Download Effect Analysis on Rational Use of Drug for Single Disease by Using

Effect Analysis on Rational Use of Drug for Single Disease by
Using The MTP Approach in 6 hospitals from ZH area
Organizer:
Dr.Tang Benxiong, Dr.Lee Zisong and Dr. Shen Xiangdong from Zhuhai Health
Bureau;
Implementation by:
Dr.Cai Yuexiu, Dr.Chen Weiguo, Dr.Lu Qikai, Dr.Zhou Peiming, Dr.Sun Yinxiang,
Dr.Zhou Yi, and Dr. Zhong Jinsong from ZH People’s Hospital;
Dr. Zhang Bomeng, Dr.Luo Wenji and Dr.Feng Wenzhou from The Fifth Affiliated
Hospital of Sun Yat-sen University;
Dr.Ding Wenqing, Dr.Hong Yuping and Dr.Zhao Yan from ZH People’s Hospital, the
Second;
Dr.Liu Zhilong, Dr. Guan Xiaobin, Dr. Zhou Jiangui and Dr. Cheng Jiehui from
Guangdong TCM Hospital, ZH Branch;
Dr. Zhang Zhonghong, Dr. Chen Decheng and Dr. Li Yiming from ZH Maternal and
Child Hospital
Dr. Tang Keqin, Dr. Li Wenyi and Dr. Li Ming from Xiangzhou People’s Hospital
Advisor:
Dr. Tang Jingbo, the Chief Physician and the Consultant of INRUD/China Core
Group;
Mr. Lee Dachuan, Deputy Director General from Division of Medical Service
Management, Department of Medical Administration, MoH,
Ms. Sun Jing, National Program Officer, WHO/China Office,
Date of establishment：April 20th, 2007
Date of wrap-up: Dec 20, 2007
INRUD/China/Zhuhai
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On July 2006, with the support from International Network for Rational Use of
Drugs INRUD and INRUD/China Core Group and WHO, Zhuhai Health Bureau and
Zhuhai Peoples Hospital with other 5 hospitals implemented Rational Use of
Antibacterial and Injection by using the MTP approach. Till Feb, 2007, 6 hospitals has
finished intervention periodically on the use of antibacterial and injection for OPD
URI and other 3 kinds of aseptic operations with promising result. The result has
been recognized in the annual meeting of WHO/SIGN dated of Oct 23-25, 2007.
This project has received continues financial assistance from WHO and obtained
further guidance from INRUD/China Core Group, Medical Administration of MoH
and WHO/China Office. Coordinated by Zhuhai Health Bureau, 6 hospitals has
finished 3 studies by using MTP approach. They are rational use of drug for HP
infection, rational use of analgesic for cancer pain and rational use of drug for
prostatectomy. 6 hospitals has achieved positive result. Here comes the summary:
1 Define intervention diseases and method:
1.1 Define intervention diseases
1.1.1 Clinical drug use for HP infection;
1.1.2 Treatment for cancer pain by using narcotic analgesic;
1.1.3 Prevention use of Antibiotics for prostatectom.
1.2 Method
Studied 3 moths in advance by using SDUIs from WHO/INRUD before intervention.
Obtained SDUIs baseline data. Studied MTP approach. Conducted MTP meeting,
discussion among MTP members and target prescribers. Analyzed causes for
irrational use of drug by referring to Clinical Guideline for Use of Antibacterial and
Guideline for Use of Narcotic Analgesic form WHO. Set up improvement target.
Conducted 3-4 cycles of MTP activities and each cycle with 4 wks interval. Judged
the intervention effect by comparing changes before and after MTP interventions.
2 Implement intervention
2.1 Government leadership has enhanced administration strength.
Coordinated by Zhuhai Health Bureau, 6 hospitals established MTP groups under the
leadership of Directors of the hospitals and Division Directors of the hospitals. By
combining hospitals own characteristics, each hospital has made its own study
program and plan. Division and department directors have directly involved in MTP
activities such as MTP meetings and supported with policies and monitored the
implementation of works in details.
2.2 Conduct MTP activities
2.2.1 Monitoring-set up intervention diseases
Based on WHO/INRUD approach, 6 hospitals has studied on indicators for
intervention diseases retrospectively. Clarified the baseline data and set up feasible
intervention target.
