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NIHR Signal Decision support tools can help GPs reduce antibiotic prescriptions for respiratory conditions

Published on 28 May 2019

doi: 10.3310/signal-000769

A 12% reduction in GP antibiotic prescriptions for respiratory conditions was achieved through the use of electronic decision and training tools. This reduction did not increase the risk of serious infections compared to usual care.

The low-cost intervention in this large NIHR-funded trial included a short training webinar for GPs and feedback on their practice’s prescribing rates. The decision support tool gave prompt access to NICE prescribing guidelines and printable patient information leaflets when a respiratory tract infection code was inserted into a patient’s medical record. However, the reduction in prescriptions was only seen in those aged 15-84; no difference was observed in older adults and younger children.

Overall the decision support was used in a minority of respiratory consultations. This was a carefully designed study which showed positive but relatively modest effects. It highlights the need for multiple approaches in the continuing efforts to tackle the complex problem of rising rates of antimicrobial resistance.

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Why was this study needed?

Unnecessary use of antibiotics has led to an increasing number of organisms becoming resistant to them. Consequently, the infections they cause are becoming harder to treat, and an estimated 25,000 people die each year across Europe as a result.

Respiratory tract infections are one of the most common reasons people visit their GP. However, many people are unaware that antibiotics are ineffective against infections such as coughs and colds, and GPs report feeling pressure to prescribe.

While efforts are underway to reduce inappropriate prescriptions, more needs to be done. Dispelling misconceptions surrounding their use is key, especially in primary care. This study built upon previous research suggesting that multifaceted electronically delivered interventions had the potential to cut prescriptions.

What did this study do?

This cluster randomised controlled trial assigned 38 GP practices to deliver usual care, and 41 to receive extra support to reduce antibiotic prescriptions for a range of infections. These included cough, acute bronchitis, common colds, otitis media, sinusitis, and sore throat.

The intervention consisted of three elements including a six-minute educational webinar for prescribers; decision support tools which comprised printable patient information leaflets and guidance as to which conditions warrant antibiotics; and monthly reports tracking prescriptions made by each practice.

Trial data was gained using anonymised electronic health records from the UK Clinical Practice Research Datalink as well as from the decision support tools themselves.

Monthly reports were at the GP practice level, so we don’t know how effective the intervention was at an individual level.

What did it find?

  • Overall the intervention group made 98.7 prescriptions per 1,000 patient years, compared with 107.6 in the control group. This meant GP practices in the intervention group were 12% less likely to prescribe (adjusted rate ratio [aRR] 0.88, 95% confidence interval [CI] 0.78 to 0.99).
  • People aged 15 to 84 were 16% less likely to have a prescription in the intervention group: 89.9 per 1,000 compared with 100.2 in the control group (aRR 0.84, 95% CI 0.75 to 0.95). This equates to one fewer prescription for every 62 adults.
  • There was no impact for those under 15 between the groups, with 139.3 versus 139.8 prescriptions per 1,000 children (aRR 0.96, 95% CI 0.82 to 1.12). The same was true for people aged 85 or older, with 114.7 versus 115.5 prescriptions per 1,000 people (aRR 0.97, 95% CI 0.79 to 1.18).
  • In the 25% of practices (the quartile) with the lowest use, decision support tools were viewed at less than 1% of respiratory consultations. In the highest quartile, up to 28% of consultations included use of the decision tool.
  • There was evidence of a linear trend with more frequent use of the tool being associated with a larger reduction in prescribing. Rates of serious bacterial infections such as pneumonia and meningitis were similar in both groups with a total of 662 out of 323,155 (0.20%) in the intervention group and 546 out of 259,520 (0.21%) in the usual care group.

What does current guidance say on this issue?

NICE has produced guidance which suggests ways to establish antimicrobial stewardship programmes. These include providing education and training to healthcare professionals on the importance of prudent prescribing as well as giving prescribing feedback.

It is recommended that individual prescribing should be benchmarked against local and national antimicrobial prescribing rates and trends. In addition, antimicrobial prescribing guidance for a range of respiratory tract infections has been published by NICE such as for cough (acute), sore throat (acute) and sinusitis (acute) which are aimed at helping healthcare professionals determine when antibiotics are needed.

What are the implications?

This low-cost intervention did result in some reduction in prescribing antibiotics for respiratory problems. The modest returns demonstrated by this study highlight the difficulties faced by those trying to reduce antibiotic prescriptions. There was little change for the very old and very young. It is unclear exactly how much influence each element of the intervention had, and it is hard to determine if adjustments could make them more effective in future. Not everyone used the available decision tools. We also know that individual doctors prescribing rates vary greatly, but this study just looked at whole practices. And the intervention did not allow doctors to compare themselves against other doctors, only looking at prescribing activity by their practice over time.

Changing people’s perceptions is perhaps the greatest challenge. By the time they get to the GP, people may already have an expectation that antibiotics will be needed. Public health campaigns need to continue informing people about the dangers of antibiotic resistance so that these ingrained health beliefs can be changed.

