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This randomized controlled trial evaluated the impact of an educational intervention on case management of malaria, diarrhea, and pneumonia in provincial hospitals in Lao P.D.R. The study focused on the effectiveness of regular feedback sessions in improving prescribers' performance. Results showed that the intervention group had a significant improvement in treatment scores compared to the control group. By introducing Standard Treatment Guidelines and using performance indicators, the study aimed to enhance patient care and optimize treatment outcomes. The feedback sessions, combined with interactive discussions, proved to be instrumental in improving clinical performance and enhancing the record-keeping system for better monitoring. The study demonstrated the value of utilizing an audit-feedback model routinely in healthcare settings.
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Effectiveness of Feedback for Improving Case Management of Malaria, Diarrhea, and Pneumonia: A Randomized Controlled Trial at Provincial Hospitals in Lao P.D.R. Kounnavong S, Wahlstrom R, Sisounthone B, Panyanouvong A, Southammavong T Ministry of Health, Lao P.D.R. International Health Care Research, Karolinska Institute, Sweden
BACKGROUND • Low quality of care, including poor case management of major diseasesat provincial hospitals (malaria, diarrhoea, pneumonia) • Limited opportunity for prescribers to be trained and to learn about new treatment options and new technologies. • Standard Treatment Guidelines (STGs)were developed within the NDP program
The first STGs covered seven of the most common and burdening diseases (malaria, pneumonia, diarrhoea, parasitosis, dengue fever, tuberculosis, leprosy). • The STGs were introduced to all prescribers at provincial hospitals • Drug and Therapeutics Committees (DTCs), were established to be instrumental for Rational Use of Drugs (RUD), including use of practice guidelines • To facilitate implementation of an audit-based system, performance indicators were developed for RUD and the new STGs
OBJECTIVES • To assess the effects of an educational intervention on management of three common diseases (malaria, pneumonia, and diarrhea) using performance indicators and an audit-feedback approach • The hypothesis was that the overall treatment score (primary) and treatment scores for each disease (secondary) will be improved
METHODS • RANDOMIZED CONTROLLED TRIAL • 8 provincial hospitals (with functioning DTC) • 24 selected Departments (12 intervention & 12 control) • OPD, Pediatric, Internal Medicine • Pair-wise balanced block design (4 pairs) • Participants (n=122): doctors & medical assistants • Duration: June 1999 to August 2000
ASSESSMENT OF CLINICAL PERFORMANCE • Using existing STG indicators • Selected aspects of the diagnostic and treatment components for case management • Source of information: record keeping book • 30 selected patients per disease • Data collectors: DTC members • The STG indicator scores measured with three months intervals per disease • Maximum score for each indicator: 10
INTERVENTION • Pre-intervention period: Introduction of STG (June-September 1999), monthly measurement of indicators • Regular feedback session with interactive discussions (September 1999 to February 2000) • One disease per month to be addressed • Content of Feedback session: reflection on the feedback & discussions on how to improve performance
RESULTS: Comparison of regular introduction of STG with intensive feedback discussions Primary outcome: • Total mean score for all three diseases increased from 6.16 to 7.38 (control) and from 6.48 to 7.94 (intervention) Secondary outcome: • Treatment indicators scores of each disease increased in both control and intervention • The difference in improvement for the mean score for all three diseases was statistically significant in favor of the intervention group
Typical Case Management: Improved in some diagnostic components of the treatment indicator • Malaria patient: weight, history, microscopy testing • Diarrhea: weight, history, palpating the fontanel in children <2, not using AB, Info on how to use ORS • Pneumonia: history, recording RC, less anti-histamine & anti-cough medication, better follow up
CONCLUSION & RECOMMENDATIONS • A systematically organized education program with repeated feedback meetings improved the performance of prescribers • The record keeping system was improved and became a good source for calculating scores • The audit-feedback model can be used systematically & become integrated into routine work
Key lessons • Indicators are a useful tool to get relevant material for feedback to prescribers related to STGs • The effect is probably enhanced through analysis of the indicators and identification of messages for change • Group discussions with prescribers, facilitated by DTC members, is an essential part of an educational intervention • This audit-feedback procedure should be used on a routine basis • Indicators should be constantly monitored and changed if reaching high scores
Implications for implementing policy and programs to improve use of medicines Short term • Time and resources are needed to support DTC work of this kind • Time is also needed for staff to participate in group discussions on feedback Long term • STGs should be developed for most important clinical problems • Indicators should be developed in connection with the STGs
Specific studies in a Future research agenda • on finding most efficient ways of feedback in a particular context • on finding most appropriate methods to develop indicators • on how to sustain impact of educational interventions (when there is no project)
