PROGRESS MADE IN P'A'L' DEVELOPMENT IN TUNISIA

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PROGRESS MADE IN P.A.L. DEVELOPMENT IN TUNISIA

• Ridha Djebeniani, NTP manager, Tunisia
• Ali Ben Kheder, Tunis Medical School, Tunisia
• Agnes Hamzaoui, Tunis Medical School, Tunisia
• Ikram Drira, Tunis Medical School, Tunisia
• Paolo Matricardi, WHO/NCD, Geneva
• Salah-Eddine Ottmani, WHO/STB/TBS, Geneva
• NTP Manager Meeting, Muscat, Oman, 12 14 June
  2005

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Tunisia background

• Population approximately 10 million (66 Urb.)
• Middle income country ? 3.000 US
• Demographic transition life expectancy 74 years
• Epidemiologic transition
• Infant mortality 22 deaths / 1000 live births
• Decrease in communicable diseases, including TB
• Increase in chronic diseases, including chronic
  respiratory diseases (CRD)

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Why to introduce PAL in Tunisia?

• TB and TB control
• DOTS targets achieved
• TB incidence has decreased by 60 since 1975
• Presently low incidence 9 SS cases / 100,000
  pop.
• 100 population covered by PHC services
• Health cost coverage system available
• HMIS and EDL available
• Health sector reform ongoing
• Respiratory conditions are the first cause of
  health care demand in PHC settings (35 45)
• Health care workers are dealing much less with TB
  than with the other respiratory illnesses,
  particularly CRDs
• Therefore Conditions to develop PAL are
  available in Tunisia
• There is a strong need to
  raise the profile of TB among the
• other respiratory
  illnesses, particularly CRDs

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PAL development process in Tunisia

• Official letter signed by the Minister of Health
  sent to EMRO/WHO requesting to explore the
  possibilities to develop PAL in Tunisia (Nov.
  2002)
• Preliminary field assessment by WHO and
  formulation of a work plan to adapt and develop
  PAL in Tunisia (Feb. 2003)
• Establishment of a National Working Group on PAL
  (April 2003)
• First draft of PAL guideline issued (Nov. 2003)
• 2nd WHO mission to review PAL guideline and
  adaptation and development of the protocol of the
  feasibility test in pilot sites (Dec. 2003)
• After revision of the PAL guideline and
  development of the training material, the
  feasibility test was carried out (Jan.- March
  2004)

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Feasibility test material and method

• Pilot sites 28 PHC centres selected in Tunis
  Metropolitan Area involvement of 73 GPs
• Eligibility criteria patients aged 5 years and
  over who attend for respiratory symptoms any of
  the 28 PHC centres
• Baseline study in late January 2004 evaluation
  of respiratory case management by the 73 GPs
• Training on PAL of the 73 GPs in late February
  2004
• Impact study in early March 2004 evaluation of
  respiratory case management by the same 73 GPs

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RESULTS

• Baseline study
  Impact study p-value
• Nbr 2366
  Nbr 1475
• --------------------------------------------------
  --------------------------------------
• Females 61.6 60.7
  0.583
• Average age 28.0 yr 30.5 yr
  lt 0.001
• Average symp.
• duration 5 days 6.6
  days lt 0.01
• Underlying
• condition 19.1 20.0
  0.300
• Prior visits 16.0 10.8
  lt 0.0001

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Distribution of respiratory conditions

• Respiratory Baseline
  Impact p-value
• Conditions study
  study
• Nbr
  2366 Nbr 1475
  
• --------------------------------------------------
  --------------------------------------------------
  -----------------
• AURI 43.2
  45.8 0.110
  
• ALRI 50.2
  42.4 lt 0.0001
• CRD (more asthma) 6.1
  9.2 lt 0.001
• TB suspect 0.2
  1.1 lt 0.001
• Others 0.3
  1.5 lt 0.0001
• --------------------------------------------------
  --------------------------------------------------
  -----------------
• Overall 100
  100.0

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Referral of respiratory patients

• Referral Baseline study Impact study
  Variation p-value
  
• No ()
  No () in
• 2366 (100.0)
  1475 (100.0)
• --------------------------------------------------
  --------------------------------------
• Overall
• referral 134 (5.7)
  172 (11.7) 101 lt 0.0001
• Hospital 24 (1.0)
  29 (2.0) 100 lt 0.02
• Specialists 50 (2.1)
  70 (4.7) 124 lt 0.0001
• Ancillary tests 88 (3.7) 125
  (8.4) 127 lt 0.0001
• Laboratory tests 23 (1.0) 13
  (0.9) - 10 0.777
• Chest x-ray 68 (2.9) 98
  (6.6) 128 lt 0.0001
• --------------------------------------------------
  --------------------------------------
• Laboratory tests other than tuberculosis
  sputum-smear examination

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SSE request among respiratory patients

• Type of study SSE request Total
  Proportion RP
• --------------------------------------------------
  -------------------------
• Baseline 9 2366
  0.4 1
• Impact 29 1475
  2.0 5.0
• X2 23.32, p lt 0.0001
• --------------------------------------------------
  -------------------------
• Total 38
  3841 1.0
• --------------------------------------------------
  -------------------------
• SSE sputum smear examination TB
  tuberculosis RP ratio of proportions.

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SSE request among patients with respiratory
symptoms for more than 2 weeks

• Type of study SSE request Total
  Proportion RP
• --------------------------------------------------
  -------------------------
• Baseline 8 160
  5.0 1
• Impact 23 129
  17.8 3.6
• X2 12.28, p lt 0.001
• --------------------------------------------------
  -------------------------
• Total 31
  289 10.7
• --------------------------------------------------
  -------------------------
• SSE sputum smear examination TB
  tuberculosis RP ratio of proportions.

