Feedback Intervention for Reducing Antibiotic Prescriptions in Township Public Hospitals, China : A randomized Crossover Trial

Abstract

Objective 1: To document the clinical pattern of antibiotics use and its overuse and misuse rates in rural primary care institutions and to evaluate the association between antibiotics use and characteristics of physicians and their patients. Methods: Medical records from 16 township public hospitals in rural areas of Guizhou Province, China were obtained from the Health Information System in 2018. Classification of unnecessary use, incorrect spectrum of antibiotic, escalated use of extended spectrum antibiotics and combined antibiotics use was based on the Guiding Principle of Clinical Use of Antibiotics (2015, China) and guidelines from the US Centers for Disease Control and Prevention. Generalized Estimating Equations were employed to determine predictive factors for inappropriate antibiotics use. Results: A total of 74,648 antibiotics prescriptions were retrieved. Uncomplicated respiratory infection was the most common disease accounting for 58.6% of all prescriptions. The main antibiotic group used was penicillins (51.5%) followed by cephalosporins and macrolides (14% each). Of 57,009 patient visits, only 8.7% of the antibiotic prescriptions were appropriate. Combined use, escalated use of extended spectrum antibiotics, incorrect spectrum and unnecessary antibiotics use was found in 7.8%, 1.9%, 4.3% and 77.3% of patient visits, respectively, of which 28.7% were given intravenously. Antibiotics misuse was significantly more likely among newly employed physicians with lower levels of professional education. Adult patients and those who had public insurance had a higher risk of being prescribed unnecessary antibiotics. Conclusion: Misuse and overuse of antibiotics for uncomplicated respiratory infection and use of cephalosporins, macrolides and injection antibiotics in primary care are the major problems of clinical practice in rural areas of Guizhou. Keywords: Antibiotics prescription, Clinical pattern, Misuse, Overuse,Primary healthcare, Primary care physician Objective 2: To implement an intervention based on an on-line feedback system, and evaluate the effect of intervention and its influencing factors among rural physicians in primary hospitals. Methods: A hospital-based cluster randomized crossover study was conducted in primary care institutions in the southwest of China from 1st February to 31st August 2018. General outpatient physicians who worked at township public hospitals for at least six months were assigned to receive a feedback intervention or not in a random sequence for 3 months. All medical records were retrieved from the health information system. The primary outcome was the 10-day antibiotic prescription rate of the physicians, defined as the number of antibiotic prescriptions divided by the total number of prescriptions during consecutive 10-day time periods. Results: We randomly selected 31 hospitals using a computer generated number from the list of 84 hospitals met the criteria. These hospitals were randomly allocated to 2 groups. Baseline comparison showed no significant difference in antibiotic prescription rate between the intervention and control groups (30.8% vs 35.2%, P-value = 0.07). At the crossover point, physicians in the intervention group had a significantly lower prescription rate than the control group (20.3% vs 33.1%, P- value <0.001). After 6 months, the rate of decline in antibiotic prescriptions rate was also significantly greater in the intervention group compared to the control group (18.9% vs 15.7%). The characteristics of physicians did not significantly determine the rate of antibiotic prescriptions. Conclusion: A computer network-based feedback intervention can significantly reduce the antibiotic prescription rate of primary care outpatient physicians and continuously affected the physicians' prescription behavior for up to 6 months. Trial registration ChiCTR1900021823 Keywords: Antibiotic prescription rate, Crossover trial, Feedback intervention, Primary care physicians, Health information system