This document summarizes evidence from a systematic review on effective interventions to improve antibiotic prescribing in primary care. The review found that interventions involving multiple components, including educational materials and meetings for physicians, were most effective at reducing total antibiotic prescribing. Delayed prescribing strategies that provide clear instructions on use were also effective. Communication skills training for physicians, with or without decision aids, reduced prescribing for respiratory tract infections. The use of near-patient tests also reduced prescribing when combined with clinical training.

1. Evidence for effective
interventions to improve
antibiotic prescribing in
primary care : what works?
Paul Little
Professor of Primary Care Research
University of Southampton

2. 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

4. Why:? we need to moderate antibiotic use…..

5. Practitioner behaviour is learned
early…

6. CHAMP
Changing behaviour of health care professionals
and the general public towards a more prudent use
of anti-microbial agents
Sixth Framework Programme:
United Kingdom, Belgium,
Switzerland, the Netherlands
Poland, Italy, Spain

7. Aim:
To determine the effectiveness of
interventions aiming to improve
antibiotic use for respiratory tract
infections in primary care
Method:
Systematic review of behavioural
interventions targeted at:
 primary care physicians
 primary care patients

8. 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

9. 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%)

10. 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%)

11. 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

12. 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’

13. 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

14. Delayed prescribing/wait and see?
weight + sea ?

15. Sore throat trial: % better by 3 days
Satisfaction, belief , intention
100 p<0.001
90
p<0.001
80
% 70
60 Antibiotic
50 No antib.
40 delayed
30
20
10
0
% better satis belief Ab future

16. 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

17. 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)

18. Delayed prescribing useful?: Sharland et al BMJ
Figure 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)
120.0
Study published
100.0
IMS data
PPA data
80.0
prescribed
60.0
used
40.0
20.0
0.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

19. Guidance introduced
Diagnosis
Israel guidance 2004:
delayed prescription
Antibiotic use + analgesic for OM
(Grossman et al Paed Inf Dis J.2010)
Analgesic use

20. Getting further funds?
With Pablo Alonso Coello:
1) RCT two modes of delayed prescribing adults: encouraging results
2) RCT of delayed prescribing in children: hoping for funding!....

21. Which Near Patient Tests (NPTs)?
RADTs and/or CRP?
van der Meer, V. et al. BMJ 2005;331:26
Copyright ©2005 BMJ Publishing Group Ltd.

22. 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

23. Comunication: Probably not
this….?:
Lack of time

24. Or this!

25. 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

26. 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

27. GRACE
INTRO (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

28. Factorial Design
No Web based
Communication Communication
Training Training
+booklet
No CRP Group1 Group2
training
Web based Group3 Group4
CRP training

29. 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

30. 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

31. 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

32. Intervention RRs: just LRTI (79.7%)
controlling for GP, practice clustering, baseline Ab prescribing
RR RR p
(basic) (adjusted)
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

33. Intervention: LRTI vs other RTI
RRs
controlling for GP and practice clustering, baseline Ab prescribing
RR RR p
(basic (basic
model model
LRTI) other RTI)
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

34. Overall Group
controlling for GP and practice clustering
RR RR p
(basic) (adjusted for patient
variables: being redone!)
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

35. What does this mean for %antibiotic
use?
LRTI Other All Cals
RTI
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)

36. 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!

37. 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

38. Conclusion
We can communicate effectively….

39.  TEACHER: Harold, what do you
call a person who keeps on talking
when people are no longer
interested?
 HAROLD: A teacher