Problem statement: The selection and use of drugs in health care facilities is not always optimal. A major reason for this could be lack of easy availability of adequate and unbiased information to the physician. Poor continuing update leading to decreased awareness has been quoted as a major determinant to failure of rational use of drugs (RDU).
Objectives: To improve awareness about RDU among physicians working in rural areas - especially antibiotic use. Focus was on rational selection and use of drugs based on relative safety, efficacy, cost, inclusion and weeding unnecessary drugs from the hospital formulary, and critical evaluation of drug information.
Design: Before and after study.
Setting: Study was conducted among (private) mission hospital facilities, the majority of them primary care, selected from all over India.
Study population: A volunteer sample of 60 physicians from hospitals in various parts of India who responded to undergo workshop training. About 90% of participants completed the follow up studies.
Interventions: Were focused, structured workshops of 2 days duration conducted by acceptable medical college faculty familiar with the nature of the work in rural mission hospitals. The format of the workshops was small group and panel discussions, problem solving exercises on clinical management, critical evaluation of new drugs, question forum and video demonstrations.
Outcome measures: Changes in drug use skills as indicated in the objectives were determined with the help of a questionnaire and measured using drug use indicators.
Results: The post intervention study done six months later showed a decrease in the number of drugs per prescription, more sensible stocking and purchase of drugs for the hospitals, adherence to use of a common hospital formulary and changes in prescribing costs. The differences were not statistically significant but the tendency of change is towards promoting RDU.
Conclusions: The study needs to be followed up by periodic reinforcement workshops. The important features noticed were the desire to get unbiased information and the need to equip the physicians with skills of critical evaluation of drug literature which are not part of physician training in the country. The need to develop agreed upon standard clinical and therapeutic guidelines and patient education modules is keenly felt. In the present context provision of the above may be contributory to improving RDU.
Rational use of drugs (RDU) by physicians is mainly promoted through Continuing Medical Education (CME). Many developing countries lack easy availability of unbiased information to the physician and poor CME update. This has been attributed as one of the causes of irrational selection and use of drugs in healthcare facilities.
To improve awareness about RDU among physicians working in rural areas - focusing on selection of drugs based on safety, efficacy, availability and cost. Prescribing from an accepted formulary, critical evaluation of drug information and drug literature was also included to promote RDU.
The study was conducted among private mission hospital facilities situated in rural areas of India. A majority of them were primary care centres. A total number of 6 workshops were conducted at various centres in the country that served as focal points for that region. The workshops were held for 2 days on Fridays and Saturdays. 60 physicians representing 60 hospitals volunteered to participate in the study. One third of them had clinical experience of 5-15 years after graduation and the rest more than 15 years. A pre-workshop questionnaire designed to highlight cost, average number of drugs and injections per prescription, availability of hospital antibiotic policy, therapeutic guidelines, formulary usage, drug purchasing and stocking practices was given. The intervention tried was the conduct of the workshop. Six months after the workshop, the post workshop questionnaire was sent.
The impact of the intervention, as measured by changes in drug use skills, was determined from an analysis of the pre and post workshop questionnaire.
These were focused structured workshops of two days duration conducted by acceptable academic clinicians, familiar with the nature of work in rural mission hospitals. The format was small group and panel discussions, problem solving exercises on clinical management, critical evaluation of new drugs and drug advertisement, video demonstrations and question forum. The workshops were of an interactive nature.
Table 1: Effect of intervention on prescribing
Table 2: Effect of intervention on drug use policy
Table 3: Effect of intervention on drug procurement practices
Observations by resource faculty
Some of the important observations by the resource faculty were the participants desire to get unbiased information on drugs and acquire skills for critical evaluation of drug literature. These are not part of the present medical curriculum in India. The need to develop agreed upon clinical, therapeutic guidelines and patient education modules will also be useful in improving RDU.
The methodology used would not permit measurement of actual practice changes and only perceived changes by the respondents are indicated. Within the short period of evaluation some drug use skills and various aspects of rational drug use are perceived to have improved. The observations by the faculty may be taken up by medical educators and other appropriate bodies. The study needs to be followed up by periodic reinforcement workshops.