Prescribing antibiotics: who or what determines it? - SWAB
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Prescribing antibiotics: who or what determines it? - SWAB

Prescribing antibiotics: who orwhat determines it?FM Haaijer-RuskampDept Clin PharmacologySWAB 2 april 2004FM Haaijer-Ruskamp

COMMONCOLDSORETHROATCOUGHSWAB 2 april 2004FM Haaijer-RuskampLancet 2003, 361:51

Prescribing decisionsKnowledge,attitudes, habits,experiencespatientdoctormakingdecisionsOther partiesactively andpassivelyinfluencingSWAB 2 april 2004FM Haaijer-Ruskampprescription

DeterminantspatientdoctorCultureHealth insuranceReimbursement structurePharmaceutical industriesAcademiaProfessional organisationsColleaguesOther professionalsSWAB 2 april 2004FM Haaijer-Ruskampprescription

What do GPs say• Doctors know the evidence• Patient pressure, too difficult to change ptsbeliefs in the consultation room• prescription for doctor-pat relationship• clinical signs: green phlegm, pus on tonsils, ptlook very unwell• Resistance is community problem, GPs’priority is individual patient• Secondary care and veterinary use moreimportant for resistance then GPs prescribingSWAB 2 april 2004FM Haaijer-RuskampButler et al 1998,Kumar et al 2003

• Telephone prescribing of antibiotics– 18% in Norway ( Rokstad, 1997)• perception of GPs of telephone prescribingof AB–uncomfortable– pat demands– pragmatic (traveling time)SWAB 2 april 2004FM Haaijer-Ruskamp

Interventions to optimise antibioticprescribing in primary care (25 RCT/CCT)Type of intervention countries # posstudiesacademic detailing US, Australia, UK, Spain 8Indiv (mailed) feedback Australia Canada 1 +1 -Interact - workshop, Nl, Sw, Dk, Slov, UK, No, 11. audit & feedback US, CanadaInteract workshops +patient educationCanada, US 3delayed prescriptionstrategy, with/withoutpat informationUK 1SWAB 2 april 2004FM Haaijer-Ruskamp

Complex GP targeted intervention inNorwaySWAB 2 april 2004FM Haaijer-Ruskamp• Summary of the main recommendations inelectronic and poster format• Patient educational material in electronic andpaper format• Computer based decision support andreminders during consultations• An increase in the fee for telephoneconsultations for these two diagnoses with nochange in the fee for an office visit• Printed material to facilitate discussions in thepractice• Interactive courses for GPs and assistants• Points in the CME programmeFlottorp et al 2002

Results% patients withantibiotics for sore throatInterv ControlBaseline 48.1% 50.8%Outcome 43.8 49.5% change -4.3 -1.3%% difference 3.0%SWAB 2 april 2004FM Haaijer-RuskampFlottorp et al 2002

Conclusion GPs• GPs important factor in overuse• Effective strategies available to limitoveruse• need for broad implementation• succes is not self evident•CAVE: slowintensive effortSWAB 2 april 2004FM Haaijer-Ruskamp

Patients and the General PublicSWAB 2 april 2004FM Haaijer-Ruskamp

Fr Germacute tonsillopharyngitisoffice visits/ 1000 136 51antibiotic prescr/ 100 94.6 69.6Common Coldoffice visits/ 1000 253 19antibiotic prescr/ 100 48.7 7.7% NOT receiving antibiotics first visitsuspected community acquired pneumonia 8 23acute bronchitis 7 31exacerbation chronic bronchitis 5 26viral lower respiratory tract infection 20 41% diagnostic tests suspected LRT infectionchest radiograph 18 27peripheral blood leukocyte count 14 27microbiologic sputum examination 3 12SWAB 2 april 2004FM Haaijer-RuskampHarbarth et al 2002

Patients’ on antibiotics in relation totheir doctors• Patients (more then doctors):– antibiotics necessary for sore throat, cough– antibiotics speed up recovery» Van Duijn et al 2002• Patient pressure and prescribing response:– expectance --> RR +– GPs perceive expectance --> RR ++» Cockburn et al 2003SWAB 2 april 2004FM Haaijer-Ruskamp

