Faculty Opinions recommendation of Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: A randomized clinical trial.

BackgroundIn 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%–23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015–2016.AimTo investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing.Design & settingLongitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016.MethodLinear generalised estimating equations models were fitted, examining the effect of the 2015–2016 QP on the number of antibiotic items per specific therapeutic group age–sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation.ResultsAntibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015–2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015–2016 QP compared with other practices (interaction p<0.001).ConclusionIn high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care.

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Investigating the mechanism of impact of the Quality Premium initiative on antibiotic prescribing in primary care practices in England: a study protocol

BMJ Open ◽

10.1136/bmjopen-2019-030093 ◽

2019 ◽

Vol 9 (8) ◽

pp. e030093 ◽

Cited By ~ 3

Author(s):

Philip Emeka Anyanwu ◽

Sarah Tonkin-Crine ◽

Aleksandra Borek ◽

Ceire Costelloe

Keyword(s):

Primary Care ◽

Least Square ◽

System Level ◽

Health Concern ◽

Ethical Review ◽

Antibiotic Prescribing ◽

Care Practices ◽

The Uk ◽

Mechanism Of Impact ◽

Primary Care Practices

IntroductionThe persistent development and spread of resistance to antibiotics remain an important public health concern in the UK and globally. About 74% of antibiotics prescribed in England in 2016 was in primary care. The Quality Premium (QP) initiative that rewards Clinical Commissioning Groups (CCGs) financially based on the quality of specific health services commissioned is one of the National Health Service (NHS) England interventions to reduce antimicrobial resistance through reduced prescribing. Emerging evidence suggests a reduction in antibiotic prescribing in primary care practices in the UK following QP initiative. This study aims to investigate the mechanism of impact of this high-cost health-system level intervention on antibiotic prescribing in primary care practices in England.Methods and analysisThe study will constitute secondary analyses of antibiotic prescribing data for almost all primary care practices in England from the NHS England Antibiotic Quality Premium Monitoring Dashboard and OpenPrescribing covering the period 2013 to 2018. The primary outcome is the number of antibiotic items per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU) prescribed monthly in each practice or CCG. We will first conduct an interrupted time series using ordinary least square regression method to examine whether antibiotic prescribing rate in England has changed over time, and how such changes, if any, are associated with QP implementation. Single and sequential multiple-mediator models using a unified approach for the natural direct and indirect effects will be conducted to investigate the relationship between QP initiative, the potential mediators and antibiotic prescribing rate with adjustment for practice and CCG characteristics.Ethics and disseminationThis study will use secondary data that are anonymised and obtained from studies that have either undergone ethical review or generated data from routine collection systems. Multiple channels will be used in disseminating the findings from this study to academic and non-academic audiences.

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Does practice characteristics explain the impact of a financial incentive on antibiotic prescribing?

European Journal of Public Health ◽

10.1093/eurpub/ckz185.287 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Cited By ~ 1

Author(s):

P Anyanwu ◽

C Costelloe

Keyword(s):

Primary Care ◽

Financial Incentive ◽

Antibiotic Prescribing ◽

Incentive Scheme ◽

Practice Characteristics ◽

Care Practices ◽

Primary Care Practices ◽

The Impact ◽

Specific Health

Abstract Background About 80% of the antibiotics prescribed in England are from primary care practices. The Quality Premium (QP) initiative that offers financial rewards on the quality of specific health services commissioned is one of the NHS England interventions to reduce antimicrobial resistance through reduced prescribing. Evaluations of the initiative suggest a reduction in antibiotic prescribing in primary care. We investigated whether the effect of this financial incentive on antibiotic prescribing is explained by variations in practice characteristics that can contribute to differences in antibiotic prescribing. Methods We used monthly prescribing data for 6,600 practices in England from NHS Digital for the year from April 2015 when antibiotic improvement was included as a QP priority and the preceding year. We fitted an initial linear generalised estimating equations model examining the effect of the incentive on antibiotic items/STAR-PU prescribed, adjusting for seasonality and number of months since implementation. We examined the consistency of the effect after the initial model was adjusted for variations in workforce, prevalence of co-morbidities (asthma, COPD, cancer, chronic kidney disease, diabetes), and deprivation index. Results Antibiotics prescribed in primary care practices in England reduced by 0.20 items/STAR-PU (95% CI:0.19-0.21) after the implementation of the initiative. This reduction flattened off in the following months with a month-on-month increase of 0.013 items (95% CI:0.012-0.013). After adjusting for practice characteristics, the immediate and month-on-month impacts remained consistent with slight attenuation of the immediate impact (0.18, 95% CI:0.17-0.18). Subgroup analyses showed the effect of the initiative was significantly more among 20% top prescribers. Conclusions Variations in practice characteristics are not a major explanation for the impact of the quality premium initiative on antibiotic prescribing in primary care practices in England. Key messages Our findings on the targeted impact of a financial incentive scheme to improve antibiotics prescribing on high prescribers are important to policymakers and antibiotic stewardship programs. Variations in practice characteristics are not a major explanation for the impact of a financial incentive scheme on antibiotics prescribing in primary care practices in England.

