Unnecessary hospitalisations and polypharmacy practices in Tajikistan: a health system evaluation for strengthening primary healthcare

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. Results 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.


BACKGROUND
Children under 5 years of age often get sick, and pregnant women require several antenatal care visits and may need medical care for pregnancyrelated conditions. Most of these diseases and conditions can be entirely and safely managed at the primary healthcare (PHC) level. The global strategy of Integrated Management of Childhood Illness (IMCI) and the Integrated Management of Pregnancy and Childbirth (IMPAC) provide standards for the management of children and women at the PHC level and for the identification of those who need timely referral for hospital care. 1 2 Observations from completed WHO assessment visits to countries in the WHO European Region showed that children with common conditions such as pneumonia or diarrhoea were often admitted to hospitals for treatment, but this was not quantified. 3 Such conditions, however, could often be managed following the IMCI approach at the PHC level rather than in an inpatient context. Hospitalisation can lead to unnecessary psychological, emotional and physical disturbances and contribute to disruption of education, increased nosocomial infections and a larger financial burden incurred both by patients and health facilities. [4][5][6][7][8][9][10] In

WHAT IS ALREADY KNOWN ON THIS TOPIC
⇒ Unnecessary hospitalisations and misuse of antibiotics cause harm and take a financial toll on users and health systems. ⇒ Primary healthcare remains underused despite being key for achieving Universal Health Coverage.

WHAT THIS STUDY ADDS
⇒ This health system evaluation in Tajikistan quantified the proportion of children and pregnant women hospitalised unnecessarily and for too long. ⇒ It quantified misuse of antibiotics, including among children with diarrhoea, and the prescription of other medications with no evidence of benefits.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
⇒ Unnecessary and unnecessarily prolonged hospitalisations are a proxy for the underperformance of primary healthcare. ⇒ The methodology can be implemented in other settings. Repeated at different points in time, it allows monitoring of health system performance. ⇒ The Ministry of Health has committed to enquire the root causes of unnecessary hospitalisations and polypharmacy and to engage in a participatory policy dialogue.

Original research
Global child health addition, patients should be hospitalised only for the time that is strictly required. 11 12 The Republic of Tajikistan is a landlocked country in Central Asia with 9 million inhabitants, of which a third are children aged 0-14 years. [13][14][15] Respiratory infections and diarrhoeal diseases remain the most common causes of childhood hospitalisations and among the top causes of death. 16 17 The fertility rate in the country (3.1 children per woman in 2021) is higher than globally and the other countries in Central Asia. 17 18 Despite PHC being key for achieving Universal Health Coverage, especially in a mountainous country with added difficulties for transportation, PHC facilities remain largely underused. 19 Data on unnecessary hospitalisation of children and pregnant women, that is, who could have been managed safely and entirely in a PHC setting, would provide a sound basis for discussion on the need to strengthen PHC and to improve the efficiency of health service delivery.
Previous observations in Tajikistan suggest that treatment of common childhood conditions often comprises multiple unnecessary and invasive drugs. 19 Assessing the prescription of antimicrobials and other drugs in hospitalised children and women will help understanding the magnitude of the problem and allow targeted solutions.
This health system evaluation was conducted in Tajikistan with the aim to quantify unnecessary and unnecessarily prolonged hospitalisations in children and pregnant women and to quantify antibiotic use and polypharmacy in hospitalised children and pregnant women.

Study design
We conducted this health system evaluation in September-October 2021 in 15 public hospitals (online supplemental figure S1). WHO consultants and a technical working group established by the Ministry of Health and Social Protection of Population (MoHSPP), comprising obstetricians and paediatricians, travelled to the hospitals for data collection.

