Improving the uptake and SusTainability of Effective interventions to promote Prudent antibiotic Use in Primary care (STEP-UP)

Lead Research Organisation: University of Oxford
Department Name: Experimental Medicine

Abstract

Bacteria are increasingly resistant to the antibiotics we use to kill them. This is a major problem for us all. The more we use antibiotics, the more resistant the bacteria become. In England, GPs prescribe about 3/4 of antibiotics used. Most of these prescriptions (about 80%) will not actually benefit the patient but all will help to increase antibiotic resistance.

Many ways to help GPs prescribe fewer antibiotics to patients who are unlikely to benefit have been tested. These have included training and strategies like 'back-up' prescriptions for patients to use if symptoms get worse. Many have worked well and GPs using them have prescribed fewer antibiotics. The problem is that GPs not taking part in the research have not started using them, so very little has changed overall.

Government policies have also been introduced to give general practices more money if doctors prescribe fewer antibiotics to patients who are unlikely to benefit. This cost millions of pounds, and reduced antibiotic use, but it is not clear how promising extra money actually makes changes happen.

When researchers test a new diagnostic tool or training package, they don't just ask whether it works, but how much it would cost the NHS to use widely. Working out 'value for money' balances costs now against benefits and risks in the future. Antibiotics are so cheap (usually under £1 for a course) that most analyses suggest everyone should always get antibiotics. The problem is that we don't have good ways to include the threat that resistance poses in the future in these cost-benefit calculations.

This means that we spend time and money looking for new 'magic bullets' to reduce antibiotic prescribing, without getting the most from what we already know can work, but is not used. We need to know why effective strategies aren't used and improve them so they are used regularly in every-day care.

This project aims first to understand in more detail how the strategies that previous studies have sown reduce antibiotic prescribing worked. We need to do this because 'common sense' ideas are often wrong: different people react in different ways to the same situation and what researchers think is going on is often not the case. This will help us come up with ways to make existing strategies more attractive and easier to use every day. These will increase their uptake across England, meaning we can continue to reduce unnecessary antibiotic use and the threat of antibiotic resistance.

We will investigate 4 different, carefully chosen, areas.
- Incentivising general practices: evaluating an England-wide policy to pay general practices to reduce unnecessary antibiotic use
- Changes to the system: exploring 'delayed prescribing' where GPs give a prescription that patients can 'cash-in' if their symptoms get worse
- Improving GPs communication skills: investigating ways to help GPs explain to patients when antibiotics are not needed
- Better-informing decision-makers: assessing how we balance the health and cost impact of antibiotic use now vs resistance in the future, and how we determine cost-effectiveness of changes in antibiotic use

In each area, we will run detailed studies to find out what the barriers are to using effective strategies, and work out ways to overcome them. These will include studies with clinical commissioning groups, with GPs, nurse prescribers, practice managers and patients. We will then develop ways to improve strategies, in partnership with different types of healthcare professionals and patients. We will test these enhancements in an implementation study. We will also develop and apply new economic evaluation research methods to assess value for money.

Our team covers expertise in health psychology, health economics, biostatistics, primary care, pharmacy and clinical epidemiology. It also provides the opportunity for younger researchers to take leadership roles whilst being supported by more experienced colleagues.

Planned Impact

Who will benefit from this research?
This research will benefit the general public, patients, primary healthcare professionals, multiple policymakers in the UK and potentially abroad (see Academic Beneficiaries), and industry. It will directly benefit individuals involved in antimicrobial prescribing and resistance, but also has potential wider application by developing methods to bridge the 'implementation gap' and to improve assessments of cost-effectiveness.

