NIHR Signal Shared decision making in primary care can reduce antibiotic prescribing

Published on 26 January 2016

Strategies, known as shared decision making, reduced antibiotic prescribing for people with acute respiratory infections by almost 40% in the short term (up to six weeks).

This Cochrane systematic review compared the strategies that promote better discussions between doctor and patient about benefits and harms of treatment in primary care. Interventions were a mix of training healthcare staff (mainly general practitioners) in better communication skills and giving patients structured information. Ten studies of over 1,100 doctors and almost half a million patients were included, but study designs could not eliminate bias, from a lack of blinding, completely. Four studies included in this review were from the UK and the other six were from high-income European countries and Canada, so the findings are applicable to the UK.

There is insufficient evidence about the long term effect (up to one year and beyond) of the strategies used to facilitate shared decision making, so it is not known whether they could reverse community-level antibiotic resistance trends. It is likely that multiple approaches will be needed.

Shared decision making in primary care can reduce antibiotic prescribing

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Why was this study needed?

Antibiotic resistance is now seen as an international public health crisis and it is important to avoid unnecessary antibiotic prescribing in primary care. Acute respiratory infections are one of the most common reasons for antibiotic prescribing even though research has shown that antibiotics have little benefits for acute middle ear infections, sinusitis, bronchitis and sore throat. This review aimed to find out whether strategies that facilitate the shared decision making process, which involves a discussion with the patient, can reduce antibiotic prescribing among primary care doctors.

What did this study do?

This was a Cochrane systematic review of randomised controlled trials that compared strategies used to facilitate the shared decision making process in primary care. Nine trials and one follow-up study of over 1,100 doctors and almost half a million patients were included. They compared a range of strategies including clinicians’ skills training and providing information or tools about the options, benefits, harms, or questions about antibiotic prescribing to either patients, or clinicians or both. All studies provided some education and communication skills training for GPs delivered through workshops, seminars or via web-based platforms. Standard systematic review and meta-analysis methods were used. Trial quality was assessed to be moderate or low, because participants in most studies were aware of whether they had received the intervention or not and others had imprecise results, ie had wide confidence intervals.

What did it find?

  • Eight of the included studies reporting short-term prescribing outcomes (up to six weeks after the consultation) showed that the various strategies for facilitating the shared decision making process, compared with usual care, reduced antibiotic prescribing by almost 40% (risk ratio [RR] 0.61, confidence interval [CI] 0.55 to 0.68).
  • Moderate quality evidence from four trials suggested that the reduction in antibiotic prescribing occurred without an increase in further patient-initiated visits for the same illness episode (RR 0.87, 95% CI 0.74 to 1.03) but the effect was not statistically significant.
  • We do not know if there was sustained reduction of antibiotic prescribing in the longer term (up to a year) as the few trials that reported this showed a non-significant trend only.
  • The costs of the strategies for improving shared decision making was not reported in most of the studies and was not evaluated in this systematic review.

What does current guidance say on this issue?

The 2008 NICE guideline on self-limiting respiratory tract infections provides recommendations about the options for antibiotic prescribing in specific patient groups and about the shared decision making process. The guideline recommends that patients' or carers' concerns and expectations should be addressed when agreeing the use of the three antibiotic prescribing strategies: no prescribing, delayed prescribing and immediate prescribing. A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions: acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis, acute cough/acute bronchitis.

Patients with severe infections, and people who are systemically very unwell, or at risk of serious illness and/or complications, and elderly people with some chronic conditions such as diabetes or heart failure can be considered for an immediate antibiotic prescribing strategy.

What are the implications?

There is an increasing interest and growing evidence on shared decision making as an important facet of health care. The studies included in this review were from several high-income European countries, including the UK and Canada so the findings are applicable to the UK. The variety of strategies that were used to facilitate shared decision making made it difficult to determine which components should be used in clinical practice or how to adapt the successful programmes to different primary care settings. There was insufficient data about the long term effect (up to one year and beyond) of the strategies used to facilitate shared decision making so it is not known whether they can reverse community-level antibiotic resistance trends.

Citation

Coxeter P, Del Mar CB, McGregor L, et al. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015;(11):CD010907.

Bibliography

Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-7.

Gillies M, Ranakusuma A, Hoffmann T, et al. Common harms from amoxicillin: a systematic review and meta-analysis of randomized placebo-controlled trials for any indication. CMAJ. 2015;187(1):E21-31.

