SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
August, 2011 - SUPPORT Summary of a systematic review | print this article | download PDF
The unnecessary use of antibiotics in the ambulatory setting can produce increased antimicrobial resistance among bacterial pathogens. This increasing prevalence of antibiotic resistance has led to the use of more expensive and broad spectrum antibiotics, contributing to increasing health care costs.
Numerous strategies to reduce inappropriate use of antibiotics have been implemented by investigators and organizations at the clinician, patient and organization level.
Key messages
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Michael A. Steinman, Sumant R. Ranji, Kaveh G. Shojania, Improving Antibiotic Selection: A Systematic Review and Quantitative Analysis of Quality Improvement Strategies. Med Care 2006; 44: 617–628
Ranji SR, Steinman M, Shojania K and Gonzalez R. Interventions to Reduce Unnecessary Antibiotic Prescribing. A Systematic Review and Quantitative Analysis. Med Care 2008;46: 847- 862
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Antibiotic resistance is a serious problem for individual patients and health care systems. The excessive use of antibiotics, particularly in ambulatory practice, has markedly increased antimicrobial resistance (AMR) among community acquired bacterial infections (Streptococcus pneumoniae, Staphylococcus aureus and Escherichia coli) warranting consideration of modifying empiric antibiotic treatment for patients with suspected infections.
One approach to reducing the incidence of infections due to antibiotic resistant organisms is to reduce the inappropriate use of antibiotics, but changing physician behavior requires identifying and addressing barriers to change in practice. Multiple interventions have been implemented to achieve this, such as educational interventions alone or combined with audit and feedback, patient education or others.
| Review objectives: To evaluate strategies to reduce unnecessary antibiotic prescribing in outpatient practice,to quantitatively compare the effect of strategies targeting clinicians, patients and/or health care systems. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Interventions | RCTs, CBAs or ITS that evaluate interventions to reduce unnecessary prescription of antibiotic for acute non bacterial illnesses using one of the following interventions: clinician and patient education,audit and feedback, clinician reminders and decision support systems, financial and regulatoryincentives and provision of delayed prescriptions. |
Twenty four trials from 23 studies tested an intervention using at least 2 distinct quality improvement (QI)strategies: clinician education combined with patient education (12 trials), clinician education combined with audit and feed back (6 trials),and clinician education combined with both patient education and audit and feedback (4 trials).The remaining 24 trials used a single QI strategy, most commonly clinician education (12 trials) or patient education (7 trials). |
| Participants | Clinicians, patients, health care system |
Patients were adults and children with respiratory infection and clinicians were most from primary care setting. |
| Settings | Outpatient setting |
17 studies were performed in the United States and 12 studies in Europe. Nearly all studies took place in outpatient primary care clinics (N= 40 studies), and the majority focused on prescribing for acute respiratory infections (N= 38 studies). |
| Outcomes | Proportion of patients visits at which antibiotic was prescribed |
Thirty trials (from 20 studies) reported changes in the proportion of visits at which patients were prescribed antibiotics |
| Date of most recent search: March 2007 | ||
| Limitations: This is a systematic review with major limitations. There is not report of risk of bias of individual studies. | ||
Michael A. Steinman, Sumant R. Ranji, Kaveh G. Shojania, Improving Antibiotic Selection: A Systematic Review and Quantitative Analysis of Quality Improvement Strategies. Med Care 2006; 44: 617–628
Ranji SR, Steinman M, Shojania K and Gonzalez R. Interventions to Reduce Unnecessary Antibiotic Prescribing. A Systematic Review and Quantitative Analysis. Med Care 2008;46: 847- 862
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
This summary has been done based on two systematic reviews: Steinman 2006 evaluated interventions that improve the prescription of recommended antibiotics. It included 26 studies, reporting 33 trials. Most of the studies assessed interventions focused on clinicians.
Ranji 2008 assessed the effectiveness of quality improvement (QI)strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often prescribed inappropriately. It included 43 studies, reporting 55 trials. 5 studies were included in both reviews.
1) Clinician Education alone vs. No intervention
Clinician Education included interventions such as: distribution of materials, educational meetings, educational outreach and educational workshops with or without guideline distribution.
In Steinman el at, 11 trials were included that assess this intervention. All of them were done in high income countries. In Ranji et al, 10 trials were included, only one of these studies was also included in Steinman review. 7 of these studies were developed in low and middle income countries (Cuba, Indonesia, Zambia, South Africa and Sri Lanka).