Inclusion criteria
We reviewed medical records of children 2-59 months of age hospitalised with a primary diagnosis of acute respiratory infection or intestinal infection (diarrhoea) and of pregnant women up to 37 gestation weeks hospitalised with a primary diagnosis of threatened preterm labour, threatened miscarriages, premature rupture of membranes or mild pre-eclampsia (table 1). These primary diagnoses are the most common causes of hospitalisations for these population groups in Tajikistan. 16

Standard of care and determination of necessary or unnecessary hospitalisations
The reference for standard of care for children was the WHO pocket book of Hospital care for children as it is broadly used in Tajikistan and has already been used in similar assessments. 20 21 For pregnant women, we used national protocols, 22-27 endorsed by experts including from WHO and aligned with the IMPAC and the content of the effective perinatal care course that had been implemented in the country. 2 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. We classified hospitalisation as unnecessarily prolonged when the patient presented all discharge criteria for longer than 24 hours prior to discharge with no new hospitalisation criteria. All unnecessary hospitalisations were considered unnecessarily prolonged.

Participant selection
In each hospital, the evaluation team randomly selected medical records (1 out of every 10 from the piles of medical records) from children and women hospitalised in January-September 2021, until obtaining 40 records for children and 40 for women. The number of 40 was chosen for feasibility and based on previous similar work. 21

Data collection, management and analysis
Data were extracted from medical records and recorded into an excel file together with the statement of necessary or unnecessary hospitalisation and prolonged hospitalisation. We analysed data with Microsoft Excel Program and Stata V. 16.0. 28 Comparison of proportions was performed using the χ 2 test or Fisher's exact test.

National ethical clearance
Clearance from the MoHSPP was obtained in the context of the project for improving quality of hospital care, with Prikaz No 708 from 12 August 2021.

Original research
Global child health 2-11 months vs children 12-59 months), time of admission (day vs night), referral (referred from another health facility vs came by themselves) and between regional and city/district hospitals (online supplemental figures S4 and S5).

Unnecessarily prolonged hospitalisations
The median duration of hospitalisation was 8 days (IQR 6-10) in children and 7 days (IQR 4-8) in women. The duration of hospitalisation did not differ between necessary and unnecessary hospitalisations. Differences by diagnoses and by hospitals are shown in online supplemental figures S6-S8. Among necessary hospitalisations, 160/254 (63.0%) were unnecessarily prolonged in children (unclear for seven children) and 51/130 (39.2%) in women. The proportion of unnecessarily prolonged hospitalisations did not differ by type of diagnoses in children but ranged from 14.3% in women with mild preeclampsia to 54.3% in those with threatened preterm labour (figure 3) and varied by hospital (online supplemental figure  S9).
Unnecessarily prolonged hospitalisations were more common among children of 12-59 months of age (69.3%) compared with infants (55.6%), although the difference was not statistically significant. Unnecessary prolonged hospitalisations were similar among type of hospitals and referral status (online supplemental figure S10).   Overall, 122/422 (28,9%) women were prescribed antibiotics during hospitalisation, mostly ampicillin, ceftriaxone or metronidazole. The reason for prescription was frequently due to secondary diagnoses such as chronic pyelonephritis or respiratory infections, which were in most cases not confirmed clinically or by laboratory tests on admission but based on diagnoses reported in the referral paper and therefore likely to be unjustified.

Polypharmacy
Hospitalised children and women received an average of 5 and 6.5 drugs, respectively. Drugs in children included oral rehydration salts, intravenous fluids and short-acting bronchodilators. Medications were often not indicated or with no evidence of benefits, such as antihistamines, probiotics, spasmolytics, mucolytics, interferon alfa-2b (Viferon), affinity-purified antibodies to human interferon gamma (Anaferon) and vitamin complex. Some children received intravenous insulin together with intravenous glucose solution.
Women were also commonly prescribed medications when they were not indicated or with no evidence of benefits, such as valerian, papaverine suppository, different types of vitamins, vitamin C and herbal tea for kidney diseases.

