Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised control
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《英国医生杂志》
1 University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, PO Box 85060, 3508 AB Utrecht, Netherlands
Correspondence to: I. Welschen i.welschen@med.uu.nl
Abstract
In the Netherlands, general practitioners prescribe almost 80% of all antibiotics, and up to two thirds of these prescriptions are issued for infections of the respiratory tract.1 These infections are often treated with antibiotics, although this has mostly not been found to be beneficial.2-6 Unnecessary use of antibiotics entails an increased risk of side effects,2 high costs,7 medicalising effects,8 and development of bacterial resistance against antibiotics.9-11 Although antibiotic prescribing rates in the Netherlands are low compared with other European countries12 and the United States, as many as 50% of such prescriptions are estimated to lack an evidence based indication.13 Non-clinical factors such as perceived patients' expectations play an important part in the decision whether or not to prescribe antibiotics.14 15
The Dutch College of General Practitioners developed evidence based guidelines for infections of the respiratory tract.16-19 However, implementation of these guidelines remains difficult.11 20 Educational outreach visits, local opinion leaders, and combinations of interventions have been shown to have the largest impact, but the results and methodological quality of these studies are highly variable.11 21 22 In general, multiple intervention strategies—including local doctors in setting guidelines, involving a leading participant from the peer review group, training doctors in communication skills (including patient centred healthcare strategies), monitoring prescribing behaviour, and sustaining the achieved consensus by means of feedback on prescribing and reminders—are considered most effective in optimising prescribing behaviour.21 23 However, such a strategy has not been evaluated for the management of respiratory tract infections in primary care. In a randomised controlled trial we evaluated the effectiveness of such a multiple intervention aiming at reducing antibiotic prescription rates for respiratory tract symptoms in primary care: the Utrecht antibiotics and respiratory tract infections (ARTI-1) study.
Methods
Forty two of the 48 peer review groups in the region of Utrecht were eligible and invited to participate. Twelve peer review groups (100 general practitioners) agreed to participate (figure). Insurance claims data showed no differences in volumes of antibiotics prescribed in participating compared with non-participating doctors. Out of 100 general practitioners who agreed to participate, 89 completed the study. Eleven were lost to follow up (intervention group 4/46; control group 7/54) because of retirement (one doctor), removal outside the region (three), illness (three), motivational problems (two) or technical problems (two). General practitioners in both arms did not differ at baseline with regard to sex, practice characteristics, and mean period since registration as general practitioner (table 1). They did not differ either regarding the extent to which the group was used to discuss indication and first choice medication in their meetings (table 1). Registered patients in both arms did not differ in 2000 and 2001 regarding age, sex, and type of diagnosis (table 2). Almost 80% (37) of the general practitioners (intervention group) attended all parts of the intervention.
Flow of participants through the trial.
Table 1 Baseline characteristics of general practitioners (n=89) participating in the study in 2000
Table 2 Patients' characteristics in 2000 and 2001 in the intervention and control groups
At baseline, mean antibiotic prescription rates for registered encounters for respiratory tract symptoms did not differ significantly between the two groups (27% v 29%, 95% confidence interval -9.1 to 5.0). In 2001, antibiotic prescription rates in the intervention group fell by 4% and those in the control group rose by 8% (mean difference in change -12%, -18.9% to -4.0%, table 3). Multilevel analysis confirmed the results of the unadjusted analysis (intervention effect -10.7%, -20.3% to -1.0%), while intra-class correlation coefficients showed that variation could be attributed to practice and group levels 0.17 and 0.09, respectively).
Table 3 Registration of patients: changes in antibiotic prescription rates and patients' satisfaction in 2000 and 2001. Values are means with standard deviations unless otherwise indicated
Patient satisfaction questionnaires were available from 83% (35) of general practitioners in the intervention group and from 91% (43) of doctors in the control group (table 2). We found no difference in patients' satisfaction in the two arms in 2000 and 2001 (table 3). The multiple intervention did not change patients' degree of satisfaction; they remained very satisfied with the consultation (mean satisfaction grade 4.2). These results were also confirmed by multilevel analysis (intervention effect on patients' satisfaction -0.03, -0.2 to 0.1).
