The practice developed and implemented a programme based on management of common respiratory tract infections and informed by NICE CG69: Antibiotic prescribing for self-limiting respiratory tract infections in adults and children. The example also demonstrates Quality Standard 121: Antimicrobial Stewardship Statement 1: ' People with a self-limiting condition, as assessed by a primary care prescriber, receive advice about self‑management and adverse consequences of overusing antimicrobials' in practice.
Consistent messages were prepared for clinicians and patients and implemented via a range of media. The practice was able to document a 15% reduction in antibiotic prescribing for respiratory tract infections within three months.
This example was shortlisted and won the 2014 NICE Shared Learning Awards.
Aims and objectives
The aim was to introduce a consistent set of messages based on the NICE respiratory tract infections (RTI) guidelines. Clinicians, staff and patients would have the best evidence available to give them the confidence to manage common respiratory tract infections effectively. This would mean that patients could treat these conditions at home rather than having to attend surgery. An important element of this approach is ensuring that all three groups also recognise the circumstances where a visit to surgery is essential.
Messages were presented in the form of leaflets, posters, waiting room flat screen messages, summaries of evidence and, most importantly, in short positive messages to patients that clinicians could give with confidence. A multidisciplinary team was responsible for development and implementation and the messages were disseminated to the whole practice.
Reasons for implementing your project
The evidence demonstrating the lack of efficacy of ampicillin in treating acute bronchitis in hospital patients was first presented 48 years ago in 1965. Since then a vast amount of sound research has demonstrated a similar lack of efficacy for antibiotic treatment of most common respiratory tract infections. This was very effectively collated and summarised in the NICE RTI guidelines in 2008. Yet successive waves of new GPs have continued to prescribe. Elsewhere we implement evidence based medicine with enthusiasm for other conditions but ignore it for these common, self-limiting conditions.
It is also recognised that many families no longer have an extended network of relatives or the support of a religious community to turn to in times of illness. With the wildly conflicting messages on the internet, patients have continued to turn to GPs for advice even when aware that little can be done. GPs have felt pressured to prescribe. This has resulted in an infantilisation of patients, left dependent on provision of an ineffective treatment that in 15-25% of patients results in harm.
GPs have been prescribing in the knowledge that their treatment is ineffective. Despite this, there have been few attempts to measure the effectiveness of systematic programmes to change to evidence based behaviours. We decided that at Churchill Medical Centre we would develop and introduce a permanent process of provision of consistent evidence to produce a measurable reduction in prescribing for common respiratory tract infections.
Our starting point was NICE CG69: Respiratory tract infections: Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. Delayed prescribing is an important element of the advice given in the 2008 guidelines. A prescription can be given and a patient advised it is not yet necessary. Scenarios are described in which it might be. Around 70% of these prescriptions are not dispensed and that there is a lower level of reattendance for the same episode of illness. This also avoids confrontation with the occasional very sceptical patient.
Our initial baseline estimates suggested we were still giving antibiotics to around half of our patients with coughs and around a third of those diagnosed as having 'upper respiratory tract infection'. Our average antibiotic provision was around 40%. We were intending reducing this percentage.
How did you implement the project
We set up a small multidisciplinary team to champion the changes and move quickly but involve colleagues as widely as possible.
Developing the messages:
We selected messages from the NICE guideline that could easily and quickly be conveyed by busy GPs to patients. Messages covered duration of illness, strong evidence regarding the inefficacy of antibiotics, how to treat common respiratory tract infections and when to call for help. Delayed prescribing was an important element.
Sharing the positive messages with patients:
All messages had to be positive. Patient were to be congratulated on their efforts at home treatment and given reinforcing instructions and safetynetting advice. Underlying all of these messages was the NICE summary of duration of illnesses and the key message - whether the cause is viral or bacterial, antibiotics are not required for most common infections.
Preparing for dissemination:
We prepared a poster giving the NICE information on duration of symptoms for common illnesses. A copy was posted in each waiting room, each clinical room and included in the flat screen waiting room messages. A copy is attached in the file associated with this submission. The poster and all the subsequent material referred top below is also available on the Self Care Forum website.
Evidence based laminated sheet A laminated sheet providing very basic cast-iron evidence-based messages to give to patients was prepared with the NICE flow chart summary of URTI management on the reverse. A copy was placed in every clinical room (see attached file). Fact sheets Self Care Forum evidence based fact sheets on common conditions were condensed onto single A4 sheets for ease of printing. We prepared our own on otitis media drawing on the NICE 2008 guidelines. The patient information fact sheets sit on every computer desk top. An example fact sheet is included in the attached file. Dissemination of the messages A go-live date was chosen. All possible methods were used to disseminate the messages within the practice, including presenting the scheme and materials at all clinical, management, admin and reception meetings for the month before we went live.
We reduced our prescribing of antibiotics for common respiratory illnesses by 15%. 67 patients avoided unnecessary antibiotics in January 2013. As many as 800 patients will avoid unnecessary antibiotics if this behaviour continues throughout the year. Although not measured, the expectation is that this will reduce the number of attendances and re-attendances.
The messages went live on 'A day'- 1st November 2012. We measured our behaviour during the preceding month and during January 2013. We had asked clinicians to inform us of the Read codes they used to record RTIs. This avoided the learning of unfamiliar Read codes and ensured we were measuring everyday practice.
We compared prescribing rates for all URTI's using the same search criteria for pre and post campaign. For each unique recorded attendance for a respiratory event, we also searched for antibiotic use. We repeated the search during January 2014 and compared the results. Note that we did not exclude delayed prescriptions from this subsequent figure, so actual antibiotics dispensed may have been lower. We also did not exclude any patients, so some of our baseline will have been prescribed evidence based antibiotics.
In October 2012 we saw 355 patients with common respiratory tract infections. An average of 41.7% of patients received an antibiotic.
In January 2013 we saw 438 patients with common respiratory conditions. An average of 26.5% of patients received an antibiotic. 67 patients therefore avoided unnecessary prescribing. Between these periods we reduced prescribing for cough from 54.5% to 37.7% and for 'URTI' from 32.6% to 19.7%. Somewhere between 700 - 800 fewer antibiotic are likely to be prescribed over a whole year. This equates to around 44-50 per 1,000 patients who will benefit if a practice introduces the same programme.
Productivity: Our intention was to implement the best possible medicine and empower patients, but the reduction in prescribing costs if we are to include pharmacy costs is significant. The other equally important improvement in productivity which we may be able to measure over two or three years is the reduction in future attendances.
Key learning points
- These results are eminentyl achievable and your results may be even better if your initial level of prescribing is higher.
- The biggest hurdle was developing the literature. Please use ours!
- Ask for multidisciplinary volunteers - this affects everyone and we had no shortage. Include reception staff.
- Inform everyone.
- Inform them again.
- Follow up with meetings to discuss progress.
- Undertake the simple evaluation we describe - it is so encouraging to receive evidence that the programme has worked.
- A valid criticism of this campaign is that we did not involve patients from the outset. We would certainly recommend this.