HAPPY AUDIT, L. Bjerrum, March 9 - Grace

Health
Alliance for Prudent
Prescribing,
Yield
se of anti-microbial
Drugs
In n the Treatment
of Respiratory Tract Infections
And
Use
Proposal for EU DG Research, March 2006
Coordinator: Research Unit of General Practice, Odense, Denmark

Research Unit for General Practice
University of Southern Denmark

HAPPY AUDIT
Objective
to reduce the occurrence of bacterial
resistance
by reducing prescribing of unnecessary
antibiotics for respiratory tract infections
by improving the use of appropriate
antibiotics in suspected bacterial
infections
by Improving the quality of diagnostic
procedures for RTIs in general practice

El PAIS, 2001

Correlation between penicillin use and prevalence of resistancy
Gossens et al: Outpatient antibiotic use in Europe and association with resistance: a cross-national database study.
The Lancet 2005

Participation of 450 GPs
12
from 12 regions
Country
Local
No of
Region
partner
GPs
Denmark APOR
1 Funen 100
Sweden BIRD
2 Blekinge 50
Lithuania FDC
3 Klaipeda 30
Russia AFMK
4 Kaliningrad 30
France CPMF
5 Paris 30
Spain SEMFYC
6 Madrid 30
7 Catalonia 30
8 Valencia 30
9 Andalusia 30
10 Galicia 30
11 Gran Canaria 30
Argentina 12 Missiones 30
Total 450
10
9
6
5
8
7
1
2
4
3
11

Facts:
Antibiotic treatment in general practice
GPs are responsible for >90% of all prescriptions
of antibiotics in most countries
The majority of prescriptions are for patients with
respiratory tract infections
Most respiratory tract infections are caused
by virus
Most respiratory infections are not dangerous
Very few respiratory infections are serious or
life threatening
Only few respiratory infections need acute
treatment
Most prescriptions are issued for fear of
serious infections – “just for sake”
Overuse of antibiotics may lead to increased
number of resistant bacteria

Distribution of focus for
infections in General Practice
Eyes
11%
Gyn
5%
GI
1%
Skin
12%
Urine
12%
Respiratory Tract
60%
Bronchii
11%
Lungs
7%
Ears
8%
Sinuses
12%
Tonsils
17%
Other
4%

Some characteristics of Primary health
care in participating countries
Time allocated for a consultation
Nordic countries: 10-15 15 minutes
Spain 5-65
6 minutes
Diagnostic test in patients with
respiratory tract infections
Nordic countries: StrepA, CRP
Spain, France: No tests
Antibiotic treatment
Nordic countries
Narrow spectrum penicillin
represents >50% of all
prescriptions
Spain, France
Narrow spectrum penicillin are
hardly not used

Different practice organization in
Practice organization
Denmark
participating countries
GPs are independent
professionals working on a
contractual base with the
government (county)
GPs are owners of practice
Group practices of 2-42
4 GPs
Solo practices
Spain
GPs are employed by the NHS
Health centres with 20-30 GPs
per centre

Different pattern of contact to
Denmark, Sweden:
General Practice
The GP represents the point of
first encounter for >95% of
people suffering health problems
Spain, France
Patients can contact other
specialist directly
Denmark, Sweden
GPs are responsible for >90% of
all prescriptions issued
Spain, France
GPs are responsible for the
majority of prescriptions, but
patients may also get antibiotics
from:
“Under the counter”
prescriptions
Other specialists

Audit Project
Odense (APO)
Organised as a quality development program within
the Research Unit of General Practice, University of
Southern Denmark
Financed by research grants combined with fees for
services
Has activities in all Danish counties and all Nordic
countries, incl. Greenland and The Faroe Islands
Aims to combine well-known postgraduate training
methods with a view to effectively implementing
guidelines and new knowledge in general practice
It is based on simple prospective self-registration
It is voluntary

The APO method: A simple and practical method for quality
development in primary care