Citation and Funding

Gulliford MC, Prevost AT, Charlton J et al. Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial. BMJ. 2019;364:I236.

This project was funded by the NIHR Health Technology Assessment Programme (project number 13/88/10).

Bibliography

DH. Antimicrobial resistance empirical and statistical evidence-base. London: Department of Health Antimicrobial Resistance Strategy Analytical Working Group; 2016.

Gulliford MC, Juszczyk D, Prevost AT et al. Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study Health Technology Assessment. 2019; 23(11).

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

NICE. Cough (acute): antimicrobial prescribing. NG120. London: National Institute for Health and Care Excellence; 2019.

NICE. Sinusitis (acute): antimicrobial prescribing. NG79. London: National Institute for Health and Care Excellence; 2017.

NICE. Sore throat (acute): antimicrobial prescribing. NG84. London: National Institute for Health and Care Excellence; 2018.

PHE. Health matters: antimicrobial resistance. London: Department of Health; 2015.

Why was this study needed?

Unnecessary use of antibiotics has led to an increasing number of organisms becoming resistant to them. Consequently, the infections they cause are becoming harder to treat, and an estimated 25,000 people die each year across Europe as a result.

Respiratory tract infections are one of the most common reasons people visit their GP. However, many people are unaware that antibiotics are ineffective against infections such as coughs and colds, and GPs report feeling pressure to prescribe.

While efforts are underway to reduce inappropriate prescriptions, more needs to be done. Dispelling misconceptions surrounding their use is key, especially in primary care. This study built upon previous research suggesting that multifaceted electronically delivered interventions had the potential to cut prescriptions.

What did this study do?

This cluster randomised controlled trial assigned 38 GP practices to deliver usual care, and 41 to receive extra support to reduce antibiotic prescriptions for a range of infections. These included cough, acute bronchitis, common colds, otitis media, sinusitis, and sore throat.

The intervention consisted of three elements including a six-minute educational webinar for prescribers; decision support tools which comprised printable patient information leaflets and guidance as to which conditions warrant antibiotics; and monthly reports tracking prescriptions made by each practice.

Trial data was gained using anonymised electronic health records from the UK Clinical Practice Research Datalink as well as from the decision support tools themselves.

Monthly reports were at the GP practice level, so we don’t know how effective the intervention was at an individual level.

What did it find?

  • Overall the intervention group made 98.7 prescriptions per 1,000 patient years, compared with 107.6 in the control group. This meant GP practices in the intervention group were 12% less likely to prescribe (adjusted rate ratio [aRR] 0.88, 95% confidence interval [CI] 0.78 to 0.99).
  • People aged 15 to 84 were 16% less likely to have a prescription in the intervention group: 89.9 per 1,000 compared with 100.2 in the control group (aRR 0.84, 95% CI 0.75 to 0.95). This equates to one fewer prescription for every 62 adults.
  • There was no impact for those under 15 between the groups, with 139.3 versus 139.8 prescriptions per 1,000 children (aRR 0.96, 95% CI 0.82 to 1.12). The same was true for people aged 85 or older, with 114.7 versus 115.5 prescriptions per 1,000 people (aRR 0.97, 95% CI 0.79 to 1.18).
  • In the 25% of practices (the quartile) with the lowest use, decision support tools were viewed at less than 1% of respiratory consultations. In the highest quartile, up to 28% of consultations included use of the decision tool.
  • There was evidence of a linear trend with more frequent use of the tool being associated with a larger reduction in prescribing. Rates of serious bacterial infections such as pneumonia and meningitis were similar in both groups with a total of 662 out of 323,155 (0.20%) in the intervention group and 546 out of 259,520 (0.21%) in the usual care group.

What does current guidance say on this issue?

NICE has produced guidance which suggests ways to establish antimicrobial stewardship programmes. These include providing education and training to healthcare professionals on the importance of prudent prescribing as well as giving prescribing feedback.

It is recommended that individual prescribing should be benchmarked against local and national antimicrobial prescribing rates and trends. In addition, antimicrobial prescribing guidance for a range of respiratory tract infections has been published by NICE such as for cough (acute), sore throat (acute) and sinusitis (acute) which are aimed at helping healthcare professionals determine when antibiotics are needed.

What are the implications?

This low-cost intervention did result in some reduction in prescribing antibiotics for respiratory problems. The modest returns demonstrated by this study highlight the difficulties faced by those trying to reduce antibiotic prescriptions. There was little change for the very old and very young. It is unclear exactly how much influence each element of the intervention had, and it is hard to determine if adjustments could make them more effective in future. Not everyone used the available decision tools. We also know that individual doctors prescribing rates vary greatly, but this study just looked at whole practices. And the intervention did not allow doctors to compare themselves against other doctors, only looking at prescribing activity by their practice over time.

Changing people’s perceptions is perhaps the greatest challenge. By the time they get to the GP, people may already have an expectation that antibiotics will be needed. Public health campaigns need to continue informing people about the dangers of antibiotic resistance so that these ingrained health beliefs can be changed.

