Implementation and outcomes of a 5-year intervention program to improve use of antibiotics in respiratory tract infection in primary care

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• 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.

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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

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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

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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 wont get better more quickly by taking
  antibiotics for a common cold

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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

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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

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Time-line of interventions
Newsletter
Case study
Mailed GP prescription feedback
Clinical audit
Academic detailing
Consumer campaign
1999 2000 2001 2002
2003
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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

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Community use of antibiotics (DDD/1000/day)
continued decline
Source DUSC data
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GP prescriptions antibiotics primarily used URTI
continued decline, reduced peaks
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GP prescribing rate all URTI problems-
significant decrease over 4 years
50.4
46.9
BEACH data
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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

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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

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Key lessons continued

• Longterm 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

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Key lessons contd

• 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

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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

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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?