2.2.2 Training- conduct MTP meeting
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MTP meeting was chaired by Directors of Hospital Quality Control Department and
Medical Science and Education Department. Investigator announced drug use
indicators to target prescribers. Analyzed the problem and found the causes.
Found out the way of solution.
2.2.2.1 Actions for medical staff: Set up Clinical Guideline for intervention diseases;
Conducted Rational Use of Drug Seminar; Commented on prescription; Managed
individuals by 3-level quality control.
Punish misbehaviors in terms of
administration and economy. Link individual’s behaviors to the year-end appraisal.
2.2.2.2 Actions for patients and publics: Enhance patients and publics knowledge on
rational use of drug by means of drug consulting desk, hospital websites, pharmacy
communication, bedside propaganda, health education column, bulletin, brochures
and seminar etc.
2.2.3 Planning-set up feasible implementation plan
After every cycle of MTP meeting, set up next MTP implementation target and plan
by discussion with target prescribers.
2.2.3.1 After 3-5 MTP cycles, Digestive Department has reached target for
intervention indicators for HP Infection, such as drug cost and prescription drugs
based on Guideline for Use of Antibacterial and Treatment Standard for HP Infection.
2.2.3.2 After 3-5 MTP cycles, for treatment of cancer pain, targets for selection of
analgesic, combination use of drug has been reached by referring to Guideline for
Cancer 3-step analgesic treatment. Improvement has been made in medication
juncture and days of using drugs.
2.2.3.3. After 3-5 MTP cycles, for prostate gland excision, Urinary Surgery referred to
Guideline for Use of Antibacterial and Pre-after Preventive Use of Antibacterial, and
made improvement on indicators such as medication juncture, type of drug, and days.
3 Achievement
Obvious achievements have been made as shown in the following tables (table 1-8):
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Table 1 Intervention on Pre/after Prostate Gland Excision AMD Use in Zhuhai People’s Hospital
Before
After 3 MTPs
n=20
n=25
0
13
↑81.30
In surgery (Case)
0
2
*
↑12.50
After surgery (Case)
20
3
↓81.25
16.15
10.88
↓32.63
Indicator
Before surgery (Case)
Average day
Change rate%**
Compliance to Guideline
(%)
Drug cost per case (RMB)
60
77.5
↑29.17
5564.41
4905.68
↓11.84
AMD (RMB)
2061.99
2226.6
NS***
37.06
45.39
↑22.47
AMD %
Remark s:
1. AMD (RMB): AMD drug cost;
2. AMD %: AMD occupies total cost;
3. n: sample;
4. * one dose before surgery, one more dose during surgery;
5. **P＜0.05；
6. ***P＞0.05；
7. Due to very limited sample size in the other 5 hospitals, only Zhuhai People’s Hospital
conducted this intervention.
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Table 2 Intervention on Cancer Pain in 2 Hospitals in Zhuhai City after 3 rounds of MTP activities
Indicator
Zhuhai People’Hospital
The Fifth Affiliated Hospital
Before(n=30)
After(n=30 )
Change rate%
a
Before(n=90)
After(n=30)
Change rate%
Stepped care
Yes%
6.67
27.27
↑308.85
78.9
96.7
↑22.56
Administration rate
Oral%
13.33
64.55
↑309.22
66.7
66.7
/
Injection%
93.33
36.45
↓60.95
21.1
13.3
↓36.97
Patch%
6.67
0
↑100
12.2
20
↑63.93
Combination
Yes%
6.67
59.10
↑782.3
11.1
13.3
19.82
Fixed administration time
Yes%
26.67
65.55
↑40.42
81.1
93.3
↑15.04
Pain evaluation
Evaluation (case)
0
21
↑70
100
100
/
Injection
32.02
20.20
↓36.91
2.64
2.06
↓21.97
Oral
2.44
72.96
↑2890.16
70.2
73.6
*
53.97
27.69
↓48.69
3.62
2.72
↓24.86
Average drug cost (RMB)
Injection/total
cost %
a
Remark 1：n: sample；a:P＜0.05；*:P＞0.05；*stands for no significant differences.