Claims data over 2000 and 2001 were in line with our results: no significant differences occurred in the number of antibiotic prescriptions between intervention and control group in 2000. In 2001, however, the mean number of antibiotic prescriptions had decreased by 9.7 prescriptions per 1000 patients (P = 0.05) in the intervention group, whereas in the control group it had increased (P = 0.60). This increase was also seen in the non-participating general practitioners in the same region (mean difference in change between intervention and control group -11.6 prescriptions/1000 patients, -23.2 to -0.03) and confirmed by multilevel analysis (table 4). After 15 months, the number of antibiotic prescriptions in the intervention group was still lower than in the pre-intervention period (data not shown). Referral rates (about 2%) remained stable over time and did not differ between intervention and control groups (mean difference in change -0.1, -2.0 to 1.8).
Table 4 Insurance claims data: changes in mean number of antibiotic prescriptions per 1000 patients in March-April-May 2000 and March-April-May 2001 at practice level. Values are means with standard deviations
Discussion
De Melker RA, Kuyvenhoven MM. Management of upper respiratory tract infections in Dutch family practice. J Fam Pract 1994;38: 353-7.
Arroll B, Kenealy T. Antibiotics for the common cold. Cochrane Database Syst Rev 2000;(2): CD000247.
Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev 2000;(4): CD000023.
Becker L, Glazier R, McIsaac W, Smucny J. Antibiotics for acute bronchitis. Cochrane Database Syst Rev 2000;(2): CD000245.
Glasziou PP, Del Mar CB, Sanders SL, Hayem M Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2004;(1): CD000219.
Williams JW, Aguilar C, Makela M, Cornell J, Hollman DR, Chiquette E, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2003;(2): CD000243.
Mainous III G, Hueston WJ. The cost of antibiotics in treating upper respiratory tract infections in a Medicaid population. Arch Fam Med 1998;7: 45-9.
Little P, Gould C, Williamsen I, Warner G, Gantly M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997;315: 350-2.
Belongia EA, Schwartz B. Strategies for promoting judicious use of antibiotics by doctors and patients. BMJ 1998;317: 668-71.
Sepp?l? H, Klaukka T, Vuopio-Varkula J, Muotiala A, Helenius H, Lager K, et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Eng J Med 1997;337: 441-6.
Arnold SR, Evans M, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care (Protocol for a Cochrane Review). Cochrane Library; Issue 1, 2003. Oxford: Update Software.
Cars O, Molstad S, Melander A. Variation in antibiotic use in the European Union. Lancet 2001;357: 1851-53.
De Melker RA. Effectiviteit van antibiotica bij veelvoorkomende luchtweginfecties in de huisartspraktijk . Ned Tijdschr Geneeskunde 1998;142: 452-6.
Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Scott N. Understanding the culture of Prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats. BMJ 1998;317: 637-42.
Davey P, Pagliari C, Hayes A. The patients' role in the spread and control of bacterial resistance to antibiotics. Clin Microbiol Infect 2002;8(suppl): 43-68.
De Bock GH, Van Duijn NP, Dagnelie CF, Geijer RMM, Van der Hell RJ, Labots-Vogelesang SM, et al. NHG-Standaard Sinusitis. Huisarts Wet 1993;36: 255-7. (Guideline on acute sinusitis of the Dutch College of General Practitioners.)
Dagnelie CF, Zwart S, Balder FA, Romeijnders ACM, Geijer RMM. NHG-standaard Acute Keelpijn (eerste herziening). Huisarts Wet 1999;42: 271-8. (Guideline on acute tonsillitis of the Dutch College of General Practitioners, first revision.)
Appelman CLM, Van Balen FAM, Van de Lisdonk EH, Van Weert HCLM, Eizenga WH.. NHG-Standaard Otitis Media Acuta (eerste herziening). Huisarts Wet 1999;33: 242-5). (Guideline on acute otitis media of the Dutch College of General Practitioners, first revision.)
Verheij TJM, Salomé PL, Bindels PJ, Chavannes AW, Ponsioen BP, Sachs APE, et al. NHG-Standaard Acuut Hoesten. Huisarts Wet 2003;46: 496-506. (Guideline on acute cough of the Dutch College of General Practitioners.)
