Abstract
ObjectivesThis study sought to assess the effectiveness and return on investment (ROI) of a multifaceted intervention aimed at improving antibiotic prescribing for acute respiratory infections in primary care.DesignLarge-sized, two-arm, open-label, pragmatic, cluster-randomised controlled trial.SettingAll primary care physicians working for the Spanish National Health Service (NHS) in Galicia (region in north-west Spain).ParticipantsThe seven spatial clusters were distributed by unequal randomisation (3:4) of the intervention and control groups. A total of 1217 physicians (1.30 million patients) were recruited from intervention clusters and 1393 physicians (1.46 million patients) from control clusters.InterventionsOne-hour educational outreach visits tailored to training needs identified in a previous study; an online course integrated in practice accreditation; and a clinical decision support system.Main outcome measuresChanges in the ESAC (European Surveillance of Antimicrobial Consumption) quality indicators for outpatient antibiotic use. We used generalised linear mixed and conducted a ROI analysis to ascertain the overall cost savings.ResultsMedian follow-up was 19 months. The adjusted effect on overall antibiotic prescribing attributable to the intervention was − 4.2% (95% CI: − 5.3% to − 3.2%), with this being more pronounced for penicillins − 6.5 (95% CI: − 7.9% to − 5.2%) and for the ratio of consumption of broad- to narrow-spectrum penicillins, cephalosporins, and macrolides − 9.0% (95% CI: − 14.0 to − 4.1%). The cost of the intervention was €87 per physician. Direct savings per physician attributable to the reduction in antibiotic prescriptions was €311 for the NHS and €573 for patient contributions, with an ROI of €2.57 and €5.59 respectively.ConclusionsInterventions designed on the basis of gaps in physicians’ knowledge of and attitudes to misprescription can improve antibiotic prescribing and yield important direct cost savings.Trial registration: Current Controlled Trials ISRCTN24158380. Registered 5 February 2009.
Highlights
Antibiotic-resistant pathogens have emerged and spread worldwide, to the point that they pose a major public health threat [1, 2]
Interventions designed on the basis of gaps in physicians’ knowledge of and attitudes to misprescrip‐ tion can improve antibiotic prescribing and yield important direct cost savings
Study population The study population comprised all primary care physicians working at primary care health centres operated by the Spanish National Health Service (NHS) in Galicia at the date of study (N ≅ 3673).The following were excluded: (1) temporary staff and medical residents in training, since such persons register very low prescribing levels for short periods, and including them might generate numerical instability in the indicators assessed; and, (2) physicians exclusively assigned to emergencies, since they do not have a designated number of listed patients, rendering it impossible to calculate indicators that require the number of patients attended as their denominator
Summary
Antibiotic-resistant pathogens have emerged and spread worldwide, to the point that they pose a major public health threat [1, 2]. This loss of efficacy against common pathogens has increased morbidity, mortality and health care costs [3, 4] in low- and high-income countries alike. Most antibiotic prescriptions are issued to outpatients: [5] in 2011, non-hospital antibiotic use in the Spanish National Health Service (NHS) in Galicia totalled 20.9 defined daily doses (DDD) per 1000 inhabitants per day [6]. While the reasons for this divergence between evidence-based guidelines and general practitioners’ prescribing behaviour are not clear, [10] they are crucial when it comes to designing strategies to help improve antibiotic prescribing [11]
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