Influencing antibiotic prescribing by prescriber feedback and management guidelines: a 5-year follow-up

BACKGROUND: The extent of use of antibiotics for upper respiratory tract infection (URTI) prompted a previous study of an educational intervention based on prescriber feedback and management guidelines. This study demonstrated a reduction in antibiotic prescribing for URTI and a more appropriate choice of antibiotic for tonsillitis/streptococcal pharyngitis. There are few long-term follow-up studies of educational programmes of this kind. OBJECTIVES: This follow-up study aimed to examine if the reduction in antibiotic prescribing observed in the intervention group of the original study remained present after 5 years, and how the prescribing behaviour of the GPs involved in the follow-up differed from a large national survey of GP prescribing. METHODS: Attempts were made to contact the 157 GPs involved in the original study. Of these, 121 were both located and currently working in general practice. Ninety-six consented to take part and, of these, 79 completed a morbidity and treatment survey of 100 patient encounters (response rate 65.3%). RESULTS: The intervention group (n = 37) maintained their pattern of prescribing of antibiotics for URTI and choice of antibiotic for tonsillitis/streptococcal pharyngitis, with no significant change between the completion of the original study and the 5-year follow-up. The control group (n = 42) showed a downward trend in antibiotic prescribing for URTI, with the effect that no significant differences remained between groups at the 5-year follow-up. At the 5-year follow-up, both groups prescribed significantly fewer antibiotics for URTI and showed greater adherence to prescribing guidelines for tonsillitis/streptococcal pharyngitis than participants in a large national GP survey (n = 984). CONCLUSION: This study demonstrated maintenance of prescribing behaviour in the intervention group in the long term. However, the changes in prescribing observed in the control group and the power limitations of the study make it uncertain whether this was the result of a sustained effect of the educational intervention. The differences in both groups from the large national GP survey suggest that other influences on prescribing (such as participation in vocational training for general practice) were also having an important effect.     

Measuring antibiotic prescribing practices among ambulatory physicians: accuracy of administrative claims data

To assess the accuracy of administrative claims data for measuring antibiotic prescribing behavior, we conducted a stratified randomized medical record review of office visits by children with pharyngitis, and adults with acute bronchitis, to primary care physicians in Colorado in 1998. The diagnoses of pharyngitis (n = 422) and acute bronchitis (n = 497) based on administrative data were verified in 83% and 79%, respectively, of medical records. The sensitivity, specificity, and positive predictive value of administrative data in identifying antibiotic treatment for pharyngitis was 68%, 91%, and 90%, respectively, and for bronchitis was 79%, 84% and 98%, respectively. The sensitivity, specificity, and negative predictive value of administrative data in identifying group A streptococcal test ordering for pharyngitis was 71%, 86%, and 30%, respectively. Absence of testing in administrative data (when present in the medical record) was more frequent among visits to physicians associated with a capitated health plan. We conclude that administrative claims data are accurate sources for measuring and profiling antibiotic prescribing practices in ambulatory practice, although they underestimate actual antibiotic treatment decisions by individual physicians. Measuring and profiling antibiotic prescribing behavior in relation to group A streptococcal test utilization may overestimate inappropriate antibiotic treatment by physicians enrolled in capitated contracts.     

The effects of the rapid strep test on physician management of streptococcal pharyngitis

Management of pharyngitis remains an important and controversial subject. A retrospective chart review at the University of South Alabama Family Practice Center was undertaken to assess changes in physician prescribing and testing patterns since the advent of rapid testing of streptococcal pharyngitis (rapid strep tests [RST]). Charts for study were identified by encounter form coding of a diagnosis of streptococcal pharyngitis or pharyngitis not otherwise specified. Control and test groups were formed based on the availability of the RST, and a stratified sample was drawn from each group. In the group of patients studied after the RST became available, data analysis showed a significantly increased likelihood that patients received antibiotics with a positive RST (odds ratio [OR] = 6.42), whereas those patients with a negative or no RST were significantly less likely to receive antibiotics (OR = 2.50 and 2.48, respectively). Group assignment was a significant predictor of test-ordering behavior (P less than 0.05). A higher than expected rate of streptococcal pharyngitis was noted in the group of patients who had the RST available to them. The RST plays an important though not fully defined role in the current management of pharyngitis.     

处方点评制度对抗生素使用的影响——基于山东省青岛市村卫生室的时间序列分析

目的：评估处方点评制度的实施对村卫生室抗生素处方比例的作用效果.方法：收集青岛市黄岛区村卫生室在处方点评制度实施前后的门诊电子处方作为研究样本,利用间断时间序列数据的分段回归模型,评估处方点评制度的作用效果.结果：处方点评制度的实施未使村卫生室抗生素处方比例立即下降,但产生了远期作用,导致抗生素处方比例每月下降0.884%（P=0.0314）.结论：处方点评制度的实施降低了村卫生室的抗生素处方比例,提高了乡村医生的安全合理用药水平.     