Grol R, Dalhuijsen J, Thomas S, In 't Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998;317: 858-61.
Wensing M, Grol R. Single and combined strategies for implementing changes in primary care: a literature review. Int J Qual Health Care 1994;6: 115-32.
Gross PA, Pujat D. Implementing practice guidelines for appropriate antimicrobial usage. A systematic review. Med Care 2001;39: II55-69.
De Meyere M, Guillemot D, Verheij TJM. Interventions in the community related to antibiotic use. Final report of the European conference on antibiotic use in Europe. European Surveillance of Antimicrobial Consumption (ESAC), Brussels, November 15-17, 2001; 38-43.
Coenen S, Kuyvenhoven MM, Butler CC, Van Rooyen P, Verheij ThJM. Variation in European antibiotic use . Lancet;358: 1272.
Lamberts H, Wood M. ICPC. International classification of primary care. Oxford: Oxford University Press, 1987.]
WHO Collaborating Centre for Drug Statistics Methodology. Anatomical therapeutic chemical (ATC) classification system: guidelines for ATC classification and DDD assignment. www.whocc.no/atcddd/ (accessed 8 Jan 2004).
Van Houwelingen JC. Dwalingen in de methodologie. III. Randomisatie op het niveau van behandelaars. Ned Tijdschr Geneesk 1998;142: 1662-5.
Hox JJ. Applied multilevel analysis. Amsterdam, TT-Publikaties, 1994.
Goldstein H. Multilevel models in educational and social research. London: Oxford University Press, 1987.
Kuyvenhoven MM, Van Balen FAM, Verheij, TJM. Outpatient antibiotic prescriptions from 1992 to 2001 in the Netherlands. J Antimicrob Chemother 2003;52: 675-8.
Zwar N, Wolk J, Gordon J, Sanson-Fisher R, Kehoe L. Influencing antibiotic prescribing in general practice: a trial of prescriber feedback and management guidelines. Fam Pract 1999;16: 495-500.
Flottorp S, Oxman AD, Havelsrud K, Treweek S, Herrin J. Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat. BMJ 2002;325: 367.(Ineke Welschen, junior re)
Correspondence to: I. Welschen i.welschen@med.uu.nl
Abstract
In the Netherlands, general practitioners prescribe almost 80% of all antibiotics, and up to two thirds of these prescriptions are issued for infections of the respiratory tract.1 These infections are often treated with antibiotics, although this has mostly not been found to be beneficial.2-6 Unnecessary use of antibiotics entails an increased risk of side effects,2 high costs,7 medicalising effects,8 and development of bacterial resistance against antibiotics.9-11 Although antibiotic prescribing rates in the Netherlands are low compared with other European countries12 and the United States, as many as 50% of such prescriptions are estimated to lack an evidence based indication.13 Non-clinical factors such as perceived patients' expectations play an important part in the decision whether or not to prescribe antibiotics.14 15
The Dutch College of General Practitioners developed evidence based guidelines for infections of the respiratory tract.16-19 However, implementation of these guidelines remains difficult.11 20 Educational outreach visits, local opinion leaders, and combinations of interventions have been shown to have the largest impact, but the results and methodological quality of these studies are highly variable.11 21 22 In general, multiple intervention strategies—including local doctors in setting guidelines, involving a leading participant from the peer review group, training doctors in communication skills (including patient centred healthcare strategies), monitoring prescribing behaviour, and sustaining the achieved consensus by means of feedback on prescribing and reminders—are considered most effective in optimising prescribing behaviour.21 23 However, such a strategy has not been evaluated for the management of respiratory tract infections in primary care. In a randomised controlled trial we evaluated the effectiveness of such a multiple intervention aiming at reducing antibiotic prescription rates for respiratory tract symptoms in primary care: the Utrecht antibiotics and respiratory tract infections (ARTI-1) study.
