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Health workers prescription practices and rational drug use in Rakai district
PHARMACOEPIDEMIOLOGY ‘‘HEALTH WORKERS PRESCRIPTION PRACTICES AND RATIONAL DRUG USE IN RAKAI DISTRICT.’’ Lynn Atuyambe, G. Bagambisa, J. C. Lule, and J. A. Okecho. Public Health Schools Without Walls, Makerere University, Kampala, Uganda. Objective: To assess extent of rational drug use (RDU) and health workers, (HW) prescription practices so as to ensuring adequate, constant supply of drugs and their rational use. Design: Descriptive cross-sectional study of randomly selected heath units (HU) stratified by level [Hospital (Hosp), Health Center (HC), Dispensary Maternity Unit (DMU), Sub Dispensary (SD)]. 17/42 HU (95% CL, 15% precision) were studied. Setting: The study was based at Government and non-Government HU. Participants: A sample of 510 cases was selected from outpatient registers using systematic random sampling techniques to determine compliance with National Standard Treatment Guidelines (NSTG). 440 systematically selected diagnoses, ( malaria, intestinal worms, ARI not pneumonia, diarrhea), were taken and compared with NSTG. Main Outcome Measure(s): Average numbers of drugs, injections, and antibiotics prescribed per encounter compared to national standards. Results: The number of drugs prescribed per case decreased as one descended to lower health care units (Hosp 2.77, HC 2.18, DMU 1.99, SD 1.92). Injections were prescribed twice as often than the Ugandan Standard of , 15% (Hosp 30%, HC 45%, DMU 29%, SD 35%) with an average of 34.75%. Antibiotics were over prescribed with an average of 68% (Hosp 75%, HC 64%, DMU 63%, SD 69%) compared to ,20% standard. This was due to poor diagnostic facilities, lack of knowledge due to inadequate training of health workers and patient demand. Compliance with NSTG for common illnesses was low with the average being 44% (malaria 49%, intestinal worms 61%, ARI not pneumonia 39%,diarrhea 27%) compared to the recommended standard of 100%. Conclusion: Over-prescription of antibiotics and injections and polypharmacy were common. Treatment guidelines should be closely adhered to and professional collaboration encouraged. Continuing medical education for HW through workshops on RDU and intensive support supervision were the actions taken.
‘‘ACUTE MYOCARDIAL INFARCTION: COMPARISON OF PUBLIC AND PRIVATE INSTITUTIONS IN CHILE.’’ F. Lanas, E. Cha´vez, J. C. Prieto, R. Corvala´n, and F. Cumsille et al. CEU, Universidad de la Frontera, Temuco, Chile Objectives: To compare: (1) prognostic patient variables, (2) pharmacologic treatment, (3) invasive diagnostic and therapeutic procedures and (4) prognosis, in patients admitted to private and public institutions, for acute myocardial infarction (AMI) in Chile. Design: Multicenter prospective cohort study. Setting: 24 public hospitals of the Ministry of Health (HMH) and 13 private hospitals (PH): (2 university hospitals, 3 hospitals of the Army Forces and 8 private clinics). Participants: 2,901 patients were admitted between September 1, 1993 and August 31, 1995. The mean age 63 6 12 years; 73.7% were men; hospital mortality was 13.4%. Main Outcome Measure(s): Prognostic factors: age, gender, anterior wall AMI, Q wave AMI, Killip Class, maximal CK levels, use of thrombolytics. Invasive diagnostic test: coronary angiography. Invasive treatment: use of angioplasty and coronary artery bypass surgery. Results: No difference was observed in female gender (HMS: 28.5%, PH: 29.8%) and age .60 years (HMS:60%, PH 61,6%, p 5 0.2). Anterior wall AMI (HMS: 52.9%, PH:48.2%, p 5 .02), Q wave AMI (HMS:82.2%, PH: 73.8%, p , .01), and grade 4 Killip class (HMS: 5%, PH:3.2%, p 5 .016) were more frequent in HMH. The time from beginning of pain to hospital admission and the use of thrombolytics was similar. The use of coronary angiography (HMS: 9.2%, PH: 62.6%, p , .01), coronary angioplasty (HMS: 1,5%, PH: 25,2%, p , .01) and coronary artery bypass surgery (HMS: 1.6%, PH: 19.4%, p , .01) was higher in PH. Crude hospital mortality was 13.9% in HMS and 12.6% in PH (p . .05) and there was no difference after adjustment for prognostic factors with a logistic regression model (OR 5 1.091, p 5 .56). Conclusion: Patients admitted to HMH had a higher prevalence of poor prognostic factors and they received fewer invasive diagnostic and therapeutic procedures, but they had a similar in-hospital prognosis.
