August, 2011 - SUPPORT Summary of a systematic review | print this article |

Which interventions can improve antibiotic prescription in ambulatory setting?

The unnecessary use of antibiotics in the ambulatory setting can produce increased antimicrobial resistance among bacterial pathogens. This increasing prevalence of antibiotic resistance has led to the use of more expensive and broad spectrum antibiotics, contributing to increasing health care costs.

Numerous strategies to reduce inappropriate use of antibiotics have been implemented by investigators and organizations at the clinician, patient and organization level.

Key messages

  • We are uncertain if clinician educational interventions alone compared with no interventions improve the percentage of patients treated with adequate antibiotics.
  • Clinician education alone may reduce the number of patient visits at which an antibiotic is prescribed.
  • We are uncertain if patient educational interventions alone decrease the proportion of visits at which an antibiotic is prescribed.
  • Clinical outcomes such as hospitalisation rates or mortality and cost effectiveness data have not been reported in the reviews included in this summary.

 

Background

Antibiotic resistance is a serious problem for individual patients and health care systems. The excessive use of antibiotics, particularly in ambulatory practice, has markedly increased antimicrobial resistance (AMR) among community acquired bacterial infections (Streptococcus pneumoniae, Staphylococcus aureus and Escherichia coli) warranting consideration of modifying empiric antibiotic treatment for patients with suspected infections.

One approach to reducing the incidence of infections due to antibiotic resistant organisms is to reduce the inappropriate use of antibiotics, but changing physician behavior requires identifying and addressing barriers to change in practice. Multiple interventions have been implemented to achieve this, such as educational interventions alone or combined with audit and feedback, patient education or others.




About the systematic review underlying this summary

 

Review objectives: To evaluate strategies to reduce unnecessary antibiotic prescribing in outpatient practice,to quantitatively compare the effect of strategies targeting clinicians, patients and/or health care systems.
Type of What the review authors searched for What the review authors found
Interventions RCTs, CBAs or ITS that evaluate interventions to reduce unnecessary prescription of antibiotic for acute non bacterial illnesses using one of the following interventions: clinician and patient education,audit and feedback, clinician reminders and decision support systems, financial and regulatoryincentives and provision of delayed prescriptions.
Twenty four trials from 23 studies tested an intervention using at least 2 distinct quality improvement (QI)strategies: clinician education combined with patient education (12 trials), clinician education combined with audit and feed back (6 trials),and clinician education combined with both patient education and audit and feedback (4 trials).The remaining 24 trials used a single QI strategy, most commonly clinician education (12 trials) or patient education (7 trials).
Participants Clinicians, patients, health care system
Patients were adults and children with respiratory infection and clinicians were most from primary care setting.
Settings Outpatient setting
17 studies were performed in the United States and 12 studies in Europe. Nearly all studies took place in outpatient primary care clinics (N= 40 studies), and the majority focused on prescribing for acute respiratory infections (N= 38 studies).
Outcomes Proportion of patients visits at which antibiotic was prescribed
Thirty trials (from 20 studies) reported changes in the proportion of visits at which patients were prescribed antibiotics
Date of most recent search: March 2007
Limitations: This is a systematic review with major limitations. There is not report of risk of bias of individual studies.

 

 

Michael A. Steinman, Sumant R. Ranji, Kaveh G. Shojania, Improving Antibiotic Selection: A Systematic Review and Quantitative Analysis of Quality Improvement Strategies. Med Care 2006; 44: 617–628

Ranji SR, Steinman M, Shojania K and Gonzalez R. Interventions to Reduce Unnecessary Antibiotic Prescribing. A Systematic Review and Quantitative Analysis. Med Care 2008;46: 847- 862

Summary of findings

This summary has been done based on two systematic reviews: Steinman 2006 evaluated interventions that improve the prescription of recommended antibiotics. It included 26 studies, reporting 33 trials. Most of the studies assessed interventions focused on clinicians.

Ranji 2008 assessed the effectiveness of quality improvement (QI)strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often prescribed inappropriately. It included 43 studies, reporting 55 trials. 5 studies were included in both reviews.

 1) Clinician Education alone vs. No intervention

Clinician Education included interventions such as: distribution of materials, educational meetings, educational outreach and educational workshops with or without guideline distribution.

In Steinman el at, 11 trials were included that assess this intervention. All of them were done in high income countries. In Ranji et al, 10 trials were included, only one of these studies was also included in Steinman review. 7 of these studies were developed in low and middle income countries (Cuba, Indonesia, Zambia, South Africa and Sri Lanka).

  •  It is uncertain if educational interventions directed to clinicians alone improve the percentage of patients treated with adequate antibiotics Clinician education alone may reduce the number of patient visits at which an antibiotic is prescribed. Clinical outcomes such as hospital admission and mortality were not reported in the reviews included in this summary.

Clinician education alone vs. no intervention

Patient or population:  clinicians.
Settings
:  ambulatory clinics in US, Cuba, Indonesia, Belgium, Sweden, Zambia, Sri Lanka, Australia.
Intervention
educational strategies (outreach visits distribution of materials, workshops).
Comparison
:no intervention. 
Outcomes Median of means (Interquartile range)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Proportion of patients treated with the adequate antibiotic1
13.9 % (8.6%- 21.6%)

11 studies1

Very low
Positive values mean intervention is better than comparator.
Reduction of patient visits at which an antibiotic was prescribed2
9% (8.2%-13%)
10 studies

low

Positive values mean intervention is better than comparator
Clinical (hospitalization admission rate, mortality) No data reported      

p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page)

1: Steinman 2006

2: Ranji 2008


2) Clinician Education + other interventions vs. No Intervention

In Steinman el at, 8 trials were included that assess clinician educational interventions + audit and feedback. All of them were done in high income countries.