Stewart et alSWAB 2 april 2004FM Haaijer-Ruskamp

Users’ expectations (%)> 50%33-5020-32turkey france spain uk belgium italyflu fever earache sore throatbad cough catarrh coldSWAB 2 april 2004FM Haaijer-RuskampBranthwaite et al 1996

Understanding patients’ perceptions• disease labeling– labels on symptoms– seriousness, uncertainty• coping strategy• attitudes / beliefs about antibioticsSWAB 2 april 2004FM Haaijer-Ruskamp

Disease labeling, B en NL•Belgium– either not labelled or bronchitis– bronchitis: ‘heavy cold’, probable cases ofinfluenza– bronchitis and flu are ‘serieus’ diseases• Netherlands– cold– common flu vs real flu– seldom seriousSWAB 2 april 2004FM Haaijer-RuskampDeschepper et al 2002

Coping strategiesFlanders Netherlandsdo nothingnurse one’s illness ++self medication ++consult doctor ++SWAB 2 april 2004FM Haaijer-RuskampDeschepper et al 2002

Attitudes and beliefs about antibioticsFlanders Netherlandsbetter safe then sorry +if there is no alternative (doctor’s ++ +decision)accepting, but rather not ++refusing +SWAB 2 april 2004FM Haaijer-RuskampDeschepper et al 2002

SWAB 2 april 2004FM Haaijer-RuskampNON- COMPLIANCE

% pats not completing antibiotic course504030201009 %16% 18%29%34%42%UKFranceBelgiumTurkeyItalySpainfeel betterother reasonsSWAB 2 april 2004FM Haaijer-RuskampBranthwaite et al, 1996

context• Impact rules and regulations, unknown– reimbursement, large variation in EU– renumeration of pharmacists• better for large quantities• Cultural contextSWAB 2 april 2004FM Haaijer-Ruskamp

Reimbursement strategies• full out-of-pocketpayment• fixed fee• co-insurance– patient charges• fixed deductible• full reimbursementEuropean situation• 2 countries, mostly– Lith, Ro• 3 countries (UK,De,Aust)• 14 countries– Fi,La,Hu,Pol,Esp,Fr,No– Port,Bul,Be,Gr,Slo,Lx,Tur• 6 countriesDk,Sw,Ice,Ma,Irl,CH• 5 countries– NL, Hr,Cz,Sk,ItSWAB 2 april 2004FM Haaijer-RuskampAdjusted from: M. Ferech; ESAC 2003

Culturally determined attitudes• Uncertainty avoidance• Power distance• Short-term versus long-term orientation• Individualism versus collectivism• Femininity versus masculinity• correlation between A.B. use (Cars, 2001)and Hofstede’s dataSWAB 2 april 2004FM Haaijer-RuskampHofstede et al , 1992

Use of antibiotics and uncertainty avoidance index (UAI)4035302520151050Fra nceSpainPortugalBelgiumIta lyGreeceFinlandIrelandAntibiotic use in DDD/1000.inhabitants and day.Uncertainty Avoidance Index120100806040200AB-useEnglandAustriaGermanySwedenDenmarkNetherland sUAIr = 0.70SWAB 2 april 2004FM Haaijer-RuskampDeschepper, 2002

Antibiotic use and Power Distance Index (PDI)4035302520151050FranceSpainPortugalBelgiumIta lyAntibiotic use in DDD/1000.inhabitants and day .Power Distance Index (PDI)GreeceFinlandIrelan dEnglandAustriaGermanySwed enDe nmarkNeth erland sSWAB 2 april 2004FM Haaijer-Ruskamp80706050403020100AB-usePDIr = 0.83

Long-term orientation and antibiotic useAB DDD/1000/day20151050UK Germ Swe NL50403020100long-term orientationantibiotic uselonterm orientationSWAB 2 april 2004FM Haaijer-Ruskamp

• doctors’ roleConclusions– aware of their own role– need for targeted support, not more information• patients’ role– overestimate the need and usefulness of drugs– non-compliance and self medication• reimbursement strategies: large variation,little known about relevance for AB• cultural background seems to be relevantSWAB 2 april 2004FM Haaijer-Ruskamp


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