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Reducing Antimicrobial Prescribing
- 1. Dr Anita Sharma GPwSI Gynaecology Clinical Lead Oldham GP Federation Educational Lead North West FDA NICE QSAC GP Member Caring, Compassionate Committed
- 2. Reducing Antimicrobial Prescribing OLDHAM CRP PROJECT Caring, Compassionate Committed 2
- 3. TODAY’S SESSION Health in Oldham Triple Aim Strategic Objectives Oldham AMR strategy in line with UK’s TARGET Workshop CRP Project Where are we now in Oldham Caring, Compassionate Committed 3
- 4. HEALTH IN OLDHAM • Registered population 242,970 (1/1/16) • 21% of households in fuel poverty • 20% BME population • Marked regional variation in health/mortality • High smoking prevalence ---24% as compared to 22% North West, 19% England • High levels of obesity---25% • Low levels of physical exercise—47% as compared to 53% NW, 56% England Caring, Compassionate Committed 4
- 5. FUTURE CHALLENGES Ageing population: 65 yrs (19%), 75 yrs (26%), 85 yrs (27%) in next 10 yrs Ethnic Population Increasing obesity, smoking, alcohol and drug abuse Multiple vascular pathology - Increasing complexity Financial constraints Caring, Compassionate Committed 5
- 6. TRIPLE AIM OBJECTIVES • To improve the health of the people of Oldham • To improve the care they receive • To deliver best value for money Caring, Compassionate Committed 6
- 7. Oldham Antimicrobial Strategy • To develop Primary Care Antimicrobial Policy • To guide professionals regarding appropriate prescribing for the treatment of commonly encountered infections • To make the right decision when to prescribe Caring, Compassionate Committed 7
- 8. Oldham’s Antimicrobial Prescribing Challenges • Oldham prescribed large numbers of antibiotics • QIPP indicator showed Oldham in the bottom national quartile • 22 practices within the bottom national quartile • 16 practices within the top national quartile Caring, Compassionate Committed 8
- 9. Oldham Antimicrobial Policy • Developed in April 2013 in collaboration with NE sector Drugs and Therapeutics • Guidance on management of RTI, UTI, ENT ,Acne, sexually transmitted infections, GI ,Eye, Viral and skin and soft tissue infections • Focus was on appropriate prescribing: Outcomes Caring, Compassionate Committed 9
- 11. This toolkit is here to help clinicians and commissioners to use antibiotics responsibility and meet CQC requirements Caring, Compassionate Committed 11
- 12. TARGET PROJECT OLDHAM PROJECT AIM To determine whether the provision of one hour workshop using the TARGET presentation explaining the HOW? And WHY? of AB prescribing results in fewer prescribing compared to controls who only have the website material. Caring, Compassionate Committed 12
- 13. METHODOLOGY • Designed by TARGET Team: Dr Cliodna McNulty, Meredith Hawking, Dr Donna Lecky • To evaluate the toolkit material RCT with a modified –Zelan design was undertaken • 28 practices stratified • 15 surgeries in the Intervention group • 1 hr workshop on TARGET materials. PACT data Caring, Compassionate Committed 13
- 14. METHODOLOGY CCG approval taken on 1.8.2013 Train the Trainer’s workshop organised 15.8.2013 Presentations, AB guidance, workshop delivery, GP commonly asked questions Practices invited to take part Workshop delivered in their practice +CPD Prescribing data shown to the practices (one year before and after the workshop) Practices were not informed that they were part of the study Caring, Compassionate Committed 14
- 15. Total items prescribed per 1000 population per practice (2012/13 Caring, Compassionate Committed 15 0.00 200.00 400.00 600.00 800.00 1000.00 AddyPractice HollinwoodMedicalPractice TrewinardPractice HopeCitadel TheParksMedicalPractice OldhamMedicalServices SpringfieldHouse VillageMedicalPractice QuaysideMedicalPractice MachHealthcareLimited PerkinsPractice FailsworthGroupPractice AkhterPractice TheRoyton&CromptonFamily… MohantyPractice StMary'sMedicalCentre HossainPractice JarvisMedicalPractice LittletownFamilyMedPract BlockLaneSurgery TheDuruPractice OakGablesMedicalPractice PennineMedicalCentre OldhamFamilyPractice GlodwickMedicalPractice LeesbrookSurgery RoytonMedicalCentre WilkinsonPractice CoppiceMedicalPractice SaddleworthMedicalPractice TheChowdhuryPractice DansonFamilyPracticeP85018 KapurFamilyCare HopwoodHouseMedicalPractice AlexandraGroupMedPract DonaldWildeMedicalCentre MoorsideMedicalPractice ChMedicalPractice JohnStreetMedicalPractice StChadsMedicalPractice LeesRoadSurgery SarafMedicalPractice RadcliffeMedicalPractice SharmaPractice WernethMedicalPractice Tetracyclines Sulfonamides & Trimethoprim Quinolones Penicillin V Penicillinase-Resistant Penicillins Metronidazole Macrolides Co-Amoxiclav
- 17. FEEDBACK Caring, Compassionate Committed 17 80% of patients attended their GP because they expected Antibiotics 30-50% of patients wanted a referral to hospital If not given antibiotics they attended Out of Hours or A&E Some joined the next door practice
- 18. FEEDBACK Caring, Compassionate Committed 18 When asked specifically if they had access to PoC CRP test would that help to reassure patient?
