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Routine antibiotic prescription and resistance monitoring in primary care physicians: A nationwide pragmatic randomized controlled trial

Applicant Bucher Heiner C.
Number 167066
Funding scheme NRP 72 Antimicrobial Resistance
Research institution Institut für klinische Epidemiologie Universitätsspital Basel
Institution of higher education University of Basel - BS
Main discipline Infectious Diseases
Start/End 01.01.2017 - 31.12.2022
Approved amount 605'097.00
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All Disciplines (2)

Discipline
Infectious Diseases
Methods of Epidemiology and Preventive Medicine

Keywords (6)

prevention; antibiotic resistance monitoring; antibiotic resistance; pragmatic trial; antibiotic use; epidemiology

Lay Summary (German)

Lead
Wir nutzen die Abrechnungsdaten von Krankenversicherern, um Hausärzten regelmässig ihren Gebrauch von Antibiotika aufzuzeigen. Wir testen, ob dies, zusammen mit Hinweisen zur lokalen Resistenzentwicklung, die Verschreibungspraxis verbessert.
Lay summary

Bei Atem- und Harnwegsinfekten setzen Hausärzte oft ungezielt Antibiotika ein. Wir entwickeln eine Massnahme, um sie zu einem umsichtigeren Gebrauch zu bewegen. Dazu werten wir mittels der Abrechnungsdaten der drei grössten Krankenversicherer (3,8 Mio. Versicherte bzw. 40% der Schweizer Bevölkerung) laufend die Verschreibungspraxis von Hausärzten aus. Knapp 2500 Ärzten geben wir darüber regelmässige Rückmeldungen sowie Informationen zur Resistenzentwicklung in ihrem Versorgungsgebiet. Zudem stellen wir ihnen Behandlungsrichtlinien für Atem- und Harnwegsinfekte zur Verfügung. Wie sich diese Intervention auswirkt, stellen wir wiederum anhand der Daten der Krankenversicherer fest. Dabei sind alle Daten anonymisiert, Namen von Ärzten und Patienten sind uns nicht bekannt.

Hintergrund
Gezielte Massnahmen für einen verbesserten Umgang mit Antibiotika, sogenannte Stewardship Programme, haben sich in vielen Ländern bewährt. In der Schweiz gibt es dazu jedoch noch wenig Erfahrungen.

Ziel
Unser Ziel ist die Entwicklung eines effektiven Interventionsprogramms, das Hausärzte zu einem gezielteren Einsatz von Antibiotika bei Atemwegs- und Harnwegsinfektionen bewegt.

Bedeutung
Unser Vorgehen kann relativ einfach auf alle Schweizer Hausärzte ausgeweitet werden, wenn es sich bewährt. Wir werden die erhobenen Verschreibungsdaten zudem mit den Daten der nationalen Datenbank für Antibiotikaresistenzen (ANRESIS) verknüpfen, wodurch sich ein Vorhersagemodell für die Resistenzentwicklung bei Harnwegsinfekten in der Grundversorgung entwickeln lässt.

Direct link to Lay Summary Last update: 05.12.2017

Lay Summary (French)

Lead
Nous utilisons les données de facturation des caisses maladie afin d’informer régulièrement les généralistes de l’emploi qu’ils font des antibiotiques. Nous testons si ces informations, couplées à des indications sur le développement local des résistances, permettent d’améliorer cette pratrique.
Lay summary

Les généralistes emploient souvent les antibiotiques de façon non ciblée pour traiter les infections urinaires et respiratoires. Nous mettons en place une mesure afin de les inciter à une utilisation plus prudente. Au moyen des données de facturation des trois principales caisses maladie (3,8 mio d’assurés ou 40% de la population suisse), nous évaluons en continu les prescriptions des généralistes. Nous fournissons à près de 2500 médecins des comptes-rendus réguliers, ainsi que des informations sur le développement des résistances dans leur zone d’intervention. Nous mettons aussi à leur disposition des lignes directrices pour le traitement des infections urinaires et respiratoires. L’effet de ces mesures sera ensuite évalué grâce aux données des assurés, qui sont entièrement anonymisées.

Contexte
Les mesures ciblées adoptées pour une meilleure gestion des antibiotiques (programmes dits de gérance) ont fait leurs preuves dans de nombreux pays. La Suisse dispose encore de trop peu d’expérience dans ce domaine.

Objectif
Notre objectif est de développer un programme d’intervention efficace qui incite les généralistes à utiliser les antibiotiques de manière plus ciblée afin de traiter les infections des voies urinaires et respiratoires.

Importance
Si elle s’avère efficace, notre démarche pourra être élargie relativement facilement à tous les généralistes suisses. Nous combinerons en outre les données de prescription recueillies à celles du Centre suisse pour le contrôle de l’Antibiorésistance (ANRESIS), ce qui permettra de développer un modèle prédictif relatif au développement des résistances qui peuvent résulter du traitement primaire des infections des voies urinaires.

Direct link to Lay Summary Last update: 05.12.2017

Lay Summary (English)

Lead
We are using billing data from health insurance providers to regularly inform general practitioners about their use of antibiotics. We are testing whether, in conjunction with information about local resistance development, this can improve prescribing habits.
Lay summary

General practitioners (GPs) often prescribe antibiotics indiscriminately for respiratory and urinary tract infections. We want to encourage them to use antibiotics more cautiously. To do this we are using the billing data from the three biggest health insurances (3.8 million insureds, or 40% of the Swiss population) to produce an ongoing evaluation of GPs’ prescribing habits. We provide nearly 2,500 GPs with regular feedback on this as well as with information on the development of resistance in their catchment area. We also provide them with guidelines for treating respiratory and urinary tract infections. We then use the data from the health insurances to analyse the impact of this intervention. All the data are anonymous; we do not know the names of any of the doctors or patients.

