1. ARTI 4 Understanding and Optimising Antibiotic Prescribing in Primary Care - 4 successive projects in the Netherlands Alike van der Velden Marijke Kuyvenhoven Theo Verheij Julius Center for Health Sciences and Primary Care University Medical Center Utrecht The Netherlands

2. ARTI (Antibiotics and Respiratory Tract Infections): linking academia to primary care practice

3. Antibiotics and Respiratory Tract Infections RTIs : acute otitis media sinusitis, cold sore throat (tonsillitis, laryngitis) acute cough (bronchitis, pneumonia)  Mostly viral and self-limiting  Effects of antibiotics are limited  Over-prescription of antibiotics resistance patients’ re-consultation unnecessary exposure to adverse effects unnecessary costs

4. Antibiotics in The Netherlands  Comparatively low antibiotic consumption (coinciding with low resistance) 450 treatments / 1000 inhabitants / year France: x3, Greece: x5  No OTC selling  80% is prescribed by general practitioners ► 4 primary care guidelines for treatment of RTIs antibiotics indicated for patients: with a severe RTI with risks of complications (suspected of) pneumonia

5. How does it work in daily practice? time pressure diagnostic uncertainty patients demanding for antibiotics Friday afternoons GPs’ habits GP-patient relationship

6. ARTI 1: insight in antibiotic prescribing Methods: detailed analysis of 2800 consultations for RTIs

7. ARTI 1: Results Antibiotic prescription for RTIs: 37% of consultations prescriptionover-prescription OMA47%5% sore throat30%58% sinusitis, cold35%53% acute cough38%48%  44% of prescriptions are not according to the guidelines: over-prescription is ▪ highest for tonsillitis and bronchitis ▪ associated with- inflammations signs - patients’ wish for an antibiotic

8. ARTI 2 and 3: interventions to optimise antibiotic prescribing ARTI 2: RCT intervention:▪ education GPs (practice level) guidelines, literature, communication ▪ monitoring/feedback prescribing data and behaviour ▪ information material patients outcome: -12% in antibiotic prescribing rate ARTI 3: CBA similar intervention:▪ education to larger groups of GPs ▪ monitoring/feedback prescribing data outcome: no reduction in number of antibiotic prescriptions

9. Implementation: ARTI 4 Antibiotic prescribing practice can be improved Barriers in implementation:- commitment of physicians - sustainability of the effect  embedment within a regular quality assurance cycle: practice accreditation* of the Dutch College of General Practitioners * improving quality in care and organisational structure of primary care practices 3 years cycle:- yearly audit - practice organisation - prescribing routines - chronic disease management - yearly ‘improvement plans’

10. ARTI 4: support and a ready-to-use plan optimising Ab prescription for RTIs reducing (chronic) use of PPIs ARTI 4: Study set-up (I) RCT with 87 primary care practices (1-7 GPs / practice) Ab and PPI practices serve as each others controls Primary outcomes: Antibiotics:Ab prescriptions / 1000 pnts / year % 2 nd choice prescriptions J01 collected via pharmacies Secondary outcomes and feed-back supplied to practices: Antibiotics:prescribing behaviour 4-weeks registration of RTIs Data collection: 1 year preceding intervention, at year 1 and 2

11. ARTI 4 study set-up (II) Multiple intervention educational meeting GPs at practice level - guidelines, literature - feedback on prescription data / behaviour - communication, patients’ pressure  improvement plan practice-specific definition of targets meanrange Ab/1000 pnt/year272140 - 535 % 2 nd choice 28%19% - 43% over-prescription 44% 0% - 67% base-line data

12. Feedback ‘Antibiotics’ during education guidelineprescribeconsiderno Ab prescribed17 not prescribed31 OMA Sore throat Sinusitis guidelineprescribeno Ab prescribed32* not prescribed12 guidelineconsiderno Ab prescribed66* not prescribed26 guidelineprescribeno Ab prescribed87* not prescribed17 Cough

13. Feedback ‘Antibiotics’ after 1 year

14. ARTI 4: intervention effect on antibiotic prescription (n=49) Intervention: Ab (n=25) Control: PPI (n=24) p= % change RTI Ab prescrip/1000 pat -11.9 (-33 – 12) -3.3 (-21 – 29) 0.03 % change 2 nd choice prescrip/1000 pat -13.5 (-56 – 31) +0.9 (-30 – 48) 0.03  ARTI4 intervention significantly reduces antibiotic prescription Goals and future plans: long-term effectiveness of this intervention (2 years) development of internet-based educational programs

15. Questions? Acknowledgements: All Dutch general practitioners involved in one of the projects