Methods
Forty two of the 48 peer review groups in the region of Utrecht were eligible and invited to participate. Twelve peer review groups (100 general practitioners) agreed to participate (figure). Insurance claims data showed no differences in volumes of antibiotics prescribed in participating compared with non-participating doctors. Out of 100 general practitioners who agreed to participate, 89 completed the study. Eleven were lost to follow up (intervention group 4/46; control group 7/54) because of retirement (one doctor), removal outside the region (three), illness (three), motivational problems (two) or technical problems (two). General practitioners in both arms did not differ at baseline with regard to sex, practice characteristics, and mean period since registration as general practitioner (table 1). They did not differ either regarding the extent to which the group was used to discuss indication and first choice medication in their meetings (table 1). Registered patients in both arms did not differ in 2000 and 2001 regarding age, sex, and type of diagnosis (table 2). Almost 80% (37) of the general practitioners (intervention group) attended all parts of the intervention.
Flow of participants through the trial.
Table 1 Baseline characteristics of general practitioners (n=89) participating in the study in 2000
Table 2 Patients' characteristics in 2000 and 2001 in the intervention and control groups
At baseline, mean antibiotic prescription rates for registered encounters for respiratory tract symptoms did not differ significantly between the two groups (27% v 29%, 95% confidence interval -9.1 to 5.0). In 2001, antibiotic prescription rates in the intervention group fell by 4% and those in the control group rose by 8% (mean difference in change -12%, -18.9% to -4.0%, table 3). Multilevel analysis confirmed the results of the unadjusted analysis (intervention effect -10.7%, -20.3% to -1.0%), while intra-class correlation coefficients showed that variation could be attributed to practice and group levels 0.17 and 0.09, respectively).
Table 3 Registration of patients: changes in antibiotic prescription rates and patients' satisfaction in 2000 and 2001. Values are means with standard deviations unless otherwise indicated
Patient satisfaction questionnaires were available from 83% (35) of general practitioners in the intervention group and from 91% (43) of doctors in the control group (table 2). We found no difference in patients' satisfaction in the two arms in 2000 and 2001 (table 3). The multiple intervention did not change patients' degree of satisfaction; they remained very satisfied with the consultation (mean satisfaction grade 4.2). These results were also confirmed by multilevel analysis (intervention effect on patients' satisfaction -0.03, -0.2 to 0.1).
Claims data over 2000 and 2001 were in line with our results: no significant differences occurred in the number of antibiotic prescriptions between intervention and control group in 2000. In 2001, however, the mean number of antibiotic prescriptions had decreased by 9.7 prescriptions per 1000 patients (P = 0.05) in the intervention group, whereas in the control group it had increased (P = 0.60). This increase was also seen in the non-participating general practitioners in the same region (mean difference in change between intervention and control group -11.6 prescriptions/1000 patients, -23.2 to -0.03) and confirmed by multilevel analysis (table 4). After 15 months, the number of antibiotic prescriptions in the intervention group was still lower than in the pre-intervention period (data not shown). Referral rates (about 2%) remained stable over time and did not differ between intervention and control groups (mean difference in change -0.1, -2.0 to 1.8).
Table 4 Insurance claims data: changes in mean number of antibiotic prescriptions per 1000 patients in March-April-May 2000 and March-April-May 2001 at practice level. Values are means with standard deviations
Discussion
De Melker RA, Kuyvenhoven MM. Management of upper respiratory tract infections in Dutch family practice. J Fam Pract 1994;38: 353-7.
Arroll B, Kenealy T. Antibiotics for the common cold. Cochrane Database Syst Rev 2000;(2): CD000247.
Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev 2000;(4): CD000023.
Becker L, Glazier R, McIsaac W, Smucny J. Antibiotics for acute bronchitis. Cochrane Database Syst Rev 2000;(2): CD000245.
Glasziou PP, Del Mar CB, Sanders SL, Hayem M Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2004;(1): CD000219.
Williams JW, Aguilar C, Makela M, Cornell J, Hollman DR, Chiquette E, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2003;(2): CD000243.
Mainous III G, Hueston WJ. The cost of antibiotics in treating upper respiratory tract infections in a Medicaid population. Arch Fam Med 1998;7: 45-9.
Little P, Gould C, Williamsen I, Warner G, Gantly M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997;315: 350-2.
Belongia EA, Schwartz B. Strategies for promoting judicious use of antibiotics by doctors and patients. BMJ 1998;317: 668-71.
