1 Version 2 Published online: July 2017 Review date: July 2019The TARGET Toolkit: Improving antimicrobial use in primary care Background for trainers and commissioners Version 2 Published online: July Review date: July 2019 TARGET Trainers Commissioners Presentation v2

2 The TARGET workshop Short presentation covering:Surveys around the publics attitudes to and use of antibiotics Evidence for approaches to reducing antibiotic use Thinking about how to improve responsible antibiotic use by: influencing personal attitudes, social norms and perceived barriers Other things to consider: Who should be involved in local plans TARGET Trainers Commissioners Presentation v2

3 Misconceptions about antibioticsQ1 Which of the following conditions, if any, do you think can be effectively treated by antibiotics? 2017 Correct answer? Aged 15-24 Lower understanding Social grade C2 or DE Base: All respondents (1,691); Fieldwork: 24th Jan–5thFeb 2017 Source: Ipsos MORI

4 Most know coughs & colds get better on their own & they should finish the courseStatement True or NOT? Please tell me to what extent you agree or disagree with the following? Perceptions are correct Lack of knowledge Base: All respondents (1,691); Fieldwork: 24th Jan–5thFeb 2017 Source: Ipsos MORI

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6 Prescribing evidence Consultations, and amoxicillin prescribing for acute cough and cold is increasing. 537 UK GP practices Hawker et al J AC 2014; TARGET Trainers Commissioners Presentation v2

7 Patient perspective data1,707 ≥16y in England % had infection in last 12 months 959 had 56% had throat, ear, sinus, chest infection or cough, flu What did they do with their most recent infection? 33% carried on most of their usual daily activities/ routine 23% took extra rest 34% took OTC medicine for symptoms 18% used alternative medicine (honey, lemon, herbal) for symptoms 0.4% took left-over antibiotics 5% Got advice from friend/family colleague McNulty et al. Ipsos Mori, 2017. TARGET Trainers Commissioners Presentation v2

8 The Patient Perspective 2017 n=249Patients visited their GP if they were worried 30% Needed treatment to help symptoms 24% Symptoms severe (breathing 11%, sleep 14%) 26% Symptoms lasted longer than I expected 15% Worried illness could get worse 11% Wanted to know the cause 9% I usually go to doctor’s surgery with these symptoms 8% I already have another health condition What did they expect? 38% Expected antibiotics 18% Advice on need for antibiotics 34% Other treatment for symptoms 17% To find out cause 25% Advice about self-care 13% Rule out more serious illness Information about illness duration 4% For referral to hospital/specialist McNulty, Nichols, French, Joshi & Butler. British Journal of General Practice, 2013 e429 TARGET Trainers Commissioners Presentation v2

9 Patient perspective dataA 2017 survey showed patients trust GPs and nurses’ advice It’s worth sharing information about the need or not for antibiotics in consultations, and self care McNulty, Butler, et al FIS 2014 TARGET Trainers Commissioners Presentation v2

10 Evidence for GP based interventionsBooklet to share with patients Antibiotic prescription 20% v 40% Intention to reconsult 55% v 76% CRP and communication skills Antibiotics in usual care 68% communication 33% CRP 39% Both 23% I M P A C3 T Francis et al BMJ 2010, Cals et al BMJ 2009;338:1374, TARGET Trainers Commissioners Presentation v2

11 Little, Williamson, Warner et al. BMJ . (1997) 314:722 - 727Patient: Delayed prescriptions Back-up/delayed prescribing can reduce antibiotic use & patient expectations English RCT comparing three treatment strategies for sore throat (n=582) , Little, Williamson, Warner et al. BMJ . (1997) 314: TARGET Trainers Commissioners Presentation v2

12 Patient: Delayed prescriptionsWhat do patients do with back-up/delayed prescriptions? IPSOS Mori Surveys: 2011 Random samples 1767> 15 yrs, England 14% Offered back-up / delayed prescribing in past year 60% collected and took the antibiotic Back-up antibiotics can reduce antibiotics by % McNulty, Butler, et al FIS 2014 TARGET Trainers Commissioners Presentation v2

13 Reflection: possible solutionsHow can we fit together this evidence and change behaviour during consultation with patients to improve antibiotic prescribing? Practice GP Evidence Patient TARGET Trainers Commissioners Presentation v2

14 TARGET Toolkit To help clinicians and commissioners to use antibiotics responsibly and meet CCG requirements TARGET Trainers Commissioners Presentation v2

15 “I want to use antibiotics responsibly”Theory of Planned Behaviour Personal Attitude Subjective Norms (peers values) Intention Behaviour Perceived Behavioural Controls (Barriers) “I want to use antibiotics responsibly”

