arti 4 understanding and optimising antibiotic prescribing in primary care -
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ARTI 4 Understanding and Optimising Antibiotic Prescribing in Primary Care - 4 successive projects in the Netherlands Alike van der Velden Marijke Kuyvenhoven Theo Verheij Julius Center for Health Sciences and Primary Care University Medical Center Utrecht The Netherlands. - PowerPoint PPT PresentationTRANSCRIPT
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ARTI 4
Understanding and Optimising Antibiotic Prescribing in Primary Care - 4 successive projects in the Netherlands
Alike van der VeldenMarijke Kuyvenhoven
Theo Verheij
Julius Center for Health Sciences and Primary Care
University Medical Center Utrecht
The Netherlands
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ARTI (Antibiotics and Respiratory Tract Infections):linking academia to primary care practice
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Antibiotics and Respiratory Tract Infections
RTIs: acute otitis media
sinusitis, cold
sore throat (tonsillitis, laryngitis)
acute cough (bronchitis, pneumonia)
Mostly viral and self-limiting
Effects of antibiotics are limited
Over-prescription of antibiotics• resistance• patients’ re-consultation• unnecessary exposure to adverse effects• unnecessary costs
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Antibiotics in The Netherlands
Comparatively low antibiotic consumption (coinciding with low resistance)
450 treatments / 1000 inhabitants / year France: x3, Greece: x5
No OTC selling
80% is prescribed by general practitioners
► 4 primary care guidelines for treatment of RTIs antibiotics indicated for patients: with a severe RTI
with risks of complications
(suspected of) pneumonia
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How does it work in daily practice?
time pressure
diagnostic uncertainty
patients demanding for antibiotics
Friday afternoons
GPs’ habits
GP-patient relationship
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ARTI 1: insight in antibiotic prescribing
Methods: detailed analysis of 2800 consultations for RTIs
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ARTI 1: Results
Antibiotic prescription for RTIs: 37% of consultations
prescription over-prescription
OMA 47% 5%
sore throat 30% 58%
sinusitis, cold 35% 53%
acute cough 38% 48%
44% of prescriptions are not according to the guidelines:
over-prescription is
▪ highest for tonsillitis and bronchitis
▪ associated with - inflammations signs
- patients’ wish for an antibiotic
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ARTI 2 and 3:interventions to optimise antibiotic prescribing
ARTI 2: RCT
intervention: ▪ education GPs (practice level)
guidelines, literature, communication
▪ monitoring/feedback prescribing data and behaviour
▪ information material patients
outcome: -12% in antibiotic prescribing rate
ARTI 3: CBA
similar intervention: ▪ education to larger groups of GPs
▪ monitoring/feedback prescribing data
outcome: no reduction in number of antibiotic prescriptions
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Implementation: ARTI 4
Antibiotic prescribing practice can be improved
Barriers in implementation: - commitment of physicians
- sustainability of the effect
embedment within a regular quality assurance cycle:
practice accreditation* of the Dutch College of General Practitioners
* improving quality in care and organisational structure of primary care practices
3 years cycle: - yearly audit
- practice organisation
- prescribing routines
- chronic disease management
- yearly ‘improvement plans’
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ARTI 4: support and a ready-to-use plan
optimising Ab prescription for RTIs
reducing (chronic) use of PPIs
ARTI 4: Study set-up (I)
• RCT with 87 primary care practices (1-7 GPs / practice)
• Ab and PPI practices serve as each others controls
• Primary outcomes:
Antibiotics: Ab prescriptions / 1000 pnts / year
% 2nd choice prescriptions
J01 collected via pharmacies
• Secondary outcomes and feed-back supplied to practices:
Antibiotics: prescribing behaviour
4-weeks registration of RTIs
• Data collection: 1 year preceding intervention, at year 1 and 2
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ARTI 4 study set-up (II)
Multiple intervention
• educational meeting GPs at practice level
- guidelines, literature
- feedback on prescription data / behaviour
- communication, patients’ pressure
• improvement plan
practice-specific definition of targets
mean range
Ab/1000 pnt/year 272 140 - 535
% 2nd choice 28% 19% - 43%
over-prescription 44% 0% - 67%
base-line data
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Feedback ‘Antibiotics’ during education
guideline prescribe consider no Ab
prescribed 1 7
not prescribed 3 1
OMA
Sore throat
Sinusitis
guideline prescribe no Ab
prescribed 3 2*
not prescribed 12
guideline consider no Ab
prescribed 6 6*
not prescribed 2 6
guideline prescribe no Ab
prescribed 8 7*
not prescribed 17
Cough
Totale antibioticaprescriptie: 1415 recepten/ 3371 patiënten (420*/ 1000) Landelijk: ±340 recepten/ 1000 inwoners Landelijk (%) Uw totale prescriptie (%) Tetracyclines: 18 20
Amoxicilline: 20 11 Fenoxymethylpen/ Feneticilline: 4 2 Flucloxacilline: 4 3 Amoxicilline/clavulaanzuur: 14 15*
Cef alosporines: 0.4 1
Trimethoprim : 4 1 Co-trimoxazol: 3 3
Macroliden: 13 21*
Chinolonen: 8 10*
Nitrofurantoïne: 11 12
Overige: 1 1 ----- ----- 100% 100%
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Feedback ‘Antibiotics’ after 1 year
Totale antibioticaprescriptie: meting 1: 1803 recepten/ 3371 pnt (535/1000) meting 2: 1485 recepten/ 3371 pnt (441/1000)
Landelijk: ±340 recepten/ 1000 inwoners (inclusief avond, weekend)
meting 1 meting 2 Tetracyclines: 332 313
Amoxicilline: 202 170 Fenoxymethylpen/ Feneticilline: 29 40 Flucloxacilline 52 59 Amoxicilline/ clavulaanzuur: 198 151
Cef alosporines 16 4
Trimethoprim 25 7 Co-trimoxazol 67 58
Macroliden: 361 261
Chinolonen: 216 154
Nitrofurantoine: 291 256
Overige: 14 12 ----- ---- 1803 1485
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ARTI 4: intervention effect onantibiotic prescription (n=49)
Intervention: Ab
(n=25)
Control: PPI (n=24)
p=
% change RTI Ab
prescrip/1000 pat
-11.9
(-33 – 12)
-3.3
(-21 – 29)
0.03
% change 2nd choice
prescrip/1000 pat
-13.5
(-56 – 31)
+0.9
(-30 – 48)
0.03
ARTI4 intervention significantly reduces antibiotic prescription
Goals and future plans:
• long-term effectiveness of this intervention (2 years)• development of internet-based educational programs
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Questions?
Acknowledgements:
All Dutch general practitioners involved in one of the projects