Age-related decline in primary care antibiotic prescribing for patients with uncomplicated respiratory tract infections following the introduction of the Quality Premium in England: Interrupted time series analysis.
Problem
The use of antibiotics globally and in England is widespread and the subsequent presence of bacteria resistant to these antibiotics is increasing. Various international and national policy and initiatives advocate the judicious and appropriate use of antibiotics with the intention of easing the rate of resistance. In 2015/16 the Quality Premium (QP), an England-wide scheme, introduced a financially incentivised measure to reduce unnecessary antibiotic prescribing, a known driver of antibiotic resistance, in primary care by 1% of total antibiotics and 10% broad-spectrum antibiotics. We investigated whether the introduction of the QP was associated with reduced prescribing in primary care for uncomplicated respiratory tract infections (RTIs) and whether this varied by age.
Approach
The study population was obtained from the Clinical Practice Research Datalink database and included patients with a permanent status in up-to-standard English GP practices, who consulted for acute uncomplicated RTIs during the study period of April 1st, 2011 – March 31st, 2017. Consultations were grouped into: acute otitis media, rhinosinusitis, sore throats, upper RTIs, lower RTIs, viral RTIs. Antibiotic prescriptions were linked to a patient’s consultation if both occurred on the same day. The antibiotic therapy codes were identified using the British National Formulary subchapter 5.1 (excluding anti-tuberculosis drugs and anti-leprotic drugs). The analyses used a segmented regression of interrupted time series, a strong-quasi experimental design, fitting monthly data to an Autoregressive Moving Average (ARMA) model to assess the impact of the QP (2015/16) on antibiotic prescribing and broad-spectrum antibiotic prescribing by General Practitioners for RTIs. We examined trends in prescribing for children, adults and elderly.
Findings
Prescribing rates decreased over the study period, with a significant drop in the level of antibiotic prescribing of 14.65 per 1,000 consultations (p<0.05) from April 2015, coinciding with the introduction of the QP. A year after implementation there was a 3% relative reduction in antibiotic prescribing for RTI consultations, with this reduction being sustained after two years. There was a concurrent slight reduction in the rate of broad-spectrum prescribing after the introduction of the QP. Antibiotic prescribing of RTI consultations for children exhibited the greatest decline with a 6% relative change in this age group two years post-QP. Of the RTI indications studied, the greatest reductions in antibiotic prescribing were seen in patients who consulted for sore throats post-QP. The reduction in antibiotic prescribing did not have a concurrent effect on re-consultation rates.
Consequences
Reviews of the impact of the QP 2015/16 on antibiotic prescribing have not yet examined the specific effect on underlying indications consulted for in primary care or derived age-related prescribing trends. Our results provide support that there was a decrease in antibiotic prescribing, and informs on which groups of patients and infection types have been most affected.