16 “My responsible use of antibiotics will make a difference to patients”Outcome beliefs Attitude “My responsible use of antibiotics will make a difference to patients” It’s important! Subjective norms Intention Behaviour Perceived Behavioural Control TARGET Trainers Commissioners Presentation v2

17 “If I prescribe responsibly – I will be rewarded for it” Rewards of Outcome beliefs Attitude “If I prescribe responsibly – I will be rewarded for it” Clinicians: lower consultations, incentives, reputation Rewards of behaviour Subjective norms Intention Behaviour Perceived Behavioural Control TARGET Trainers Commissioners Presentation v2

18 Consultation rates v prescribing537 UK GP practices Practices who reduced prescribing in GPRD study experienced a reduced consultation rate Thus patients can be retrained not to expect antibiotics Hawker et al JAC 2014; Ashworth et al BJGP 2005.

19 “My peers also believe in responsible prescribing”Outcome beliefs Attitude “My peers also believe in responsible prescribing” Rewards of outcome Peer / societal beliefs Subjective norms Intention Behaviour Perceived Behavioural Control TARGET Trainers Commissioners Presentation v2

20 Importance of the team approachWhole practice team invited to TARGET workshops Out of hours Dentists Vets Nationally EU and Worldwide

21 Teach our future generation about antibiotic resistance and usee-Bug is a health education resource for school aged children Learn about microbes, the spread and treatment of infection, and antibiotics

22 “I want to prescribe responsibly because my peers would want me to”Outcome beliefs Attitude “I want to prescribe responsibly because my peers would want me to” Clinicians, CCGs, hospitals, countries: respect, audits, cost, patient outcomes Rewards of outcome Normative beliefs Subjective norms Intention Behaviour Motivation to comply Perceived Behavioural Control TARGET Trainers Commissioners Presentation v2

23 DDD per 1000 inhabitants per day (2015) (ECDC)UK Prescribing DDD per 1000 inhabitants per day (2015) (ECDC)

24 Prescribing: local dataTotal antibiotics % of total: cephalosporins and quinolones Beech et al 2014: 2013 e-PACT data in England

25 TARGET: Audits & action planningAudit templates for: Sore throat Otitis media Acute otitis externa Acute cough Acute rhinosinusitis UTI A self assessment checklist

26 Financial incentives or indicatorsIncentives can be effective while in place QIPP 2017/19 Total antibiotics % broad spectrums % trimethoprim Ratio Trim/ Nitrofurantoin Decreasing: Total or the 4Cs Increasing prescribing in line with guidance Overall, payment for each service, episode or visit; payment for providing care for a patient or specific population; and payment for providing a pre-specified level of care or providing a change in activity or quality of care were generally effective. Mixed or other system interventions produced mixed results and payment for working for a specified time period was generally ineffective. Looking at different groups of outcomes, financial incentives were generally effective at improving processes of care, referrals and admissions, and prescribing costs; they had mixed effects on consultation or visit rates and were generally ineffective in promoting compliance with guidelines. They are generally effective in improving prescribing costs outcomes (improving 28/34 outcomes from 10 studies in one review Financial incentives used to encourage chlamydia testing will strongly influence personal attitude and practice subjective norms, but have been shown to be ineffective in isolation23 or to have a short-term effect24 as they are unlikely to influence long-term attitudes about the importance of testing unless combined with other interventions, as in Kalwij’s initiative.21 We also saw a temporary increase in testing prior to April 2009, 2010 and 2011 (see Web only figure 3), as practices sought to reach local targets. TARGET Trainers Commissioners Presentation v2

27 “I have the confidence to prescribe antibiotics responsibly”Outcome beliefs Attitude Rewards of outcome Normative beliefs Subjective norms Intention Behaviour Motivation to comply Self efficacy “I have the confidence to prescribe antibiotics responsibly” Clinicians: knowledge, guidance Perceived Behavioural Control TARGET Trainers Commissioners Presentation v2

28 TARGET: Antibiotic Management GuidanceMake available to ALL in practice and out of hours, So patients do not go to another GP or out of hours TARGET Trainers Commissioners Presentation v2

30 Patients: “I have the confidence to use antibiotics responsibly”Knowledge of signs of severity, over-coming fears, self-care of symptoms Outcome beliefs Attitude Rewards of outcome Normative beliefs Subjective norms Intention Behaviour Motivation to comply Self efficacy Perceived Behavioural Control TARGET Trainers Commissioners Presentation v2

