Dr.little mesa 3
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Dr.little mesa 3 Presentation Transcript

  • 1. Evidence for effectiveinterventions to improveantibiotic prescribing inprimary care : what works? Paul Little Professor of Primary Care Research University of Southampton
  • 2. Overview Recent systematic review of patient and doctor oriented interventions (from CHAMP) Evidence for delayed prescribing Recent studies in communication skills and near patient tests Trial data from GRACE intro
  • 3. Why:? we need to moderate antibiotic use…..
  • 4. Practitioner behaviour is learned early…
  • 5. CHAMP Changing behaviour of health care professionals and the general public towards a more prudent use of anti-microbial agentsSixth Framework Programme:United Kingdom, Belgium, Switzerland, the NetherlandsPoland, Italy, Spain
  • 6. Aim: To determine the effectiveness of interventions aiming to improve antibiotic use for respiratory tract infections in primary careMethod: Systematic review of behavioural interventions targeted at: primary care physicians primary care patients
  • 7. Physician interventionsLiterature review • MEDLINE, EMBASE, Cochrane • 1990-2010Methods, outcomes • effective intervention: significant decrease in total antibiotic prescription, or significant increase in 1st choice prescription • control group and before/after measurement also no control, or controlled but no before measurement
  • 8. Interventions aimed at p.c. physicians: characteristics58 studiesdesigns: mostly CBA (controlled before/after), RCT • encompassed 101 interventions • 77%: multiple, 40%: multifaceted • interventions contained an average of 3 intervention elements Most often used elements:  educational material for physician (70%)  educational meetings (56%)  educational material for patients (40%)  audit/feedback (37%) Training in communication (9%) NPT (8%)
  • 9. RTI interventions aimed at p.c. physicians: effectiveness (I)Overall effectiveness • 60% of interventions significantly improved antibiotic prescription • ↓ total prescription (n=59, 43 (73%) effective): • mean -11.6% (-72% - 19%) • ↑ 1st choice prescription (n=28, 9 (32%) effective) • +9.6% (5% to 41%)
  • 10. Type of study designStudy type Outcome Total AB (%) n First choice n RCT/CBA -8.7 (-27 – 18.8) 33 9.2 (-2 – 27.2) 15 No CBA -12.3 (-37 – 4.3) 16 11.1 (-5 – 41) 11 CA -20.3 (-72 – -1) 10 3.6 (2 – 5.1) 2
  • 11. RTI interventions aimed at p.c. physicians: effectiveness (II)Determinants of effectiveness (multivariate analysis)• ‘multiple intervention’ OR: 6.5 (2 to 22)• ‘physician materials’ OR: 5.5 (1.7 to 18)• ‘patient materials OR 1.4 (0.4 to 5)• audit/feedback OR 0.5 (0.2 to 2)• promising: ‘communications skills’ and ‘near patient testing’
  • 12. RTI interventions aimed at patients:Meta-analysis of 33 interventions• cognitive outcomes: modest (attitudes knowledge)• delayed or refused prescription: effective• education, information material: not effective• no worsening of patients’ satisfaction
  • 13. Delayed prescribing/wait and see? weight + sea ?
  • 14. Sore throat trial: % better by 3 days Satisfaction, belief , intention 100 p<0.001 90 p<0.001 80% 70 60 Antibiotic 50 No antib. 40 delayed 30 20 10 0 % better satis belief Ab future
  • 15. Delayed prescribing? It is not: ‘wait and see a few days…….’ It is: • Strong message: antibiotics aren’t needed  problems not benefits • Clear natural history information…….  Otitis: 3 days  Sore throat: 5 days  Cold: 7 days  Chest infection: 10 days • Clear instructions when to use Abs  If much worse, or not starting to improve a little by the end of the expected natural history
  • 16. Cochrane review of delayed prescribing: ? Is no prescribing better  10 studies: heterogeneity (no meta-anal.)  Antibiotic use (6 studies):No or delayed effective in short term • Immediate 93% (92% satisfied) • Delayed 28-30% (87% satisfied) • No 14% (83% satisfied)  only 3 studies comparing no/delayed!  NB Reconsultation not addressed properly in the Cochrane review • Higher reconsultation in no groups in short (1m) and longer term (1 yr) (LRTI, sore throat)
  • 17. Delayed prescribing useful?: Sharland et al BMJ Figure 1: Time trend in antibiotic prescribing to children in UK general practice 1993-2004 estimated from national prescribing data and the IMS GP prescribing database (1993=100)120.0 Study published100.0 IMS data PPA data 80.0 prescribed 60.0 used 40.0 20.0 0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
  • 18. Guidance introducedDiagnosis Israel guidance 2004: delayed prescriptionAntibiotic use + analgesic for OM (Grossman et al Paed Inf Dis J.2010)Analgesic use
  • 19. Getting further funds?With Pablo Alonso Coello:1) RCT two modes of delayed prescribing adults: encouraging results2) RCT of delayed prescribing in children: hoping for funding!....
  • 20. Which Near Patient Tests (NPTs)? RADTs and/or CRP? van der Meer, V. et al. BMJ 2005;331:26Copyright ©2005 BMJ Publishing Group Ltd.
  • 21. Use of NPTs: sore throat Worrall et al RCT Four strategies: Antibiotic use • Centor 55% • Usual care 58% • RAT 27% • RAT with Centor 38% NB: Small trial, no symptomatic outcomes, no comparison with alternative prescribing strategies
  • 22. Comunication: Probably not this….?: Lack of time
  • 23. Or this!