How will they benefit from this research?
The major impact is continued year-on-year reductions in antimicrobial prescribing and consequently resistance.
- The general public will benefit from reduced antimicrobial resistance at a societal level, reducing their exposure to, and risks associated with infection with, antibiotic-resistant bacteria
- Patients will benefit from not receiving unnecessary antibiotics with associated side-effects, having increased understanding of why their GP might recommend this, greater ability to self-manage minor infections and with the 'safety net' of a delayed prescription if their symptoms worsen
- Primary healthcare professionals (GPs, nurse prescribers, practice managers, community pharmacists) will benefit from increased confidence in not prescribing immediate antibiotics, through use of delayed prescribing and improved consultation skills
- Improved consultation skills may also provide benefits beyond infections and antibiotics
- Resulting increased patient knowledge may also lead to reduced consultation for self-limiting illnesses, with increased appointment availability benefiting patients and professionals
- Clinical commissioning groups will benefit from identifying the most effective ways to implement financial incentives to improve clinical practice, which should be generalisable to other conditions beyond infections and antibiotics
- Public Health England and the Department of Health will benefit from evidence to indicate how interventions shown to be effective in research studies can be rolled out to actually change clinical practice
- National Institute for Clinical Excellence (and others including guideline developers, public health agencies, health technology assessors) will benefit from novel improved methods to assess the cost-effectiveness of interventions
- Industrial partners aiming to promote the uptake of point of care tests and improved diagnostics into primary care, and commissioners considering paying for such interventions, will benefit from in depth information about barriers and opportunities to uptake and sustained use

What will be done to ensure that they have the opportunity to benefit?
Our overarching objective to accelerate the uptake and maximise the sustainability of interventions to reduce prescribing in primary care is directed at ensuring that all groups above benefit from the research.

First, we will communicate and engage with patients and primary healthcare professionals through co-design workshops to ensure that research outputs accurately address the underpinning barriers and facilitators to intervention uptake, increasing their opportunity to benefit. This will be assisted by the inclusion of GPs and pharmacists at various career stages in the research team. We will communicate and engage with the clinical commissioning groups through the workshops and feedback activities within WS1.

At an institutional level, we will engage with policymakers through our advisory board which will include members representing DH (Mike Sharland, Chair of the Antimicrobial Resistance and Hospital Associated Infection (ARHAI) Advisory Committee), NHS England (e.g. leader in National Patient Safety) and NICE, as well as academics (as above). This will provide opportunities for them to shape the research before it starts, whilst it is ongoing, and throughout dissemination. Public representation on the advisory board will ensure that the research remains grounded in patient relevance

Publications

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Pouwels KB (2020) Estimating the effect of healthcare-associated infections on excess length of hospital stay using inverse-probability weighted survival curves. in Clinical infectious diseases : an official publication of the Infectious Diseases Society of America

 
Description Results from the in-depth investigation of the mechanisms of action of the national financial incentive to reduce antibiotic prescribing (the "Quality Premium") showed that the financial incentive was viewed positively at both the practice and clinical commissioning group level. However, the implementation of strategies to achieve the target varied considerably; the incentive helped influence change mainly by raising the priority of stewardship activities and defining change targets rather than providing additional funding. Variations in practice characteristics were not a major explanation of variation in the effect of the incentive on antibiotic prescribing across primary care practices. The effect was larger among high prescribing practices and those with relatively high diabetes prevalence. We have developed an implementation package of interventions targeting high antibiotic prescribing general practices through an iterative process gathering views of healthcare professionals from high prescribing practices and clinical commissioning groups, and patients and the public. The implementation materials aim to increase uptake of interventions (delayed prescriptions, enhanced communication skills, point-of-care C-reactive protein testing) already shown to be effective in reducing immediate antibiotic prescribing in an approach tailored to context-specific facilitators and barriers, providing ongoing decreases in antibiotic use over the next decade. Results of an online choice experiment showed that (i) the public have some understanding that immediate antibiotics are not needed for colds, but better education on their (lack of) role in viral sore throats may be helpful, (ii) primary care doctors wishing to use more delayed prescription, but concerned about patient acceptance, could increase use among the more amenable groups, including females, and people who are knowledgeable about antibiotics, (iii) patients will need reassurance that delayed prescription is appropriate for the more serious symptoms such as fever, and on the typical duration of these illnesses.

Results of a study estimating costs associated with bloodstream infection showed that wider adoption of inverse-probability weighted survival curves or alternative techniques that address time-varying confounding could lead to better informed decision making around the impact of healthcare associated infections and other time-dependent exposures on costs.
Exploitation Route To maximise impact, mechanisms of action of financial incentives should be considered pre-implementation.