31 TARGET: Patient information leafletsTARGET Treating Your Infection – Respiratory Tract Infection Leaflet All sections can be personalised and added to by the GP “Most get better by” section educates patients about when to consult Safety netting Back-up prescription Information about antibiotics & resistance Read codes: Delayed:8CAk, Leaflet: 8CE TARGET Trainers Commissioners Presentation v2

32 TARGET: Resources for clinical & waiting areasPosters for Display Videos for patient waiting areas TARGET Trainers Commissioners Presentation v2

33 External factors Outcome beliefs Rewards of outcome NormativeMotivation to comply Attitude Subjective norms Perceived Behavioural Control Intention Behaviour External factors “I can overcome other barriers preventing me using antibiotics responsibly” Clinicians: time, forgetfulness, computers, prescriptions, regulations Patients: cost, work TARGET Trainers Commissioners Presentation v2

34 Tactics to improve prescribing must therefore be multi-factorialOutcome beliefs Rewards of outcome Normative Motivation to comply Self efficacy External factors Attitude Subjective norms Perceived Behavioural Control Intention Behaviour Tactics to improve prescribing must therefore be multi-factorial TARGET Trainers Commissioners Presentation v2

35 To convert intentions into behavioursAction planning To convert intentions into behaviours HOW? Use the TARGET leaflets to reduce patient expectations Understand how to use the TARGET leaflets and set them up on the computer system Develop computer prompt or use patient.co.uk to increase use of leaflet Use back-up/delayed prescribing (the leaflet will help) Refer to the posters to introduce antibiotics Make sure everyone has access to antibiotic guidance Agree antibiotic audits and put them on the next practice agenda Give an individual responsibility of taking these forward TARGET Trainers Commissioners Presentation v2

36 Action plan: to reduce community Clostridium difficileReduce use of Ciprofloxacin Cephalosporins Co-amoxiclav Increase use of Nitrofurantoin Trimethoprim Pivmecillinam for UTI Co-amoxiclav ONLY recommended for: Pyelonephritis in pregnancy Facial cellulitis or prophylaxis post dog or human bites Diverticulitis Severe sinusitis unresponsive to penicillin V NHS Organisation Targets for C. difficile infections: TARGET Trainers Commissioners Presentation v2

37 Influence of lab susceptibility reporting of antibiotics on prescribing: MIQUEST UTI searchCo-amoxiclav reported Cefalexin reported Co-amoxiclav reported McNulty et al JAC TARGET Trainers Commissioners Presentation v2

38 Educate school aged childrenWhat can we do to influence antibiotic use in year olds and children? We can inform young people about prudent antibiotic use; they are our future generation of antibiotic users But as important Half of children consulting their GP have an infection Majority are respiratory Antibiotics are the most common childhood medicines If we reduce infections in children and adults we reduce antibiotic use TARGET Trainers Commissioners Presentation v2

39 Who should be involved and influences your local stewardship plan for primary care?Make use of the trainer pack Think about in your area: Who leads the action plan Who pushes Who benefits Who hinders

40 Who should be involved and influences your local action plan?Who leads A group of individuals across the CCG (a collaborative),with a leader Clinicians Group of pharmacists Commissioners involved in leading Collaborative will discuss how to develop a plan Include patient representative 2. Who pushes…. Patients CCG Professional bodies Public Health Area Team CQC Commissioning Support Units

41 Who should be involved and influences your local action plan?3. Who benefits? Patients Society Professionals Health System 4. Who hinders? Competing priorities Contradictions – time, geography etc Evidence Organisation/professional silos ,

42 Exploring barriers to implementation of an effective local plan and overcoming themRolling out workshops – trainer packs and developing a plan of action who trains the trainers and then gives workshops and to whom? who organises? who pays? other alternatives to workshops

43 Exploring barriers to implementation of an effective local plan and overcoming them2. Collecting ePACT/ Fingertips/ PrescQiPP data Who will collect, How will data be fed back to staff Who will develop graphs for workshops and what will you present? Developing indicators and audit and feeding back progress – who will do this? When?

44 Prescribing: local dataCCG Average Vs Your Practice (Practice A and Practice B) Total items prescribed per 1000 population per practice (2012/13 – 2016/17) CCG Surgery A Surgery B TARGET Trainers Commissioners Presentation v2

45 Exploring barriers to implementation of an effective local plan and overcoming them 3. Promoting resources in the TARGET toolkit? Patient leaflets and any modifications: could just encourage use, or print, or design other format, or link into local computer systems Videos and posters Social media National campaigns

46 Many thanks to: The TARGET team at the PHE PCUThe TARGET team at the RCGP All those involved in TARGET materials The GPs and patients: involved in evaluation and interviews The IPSOS Mori team The PHE e-Bug team TARGET Trainers Commissioners Presentation v2