1. CHAMP Physician Education is Essential in Improving Antibiotic Use in Primary Care: review of behavioural interventions Alike van der Velden Marijke Kuyvenhoven Denise de Ridder, Paul Little Theo Verheij Julius Center for Health Sciences and Primary Care University Medical Center Utrecht The Netherlands

2. Respiratory Tract Infections and Antibiotics  Mostly viral and self-limiting  Effect of antibiotics is limited to negligible  Over-prescription of antibiotics resistance patients’ re-consultation unnecessary exposure to adverse effects unnecessary costs  Guidelines on ‘appropriate antibiotic treatment of infectious diseases’ appeared not sufficient to restrict antibiotic prescribing

3. Use of Antibiotics in Europe Large variation in antibiotic use within Europe European differences with respect to:  primary care organisation guidelines use of diagnostic tests  physicians’ habits prescribing for tonsillitis, otitis media  OTC selling of antibiotics  patient-related factors beliefs, knowledge antibiotics accepting self-limitedness consultation behaviour common cold: 50% (France), 1.2% (t N)  influence pharmaceutical companies

4. CHAMP Sixth Framework Programme: United Kingdom, Belgium, Switzerland, the Netherlands Poland, Italy, Spain Changing behaviour of health care professionals and the general public towards a more prudent use of anti-microbial agents

5. CHAMP: Work Package 4, part 1 and 2 Method: Systematic review of behavioural interventions targeted at: primary care physicians primary care patients Aim: To determine the effectiveness of interventions aiming to improve antibiotic use for respiratory tract infections in primary care

6. Interventions aimed at primary care physicians Literature review MEDLINE, EMBASE, Cochrane 1990-2010 high-income countries Outcomes targets, intervention type and elements effective intervention: - significant decrease in total antibiotic prescription, or - significant increase in 1 st choice prescription effectiveness: difference measurements in terms of percentages

7. Interventions aimed at p.c. physicians: characteristics Inclusion of 58 studies, describing 87 interventions  77%: multiple  40%: more targets  most often used intervention elements:  educational material physician (70%)  educational meetings (56%)  educational material patients (40%)  audit/feedback (37%)  new intervention elements:  training communication skills (9%)  near-patient testing (8%)

8. I nterventions aimed at p.c. physicians : effectiveness Effectiveness: 1) frequency 2) differences measurements (%)  Interventions aimed at decreasing overall prescription are more often effective and have higher effectiveness than interventions aimed at increasing 1 st choice prescription total AB ↓ (n=59) 1 st choice AB ↑ (n=28) effective interventions 1 43 (73%)9 (32%) mean effectiveness 2 -11.6% (-72% – 19%)9.6 (-5% – 41%)

9. I nterventions aimed at p.c. physicians : determinants of effective interventions characteristics ‘multiple intervention’OR: 6.5 (2 - 22) ‘more targets’OR: 1.4 (0.4 - 5) elements ‘educational material physician’OR: 5.5 (1.7-18) ‘educational meeting’OR: 2.1 (0.7 -7) ‘educational material patients’OR: 1.4 (0.4 -5) ‘audit/feedback’OR: 0.5 (0.2 -2)  no significant added value was found from adding ‘educational material patients’ or ‘audit/feedback’ to physician education promising elements:‘training communications skills’ ‘near-patient testing’

10. I nterventions aimed at p.c. patients: characteristics and effectiveness Meta-analysis: 33 patient-oriented interventions to promote prudent use of antibiotics  Outcomes:- cognitive (attitudes, knowledge) - antibiotic use - patients’ satisfaction  Results:- very small positive effect on cognitive outcomes - moderate effect on antibiotic use:  ‘delayed’ or ‘refused’ prescription  education, information material were not effective - no effect on patients’ satisfaction  Importance and central role of the general practitioner in reducing use of antibiotics

11. First steps towards prudent use of antibiotics  primary care guidelines  monitoring prescription and use of antibiotics Educating primary care physicians:  enhancing knowledge and awareness of antibiotics and related problems  increasing the impact of the intervention: - delayed or refused prescription requires communication with patients - training in communication skills supplemented with patient information material - near-patient testing diagnostic uncertainty, communication