We are currently conducting an implementation study to assess whether a "low intensity" tailored intervention can reduce antibiotic prescribing in nine high-prescribing practices. We are also continuing work in the other areas above.

Continuing education for GPs could stress the facts that delayed prescriptions were an acceptable strategy to most patients, providing it was explained well, and could target their use of these strategy to specific groups to increase uptake.

Better methods for estimating costs of time-dependent exposures such as bloodstream infection could be used more widely to improve research accuracy.
Sectors Healthcare

 
Description 13th International Health Economics Association Congress
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact Organised session presenting challenges in the health economic assessment of antimicrobial resistance at the leading health economics conference, in order to highlight the importance of this field to researchers, and promote discussion and collaboration.
 
Description Advisory Committee on Antimicrobial Prescribing, Resistance and Healthcare Associated Infection - Sarah Tonkin Crine
Geographic Reach National 
Policy Influence Type Membership of a guideline committee
Impact The Advisory Committee on Antimicrobial Prescribing, Resistance and Healthcare Associated Infection provides practical and scientific advice to the government on minimising the risk of healthcare associated infections. Dr Sarah Tonkin-Crine provides a health psychology and behaviour change perspective.
 
Description MOOC - Tackling Antimicrobial Resistance: A social science approach
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact With additional funding from the ESRC, we jointly developed a free online course, with researchers from another ESRC-funded project (ASPIRES), titled "Tackling Antimicrobial Resistance: A Social Science Approach" hosted on https://www.futurelearn.com/courses/social-science -for-tackling-antimicrobial-resistance. The course builds on the social science expertise from both research groups and includes clinical examples of antimicrobial stewardship from the UK, USA, India, South Africa, Uganda, and Australia. The 3-week course was developed in collaboration with BSAC and has been run twice, in November 2019 and March 2020. Participants learn: (i) What is social science and why do we need a social science perspective for tackling antimicrobial resistance (AMR)? (ii) Insights on implementing antimicrobial stewardship to tackle AMR across different settings (iii) Introduction to realist review (iv) Introduction to ethnography (v) Introduction to implementation science. The November 2019 course attracted 563 participants from 88 countries worldwide. Feedback was very positive with participants highly rating the course for its information content and usefulness for the future.
URL https://www.futurelearn.com/courses/social-science-for-tackling-antimicrobial-resistance
 
Description Social Science Research Methodologies Workshop: Tackling Antimicrobial Resistance
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact With additional funding from the ESRC, we jointly delivered a one-day workshop, with researchers from another ESRC-funded project (ASPIRES), that explored how social sciences methodologies can improve strategies to change antibiotic prescribing behaviours. The workshop supported knowledge exchange across ESRC-funded AMR Theme 4 researchers and enabled our social science expertise to be shared with over 40 other clinicians and PhD students from multiple countries worldwide. It included practical sessions on "Ethnographic methods and face-to-face interviews" and "Realist review". The content has since been developed as a free online course hosted on the online FutureLearn platform which will further widen participation and increase knowledge and skills in social science research relating to antimicrobial resistance.
URL https://www.imperial.ac.uk/news/190369/stronger-collaborations-with-social-sciences-essential/
 
Description ENACT - Exploring the implementation of iNterventions to reduce Antibiotic use and Catheter associated urinary Tract infections
Amount £59,539 (GBP)
Organisation Public Health England 
Sector Public
Country United Kingdom
Start 09/2018 
End 03/2019
 
Description National AMR Training Programme (2 PhD students)
Amount £145,425 (GBP)
Organisation Medical Research Council (MRC) 
Department Medical Research Foundation
Sector Charity/Non Profit
Country United Kingdom
Start 09/2018 
End 08/2023
 
Description Social Science Training
Amount £82,412 (GBP)
Funding ID ES/P008232/1 
Organisation Economic and Social Research Council 
Department ESRC Seminar Series
Sector Academic/University
Country United Kingdom
Start 04/2018 
End 03/2019
 
Description The role of locum GPs in antimicrobial stewardship: a mixed-methods study
Amount £29,218 (GBP)
Organisation Royal College of General Practitioners 
Sector Academic/University
Country United Kingdom
Start 06/2019 
End 10/2020
 