Remark 2:  Patch is suggested according to the "Guideline". This hospital did not sampled cases prescribed with patches after the 3rd round of MTP
intervention.
Remark 3: The other 4 hospitals did not carry out interventions on this treatment due to very limited amount of samples.
Remark 4: The average drug costs increased dramatically in Zhuhai People’Hospital after the interventions, which was due to that according to the
"Guideline", oral administration was recommended. And the rate of injections use decreased substantially after interventions, and meanwhile, oral
administrations increased. However, the selected controlled released tablet was very expensive.
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Table 3 Intervention on HP infection AMD Use in Zhuhai Peoples’Hosptial
Indicator
Diagnostic Test%
Average drug cost per encounter
Compliance to
Indicator
Breath
Standard course%
Bacterial
Guideline%
OPD
Before n=100
prescriptio
After 1
n
After 2
Total cost RMB）
Paper
test
Culture
100
0
0
60.21
79.64
126.33
st
MTP n=100
100
0
0
80.30
89.09
203.90
nd
MTP n=100
100
0
0
100
100
256.87
Change rate%*
—
—
—
↑66.02
↓25.27
↑103.33
Inpatient
Before n=27
100
22.22
0
88.89
22.22
-
Cases
After the 1
100
0
0
100
88.90
-
100
0
0
100
91.67
-
—
—
—
↑12.50
↓312.55
-
st
MTP
meeting n=9
After the second MTP
meeting n=25
Change rate %*
Remark 1 : n:sample；*P＜0.05；↑increase rate；
“Change rate”: comparison between result of last meeting and the data before the meeting.
Remark 2: Average drug cost per encounter increased, due to that according to the "Guideline", treatment period increased, and this hospital selected the most
expensive recommended medicines.
Remark 3: The average treatment cost for inpatients are not included, due to that the patients are concomitted with HP infection.
Table 4
Intervention on HP infection AMD Use in OPD in The Fifth Affiliated Hospital of Sun Yat-sen Universitity
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Indicator
After the 1
st
nd
MTP
After the 2
MTP
Before
meeting
meeting
n=100
n=100
Change rate%*
n=300
Diagnosis test
Paper test
0
0
0
—
Breath test
0
0
0
—
100
100
100
—
Select drug based on Guideline %
92
98
100
↑8.69
Compliance to standard treatment %
100
100
100
0
Average
152
145
149
**
Bacterial culture
cost
per
Total cost
encounter
Remarks：n:sample；*P＜0.05；**stands for no significant differences; "Change rate” comparison between result of last meeting and the
data before the meeting
Table 5 Intervention on HP infection AMD Use in OPD in Zhuhai People’s Hospital, the Second
st
Indicator
Diagnosis test
Paper test
Select drug based on Guideline %
nd
rd
Before
n=100
After the 1 MTP
meeting
n=66
After the 2 MTP
meeting
n=48
After the 3 MTP
meeting
n=46
Change
rate%*
80
86
100
100
↑25
80
89.6
91.3
↑26.81
72
7
Compliance to standard treatment %
Average cost per
Total cost
73
137.26
83
90
91.3
↑25.07
118.4
104.3
108
↓21.32
encounter
Remarks：n:sample；*P＜0.05；"Change rate” comparison between result of last meeting and and the data before the meeting
Table 6
Intervention on HP infection AMD Use in OPD in Zhuhai Maternal and Child Hospital
st
Indicator
Diagnosis test
rd
After the 1 MTP
meeting
n=100
After the 2 MTP
meeting
n=100
After the 3 MTP
meeting
n=100
Change rate%*
Paper test
76
78
86
91
↑19.74
Breath test
0
0
0
0
—
Bacterial culture
0
0
0
0
—
64
72
80
↑35.59
55
63
81
↑62.00
119.58
112.35
103.74
↓17.42
Select drug based on Guideline %
59
Compliance to standard treatment %
50
Average cost per
nd
Before
n=100
Total cost
125.62
encounter
Remarks：n:sample；*P＜0.05；"Change rate” comparison between result of last meeting and the data before the meeting
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Table 7 Intervention on HP infection AMD Use in OPD in TCM Hospital of Guangdong Province
st
Indicator
Diagnosis test
Paper test
After the 1 MTP
meeting
n=90
After the 2 MTP
meeting
n=48
Change
rate%*
70.6
85.4
92
↑30.74
75
82.0
↑20.59
72
85
↑30.77
120.8
113.2
8.99
Select drug based on Guideline %
68
Compliance to standard treatment %
65
Average cost per
Total cost
nd
Before
n=85
124.38
encounter
Remarks：n:sample；*P＜0.05；"Change rate” comparison between result of last meeting and the data before the meeting
