Practical approach to lung health in Nepal: better prescribing and reduction of cost

To assess the impact of Practical Approach to Lung Health (PAL) guidelines on prescription behaviour and the total cost of prescription for patients with asthma, chronic obstructive pulmonary disease and pneumonia.

Pre- and post-intervention comparison in a cluster randomized trial of primary care facilities. Seven health posts and 33 subhealth posts in Nepal were stratified by type and randomized into intervention and control groups. Health workers from the intervention facilities received 5 days training on the adapted PAL guidelines and their use. To collect prescription details, we used carbon-copy prescription pads in both groups. To measure the impact of PAL guidelines we used the World Health Organization's rational use of drug indicators and drug cost indicators, in a multivariate regression analysis.

The PAL guidelines led to fewer prescriptions of multiple drugs and to more prescriptions of generic and essential drugs. The guidelines also lowered average prescription cost and wastage by disease except for chronic obstructive pulmonary disease although not to a statistically significant degree. Similarly, the prescription of antibiotics and adherence to guidelines improved, albeit not statistically significant.

There is evidence that the implementation of PAL guidelines promotes rational use of drugs for some respiratory diseases. The expected health effects of PAL guidelines should be compared with their implementation costs before continuing training on lung health, and strategies put in place to sustain the effects.