Session Guide
Standard Treatments
STANDARD TREATMENTSSESSION GUIDE
Standard Treatments
SESSION GUIDE
PURPOSE AND CONTENT
Experience has shown that even when drug supply is based on an essential drug list, ample opportunity exists for ineffective, unsafe, or wasteful prescribing. Standard treatments list the preferred drug and nondrug treatments for common health problems experienced by people in a specific health system. As such, they represent one approach to promoting therapeutic effective and economically efficient prescribing. Standard treatments are currently used in the U.S., Europe, Latin America, Asia, Africa, and the Western Pacific.
When implemented effectively, standard treatments offer advantages to patients (more consistency, treatment efficacy), providers (gives an expert consensus, quality of care standard, basis for monitoring), supply managers (makes demand more predictable, allows prepacks), and health policy makers (provides focus for therapeutic integration of special programs, promotes efficient use of funds). But effective implementation is perhaps the greatest challenge in introducing standard treatments.
OBJECTIVES
[VA 1]
To develop your ability to:
1.Recognize and convey to others the advantages and potential benefits of standard treatments in promoting effective drug use.
2.Develop clinically effective, economically efficient, and locally appropriate standard treatment protocols for priority health problems.
3.Prepare a plan to effectively implement standard treatments in your setting through printed reference materials (manuals, posters, training materials); preservice, inservice, and reinforcement training; and monitoring and supervision focused on the priority health problems and their standard treatment.
PREPARATION
1.Read the Session Notes.
2.Read the Case Study, "A Second Edition? Standard Treatments in Pagalia." Look carefully at the Questions to Consider both before and after reading the case.
FURTHER READING
1.Managing Drug Supply, 2, Chapter 11, Treatment Guidelines and Formulary Manuals, p. 138-149.
WEB PAGES
Rational Drug Use in Rural Health Units of Uganda: Effect of National Standard Treatment Guidelines on National Drug Use. [
[These pages are not yet up. Please check when they are]
ICIUM POSTERS
2F-1. Improvement of prescribing practices after launching ARI project, Choudhury SAR, Baqui QBOF,
2F-2. Effect of standard treatment guidelines with or without prescription audit on prescribing for diarrhoea and acute respiratory infection in some government health facilities of Bangladesh, Chowdhury AKA, Khan OF, Matin MA, Khadiza B, Galib MA,
2F-4. Impact of pilot intervention (standard treatment guidelines, training) on prescribing patterns in Dar es Salaam, Wiedenmayer K. Mtasiwa D, Majapa N, Lorenz N,
Standard Treatments
SESSION NOTES
INTRODUCTION
Local manuals are needed in every health system because of differing decisions about drug choices and the patterns of illness within a country. Disease oriented manuals are called treatment guidelines (STGs), treatment protocols, or prescribing policies. Drug Oriented manuals are called Therapeutic Formularies.
The selection of drugs to be included on the essential drug list is based on the prevalent pattern of illness and the standard treatments decided upon to treat these conditions. Training, drug supply, assessment and quality evaluation are based on these standard treatments.
Thus developing and updating standard treatments are a very important part of any essential drugs program and a basic component of any effort to improve rational use of drugs.
[VA 2]
This session will review the dangers of therapeutic anarchy, discuss the advantages of standard treatments, and assess the impacts of standard treatments. The final part of the session will review the development and implementation of standard treatments.
A. THE NEED: A SOLUTION TO THERAPEUTIC ANARCHY
Standard treatments have existed for as long as the art of healing has existed. Traditional healers developed their standard set of cures and now pass them from generation to generation. The history of early scientific medicine was one of identifying patterns of signs and symptoms which revealed an underlying disease, assigning a name to that disease, and searching for the effective remedy for it.
In this century, however, modern medicine has gone far beyond the stage where each disease has but one treatment. Instead, each disease may have many acceptable treatments. And if individual symptoms are treated without at least a working diagnosis, the number of possible treatments can be endless.
Doctors, nurses, pharmacists, community health workers, and other health care providers learn about all of the treatments which could be used, instead of focusing on the best treatment that should be used. Casual observation as well as more systematic study of prescribing practices frequently reveals a pattern of tremendous diversity among prescribers in the treatment of even the most common conditions. Polypharmacy is one problem; for example, three, four, five, six, and sometimes more drugs for acute viral gastroenteritis, for which only oral rehydration therapy is effective in reducing morbidity and mortality. Other common problems considered in greater detail elsewhere are incorrect drug choices, overdosing, underdosing, and choice of more expensive drugs when less expensive drugs would be equally or more effective.
[VA3]
Standard treatments -- also known as standard treatment schedules (STS); standard treatment protocols; therapeutic guidelines; and so forth -- list the preferred drug and nondrug treatments for common health problems experienced by people in a specific health system. Each drug treatment should include for each health problem the name, dosage form, strength, average dose (pediatric and adult), number of doses per day, and number of days of treatment. Other information on diagnosis and advice to the patient may also be included.
