Meryl Davies (HDUHB) and Jo McCarthy (PHW)
Hywel Dda University Health Board with Public Health Wales
This Bevan Exemplar project examined prescribing practices and introduced education to impact antimicrobial prescribing.
Antimicrobial resistance is rising across the globe with antibiotics becoming a finite resource which are less effective at treating common bacteria. Inappropriate and over prescribing of antibiotics are key drivers in antimicrobial resistance.
The majority of antibiotic prescribing occurs in primary care, and around 20% of these prescriptions are thought to be ‘inappropriate’ (NHS England 2018), yet interventions and education around antibiotics frequently focus on secondary care prescribing. When there is engagement with Primary Care, it is commonly targeted to high prescribers and involves a directive approach and informing colleagues of national guidance.
In Wales, to date, there has not been a Primary Care intervention looking at both high and low prescribing practices and explores the reasons behind prescribing decisions, and involves face-to-face education from an Antimicrobial Pharmacist and a Microbiologist. It was therefore important to see what, if any, impact this approach could have on changing prescribing behaviours.
The overall aim of the project was to improve the appropriateness of antimicrobial prescribing in Primary Care. Secondary aims were to identify factors which can positively or negatively impact on the appropriateness of antimicrobial prescribing and strengthen links between Microbiology, the Antimicrobial Pharmacist and General Practices in Hywel Dda.
Four high and low prescribing practices were involved in the project. Practices were defined as high/low prescribers of antibiotics using data from All Wales Therapeutics and Toxicology Centre (AWTTC), hosted on the SPIRA database. However, many high prescribing practices had been audited in the past year and therefore had to be excluded from being part of the project.
There were challenges around timing of the face-to-face education and feedback sessions, due to Microbiologist and GP commitments, this meant that a significant amount of time was spent on arranging dates and for one session a Microbiologist was unavailable. Lack of GP availability also meant that a planned ‘sharing good practice’ session for the participating surgeries could not go ahead during the timeline of the project.
At initial audit low prescribing practices prescribed quinolones, cephalosporins and co-amoxiclav more appropriately than high prescribing practices (79.2% compared to 54.9%). 6 months after the education sessions the practices were re-audited, appropriateness of prescribing across the three groups of antibiotics audited was around the same for the low prescribers (75.7%) while appropriateness had increased for the high prescribers, from 54.9% to 72.8%.
In addition to prescribing data, financial data has been collected demonstrating the monetary implications of reducing antimicrobial prescribing in terms of total drug spend. This will be analysed alongside information around the reduction in audit times when practices improve their prescribing, to inform a business case for further Primary Care Antimicrobial Pharmacist posts across Hywel Dda. The project has demonstrated that, pre-intervention, low prescribers appear to also be more appropriate prescribers, and that auditing and providing bespoke education sessions can take high prescribing surgeries to a position where they prescribe as appropriately as low prescribing counterparts. Therefore rolling out the process throughout Hywel Dda could considerably impact on both drug and auditor costs in future.
Feedback and profiling forms have been collected from participating surgeries, enabling practices to both reflect on the challenges they face around antimicrobial prescribing and their prescribing practices in surgery. Once analysed, findings will be anonymised and shared amongst all surgeries within Hywel Dda so that systems and procedures which increase the appropriateness of antimicrobial prescribing can be shared.