yudatiningsih I.1,Sunartono H.1,SuryawatiS.2
       1Sleman District Health Office,
2 Center for Clinical Pharmacology and Drug

  Policy Studies, Gadjah Mada University,
            Yogyakarta, Indonesia
ABSTRACT
Problem Statement: To gain a maximum impact, efforts to improve rational use of medicine should
be continuously conducted, especially at the primary health service level. The Sleman District
Health Office conducted a managerial intervention using Monitoring-Training-Planning
(MTP)strategy at 31 health centers (HCs) in 1999. The MTP activity reduced antibiotic use for
acute respiratory infection (ARI) from 50% to 20%. One year after MTP, antibiotic use was
measured again, and the result showed that it varied among HCs from 12% to 53%. This finding
indicated that the antibiotic use after MTP could increase again, and therefore enforcement efforts
should be conducted. References indicated that feedback is effective in enforcing the impact of
interventions
Objectives: To evaluate whether feedback could maintain the effect of MTP in reducing the use of
antibiotics.
Design: Randomized controlled study with parallel design .
Setting and Populations: Twelve of 25 HCs were randomly selected to participate in the study. They
were randomly assigned into two groups: the test group (6 HCs) received feedback and the control
group (6HCs) did not receive feedback. Data collection was conducted at 6 month before and 6-
month after the feedback sessions.
Intervention: Feedback was carried out by district health office staff in a single 2-hour meeting at
the district health office, including the presentation of pre-MTP, post-MTP and pre-feedback data.
Participants in the feedback meeting consisted of doctors, nurses, and midwives from 6 HCs.
Outcome Measures: % antibiotics given and average number of drugs per encounter for ARI
treatment in children 0-14 years old.
Results: Compared with the MTP results, the pre-feedback data on antibiotic use showed an
increase, although it did not achieve the level o significance (p>0.05). After feedback, the test group
showed a significant decrease in % antibiotics given (from 34% to 11% ) and the average number of
drugs per encounter (from 3.5 to 3.2), while the control group showed a significant increase in %
antibiotics (from 35% to 40%) and average number of drugs per encounter (from 3.6 to 3.7). This
means that MTP has a lasting impact, but the feedback enhanced the impact significantly.
Conclusions: Feedback enhances the impact of even an effective intervention such as MTP.
BACKGROUND
 Acute respiratory tract infection (ARI) is still a
 leading cause of childhood morbidity in
 developing countries. In Indonesia, the
 prevalence of ARI is about 21.4 per 1000
 population, with >60 % of cases in the under-
 five age group.
 The problem that related to ARI treatment is
 inappropriate antibiotics medications.
 Percentage of antibiotics used for ARI
 treatment in children achieves 68%, while
 pneumonia cases are only 2% of the total ARI
 cases.
BACKGROUND (Con’t)
   In 1999, Sleman district health office conducted a
    managerial intervention using Monitoring-
    Training-Planning (MTP) strategy to improve use
    of medicine at 31 HCs
   The MTP activity reduced the antibiotics use for
    ARI from 50% to 20%.
   One year after MTP, the antibiotics use was re-
    evaluated. The result showed that it varied among
    HCs, from 12% to 53%
   This finding indicated that the antibiotics use after
    MTP increased, therefore enforcement should be
    conducted. Previous studies suggested that
    feedback is effective to enforce the impact of
OBJECTIVES
To evaluate whether a
feedback could
maintain the effect of
MTP (Monitoring -
Training - Planning)
in reducing the use of
DESIGN AND SAMPLE
SELECTION
   Design: randomised control study with parallel design
   It involved 12 HCs in Sleman district, Yogyakarta,
    Indonesia
   Prescribers included physicians, nurses and midwife per
    HC
   12 of 25 HCs underwent MTP were randomly selected
    to participate in the study
   12 HCs were randomly assigned into 2 groups: the test
    group (6 HCs) received feedback and the control group
    (6HCs) did not receive feedback
   Data collections were conducted for 6 month before and
    6 month after feedback
FEEDBACK INTERVENTION
   The feedback was carried out in October, 2000. The
    prescribers consist of 1 doctor, 1 nurses, and 1
    midwife in each health centers (test group) were
    involved in the study. They were invited to feedback
    meeting in health office of Sleman district
   The feedback was conducted one time only for the
    test group, and lasted in 2 hours. The meeting were
    conducted in the formal setting in district health office
   In this study, the feedback was carried out by district
    health office staff to show them the data collections
    displayed their pre-MTP, post-MTP and pre-
    feedback performances
THE RESEARCH ACTIVITY
   This Study
                                            Feedback
                              pre                            post
                      6   5    4    3   2      1    1    2   3    4   5    6
                  6                         Test Group
  25        12
                                                                                      Analysis
  HCs       HCs
                  6
                                        Control Group
Underwent
  MTP


