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2h. AMR: Strengthening National Policies on Antimicrobial Resistance
Report Cards and Prescribing Behavior: Assessing the Impacts of Public Disclosure on Antibiotic Prescribing Rates in South Korea
Harvard School of Public Health, United States of America
Problem statement: In Korea, a policy to separate dispensing and prescribing was introduced in 2000, followed by a policy to provide feedback on individual prescribing patterns in 2001. Yet the antibiotic prescribing rate (APR) for acute upper respiratory tract infection (AURI) was still very high at about 65% in 2005. Antibiotic overuse contributes to escalating pharmaceutical expenditures and high antibiotic resistance in the country.
Policy: Since February 2006, the APR for AURI of all health care providers has been publicly disclosed on the website of the Health Insurance Review Agency in the form of report cards for each facility.
Objectives: To assess the impacts of the public disclosure of health care providers’ APRs for AURIs and whether public disclosure changed antibiotic prescribing behavior in Korea.
Design: Time-series without comparison series
Setting: Public and private care providers in Korea who contract with the National Health Insurance (NHI)
Study population: All health care providers that had more than 100 AURI patient visits for 3 months based on NHI claims data from the first quarter of 2004 to the fourth quarter of 2009. The study included 15,669 health care providers from 249 districts in 16 metropolitan areas or states.
Outcome measures: APR for AURI, defined as the total number of antibiotic prescriptions for patients diagnosed with AURI, divided by the total number of patients diagnosed with AURI, for all health care providers at a specific facility
Results: Nationwide, the disclosure policy successfully reduced the APR for AURI in all types of health care providers by 8.9%. Restricted to primary care clinics, the response to public disclosure varied across specialties. Pediatricians were the most sensitive specialty group to public disclosure. We found a heterogeneous impact of report cards on antibiotic use for AURI among quartile groups of providers based on the mean APR prior to the introduction of report cards. Although primary clinics in the fourth quartile (highest use of antibiotics) reduced their APR for AURI by 16.93 percentage points (19%), primary clinics in the first quartile increased their APR for AURI by 1.6 percentage points (8%). (All estimates are statistically significant at 5%.)
Conclusions: Public disclosure of APR for health care providers through report cards available on the Internet can be an effective intervention to reduce the use of antibiotics. The heterogeneous impacts of public disclosure suggest that more-tailored interventions are necessary to maximize the intended impacts of public disclosure.
Funding source: None to declare
Consumption of Antibiotics Before and After Sales Regulations in Chile and Venezuela
1National Institute of Public Health; 2University of California, San Francisco
Problem statement: In recent years, various middle-income countries have enforced the regulation of antibiotic sales only with prescription, among them Chile in 1999 and Venezuela in 2006. This regulation may have an impact on the use of antibiotics, but there has been little systematic evaluation of their effect over time.
Objectives: To analyze the change in consumption of antibiotics (AB) in Chile and Venezuela between 1997 and 2007
Design: Interrupted time-series analysis of systemic AB consumption for Chile and Venezuela and six other Latin American countries (Argentina, Brazil, Colombia, Mexico, Peru, and Uruguay) as control group between 1997 and 2007
Setting: Analysis was based on the market intelligence data of AB sales aggregated at the national level [World Health Organization (WHO) Anatomic Therapeutic Chemical (ATC) code J01] between 1997 and 2007.
Study population: The total AB consumption, and stratification by broad-spectrum therapeutic groups were analyzed: quinolones, macrolides/lincosamides, and third-generation cephalosporins. The trend of consumption of these three groups was contrasted with three narrow spectrum groups: penicillin, trimethoprim-sulfamethoxazole, and first- and second-generation cephalosporins.
Policies: Whereas the sale regulation in Venezuela only included the broad spectrum groups, for Chile the regulation affected all AB. The other six countries studied have not implemented sale regulations or other restrictions between 1997 and 2007.
Outcome measure(s): Yearly AB sales aggregated by country, expressed in defined daily dose per 1000 inhabitants per day (DDD)
Results: Between 1998 and 2000 (immediately following the regulatory change in Chile), total AB consumption in Chile decreased by 33.2% (from 14.4 to 9.6 DDD), but it increased between 2002 and 2007 (9.3 to 12.5 DDD; +25.8%). In Venezuela, consumption increased by 16.8% (13.7 to 16.0 DDD) after regulator changes. The mean consumption for the six other countries studied increased 8.3% (10.4 to 11.3 DDD) in the 10 years analyzed. Within the first two years after regulatory change, the consumption of quinolones increased in Chile from 0.6 to 0.8 DDD (21.0%) and in Venezuela from 1.85 to 2.49 DDD (34.6%). In contrast, the consumption of narrow-spectrum AB, such as penicillin, decreased in Chile 34.4% (8.3 to 5.4 DDD), but not in Venezuela (2.2 to 2.7 DDD; +32.8%).