Citation and Funding

Gulliford MC, Prevost AT, Charlton J et al. Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial. BMJ. 2019;364:I236.

This project was funded by the NIHR Health Technology Assessment Programme (project number 13/88/10).

Bibliography

DH. Antimicrobial resistance empirical and statistical evidence-base. London: Department of Health Antimicrobial Resistance Strategy Analytical Working Group; 2016.

Gulliford MC, Juszczyk D, Prevost AT et al. Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study Health Technology Assessment. 2019; 23(11).

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

NICE. Cough (acute): antimicrobial prescribing. NG120. London: National Institute for Health and Care Excellence; 2019.

NICE. Sinusitis (acute): antimicrobial prescribing. NG79. London: National Institute for Health and Care Excellence; 2017.

NICE. Sore throat (acute): antimicrobial prescribing. NG84. London: National Institute for Health and Care Excellence; 2018.

PHE. Health matters: antimicrobial resistance. London: Department of Health; 2015.

Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial

Published on 14 February 2019

Gulliford, M. C.,Prevost, A. T.,Charlton, J.,Juszczyk, D.,Soames, J.,McDermott, L.,Sultana, K.,Wright, M.,Fox, R.,Hay, A. D.,Little, P.,Moore, M. V.,Yardley, L.,Ashworth, M.

Bmj Volume 364 , 2019

OBJECTIVES: To evaluate the effectiveness and safety at population scale of electronically delivered prescribing feedback and decision support interventions at reducing antibiotic prescribing for self limiting respiratory tract infections. DESIGN: Open label, two arm, cluster randomised controlled trial. SETTING: UK general practices in the Clinical Practice Research Datalink, randomised between 11 November 2015 and 9 August 2016, with final follow-up on 9 August 2017. PARTICIPANTS: 79 general practices (582 675 patient years) randomised (1:1) to antimicrobial stewardship (AMS) intervention or usual care. INTERVENTIONS: AMS intervention comprised a brief training webinar, automated monthly feedback reports of antibiotic prescribing, and electronic decision support tools to inform appropriate prescribing over 12 months. Intervention components were delivered electronically, supported by a local practice champion nominated for the trial. MAIN OUTCOME MEASURES: Primary outcome was the rate of antibiotic prescriptions for respiratory tract infections from electronic health records. Serious bacterial complications were evaluated for safety. Analysis was by Poisson regression with general practice as a random effect, adjusting for covariates. Prespecified subgroup analyses by age group were reported. RESULTS: The trial included 41 AMS practices (323 155 patient years) and 38 usual care practices (259 520 patient years). Unadjusted and adjusted rate ratios for antibiotic prescribing were 0.89 (95% confidence interval 0.68 to 1.16) and 0.88 (0.78 to 0.99, P=0.04), respectively, with prescribing rates of 98.7 per 1000 patient years for AMS (31 907 prescriptions) and 107.6 per 1000 patient years for usual care (27 923 prescriptions). Antibiotic prescribing was reduced most in adults aged 15-84 years (adjusted rate ratio 0.84, 95% confidence interval 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 patients (95% confidence interval 40 to 200). There was no evidence of effect for children younger than 15 years (adjusted rate ratio 0.96, 95% confidence interval 0.82 to 1.12) or people aged 85 years and older (0.97, 0.79 to 1.18); there was also no evidence of an increase in serious bacterial complications (0.92, 0.74 to 1.13). CONCLUSIONS: Electronically delivered interventions, integrated into practice workflow, result in moderate reductions of antibiotic prescribing for respiratory tract infections in adults, which are likely to be of importance for public health. Antibiotic prescribing to very young or old patients requires further evaluation. TRIAL REGISTRATION: ISRCTN95232781.

Expert commentary

This trial’s low-cost intervention could be upscaled to achieve meaningful reductions in antibiotic prescribing for respiratory tract infections (coughs, sore throat, ear ache) by GPs nationally over an entire year. While this is a remarkable first step, the research team has set itself a daunting but exciting challenge by successfully delivering this efficient intervention and study design.

Questions that remain unanswered are whether such interventions can influence prescribing quality (as well as what antibiotic class to prescribe for any given patient), taking into account longer-term trends in demographics, antibiotic resistance, the severity of viral epidemics, and thresholds for help-seeking behaviour.

Dr Oliver Van Hecke and Professor Chris C Butler, Nuffield Department of Primary Care Health Sciences, University of Oxford

The commentators declare no conflicting interests

Expert commentary

The overuse of antibiotics and the associated rise antibiotic resistance are major threats to global health. A high proportion of antibiotics are prescribed in primary care and interventions that can reduce the overall level of prescribing of antibiotics are important in limiting the rise of antibiotic resistance.

This study showed that an electronically-delivered intervention could reduce antibiotic prescribing in primary care, without having much impact on complication rates from untreated infections. The study confirms that electronic interventions can be a useful component of strategies to reduce antibiotic prescribing in primary care settings.

Azeem Majeed, Professor of Primary Care and Head of the Department of Primary Care & Public Health, Imperial College London

The commentator declares no conflicting interests