Sepp?l? H, Klaukka T, Vuopio-Varkula J, Muotiala A, Helenius H, Lager K, et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Eng J Med 1997;337: 441-6.
Arnold SR, Evans M, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care (Protocol for a Cochrane Review). Cochrane Library; Issue 1, 2003. Oxford: Update Software.
Cars O, Molstad S, Melander A. Variation in antibiotic use in the European Union. Lancet 2001;357: 1851-53.
De Melker RA. Effectiviteit van antibiotica bij veelvoorkomende luchtweginfecties in de huisartspraktijk . Ned Tijdschr Geneeskunde 1998;142: 452-6.
Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Scott N. Understanding the culture of Prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats. BMJ 1998;317: 637-42.
Davey P, Pagliari C, Hayes A. The patients' role in the spread and control of bacterial resistance to antibiotics. Clin Microbiol Infect 2002;8(suppl): 43-68.
De Bock GH, Van Duijn NP, Dagnelie CF, Geijer RMM, Van der Hell RJ, Labots-Vogelesang SM, et al. NHG-Standaard Sinusitis. Huisarts Wet 1993;36: 255-7. (Guideline on acute sinusitis of the Dutch College of General Practitioners.)
Dagnelie CF, Zwart S, Balder FA, Romeijnders ACM, Geijer RMM. NHG-standaard Acute Keelpijn (eerste herziening). Huisarts Wet 1999;42: 271-8. (Guideline on acute tonsillitis of the Dutch College of General Practitioners, first revision.)
Appelman CLM, Van Balen FAM, Van de Lisdonk EH, Van Weert HCLM, Eizenga WH.. NHG-Standaard Otitis Media Acuta (eerste herziening). Huisarts Wet 1999;33: 242-5). (Guideline on acute otitis media of the Dutch College of General Practitioners, first revision.)
Verheij TJM, Salomé PL, Bindels PJ, Chavannes AW, Ponsioen BP, Sachs APE, et al. NHG-Standaard Acuut Hoesten. Huisarts Wet 2003;46: 496-506. (Guideline on acute cough of the Dutch College of General Practitioners.)
Grol R, Dalhuijsen J, Thomas S, In 't Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998;317: 858-61.
Wensing M, Grol R. Single and combined strategies for implementing changes in primary care: a literature review. Int J Qual Health Care 1994;6: 115-32.
Gross PA, Pujat D. Implementing practice guidelines for appropriate antimicrobial usage. A systematic review. Med Care 2001;39: II55-69.
De Meyere M, Guillemot D, Verheij TJM. Interventions in the community related to antibiotic use. Final report of the European conference on antibiotic use in Europe. European Surveillance of Antimicrobial Consumption (ESAC), Brussels, November 15-17, 2001; 38-43.
Coenen S, Kuyvenhoven MM, Butler CC, Van Rooyen P, Verheij ThJM. Variation in European antibiotic use . Lancet;358: 1272.
Lamberts H, Wood M. ICPC. International classification of primary care. Oxford: Oxford University Press, 1987.]
WHO Collaborating Centre for Drug Statistics Methodology. Anatomical therapeutic chemical (ATC) classification system: guidelines for ATC classification and DDD assignment. www.whocc.no/atcddd/ (accessed 8 Jan 2004).
Van Houwelingen JC. Dwalingen in de methodologie. III. Randomisatie op het niveau van behandelaars. Ned Tijdschr Geneesk 1998;142: 1662-5.
Hox JJ. Applied multilevel analysis. Amsterdam, TT-Publikaties, 1994.
Goldstein H. Multilevel models in educational and social research. London: Oxford University Press, 1987.
Kuyvenhoven MM, Van Balen FAM, Verheij, TJM. Outpatient antibiotic prescriptions from 1992 to 2001 in the Netherlands. J Antimicrob Chemother 2003;52: 675-8.
Zwar N, Wolk J, Gordon J, Sanson-Fisher R, Kehoe L. Influencing antibiotic prescribing in general practice: a trial of prescriber feedback and management guidelines. Fam Pract 1999;16: 495-500.
Flottorp S, Oxman AD, Havelsrud K, Treweek S, Herrin J. Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat. BMJ 2002;325: 367.(Ineke Welschen, junior re)