'Evidence-based' perioperative antibiotic prophylaxis policy in Belgian hospitals after a change in the reimbursement system

The costs of antibiotics in Belgian hospitals are nearly fully reimbursed by the health insurance. Such a situation is not conductive to rational drug use. A new reimbursement system for perioperatively-administered antibiotics in Belgian hospitals was implemented in May 1997 by Royal Decree. A reimbursement code for antibiotic use was linked to the reimbursement of surgical interventions. This code represents a reimbursement which covers 75% of the cost of perioperative prophylaxis based on optimal indication, dose, and duration as recommended by international and Belgian consensus guidelines. The actual antibiotic prescribed during the 72-hour perioperative period (the day before, during and after surgery) is reimbursed at only 25% of its full cost. Thus, if the perioperative prophylactic antibiotic regimen complies with the evidence-based guidelines, the costs of antibiotic prescribing will be fully reimbursed by the health insurance (75% of the standard +25% of the actual costs). The new reimbursement system does not apply to antibiotics which are prescribed for treatment of intercurrent infections; these antibiotics continue to be fully reimbursed. Annual expenditures for antibiotics, for both antibiotic treatment and prophylaxis, nationwide and per hospital, have shown marked improvements in perioperative antibiotic use after the decree was implemented. Surgeons' adherence to the evidence-based standard of prophylactic antibiotic use has improved over time. In conclusion, rapid implementation of the perioperative antibiotic prophylaxis policy was achieved through changes in the reimbursement of antibiotics for surgery patients.     

Office-related antibiotic prescribing for persons aged ≤ 14 years--United States, 1993-1994 to 2007-2008

In 2003, the Institute of Medicine identified antibiotic resistance as a key microbial threat to health in the United States and recommended promoting appropriate antibiotic use as an important strategy to address this threat. Antibiotic use contributes to development of antibiotic resistance on both the individual and country level. To examine trends in pediatric antibiotic prescribing in physician offices, CDC analyzed data from the National Ambulatory Medical Care Survey (NAMCS) for the period 1993-1994 to 2007-2008. This report summarizes the results of that analysis, which found that antibiotic prescribing rates for persons aged ≤ 14 years who had visited physician offices decreased 24% from 300 antibiotic courses per 1,000 office visits in 1993-1994 to 229 antibiotic courses per 1,000 office visits in 2007-2008. Among the five acute respiratory infections (ARIs) examined, antibiotic prescribing rates decreased 26% for pharyngitis and 19% for nonspecific upper respiratory infection (common cold); prescribing rates for otitis media, bronchitis, and sinusitis did not change significantly. Although the overall antibiotic prescribing rate for persons aged ≤ 14 years has decreased, the rate remains inappropriately high. Further efforts are needed to decrease inappropriate antibiotic prescribing for persons aged ≤ 14 years.     

Antibiotics for upper respiratory tract infections. Follow-up utilization and antibiotic use.

OBJECTIVES: To examine the effects of antibiotic prescribing during an initial visit for viral respiratory tract infections on future care seeking and the cost of care. MATERIALS AND METHODS: Retrospective analysis of recorded visits for viral respiratory tract infections (N = 49,862) between January 1, 1995, and December 31, 1997, to practices in a large network of affiliated practices that use the same electronic medical record. RESULTS: Patients receiving antibiotics at the initial visit were less likely to return for a second visit, but this difference was small (15.4% vs 17.4%, P < .001). When returning for the second visit, those who received an antibiotic on the initial visit were prescribed more expensive antibiotics than those who had not received an antibiotic on the initial consultation. Overall, cost from initial antibiotic use outweighed any benefit from reduced utilization in adults and children. CONCLUSIONS: Antibiotic prescribing at an initial contact for a viral respiratory tract illness may reduce the likelihood that an individual will return for a subsequent visit, but adds substantial costs to care for the initial antibiotic and for more expensive antibiotics used on subsequent visits.     

Influencing antibiotic prescribing in general practice: a trial of prescriber feedback and management guidelines.

BACKGROUND: The extent of use of antibiotics to treat upper respiratory infections in general practice is an area for concern due to the increasing problem of bacterial resistance. Effective educational strategies to promote rational prescribing are needed. OBJECTIVES: We aimed to examine the effectiveness of prescriber feedback and management guidelines in reducing antibiotics prescribing by GP trainees for undifferentiated upper respiratory tract infection, and in improving the choice of antibiotic for tonsillitis/streptococcal pharyngitis. The research tested a stepwise approach to targeting educational input to high prescribers. METHOD: General Practice trainees in New South Wales (n = 157) were randomly allocated to a treatment group (n = 78) which received an education intervention on antibiotic use, or to a control group (n = 79) which received an intervention on an unrelated topic. Trainees completed three practice activity surveys, each of 110 consecutive patient encounters, with 6-month intervals between surveys. Prescriber feedback and management guidelines on use of antibiotics for URTI and choice of antibiotic for tonsillitis/streptococcal pharyngitis were delivered in a written form between surveys 1 and 2. An educational outreach visit to high prescribers occurred between surveys 2 and 3. Outcome measures were the rate of antibiotic prescribing for all indications, for URTI and prescribing of select antibiotics for tonsillitis/streptococcal pharyngitis. RESULTS: Antibiotic prescribing by the intervention group declined over three occasions from 25.0 to 23.3 to 19.7 per 100 URTI problems, while the control group increased from 22.0 to 25.0 to 31.7 per 100 URTI problems (P = 0.002). Prescribing in agreement with accepted guidelines for tonsillitis/streptococcal pharyngitis increased over time in the intervention group from 55.6 to 69.8 to 73.0 per 100 problems, but decreased in the control group from 59.6 to 57.5 to 58.5 (P = 0.05). CONCLUSION: Prescriber feedback and management guidelines were shown to influence antibiotic prescribing for URTI and choice of antibiotic for tonsillitis/streptococcal pharyngitis. This study provides a model for targeting educational input to those prescribers who most need to change their behaviour.