  • 24. Use of NPTs and communication skills training for LRTI Cals et al Four groups: antibiotic use • Usual care 68% • CRP 39% • Communication skills 33% • Both 23% Communication skills training:  Seminar 11 key tasks e.g. exploring patients’ fears and expectations, asking patients’ opinion on antibiotics, and outlining the natural duration of cough in lower respiratory tract infection  Peer review of transcripts with simulated patients
  • 25. Communication: internet training using a booklet Francis et al: antibiotic use for children with RTIs • 19.5% booklet • 40.8% usual care Encouraged booklet use within the consultation to facilitate the use of communication skills:  exploring the parent’s main concerns/expectations  discussing prognosis, treatment options  any reasons that should prompt reconsultation
  • 26. GRACEINTRO (INternet TRaining for antibiOtic use) Trial Paul Little, Beth Stuart, Elaine Douglas, Sarah Tonkin-Crine, Sibyl Anthierens, Nick Francis, Kerry Hood, Mark Kelly, Hasse Melbye, Jochen Cals, Mike Moore, Samuel Coenen, Maciek Godycki-Cwirko, Artur Mierzecki, Toni Torres, Carl Llor, Peter Edwards, Miriam Santer, Mark Mullee, Gilly O’Reilly, Curt Brugman, Samuel Coenen Herman Goossens Theo Verheij, Chris Butler, Lucy Yardley, on behalf of the GRACE consortium. Thanks to ORION diagnostica
  • 27. Factorial Design No Web based Communication Communication Training Training +bookletNo CRP Group1 Group2trainingWeb based Group3 Group4CRP training
  • 28. Intervention Building on CHAMP, qualitative work, prior experience (e.g.EQUIP/STAR/IMPACT) • Internet ‘Communication’ package  Presentation of Evidence • Natural history, effectiveness of Abs etc • Glossy booklet shared with patients (alla EQUIP)  Communication skills training (EQUIP;IMPACT;STAR/) use of booklet • Video clips tailored to individuals and country • forum facilities :questions, responses by GRACE team  Practice-based discussion: • recent prescribing cases (alla EQUIP/STAR) • brief audit of prescribing
  • 29. Communication/Information sharing Addressing the patients world • Concerns • Expectations • Attitude to antibiotics Information exchange / discuss booklet • Duration / prognosis • Likely benefits / risks of antibiotics • Self-help treatments • Reasons to reconsult Wrap up • Summarise situation • Check for understanding and further concerns
  • 30. CRP• Communication package vs No Package• Half of each of the above groups get training in the use of CRP  Develop web based CRP training package • Derive evidence based+/- consensus cut points and SOP (CRP for individuals where clinician unsure) • Jochen Cals and Hasse Melbye
  • 31. Intervention RRs: just LRTI (79.7%) controlling for GP, practice clustering, baseline Ab prescribing RR RR p (basic) (adjusted)Control 1.0 1.0CRP 0.51 0.52(0.34 to 0.73) <0.001Communic’n 0.69 0.73 (0.52 to 0.94) 0.010Both 0.43 0.37 (0.25 to 0.54) <0.001 Multivariate model controlled for: •Age (N/S), smoking (N/S) gender (N/S) •Comorbidity, baseline symptoms •Crepitations, wheeze, pulse>100, temp >37.8, RR (N/S), low BP (N/S), •GP rating of severity, and prior duration cough
  • 32. Intervention: LRTI vs other RTI RRs controlling for GP and practice clustering, baseline Ab prescribing RR RR p (basic (basic model model LRTI) other RTI)Control 1.0 1.0CRP 0.51 0.56 (0.33 to 0.87) 0.008Communic’n 0.69 0.58 (0.34 to 0.92) 0.016Both 0.43 0.43 (0.24 to 0.69) <0.001
  • 33. Overall Group controlling for GP and practice clustering RR RR p (basic) (adjusted for patient variables: being redone!)Control 1.0 1.0CRP 0.53 0.47 (0.35 to 0.64) <0.001Communic’n 0.70 0.66 (0.50 to 0.85) <0.001Both 0.45 0.39 (0.28 to 0.54) <0.001
  • 34. What does this mean for %antibiotic use? LRTI Other All Cals RTIControl 62% 45% 58% 67%CRP 37% 27% 35% 39%Comm’n 43% 28% 41% 33%Both 33% 24% 31% 23% Communication package not quite so effective as in Cals approx. 2/3 (NB internet - not Cals et al workshops)
  • 35. INTRO Conclusion Internet based communication behavioural intervention with practice meetings are effective in reducing prescribing • very little variation due to Network • variations (e.g. fewer practice meetings, booklet changes) may not be important? Internet based CRP training and training by supplier is effective in reducing prescribing • It may be the training and providing tests as much as doing the test? • Caution: if CRP not useful in excluding pneumonia then the rationale and the training package may be difficult to use!
  • 36. So what works? Multiple interventions including educational meetings and material for physicians Structured use of delayed prescribing or no prescribing strategy  NB multiple simple components for delayed Use of NPTs? Communication skills training +/- booklet
  • 37. ConclusionWe can communicate effectively….
  • 38.  TEACHER: Harold, what do you call a person who keeps on talking when people are no longer interested? HAROLD: A teacher