Antibiotic prescribing for common infections in UK general practice: variability and drivers

Abstract Objectives To examine variations across general practices and factors associated with antibiotic prescribing for common infections in UK primary care to identify potential targets for improvement and optimization of prescribing. Methods Oral antibiotic prescribing for common infections was analysed using anonymized UK primary care electronic health records between 2000 and 2015 using the Clinical Practice Research Datalink (CPRD). The rate of prescribing for each condition was observed over time and mean change points were compared with national guideline updates. Any correlation between the rate of prescribing for each infectious condition was estimated within a practice. Predictors of prescribing were estimated using logistic regression in a matched patient cohort (1:1 by age, sex and calendar time). Results Over 8 million patient records were examined in 587 UK general practices. Practices varied considerably in their propensity to prescribe antibiotics and this variance increased over time. Change points in prescribing did not reflect updates to national guidelines. Prescribing levels within practices were not consistent for different infectious conditions. A history of antibiotic use significantly increased the risk of receiving a subsequent antibiotic (by 22%–48% for patients with three or more antibiotic prescriptions in the past 12 months), as did higher BMI, history of smoking and flu vaccinations. Other drivers for receiving an antibiotic varied considerably for each condition. Conclusions Large variability in antibiotic prescribing between practices and within practices was observed. Prescribing guidelines alone do not positively influence a change in prescribing, suggesting more targeted interventions are required to optimize antibiotic prescribing in the UK.

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Local implementation of AMS initiatives: a mixed-methods study

British Journal of General Practice ◽

10.3399/bjgp18x697025 ◽

2018 ◽

Vol 68 (suppl 1) ◽

pp. bjgp18X697025 ◽

Cited By ~ 2

Author(s):

Rosalie Allison ◽

Donna Lecky ◽

Elizabeth Beech ◽

Ceire Costelloe ◽

Diane Ashiru-Oredope ◽

...

Keyword(s):

Primary Care ◽

Qualitative Interviews ◽

Antibiotic Prescribing ◽

Out Of Hours ◽

Face To Face ◽

E Learning ◽

General Practices ◽

Primary Care Practitioners ◽

Future Work ◽

Common Infections

BackgroundThe NHS English Quality Premium recommends that inappropriate antibiotic prescribing is reduced; there are a range of national antimicrobial stewardship (AMS) initiatives to support this.AimThe aim of this study is to assess AMS activities in primary care across England. The findings will be used to inform how the RCGP, PHE and NHS can help optimise stewardship activities.MethodQualitative interviews: with AMS leads within Clinical Commissioning Groups’ (CCGs) and Commissioning Support Units’ (CSUs) medicines management teams. Questionnaire: informed by the qualitative data, sent to all 209 CCGs in England in 2017.ResultsIn total, 89% (187/209) of CCGs returned a questionnaire; 82% of AMS leads reported spending only 0.1 whole-time equivalent on AMS activities, as it was only one role within a wider remit, so dedicating time is challenging. 99% (167/169) of CCGs had delivered AMS education in the last 2 years: 140 face-to-face; 121 via e-learning. 99% (184/186) actively promoted the TARGET Antibiotics Toolkit; 94% (175/187) actively promoted TARGET patient leaflets: 92% The Treating Your Infection (TYI) leaflet. 90% (166/185) used the PHE managing common infections guidance: 81% (149/185) modify or localise; 41/185 (22%) signpost directly to it. Eighty-six CCGs reported using CCG audit tools and 82 CCGs reported using TARGET’s audit tools. 85% (142/168) fed back antimicrobial prescribing data to the CCG/CSU board; 100% (169/169) to general practices and 33% (56/169) to out-of-hours providers.ConclusionAlthough CCGs reported promoting these AMS activities, there was little evaluation of uptake by primary care practitioners. Future work should focus on measuring AMS uptake; having staff dedicated solely to AMS could facilitate this.

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Trends in Antibiotic Prescribing in Out-of-Hours Primary Care in England from January 2016 to June 2020 to Understand Behaviours during the First Wave of COVID-19

Antibiotics ◽

10.3390/antibiotics10010032 ◽

2021 ◽

Vol 10 (1) ◽

pp. 32

Author(s):

Nina J. Zhu ◽

Monsey McLeod ◽

Cliodna A. M. McNulty ◽

Donna M. Lecky ◽

Alison H. Holmes ◽

...

