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Direct feedback could cut GP antibiotic prescribing, say researchers

This could add up to overall reduction of 0.85% across England

Caroline White

Friday, 19 February 2016

Sending GPs a letter, giving them feedback on their antibiotic prescribing habits, could cut unnecessary prescriptions of these drugs, finds research* published in The Lancet.

In the first nationwide clinical trial of its kind, giving feedback to GPs with the highest antibiotic prescribing rates cut prescribing by an average of 3.3% over 6 months.

The UK has a target of reducing antibiotic prescribing in primary care by 4% by 2018. The use of behavioural science to help GPs to improve their prescribing is an area of emerging interest to help reach this target.

“We know that drug resistant infections are one of the biggest health threats we face. This innovative trial has shown effective and low cost ways to reduce unnecessary prescribing of antibiotics which is essential if we are to preserve these precious medicines and help to save modern medicine as we know it,” comments Dame Sally Davies, Chief Medical Officer for England and the signatory to the letter.

“We estimate that this simple intervention could reduce England’s antibiotic prescribing by 0.85% overall, despite costing just 6p per prescription saved. This kind of feedback could also be provided for many other kinds of drugs, and by anyone who is interested in doing so, since all this information is publicly available online,” added lead author Michael Hallsworth, of the Behavioural Insights Team, London.

The researchers assessed two mail-based randomly assigned interventions, targeting 1,581 practices across England with antibiotic prescribing rates in the top 20% for their area. In one half of the trial, they sent half the GPs a letter which stated that, “80% of practices in their local area prescribe fewer antibiotics per head than yours”, and set out three simple ways to curb unnecessary prescriptions. The letters were signed by the Chief Medical Officer. The remainder of the GPs did not get the letter.

The second half of the trial tested the effect of an education campaign targeted at patients, which promoted reduced use of antibiotics (posters and leaflets for GP practices).

Over six months in winter 2014-15, GPs who had received the feedback letter cut their rate of antibiotic items dispensed per 1,000 population to 126.98, compared to 131.24 for those who didn’t get the letter.

This is a relative difference of 3.3%, equivalent to 73,406 fewer antibiotic items dispensed.

The material cost of the letters was just £0.06 per prescription prevented, with estimated savings in direct prescribing costs of £92,356. In contrast, there was no significant difference in the rate of antibiotics dispensed for the patient-focused education campaign (135.00 vs 133.98 antibiotic items dispensed per 1,000 of the population).

“This intervention demonstrates two key points,” explained Dr Tim Chadborn, Behavioural Insights Lead Researcher at Public Health England: “the importance of behaviour in protecting the public's health and the cost-effectiveness of the evidence-based behavioural insights approach.”

“Tackling antimicrobial resistance is a priority for Public Health England and we are actively developing the potential for behavioural science to be applied more widely in the coordinated national response to this threat,” he added.

In a linked comment,** Ian Gould from Aberdeen Royal Infirmary and Timothy Lawes from Royal Aberdeen Children’s Hospital, say there is a clear case for integrating behavioural approaches into antibiotic stewardship. But they caution that it is also important to see the effect size in perspective.

They write: “The investigators highlight that their feedback intervention could reduce primary-care prescribing in England by 0·85%, against a 5-year aim of reducing prescribing in primary care by 4%. Between 2000 and 2014, UK primary-care antibiotic use expanded by 46%, from 14·3 to 20·9 defined daily doses per 1,000 inhabitant days. During the same period, antibiotic use fell in several European countries, and UK consumption is now twice that of the Netherlands. Inpatient consumption also continues to increase.”

Dr Maureen Baker, Chair of the Royal College of GPs, said: “GPs can come under huge pressure from patients to prescribe antibiotics, even when we know they are not the best course of action. Our patients need to realise that this is dangerous for each and every one of us, not just 'other people'.”

She added that GPs already undertake regular prescribing reviews, and that reminder letters could be seen as an extension of this. But she cautioned: “it’s important that doctors who receive letters don’t feel overly-criticised as a result. There is nothing to say that doctors who prescribe the most antibiotics are doing so inappropriately; some doctors will prescribe more than others simply as a result of the demographics of their patients.”

* Hallsworth M, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. The Lancet, February 2016. DOI: 10.1016/S0140-6736(16)00215-4

** Gould IM, Lawes T. Antibiotic stewardship: prescribing social norms. The Lancet, February 2016. DOI: 10.1016/S0140-6736(16)00007-6

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