From 17 to 1: Nudging Prescribers to Reduce Total Antimicrobial Prescribing (2018)

East and North Herts CCG

Introduction

To improve antibiotic prescribing across East and North Herts NHS CCG.

How was the project established? / How is it currently being established?

The need for a dedicated project to reduce antimicrobial prescribing was identified in September 2016 when the total antimicrobial prescribing across East and North Herts CCG was 1.162 items per STAR-PU. This exceeded the limit outlined in the NHSE Quality Premium (QP - defined as equal to or below the England 2013/14 mean performance of 1.161 items per STAR-PU). As of January 2017, 17 (30%) of 58 individual GP practices across the CCG were above the QP threshold. This relative high total antibiotic prescribing rate across the organisation was a consequence of an average 4.3% rise in prescribing in the 12 months since January 2016.

The project involved enhanced antimicrobial stewardship (AMS) in the 20 practices with the highest rate of total antimicrobial prescribing in the CCG. Two behavioural interventions were used support AMS in these practices - an evidenced based 'nudge', along with a more traditional prescribing audit.

The 'nudge' was based on an American study which showed that displaying a poster-sized commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control(1). As in this study, the signed pledge (see appendix) was displayed in each consulting room of the identified practices.

The audit required a named individual (a so called 'antimicrobial stewardship lead') from each practice to be responsible for undertaking the audit and it would detail the number of acute antimicrobial items authorised each month by individual prescribers within the practice. The data would be emailed back to the antimicrobial prescribing lead in the CCG as well as disseminated amongst prescribers within the practice to allow for peer comparison of prescribing rates in the practice. Benchmarking in this way has been shown to reduce the rate of inappropriate antibiotic prescribing specifically for acute respiratory tract infections in primary care(2).

Who are the main beneficiaries of the project? How would they benefit?

Should the AMS interventions result in reduced total antimicrobial prescribing the following would benefit:

The Practice:

By reducing antimicrobial prescribing rates, appointments may be freed. Evidence has shown that reducing antimicrobial prescribing rates for acute respiratory tract infections can reduce subsequent consultation rates for these same conditions3. Reducing inappropriate prescribing will also support patient self-management and self-care initiatives.

The public:

Over-prescribing of antibiotics is associated with an increased risk of adverse effects, more frequent re-attendance, increased medicalisation of self-limiting conditions and contributes to antimicrobial resistance.

The CCG:

Reducing antimicrobial prescribing would ensure that the CCG achieves the prescribing targets of The Quality Premium. This scheme rewards CCGs financially for improvements in the quality of the services they commission. Encouraging self-management where appropriate is consistent with the aims of the wider self-care agenda of the CCG.

What were the main outcomes and / or achievements of the project?

• Total antibiotic prescribing in the targeted practices fell 12% in the 12 months following the AMS intervention which started January 2017. This compared to a 4.3.4% rise in prescribing in these same practices prior to the intervention (graph1).
• Total antibiotic prescribing across the CCG fell 7.7% from Jan 2017 to Jan 2018 (see graph 1). This compares to a 5% reduction in total antibiotic prescribing across all CCGs in England over the same time.
• A single practice (1%) across the CCG had total antibiotic prescribing above the QP ceiling in March 2018 compared to 17 practices (30%) in January 2017 compared to.

Please see full project pack for graphs.