- 19. NICE pathway (POC) CRP Test Caring, Compassionate Committed 19 NICE guideline CG191 recommends that GPs should consider carrying out a point of care (POC) C-reactive protein (CRP) test for people presenting in primary care with symptoms of lower respiratory tract infection. Pneumonia not diagnosed or not clear if antibiotic should be prescribed CRP rapid test < 20mg/L Do not routinely offer antibiotic therapy 20-100 mg/L Consider a delayed antibiotic prescription >100 mg/L Offer antibiotic therapy
- 20. Current Prescribing in Primary care Caring, Compassionate Committed 20 • 78.5% of antibiotic prescribing is in Primary Care. • Antibiotic prescribing by GPs increased by 4% between 2010 and 2013. • Over half of antibiotics prescribed in Primary Care are for respiratory tract infections (RTI). • However, systematic reviews have shown that most of these infections are viral and patients derive little benefit from antibiotic treatment.
- 21. PROJECT PLAN Caring, Compassionate Committed 21
- 22. PROJECT PLAN Caring, Compassionate Committed 22
- 24. PRACTICE SELECTION Caring, Compassionate Committed 24 Oldham CCG consisting of 45 GP practices. 8 highest prescribing practices were randomly selected from the top 12 prescribers (by total antibiotic prescription). GP practices approached by letter and telephone Appropriate Governance and Ethical approval was taken Alere—now Abbott PoC CRP was chosen
- 25. Oldham CRP Project Caring, Compassionate Committed 25 Started in Jan 2016 800 CRP tests were available to be used by 8 practices Usage per practice: Practice A 97 Practice B 11 Practice C 11 Practice D 75
- 26. Oldham CRP Project Caring, Compassionate Committed 26 Practice E 43 Practice F 18 Practice G 100 Practice H 0 Total number of CRP tests completed: 359 59 were excluded Final included sample: 300 43% were Male, 57% Female
- 27. Patient presenting condition Caring, Compassionate Committed 27
- 28. CRP results Caring, Compassionate Committed 28
- 29. Were antibiotics prescribed after the CRP Test ? Caring, Compassionate Committed 29
- 30. Re-consultation (within 4 weeks) per CRP Test Score Caring, Compassionate Committed 30
- 31. Hospitalisation and complication rates Caring, Compassionate Committed 31
- 32. Big Question Is C-Reactive Protein PoC testing feasible in routine General Practice, improving diagnostics certainty and AB use ?
