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  3. Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial
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Research

Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.d8173 (Published 02 February 2012) Cite this as: BMJ 2012;344:d8173
  1. Christopher C Butler, professor of primary care medicine1,
  2. Sharon A Simpson, senior research fellow12,
  3. Frank Dunstan, professor of medical statistics1,
  4. Stephen Rollnick, professor of healthcare communication1,
  5. David Cohen, professor of health economics3,
  6. David Gillespie, statistician12,
  7. Meirion R Evans1,
  8. senior lecturer in epidemiology and public health,
  9. M Fasihul Alam, research fellow3,
  10. Marie-Jet Bekkers, research associate12,
  11. John Evans, information manager12,
  12. Laurence Moore, professor of public health improvement4,
  13. Robin Howe, consultant microbiologist5,
  14. Jamie Hayes, director, Welsh medicines resource centre6,
  15. Monika Hare, trial manager12,
  16. Kerenza Hood, professor and director12
  1. 1Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, CF14 4XN, UK
  2. 2South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff
  3. 3Health Economics and Policy Research Unit, University of Glamorgan, Pontypridd
  4. 4Cardiff Institute of Society and Health, School of Social Sciences, Cardiff University, Cardiff
  5. 5National Public Health Service Microbiology Cardiff (Velindre NHS Trust), University Hospital of Wales, Cardiff
  6. 6Welsh Medicines Resource Centre (WeMeReC), Academic Centre, University Hospital Llandough, Penarth
  1. Correspondence to: C C Butler butlercc{at}cf.ac.uk
  • Accepted 5 November 2011

Abstract

Objective To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care.

Design Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation.

Setting 68 general practices with about 480 000 patients in Wales, United Kingdom.

Participants 34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed.

Interventions Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice based seminar reflecting on the practices’ own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care.

Main outcome measures Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year’s dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs.

Results The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% confidence interval 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was £2923 (€3491, $4572) per practice (SD £1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (−0.4% to 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice.

Conclusion The STAR educational programme led to reductions in all cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs.

Trial registration ISRCT No 63355948.

Footnotes

  • We thank the other members of the STAR study team for their contribution to the design and development of this study: Jackie Swain of Cardiff University, who was the study administrator, and Patrick Cannon, Valerie Dougall, James Goldsmith, and Dan Bruce of the Healthcare Learning Company, London, who designed and produced the online learning environment. We thank the independent members of the trial steering committee, Ian Williamson (chair), Alistair Hay, and Alan Montgomery (independent statistician).

  • Contributors: CCB conceived the study, acted as principal investigator, and led the protocol development, study implementation, interpretation, and report writing. SAS contributed to protocol development and study implementation, including a special contribution to the intervention development, interpretation, and report writing. FD contributed to the design of the study, data management, interpretation of the results, and writing, revised the report, and led aspects of the statistical analysis. SR contributed to protocol development and report writing and conceived the learning programme structure and directed its development. DC contributed to protocol development, interpretation, and report writing and planned and led the analyses of costs. MRE contributed to protocol development, study implementation, and data interpretation and assisted in drafting the manuscript. MFA contributed to the economic statistical analysis and interpretation of data and assisted in drafting the manuscript. M-JB was the trial manager for part of the study, led on the process evaluation interviews, and contributed to report writing. JE acted as the data manager, liaised with providers regarding data collection, developed and implemented extraction methods from primary care systems, contributed to the data management, study implementation, and report writing. DG contributed to the data management, statistical analysis and interpretation of the data, report writing, and drafting of the manuscript. LM contributed to protocol development and reviewed the manuscript. RH contributed to the study design, with a particular focus on outcome measurement. He helped develop the seminar intervention and contributed to the report writing. JH contributed to the development and led the delivery of the face to face component of the intervention, interpretation and draft manuscripts. MH contributed to study implementation, data collection, and interpretation and report writing, and was the trial manager for part of the study. KH contributed to the design of the study, data management, statistical analysis and interpretation of the results, and writing the report. All authors have given final approval of the submitted manuscript. CCB is guarantor.

  • Funding: This study was funded by the UK Medical Research Council (G0500956). The South East Wales Trials Unit is funded by the National Institute for Health and Social care Research, which also provide service support costs.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study was approved by the multicentre research ethics committee (MREC 06/MRE09/31) and all local health boards in Wales. Consent was obtained from clinicians but not from individual patients, but the presented data are anonymised and risk of identification is low.

  • Data sharing: No additional data available.

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