Clinician education alone vs. no intervention |
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| Patient or population: clinicians. Settings: ambulatory clinics in US, Cuba, Indonesia, Belgium, Sweden, Zambia, Sri Lanka, Australia. Intervention: educational strategies (outreach visits distribution of materials, workshops). Comparison:no intervention. |
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| Outcomes | Median of means (Interquartile range) |
No of Participants (studies) |
Quality of the evidence (GRADE) |
Comments |
| Proportion of patients treated with the adequate antibiotic1 |
13.9 % (8.6%- 21.6%) |
11 studies1 |
Very low |
Positive values mean intervention is better than comparator. |
| Reduction of patient visits at which an antibiotic was prescribed2 |
9% (8.2%-13%) |
10 studies |
low |
Positive values mean intervention is better than comparator |
| Clinical (hospitalization admission rate, mortality) | No data reported | |||
|
p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page) 1: Steinman 2006 2: Ranji 2008 |
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In Steinman el at, 8 trials were included that assess clinician educational interventions + audit and feedback. All of them were done in high income countries.
In Ranji et al, 3 trials assessed clinician education + audit and feedback + patient education. These 3 studies were developed in high income countries too.
Clinician education + other interventions vs. No intervention |
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| Patient or population: clinicians, patients Settings: ambulatory clinics in US, The Netherlands, UK, Sweden, Australia, Mexico Intervention: educational strategies (workshops, group educational outreach) with feedback or with feedback and patient education Comparison: no intervention. |
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| Outcomes | (Median and IQ range) |
No of Participants (studies) |
Quality of the evidence (GRADE) |
Comments |
| Proportion of patients treated with the adequate antibiotic1 |
3.4 % (1.8%- 9.7%) |
8 studies1 |
Low |
Intervention is clinician education + audit and feedback |
| Reduction of patient visits at which an antibiotic was prescribed2 |
11% (10-5%- 17%) |
3 studies2 |
Very low |
Intervention is clinician education+ audit and feedback+ patient education |
| Clinical outcomes | Not reported | |||
| p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page) |
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|
1: Steinman 2006 2: Ranji 2008 |
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Only Ranji et al. reports results for this comparison. 6 trials were included, 5 studies were done in the USA and implemented written educational material to patients; there is one study conducted in Cuba using patient educational meetings.
Patient education alone vs. No intervention |
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| Patient or population: patients. Settings: ambulatory clinics, USA, Cuba. Intervention: educational strategies (written, meetings) Comparison: no intervention. |
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| Outcomes | (Median and IQ range) |
No of Participants (studies) |
Quality of the evidence (GRADE) |
Comments |
| Reduction of patient visits at which an antibiotic was prescribed1 |
7.5% (3.5%-13%) |
6 studies2 |
Very low |
Positive values mean intervention is better than comparator |
| Clinical outcomes |
Not reported |
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|
p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page) 1: Ranji 2008 |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
|
The 2 reviews included in this summary covered an extensive range of settings and interventions developed in several countries. Only one review includes trials conducted in low and middle income countries. Overall, strategies assessed result in small improvement in antibiotic prescription. |
Correct use of antibiotic by patients will depend upon several other issues than physician prescription: country regulatory policies about sell and dispensing of these drugs, self medication habits of patients, access to health care, importance of unregulate market for these drugs. |
| EQUITY | |
| Some of the studies that provide evidence about effect of clinician education alone were conducted in LMICs, but they do not provide information about differential effect in disadvantage populations |
Strategies that improve rational use of antibiotic could help decrease some health costs and consequently could contribute to decreease some inquities in health. This is specially true in countries were medicines are financed importantly with out of pocket money |
| ECONOMIC CONSIDERATIONS | |
|
The reviews reported in this summary do not report costs outcomes
|
The cost of interventions is likely to be highly variable and must be estimated based on specific local conditions These interventions could save costs arising from unnecessary medication and treatment of drug resistant strains among others. Evidence from cost effectiveness studies is needed It is necessary to assess the impact on health system costs considering the savings derived by the correct use of antibiotic and the expenses needed to implement interventions in low and middle income enviroment |
| MONITORING & EVALUATION | |
|
Reviews reported a high uncertainty about effects of interventions to increase rational use of antibiotics
|
More adequate studies (maybe good quality cluster randomised control trials) are required to increase certainty of effect of interventions to improve rational use of antibiotic in ambulatory setting
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
|
Holloway K and van Dijk L. The World Medicine Situation 2011. Rational Use of Medicines. WorldHealth Organization 2011. Available on http://apps.who.int/medicinedocs/en/d/Js18064en/
Penaloza B. Pontificia Universidad Catolica de Chile.
Non declared. For details, see: www.support-collaboration.org/summaries/coi.htm.
This summary has been peer reviewed by: [Name, Country;]
Penaloza B. Which interventions can improve antibiotic use in ambulatory setting?.. A SUPPORT Summary of a systematic review. May 2013. www.support-collaboration.org/summaries.htm.
All Summaries:
evidence informed health policy, evidence based, systematic review, health sys-tems research, health care, low and middle income countries, developing countries, primary health care quality improvement, antibiotic prescribing,
