Primary care setting for intervention program

1. Implementation and outcomes of a 5-year intervention program to improve use of antibiotics in respiratory tract infection in primary care Judith Mackson Education and QA Program Manager L Weekes, C Bottomley, K Easton, L McMartin, M Fletcher, L Pont, L Kenyon, S Wutzke, J Mandryk, C Babcock.

2. Primary care setting for intervention program • Fee-for-service subsidised consultations • Subsidised antibiotic supply for low-income people • Unrestricted general practitioner (GP) prescribing rights for oral antibiotics except for quinolones • Variable awareness of best-practice guidelines for antibiotic prescribing • Rapidly changing cultural mix of patients and GPs in urban areas • Highly regulated pharmacy services

3. Need to understand influences on antibiotic prescribing in primary care Complex biomedical and social factors including: Patient • Desire for tangible outcome of consultation • Perceptions of effectiveness esp. in viral illness Doctor • Information gap regarding best-practice prescribing • Desire to satisfy patient demand • Consultation process: short, fee-for-service • Marketing especially newer antibiotics

4. Key messages to address influencing factors For health professionals • limited indications in URTI • no role in viral illness • limited role in sore throat, otitis media, sinusitis: use only if benefit can be expected • appropriate selection • use narrow spectrum • amoxycillin drug of choice for most URTIs • review your prescribing • discuss realistic expectations with patients For consumers • You won’t get better more quickly by taking antibiotics for a common cold

5. Program objectives • To decrease volume of antibiotic prescriptions by GPs for upper respiratory tract infections (URTI) and acute bronchitis • Low rates for acute bronchitis, pharyngitis, lower rates acute otitis media (AOM), acute sinusitis • To increase proportion of first-line antibiotic selection when an antibiotic required (appropriate and minimises selection pressure) • Amoxycillin first-line AOM, acute sinusitis, penicillin V first line strep throat and tonsillitis • To encourage a more judicious approach to antibiotic prescribing for URTI and bronchitis • To inform consumers of limited benefit of antibiotics in URTI and to encourage symptom management

6. Multifaceted interventions For health professionals • Written materials and GP prescription feedback annually for 5 years, voluntary educational & quality assurance activities for GPs, patient education leaflets For consumers • Media advertising, ‘grass roots’ meetings over 3-4 years

7. Time-line of interventions Newsletter Case study MailedGP prescription feedback Clinical audit Academic detailing Consumer campaign 1999 2000 2001 2002 2003

8. Evaluation of program • Process including participation rates • Awareness, knowledge and attitudes GP, pharmacist and consumer • GP use of antibiotic guidelines • Antibiotic utilisation, prescribing rates • Total volume, GP prescribing URTI, first-line selection, undesirable switching

9. Community use of antibiotics (DDD/1000/day)– continued decline Source: DUSC data

10. GP prescriptions antibiotics primarily used URTI –continued decline, reduced peaks

11. GP prescribing rate all URTI problems- significant decrease over 4 years 50.4% 46.9% BEACH data

12. Conclusions • Sustained decrease total use antibiotics • Sustained decrease GP prescribing • Decreased GP prescribing rate for URTI • Change in mix of drugs toward recommended first-line agents • Fewer consumers believed antibiotics were appropriate for treating colds or ‘flu

13. Key lessons from this program • Develop good processes to understand the determinants that lead to inappropriate antibiotic use locally • eg concern regarding S. pneumoniae resistance reduced prescriber confidence in amoxycillin for all indications • Planning may have unexpected findings. .. • Common colds needs common sense message developed not because of high rate of prescribing in common cold, but a complex of symptoms which consumers understood • Prescribers not motivated by global antibiotic burden and confusion regarding antimicrobial resistance among prescribers and consumers means not a useful message

14. Key lessons continued • Long–term programs are required to allow for repetition and refinement of program messages • Different interventions may be required to change total prescribing rate verus change in antibiotic selection • Some prescribing more difficult to change • Acute bronchitis – due to severity of symptoms, diagnostic uncertainty? • Roxithromycin – heavily marketed, once daily dosing, few adverse effects

15. Key lessons cont’d • A consumer campaign may be a key component to reduce patient demand and GP perceptions of demand and therefore total volume • Can effectively use media to disseminate messages to the community especially via local radio • More possibility of change in antibiotic use than other drug classes • Financial and professional incentives for GPs important for voluntary participation

16. Implications for policies and programs • Long term programs allowing repetition • National versus regional programs: design messages and interventions tailored to the prescribers and consumers where influences on drug use can be understood • Expertise in social marketing for consumer campaigns, need to target audiences for best use of funds

17. Research questions • Can models be developed to engage pharmaceutical industry in appropriate marketing? • What is the optimally low level of antibiotic prescribing? • What indicators are needed to ensure no unintended effects? • What is the optimal mix of interventions for what time period? Where has change not occurred? • Has this program resulted in reduced rate of development of antimicrobial resistance?