Implementation and outcomes of a 5-year intervention program to improve use of antibiotics

in respiratory tract infection in primary care

Judith Mackson

Education and QA Program Manager

L Weekes, C Bottomley, K Easton, L McMartin, M Fletcher, L Pont,

L Kenyon, S Wutzke, J Mandryk, C Babcock.

Primary care setting for intervention program

• Fee-for-service subsidised consultations• Subsidised antibiotic supply for low-income people• Unrestricted general practitioner (GP) prescribing

rights for oral antibiotics except for quinolones• Variable awareness of best-practice guidelines for

antibiotic prescribing• Rapidly changing cultural mix of patients and GPs in

urban areas• Highly regulated pharmacy services

Need to understand influences on antibiotic prescribing in primary care

Complex biomedical and social factors including:Patient

– Desire for tangible outcome of consultation– Perceptions of effectiveness esp. in viral illness

Doctor– Information gap regarding best-practice prescribing– Desire to satisfy patient demand– Consultation process: short, fee-for-service– Marketing especially newer antibiotics

Key messages to address influencing factors

For health professionals– limited indications in URTI

• no role in viral illness• limited role in sore throat, otitis media, sinusitis: use only if

benefit can be expected

– appropriate selection• use narrow spectrum• amoxycillin drug of choice for most URTIs

– review your prescribing– discuss realistic expectations with patients

For consumers– You won’t get better more quickly by taking antibiotics for a

common cold

Program objectives

• To decrease volume of antibiotic prescriptions by GPs for upper respiratory tract infections (URTI) and acute bronchitis– Low rates for acute bronchitis, pharyngitis, lower rates acute

otitis media (AOM), acute sinusitis • To increase proportion of first-line antibiotic selection when an

antibiotic required (appropriate and minimises selection pressure)– Amoxycillin first-line AOM, acute sinusitis, penicillin V first line

strep throat and tonsillitis• To encourage a more judicious approach to antibiotic prescribing

for URTI and bronchitis• To inform consumers of limited benefit of antibiotics in URTI and to

encourage symptom management

Multifaceted interventions

For health professionals• Written materials and GP prescription

feedback annually for 5 years, voluntary educational & quality assurance activities for GPs, patient education leaflets

For consumers• Media advertising, ‘grass roots’

meetings over 3-4 years

1999 2000 2001 2002 2003

Time-line of interventions

Academic detailing

Mailed GP prescription feedback

Clinical audit

Newsletter

Consumer campaign

Case study

Evaluation of program

• Process including participation rates• Awareness, knowledge and attitudes GP,

pharmacist and consumer• GP use of antibiotic guidelines• Antibiotic utilisation, prescribing rates

– Total volume, GP prescribing URTI, first-line selection, undesirable switching

Community use of antibiotics (DDD/1000/day) – continued decline

National antibiotic utilisation

0

5

10

15

20

25

30

1995 1996 1997 1998 1999 2000 2001 2002 2003

Year

DDD/

1000

pop

ulat

ion/

day

All antibiotics (ATC J01 -oral + parenteral)

AMOXYCILLIN

AMOXYCILLIN w ith CLAVULANIC AC

CEFACLOR

CEFUROXIME

CLARITHROMYCIN

DOXYCYCLINE

ERYTHROMYCIN

PENICILLIN V

ROXITHROMYCIN

CEPHALEXIN

Source: DUSC data

GP prescriptions antibiotics primarily used URTI –continued decline, reduced peaks

GP prescribing rate all URTI problems- significant decrease over 4 years

Percentage of URTI problems where an antibiotic was prescribed-BEACH data (URTI=our defintion)

43

44

45

46

47

48

49

50

51

52

1999 2000 2001 2002

year

per

cen

tag

e o

f U

RT

I pro

ble

ms

n URTI

encoutners=12 809

n URTI

encoutners=10 900

n URTI

encoutners=10 004

n URTI

encoutners=11 046

BEACH data

50.4%

46.9%

Conclusions

• Sustained decrease total use antibiotics• Sustained decrease GP prescribing• Decreased GP prescribing rate for URTI• Change in mix of drugs toward recommended

first-line agents• Fewer consumers believed antibiotics were

appropriate for treating colds or ‘flu

Key lessons from this program

• Develop good processes to understand the determinants that lead to inappropriate antibiotic use locally– eg concern regarding S. pneumoniae resistance reduced

prescriber confidence in amoxycillin for all indications

• Planning may have unexpected findings. ..– Common colds needs common sense message developed

not because of high rate of prescribing in common cold, but a complex of symptoms which consumers understood

– Prescribers not motivated by global antibiotic burden and confusion regarding antimicrobial resistance among prescribers and consumers means not a useful message

Key lessons continued

• Long–term programs are required to allow for repetition and refinement of program messages

• Different interventions may be required to change total prescribing rate verus change in antibiotic selection

• Some prescribing more difficult to change– Acute bronchitis – due to severity of symptoms,

diagnostic uncertainty?– Roxithromycin – heavily marketed, once daily

dosing, few adverse effects

Key lessons cont’d

• A consumer campaign may be a key component to reduce patient demand and GP perceptions of demand and therefore total volume

• Can effectively use media to disseminate messages to the community especially via local radio

• More possibility of change in antibiotic use than other drug classes

• Financial and professional incentives for GPs important for voluntary participation

Implications for policies and programs

• Long term programs allowing repetition• National versus regional programs: design

messages and interventions tailored to the prescribers and consumers where influences on drug use can be understood

• Expertise in social marketing for consumer campaigns, need to target audiences for best use of funds

Research questions

• Can models be developed to engage pharmaceutical industry in appropriate marketing?

• What is the optimally low level of antibiotic prescribing?

• What indicators are needed to ensure no unintended effects?

• What is the optimal mix of interventions for what time period? Where has change not occurred?

• Has this program resulted in reduced rate of development of antimicrobial resistance?