ARTI 4 Understanding and Optimising Antibiotic Prescribing in Primary Care -

1. 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

2. ARTI (Antibiotics and Respiratory Tract Infections):linking academia to primary care practice

3. 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

4. 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

5. How does it work in daily practice? diagnostic uncertainty time pressure patients demanding for antibiotics GP-patient relationship Friday afternoons GPs’ habits

6. ARTI 1: insight in antibiotic prescribing Methods: detailed analysis of 2800 consultations for RTIs

7. ARTI 1: Results Antibiotic prescription for RTIs: 37% of consultations • 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

8. 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

9. 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’

10. ARTI 4: Study set-up (I) ARTI 4:supportand aready-to-use plan optimising Ab prescription for RTIs reducing (chronic) use of PPIs • 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

11. 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 base-line data

12. Feedback ‘Antibiotics’ during education OMA Sore throat Sinusitis Cough

13. Feedback ‘Antibiotics’ after 1 year

14. ARTI 4: intervention effect onantibiotic prescription (n=49) • ARTI4 intervention significantly reduces antibiotic prescription • Goals and future plans: • long-term effectiveness of this intervention (2 years) • development of internet-based educational programs

15. Questions? Acknowledgements: All Dutch general practitioners involved in one of the projects