How can we support general practices to implement effective interventions to reduce unnecessary antibiotic use?

Problem

Antibiotic resistance is a worldwide public health priority. Interventions are required to reduce unnecessary antibiotic use. Several types of interventions are effective at reducing antibiotic prescribing by primary care clinicians and antibiotic use by patients. Three are: training in use of C-reactive protein point-of-care testing (CRP POCT), communication skills training for clinicians and use of delayed prescriptions (DP). However, these interventions appear to be rarely used in UK general practice. We sought to develop support materials to increase engagement and adoption of these three interventions in general practice.

Approach

We used the Person-Based Approach to inform the development of support materials. This approach combines theory, evidence and person-based approaches. We used intervention content from previous interventions shown to be effective and drew on relevant theories of change. We sought clinicians’ views and experiences to make decisions about the content and delivery of materials in three stages:• Focus groups with clinicians in 9 high-antibiotic prescribing practices discussing use of the three interventions.• Four workshops, two with clinicians and two with citizens, discussing initial ideas for, and drafts of, support materials.• Think-aloud interviews (22) with clinicians to feedback on draft support materials.

Findings

Focus group data indicated that clinicians struggled to identify scenarios for which interventions would be most useful and often had contradicting views. Clinicians had no access to POCT CRP, mainly due to cost, but varied in whether, and how, they thought tests would be helpful. Training in communication skills and use of DP were sometimes seen as unnecessary but some were open to the idea of refining their existing skills for “difficult patients”.In workshops, clinicians wanted brief materials that covered multiple scenarios. They suggested one patient booklet which would “suit all ages and cover all infections” and communication skills on “one A4 sheet”. Preference for type of CRP POCT was based on cost and time to result. Clinicians felt that a ‘champion’ within each practice could help adoption of interventions. Citizens initially struggled with the concept of a DP but identified communication strategies which could be better understood by patients.In think aloud interviews clinicians requested minimal content, clear links to evidence, examples of other clinicians’ experience and easily accessible summary sheets. Some particularly liked examples of alternative explanations for patients when not giving a prescription or when giving a DP. Some terminology needed to be adapted to better resonate with clinicians.

Consequences

There appeared to be a clash between the format and length of support materials which clinicians considered ideal and the breadth and detail of content which was thought to be useful. With detailed input from clinicians we developed support materials for practices which are currently being evaluated in an implementation study with 9 high-antibiotic prescribing general practices.