Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial

Christopher C Butler, Sharon A Simpson, Frank Dunstan, Stephen Rollnick, David Cohen, David Gillespie, Meirion R Evans, M Fasihul Alam, Marie-Jet Bekkers, John Evans, Laurence Moore, Robin Howe, Jamie Hayes, Monika Hare, Kerenza Hood, Christopher C Butler, Sharon A Simpson, Frank Dunstan, Stephen Rollnick, David Cohen, David Gillespie, Meirion R Evans, M Fasihul Alam, Marie-Jet Bekkers, John Evans, Laurence Moore, Robin Howe, Jamie Hayes, Monika Hare, Kerenza Hood

Abstract

Objective: To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care.

Design: Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation.

Setting: 68 general practices with about 480,000 patients in Wales, United Kingdom.

Participants: 34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed.

Interventions: Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice based seminar reflecting on the practices' own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care.

Main outcome measures: Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year's dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs.

Results: The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% confidence interval 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was £2923 (€3491, $4572) per practice (SD £1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (-0.4% to 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice.

Conclusion: The STAR educational programme led to reductions in all cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs. Trial registration ISRCT No 63355948.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4788299/bin/butc891259.f1_default.jpg
Fig 1 Screenshot of the whole programme
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4788299/bin/butc891259.f2_default.jpg
Fig 2 Screenshot of the “What would you do?” section
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4788299/bin/butc891259.f3_default.jpg
Fig 3 Example of data fed back during practice based seminars: “Your practices’ antibiotic prescribing and resistance in urine samples compared to your Local Health Board (LHB) and all Wales, averaged over seven years”
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4788299/bin/butc891259.f4_default.jpg
Fig 4 Participant flow diagram