Number of consultations today:
Registration date:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
sex
day month year
%
Infection focus
only 1 x
1 - 3 x
3 4 5 6 7 8 9 10 11 12 13 16
only 1 x
only 1 x
min. 1 max. 7 x
30
only 1 x
Remarks
Copyright: Audit Projekt Odense, Winsløwparken 19 - 5000 Odense C, DK
Number of consultations today:
Registration date:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
day
sex
month year
%
Type of
contact Infection focus
form
only 1 x only 1 x only 1 x
1 - 3 x
3 4 5 6 7 8 9 10 11 12 13 16
only 1 x
only 1 x
min. 1 max. 7 x
30
Certificate
(sick-leave)
only 1 x
Remarks
Copyright: Audit Projekt Odense, Winsløwparken 19 - 5000 Odense C, DK
% af regi streringer
100%
75%
50%
25%
0%
Nor mal t
O TOS KO PIFUN D
Pat ologi sk
norm al undertry k flad kurve andet ubrugel ig
The Audit circle:
GP:
0 1
AUDIT: Respiratory Infections in General Practice - 2001
Contact
Diagnosis and
treatment
Infection Antibiotic
origin treatment
Choice of antibiotics
Date of Birth
Total
␇ 1 2 3 4 5 11 14 15 17 18 19 20 21 22 23 24 25 26 27 28 29 31 32 33
First pilot
First registration
TYMPANOMETRIFUND RELATERET TIL OTOSKOPI FUND
Project group
First follow-up meeting
Idea
Analysis of
quality problems
Implementation strategy
Final courses
and evaluation
GP:
0 1
Date of Birth
Total
AUDIT: Respiratory Infections in General Practice - 2001
Con-
only 1 x only 1 x
Type of
contact tact
form
Diagnosis and Infection
treatment origin
Antibiotic
treatment
Choice of antibiotics
␇ 1 2 3 4 5 11 14 15 17 18 19 20 21 22 23 24 25 26 27 28 29 31 32 33
Certificate
(sick-leave)
Courses
Reminders
Workshops
Second registration

Guidelines - respiratory
tract infections
1995
1997
1999
2002
2004
2006
1992-93
FIRST
REGISTRATION
Editorial
board
FINAL CONFERENCE
CONSENSUS CONFERENCE
SECOND
REGISTRATION
NEWSLETTER
STRATEGY
CONFERENCE
NEWSLETTERv
NEWSLETTERS

Change in treatment of pneumonia in
Denmark 1992-1995
70
PERCENT
60
50
40
30
20
10
0
PENI-
CILLIN
AMPI-
CILLIN
ERYTHRO-
MYCIN
TETRA-
CYCLINE
OTHER
ANTIB.
OTHER
MED.
NO
MED.
24 G.P.'s
1992 n=62 1993 n=127 1995 n=107

Antibiotic Audit 2001: variation between GPs
Antibiotic prescription for tonsillitis in different practices in i
Denmark before intervention
Practices (%)
30
25
20
15
10
5
0
Consultations (%)
90-100%
80-89%
70-79%
60-69%
50-59%
40-49%
30-39%
20-29%
10-19%
0-9%

Antibiotic Audit 2002: variation between GPs
Antibiotic prescription for tonsillitis in different practices in i
Denmark after intervention
Practices (%)
40
35
30
25
20
15
10
5
0
Consultations (%)
90-100%
80-89%
70-79%
60-69%
50-59%
40-49%
30-39%
20-29%
10-19%
0-9%

European Audit 2001
Treatment of tonsillitis in different countries
80
70
60
50
40
30
20
10
0
Denmark Norway Sweden Spain
Cephalosporine
Macrolide
Amoxacillin
V-penicillin

European Audit 2001
Use of tests in patients with tonsillitis in different countries
100
90
80
70
60
50
40
30
20
10
0
Denmark Norway Sweden Spain
No test
Other
CRP
StrepA

Percentage of consultations with antibiotic prescribing in relation to
focus for infection
%
80
70
60
50
40
30
Before intervention
After Intervention
20
10
0
Ears
Tonsils
Pharynx
Sinuses
Bronchii/lungs
Multiple foci
Unknown focus
All resp infections
Focus for respiratory infection

Main results
Effects of change
The intervention led to a significant reduction in antibiotic
prescribing.
Before the intervention 36% (29%-44%) of consultations were
followed by antibiotic prescribing
After the intervention 24% (20%-29%) 29%) of consultations were
followed by antibiotic prescribing
The reduction was most pronounced in patients with sinusitis
and lower RTIs.
Lessons learnt
Improvement of diagnostic procedures may lead to a
reduction of antibiotic prescribing in primary health care
in Spain.

How do we influence doctors to change
their prescribing habbits ?
Written material
Training courses
Prescription feedback
Reminders
Academic detailing
Audit interventions
Guidelines combined
with other initiatives
Etc…

How can doctors change habbits
concerning antibiotic use?
Important conditions for change
of habbits
Recognize that there is a
problem, and something has
to be changed
Motivation and willingness to
change habbits
Feeling of a personal
responsiblility for
participating in the
intervention

Experience from audit
When performing guidelines
for general practice they
should be adapted to local
conditions
Initiatives should be taken to
implement them in the most
effective way, adapted to
local conditions
When introducing guidelines
they should be followed up
by other initiatives

What do patients with respiratory
infections want from the GP ?
Some patients with RTI expect the doctor to perform a test
to confirm that they don’t t need antibiotics
Frequent in Nordic countries
Infrequent in Southern Europe
Some patients with RTI expect the doctor to issue an
antibiotic prescription for their symptoms
Doctors are highly influenced by patients demand
Prescribing may be a way of showing the patient
that the doctor understands and accepts the
patient’s s problem and is willing to help.

