Article Text

Impact of educational interventions on the physicians for early switchover of parenteral drugs to oral therapy
  1. Emmanuel James,
  2. Jissa Maria Cyriac
  1. Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham University, Kochi, India
  1. Correspondence to Emmanuel James, Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham University, AIMS Health Sciences Campus, AIMS Ponekkara PO, Kochi, Kerala 682041, India; emmanuelj{at}aims.amrita.edu

Abstract

The impact of educational interventions on physicians by clinical pharmacists for early switchover of parenteral drugs to oral therapy was evaluated prospectively in 340 patients receiving parenteral medications in a tertiary care teaching hospital. Patients switched over from parenteral to oral therapy within the appropriate time increased from 48.2% in the preintervention group to 78.8% in the postintervention group (p=0.000). Significant reduction in duration of hospital stay (p=0.005) and mean cost of therapy (p=0.021) was observed in patients in the postintervention group. The mean knowledge score obtained by physicians increased in the postintervention phase (p=0.000). Educational interventions on the physicians by clinical pharmacists and implementation of locally developed guidelines can facilitate early switchover of parenteral medications to oral therapy. This, in turn, can reduce duration of parenteral medication use, cost of drug therapy, length of hospital stay and, eventually, the total cost of treatment.

  • IV to PO switch over therapy
  • duration of hospital stay
  • Educational interventions
  • clinician's knowledge assessment
  • cost of therapy

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Introduction

The majority of patients with severe infections admitted to a hospital are initially started with parenteral medications. Despite improvements in clinical signs, a high proportion of the hospitalised patients continue to receive parenteral therapy. This practice may lead to infections from intravenous lines, increased duration of hospital stay and unnecessary health-related costs. A short intravenous course of therapy for 2–3 days followed by oral medications for the remainder of the course is found to be beneficial to many patients and is widely practiced in some countries.1–3 In the Indian scenario, we have yet to accomplish an ideal intravenous to PO (per oral) conversion programme in our day-to-day clinical practice. Among the various routes of administration of medications, oral administration is considered to be the most acceptable and economical method of administration.1 One of the major aspects to reduce the overuse and, thereby improve the rational use of injections, is to switch over to an oral form within an appropriate time. Increasing the awareness of the prescribers regarding the advantages of early switchover therapy will help to accomplish this task, but there is only one study reported from India regarding this topic.4 The present study was undertaken with an objective to assess the impact of the clinical pharmacist’s educational interventions to the physicians for early switchover of parenteral drugs to oral therapy in patients receiving parenteral medications in a tertiary care teaching hospital.

Methods

A prospective, interventional study was carried out at the general medicine department of Amrita Institute of Medical Sciences and Research Centre (AIMS), a 1200 bed tertiary care teaching hospital in Kochi, Kerala, India. The study was approved by the institutional ethical committee, and written informed consent was obtained from all the study participants. The study population consisted of patients admitted in the Annex ward under the general medicine department of AIMS and who received parenteral medications and satisfied the inclusion and exclusion criteria (see online supplementary data 1). The preintervention study was carried out from 1 September 2012 to 31 December 2012 and the postintervention study from 1 February 2013 to 31 May 2013. The educational intervention phase was for a period of 1 month from 1 January 2013 to 31 January 2013. The first intervention involved an oral presentation to the physicians of the ward in their morning meetings to introduce the switchover guidelines and various aspects of bioavailability of oral and parenteral medications. The second intervention involved distribution of pamphlets to the physicians in the general medicine department regarding criteria for intravenous to oral switchover.

Necessary data were collected from the patient's medical records as well as by direct interview of the patients or their care givers. Data regarding parenteral medications prescribed, indication, dose, frequency, duration, medication cost, clinical status and length of hospital stay of the patients were recorded. The date of intravenous to oral switchover was also noted. If any micro-organism was isolated, the resistance pattern was checked to determine the choice of the oral form. The same data collection method was followed in both preintervention and postintervention phases.

For evaluating eligibility for switchover, investigators developed an intravenous to PO switchover guideline1 ,5 (see online supplementary data 1). On a daily basis, investigators checked whether the patient was fulfilling the criteria for switchover. In the preintervention phase, investigators made a list of patients who were eligible for switchover, but not converted, and also whose medications were converted to the oral form at the appropriate time by the prescriber. The cost of intravenous medications was calculated for the preintervention and postintervention group patients. Total drug cost was calculated by excluding the hidden costs (diluents, needles, syringes, cannula and nursing time) for parenteral therapy, while hidden costs were included in the calculation of total cost of parenteral therapy. A standard validated questionnaire comprising of 30 questions was used to assess the physician's knowledge and beliefs on switching from parenteral to oral therapy. The respondents rated the questions on a 5-point Likert scale and the score obtained by each physician was calculated. The knowledge of physicians was reassessed using the same questionnaire during the postintervention period.

