Sustainable Financial Incentives To Improve Prescription Practices For Malaria

描述（由申请人提供）：在控制疟疾方面的全球投资已经导致疟疾负担的一些令人兴奋的减少。在一些地区，与疟疾有关的死亡人数下降了90%以上。随着疟疾传播的减少，更多的儿童发烧是由其他原因引起的。然而，这些发烧仍然被当作疟疾来治疗，尽管常常有诊断检测。在肯尼亚一个典型的农村卫生机构中，在没有诊断测试的情况下，90%以上的发热病人得到抗疟药处方。即使有显微镜检查或快速诊断检测（RDTs），仍有50-80%的阴性患者得到抗疟药处方。儿童发烧治疗不当可对患者造成严重后果，并可加速耐药性的传播。除了给患者带来风险之外，过度使用抗疟药物也给政府卫生系统带来了财政压力。虽然各国政府有相当大的动机减少药品成本和浪费，但在适当的决策层面却没有感受到财政压力。该项目旨在测试一种创新的、可持续的财政激励措施，旨在减少用抗疟药物治疗不当的非疟疾发烧病例的数量。我们将测试一项针对卫生机构的财政激励措施，以确定它是否能提高对诊断结果和临床方案的遵守程度。肯尼亚西部的18个农村卫生设施将被登记，并随机分配到两支队伍中的一支。我们将比较单独诊断疟疾的临床和技术培训（第1组）与与处方做法相关的培训加财政激励（第2组）在改善疟疾和非疟疾发烧的诊断和治疗方面的有效性。对诊断结果为阴性的患者开抗疟药的做法，将在有和没有激励机制的机构之间进行比较。次要结果将包括卫生中心常规显微镜检查的敏感性和特异性、玻片阴性发烧的替代治疗方法的使用以及抗疟疾药物缺货的频率。

DESCRIPTION (provided by applicant): Global investments in controlling malaria have led to some exciting reductions in the burden of malaria. In some areas, malaria-related deaths have dropped by more than 90%. As malaria transmission declines, a greater fraction of pediatric fevers are from other causes. However, these fevers continue to be treated as malaria, often despite the availability of diagnostic testing. In a typical rural health facility in Kenya, more tan 90% of febrile patients are prescribed an antimalarial when no diagnostic tests are available. Even when microscopy or rapid diagnostic tests (RDTs) are available, between 50-80% of patients with a negative test are nonetheless prescribed antimalarials. Inappropriately treated fevers in children can lead to serious consequences for the patient and can accelerate the spread of drug resistance. In addition to the risk to patients, overuse of antimalarials also puts financial strain on the government health system. Although there is considerable incentive for governments to reduce drug costs and wastage, the financial pressure is not experienced at the appropriate levels of decision- making. This project aims to test an innovative, sustainable financial incentive designed to reduce the number of non-malarial fevers that are treated inappropriately with antimalarial drugs. We will test a financial incentive targeted at the health facility to determine if it improves adherence to diagnostic results and clinical protocols. Eighteen rural health facilities in Western Kenya will be enrolled and randomly allocated to one of two arms. We will compare the effectiveness of clinical and technical training in diagnosis of malaria alone (Arm 1) to training plus financial incentives linked to prescription practices (Arm 2 in improving diagnosis and treatment of malaria and non-malaria fevers. The practice of prescribing antimalarials to patients with a negative diagnostic will be compared between facilities with and without the incentive structure. Secondary outcomes will include sensitivity and specificity of routine microscopy at health centers, use of alternative treatments for slide negative fevers, and frequency of stock-outs of antimalarial drugs. PUBLIC HEALTH RELEVANCE: This project will tackle an important implementation research problem. It seeks to test solutions to the problem of poor adherence to evidence-based clinical guidelines for malaria treatment, and thereby reduce inappropriate antimalarial drug use and drug wastage. This project will be conducted in collaboration with Kenya's Division of Malaria Control and avenues to roll-out the intervention, if successful, will be actively explored.