Keyword(s):

Primary Care ◽

Time Series ◽

Patient Outcomes ◽

Broad Spectrum ◽

Antibiotic Prescribing ◽

Broad Spectrum Antibiotic ◽

Out Of Hours ◽

Broad Spectrum Antibiotics ◽

National Quality ◽

General Practices

We describe the trend of antibiotic prescribing in out-of-hours (OOH) general practices (GP) before and during England’s first wave of the COVID-19 pandemic. We analysed practice-level prescribing records between January 2016 to June 2020 to report the trends for the total prescribing volume, prescribing of broad-spectrum antibiotics and key agents included in the national Quality Premium. We performed a time-series analysis to detect measurable changes in the prescribing volume associated with COVID-19. Before COVID-19, the total prescribing volume and the percentage of broad-spectrum antibiotics continued to decrease in-hours (IH). The prescribing of broad-spectrum antibiotics was higher in OOH (OOH: 10.1%, IH: 8.7%), but a consistent decrease in the trimethoprim-to-nitrofurantoin ratio was observed OOH. The OOH antibiotic prescribing volume diverged from the historical trend in March 2020 and started to decrease by 5088 items per month. Broad-spectrum antibiotic prescribing started to increase in OOH and IH. In OOH, co-amoxiclav and doxycycline peaked in March to May in 2020, which was out of sync with seasonality peaks (Winter) in previous years. While this increase might be explained by the implementation of the national guideline to use co-amoxiclav and doxycycline to manage pneumonia in the community during COVID-19, further investigation is required to see whether the observed reduction in OOH antibiotic prescribing persists and how this reduction might influence antimicrobial resistance and patient outcomes.

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Inappropriate Azithromycin Use in Nine Primary-Care Clinics Before and After Implementation of Provider Guidance in the EMR

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.869 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s292-s293

Author(s):

Alexandria May ◽

Allison Hester ◽

Kristi Quairoli ◽

Sheetal Kandiah

Keyword(s):

Primary Care ◽

Retrospective Chart Review ◽

Antibiotic Prescribing ◽

Upper Respiratory Tract ◽

National Guidelines ◽

Targeted Interventions ◽

Primary Care Clinics ◽

Before And After ◽

Upper Respiratory ◽

Tract Infections

Background: According to the CDC Core Elements of Outpatient Stewardship, the first step in optimizing outpatient antibiotic use the identification of high-priority conditions in which antibiotics are commonly used inappropriately. Azithromycin is a broad-spectrum antimicrobial commonly used inappropriately in clinical practice for nonspecific upper respiratory infections (URIs). In 2017, a medication use evaluation at Grady Health System (GHS) revealed that 81.4% of outpatient azithromycin prescriptions were inappropriate. In an attempt to optimize outpatient azithromycin prescribing at GHS, a tool was designed to direct the prescriber toward evidence-based therapy; it was implemented in the electronic medical record (EMR) in January 2019. Objective: We evaluated the effect of this tool on the rate of inappropriate azithromycin prescribing, with the goal of identifying where interventions to improve prescribing are most needed and to measure progress. Methods: This retrospective chart review of adult patients prescribed oral azithromycin was conducted in 9 primary care clinics at GHS between February 1, 2019, and April 30, 2019, to compare data with that already collected over a 6-month period in 2017 before implementation of the antibiotic prescribing guidance tool. The primary outcome of this study was the change in the rate of inappropriate azithromycin prescribing before and after guidance tool implementation. Appropriateness was based on GHS internal guidelines and national guidelines. Inappropriate prescriptions were classified as inappropriate indication, unnecessary prescription, excessive or insufficient treatment duration, and/or incorrect drug. Results: Of the 560 azithromycin prescriptions identified during the study period, 263 prescriptions were included in the analysis. Overall, 181 (68.8%) of azithromycin prescriptions were considered inappropriate, representing a 12.4% reduction in the primary composite outcome of inappropriate azithromycin prescriptions. Bronchitis and unspecified upper respiratory tract infections (URI) were the most common indications where azithromycin was considered inappropriate. Attending physicians prescribed more inappropriate azithromycin prescriptions (78.1%) than resident physicians (37.0%) or midlevel providers (37.0%). Also, 76% of azithromycin prescriptions from nonacademic clinics were considered inappropriate, compared with 46% from academic clinics. Conclusions: Implementation of a provider guidance tool in the EMR lead to a reduction in the percentage of inappropriate outpatient azithromycin prescriptions. Future targeted interventions and stewardship initiatives are needed to achieve the stewardship program’s goal of reducing inappropriate outpatient azithromycin prescriptions by 20% by 1 year after implementation.Funding: NoneDisclosures: None