‘‘ENDOSCOPIC VARICEAL LIGATION COMPARED WITH ENDOSCOPIC SCLEROTHERAPY FOR BLEEDING OESOPHAGEAL VARICES (OV): A RANDOMIZED CONTROLLED TRIAL.’’ Abdel-Hamid A. Serwah, M. R. Habba, and A. Abdel-Hamid. CEU, Suez Canal University, Ismailia, Egypt. Background: Band ligation is a new procedure in the treatment of variceal bleeding, which results in scar formation of varices without adverse effects. Objectives: To compare the efficacy and safety of band ligation (EVL) and sclerotherapy (EST) in patients with bleeding OV. Design: Randomized controlled trial. Setting: A tertiary care university hospital. Participants: Patients with variceal bleeding after surviving the attack of bleeding. Interventions: After initial treatment of acute bleeding, a total of 185 patients were randomly assigned to receive EVL (91) or EST (94). The treatments were repeated every 2 weeks until variceal obliteration was achieved. The patients with obliterated varices (EVL, 63 and EST, 61) were then followed up for a mean of 1 year by endoscopic examinations every 3 months or for any episode of rebleeding. The compared groups were well balanced for age, sex, Child-Pugh classes and follow-up mean. Main Outcome Measures: Patients were assessed for further bleeding, for time in hospital, for number of treatment sessions required, for complications and for mortality. Results: The interim analysis showed: EVL (63) Mean duration (days) Mean sessions Recurrence of varices Rebleeding within 1 year Severe chest pain Bleed-related mortality Other complications
5114 4.217 12 (19%) 7 (11 %) 2 (3.2%) 5 (7.9%) 2 (3.2%)
EST (61)
P
72 1 6 6.3 1 0.9 14 (23%) 12 (19.7%) 11 (18%) 6 (9.8%) 11 (18%)
,0.05 ,0.05 NS NS ,0.01 NS ,0.05
RR (95 %CI)
0.18 (0.04-0.8) 0.12 (0.02-0.09)
Conclusion Band ligation is safe, effective and rather simple and a quicker procedure to treat OV.
‘‘EVALUATION OF FOUR INTERVENTIONS TO IMPROVE PRESCRIPTION PATTERN IN SHORT DURATION FEVER—A MULTICENTRIC STUDY.’’ Molly Thomas, Kurien Thomas and Study Group. CEU, Christian Medical College and Hospital, Vellore, St. John’s Medical College, Bangalore, Mahatma Gandhi Medical College, Sevagram, Christian Medical College & Hospital, Ludhiana, India. Objectives: To evaluate the effect of four interventions on prescriptions for ‘‘short duration of fever’’ by interns in changing prescribing patterns. Design: Multicentric non-randomized controlled trial. Participants: Interns from 4 different medical schools chosen on the basis of common criteria. Methodology: Common clinical conditions presenting as short duration fever were identified and a consensus treatment guideline made. A ‘‘Prescription Score’’ was developed to evaluate prescriptions. Interventions tested were: structured therapeutic audit, clinicopharmacological discussions, group discussion on management of diseases presenting with fever and ‘sham’ intervention. Each intervention was confined to one of the study centers to avoid contamination. Repeated measures ANOVA was used. Main Outcome Measure: Change in Prescription Score. Results: A total of 210 students from the four centers were enrolled. The mean pretest scores obtained by the interns were 35 (Bangalore), 37 (Ludhiana), 39 (Vellore), and 35 (Sevagram) from a total score of 45. The mean post-test scores were 39 (Bangalore), 38 (Ludhiana), 41 (Vellore), and 35 (Sevagram). In the repeated measures analysis, the sham intervention scored a difference in mean value of 0.84%, clinicopharmacological discussions 6.34%, group discussion of disease management 3.46% and structured therapeutic audit 44.6%. This difference between interventions was statistically significant at p 5 0.007. Conclusions: The most effective intervention to change prescribing pattern is structured therapeutic audit.
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‘‘ACUTE MYOCARDIAL INFARCTION: COMPARISON OF PUBLIC AND PRIVATE INSTITUTIONS IN CHILE.’’ F. Lanas, E. Cha´vez, J. C. Prieto, R. Corvala´n, and F. Cumsille et al. CEU, Universidad de la Frontera, Temuco, Chile Objectives: To compare: (1) prognostic patient variables, (2) pharmacologic treatment, (3) invasive diagnostic and therapeutic procedures and (4) prognosis, in patients admitted to private and public institutions, for acute myocardial infarction (AMI) in Chile. Design: Multicenter prospective cohort study. Setting: 24 public hospitals of the Ministry of Health (HMH) and 13 private hospitals (PH): (2 university hospitals, 3 hospitals of the Army Forces and 8 private clinics). Participants: 2,901 patients were admitted between September 1, 1993 and August 31, 1995. The mean age 63 6 12 years; 73.7% were men; hospital mortality was 13.4%. Main Outcome Measure(s): Prognostic factors: age, gender, anterior wall AMI, Q wave AMI, Killip Class, maximal CK levels, use of thrombolytics. Invasive diagnostic test: coronary angiography. Invasive treatment: use of angioplasty and coronary artery bypass surgery. Results: No difference was observed in female gender (HMS: 28.5%, PH: 29.8%) and age .60 years (HMS:60%, PH 61,6%, p 5 0.2). Anterior wall AMI (HMS: 52.9%, PH:48.2%, p 5 .02), Q wave AMI (HMS:82.2%, PH: 73.8%, p , .01), and grade 4 Killip class (HMS: 5%, PH:3.2%, p 5 .016) were more frequent in HMH. The time from beginning of pain to hospital admission and the use of thrombolytics was similar. The use of coronary angiography (HMS: 9.2%, PH: 62.6%, p , .01), coronary angioplasty (HMS: 1,5%, PH: 25,2%, p , .01) and coronary artery bypass surgery (HMS: 1.6%, PH: 19.4%, p , .01) was higher in PH. Crude hospital mortality was 13.9% in HMS and 12.6% in PH (p . .05) and there was no difference after adjustment for prognostic factors with a logistic regression model (OR 5 1.091, p 5 .56). Conclusion: Patients admitted to HMH had a higher prevalence of poor prognostic factors and they received fewer invasive diagnostic and therapeutic procedures, but they had a similar in-hospital prognosis.