Background
Targeted measures, known as stewardship programmes, have been implemented successfully in many countries to improve the way antibiotics are used. There is little experience of this in Switzerland, however.

Aim
Our goal is to develop an effective intervention programme that will encourage general practitioners to use antibiotics more specifically when treating respiratory and urinary tract infections.

Relevance
If our approach proves useful, it will be relatively easy to extend it to all GPs in Switzerland. We will also be linking the prescribing data that have been collected with the data in the national antibiotic resistance database (ANRESIS). This will make it possible to generate a predictive model for the development of resistance in urinary tract infections in primary care.

Direct link to Lay Summary Last update: 05.12.2017

Responsible applicant and co-applicants

Employees

Project partner

Collaboration

Group / person Country
Types of collaboration
Centre for Primary Health Care, University of Basel Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
Infectious Diseases and Paediatric Pharmacology Great Britain and Northern Ireland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
Institute of Pharmaceutical Medicine, University of Basel Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
- Exchange of personnel
Cura futura Bern Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
- Industry/business/other use-inspired collaboration
Division of Infectious Diseases and Hospital Hygiene Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
- Research Infrastructure
Institute for Infectious Diseases, University of Bern Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
- Research Infrastructure

Scientific events

Active participation

Title Type of contribution Title of article or contribution Date Place Persons involved
DIGITAL ID2020 Conference Poster Using routinely collected data to conduct a pragmatic randomized controlled trial: an example addressing antibiotic prescription and resistance monitoring in Swiss primary care. 20.01.2020 Basel, Switzerland Bucher Heiner C.; Glinz Dominik;


Associated projects

Number Title Start Funding scheme
140997 Routine Prescription Feedback and Peer Comparison to Lower Antibiotic Prescriptions in Primary Care - a Pragmatic Randomized Controlled Trial 01.06.2012 Project funding (Div. I-III)
167066 Routine antibiotic prescription and resistance monitoring in primary care physicians: A nationwide pragmatic randomized controlled trial 01.01.2017 NRP 72 Antimicrobial Resistance

Abstract

Background. Antibiotic resistance is an increasingly serious problem worldwide and associated with the exposure and overall uptake of antibiotics in the population. In Europe, 80% to 90% of antibiotics are used in primary care. Acute respiratory tract infections (ARTI), although primarily of viral origin, and urinary tract infections (UTI) are the most frequent reasons for antibiotic prescribing.Methods. The project aims to reduce antibiotic overuse and unnecessary use of broad spectrum antibiotics in primary care in Switzerland. We propose a nationwide pragmatic randomized intervention trial on routine antibiotic prescription feedback and resistance monitoring in primary care physicians (general internal medicine and pediatrics). We use only few inclusion criteria to maximize the target population and generalizability. We will include physicians with normal and high antibiotic prescription rates (i.e. the top 75% antibiotic prescribers) and with more than 100 patients per year.Intervention. We will use routinely collected individual patient claims data from the three largest Swiss health insurers with about 3.8 million insured persons (40% of Swiss population) for recruitment and selection of participants, intervention and outcome measurement. We will also use national antibiotic resistance data from the Swiss Centre for Antibiotic resistance (Anresis). We will randomize physicians to continuous personalized feedback and updated antibiotic resistance data from the community over 2 years. This will allow them to compare their own prescribing behavior to that of colleagues and to evaluate long-term trends in their own prescribing. In addition we will support them with evidence-based treatment guidelines for the management of ARTI and UTI and with patient information on moderate antibiotic use. Physicians in the control group receive no feedback or information material and will not be notified. Physicians in the intervention group will not have to provide informed consent but may opt out from the study at any time. Investigators will take any measures to guarantee the confidentiality of all data and all physician and patient data provided to investigators by health insurers will be completely anonymized.The primary endpoint is the overall antibiotic use, defined as prescribed defined daily doses (DDD) of antibiotics per 100 patient consultations. Secondary endpoints are: (1) use of the broad spectrum antibiotics quinolones and (2) oral cephalosporines; (3- 4) hospitalizations (all-cause and due to infection); (5-8) antibiotic use in four specific age groups; (9) costs (antibiotics, outpatient and hospital costs due to infections). We will assess the outcomes after one and after two years. With the total sample size of 2590 physicians who will be allocated in a 2 to 1 ratio the trial has a statistical power of 90% to detect a minimum reduction of 5% in overall antibiotic use between the two groups. All analyses will be according to intention-to-treat.In a feasibility sub-study we will link insurance data with national antibiotic resistance data (Anresis) by anonymized privacy preserving probabilistic record linkage (based on the matching variables: encrypted ZSR no of physician and laboratory, test date, age and sex of patients). We will use this novel linkage system to analyze a sub-population of patients with matched insurance and resistance data and evaluate risk factors that may affect antibiotic resistance on the patient level. Ideally, this system would allow us to evaluate the impact of the trial intervention program on resistance profiles of patients cared by physicians included in the trial.A health economic evaluation will be integrated part of the trial. Intervention costs will be recorded as part of the study. Costs to the obligatory health insurance are directly available from the insurers' claims data. This will allow for an assessment of the overall cost impact from the health insurers' perspective. Costs from the societal perspective, i.e. including indirect costs due to time off work, will be estimated using modelling techniques.
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