NIHR DC Discover

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NIHR Signal Tools for GPs can help reduce unnecessary antibiotic prescribing

Published on 30 October 2018

doi: 10.3310/signal-000667

Interventions to reduce inappropriate antibiotic prescribing for upper respiratory tract infections are most effective when they provide a negotiation tool to support patient interaction. These interventions are more likely to be rejected if they are perceived as interfering with individual clinical judgment or damaging patient relationships.

Upper respiratory tract infections often resolve themselves within a few days, without the need for antibiotics, yet antibiotics are often prescribed. This systematic review of qualitative studies explored what primary care professionals who prescribe thought about interventions designed to reduce antibiotic prescribing for acute respiratory infections.

These findings indicate that a successful implementation of such interventions requires understanding prescriber perspectives to ensure that the selected tools meet their needs. Implementation based on a one-size-fits-all approach can lead to prescribers rejecting them.

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Why was this study needed?

Inappropriate antibiotic prescribing wastes NHS money on prescriptions that are not actually helping people to get better quickly and may even cause harm. It also contributes to the growing global problem of antibiotic resistance, which threatens the long-term effectiveness of these drugs. The NHS has committed to halving inappropriate antibiotic prescribing by 2020.

In 2018, Public Health England estimated that at least 20% of antibiotics are prescribed inappropriately in England. This includes situations where the illness will resolve naturally in a few days or for viruses where antibiotics do not help.

For acute coughs that were not complicated by other conditions, Public Health England found that antibiotics were prescribed in 41% of consultations but were only appropriate in around 10%. This review aimed to identify tools that GPs find most useful for reducing inappropriate antibiotic prescriptions for acute coughs.

What did this study do?

This systematic review included 53 qualitative studies with over 1,200 participants on interventions for antibiotic prescribing for primary care professionals for acute respiratory tract infections. The review updates a previous review, published in 2011.

Studies using qualitative methods, such as interviews and focus groups, were included if they incorporate the perspectives of primary care professionals.

Meta-ethnography was used to draw conclusions; this is the qualitative equivalent of meta-analysis. Papers were grouped into broad themes; then their contents analysed to identify first-order constructs based on direct participant quotes and second-order constructs where original study authors had interpreted responses.

As most included studies were from the UK and Scandinavia, findings are likely to be applicable to UK practice.

What did it find?

  • Primary care professionals were most likely to accept interventions that they perceived as supportive aids, those that support clinical decision making and enhance their interactions with patients through creating golden moments for patient education to help empower them.
  • Interventions viewed as a compromise were acceptable in certain situations, such as deadlock overtreatment due to clinical uncertainty. Supporting prescribers to cope with the pressure to prescribe from some patients, by providing a negotiation tool to avoid or limit conflict, was another advantage.
  • Primary care professionals were more likely to reject interventions that they perceived as a source of distress for them and their patients. This distress could arise from fears around inappropriate treatment decisions due to the use of interventions, potential disconnect between the prescriber’s clinical judgment and what the intervention says. They were also worried about the impact on relationships with patients, as some interventions could result in reduced shared decision making.
  • Rejection of interventions was also more likely where they were viewed as unnecessary. This was usually from more experienced prescribers, who felt that they did not require this level of support but recognised their value for inexperienced practitioners – whether newly qualified or new to prescribing.

What does current guidance say on this issue?

NICE 2008 guidelines recommend that for self-limiting upper respiratory tract infections, three broad options should be considered: no prescribing delayed prescribing and immediate prescribing. The treatment decision should be reached through discussion with the patient and education about the natural history of such conditions.

The guidelines include a list of situations in which a patient may be at risk of developing complications, and immediate antibiotic prescribing is recommended. NICE also issued guidelines in 2015 on antimicrobial stewardship, recommending a variety of interventions including decision support tools.

What are the implications?

