Dear HIFA and CHIFA colleagues,
CITATION: Unnecessary hospitalisations and polypharmacy practices in Tajikistan: a health system evaluation for strengthening primary healthcare.
Jullien S et al.
Arch Dis Child. 2023 Jan 13:archdischild-2022-324991. doi: 10.1136/archdischild-2022-324991.
https://adc.bmj.com/content/early/2023/01/13/archdischild-2022-324991
BACKGROUND: Children and pregnant women require multiple contacts with the healthcare system. While most conditions can be managed by primary healthcare (PHC) providers, hospitalisations are common. This health system evaluation in Tajikistan quantifies unnecessary and unnecessarily prolonged hospitalisations and assesses antibiotic and polypharmacy practices.
METHODS: Data were retrospectively collected from randomly selected medical records from 15 hospitals. Inclusion criteria were children 2-59 months of age with a primary diagnosis of acute respiratory infection or diarrhoea, or pregnant women with threatened preterm labour, threatened miscarriages, premature rupture of membranes or mild pre-eclampsia, hospitalised between January and September 2021.
ESULTS: Among 440 children and 422 pregnant women, unnecessary hospitalisations accounted for 40.5% and 69.2% of hospitalisations, respectively, ranging from 0% to 92.7% across the hospitals. Among necessary hospitalisations, 63.0% and 39.2% were unnecessarily prolonged in children and women, respectively.Prior to admission, 36.8% of children had received antibiotics, in which more than half intramuscularly. During hospitalisation, 92.5% of children and 28.9% of women received antibiotics. Children and women received an average of 5 and 6.5 drugs, respectively; most were not indicated or with no evidence of benefits.
CONCLUSIONS: The methodology is applicable across all health systems and can provide important insights on health service use and resource waste. Findings of this assessment in Tajikistan have led to evidence-based decisions and actions from stakeholders and policy makers with the goal of strengthening PHC and improving the management of common diseases in children and pregnant women.
COMMENT (NPW): The authros state in the full text: 'Unnecessary hospitalisations were common, accounting for 40.5% and 69.2% of hospitalisations in children and pregnant women, respectively. Among necessary hospitalisations, children and women were commonly kept too long when they could have safely been discharged. The misuse of antibiotics was considerable, which is of particular concern for the potential direct harm for the patients and for accelerating antimicrobial resistance, a global public health challenge.29 While antibiotics might well be indicated in children with severe pneumonia, the choice of antibiotics was not conformed to guidelines in a considerable proportion of cases. The situation is more worrying in children with diarrhoea, for which antibiotics are not indicated (except in case of dysentery) and can cause harm. Despite only one child with dysentery, 85.9% of children hospitalised with diarrhoea received antibiotics. In addition, children and women were commonly prescribed medication with no evidence of benefits.'
A limitation is that the authors are having to rely on medical records to assess whether an admission was necessary. 'For the classification of hospitalisation into necessary or unnecessary, we compared the clinical characteristics on admission from medical records against the standard of care (online supplemental tables S1 and S2). We classified hospitalisation as necessary if at least one criterion for hospitalisation was found, unnecessary if all the hospitalisation criteria were documented in the medical records and the child or woman did not meet any or unclear if information was missing.'
They note that 'The Ministry of Health has committed to enquire the root causes of unnecessary hospitalisations and polypharmacy and to engage in a participatory policy dialogue.'
It seems likely there are similar issues worldwide. Can anyone find comparable data from other countries?
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Dr Neil Pakenham-Walsh, HIFA Coordinator
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