Description Imperial 
Organisation Imperial College London
Country United Kingdom 
Sector Academic/University 
PI Contribution Key Co-Investigator. Oversee the project and provide advice. Ensure governance and ethics approvals are in place. Ensure project milestones are met. Lead analysis and publications.
Collaborator Contribution Key Co-Investigator. Oversee the project and provide advice. Ensure governance and ethics approvals are in place. Ensure project milestones are met. Lead analysis and publications.
Impact N/A - Project started in May 2017
Start Year 2017
 
Description PHE 
Organisation Public Health England
Country United Kingdom 
Sector Public 
PI Contribution Key Co-Investigator. Oversee the project and provide advice. Ensure governance and ethics approvals are in place. Ensure project milestones are met. Lead analysis and publications.
Collaborator Contribution Key Co-Investigator. Jointly oversee workstream 4 and provide advice.
Impact N/A - Project started in May 2017.
Start Year 2017
 
Description Southampton 
Organisation University of Southampton
Country United Kingdom 
Sector Academic/University 
PI Contribution Key Co-Investigator. Oversee the project and provide advice. Ensure governance and ethics approvals are in place. Ensure project milestones are met. Lead analysis and publications.
Collaborator Contribution Investigator. Provide advice.
Impact N/A - Project started in May 2017
Start Year 2017
 
Description Big Data and AMR 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Podcast on Antibiotics awareness day
Year(s) Of Engagement Activity 2019
 
Description Big healthcare data and AMR 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Presentation to industry delegation from pharmaceutical industry delegation from Japan.
Year(s) Of Engagement Activity 2017
 
Description Citizen workshops around delayed prescriptions 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Two citizen workshops were conducted to explore attitudes to and views about (i) delayed antibiotic prescriptions and (ii) enhanced consultation communications with patient information leaflets as two mechanisms to reducing inappropriate antibiotic prescribing in primary care. Results informed development of the intervention being tested in the project.
Year(s) Of Engagement Activity 2019
 
Description Data visualisation and AMR - using healthcare data to tackle public health issues 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Presentation to policymakers on using routine healthcare data to tackle AMR
Year(s) Of Engagement Activity 2017
 
Description Estimating future prevalence and cost of AMR and how to incorporate this into economic evaluations - Koen Pouwels 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Postgraduate students
Results and Impact Invited talk at the Academic Unit of Health Economics at the University of Leeds, 21 April 2020
Year(s) Of Engagement Activity 2019
 
Description Estimating the impact of antibiotic resistant infections on clinical outcomes and excess length of hospital stay in the presence of time-varying confounding - Koen Pouwels 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact Talk at the Institut Pasteur, Paris
Year(s) Of Engagement Activity 2020
 
Description Estimating the impact of hospital-acquired infections in the presence of time-varying confounding - Koen Pouwels 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Third sector organisations
Results and Impact Invited talk at the Health Foundation, London, 6 February 2020.
Year(s) Of Engagement Activity 2019
 
Description Imperial Late Event - Infection 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact 30min talk to. general audience on the use of routine clinical data to target AMR infections
Year(s) Of Engagement Activity 2019
URL https://www.imperial.ac.uk/news/193992/college-gets-infectious-novembers-imperial-lates/
 
Description Mrs X 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Participated in a 'meet the experts' Q&A panel after a showing of Mrs X a play based on AMR
Year(s) Of Engagement Activity 2019,2020
URL https://www.imperial.ac.uk/news/193992/college-gets-infectious-novembers-imperial-lates/
 
Description Studio panel member in international TV broadcast 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact Expert panel member on 'Roundtable' discussion on AMR.
Year(s) Of Engagement Activity 2017
URL https://www.youtube.com/watch?v=p4M3dQfwY_g
 
Description The economics of AMR. What are current and likely future costs of AMR and how to incorporate this into economic evaluation - Koen Pouwels 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Industry/Business
Results and Impact Invited talk at GSK event on 'How can vaccines defeat antimicrobial resistance?', Siena, 21 November 2019
Year(s) Of Engagement Activity 2019