When implementing interventions to reduce unnecessary antibiotic prescribing for acute respiratory tract infections in primary care, the views of the staff using these tools should be considered. Engaging staff in the process ensures that tools meet their needs and are adaptable to context.

This applies to choosing which tool to implement and considering staff perceptions during implementation, in order to ensure that staff feel positive about the tool. Failing to do so can lead to a rejection of such tools or overriding of the decisions reached using them, rendering them ineffective.

Citation and Funding

Germeni E, Frost J, Garside R, et al. Antibiotic prescribing for acute respiratory tract infections in primary care: an updated and expanded meta-ethnography. Br J Gen Pract. 2018;68(674):e633-45.

Three authors were partially supported by the UK National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula. One author was supported by an Advanced Postdoc Mobility grant from the Swiss National Science Foundation (P300P1_164574).

Bibliography

NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NG15. London: National Institute for Health and Care Excellence; 2015.

NICE. Respiratory tract infections (self-limiting): prescribing antibiotics. CG69. London: National Institute for Health and Care Excellence; 2008.

PHE. Research reveals levels of inappropriate prescriptions in England. London: Public Health England; 2018.

PHE. Financial incentives effective at reducing antibiotic prescribing. London: Public Health England; 2018.

Why was this study needed?

Inappropriate antibiotic prescribing wastes NHS money on prescriptions that are not actually helping people to get better quickly and may even cause harm. It also contributes to the growing global problem of antibiotic resistance, which threatens the long-term effectiveness of these drugs. The NHS has committed to halving inappropriate antibiotic prescribing by 2020.

In 2018, Public Health England estimated that at least 20% of antibiotics are prescribed inappropriately in England. This includes situations where the illness will resolve naturally in a few days or for viruses where antibiotics do not help.

For acute coughs that were not complicated by other conditions, Public Health England found that antibiotics were prescribed in 41% of consultations but were only appropriate in around 10%. This review aimed to identify tools that GPs find most useful for reducing inappropriate antibiotic prescriptions for acute coughs.

What did this study do?

This systematic review included 53 qualitative studies with over 1,200 participants on interventions for antibiotic prescribing for primary care professionals for acute respiratory tract infections. The review updates a previous review, published in 2011.

Studies using qualitative methods, such as interviews and focus groups, were included if they incorporate the perspectives of primary care professionals.

Meta-ethnography was used to draw conclusions; this is the qualitative equivalent of meta-analysis. Papers were grouped into broad themes; then their contents analysed to identify first-order constructs based on direct participant quotes and second-order constructs where original study authors had interpreted responses.

As most included studies were from the UK and Scandinavia, findings are likely to be applicable to UK practice.

What did it find?

  • Primary care professionals were most likely to accept interventions that they perceived as supportive aids, those that support clinical decision making and enhance their interactions with patients through creating golden moments for patient education to help empower them.
  • Interventions viewed as a compromise were acceptable in certain situations, such as deadlock overtreatment due to clinical uncertainty. Supporting prescribers to cope with the pressure to prescribe from some patients, by providing a negotiation tool to avoid or limit conflict, was another advantage.
  • Primary care professionals were more likely to reject interventions that they perceived as a source of distress for them and their patients. This distress could arise from fears around inappropriate treatment decisions due to the use of interventions, potential disconnect between the prescriber’s clinical judgment and what the intervention says. They were also worried about the impact on relationships with patients, as some interventions could result in reduced shared decision making.
  • Rejection of interventions was also more likely where they were viewed as unnecessary. This was usually from more experienced prescribers, who felt that they did not require this level of support but recognised their value for inexperienced practitioners – whether newly qualified or new to prescribing.

What does current guidance say on this issue?

NICE 2008 guidelines recommend that for self-limiting upper respiratory tract infections, three broad options should be considered: no prescribing delayed prescribing and immediate prescribing. The treatment decision should be reached through discussion with the patient and education about the natural history of such conditions.