NHS Choices. The Antibiotic Awareness Campaign. London: Department of Health; 2015.

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

Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014;(3):CD000245.

Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013;(11):CD000023.

Venekamp RP, Sanders S, Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015;(6):CD000219.

Why was this study needed?

Antibiotic resistance is now seen as an international public health crisis and it is important to avoid unnecessary antibiotic prescribing in primary care. Acute respiratory infections are one of the most common reasons for antibiotic prescribing even though research has shown that antibiotics have little benefits for acute middle ear infections, sinusitis, bronchitis and sore throat. This review aimed to find out whether strategies that facilitate the shared decision making process, which involves a discussion with the patient, can reduce antibiotic prescribing among primary care doctors.

What did this study do?

This was a Cochrane systematic review of randomised controlled trials that compared strategies used to facilitate the shared decision making process in primary care. Nine trials and one follow-up study of over 1,100 doctors and almost half a million patients were included. They compared a range of strategies including clinicians’ skills training and providing information or tools about the options, benefits, harms, or questions about antibiotic prescribing to either patients, or clinicians or both. All studies provided some education and communication skills training for GPs delivered through workshops, seminars or via web-based platforms. Standard systematic review and meta-analysis methods were used. Trial quality was assessed to be moderate or low, because participants in most studies were aware of whether they had received the intervention or not and others had imprecise results, ie had wide confidence intervals.

What did it find?

  • Eight of the included studies reporting short-term prescribing outcomes (up to six weeks after the consultation) showed that the various strategies for facilitating the shared decision making process, compared with usual care, reduced antibiotic prescribing by almost 40% (risk ratio [RR] 0.61, confidence interval [CI] 0.55 to 0.68).
  • Moderate quality evidence from four trials suggested that the reduction in antibiotic prescribing occurred without an increase in further patient-initiated visits for the same illness episode (RR 0.87, 95% CI 0.74 to 1.03) but the effect was not statistically significant.
  • We do not know if there was sustained reduction of antibiotic prescribing in the longer term (up to a year) as the few trials that reported this showed a non-significant trend only.
  • The costs of the strategies for improving shared decision making was not reported in most of the studies and was not evaluated in this systematic review.

What does current guidance say on this issue?

The 2008 NICE guideline on self-limiting respiratory tract infections provides recommendations about the options for antibiotic prescribing in specific patient groups and about the shared decision making process. The guideline recommends that patients' or carers' concerns and expectations should be addressed when agreeing the use of the three antibiotic prescribing strategies: no prescribing, delayed prescribing and immediate prescribing. A no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions: acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis, acute cough/acute bronchitis.

Patients with severe infections, and people who are systemically very unwell, or at risk of serious illness and/or complications, and elderly people with some chronic conditions such as diabetes or heart failure can be considered for an immediate antibiotic prescribing strategy.

What are the implications?

There is an increasing interest and growing evidence on shared decision making as an important facet of health care. The studies included in this review were from several high-income European countries, including the UK and Canada so the findings are applicable to the UK. The variety of strategies that were used to facilitate shared decision making made it difficult to determine which components should be used in clinical practice or how to adapt the successful programmes to different primary care settings. There was insufficient data about the long term effect (up to one year and beyond) of the strategies used to facilitate shared decision making so it is not known whether they can reverse community-level antibiotic resistance trends.

Citation

Coxeter P, Del Mar CB, McGregor L, et al. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015;(11):CD010907.

Bibliography

Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-7.

Gillies M, Ranakusuma A, Hoffmann T, et al. Common harms from amoxicillin: a systematic review and meta-analysis of randomized placebo-controlled trials for any indication. CMAJ. 2015;187(1):E21-31.

NHS Choices. The Antibiotic Awareness Campaign. London: Department of Health; 2015.

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

Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014;(3):CD000245.

Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013;(11):CD000023.

Venekamp RP, Sanders S, Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015;(6):CD000219.

Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care

Published on 13 November 2015

Coxeter, P.,Del Mar, C. B.,McGregor, L.,Beller, E. M.,Hoffmann, T. C.