Standard treatments should consider both drug and nondrug treatments. "Reassurance," for example, might be the proper standard treatment for a child who is shorter than other children of his or her age, but who shows a normal growth curve, no signs of malnutrition or chronic disease, and has shorter than average parents.
[VA 4]
Health problems including specific diagnoses ("malaria"), symptoms ("headache"), and preventive health services (EPI immunizations, antenatal vitamin and mineral supplements) may also be included in such a manual.
Standard treatments are currently in use in parts of the U.S., Europe, Latin America, Asia, Africa, and the Western Pacific. Experience shows that even the shortest essential drug list offers ample opportunity to misuse drugs by improper treatment of common problems. Thus, essential drug programs are finding that the development of standard treatments is necessary for therapeutically effective and economically efficient use of drugs.
Standard treatments are used at different points of the therapeutic process. They may be used for diagnosis, to decide on treatment and drug supply and to assist with adherence to the prescribed treatment. This will hopefully lead to the desired clinical outcome.
[VA 5]
Figure 1
STANDARD TREATMENTS IN THE THERAPEUTIC PROCESS
B. ADVANTAGES OF STANDARD TREATMENTS
Standard treatments offer a number of potential advantages for patients, health providers, supply managers, and health policy makers. Figure 1 illustrates the points in the therapeutic process at which standard treatments can act. Potential benefits of introducing standard treatments include the following:
[VA6]
For Patients
•consistency among prescribers reduced confusion and increased compliance
•most effective treatments prescribed
•improved supply of drugs if drugs are prescribed only when needed.
For Providers
•gives expert consensus on most effective, economical treatment for a specific setting
•provider can concentrate on correct diagnosis
•provide a standard to assess quality of care
•can also provide a simple basis for monitoring and supervision.
[VA7]
For Supply Management Staff
•performance standard for drug supply -- there should be sufficient quantities of drugs available for the most commonly treated problems at the different levels of the health system
•facilitates pre-packaging of course-of-therapy quantities of commonly prescribed items for common conditions
•drug demand more predictable, so forecasting more reliable.
For Health Policy Makers
•provide a method to control costs by using drug funds more efficiently
•serve as a basis to assess and compare quality of care
•development and implementation of a single set of standard treatments can be a vehicle for integrating special programs (diarrhea disease control, acute respiratory infection, tuberculosis control, malaria, and so on) at the primary health care facilities.
Standard treatments do not take the thinking out of health care. Instead, they focus the thinking on other critical aspects of the therapeutic process: careful identification of signs and symptoms; correct diagnosis; and effective patient counseling on proper use of those few drugs or non-drug treatments that will truly benefit the patient.
Sometimes medical school faculty, consultant physicians, and other health care providers oppose standard treatments, fearing they will lead to "cook book" medicine and loss of the "right to prescribe." This fear has proven largely unfounded; doctors in the most prestigious medical institutions in developed and developing countries are writing and promoting such handbooks.
[VA8]
C.KEY FEATURES OF STANDARD TREATMENTS
Standard treatments have been used for many years in some countries. Standard treatments now exist for common illnesses of children, common adult illnesses, and obstetrics and gynecology. The existence of these treatments has reportedly had a major impact on the consistency, effectiveness, and economy of prescribing. Key features of standard treatments, as they have been implemented for instance in Papua New Guinea, include:
•Simplicity -- The number of health problems is limited. For each health problem, a few key clinical diagnostics criteria are listed. Finally, drug and dosage information is clear and concise.
• Credibility -- The treatments were initially developed for patients by the most respected clinicians in the country. Revisions based on actual experience have further added to the credibility. Input from paramedical staff has been actively sought and acknowledged.
• Same standards for all levels -- Doctors and other health care providers use the same standard treatments. The referral criteria differ, but the first choice treatment for a patient depends on the patient's diagnosis and condition -- not on the prescriber. So if a patient attends a teaching hospital or a low level dispensary with a common condition the treatment will be exactly the same. If the patient does not respond to treatment they may be referred to a higher level to receive the second line therapy which would be given in hospital.
• Drug supply based on standards -- The standard treatments are coordinated with the supply of drugs. If changed circumstances require a new drug for the standard treatment, then the supply system responds.
• Introduced in pre-service training -- Standard treatment manuals are distributed during pre-service training and their use becomes habit.
• Dynamic (regular updates) -- As bacterial resistance patterns change or other factors alter therapeutic preferences, the standards are revised to reflect current recommendations.
• Durable pocket manuals -- The standard treatments are published as small, durable pocket manuals, which makes them convenient to carry and use.