Results

One hundred and seventy patients each were included in preintervention and postintervention phases. In the preintervention group, 55.8% of patients were men and 44.1% were women, whereas, the postintervention group consisted of 58.8% men and 41.1% women (p=0.999). Mean age of patients in the preintervention and postintervention groups was 49.16±15.78 and 49.69±19.48 years, respectively. Eighty-two patients in the preintervention group and 134 patients in the postintervention group were switched over from parenteral to oral therapy (p=0.000). Antibacterials were the major drug classes involved in switched therapy and gastrointestinal agents ranked second. A total of 427 intravenous medications were administered to 170 patients of the preintervention group, but the number of intravenous medications dropped to 351 in the postintervention group (table 1).

Table 1

Parenteral medications prescribed for preintervention and postintervention group patients

Forty out of the 50 physicians practicing in the general medicine department returned the questionnaire on completion. The mean knowledge score of the consultants increased from 117.2±7.9 in the preintervention phase to 142.2±5.1 points in the postintervention phase (see online supplementary data 2). Mean knowledge score obtained by the consultants, MD students and house surgeons increased by 25%, 28.7% and 23.5%, respectively, in the postintervention phase (p=0.000 in all the cases). Mean total cost of intravenous therapy per patient in the preintervention group was €44.63±64.86 and €28.74±61.45 in the postintervention group (p=0.021), but the total drug cost was €7419 and €4733, respectively, in the preintervention and postintervention groups (p=0.032). There was significant reduction in the duration of parenteral therapy in the postintervention group in case of antibiotics (p=0.004), antivirals (p=0.000), analgesics (p=0.000) and multivitamins (p=0.000) (see online supplementary data 3). The median duration of intravenous therapy was 3 days (range 1–8) in the preintervention group and 2 days (range 1–5) in the postintervention group. The mean duration of hospital stay of the study patients was 6.88±2.78 and 6.07±2.56 days, respectively, in the preintervention and postintervention groups (p=0.005).

Discussion

Our study points out that educational intervention on the physicians by clinical pharmacists can facilitate early switchover of parenteral drugs to oral therapy in eligible patients. Reduction in the total number of intravenous medications and the duration of parenteral therapy in postintervention group patients may be due to the educational interventions by the pharmacists on the physicians regarding intravenous to oral switched therapy. The awareness that some of the oral medications have bioavailability somewhat similar to intravenous medications must have influenced the physicians to prescribe the oral medications for appropriate patients. During the postintervention phase, a lesser number of antifungals was prescribed because of the awareness that bioavailability of oral antifungals like fluconazole is >90%, comparable with its parenteral bioavailability. In the postintervention group, fluconazole was given parenterally only if the patient was not able to take oral medications or the patient was in strict Nothing Per Orem (NPO) for a procedure. A study conducted by Sevinc3 found that median days of intravenous therapy reduced from six in the preintervention group to four in the postintervention group.

After the implementation of intravenous to PO switchover guidelines, the percentage of patients converted within the appropriate time increased significantly in the postintervention group. Also, the number of patients eligible for switchover, but not converted within the appropriate time, was less in the postintervention group in comparison with the preintervention group. Enhanced conversions from intravenous to oral therapy were also reported in other studies.6 ,7 A study conducted by Palanisamy4 found that the average length of patient stay was 6.81±2.69 and 6.21±2.40 days in preintervention and postintervention groups, respectively. There was a significant reduction in the mean duration of hospital stay of intravenous-treated patients in the postintervention phase in our study. A major part of the financial burden of a patient may be contributed by cost of parenteral medications. Thus, early switchover to oral medications can contribute to reduction in hospital costs. Due to the educational interventions by the clinical pharmacists there was a marked reduction in the use of parenteral medications in the postintervention phase and, thus, a marked reduction in the cost of therapy. Similar reduction in cost of therapy was reported in earlier studies from other countries,8–10 but in our study, cost estimation did not account for cost reduction due to early discharge of the patients. Moreover, these studies involved direct clinical interventions of the pharmacists. In a resource-poor setting, educational interventions may be cheaper but may not be fully efficient.

The intervention was effective in improving the knowledge of physicians regarding intravenous to oral switched therapy since there was a significant increase in their knowledge score in the postintervention phase. The study was not designed to measure the clinical outcome of the two patient groups which may be a limitation of the study. Similarly, inadequate control of the disease pattern in preintervention and postintervention phases could also have influenced the duration of hospital stay of the patients. Sustainability of the educational interventions and the need for such interventions periodically, can be studied in future.

Conclusions

Educational interventions on the physicians by a clinical pharmacist and implementation of locally developed guidelines can facilitate early switchover of parenteral medications to oral therapy and reduce the overprescribing of parenteral medications. Early switchover of parenteral medications to oral therapy can reduce patient's hospital stay and cost of therapy.

Acknowledgments

We express our gratitude to Dr Prem Nair, Medical Director, Amrita Institute of Medical Sciences (AIMS), Kochi, and Dr Shantikumar V Nair, Dean of Research, AIMS Health Sciences Campus, Kochi, for providing necessary facilities to carry out the work.

References

Supplementary materials

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Footnotes

  • Contributors JMC collected the data; EJ and JMC were involved in design of the study, analysis and interpretation of the results and preparation of the manuscript.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Institutional Review Board of Amrita Institute of Medical Sciences & Research Centre.

  • Provenance and peer review Not commissioned; externally peer reviewed.