Conclusions: The enforcement of the regulation on the sale of AB with prescription in Chile contributed to a change in trends in total consumption, particularly for narrow spectrum AB, during the first years of implementation, but it did not have medium- to long-term effects. In Venezuela, however, a short-term change in dispensing trends was not observed. Understanding the reasons for these differences can be used to inform the development of policies in other countries and to optimize existing regulations.
Funding source(s): Information not provided
Antibiotics Smart Use Program: A Mixed Model to Promote Rational Use of Medicines
1Food and Drug Administration, Ministry of Public Health, Thailand; 2International Health Policy Program, Ministry of Public Health, Thailand; 3Faculty of Medicine, Chulalongkorn University; 4Faculty of Pharmacy, Srinakharinwirot University
Problem statement: The Antibiotics Smart Use Program (ASU) was originated to develop methodologies to promote rational use of medicines (RUM). This study assumed that RUM is behavior oriented; it cannot be achieved unless irrational drug use behaviors are changed into rational ones. ASU offered a mixed model for RUM by initiating attitude and behavior changes at an individual level and then scaling up and sustaining achievement via 3 strategies—development of a collaborative network, policy advocacy, and forming a social norm. Antibiotics were prioritized for this study because of the urgency and severity of the antimicrobial resistance situation pressing serious health threats.
Objective: To develop and test a mixed model of ASU in promoting RUM
Design: ASU used a quasi-experimental design aiming at reducing unnecessary use of antibiotics in upper respiratory infections, acute diarrhea, and simple wounds. The PRECEDE-PROCEED model and selected constructs from health behavior theories were used to plan the program. ASU has 3 phases. Phase I aimed to test interventions by changing antibiotics prescribing behavior (2007-8). Phase II aimed to test feasibility of scaling up the program (2008-9). Phase III is on-going and aims to promote program sustainability (2010-12).
Settings: Phase I was conducted in 1 province covering 10 district hospitals and 87 health centers. Phase II involved 3 provinces (large, medium, and small) and 2 hospital networks (public and private hospitals) covering 44 hospitals and 627 health centers.
Population: Health professionals and patients in the targeted sites
Intervention: Phase I used multifaceted interventions (e.g., treatment guideline, herbal substitutes for antibiotics, and patient education) to change prescribing behavior and was based on the pre-test and post-test design with a control group. In phase II, the decentralized networks between local and central partners were developed to scale up the program. Local partners adapted the concept to suit the local context. Central partners provided technical support, promoted the sense of local ownership, and advocated policy.
Policies: ASU was integrated in the pay-for-performance criteria for community hospitals in 2009 by the National Health Security Office (NHSO), which is responsible for the universal coverage scheme. In 2010, the criteria were expanded to cover all hospital levels.
Outcome measure: Reduction in the number of antibiotic prescriptions, improved patients’ health and satisfaction (phase I); expansion of ASU program (phase II)
Results: Phase I showed an 18%-46% reduction in antibiotic use; 97% of 1,200 targeted patients recovered or felt better regardless of taking antibiotics. Phase II indicated an increased diffusion of ASU to 22 local projects in 15 provinces. Recent data indicated that 95.6% of some 637 hospitals under NHSO contract implemented ASU at a certain level.
Conclusions: A mixed model of ASU can reduce unnecessary antibiotics use and can be scaled up to the national level. A bottom-up approach targeted at the individual is important in initiating behavioral change. A top-down approach (i.e., policy support) and decentralized networks are crucial for scaling up and sustaining the program.
Funding sources: Thai Food and Drug Administration, WHO, Health Systems Research Institution, NHSO, Drug System Monitoring and Development Centre, Thai Health Promotion Foundation
Capacity-Building for Country and Regional Level Advocacy and Interventions to Contain Antimicrobial Resistance in Africa
1Strengthening Pharmaceutical Systems (SPS) Program, Management Sciences for Health (MSH), Arlington, VA, USA; 2MSH/SPS Zambia; 3MSH/SPS Kenya; 4MSH/SPS Ethiopia
Problem statement: Antimicrobial resistance (AMR) has made many first-line treatments ineffective. Recent XDR-TB outbreaks highlight the severity of the problem; however, AMR containment activities are insufficient in resource-limited countries because of inadequate local capacity and little advocacy.