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The Stroke Prevention Programme: a programme of research to inform optimal stroke prevention in primary care

Programme Grants for Applied Research ◽

10.3310/pgfar04030 ◽

2016 ◽

Vol 4 (3) ◽

pp. 1-290

Author(s):

Kate Fletcher ◽

Jonathan Mant ◽

Richard McManus ◽

Richard Hobbs

Keyword(s):

Primary Care ◽

Cost Effectiveness ◽

Usual Care ◽

Research Programme ◽

Cost Effective ◽

Self Management ◽

Controlled Trials ◽

National Guidelines ◽

History Of ◽

General Practices

BackgroundThe management of cardiovascular (CV) risk factors in community populations is suboptimal. The aim of this programme was to explore the role of three approaches [use of a ‘polypill’; self-management of hypertension; and more intensive targets for blood pressure (BP) lowering after stroke] to improve prevention of CV disease (CVD) in the community.Research questions(1) Is it more cost-effective to titrate treatments to target levels of cholesterol and BP or to use fixed doses of statins and BP-lowering agents (polypill strategy)? (2) Will telemonitoring and self-management improve BP control in people on treatment for hypertension or with a history of stroke/transient ischaemic attack (TIA) in primary care and are they cost-effective? (3) In people with a history of stroke/TIA, can intensive BP-lowering targets be achieved in a primary care setting and what impact will this have on health outcomes and cost-effectiveness?DesignMixed methods, comprising three randomised controlled trials (RCTs); five cost-effectiveness analyses; qualitative studies; analysis of electronic general practice data; a screening study; a systematic review; and a questionnaire study.SettingUK general practices, predominantly from the West Midlands and the east of England.ParticipantsAdults registered with participating general practices. Inclusion criteria varied from study to study.InterventionsA polypill – a fixed-dose combination pill containing three antihypertensive medicines and simvastatin – compared with current practice and with optimal implementation of national guidelines; self-monitoring of BP with self-titration of medication, compared with usual care; and an intensive target for systolic BP of < 130 mmHg or a 10 mmHg reduction if baseline BP is < 140 mmHg, compared with a target of < 140 mmHg.ResultsFor patients known to be at high risk of CVD, treatment as per guidelines was the most cost-effective strategy. For people with unknown CV risk aged ≥ 50 years, offering a polypill is cost-effective [incremental cost-effectiveness ratio (ICER) of £8115 per quality-adjusted life-year (QALY)] compared with a strategy of screening and treating according to national guidelines. Both results were sensitive to the cost of the polypill. Self-management in people with uncontrolled hypertension led to a 5.4 mmHg [95% confidence interval (CI) 2.4 to 8.5 mmHg] reduction in systolic BP at 1 year, compared with usual care. It was cost-effective for men (ICER of £1624 per QALY) and women (ICER of £4923 per QALY). In people with stroke and other high-risk groups, self-management led to a 9.2 mmHg (95% CI 5.7 to 12.7 mmHg) reduction in systolic BP at 1 year compared with usual care and dominated (lower cost and better outcome) usual care. Aiming for the more intensive BP target after stroke led to a 2.9 mmHg (95% CI 0.2 to 5.7 mmHg) greater reduction in BP and dominated the 140 mmHg target.ConclusionsPotential for a polypill needs to be further explored in RCTs. Self-management should be offered to people with poorly controlled BP. Management of BP in the post-stroke population should focus on achieving a < 140 mmHg target.Trial registrationCurrent Controlled Trials ISRCTN17585681, ISRCTN87171227 and ISRCTN29062286.FundingThe National Institute for Health Research (NIHR) Programme Grants for Applied Research programme. Additional funding was provided by the NIHR National School for Primary Care Research, the NIHR Career Development Fellowship and the Department of Health Policy Research Programme.