- 33. FEASIBILITY 33 C-reactive protein point-of-care testing in Oldham CCG • 45% (359) CRP tests used over 6 months • 78% of CRP results were <20mg/L 88 21 5 21 4 58 100 3.4 0 10 20 30 40 50 60 70 80 90 100 <20mg/L 20-100mg/L 100mg/L Results and compliance with NICE (%) CRP result Self-care advice only Delayed antibiotics Immediate antibiotics Antibiotic from other i.e. OOH 88% in line with NICE guidance: Self care advice only 21% in line with NICE guidance: Delayed antibiotic 100% in line with NICE guidance: Immediate antibiotic
- 34. Post CRP test patient questionnaires 34 C-reactive protein point-of-care testing in Oldham CCG • 50% completion • Patients were positive about CRP, no dislikes reported • 88% comfortable; 84% convenient; 92% useful; 85% explained very well • Patients believed POC CRP: aids clinical diagnosis; provides quick results; reduces unnecessary antibiotic use • 78% would be happy to have CRP at a local pharmacy • framework “Helps diagnosis and treatment” “Quick, simple, easy and gave instant results” “Saves issuing antibiotics when not needed”
- 35. GP staff interviews 35 C-reactive protein point-of-care testing in Oldham CCG • The GP staff interview findings are published in the BMJ Open, Oct 2018
- 36. GP staff interviews (26 staff, 12 practices) 36 C-reactive protein point-of-care testing in Oldham CCG • Staff viewed CRP POCT as a “tool in your armoury” to support clinical decision and educate patients. • Barriers; cost, time, easy access to the machine, and the effects on clinical workflow. • Only fully utilised in practices with single staff member who saw most acute cases • Further machine development is needed to simplify process and increases access by reducing cost and size Capability •Clear local guidance •Training: to perform •Knowledge: of value to reduce antibiotics when to use •Skills: to take, perform & interpret test Opportunity •Funding to support •Easy access in surgery •Time to use in consultation •Adaptable clinical workflow •Patient awareness Motivation •Confidence in the test •Belief in benefits of CRP •Belief supports clinical decisions and diagnostic certainty •Feel patients will accept the result •Intent to use test appropriately
- 37. FUNDING This work was supported by Public Health England £4,200 More funding has come from PHE £4,500 Alere (ABBOTT): Provided machines (free of charge) and reduced rate PoC £2/ Publications: BMJ article and other magazines My Presentations 37 C-reactive protein point-of-care testing in Oldham CCG
- 38. WHAT NEXT FOR OLDHAM Caring, Compassionate Committed 38 PoC CRP testing well received by GP practice staff as an additional diagnostic tool to support clinical decision NICE guidelines CG191 recommends PoC CRP testing Used in Norway, Sweden, Netherlands, Germany, Estonia, Czech Republic
- 39. QUALITY PREMIUMS Caring, Compassionate Committed 39 • In April 2015, NHS England included antibiotic prescribing in the 2015/16 Quality Premium guidance for Clinical Commissioning Groups (CCG). • Of the total £5 per patient available to CCGs, 10% is attributed to improving antibiotic prescribing, an average of £127,000.*
Notes de l'éditeur
- Feasibility additional figures 300 used in analysis; 82% CRP tests were administered on patients who met study criteria Practices varied in CRP uptake 3 x <10 CRP test 2 x 10-60 CRP tests 3 x >60 CRP tests Most CRP results were <20mg/L (78%) The following CRP results were managed in line with NICE guidance: 88% of patients with a CRP result of <20mg/L 21% of patients with a CRP result of 20-100mg/L 100% of patients with a CRP results of >100mg/L 12% of patients who had a CRP test re-consulted with the same presenting conditions within 4 weeks. Patient’s with CRP results <20mg/L re-consulted less (10%) than patients with CRP results 20-100mg/L (20%) or >100mg/L (40%).
- Questionnaire given to patients after receiving a CRP POCT to assess patient views on CRP testing in general practice Patients were positive about CRP: 88% comfortable; 84% convenient; 92% useful; 85% explained very well CRP tests were conducted by a Prescribing Pharmacist (38%), GP (33%) or Nurse (22%) Most patients said CRP took 5 (62%) or 10 mins (22%). Patients believed CRP: aids clinical diagnosis; provides quick results; reduces unnecessary antibiotic use Overall patients did not report any dislikes about the CRP test Nearly three quarters of patients stated they would be happy for a CRP test to be done at a local pharmacy (73%).
- Results Seven intervention and five control practices consented to participate. Participants compromised of 26 general practice staff; fifteen General Practitioner’s, five Practice Managers, three Practice Nurses, and one Prescribing Pharmacist, Community Matron and Healthcare Assistant. Qualitative data from eleven interviews, three focus-groups and one hand written response was collected. Participants believed that CRP POCT can increase diagnostic certainty, help target appropriate treatments, help manage patient expectations and patient demand for antibiotics, support patient education, and improve appropriate antibiotic prescribing. Barriers to implementing CRP POCT include; financial support, time, access to the CRP POCT machine, and the effects on clinical workflow. Conclusions CRP POCT was well received by many general practice staff as an additional diagnostic “tool in your armoury” to support clinical decision making in the management of LRTI. To see an increase in the implementation of CRP POCT, further research into machine development is required, to overcome time, cost and access barriers. Further evidence of the impact of CRP POCT on appropriate antimicrobial prescribing is required to inform future guidance which will be the initial facilitator for behaviour change.