Table 8 Intervention on Inpatient Concommitted with HP infection AMD Use in Zhuhai Xiangzhou People’s Hospital
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Indicator
Before
After the 1
st
MTP
nd
After the 2
MTP
Change rate%*
n=17
n=20
n=20
100
100
100
—
Select drug based on Guideline %
80
90
↑38.46
Compliance to standard treatment %
100
100
↑49.25
307.03
300.43
**
Diagnosis test
Average
cost
Paper test
per
Total cost
299.34
encounter
Remark 1：n:sample； *P＜0.05； **stands for no significant differences；“Change rate” comparison between result of last meeting and
the data before the meeting;
Remark 2: The average drug costs increased dramatically in Zhuhai Xiangzhou People’s Hospital after the interventions, which was due to that
according to the "Guideline", oral administration was recommended. And the rate of injections use decreased substantially after interventions, and
meanwhile, oral administrations increased. However, the selected controlled released tablet was very expensive.
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3.2 Effect Analysis
3.2.1 Drug use for HP infection has improved obviously: 6 hospitals prescribe drugs
with clear experiment diagnosis; Follow the standard way of drug selection and
course of treatment. Compliance to Guideline increased a lot. (Table 3-8).
Problem exists:
1. There are 3 kinds of diagnosis tests and they are paper test, breath test and
bacterial culture. Based on Guideline, any of these 3 kind of tests can be used as
the preliminary HP infection diagnosis. Bacterial culture can certain the
diagnosis. But only The Fifth Affiliated Hospital of Sun Yat-sen University has
bacterial culture facilities, and other 5 hospitals only use paper test. Diagnosis
facility should also be a factor for intervention.
2. 2. Drug cost: 6 hospitals has increased course to different level. The reason is that
in Guideline, it requires 7-15 days and three combination of AMD are allowed
such as clarithromycin extended action tablet. All 6 hospitals use it.
3.2.2. Compliance to Guideline for Use of Narcotic Analgesic increased in selecting
analgesic. Oral administration has been increased. 70% Pain evaluation has been
conducted but 0% before intervention. Changed the wrong concept that only use
pethidine to cure pain. Meanwhile, strengthened adjunctive therapy and attached
importance to combination use of drug in order to increase the effect of analgesic and
decrease adverse effect.
Problem exists:
1. Although change rate reaches 308.85% from 6.67% to 27.27% before and after
intervention by stepped medication in Zhuhai People’s Hospital, the target is
100%. The reason is that intervention has been done in Oncology department
but Department of Gynecology and General Surgery didn’t follow stepped medication
principle. MTP activities still need to change the concept of physicians in using narcotic
analgesic.
2. There are decreases in using injection in these 2 hospitals. Oral medication is advocated in
Guideline and The Fifth Affiliated Hospital of Sun Yat-sen University has done comparable
good job even before MTP activities. It decreased from 93.33% to 36.45% and its change
rate is 60.95% after intervention in Zhuhai People’s Hospital, but it is still higher than The
Fifth Affiliated Hospital of Sun Yat-sen (decreased from 21.1% to 13.3%). The main reason
is that physicians from Gynecology and Surgery Department thinks morphine injection is
cheaper than oral.
3. Use of Patch: Oral drug and external preparation is advocated in Guideline, but fentanyl skin
patch is expensive. During the 3rd cycle of MTP, investigator from Zhuhai People’s Hospital
didn’t collect such sample;
4. Pain evaluation: Based on Guideline, patients have to receive pain evaluation before
medication in order to ensure standard medication. It increased from 0 to 70% after
intervention in Zhuhai People’s Hospital. But, General Surgery Department didn’t do such
evaluation, which means stepped medication hasn’t completely accepted by physicians so that
MTP has to be continued. There is no change in The Fifth Affiliated Hospital since they have
followed Guideline well before MTP activities.