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Common Infections and Antibiotic Prescribing during the First Year of the COVID-19 Pandemic: A Primary Care-Based Observational Cohort Study

Antibiotics ◽

10.3390/antibiotics10121521 ◽

2021 ◽

Vol 10 (12) ◽

pp. 1521

Author(s):

Josi A. Boeijen ◽

Alike W. van der Velden ◽

Saskia Hullegie ◽

Tamara N. Platteel ◽

Dorien L. M. Zwart ◽

...

Keyword(s):

Infectious Disease ◽

Primary Care ◽

Cohort Study ◽

Respiratory Tract ◽

Observational Cohort Study ◽

Antibiotic Prescribing ◽

Prescription Rates ◽

Observational Cohort ◽

Ear Infections ◽

Common Infections

Presentation and antibiotic prescribing for common infectious disease episodes decreased substantially during the first COVID-19 pandemic wave in Dutch general practice. We set out to determine the course of these variables during the first pandemic year. We conducted a retrospective observational cohort study using routine health care data from the Julius General Practitioners’ Network. All patients registered in the pre-pandemic year (n = 425,129) and/or during the first pandemic year (n = 432,122) were included. Relative risks for the number of infectious disease episodes (respiratory tract/ear, urinary tract, gastrointestinal, and skin), in total and those treated with antibiotics, and proportions of episodes treated with antibiotics (prescription rates) were calculated. Compared to the pre-pandemic year, primary care presentation for common infections remained lower during the full first pandemic year (RR, 0.77; CI, 0.76–0.78), mainly attributed to a sustained decline in respiratory tract/ear and gastrointestinal infection episodes. Presentation for urinary tract and skin infection episodes declined during the first wave, but returned to pre-pandemic levels during the second and start of the third wave. Antibiotic prescription rates were lower during the full first pandemic year (24%) as compared to the pre-pandemic year (28%), mainly attributed to a 10% lower prescription rate for respiratory tract/ear infections; the latter was not accompanied by an increase in complications. The decline in primary care presentation for common infections during the full first COVID-19 pandemic year, together with lower prescription rates for respiratory tract/ear infections, resulted in a substantial reduction in antibiotic prescribing in Dutch primary care.

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Interrupted Time-Series Analysis to Evaluate the Impact of a National Antimicrobial Stewardship Campaign on Antibiotic Prescribing: A Typical Practice in China’s Primary Care

Clinical Infectious Diseases ◽

10.1093/cid/ciaa962 ◽

2020 ◽

Cited By ~ 2

Author(s):

Hui Li ◽

Yanhong Gong ◽

Jing Han ◽

Shengchao Zhang ◽

Shanquan Chen ◽

...

Keyword(s):