Cochrane Database Syst Rev Volume 11 , 2015

BACKGROUND: Shared decision making is an important component of patient-centred care. It is a set of communication and evidence-based practice skills that elicits patients' expectations, clarifies any misperceptions and discusses the best available evidence for benefits and harms of treatment. Acute respiratory infections (ARIs) are one of the most common reasons for consulting in primary care and obtaining prescriptions for antibiotics. However, antibiotics offer few benefits for ARIs, and their excessive use contributes to antibiotic resistance - an evolving public health crisis. Greater explicit consideration of the benefit-harm trade-off within shared decision making may reduce antibiotic prescribing for ARIs in primary care. OBJECTIVES: To assess whether interventions that aim to facilitate shared decision making increase or reduce antibiotic prescribing for ARIs in primary care. SEARCH METHODS: We searched CENTRAL (2014, Issue 11), MEDLINE (1946 to November week 3, 2014), EMBASE (2010 to December 2014) and Web of Science (1985 to December 2014). We searched for other published, unpublished or ongoing trials by searching bibliographies of published articles, personal communication with key trial authors and content experts, and by searching trial registries at the National Institutes of Health and the World Health Organization. SELECTION CRITERIA: Randomised controlled trials (RCTs) (individual level or cluster-randomised), which evaluated the effectiveness of interventions that promote shared decision making (as the focus or a component of the intervention) about antibiotic prescribing for ARIs in primary care. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted and collected data. Antibiotic prescribing was the primary outcome, and secondary outcomes included clinically important adverse endpoints (e.g. re-consultations, hospital admissions, mortality) and process measures (e.g. patient satisfaction). We assessed the risk of bias of all included trials and the quality of evidence. We contacted trial authors to obtain missing information where available. MAIN RESULTS: We identified 10 published reports of nine original RCTs (one report was a long-term follow-up of the original trial) in over 1100 primary care doctors and around 492,000 patients.The main risk of bias came from participants in most studies knowing whether they had received the intervention or not, and we downgraded the rating of the quality of evidence because of this.We meta-analysed data using a random-effects model on the primary and key secondary outcomes and formally assessed heterogeneity. Remaining outcomes are presented narratively.There is moderate quality evidence that interventions that aim to facilitate shared decision making reduce antibiotic use for ARIs in primary care (immediately after or within six weeks of the consultation), compared with usual care, from 47% to 29%: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55 to 0.68. Reduction in antibiotic prescribing occurred without an increase in patient-initiated re-consultations (RR 0.87, 95% CI 0.74 to 1.03, moderate quality evidence) or a decrease in patient satisfaction with the consultation (OR 0.86, 95% CI 0.57 to 1.30, low quality evidence). There were insufficient data to assess the effects of the intervention on sustained reduction in antibiotic prescribing, adverse clinical outcomes (such as hospital admission, incidence of pneumonia and mortality), or measures of patient and caregiver involvement in shared decision making (such as satisfaction with the consultation; regret or conflict with the decision made; or treatment compliance following the decision). No studies assessed antibiotic resistance in colonising or infective organisms. AUTHORS' CONCLUSIONS: Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term. Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death.

Antibiotics are used for treating bacterial infections in both humans and animals. However, in time bacteria can adapt and become resistant to antibiotics. Antibiotic resistance means that bacterial infections can pose a significant threat to people as some diseases become harder to treat. To prevent this from happening it is very important to avoid using antibiotics inappropriately, for example for certain infections where there is little or no benefit from antibiotic treatment.

Expert commentary

Antimicrobial resistance (AMR), now at the top of the public health agenda internationally, is a complex, multifaceted problem. This Cochrane review highlights the pivotal role played by primary care clinicians as one part of its multifaceted solution, and synthesises the evidence regarding the effects that their consultation style has on subsequent antibiotic prescribing and consumption.

In considering the implications for NHS/UK policy, there are some limitations to consider. First, as pointed out by the authors themselves, some of the contributing studies were not blinded meaning some of the desirable effects could be due to performance and Hawthorne bias. That said these open studies may provide estimates of effects closer to ‘real-world’ effectiveness since these studies replicate more closely how interventions would be operationalised in a health service. Second, although some of the studies use web-based interventions that could be adopted relatively quickly by the NHS, an analysis of their short and long term cost-effectiveness has not been included. This may, in part, be due to the well-recognised challenges of costing AMR. However, the time to act is now, and in this reviewer's opinion, investment supporting the adoption of these interventions in the NHS is both timely and sensible and, because shared decision making is a generic consultation skill, could result in wider benefits.

Alastair Hay, Professor of Primary Care, University of Bristol