[VA 9]
D.DEVELOPMENT OF STANDARD TREATMENTS
Experience from several countries suggests the following important considerations in the development of standard treatments:
1.Target priority conditions
2.Base on local disease factors
3.Coordinate with special programs
4.Use fewest drugs necessary
5.Choose cost-effective treatments
6.Use essential drug list drugs only
7.Involve respected clinicians
8.Consider patient perspective
In the interest of therapeutic and economic efficiency, standard treatments should target those conditions which contribute the most to rates of morbidity and mortality. Note that some conditions which contribute substantially to the number of patients treated, and therefore to the total cost of drugs provided, contribute little to mortality. Skin conditions are a common example of this. Such problems may nevertheless be priorities for the development of standard treatments precisely because they do absorb a large percent of the drug budget.
In terms of selection of health problems, standard treatments fall into one of three categories:
[VA 10]
•Individual -- A standard treatment is prepared for only one problem or set of problems -- only diarrhea disease, only ARI, or only malaria.
•Selective --Standard treatments are prepared for a small number of high priority problems, perhaps six to twelve. For example, a "package" of treatments for diarrhea disease, ARI, antenatal care, immunization screening, malaria, and tuberculosis.
•Comprehensive --Standard treatments are prepared for 30, 50, 100, or even more common health problems. When published, such standard treatments become more like textbooks than basic references. The number of treatments developed should be appropriate to the specific situation. But individual treatments developed one-by-one may miss the opportunity to use the process to integrate several special programs. At the other extreme, comprehensive standard treatments risk overwhelming health workers with new information, thus reducing the chance that any of the standard treatments -- even those for common, high priority problems -- will be followed. There may be a place for targeting different levels of the health system with manuals containing differing amounts of information.
Information on local disease patterns should also be considered. Seldom do PHC workers have access to clinical laboratories. But results from surveys using available district, regional or national laboratory facilities can be used to make scientifically-based selections of preferred drugs for certain types of diarrhea, ARI, malaria, tuberculosis and other infectious diseases. Dynamic standard treatments are periodically updated to reflect changes in treatment patterns.
Development of standard treatments should aim at therapeutic integration through coordination with special programs such as diarrhea disease control, ARI, malaria, and so forth. PHC standard treatments should reinforce recommendations of special programs and, at the same time, PHC experience should be used by special programs in developing their treatment recommendations. [Link to CDR site ]
Individual drug selections should, of course, be based on the principles of choosing the fewest drugs necessary to effectively treat an individual condition, on choice of the most cost-effective treatment, and on the essential drug list (if one exists). If an essential drug list does not exist for the level of health care at which the treatments will be used, then the process of producing standard treatments should also produce an essential drug list.
Development of standard treatments must involve respected clinicians from all levels. This might include leading professors from local medical schools as well as experienced district medical officers and outstanding community health staff. In Zimbabwe the "best and the brightest" field staff were invited to participate in the revision.
Finally, the patient perspective must be considered. Issues of patient adherence to treatment (compliance) and prevailing patient preferences must be weighed against considerations of efficacy, safety, and cost.
There are many examples of standard treatments available, some of which are listed in Annex One. The Australian guidelines are particularly useful in that they are revised regularly, and the text is available on computer diskette so that it can be easily adapted to other settings, which is what Botswana did.
The address of the Australian group is:
Therapeutic Guidelines Ltd.
Chelsea House, 3rd Floor
55 Flemington Road
North Melbourne VIC 3051
Australia
phone: (61) 3 9329 1566
fax: (61) 3 9326 5632
The World Health Organization's Drug Action Programme in Geneva can also assist with resource materials. [
[VA 11]
E.IMPLEMENTATION OF STANDARD TREATMENTS
In terms of impact on prescribing and drug use patterns, the greatest weakness in past efforts to introduce standard treatments has probably not been in the development of reasonable standards, but in the effective implementation of the standards once they have been developed. Prescribing patterns change slowly.
The following are important elements for a plan to implement standard treatments:
- Printed reference materials
- Official Launch
- Initial training
- Reinforcement training
- Monitoring
- Supervision
Printed reference materials can include manuals, posters, and training materials. Depending on the number of treatments involved, printed references may be in the form of wall charts, pocket handbooks, or larger "shelf-size" reference books.
Some people feel that wall charts provide a better reminder to health workers, are more permanent, and help the patient better understand the treatment process. Others feel that a handbook is more effective, provided it fits into the pocket, is durable, and is well-organized. Pocketbooks can also include information about individual drugs or other reference data.
The contents of pocket manuals can be organized in summary tables, in diagnostic and treatment decision trees or flow charts, or simply in written text.
An official launch is very important. The Minister of Health, the Chairmen of professional bodies, leading clinicians should present the new guidelines at a public forum. Ideally, the presentation should be covered by the press and broadcast media and attended by representatives of health worker associations.
Initial training is also important. Ideally, standard treatments should be introduced during formal pre-service training for doctors as well as other health care providers. Use of the standard treatments and the reference manual or wall chart from early in training develops good habits for later clinical practice. This implies that examinations should include questions on standard treatments.