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3.2.3 Prostate gland excision intervention for preventive use of drug has been
conducted in Zhuhai Peoples’ Hospital. From the indicators, Compliance to
Guideline is increased. Pre use of drug increased from 0% to 81.30%; While, days
of drug use decreased from 16.15days to 10.88days.
Problem exists:
1. After 3 cycles of MTP, the change rate is 81.3% instead of 100%. The reason is
that there is waiting time before operating room receiving the patients, which
leads to uncertain of medication time;
2. AMD cost increased after intervention since based on Guideline, the second
generation of cephalon can be used. There are two kinds of the second generation of
cephalons in Zhuhai People’s Hospital: locally produced and imported. Some prescription
samples used mandokef injection imported and its price is 25RMB/piece higher after 3 cycles
of MTP.
3. This intervention was only conducted in Zhuhai People’s Hospital since there is
little samples in other hospitals
4 Significance of this project
4.1 Strong support from Leaders from Government and Hospital Management team.
This project has received great support from MoH, Zhuhai Health Bureau and
Hospital Management team. Zhuhai Health Bureau has undertaken the role of bridge
since the implementation of MTP project in Zhuhai area. On May, 2007, Prescription
Management has been issued. Comments on Prescriptions and 3-Level Prescription
Quality Control has been issued by Zhuhai People’s Hospital. In last August, as the
pilot unit, Zhuhai Health Bureau has drafted Comment on Prescription Approach and
integrated it into hospital prescription management.
4.2 Leading role by the Director of each department and cooperation from clinical
physician. Only with administrative methods cannot change doctors’ misbehavior.
MTP mode is to communicate with prescribers, and analyze the cause of the problem.
With full understanding, trust and cooperation, find the effective way for solution and
set up target for improvement. For example, Director of Digest Department
initiatively undertake works related to their department, which helps a lot for MTP
effectiveness in accuracy and specification.
4.3 Full play DTC function, set up STG and promote Rational Use of Drug
Setting up Clinical Guideline is the base for intervention. In the past, DTC mainly
focused on new drugs and drug tender. After MTP activities, Guideline for Single
Disease Drug Use and promoting rational use of drug becomes the important content
of DTC.
4.4 That pharmacists involve in clinical practices is of great importance.
Pharmacists discuss with patients directly can reduce or avoid drug adverse reaction,
which may lead to bad effect on patient’s physiology and psychology. For cancer
pain, pharmacists in Zhuhai People’s Hospital joins physician to clinical rounds in
order to know the effect of drug and set up rational treatment.
4.5 Difficulties
4.5.1 Stronger administration support and effective method are needed. Resistance
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to rational drug of use still exists in hospitals. We need more support in
administration and economy as a public hospital in order to promote MTP widely.
Eliminate medicine depends on drug sale.
4.5.2 Currently, National Guideline and formulary are undertaken. We need it for
standard practice.
4.5.3 Rational use of drug is a long-term construction. We found some indicators went back to
original level after some time. Some physicians think only during MTP activities, they may pay
attention to it but after MTP, they keeps their original behavior and to some extent it is due to
personal interest.
4.5.4 Rational use of drug is an system which involves in manager, physician, pharmacist, patient
and guardian. Half of the patients didn’t obey doctors’ order. For example, patients with cancer
are afraid of nausea, vomit and constipation and refuse to take or forget to take medicine, so that
effect is not good. As a result, we need to promote rational use of drug in social level in order to
create a phenomenon of rational use of drug.
5 Conclusions
MTP approach stimulates rational use of medicine in clinic
MIP is humanized, standard and effective way for improving rational use of drug. It is a practical
mode for standardizing medical behavior and decreasing cost. But the foundation of the
effectiveness of MIP mode lies in the protection of government as public facilities and eliminates
medicine depends on drug sale.
Reference
Chen WG, Lu QK et all. Intervention on Overuse of Antibacterial and Injection in 6 hospitals in
Zhuhai area by using MTP approach. Chinese Journal of Pharmacoepidemiology, 2007, 56 (6).
Suryawati S. Using the MTP Approach to Reduce Inappropriate Use of Antibiotics in Hospitals.
China Science and Technology Press, BJ.
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