„ Can we change doctor’s prescribing antibiotic habits? “

„ Can we change doctor’s prescribing antibiotic habits? “ Ass Prof Katarina Stavrikj Center for Family Medicine, Medical Faculty Skopje, Macedonia In colaboration with Valentina Risteska Nejashmikj, Radmila Ristovska , Irena Kondova Topuzovska, Vesna Velic

Background 2007 – Cochrane guidelines 2010-2015 National committee for antibacterial resistance 2010 specialization/retraining in FM 2013 HIF-CME education for GP (Treatment of respiratory tract infections) 2014 Agency for medicine, Ministry of health – education of parents in kindergartens Population ~2 million 1500 GP 2007 –gate keeping system 2012 – Department of FM at Medical Faculty Skopje 2014 electronic health records in PHC

Participation of ATC group J01 in total DDD drugs prescriptions covered by HIFM in community (2012-2014*) Total DDD DDD for J01

Background RM- Estimated 100% consumption RM- Reimbursement data

A marked reduction in the use of antibiotics was found in all the countries involved Prescription of antibiotics in patients with RTIs before and after the intervention (2008/2009) HAPPY AUDIT Report- Total results 2008/2009 from 6 countries and 618/511 GPs, 2010 Prescription of antibiotics in patients with RTIs before and after the intervention (2008/2009)

440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithuania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.

Main results: Median intention scores in the intervention groups were reduced, following the educational intervention, in comparison to the control group. High overall acceptance and perceived practicality of the intervention programme by GPs, especially in settings from the East Mediterranean region

27 studies (62%) in primary care reported positive results for all measured outcomes; 14 studies (30%) in primary care reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only 4 studies in primary care failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions

Lalana-JosaP, Laclaustra Mendlizabel B et al. Does the prescribing of antibiotics in paediatrics improve after a multidisciplinary intervention?. Enfem Infecc Microbiol Clin. 2015; 33(2):78-83. doi: 10.1016/j.eimc.2014.05.017. CONCLUSION: Antibiotic prescribing decreased, but there were no statistically significant differences between the two groups. The high satisfaction of paediatricians in the intervention group makes it necessary to continue with these kinds of strategies to improve antibiotic use in outpatients.

E-quality program 2014/2015: Project: Investigation of GPs prescribing habits of antibiotics for acute respiratory tract infections followed by educational intervention

No of patients with ARTI 58% of patients with ARTI are treated with antibiotics

13% cold, 80% tonsilopfaringitis 68% bronchitis are treated with Ab Diagnosis 13% cold, 80% tonsilopfaringitis 68% bronchitis are treated with Ab

Specialization 45% versus 70%

Symptoms Most common symptoms were antibiotic is prescribed sore throat 75% temperature70%

Reasons for prescription 84% by indication, 4% patient pressure 4.4% recommended by specialist

Lab tests

Intervention program Educational intervention group - 50 GP from the first survey (November 2014) participation in the first survey Workshops (2014) Symposium (May 2015) Intervention programme (September/October 2015) Control group - New 50 GP invited from each region

Intervention programme One day educational workshop – (Bitola and Skopje) Clinical guidelines for tonsilopharyngits and bronchitis Access to Point of care tests: (Strep A test and CRP) Communication skills doctor-patient (temperature and cough) Web access to the materials

Knowledge test “The duration of acute cough” is approximately 3 weeks (P=0,006) “A child who has recurrent cough without fever” should be referred to a specialist (P=0,035), “80% of children with AOM recover without AB treatment in 4 days” (P=0,018) “rest in bed, lot of liquids and symptomatic treatment for self-care” (p=0,025)

Prescription of antibiotics 2014/2015 1% reduction in prescription of antibiotics (NS)

Prescription of antibiotics and intervention (2015) 2.2% reduction in antibiotic prescription (NS) Pearson Chi-square=2,94, df=1, p=0,087

Prescription of antibiotics and diagnosis ICD 10 % Significant less prescription of antibiotics for H65, J02.0 and J04.0 * * * * p<0.05

Specialization 13.6% reduction in antibiotic prescription (P<0.05)

Reasons for prescription %

Lab test %

Conclusions Education alone result in non sustainable improvements in antibiotic prescribing 2.2% reduction in antibiotics prescription for RTIs in intervention group 1% reduction in antibiotics prescription for RTIs compared 2014/2015 13.6% reduction in antibiotics prescription for RTIs in specialist in family medicine +CME

Recommendations Educational intervention – Yes – continuous Different educational methods TEAM WORK - Educational strategies + other stewardship strategies (patient education, appointment system, access to point of care, electronic system of antibiotic decision…) Young doctors, trainees – Specialization, on line CME Older GP - CME –face to face education

2 Symposium: Antibiotics in Primary Care November 2016, Skopje