Objective: To build country and regional capacity to generate coalitions for AMR advocacy and interventions
Setting: Country-level interventions in Zambia and Ethiopia; regional interventions through two regional bodies—the faith-based Ecumenical Pharmaceutical Network (EPN) located in Kenya and the government-affiliated Regional Pharmaceutical Forum (RPF) located in Tanzania
Interventions: We conducted a rapid appraisal to identify key issues and players affecting AMR and to form a multidisciplinary local champion group. Based on the findings, SPS and its predecessor, RPM Plus, helped initiate the coalition-building process by facilitating advocacy and stakeholder meetings. As a result, Zambian and Ethiopian stakeholders formed country-level AMR working groups—Zambia’s was voluntary and Ethiopia’s was institutionalized by the Drug Administration and Control Authority. EPN and RPF stakeholders embraced AMR activities as crucial to their existing goal of promoting rational medicine use. These country and regional stakeholders expanded advocacy, coalitions, and actions to support AMR containment.
Outcome measures: AMR advocacy activities and interventions carried out by country and regional stakeholders in Africa
Results: The Zambian and Ethiopian working groups, EPN, and RPF generated widespread advocacy through their AMR call-to-action meetings and documents. The Zambian working group facilitated other in-country stakeholders to revise the national standard treatment guidelines; improve the medicine quality assurance system through document and visual inspection and Minilab testing; increase public awareness of AMR through mass media; and reform the medical curriculum to include AMR topics. The Ethiopian working group catalyzed a national AMR baseline survey, developed intervention plans, and facilitated journalist training, which led to AMR media coverage. Following the initial support from SPS, EPN spearheaded sustained advocacy and actions through its members. For example, participants of a regional EPN–SPS AMR workshop carried out more than 40 AMR-related activities within one year. RPF revised its regional pharmaceutical strategy to include AMR components and advocated for AMR through presentations at high-level meetings.
Conclusions: The Zambia, Ethiopia, EPN, and RPF experiences show that an initial capacity-building step to bring together local stakeholders to a common platform helps them generate a viable, multifaceted response to preserve antimicrobial effectiveness and contain AMR. The capacity-building process also facilitates South–South collaboration.
Funding sources: MSH/RPM Plus and SPS through US Agency for International Development
Use of Antibiotics Among Mothers After Normal Delivery in Two Provinces in Lao PDR
1Ministry of Health, Laos; 2IHCAR, Karolinska Institute, Sweden
Problem Statement: Self medication with antibiotics is widespread in low-income countries, including Laos. Such use might be irrational and increase the risk of antimicrobial resistance. A particular concern in Laos is the use of antibiotics by the woman after normal delivery. A population-based study on the use of antibiotics among mothers after normal delivery had not been carried out in Lao PDR.
Objectives: To describe the use of antibiotics among mothers after normal delivery in two provinces in Laos and to assess their knowledge about antibiotics, in order to give evidence to policy makers for further interventions.
Design: Cross-sectional survey with structured questionnaires including closed and open-ended questions. Women who had had a normal delivery in the 12 months preceding the study were interviewed in their homes.
Setting and Population: Forty-three villages in four districts (two urban and two rural districts) in Luangprabang (LPB) and Champasack (CPS) provinces. A total of 300 mothers were interviewed, 237 had delivered at homes and 63 in hospitals.
Intervention: The study was part of an information and education strategy to increase knowledge and awareness about risks and benefits of using antibiotics.
Outcome Measures: Percentage of mothers using antibiotics after normal delivery, percentage of advisers for using antibiotics, percentage of kind of antibiotics used, and percentage of sources of information received.
Results: Fifty-eight of 237 women (25%) delivering at home used antibiotics, significantly (p<0.05) more often in CPS (40%) than in LPB (8%). Twenty-four of these women (41%) had been advised by health workers to use antibiotics, while the others used it after their own decision or the advice from relatives or friends. Fifty of the 63 mothers (79%), who had normal deliveries at hospitals, received antibiotics. This was significantly (p<0.05) higher than for those who had normal deliveries at homes (24.5%). Ampicillin was the most commonly used antibiotic, followed by Amoxycillin and Tetracyclin. Few women knew about the reasons for treatment with antibiotics and even fewer about antibiotic resistance. Thirty-seven percent of the mothers had ever heard information about drugs, mostly through television and radio.
Conclusions: The inappropriate use of antibiotics after normal delivery should be discouraged, and obstetric practitioners should be more restrictive in prescribing antibiotics. Standard treatment guidelines for post partum women should be developed. The Food and Drug Department needs to develop more appropriate health messages and feasible methods to increase accessibility of the information for the people in rural areas.
Funding sources: Swedish International Development Cooperation Agency (Sida) and Ministry of Health, Lao PDR.
Key Words: antibiotics, normal delivery, self-medication, Lao PDR