Primary Care ◽

Time Series ◽

Antimicrobial Stewardship ◽

Broad Spectrum ◽

Interrupted Time Series ◽

Antibiotic Prescribing ◽

Interrupted Time Series Analysis ◽

Targeted Interventions ◽

The Impact ◽

Outpatient Prescriptions

Abstract Background After implementing the 2011 national antimicrobial stewardship campaign, few studies focused on evaluating its effect in China’s primary care facilities. Methods We randomly selected 11 community health centers in Shenzhen, China, and collected all outpatient prescriptions of these centers from 2010–2015. To evaluate the impact of local interventions on antibiotic prescribing, we used a segmented regression model of interrupted time series to analyze seven outcomes, i.e., percentage of prescriptions with antibiotics, and percentages of prescriptions with broad-spectrum antibiotics, with parenteral antibiotics, and with two or more antibiotics in all prescriptions or antibiotics-containing prescriptions. Results Overall, 1 482 223 outpatient prescriptions were obtained. The intervention was associated with a significant immediate change (–5.2%, P=.04) and change in slope (–3.1% per month, P<.01) for the percentage of prescriptions with antibiotics, and its relative cumulative effect at the end of the study was –74.0% (95% confidence interval, –79.0% to –69.1%). After the intervention, the percentage of prescriptions with broad-spectrum, and with parenteral antibiotics decreased dramatically by 36.7% and 77.3%, respectively, but their percentages in antibiotic-containing prescriptions decreased insignificantly. Percentage of prescriptions with two or more antibiotics in all prescriptions or antibiotics-containing prescriptions only showed immediate changes, but significant changes in slope were not observed. Conclusions A typical practice in Shenzhen, China, showed that strict enforcement of antimicrobial stewardship campaign could effectively reduce antibiotic prescribing in primary care with a stable long-term effect. However, prescribing of broad-spectrum and parenteral antibiotics was still prevalent. More targeted interventions are required to promote appropriate antibiotic use.

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Comparison of antibiotic prescribing records in two UK primary care electronic health record systems: cohort study using CPRD GOLD and CPRD Aurum databases

BMJ Open ◽

10.1136/bmjopen-2020-038767 ◽

2020 ◽

Vol 10 (6) ◽

pp. e038767

Author(s):

Martin C Gulliford ◽

Xiaohui Sun ◽

Thamina Anjuman ◽

Eleanor Yelland ◽

Tarita Murray-Thomas

Keyword(s):

Primary Care ◽

Cohort Study ◽

Electronic Health Record ◽

Clinical Practice Research Datalink ◽

Antibiotic Prescribing ◽

Health Record ◽

Medical Diagnoses ◽

General Practices ◽

Electronic Health ◽

Tract Infections

ObjectivesWe aimed to evaluate recording of antibiotic prescribing from two primary care electronic health record systems.DesignCohort study.SettingUK general practices contributing to the Clinical Practice Research Datalink (CPRD) databases: CPRD GOLD (Vision data) and CPRD Aurum (EMIS data). English CPRD GOLD general practices were analysed as a subgroup, as all CPRD Aurum practices were located in England.Participants158 305 patients were randomly sampled from CPRD Aurum and 160 394 from CPRD GOLD.Outcome measuresAntibiotic prescriptions in 2017 were identified. Age-standardised and sex-standardised antibiotic prescribing rates per 1000 person years were calculated. Prescribing of individual antibiotic products and associated medical diagnoses was evaluated.ResultsThere were 101 360 antibiotic prescriptions at 883 CPRD Aurum practices and 112 931 prescriptions at 290 CPRD GOLD practices, including 112 general practices in England. The age-standardised and sex-standardised antibiotic prescribing rate in 2017 was 512.6 (95% CI 510.4 to 514.9) per 1000 person years in CPRD Aurum and 584.3 (582.1 to 586.5) per 1000 person years in CPRD GOLD (505.2 (501.6 to 508.9) per 1000 person years if restricted to practices in England). The 25 most frequently prescribed antibiotic products were similar in both databases. One or more medical codes were recorded on the same date as an antibiotic prescription for 72 989 (74%) prescriptions in CPRD Aurum, 84 756 (78%) in CPRD GOLD and 28 471 (78%) for CPRD GOLD in England. Skin, respiratory and genitourinary tract infections were recorded for 39 035 (40%) prescriptions in CPRD Aurum, 41 326 (38%) in CPRD GOLD, with 15 481 (42%) in English CPRD GOLD practices only.ConclusionEstimates for antibiotic prescribing and infection recording were broadly similar in both databases suggesting similar recording across EMIS and Vision systems. Future research on antimicrobial stewardship can also be conducted using primary care data in CPRD Aurum.

