This study showed that a combined intervention programme targeting GPs and patients and focusing on improving diagnostic procedure and treatment in patients with RTIs led to a marked reduction in antibiotic prescribing and a significant change in the choice of antibiotics. A considerable reduction in antibiotic prescribing was found in Argentina, Lithuania, Russia and Spain. In Denmark and Sweden we found no significant changes in the overall use of antibiotics, but marked changes were found related to the choice of antibiotics.
The intervention aimed to help GPs to distinguish between viral and bacterial aetiology. All practices were offered access to POC tests (StrepA and CRP) and the practice staff was instructed how to interpret the results. GPs were encouraged to employ a rational use of antibiotics according to the HAPPY AUDIT guidelines, and they were requested only to prescribe antibiotics to patients with a suspected bacterial aetiology.
All GPs were exposed to the multifaceted intervention activities, and based on the results in this study it is not possible to identify the elements that had the highest impact on the prescibing pattern. The majority of GPs (GPs from Argentina, Spain, Russia amd Lithuania) did not have access to POC test before the intervention, while most GPs from the Nordic countries used POC tests routinely. The marked effect of the intervention found outside the Nordic countries may to a certain extent be due to the introduction of POC tests in practice.
Our data must, however, be interpreted with caution due to a number of limitations. GPs participated on a voluntary basis and probably their prescribing habits may not represent the average use of antibiotics in their country . GPs that were willing to register their antibiotic prescribing may have been more interested in quality development and research than GPs in general. Furthermore, they were willing to dedicate sufficient time to complete patient reports without economic incentives. The amount of time involved in this project could be considered to be a prominent barrier to participation, as GPs might find it difficult to dedicate the time in their daily work. However, earlier studies using the same type of data registration did not find it very time-consuming. Each registration takes less than 2 minutes, but the GPs also needed to allocate sufficient time for the subsequent courses and other activities planned during the intervention period.
Another limitation which should be taken into account is the fact that performing a registration on antibiotic use may in itself influence the prescribing habits. However, studies have shown that the reliability of this methodology applied in different countries is high and findings are correlated with the real prescribing in practice .
In our study, we asked the GPs to register what happened during the consultation, but patients were not followed after the consultation and thus we have no knowledge about the consequence of reducing antibiotic prescribing for the patients involved. From a theoretical point of view, the decision to treat should be taken after a diagnosis has been established. In general practice, however, the diagnostic procedures and the decision to treat are intricately linked. The GP may decide whether or not to prescribe an antibiotic at the same time, or even before, he classifies a specific diagnosis to the patient. After making the decision to prescribe the GP may thus adjust the diagnosis to fit the decision about treatment. This may lead to a diagnostic misclassification bias. However, this potential bias will affect the validity of the diagnosis both before and after the intervention and it only has a small likelihood of influencing the effect of the intervention.
Due to the limited time allocated for the registration process in practice only the typical signs and symptoms of RTIs according to the medical literature were recorded. This may lead to some limitations. The before-after design without a control group suffers from some limitations due to the fact that changes in antibiotic prescribing could be due to factors other than the intervention performed by the investigators. Non-biomedical factors that might represent powerful predictors of antibiotic prescription such as market regulation and socio-economic factors were not taken into account in this study.
This is a pragmatic study where registration of patients was performed in a natural practice setting. Patients were not informed about the project prior to the consultations. GPs participating in the audit were not allocated extra time for consultations, and they were not able to make considerable changes in their practice activities during the 3 weeks of registration. Thus, they attended the same patients as if they were not participating in the study. Therefore, it is most likely that our results can be extrapolated to other areas and practices with similar settings.