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

2. „ 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

3. Background 2007 – Cochrane guidelines
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

4. Participation of ATC group J01 in total DDD drugs prescriptions covered by HIFM in community ( *)
Total DDD
DDD for J01

5. Background
RM- Estimated 100% consumption
RM- Reimbursement data

6. 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)

7. 440 GPs registered consultations; before the intervention (2008) and 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%.

8. 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

9. 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

10. 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): doi: /j.eimc
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.

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

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

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

14. Specialization
45% versus 70%

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

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

17. Lab tests

18. 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

19. 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

20. 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)

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

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

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

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

25. Reasons for prescription%

26. Lab test %

27. 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

28. 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

29. 2 Symposium: Antibiotics in Primary Care November 2016, Skopje