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