IMPACT OF EDUCATIONAL INTERVENTION ON PRESCRIBING BEHAVIOUR AND COST OF THERAPY IN BRONCHIAL ASTHMA IN COLONY HOSPITALS OF DELHI Kotwani A, Gupta U, Suri JC*, Roy Chaudhury R** Department of Pharmacology, Maulana Azad Medical College, New Delhi – *Respiratory Medicine, Safdarjung Hospital, ** DSPRUD, New Delhi

Impact of Educational Intervention on Prescribing Behaviour and Cost of Therapy in Bronchial Asthma in Colony Hospitals of Delhi Kotwani A, Gupta U, Suri JC*, Roy Chaudhury R** Department of Pharmacology, Maulana Azad Medical College, New Delhi – *Respiratory Medicine, Safdarjung Hospital, ** DSPRUD, New Delhi Base line survey revealed that the treatment for chronic bronchial asthma is irrational and cost of therapy is high compared to Standard Treatment Guidelines (STG). A prospective, randomized controlled study was designed to study the impact of two consecutive face-to-face educational intervention for prescribers on prescribing behaviour and cost of therapy in bronchial asthma. After first intervention, 6% prescriptions were according to STG; After second intervention, again 6% prescriptions were according to STG, though 9% of the prescriptions had steroid inhalations but other medicines differed from STG. In control facility none of the prescriptions was according to STG. Cost of treatment in both the control and intervention facilities was significantly higher as compared to the treatment given according to STG. Cost of treatment given by pooled procurement of medicines is statistically less as compared to the same medicines purchased from the retailers.

BACKGROUND Cost of irrational drug use is enormous in terms of limited resources and adverse clinical consequences. Chronic common illnesses, like bronchial asthma and hypertension are an economic burden to the country. Baseline survey done, revealed that 98% and 3% of the prescriptions for mild hypertension and for chronic bronchial asthma respectively were according to STGs in colony hospital (Secondary health care facility) of Delhi. Qualitative assessment of prescribers behaviour revealed that misconception for treatment of bronchial asthma is a major cause of irrational prescribing. Hence, a face-to-face educational intervention study was conducted.

AIMS OF THE STUDY Impact of two consecutive educational intervention on prescribing behaviour of doctors for bronchial asthma treatment in colony hospital. Effect of change in prescribing behaviour, if any, after intervention on cost of therapy in bronchial asthma. STUDY DESIGN A prospective randomized controlled study of prescription monitoring from the outpatient department of two public colony hospitals. SAMPLE SIZE Prescribers of two colony hospitals, intervention and control. 100 prescriptions of patients who were on maintenance therapy for bronchial asthma at each health facility.

METHODS Two colony hospitals who had shown in baseline survey irrational prescription were chosen, in one, educational intervention was done and other acted as control. A training programme (face-to-face educational intervention) was done for prescribers of one colony hospital at respiratory medicine department of a tertiary care hospital. STGs for treatment of bronchial asthma, patient education and proper use of inhalers were discussed. Published literature was given. STGs for chronic bronchial asthma – Regular use of inhaled corticosteroid, like Budesonide, Flutiacasone or Beclomethasone (  g) as per severity of disease. Use of bronchodilater (salbutamol) as and when required.

METHODS Contd. After one month of training, hundred prescriptions of chronic bronchial asthma from OPD of colony hospitals (intervention and control) were monitored using the same performa as was used for base line survey (characteristics of the patient, diagnosis, no. of drugs prescribed, their name, dose, duration and route of administration). For re-enforcement, a second, similar training programme for the same prescribers was done after a gap of 3 months. After one month of the second training programme, 100 prescriptions were monitored as before, from both the health facilities.

Intervention Educational training programme

RESULTS All completed performas were computed with regard to number of drugs prescribed, drugs from EDL and cost of 14 days treatment at the rate at which the public facility is procuring medicines (pooled procurement). 14 days estimated cost of therapy according to STG was calculated for each patient at pooled procurement rate. 14 days cost of therapy for each patient was also calculated at retail/market price. Prescription Monitoring

Effect of 1 st Intervention on prescribing behaviour in chronic bronchial asthma patients CharacteristicsControlIntervention No. of prescriptions100 No. of drugs prescribed No. of prescriptions according to STG 06 No. of non essential drugs prescribed 08

Cost of treatment for bronchial asthma after 1 st intervention Cost (mean + S.D.) control Cost (mean + S.D.) intervention Treatment given at facility Rs Rs Treatment According to STG (estimated) Rs **Rs ** Treatment given at facility (retail price) Rs **Rs ** ** p < 0.001

Effect of 2 nd Intervention on prescribing behaviour in chronic bronchial asthma patients CharacteristicsControlIntervention No. of prescriptions100 No. of drugs prescribed No. of prescriptions according to STG 06 No. of non essential drugs prescribed 719 NOTE- 9% prescriptions had steroid inhalers, but in addition they also contained antihistaminics which are not there in the STG.

Cost of treatment for bronchial asthma after 2 nd intervention Cost (mean + S.D.) control Cost (mean + S.D.) intervention Treatment given at facility Rs Rs Treatment According to STG (estimated) Rs **Rs ** Treatment given at facility (retail price) Rs **Rs ** ** p < 0.001

CONCLUSIONS This study has shown that even though the prescribers are prescribing from EDL, their prescriptions for chronic bronchial asthma are irrational. Two face-to-face educational training programmes have changed the prescribing behaviour to a small extent in the treatment of bronchial asthma. Pooled procurement system of purchasing medicines is very economical and money saved can be used to purchase more essential drugs. Recommendations: Another mode of intervention e.g. managerial or regulatory may also be used along with educational intervention to change the prescribing behaviour of doctors for the treatment of bronchial asthma. Corticosteroid inhalers should be included in essential drug list and made available for all public facilities.