The guidelines include a list of situations in which a patient may be at risk of developing complications, and immediate antibiotic prescribing is recommended. NICE also issued guidelines in 2015 on antimicrobial stewardship, recommending a variety of interventions including decision support tools.

What are the implications?

When implementing interventions to reduce unnecessary antibiotic prescribing for acute respiratory tract infections in primary care, the views of the staff using these tools should be considered. Engaging staff in the process ensures that tools meet their needs and are adaptable to context.

This applies to choosing which tool to implement and considering staff perceptions during implementation, in order to ensure that staff feel positive about the tool. Failing to do so can lead to a rejection of such tools or overriding of the decisions reached using them, rendering them ineffective.

Citation and Funding

Germeni E, Frost J, Garside R, et al. Antibiotic prescribing for acute respiratory tract infections in primary care: an updated and expanded meta-ethnography. Br J Gen Pract. 2018;68(674):e633-45.

Three authors were partially supported by the UK National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula. One author was supported by an Advanced Postdoc Mobility grant from the Swiss National Science Foundation (P300P1_164574).

Bibliography

NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NG15. London: National Institute for Health and Care Excellence; 2015.

NICE. Respiratory tract infections (self-limiting): prescribing antibiotics. CG69. London: National Institute for Health and Care Excellence; 2008.

PHE. Research reveals levels of inappropriate prescriptions in England. London: Public Health England; 2018.

PHE. Financial incentives effective at reducing antibiotic prescribing. London: Public Health England; 2018.

Antibiotic prescribing for acute respiratory tract infections in primary care: an updated and expanded meta-ethnography

Published on 20 June 2018

Germeni, E.,Frost, J.,Garside, R.,Rogers, M.,Valderas, J. M.,Britten, N.

Br J Gen Pract , 2018

BACKGROUND: Reducing unnecessary prescribing remains a key priority for tackling the global rise of antibiotic-resistant infections. AIM: The authors sought to update a 2011 qualitative synthesis of GPs' experiences of antibiotic prescribing for acute respiratory tract infections (ARTIs), including their views of interventions aimed at more prudent prescribing. They expanded the original scope to encompass all primary care professionals (PCPs) who can prescribe or dispense antibiotics for ARTIs (for example, nurses and pharmacists). DESIGN AND SETTING: Systematic review and meta-ethnography of qualitative studies. METHOD: A systematic search was conducted on MEDLINE, EMBASE, PsycINFO, CINAHL, ASSIA, and Web of Science. No date or language restrictions were used. Identified studies were grouped according to their thematic focus (usual care versus intervention), and two separate syntheses were performed. RESULTS: In all, 53 articles reporting the experiences of >1200 PCPs were included. Analysis of usual-care studies showed that PCPs tend to assume multiple roles in the context of ARTI consultations (the expert self, the benevolent self, the practical self), depending on the range of intrapersonal, interpersonal, and contextual situations in which they find themselves. Analysis of intervention studies identified four possible ways in which PCPs may experience quality improvement interventions (compromise, 'supportive aids', source of distress, and unnecessary). CONCLUSION: Contrary to the original review, these results suggest that the use of the same intervention is experienced in a totally different way by different PCPs, and that the same elements that are perceived as benefits by some could be viewed as drawbacks by others. Acceptability of interventions is likely to increase if these are context sensitive and take into account PCPs' varying roles and changing priorities.

Expert commentary

Overusing antibiotics diminishes their effectiveness over time. Antibiotics are not needed by most people with chest infections as these conditions usually clear up on their own.

GPs and others overprescribe antibiotics for a variety of reasons. This study provides useful information for those designing interventions that encourage GPs to follow prescribing guidelines.

Interventions need to be tailored to take account of the different health care systems GPs operate in and the types of situations they face. Interventions also need to be multifaceted and sufficiently flexible so that elements can be adjusted according to different prescribers’ circumstances and priorities.

Dr Helen Allbutt, Principal Lead, NHS Education for Scotland