Abstract
BackgroundAntimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study “Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)” aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components.MethodsA mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data.ResultsUptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use.ConclusionsThe process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population.Trial registrationISRCTN, ISRCTN15061174. Registered 13 July 2018 – Retrospectively registered
Highlights
The process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics
Study design The CHANGE-3 study was conducted as a two-armed cluster-RCT with a practice team intervention and a control group and a regional intervention which addressed the general public through a multi-media awareness campaign
Medical Assistant (MA) had a mean age of 41 years and almost exclusively were female (100% Intervention Group (IG); 98% Control Group (CG))
Summary
About 90% of the used antibiotics are prescribed in ambulatory care, mainly by General Practitioners (GPs) [3], most commonly during 41% of the consultations for acute respiratory tract infections (ARTI) and with 52% of those in accordance with guideline recommendations [4] Such prescribing patterns can be based on a deceptive safety culture and a misinterpretation of patient expectations [5, 6]. The appropriate use of antibiotics has been the topic of health services research in recent years, which has contributed to a growing evidence base regarding effects of educational interventions for physicians These contributions include findings related to peer exchange mechanisms and audit and feedback processes [7], provider-patient communication and shared decision making [8, 9], internetbased training [10] and addressing the complete practice team to optimize organizational processes [11]. A recent systematic review summarized the evidence on the effectiveness of interventions aiming to reduce antibiotic prescriptions in primary care and concluded that generalizability of observed effects of implementation strategies was limited due to heterogeneous designs and outcome measures [12]
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