Understanding variation in quality improvement: the treatment of sore throats in primary care

BACKGROUND: In 1988, two practices attempted to improve the prescribing of antibiotics for sore throat. The initiative produced only modest improvements in prescribing practice, a finding the authors found difficult to explain. This paper reanalyses the data from an audit of antibiotic prescribing for sore throat in general practice. OBJECTIVE: Our aim was to demonstrate the use of Shewhart control charts and to obtain fresh insight into the variations in clinical practice revealed in clinical audit data. METHODS: We use Shewhart control charts to explore variation in antibiotic prescribing between GPs and to suggest the action most likely to result in improvement. RESULTS: Using control charts, it is possible to distinguish two categories of GPs: low prescribers of antibiotics and high prescribers of antibiotics. Low prescribers of antibiotics show common cause variation, indicating that their prescribing is a stable process. Among low prescribers, improvement can best be achieved by changing the common underlying process. One high prescriber of antibiotics is affected by special cause variation. Among high prescribers, improvement can best be achieved by investigating the special causes affecting this GP and learning lessons from the findings. CONCLUSION: The original improvement effort took the same action on all GPs in both practices. Our analysis suggests that such an approach was unlikely to be successful and that different actions were needed for high and low prescribers. The control charts provide fresh insights on the original data and guide improvement efforts.     

Effect of a rapid diagnostic method on prescribing patterns and ordering of throat cultures for streptococcal pharyngitis

The sensitivity and specificity of a rapid identification test for group A beta-hemolytic streptococcus and its impact on prescribing antibiotics and ordering throat cultures were evaluated in a primary care office setting. The calculated sensitivity, specificity, positive predictive value, and negative predictive value were 82 percent, 92 percent, 76 percent, and 94 percent, respectively. Throat cultures were ordered for 98 percent of patients with acute pharyngitis regardless of the method of testing available. After use of the rapid identification test within the office, a reduction was observed in physician prescribing of antibiotics before the throat culture results were known. Physicians were more likely to initiate antibiotics immediately when rapid test results for streptococcal infection were positive and provide patient education regarding symptomatic treatment when the results were negative. The rapid identification test is an acceptable alternative to the standard culture technique in the family practice office. The rapid test was apparently responsible for the observed reduction in antibiotic prescribing and should reduce unnecessary cost and antibiotic exposure in the ambulatory setting.     

Socially responsible antibiotic choices in primary care: a qualitative study of GPs' decisions to prescribe broad-spectrum and fluroquinolone antibiotics

BACKGROUND: There is considerable variation within and between countries in general medical practitioners' (GPs') prescribing of broad-spectrum antibiotics such as fluroquinolones, and resistance to these agents is increasing worldwide. Urgently promoting cautious fluroquinolone prescribing in primary care may limit increase in resistance. OBJECTIVE: We therefore interviewed 40 GPs in order to explore the reasons for their choice of prescribed antibiotic, in particular their decision to prescribe fluroquinolones. METHODS: We used a grounded theory approach to data collection and analysis, incorporating purposive and theoretical sampling, based on high and average fluroquinolone prescribing. Interviews were conducted with 26 GPs from practices known to be high prescribers of fluroquinolone antibiotics and 14 from average fluroquinolone prescribing practices. RESULTS: Chosing to prescribe a broad-spectrum antibiotic such as a fluroquinolone, rather than a narrow-spectrum antibiotic, related to a number of clinical considerations, perceptions of patient expectations and organizational influences. GPs from high fluroquinolone prescribing practices were more likely to prioritize patients' immediate needs, whereas GPs from average prescribing practices were more likely to consider longer term issues. GPs from both high and average fluroquinolone prescribing practices justified their antibiotic choices on the basis of a desire to do their best for their patients and society. CONCLUSION: Choosing to prescribe powerful, broad-spectrum antibiotics such as fluroquinolones, as well as choosing to keep these agents in reserve, was justified on the basis of social responsibility. Strategies to change fluroquinolone and broad-spectrum antibiotic prescribing will need to take into account clinicians' perceptions of social responsibility.     

European Antibiotic Awareness Day 2011: antibiotics--a powerful tool and a dwindling resource

The increasing resistance of microorganisms to a range of antibiotics is of growing concern to healthcare professionals world wide. A correlation between antibiotic resistance and high prescribing rates has long been established. However, despite numerous awareness campaigns, antibiotic prescribing rates are still high and increasing in many countries including the UK. The European Antibiotic Awareness Day on 18 November 2011 provides a platform to remind prescribers and the general public about the dangers of antibiotic overuse. The key message is to encourage prudent antibiotic prescribing so that antibiotics remain a safe and effective resource for the future.