‘‘ENDOSCOPIC VARICEAL LIGATION COMPARED WITH ENDOSCOPIC SCLEROTHERAPY FOR BLEEDING OESOPHAGEAL VARICES (OV): A RANDOMIZED CONTROLLED TRIAL.’’ Abdel-Hamid A. Serwah, M. R. Habba, and A. Abdel-Hamid. CEU, Suez Canal University, Ismailia, Egypt. Background: Band ligation is a new procedure in the treatment of variceal bleeding, which results in scar formation of varices without adverse effects. Objectives: To compare the efficacy and safety of band ligation (EVL) and sclerotherapy (EST) in patients with bleeding OV. Design: Randomized controlled trial. Setting: A tertiary care university hospital. Participants: Patients with variceal bleeding after surviving the attack of bleeding. Interventions: After initial treatment of acute bleeding, a total of 185 patients were randomly assigned to receive EVL (91) or EST (94). The treatments were repeated every 2 weeks until variceal obliteration was achieved. The patients with obliterated varices (EVL, 63 and EST, 61) were then followed up for a mean of 1 year by endoscopic examinations every 3 months or for any episode of rebleeding. The compared groups were well balanced for age, sex, Child-Pugh classes and follow-up mean. Main Outcome Measures: Patients were assessed for further bleeding, for time in hospital, for number of treatment sessions required, for complications and for mortality. Results: The interim analysis showed: EVL (63) Mean duration (days) Mean sessions Recurrence of varices Rebleeding within 1 year Severe chest pain Bleed-related mortality Other complications
5114 4.217 12 (19%) 7 (11 %) 2 (3.2%) 5 (7.9%) 2 (3.2%)
EST (61)
P
72 1 6 6.3 1 0.9 14 (23%) 12 (19.7%) 11 (18%) 6 (9.8%) 11 (18%)
,0.05 ,0.05 NS NS ,0.01 NS ,0.05
RR (95 %CI)
0.18 (0.04-0.8) 0.12 (0.02-0.09)
Conclusion Band ligation is safe, effective and rather simple and a quicker procedure to treat OV.
‘‘EVALUATION OF FOUR INTERVENTIONS TO IMPROVE PRESCRIPTION PATTERN IN SHORT DURATION FEVER—A MULTICENTRIC STUDY.’’ Molly Thomas, Kurien Thomas and Study Group. CEU, Christian Medical College and Hospital, Vellore, St. John’s Medical College, Bangalore, Mahatma Gandhi Medical College, Sevagram, Christian Medical College & Hospital, Ludhiana, India. Objectives: To evaluate the effect of four interventions on prescriptions for ‘‘short duration of fever’’ by interns in changing prescribing patterns. Design: Multicentric non-randomized controlled trial. Participants: Interns from 4 different medical schools chosen on the basis of common criteria. Methodology: Common clinical conditions presenting as short duration fever were identified and a consensus treatment guideline made. A ‘‘Prescription Score’’ was developed to evaluate prescriptions. Interventions tested were: structured therapeutic audit, clinicopharmacological discussions, group discussion on management of diseases presenting with fever and ‘sham’ intervention. Each intervention was confined to one of the study centers to avoid contamination. Repeated measures ANOVA was used. Main Outcome Measure: Change in Prescription Score. Results: A total of 210 students from the four centers were enrolled. The mean pretest scores obtained by the interns were 35 (Bangalore), 37 (Ludhiana), 39 (Vellore), and 35 (Sevagram) from a total score of 45. The mean post-test scores were 39 (Bangalore), 38 (Ludhiana), 41 (Vellore), and 35 (Sevagram). In the repeated measures analysis, the sham intervention scored a difference in mean value of 0.84%, clinicopharmacological discussions 6.34%, group discussion of disease management 3.46% and structured therapeutic audit 44.6%. This difference between interventions was statistically significant at p 5 0.007. Conclusions: The most effective intervention to change prescribing pattern is structured therapeutic audit.
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