References

    1. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005;365:579-87.
    1. Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
    1. Glasziou P, del Mar C, Sanders S, Hayem M. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2004;1:CD000219.
    1. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev 2006;4:CD000023.
    1. Arroll B, Kenealy T. Are antibiotics effective for acute purulent rhinitis? Systematic review and meta-analysis of placebo controlled randomised trials. BMJ 2006;333:279-81.
    1. Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams JW Jr, Makela M. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2008;2:CD000243.
    1. Smucny J, Fahey T, Becker L, Glazier R. Antibiotics for acute bronchitis. Cochrane Database Syst Rev 2004;4:CD000245.
    1. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet 2007;369:482-90.
    1. Cosby JL, Francis N, Butler CC. The role of evidence in the decline of antibiotic use for common respiratory infections in primary care. Lancet Infect Dis 2007;7:749-56.
    1. Little P, Gould B, Williamson I, Warner G, Gantley M, Kinmonth A-L. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997;315:350-2.
    1. Butler CC, Hillier S, Roberts Z, Dunstan F, Howard A, Palmer S. Antibiotic-resistant infections in primary care are symptomatic for longer and increase workload: outcomes for patients with E coli UTIs. Br J Gen Pract 2006;56:686-92.
    1. Alam MF, Cohen D, Butler C, Dunstan F, Roberts Z, Hillier S, et al. The additional costs of antibiotics and re-consultations for antibiotic-resistant Escherichia coli urinary tract infections managed in general practice. Int J Antimicrob Agents 2009;33:255-7.
    1. Ball P, Baquero F, Cars O, File T, Garau J, Klugman K, et al. Antibiotic therapy of community respiratory tract infections: strategies for optimal outcomes and minimized resistance emergence. J Antimicrob Chemother 2002;49:31-40.
    1. Butler CC, Dunstan F, Heginbothom M, Mason B, Roberts Z, Hillier S, et al. Containing antibiotic resistance: decreased antibiotic-resistant coliform urinary tract infections with reduction in antibiotic prescribing by general practices. Br J Gen Pract 2007;57:785-92.
    1. Seppala H, Klaukka T, Vuopio-Varkila J, Muotiala A, Helenius H, Lager K, et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. Finnish Study Group for Antimicrobial Resistance. N Engl J Med 1997;337:441-6.
    1. Guillemot D, Varon E, Bernede C, Weber P, Henriet L, Simon S, et al. Reduction of antibiotic use in the community reduces the rate of colonization with penicillin G-nonsusceptible Streptococcus pneumoniae. Clin Infect Dis 2005;41:930-8.
    1. Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA 2009;302:758-66.
    1. Thompson PL, Spyridis N, Sharland M, Gilbert RE, Saxena S, Long PF, et al. Changes in clinical indications for community antibiotic prescribing for children in the UK from 1996 to 2006: will the new NICE prescribing guidance on upper respiratory tract infections just be ignored? Arch Dis Child 2009;94:337-40.
    1. Meropol SB, Chen Z, Metlay JP. Reduced antibiotic prescribing for acute respiratory infections in adults and children. Br J Gen Pract 2009;59:e321-8.
    1. Huttner B, Goossens H, Verheij T, Harbarth S. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis 2010;10:17-31.
    1. Butler CC, Hood K, Verheij T, Little P, Melbye H, Nuttall J, et al. Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. BMJ 2009;338:b2242.
    1. Coenen S, Kuyenhoven MM, Butler CC, Van Royen P, Verheij TJ. Variation in European antibiotic use. Lancet 2001;358:1272.
    1. Ranji SR, Steinman MA, Shojania KG, Gonzales R. Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Med Care 2008;46:847-62.
    1. Ostini R, Hegney D, Jackson C, Williamson M, Mackson JM, Gurman K, et al. Systematic review of interventions to improve prescribing. Ann Pharmacother 2009;43:502-13.
    1. Martens J, Winkens R, van der Weijden T, de Bruyn D, Severens J. Does a joint development and dissemination of multidisciplinary guidelines improve prescribing behaviour: a pre/post study with concurrent control group and a randomised trial. BMC Health Serv Res 2006;2:145.
    1. Van Driel M, Coenen S, Dirven K, Lobbestael J, Janssens I, Van Roven P, et al. What is the role of quality circles in strategies to optimise antibiotic prescribing? A pragmatic cluster-randomised controlled trial in primary care. Qual Saf Health Care 2007;16:197-202.
    1. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 1995;153:1423-31.
    1. Davis DA, Thompson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-5.
    1. Thomson O’Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000;2:CD000409.
    1. Finch RG, Metlay JP, Davey PG, Baker LJ. Educational interventions to improve antibiotic use in the community: report from the International Forum on Antibiotic Resistance (IFAR) colloquium, 2002. Lancet Infect Dis 2004;4:44-3.
    1. Foy R, MacLennan G, Grimshaw J, Penney G, Campbell M, Grol R. Attributes of clinical recommendations that influence change in practice following audit and feedback. J Clin Epidemiol 2002;55:717-22.
    1. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev 2005;4:CD003539.
    1. Eccles M, Grimshaw J, Walker A, Johnston M, Pitts N. Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol 2005;58:107-12.
    1. Schiff GD, Galanter WL. Promoting more conservative prescribing. JAMA 2009;301:865-7.
    1. Butler CC, Prout H, Kinnersley P, Rollnick S, Edwards A, Elwyn G. Shared decision making and antibiotics in primary care. J Antimicrobial Chemother 2001;48:435-40.
    1. Cals JW, Butler CC, Hopstaken RM, Hood K, Dinant GJ. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ 2009;338:b1374.
    1. Francis NA, Butler CC, Hood K, Simpson S, Wood F, Nuttall J. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ 2009;339:b2885.
    1. Butler CC, Rollnick S, Maggs-Rapport F, Pill RM, Stott NCH. Understanding the culture of prescribing: a qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ 1998;317:637-42.
    1. Wood F, Simpson S, Butler CC. Socially responsible antibiotic choices in primary care: a qualitative study of GPs’ decisions to prescribe broad-spectrum and fluroquinolone antibiotics. Fam Pract 2007;24:427-34.
    1. Grol R, Baker R, Moss F. Quality improvement research: understanding the science of change in health care. Qual Saf Health Care 2002;11:110-1.
    1. Butler CC, Rollnick S, Kinnersley P, Jones A, Stott NCH. Reducing antibiotics for respiratory tract symptoms in primary care; consolidating “why” and considering “how.” Br J Gen Pract 1998;48:1865-70.
    1. Rollnick S, Mason P, Butler CC. Health behaviour change: a guide for practitioners. Churchill Livingstone, 1999.
    1. Simpson SA, Butler CC, Hood K, Cohen D, Dunstan F, Evans MR, et al. Stemming the tide of antibiotic resistance (STAR): a protocol for a trial of a complex intervention addressing the “why” and “how” of appropriate antibiotic prescribing in general practice. BMC Fam Pract 2009;10:20.
    1. Carter B, Hood K. Balance algorithm for cluster randomized trials. BMC Med Res Methodol 2008;8:65.
    1. Xiao L, Lavori PW, Wilson SR, Ma J. Comparison of dynamic block randomization and minimization in randomized trials: a simulation study. Clin Trials 2011;8:59-69.
    1. Rollnick S, Miller WR, Butler C. Motivational interviewing in health care. Guildford Press, 2008.
    1. Cals JW, Scheppers NA, Hopstaken RM, Hood K, Dinant GJ, Goettsch, et al. Evidence based management of acute bronchitis; sustained competence of enhanced communication skills acquisition in general practice. Patient Educ Couns 2007;68:270-8.
    1. Rollnick S, Seale C, Kinnersley P, Rees M, Butler C, Hood K. Developing a new line of patter: can doctors change their consultations for sore throat? Med Educ 2002;36:678-81.
    1. Rollnick S, Kinnersley P, Butler C. Context-bound communication skills training: development of a new method. Med Educ 2002;36:377-83.
    1. Lambert MF, Masters GA, Brent SL. Can mass media campaigns change antimicrobial prescribing? A regional evaluation study. J Antimicrobial Chemother 2007;59:537-43.
    1. Curtis L. Unit costs of health and social care. Personal Social Services Research Unit, University of Kent, Canterbury, 2008.
    1. British Medical Association and the Royal Pharmaceutical Society of Great Britain. British National Formulary. 54th ed. BMA and the Royal Pharmaceutical Society of Great Britain, 2007.
    1. McIsaac W, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ 2000;163:811-5.
    1. Eldridge S, Kerry S, Torgerson DJ. Bias in identifying and recruiting participants in cluster randomised trials: what can be done? BMJ 2009;339:b4006.
    1. Welschen I, Kuyvenhoven M, Hoes A, Verheij TJ. Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial. BMJ 2004;329:431.
    1. Bekkers MJ, Simpson SA, Dunstan F, Hood K, Hare M, Evans CC, et al. Enhancing the quality of antibiotic prescribing in primary care: qualitative evaluation of a blended learning intervention. BMC Fam Pract 2010;11:34.
    1. McNulty CA, Nichols T, Boyle PJ, Woodhead M, Davey P. The English antibiotic awareness campaigns: did they change the public’s knowledge of and attitudes to antibiotic use? J Antimicrobial Chemother 2010;65:1526-33.

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