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Variability in the Diagnosis and Treatment of Group A Streptococcal Pharyngitis by Primary Care Pediatricians

Infection Control and Hospital Epidemiology ◽

10.1017/s0899823x00194036 ◽

2014 ◽

Vol 35 (S3) ◽

pp. S79-S85 ◽

Cited By ~ 3

Author(s):

Julie L. Fierro ◽

Priya A. Prasad ◽

A. Russell Localio ◽

Robert W. Grundmeier ◽

Richard C. Wasserman ◽

...

Keyword(s):

Primary Care ◽

Streptococcal Pharyngitis ◽

Diagnosis And Treatment ◽

Pediatric Primary Care ◽

Antibiotic Prescribing ◽

Acute Pharyngitis ◽

Significant Variability ◽

Group A ◽

Care Practices ◽

Primary Care Practices

Objective.To compare practice patterns regarding the diagnosis and management of streptococcal pharyngitis across pediatric primary care practices.Design.Retrospective cohort study.Setting.All encounters to 25 pediatric primary care practices sharing an electronic health record.Methods.Streptococcal pharyngitis was defined by an International Classification of Diseases, Ninth Revision code for acute pharyngitis, positive laboratory test, antibiotic prescription, and absence of an alternative bacterial infection. Logistic regression models standardizing for patient-level characteristics were used to compare diagnosis, testing, and broad-spectrum antibiotic treatment for children with pharyngitis across practices. Fixed-effects models and likelihood ratio tests were conducted to analyze within-practice variation.Results.Of 399,793 acute encounters in 1 calendar year, there were 52,658 diagnoses of acute pharyngitis, including 12,445 diagnoses of streptococcal pharyngitis. After excluding encounters by patients with chronic conditions and standardizing for age, sex, insurance type, and race, there was significant variability across and within practices in the diagnosis and testing for streptococcal pharyngitis. Excluding patients with antibiotic allergies or prior antibiotic use, off-guideline antibiotic prescribing for confirmed group A streptococcal pharyngitis ranged from 1% to 33% across practices (P < .001). At the clinician level, 13 of 25 sites demonstrated significant within-practice variability in off-guideline antibiotic prescribing (P ≤ .05). Only 18 of the 222 clinicians in the network accounted for half of all off-guideline antibiotic prescribing.Conclusions.Significant variability in the diagnosis and treatment of pharyngitis exists across and within pediatric practices, which cannot be explained by relevant clinical or demographic factors. Our data support clinician-targeted interventions to improve adherence to prescribing guidelines for this common condition.

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General practitioners’ accounts of negotiating antibiotic prescribing decisions with patients: a qualitative study on what influences antibiotic prescribing in low, medium and high prescribing practices

BMC Family Practice ◽

10.1186/s12875-019-1065-x ◽

2019 ◽

Vol 20 (1) ◽

Cited By ~ 4

Author(s):

Marieke M. van der Zande ◽

Melanie Dembinsky ◽

Giovanni Aresi ◽

Tjeerd P. van Staa

Keyword(s):

Public Health ◽

Primary Care ◽

General Practitioners ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Structured Interviews ◽

North West ◽

Care Practices ◽

Primary Care Practices ◽

Supportive Practice

Abstract Background Antimicrobial resistance (AMR) is high on the UK public health policy agenda, and poses challenges to patient safety and the provision of health services. Widespread prescribing of antibiotics is thought to increase AMR, and mostly takes place in primary medical care. However, prescribing rates vary substantially between general practices. The aim of this study was to understand contextual factors related to general practitioners’ (GPs) antibiotic prescribing behaviour in low, high, and around the mean (medium) prescribing primary care practices. Methods Qualitative semi-structured interviews were conducted with 41 GPs working in North-West England. Participants were purposively sampled from practices with low, medium, and high antibiotic prescribing rates adjusted for the number and characteristics of patients registered in a practice. The interviews were analysed thematically. Results This study found that optimizing antibiotic prescribing creates tensions for GPs, particularly in doctor-patient communication during a consultation. GPs balanced patient expectations and their own decision-making in their communication. When not prescribing antibiotics, GPs reported the need for supportive mechanisms, such as regular practice meetings, within the practice, and in the wider healthcare system (e.g. longer consultation times). In low prescribing practices, GPs reported that increasing dialogue with colleagues, having consistent patterns of prescribing within the practice, supportive practice policies, and enough resources such as consultation time were important supports when not prescribing antibiotics. Conclusions Insight into GPs’ negotiations with patient and public health demands, and consistent and supportive practice-level policies can help support prudent antibiotic prescribing among primary care practices.

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