ARTI 4

Understanding and Optimising Antibiotic Prescribing in Primary Care - 4 successive projects in the Netherlands

Alike van der VeldenMarijke Kuyvenhoven

Theo Verheij

Julius Center for Health Sciences and Primary Care

University Medical Center Utrecht

The Netherlands

ARTI (Antibiotics and Respiratory Tract Infections):linking academia to primary care practice

Antibiotics and Respiratory Tract Infections

RTIs: acute otitis media

sinusitis, cold

sore throat (tonsillitis, laryngitis)

acute cough (bronchitis, pneumonia)

Mostly viral and self-limiting

Effects of antibiotics are limited

Over-prescription of antibiotics• resistance• patients’ re-consultation• unnecessary exposure to adverse effects• unnecessary costs

Antibiotics in The Netherlands

Comparatively low antibiotic consumption (coinciding with low resistance)

450 treatments / 1000 inhabitants / year France: x3, Greece: x5

No OTC selling

80% is prescribed by general practitioners

► 4 primary care guidelines for treatment of RTIs antibiotics indicated for patients: with a severe RTI

with risks of complications

(suspected of) pneumonia

How does it work in daily practice?

time pressure

diagnostic uncertainty

patients demanding for antibiotics

Friday afternoons

GPs’ habits

GP-patient relationship

ARTI 1: insight in antibiotic prescribing

Methods: detailed analysis of 2800 consultations for RTIs

ARTI 1: Results

Antibiotic prescription for RTIs: 37% of consultations

prescription over-prescription

OMA 47% 5%

sore throat 30% 58%

sinusitis, cold 35% 53%

acute cough 38% 48%

44% of prescriptions are not according to the guidelines:

over-prescription is

▪ highest for tonsillitis and bronchitis

▪ associated with - inflammations signs

- patients’ wish for an antibiotic

ARTI 2 and 3:interventions to optimise antibiotic prescribing

ARTI 2: RCT

intervention: ▪ education GPs (practice level)

guidelines, literature, communication

▪ monitoring/feedback prescribing data and behaviour

▪ information material patients

outcome: -12% in antibiotic prescribing rate

ARTI 3: CBA

similar intervention: ▪ education to larger groups of GPs

▪ monitoring/feedback prescribing data

outcome: no reduction in number of antibiotic prescriptions

Implementation: ARTI 4

Antibiotic prescribing practice can be improved

Barriers in implementation: - commitment of physicians

- sustainability of the effect

embedment within a regular quality assurance cycle:

practice accreditation* of the Dutch College of General Practitioners

* improving quality in care and organisational structure of primary care practices

3 years cycle: - yearly audit

- practice organisation

- prescribing routines

- chronic disease management

- yearly ‘improvement plans’

ARTI 4: support and a ready-to-use plan

optimising Ab prescription for RTIs

reducing (chronic) use of PPIs

ARTI 4: Study set-up (I)

• RCT with 87 primary care practices (1-7 GPs / practice)

• Ab and PPI practices serve as each others controls

• Primary outcomes:

Antibiotics: Ab prescriptions / 1000 pnts / year

% 2nd choice prescriptions

J01 collected via pharmacies

• Secondary outcomes and feed-back supplied to practices:

Antibiotics: prescribing behaviour

4-weeks registration of RTIs

• Data collection: 1 year preceding intervention, at year 1 and 2

ARTI 4 study set-up (II)

Multiple intervention

• educational meeting GPs at practice level

- guidelines, literature

- feedback on prescription data / behaviour

- communication, patients’ pressure

• improvement plan

practice-specific definition of targets

mean range

Ab/1000 pnt/year 272 140 - 535

% 2nd choice 28% 19% - 43%

over-prescription 44% 0% - 67%

base-line data

Feedback ‘Antibiotics’ during education

guideline prescribe consider no Ab

prescribed 1 7

not prescribed 3 1

OMA

Sore throat

Sinusitis

guideline prescribe no Ab

prescribed 3 2*

not prescribed 12

guideline consider no Ab

prescribed 6 6*

not prescribed 2 6

guideline prescribe no Ab

prescribed 8 7*

not prescribed 17

Cough

Totale antibioticaprescriptie: 1415 recepten/ 3371 patiënten (420*/ 1000) Landelijk: ±340 recepten/ 1000 inwoners Landelijk (%) Uw totale prescriptie (%) Tetracyclines: 18 20

Amoxicilline: 20 11 Fenoxymethylpen/ Feneticilline: 4 2 Flucloxacilline: 4 3 Amoxicilline/clavulaanzuur: 14 15*

Cef alosporines: 0.4 1

Trimethoprim : 4 1 Co-trimoxazol: 3 3

Macroliden: 13 21*

Chinolonen: 8 10*

Nitrofurantoïne: 11 12

Overige: 1 1 ----- ----- 100% 100%

Feedback ‘Antibiotics’ after 1 year

Totale antibioticaprescriptie: meting 1: 1803 recepten/ 3371 pnt (535/1000) meting 2: 1485 recepten/ 3371 pnt (441/1000)

Landelijk: ±340 recepten/ 1000 inwoners (inclusief avond, weekend)

meting 1 meting 2 Tetracyclines: 332 313

Amoxicilline: 202 170 Fenoxymethylpen/ Feneticilline: 29 40 Flucloxacilline 52 59 Amoxicilline/ clavulaanzuur: 198 151

Cef alosporines 16 4

Trimethoprim 25 7 Co-trimoxazol 67 58

Macroliden: 361 261

Chinolonen: 216 154

Nitrofurantoine: 291 256

Overige: 14 12 ----- ---- 1803 1485

ARTI 4: intervention effect onantibiotic prescription (n=49)

Intervention: Ab

(n=25)

Control: PPI (n=24)

p=

% change RTI Ab

prescrip/1000 pat

-11.9

(-33 – 12)

-3.3

(-21 – 29)

0.03

% change 2nd choice

prescrip/1000 pat

-13.5

(-56 – 31)

+0.9

(-30 – 48)

0.03

ARTI4 intervention significantly reduces antibiotic prescription

Goals and future plans:

• long-term effectiveness of this intervention (2 years)• development of internet-based educational programs

Questions?

Acknowledgements:

All Dutch general practitioners involved in one of the projects