Why are antibiotics prescribed for non-
bacterial infections ?
Doctors may be too busy to perform a
thorough examination or a laboratory
investigation
In a busy practice, a prescription can be used
to terminate the consultation
If you are in doubt you may prescribe ”just to
be safe”

The consortium
Participant organisation name
Short name
Type
Research
Country
Internat.
Health
authority
Assoc.
of GPs
SME
Research Unit for General Practice in Odense RUPO DK GOV X
GP Consultants GPC DK PRC X
Ministry of the Interior and Health MIH DK GOV X
Blekinge Institute for Research and Development BIRD SE PNP X
National Board of Health and Welfare NBHW SE GOV X
FD Centre FDC LT PNP X
State Patient Fund SPF LT GOV X
Association of Family Doctors, Kaliningrad AFMK RU PNP X
College of Family Physicians in Paris CPMF FR PNP X
Spanish Society of Family Medicine SEMFYC ES PNP X
University of Las Palmas de Gran Canaria ULPGC ES GOV X
Consejería de Sanidad del Gobierno de Canarias CSGC ES GOV X
Misiones Association of General Family Medicine and
Health Team
AMMeGeFES AR PNP X
World Health Organisation, Collaborating Centre for
Drug Statistics Methodology
WHO-CC NO INO X X
World Organisation of Family Doctors WONCA SI INO X X X
European Drug Utilisation Research Group EuroDURG BE INO X X
17 participants from 8 EU countries and 2 INCO countries

Project structure
Planning of audits and intervention
WP2
Planning of
Audit
cycles
WP3
Development
of
Indicators
WP4
Intervention
material
for Patients
WP5
Intervention
for
Professionals
Audit
implementation
plan
Audit
guideline
Intervention
material for
patients
Intervention
material for
professionals
Initial registration
Intervention
WP6 APO cycles in the Nordic Region (2 APO cycles)
WP7 APO cycles in the Baltic Region (2 APO cycles)
Final registration
GP
registration
data
WP10 Analysis
of the audit
results
WP8 APO cycles in France (1 APO cycle)
WP9 APO cycles in Hispano-America (7 APO cycles)
Understanding the
effect of intervention
Analysis and dissemination
WP11
Evaluation and
working
conference
Conclusions and
recommendations
GP
registration
data
WP12
Preparing
material for
media
campaigns

Project time schedule
2007 2008 2009 2010
X
X
Analysis and conference
Second registration of Patients
Intervention: GPs and patients
First registration of Patients
First invitation of GPs
Total project period: 3 years (April 2007 – March 2010)

Dissemination
Follow-up meetings for GPs in each region
HAPPY AUDIT Conference (month 36)
Scientific publications and conference presentations
Media campaigns targeting professionals and the
public (to be financed by EU in separate projects)
HAPPY AUDIT
HAPPY AUDIT
HAPPY
AUDIT

Time schedule
First partner meeting: October 2005
Submission to EU: March 2006
Evaluation by EU: July 2006
Contract negotiation: November 2006
Project start: April 2007
First registration: January 2008 *
Second registration: January 2009 *
End of project: March 2010
* Plus 6 months for Argentina

Project time schedule
Work package
WP1 Project Management
WP2 Planning of audit cycles
WP3 Development of indicators
WP4 Intervention materials for Patients
WP5 Intervention materials for Professionals
WP6 APO cycles in the Nordic Region (2 APO cycles)
WP7 APO cycles in the Baltic Region (2 APO cycles)
WP8 APO cycles in France (1 APO cycle)
WP9 APO cycles in Hispano-America (6 APO cycles)
WP10 Analysis of the audit results
WP11 Evaluation and working conference
WP12 Preparing material for media campaigns
M1 Guidelines for professionals completed Month 6
M2 Initial registration completed Month 13
M3 Intervention completed Month 21
M4 Working conference completed Month 35
Total project period: 3 years (2007-2009)
Month
6 12 18 24 30 36
M1 M2 M3 M4

Financing
EU-contribution:
Own financing 1 :
Total project cost:
1,5 million €
0,8 million €
2,3 million €
1 By contribution of permanent staff of the
participants