In Ranji et al, 3 trials assessed clinician education + audit and feedback + patient education. These 3 studies were developed in high income countries too.

  • Clinician educational interventions plus audit and feedback compared with no interventions may improve the proportion of patients treated with adequate antibiotics. The quality of this evidence was low.
  • It is uncertain if clinician education plus audit and feedback plus patient education decreases the number of patient visits at which an antibiotic is prescribed.Clinical outcomes such as hospital admission and mortality were not reported.

Clinician education + other interventions vs. No intervention

Patient or populationclinicians, patients
Settings
ambulatory clinics in US, The Netherlands, UK, Sweden, Australia, Mexico
Intervention
educational strategies (workshops, group educational outreach) with feedback or with feedback and patient education
Comparison
no intervention.
Outcomes (Median and IQ range)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Proportion of patients treated with the adequate antibiotic1
3.4 % (1.8%- 9.7%)

8 studies1

Low

Intervention is clinician education + audit and feedback
Reduction of patient visits at which an antibiotic was prescribed2
11% (10-5%- 17%)
3 studies2
Very low
Intervention is clinician education+ audit and feedback+ patient education
Clinical outcomes Not reported      
p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page)

1: Steinman 2006 

2: Ranji 2008


2) Patient Education Alone vs. No Intervention

Only Ranji et al. reports results for this comparison. 6 trials were included, 5 studies were done in the USA and implemented written educational material to patients; there is one study conducted in Cuba using patient educational meetings.

  • It is uncertain if patient education alone decreases the proportion of patient visits at which an antibiotic is prescribed.
  • Clinical outcomes such as hospital admission and mortality were not reported.

Patient education alone vs. No intervention

Patient or population: patients.
Settings
: ambulatory clinics, USA, Cuba. 
Intervention
: educational strategies (written, meetings)
Comparison
: no intervention.
Outcomes (Median and IQ range)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Reduction of patient visits at which an antibiotic was prescribed1
7.5% (3.5%-13%)

6 studies2

Very low
Positive values mean intervention is better than comparator
Clinical outcomes
Not reported



p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page)

1: Ranji 2008


 


 


 

 

 

 

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

The 2 reviews included in this summary covered an extensive range of settings and interventions developed in several countries. Only one review includes trials conducted in low and middle income countries.

Overall, strategies assessed result in small improvement in antibiotic prescription.

Correct use of antibiotic by patients will depend upon several other issues than physician prescription: country regulatory policies about sell and dispensing of these drugs, self medication habits of patients, access to health care, importance of unregulate market for these drugs.
EQUITY
Some of the studies that provide evidence about effect of clinician education alone were conducted in LMICs, but they do not provide information about differential effect in disadvantage populations
Strategies that improve rational use of antibiotic could help decrease some health costs and consequently could contribute to decreease some inquities in health. This is specially true in countries were medicines are financed importantly with out of pocket money
ECONOMIC CONSIDERATIONS

The reviews reported in this summary do not report costs outcomes

 

  • There is not evidence about the impact in health systems of low and middle income countries in terms of costs and cost effectiveness of educational interventions to improve proper use of antibiotics

 


The cost of interventions is likely to be highly variable and must be estimated based on specific local conditions

These interventions could save costs arising from unnecessary medication and treatment of drug resistant strains among others. Evidence from cost effectiveness studies is needed

It is necessary to assess the impact on health system costs considering the savings derived by the correct use of antibiotic and the expenses needed to implement interventions in low and middle income enviroment

MONITORING & EVALUATION

Reviews reported a high uncertainty about effects of interventions to increase rational use of antibiotics

 

 

  • Results reported in the included studies have been observed for specific health conditions (mainly antibiotics in respiratory infection) and include numerous types of interventions

 

More adequate studies (maybe good quality cluster randomised control trials) are required to increase certainty of effect of interventions to improve rational use of antibiotic in ambulatory setting

 

  • Use of strategies to increase rational use of antibiotic should be monitorised.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm


 

Additional information

Related literature

Holloway K and van Dijk L. The World Medicine Situation 2011. Rational Use of Medicines. WorldHealth Organization 2011. Available on http://apps.who.int/medicinedocs/en/d/Js18064en/

This summary was prepared by

Penaloza B. Pontificia Universidad Catolica de Chile.

Conflict of interest

Non declared. For details, see: www.support-collaboration.org/summaries/coi.htm.

Acknowledgements

This summary has been peer reviewed by: [Name, Country;]

This summary should be cited as

Penaloza B. Which interventions can improve antibiotic use in ambulatory setting?.. A SUPPORT Summary of a systematic review. May 2013. www.support-collaboration.org/summaries.htm.

Keywords

All Summaries:

evidence informed health policy, evidence based, systematic review, health sys-tems research, health care, low and middle income countries, developing countries, primary health care quality improvement, antibiotic prescribing,

 



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