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Evidence for effective interventions to improve antibiotic prescribing in primary care : what works?
Paul Little
Professor of Primary Care Research
University of Southampton
Overview
Recent systematic review of patient and doctor oriented interventions (from CHAMP)
Evidence for delayed prescribing Recent studies in communication
skills and near patient tests Trial data from GRACE intro
Why:? we need to moderate antibiotic use…..
Practitioner behaviour is learned early…
CHAMP
Sixth Framework Programme:United Kingdom, Belgium,
Switzerland, the NetherlandsPoland, Italy, Spain
Changing behaviour of health care professionals
and the general public towards a more prudent use
of anti-microbial agents
Method:Systematic review of behavioural interventions targeted at:
primary care physicians primary care patients
Aim:To determine the effectiveness of interventions aiming to improve antibiotic use for respiratory tract infections in primary care
Physician interventions
Literature review• MEDLINE, EMBASE, Cochrane• 1990-2010
Methods, outcomes• effective intervention:
significant decrease in total antibiotic prescription, or
significant increase in 1st choice prescription• control group and before/after measurement
also no control, or controlled but no before measurement
Interventions aimed at p.c. physicians:characteristics
58 studies
designs: mostly CBA (controlled before/after), RCT• encompassed 101 interventions• 77%: multiple, 40%: multifaceted• interventions contained an average of 3 intervention elements.
Most often used elements: educational material for physician (70%) educational meetings (56%) educational material for patients (40%) audit/feedback (37%)Training in communication (9%)NPT (8%)
RTI interventions aimed at p.c. physicians:effectiveness (I)
Overall effectiveness • 60% of interventions significantly improved antibiotic
prescription• ↓ total prescription (n=59, 43 (73%) effective):
• mean -11.6% (-72% - 19%)• ↑ 1st choice prescription (n=28, 9 (32%) effective)
• +9.6% (5% to 41%)
Type of study design
Study type Outcome Total AB (%) n First choice n RCT/CBA -8.7 (-27 – 18.8) 33 9.2 (-2 – 27.2) 15 No CBA -12.3 (-37 – 4.3) 16 11.1 (-5 – 41) 11 CA -20.3 (-72 – -1) 10 3.6 (2 – 5.1) 2
RTI interventions aimed at p.c. physicians:effectiveness (II)
Determinants of effectiveness (multivariate analysis)• ‘multiple intervention’ OR: 6.5 (2 to 22)• ‘physician materials’ OR: 5.5 (1.7 to 18)• ‘patient materials OR 1.4 (0.4 to 5) • audit/feedback OR 0.5 (0.2 to 2)
• promising: ‘communications skills’ and ‘near patient testing’
RTI interventions aimed at patients:
Meta-analysis of 33 interventions • cognitive outcomes: modest (attitudes knowledge)• delayed or refused prescription: effective • education, information material: not effective• no worsening of patients’ satisfaction
Delayed prescribing/wait and see?
weight + sea ?
Sore throat trial: % better by 3 daysSatisfaction, belief , intention
010
2030
4050
6070
8090
100
% better satis belief Ab future
AntibioticNo antib.delayed
%
p<0.001p<0.001
Delayed prescribing? It is not: ‘wait and see a few days…….’ It is:
• Strong message: antibiotics aren’t needed problems not benefits
• Clear natural history information……. Otitis: 3 days Sore throat: 5 days Cold: 7 days Chest infection: 10 days
• Clear instructions when to use Abs If much worse, or not starting to improve a little
by the end of the expected natural history
Cochrane review of delayed prescribing: ? Is no prescribing better 10 studies: heterogeneity (no meta-anal.) Antibiotic use (6 studies):No or delayed
effective in short term• Immediate 93% (92% satisfied)• Delayed 28-30% (87% satisfied)• No 14% (83% satisfied)
only 3 studies comparing no/delayed!
NB Reconsultation not addressed properly in the Cochrane review• Higher reconsultation in no groups in short (1m)
and longer term (1 yr) (LRTI, sore throat)
Delayed prescribing useful?: Sharland et al BMJFigure 1: Time trend in antibiotic prescribing to children in UK general practice 1993-2004 estimated from national prescribing data and the IMS GP prescribing database (1993=100)
0.0
20.0
40.0
60.0
80.0
100.0
120.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
IMS data
PPA data
prescribed
used
Study published
Israel guidance 2004:delayed prescription + analgesic for OM(Grossman et al Paed Inf Dis J.2010)
Diagnosis
Antibiotic use
Analgesic use
Guidance introduced
Getting further funds?
With Pablo Alonso Coello: 1) RCT two modes of delayed prescribing adults: encouraging results2) RCT of delayed prescribing in children: hoping for funding!....
Copyright ©2005 BMJ Publishing Group Ltd.
van der Meer, V. et al. BMJ 2005;331:26
Which Near Patient Tests (NPTs)? RADTs and/or CRP?
Use of NPTs: sore throat
Worrall et al RCT Four strategies: Antibiotic use
• Centor 55% • Usual care 58%• RAT 27%• RAT with Centor 38%
NB: Small trial, no symptomatic outcomes, no comparison with alternative prescribing strategies
Lack of time
Comunication: Probably not this….?:
Or this!