DISCUSSION
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.
Identifying contributing factors and understanding the rationale behind such practices (unnecessary hospitalisations and unnecessary medications) are primordial to allow targeted solutions. While quality education and training doctors on hospitalisation criteria and management of common diseases following standards of care are surely needed, other actions are also needed for improving quality of care.
National regulations that mandate hospitalisations probably contribute to unnecessary hospitalisations; for example, a referred patient coming at night needs to be hospitalised. In some cases, it is unclear whether practices are mandated by law or are the consequence of what healthcare worker believed to be regulated by law.
Allocation of public resources to the health sector is limited in Tajikistan, which is reflected in low salaries of health workers and high out-of-pocket payments for healthcare at all levels. 30 Spending on medicines accounts for 37% of out-of-pocket payments. 31 Reliance on informal payments to supplement salaries, and salaries and workforce directly linked to hospital bed occupancy, are likely to lead to non-evidence-based treatment and unnecessary hospitalisations. In addition, the common perception of patients and caregivers not feeling well taken care of if no medication is prescribed is likely to worsen the prescription of unnecessary drugs, despite the considerable cost incurred. Seven days' treatment with four or five of the commonly used drugs was estimated, based on observations and data collected during this assessment, to a cost of 320 Tajikistani somoni (25 euros), which corresponds to around 20% of an average monthly salary. Investigations such as laboratory testing and parenteral medications are also expected by many patients to feel well taken care of. Awaiting investigations results and completing parenteral antibiotic courses (while sometimes not required or could have been given orally at home) could partly explained some of the prolonged hospitalisations. In addition, the Tajik population seems to consider hospital care superior to the care they could receive at PHC level. This surely lowers the threshold for admitting people to hospitals, leading to increased unnecessary hospitalisations. The PHC approach is key to achieving the goal of Health for All, which is physical, mental and social well-being for everyone in the community. [32][33][34] Understanding community and health workers practices, perceptions and behaviours on healthcare and hospitalisation is key to success towards PHC and high-quality health services. 34 This health system evaluation identified areas of concerns where qualitative research is warranted, including understanding the root causes of unnecessary hospitalisations. 35 Based on these findings, the MoHSPP has committed to reviewing rules and regulations associated with hospitalisations, reviewing funding and financing systems for incentives for unnecessary hospitalisation, strengthening PHC and raising awareness on the harm of unnecessary hospitalisation and on the ineffectiveness of antibiotics for viral infections.
Another key achievement of this assessment is the identification of reliable indicators for monitoring progress. This health system evaluation in Tajikistan allowed to quantify children in hospitals that could have benefitted from PHC services. To the best of our knowledge, this kind of system evaluation has not previously been implemented elsewhere. The recognition of the need for reducing hospitalisations, however, is not new. A decade ago, researchers developed a tool to monitor potentially avoidable hospitalisations (those which might be avoided by government policies ensuring socioeconomic resources, access to timely, appropriate and affordable PHC, and the implementation of health promotion and disease prevention strategies) in children. 36 37 By contrast with the potentially avoidable hospitalisations approach, which integrates many factors and is based on estimates, the methodology we used is easy to implement in all settings. Repeated at different points in time, the quantification of two specific and objective indicators (unnecessary hospitalisations and unnecessarily prolonged hospitalisations) allows monitoring the effectiveness of interventions for improving quality of hospital care. Such indicators may well have their role in measuring effectiveness, safety and indirectly access, within the

Original research
Global child health health system performance assessment framework for universal health coverage. 38 The limitations of this evaluation include the retrospective data collection from medical records. Information not recorded in the medical charts may lead to an overestimation of unnecessary and unnecessarily prolonged hospitalisations. For example hospitalisation of women or children due to social circumstances that might not be documented.
The strengths of this evaluation are multiple. Data were collected in 15 hospitals with different settings throughout Tajikistan (Soghd oblast, the Rayon Republican Subordinations and Dushanbe), making the findings most likely applicable to the whole country. Methodology was transparent, systematic and rigorous, making the evaluation reproducible for data comparison and tracking progress (monitoring) by following the same methodology, and for replication of this health system evaluation to other settings. This assessment focused on the most common diagnoses in hospitalised children and pregnant women in Tajikistan. The use of these findings for strengthening the management of these common diagnoses in PHC are likely to have a considerable impact in the overall quality of care for children and pregnant women.

CONCLUSIONS
Findings of this assessment in Tajikistan have led to evidencebased 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.
Unnecessary hospitalisations and unnecessarily prolonged hospitalisations constitute two objective indicators for evaluating and monitoring progress in health system performance to ensure universal health coverage.