                      May Jun Jul Aug Sep Okt Nop Des            Jan Feb Mrt Apr

1999                          2000                                             2001
ANALYSIS
   The percentage patients receiving antibiotics and
    average number of drug per encounter for ARI
    treatment in children 0 - 14 years old were calculated
    based on 100 randomly selected prescriptions/ month
    at each HC
   This survey covered the period of 6 months before the
    feedback (April - September, 2000) and 6 months after
    the feedback (November, 2000 - April, 2001). Data
    were collected by staff from the district health office
    who had been trained in methods recommended by
    WHO
   The pre-post change of the study outcomes was then
    computed, and Student’s t-test were applied to test the
    difference between the average change in the test
    group and the control group
RESULTS
   The study and control groups were similar during the baseline
    period in rate of antibiotics use (34% of patients in the test group
    vs. 35% among control), and in the number of drugs prescribed
    per patient encounter 3.5 vs 3.6. Non of these differences was
    statistically significant
   Compare the MTP results, the pre-feedback data on antibiotics
    use tended to increase, although did not achieve the level of
    significance (p>0.05). This means that MTP has a long –term
    impact
   After feedback, the test group showed a significant decrease of
    antibiotic use (from 34% to 11%) and the average number of drug
    per encounter (from 3.5 to 3.2), while the control group showed
    significant increases in antibiotic use (from 35% to 40%) and
    average number of drug per encounter (from 3.6 to 3.7). This
    means that the feedback is effective in further reducing the use
    of ABs in the ARI treatment.
ANTIBIOTIC USE IN ARI TREATMENT


100

80

                                                                             This Study
60

                                                                                                                                                                                                    Control Group
40               Underwent
                    MTP

20
                                                                                                                                                                                                              Test Group
                                                                                                                                                               Feedback
 0
            9            9            9          9          '9 9         0           0            0         0           00         0         0            0            0          0          '0 0         1         1            1         1
        s' 9      p '9            t'9        p'9        s            n '0         b'0      t '0         r'0        i'          n '0      l '0      g '0         p '0          p'0        s            n '0       b'0      t '0         r'0
      Ag        Se           Ok           No         De            Ja        Fe          Mr           Ap        Me           Ju        Ju        Au           Se           No         De            Ja        Fe        Mr           Ap
THE NUMBER OF DRUGS PRESCRIBED
PER PATIENT

10

 8
                                                                            This Study
 6
                                                                                                                                                                                    Control Group
               Underwent
 4                MTP

                                                                                                                                                                                              Test Group
 2
                                                                                                                                                             Feedback

 0
           9             9            9      '9 9          '9 9         0           0            0         0           00         0         0            0            0      '0 0          '0 0         1           1            1         1
       s' 9       p '9            t'9      op          s            n '0         b'0      t '0         r'0        i'          n '0      l '0      g '0         p '0        op          s            n '0         b'0      t '0         r'0
     Ag         Se           Ok           N         De            Ja        Fe          Mr           Ap        Me           Ju        Ju        Au           Se           N         De            Ja        Fe          Mr           Ap
CONCLUSIONS
Feedback  is proven effective to
 strengthen an intervention to
 reduce the use of antibiotics in
 health centers
Feedback  enhances the impact
 of even an effective intervention
 such as MTP

				
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