Use of NPTs and communication skills training for LRTI
Cals et al Four groups: antibiotic use
• Usual care 68%• CRP 39%• Communication skills 33%• Both 23%Communication skills training:
Seminar 11 key tasks e.g. exploring patients’ fears and expectations, asking patients’ opinion on antibiotics, and outlining the natural duration of cough in lower respiratory tract infection
Peer review of transcripts with simulated patients
Communication: internet training using a booklet
Francis et al: antibiotic use for children with RTIs• 19.5% booklet• 40.8% usual care
Encouraged booklet use within the consultation to facilitate the use of communication skills:
exploring the parent’s main concerns/expectations discussing prognosis, treatment options any reasons that should prompt reconsultation
GRACEINTRO (INternet TRaining
for antibiOtic use) Trial Paul Little, Beth Stuart, Elaine Douglas, Sarah Tonkin-Crine,
Sibyl Anthierens, Nick Francis, Kerry Hood, Mark Kelly, Hasse Melbye, Jochen Cals, Mike Moore, Samuel Coenen, Maciek
Godycki-Cwirko, Artur Mierzecki, Toni Torres, Carl Llor, Peter Edwards, Miriam Santer, Mark Mullee, Gilly O’Reilly, Curt Brugman, Samuel Coenen Herman Goossens Theo Verheij,
Chris Butler, Lucy Yardley, on behalf of the GRACE consortium.
Thanks to ORION diagnostica
Factorial Design
No CommunicationTraining
Web based CommunicationTraining +booklet
No CRP training
Group1 Group2
Web basedCRP training
Group3 Group4
Intervention Building on CHAMP, qualitative work,
prior experience (e.g.EQUIP/STAR/IMPACT) • Internet ‘Communication’ package
Presentation of Evidence• Natural history, effectiveness of Abs etc• Glossy booklet shared with patients (alla EQUIP)
Communication skills training (EQUIP;IMPACT;STAR/) use of booklet
• Video clips tailored to individuals and country• forum facilities :questions, responses by GRACE team
Practice-based discussion:• recent prescribing cases (alla EQUIP/STAR)• brief audit of prescribing
Communication/Information sharing
Addressing the patients world• Concerns• Expectations• Attitude to antibiotics
Information exchange / discuss booklet• Duration / prognosis• Likely benefits / risks of antibiotics• Self-help treatments• Reasons to reconsult
Wrap up• Summarise situation• Check for understanding and further concerns
CRP
• Communication package vs No Package• Half of each of the above groups get training in
the use of CRP Develop web based CRP training package
• Derive evidence based+/- consensus cut points and SOP (CRP for individuals where clinician unsure)
• Jochen Cals and Hasse Melbye
Intervention RRs: just LRTI (79.7%)controlling for GP, practice clustering, baseline Ab prescribing
RR(basic)
RR(adjusted)
p
Control 1.0 1.0
CRP 0.51 0.52(0.34 to 0.73) <0.001
Communic’n 0.69 0.73 (0.52 to 0.94) 0.010
Both 0.43 0.37 (0.25 to 0.54) <0.001
Multivariate model controlled for:•Age (N/S), smoking (N/S) gender (N/S)•Comorbidity, baseline symptoms•Crepitations, wheeze, pulse>100, temp >37.8, RR (N/S), low BP (N/S),•GP rating of severity, and prior duration cough
Intervention: LRTI vs other RTI RRs
controlling for GP and practice clustering, baseline Ab prescribing
RR(basic modelLRTI)
RR(basic modelother RTI)
p
Control 1.0 1.0
CRP 0.51 0.56 (0.33 to 0.87) 0.008
Communic’n 0.69 0.58 (0.34 to 0.92) 0.016
Both 0.43 0.43 (0.24 to 0.69) <0.001
Overall Groupcontrolling for GP and practice clustering
RR(basic)
RR(adjusted for patient variables: being redone!)
p
Control 1.0 1.0
CRP 0.53 0.47 (0.35 to 0.64) <0.001
Communic’n 0.70 0.66 (0.50 to 0.85) <0.001
Both 0.45 0.39 (0.28 to 0.54) <0.001
What does this mean for %antibiotic use?
LRTI OtherRTI
All Cals
Control 62% 45% 58% 67%
CRP 37% 27% 35% 39%
Comm’n 43% 28% 41% 33%
Both 33% 24% 31% 23%
Communication package not quite so effective as in Cals approx. 2/3 (NB internet - not Cals et al workshops)
INTRO Conclusion Internet based communication behavioural
intervention with practice meetings are effective in reducing prescribing• very little variation due to Network • variations (e.g. fewer practice meetings,
booklet changes) may not be important? Internet based CRP training and training
by supplier is effective in reducing prescribing• It may be the training and providing tests as
much as doing the test?• Caution: if CRP not useful in excluding
pneumonia then the rationale and the training package may be difficult to use!
So what works?
Multiple interventions including educational meetings and material for physicians
Structured use of delayed prescribing or no prescribing strategy
NB multiple simple components for delayed Use of NPTs? Communication skills training +/-
booklet
ConclusionWe can communicate effectively….
TEACHER: Harold, what do you call a person who keeps on talking when people are no longer interested?
HAROLD: A teacher