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