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SSE done among patients to whom SSE was
requested

• Type of study SSE done Total
  Proportion RP
• --------------------------------------------------
  -------------------------
• Baseline 5 9
  55.6 1
• Impact 25 29
  86.2 1.6
• p lt 0.07
• --------------------------------------------------
  -------------------------
• Total 30 38
  78.9
• --------------------------------------------------
  -------------------------
• SSE sputum smear examination TB
  tuberculosis RP ratio of proportions
• p-value associated with Fisher exact test.

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SSE done among all respiratory patients

• Type of study SSE done Total
  Proportion RP
• --------------------------------------------------
  -------------------------
• Baseline 5 2366
  0.2 1
• Impact 25 1475
  1.7 8.5
• X2 25.81, p lt 0.00001
• --------------------------------------------------
  -------------------------
• Total 30
  3841 2.4
• --------------------------------------------------
  -------------------------
• SSE sputum smear examination TB
  tuberculosis RP ratio of proportions.

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Detection of sputum smear-positive pulmonary TB
(SSPTB) among respiratory patients

• Study SSPTB Total
  Proportion RP
• --------------------------------------------------
  ----------------
• Baseline 0 2366
  0.0 1
• Impact 1 1475
  0.0 -----
• p-value associated with Fisher exact test 0.384
• --------------------------------------------------
  ----------------
• Overall 1 3841
  0.0

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Overall drug prescription

• Baseline study
  Impact study Variation
• Nbr 2366
  Nbr 1475
• --------------------------------------------------
  --------------------------------------------------
  ------
• Any drug
• prescription 98.9
  96.4 - 2.5
  
• Nbr of drugs per
• prescription 3.2
  2.6 - 18.8
• Average cost
• per any patient 8.3 DT
  6.7 DT - 19.3
• Average cost per
• ALRI patient 8.0 DT
  6.0 DT - 24.5
• Average cost per
• CRD patient 10.0 DT
  7.2 DT - 28.2

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Antibiotic prescription among the 3763 patients
who received drug prescription

• Baseline study
  Impact study Variation
• Nbr 2341
  Nbr 1422
• --------------------------------------------------
  --------------------------------------------------
  ------
• Any antibiotic
• prescription 71.3
  57.8 - 19.0
  
• Average cost
• per any patient 4.5 DT
  3.8 DT - 16.1
• Average cost per
• ALRI patient 4.2 DT
  3.1DT - 26.2
• Average cost per
• CRD patient 3.3 DT
  2.8 DT - 16.7

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Bronchodilator prescription

• Bronchodilator Baseline
  Impact Variation p-value
• drug study
  study in
• No 2341
  No 1422
• --------------------------------------------------
  --------------------------------------
• Any bronchodilator 4.7 5.8
  23.4 0.141
• Inhaled ß agonist 2.2
  4.7 113.0 lt 0.0001
• Other ß agonist form 0.5 0.1
  - 80.0 0.07
• Theophylline 2.6
  2.3 - 11.5 0.547
• Other Bronchodilator 0.3 0.0
  - 100.0 0.530
• --------------------------------------------------
  --------------------------------------
• Among patients who were prescribed bronchodilator
• Inhaled ß agonist 46.8
  80.7 72.4 lt 0.0001
• Average cost
• per patient 4.3 DT
  2.7 DT - 36.4 lt 0.03
  

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Corticosteroid prescription

• Corticosteroid Baseline
  Impact Variation p-value
• drug study
  study in
• No 2341
  No 1422
• --------------------------------------------------
  --------------------------------------
• Any cortico-steroid 8.1
  5.2 - 35.8 lt 0.001
• Bronchial inhalation 1.5 1.3
  - 20.0 0.617
• Nasal inhalation 0.2
  0.3 50.0 0.737
• Tablets 0.7
  0.4 - 43.0 0.246
• Injection 6.1
  3.6 - 41.0 lt 0.002
• --------------------------------------------------
  --------------------------------------
• Among patients who were prescribed corticosteroid
• Inhaled
• Corticosteroid 18.9
  25.7 36.0 0.227
• Average cost
• per patient 2.7 DT
  2.9 DT 8.4 0.505
  

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PAL impact on the prescription of the other drugs
among patients who received any drug
prescription, Tunisia

• Baseline study
  Impact study Variation
• Nbr 2341
  Nbr 1422
• --------------------------------------------------
  --------------------------------------------------
  ------
• Expectorant 53.7
  28.3 - 47.3
• Vitamin 15.0
  12.8 - 14.7
• NSAID 21.5
  15.3 - 28.8
• Aspirin 29.6
  19.8 - 33.1
• Antitussive 20.2
  19.8 - 2.0
• Nasal decongestant 27.5
  27.6 0.4
• Paracetamol 45.0
  53.0 17.8
• Average cost per (Nbr 2302 patients)
  (Nbr 1354 patients)

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Lessons learnt from the feasibility test

• Bias (season and clustering effects reduced
  comparability?)
• Good data set with many variables on respiratory
  conditions in PHC setting
• Findings suggest that training of GPs on PAL is
  likely to improve the quality of the process of
  identifying TB cases among respiratory patients
• PAL reduces the prescription of drugs in general
  and of antibiotics in particular, as well as of
  adjuvant drugs
• PAL reduces the average cost of drug prescription
  in general, and tends to improve the quality of
  drug prescription in CRD patients, particularly
  in asthma and COPD patients

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What are the next steps needed in PAL
development?

• Review of the PAL guideline and training material
  on the basis of the findings of the feasibility
  test (already done)
• Development of a national PAL implementation plan
  by the NWG
• National review meeting with key departments of
  the MOH and potential donors on PAL activities
  carried out so far
• Adoption of the national plan of PAL
  implementation under the leadership of the NTP.

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