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Exploring Primary Care Clinicians’ Views about How Best to Implement a Potential Trial around Point-of-Care Tests for Common Infections in South Africa

Diagnostics ◽

10.3390/diagnostics11112100 ◽

2021 ◽

Vol 11 (11) ◽

pp. 2100

Author(s):

Alice Epps ◽

Charlotte Albury ◽

Oliver Van Hecke

Keyword(s):

South Africa ◽

Primary Care ◽

Point Of Care ◽

Feasibility Trial ◽

Antibiotic Prescribing ◽

Western Cape ◽

Middle Income ◽

Primary Care Clinicians ◽

Point Of Care Tests ◽

Common Infections

Optimisation of antibiotic prescribing is critical to combat antimicrobial resistance. Point-of-care tests (POCTs) for common infections could be a valuable tool to achieve this in primary care. Currently, their use has primarily been studied in high-income countries. Trials in low-and-middle-income countries face challenges unique to their setting. This study aims to explore the barriers and facilitators for a future trial of POCTs for common infections in South Africa. Twenty-three primary care clinicians in the Western Cape Metropole were interviewed. Interview transcripts were analysed using thematic analysis. We identified three key themes. These themes focused on clinicians’ views about proposed trial design and novel POCTs, clinicians’ perspectives about trial set-up, and specific trial procedures. Participants were overall positive about the proposed trial and POCTs. Potential issues centred around the limited space and technology available and participant retention to follow-up. Additionally, impact on clinic workload was an important consideration. These insights will be invaluable in informing the design of a feasibility trial of POCTs in this setting.

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Change in the use of diagnostic tests in the management of lower respiratory tract infections: a register-based study in primary care

BJGP Open ◽

10.3399/bjgpopen20x101015 ◽

2020 ◽

Vol 4 (1) ◽

pp. bjgpopen20X101015 ◽

Cited By ~ 1

Author(s):

Anna B Moberg ◽

Olof Cronberg ◽

Magnus Falk ◽

Katarina Hedin

Keyword(s):

Primary Care ◽

Respiratory Tract ◽

Diagnostic Tests ◽

Lower Respiratory Tract ◽

Respiratory Tract Infections ◽

Acute Bronchitis ◽

Antibiotic Prescribing ◽

Lower Respiratory Tract Infections ◽

Tract Infections ◽

Over Time

BackgroundDifferentiating between pneumonia and acute bronchitis is often difficult in primary care. There is no consensus regarding clinical decision rules for pneumonia, and guidelines differ between countries. Use of diagnostic tests and change of management over time is not known.AimTo calculate the proportion of diagnostic tests in the management of lower respiratory tract infections (LRTIs) in a low antibiotic prescribing country, and to evaluate if the use and prescription pattern has changed over time.Design & settingA register-based study on data from electronic health records from January 2006 to December 2014 in the Kronoberg county of south east Sweden.MethodData regarding use of C-reactive protein (CRP), chest x-rays (CXRs), microbiological tests, and antibiotic prescriptions were assessed for patients aged 18–79 years, with the diagnosis pneumonia, acute bronchitis, or cough.ResultsA total of 54 229 sickness episodes were analysed. Use of CRP increased during the study period from 61.3% to 77.5% for patients with pneumonia (P<0.001), and from 53.4% to 65.7% for patients with acute bronchitis (P<0.001). Use of CXR increased for patients with acute bronchitis from 3.1% to 5.1% (P<0.001). Use of microbiological tests increased for patients with pneumonia, from 1.8% to 5.1% (P<0.001). The antibiotic prescription rate decreased from 18.6 to 8.2 per 1000 inhabitants per year for patients with acute bronchitis, but did not change for patients with pneumonia.ConclusionUse of CRP and microbiological tests in the diagnostics of LRTIs increased despite the fact that the incidence of pneumonia and acute bronchitis was stable.

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How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals

Journal of Antimicrobial Chemotherapy ◽

10.1093/jac/dkaa224 ◽

2020 ◽

Vol 75 (9) ◽

pp. 2681-2688 ◽

Cited By ~ 1

Author(s):

Aleksandra J Borek ◽

Sibyl Anthierens ◽

Rosalie Allison ◽

Cliodna A M McNulty ◽

Donna M Lecky ◽

...

Keyword(s):

Primary Care ◽

General Practice ◽

Financial Incentives ◽

Financial Incentive ◽

Antibiotic Prescribing ◽

Telephone Interviews ◽

Local Resources ◽

Additional Funding ◽

General Practices ◽

Competing Priorities

Abstract Background The Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented. Objectives To understand responses to the QP and how it was perceived to influence antibiotic prescribing. Methods Semi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically. Results The findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off. Conclusions CCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation.

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