Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study.

Philip Emeka Anyanwu,Aleksandra Borek,Susan Hopkins,Céire Costelloe,Benedict W J Hayhoe,Michael Moore,Monsey Mcleod,Koen Pouwels,Anne Walker,Sarah Tonkin-Crine,Azeem Majeed

doi:10.3399/bjgpopen20x101052

Abstract

BackgroundIn 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%–23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015–2016.AimTo investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing.Design & settingLongitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016.MethodLinear generalised estimating equations models were fitted, examining the effect of the 2015–2016 QP on the number of antibiotic items per specific therapeutic group age–sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation.ResultsAntibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015–2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015–2016 QP compared with other practices (interaction p<0.001).ConclusionIn high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care.

Highlights

The overuse of antibiotics drives resistance through the selection of antibiotic-resistant strains of organisms.[1,2,3] Primary care is the main contributor to antibiotic usage in England, constituting approximately 73% of antibiotics prescribed in 2017.4 It is estimated that 9%–23% of antibiotic prescriptions in primary care practices in England between 2013 and 2015 were inappropriate, which is based on prescribing guidelines.[5]Antibiotic prescribing is recommended in the management of respiratory tract infections (RTIs) in some patients, including older patients with diabetes or heart failure, who are considered at particular risk of developing complications.[6]
In high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the Quality Premium (QP) compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care
The QP has previously been associated with reductions in antibiotic prescribing in primary care practices in England

Summary

Introduction

The overuse of antibiotics drives resistance through the selection of antibiotic-resistant strains of organisms.[1,2,3] Primary care is the main contributor to antibiotic usage in England, constituting approximately 73% of antibiotics prescribed in 2017.4 It is estimated that 9%–23% of antibiotic prescriptions in primary care practices in England between 2013 and 2015 were inappropriate, which is based on prescribing guidelines.[5]Antibiotic prescribing is recommended in the management of respiratory tract infections (RTIs) in some patients, including older patients with diabetes or heart failure, who are considered at particular risk of developing complications.[6]. Several approaches have been adopted to reduce primary care antibiotic prescribing in England including: increased surveillance and prescribing feedback; the provision of C-reactive protein point- of-care testing; education and training interventions targeted at prescribers and patients; public antimicrobial stewardship (AMS) campaigns; and financial incentives.[9,10] The QP is an NHS England performance-related incentive scheme established in 2013 to reward CCGs financially, based on the quality of specific health services considered to be national or local priorities and commissioned over a specific period.[9] Individual GP practices did not receive financial remuneration in relation to this award. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015–2016

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