‘Nudge’ letters prompt sustained drop in antibiotic prescribing

Doug Hendrie

15/09/2020 4:19:17 PM

It is estimated GPs issued around 190,000 fewer antibiotic prescriptions as a result of the compliance campaign.

News teaser

Comparing GP antibiotic prescribing rates to peer averages led to a 12% drop in prescribing, and the effect has now shown to be maintained a year afterwards, according to a recent update from the Federal Government’s Behavioural Economics Team (BETA).
The effect remained surprisingly strong after a year, with a 9% reduction seen – or around 190,000 fewer prescriptions.
The results have been hailed by antibiotic resistance experts as a step in the right direction to getting Australia’s rates of prescribing trending downwards to fend off the growing threat of antibiotic-resistant superbugs.
GP prescribing rates began falling in 2016 after two decades of increases, according to the 2019 Third Australian report on antimicrobial use and resistance in human health.
However, Australian antibiotic prescribing rates in primary care are still in the world’s top 25%, with a notable spike seen during cold and flu season.
Patient expectations, time pressure and uncertainty over diagnoses are all linked to increased prescribing.
The decreased prescribing results come from a 2017 BETA trial where the top 30% of antibiotic prescribers were sent letters from then-Chief Medical Officer Professor Brendan Murphy comparing their prescribing with peers.
Different variants of the letter were trialled, with the greatest impact seen in the group that received a letter comparing their prescribing to their peers, with an accompanying graph and a letter outlining how to reduce antibiotic use.
The impact of the intervention has been broadly welcomed by evidence-based healthcare expert Professor Paul Glasziou and Chair of the RACGP Expert Committee – Quality Care (REC–QC) Professor Mark Morgan. 
By contrast, other ‘nudge’ letters targeting rates of opioid prescribing and co-claiming of mental health items were not well received by GPs, with concerns over poor targeting, a heavy-handed tone and unintended consequences.
In response, the BETA team is understood to have sought more input in co-designing letters with GP representatives.
Professor Morgan told newsGP the RACGP supports antimicrobial stewardship and GPs have a major role to play.
But he said it remains unclear whether the reduction in antibiotic prescribing actually means inappropriate prescribing had decreased (as opposed to appropriate prescribing), and the new study had not collected any data about unintended consequences, such as any potential increase in morbidity and mortality from infections.
‘We acknowledge research has demonstrated a significant over-use of antibiotics to treat self-limiting conditions. This is especially true for acute respiratory infections,’ he said.
Professor Morgan said some GPs who received the letter reported a fear of being watched, while others reflected on their prescribing practice.
Professor Glasziou told newsGP he was surprised by how long the effect on antibiotic prescribing appeared to last after receiving the letter.
‘It’s great news it still had an effect at 12 months,’ he said. ‘Brendan Murphy should be congratulated for beginning this study – it’s one of the most substantial reductions we’ve seen in antibiotic prescribing in the community.
‘This is an incredibly cost-effective intervention to run. It’s good news for Australia. Our antibiotic prescribing had been climbing for years, so it’s good to see reduction occurring.’
But Professor Glasziou said there is still much to do to combat the threat of antimicrobial resistance, which the World Health Organization has flagged as one of the world’s major health threats.
He said the Swedish model of targeting antibiotic use in primary care has led to a more than 50% reduction in prescribing over two decades.
‘We need to repeat this and other interventions over the next decade to get our rate down to Sweden’s level,’ Professor Glasziou said. ‘They are now close to the minimum antibiotic prescribing level, and they have shown no increase in complications from reduced prescribing. 
‘In Australia, we could get to something like 25% of current prescribing and still cover all of the things you really need to in primary care – severe cellulitis, streptococcal sore throats, and so on.’
However, Professor Glasziou stresses that reducing antibiotic prescribing rates cannot rely on one intervention, and requires training.
‘It’s not a quick, simple intervention,’ he said. ‘Learning to prescribe less in a targeted way is a highly skilful procedure.
‘[For example], you have to learn how to very carefully target antibiotics to the right kids with otitis media, the right sore throats and discuss it with patients about what to watch for, as well as doing extra testing and learning delayed prescribing. You can’t just ask people to just do it.’
Antibiotic-resistant bacteria already kill an estimated 700,000 people annually around the world, with the toll likely to rise to 10 million a year if nothing is done, according to an influential 2014 report commissioned by the UK government. 

A Department of Health spokesperson told newsGP there are no further trials planned at this stage, but declined to say if there are plans for a wider rollout.

‘The Australian Government does not currently have targets for reduction in antimicrobial prescribing in primary care,’ the spokesperson said.

‘Australia’s National Antimicrobial Resistance Strategy ... focuses on ensuring antimicrobial prescribers are supported through evidence-based antimicrobial prescribing guidelines and effective stewardship practices to encourage appropriate antimicrobial usage.’

Log in below to join the conversation.

antimicrobial resistance compliance prescribing


Login to comment

Dr Duncan MacWalter   16/09/2020 8:44:15 AM

How well was the drop off in vURTI presentations due to covid-19, socially distancing, telehealth and increased flu immunisation been modelled into this?

It's say there have been a much bigger factor before we encourage more of these nudge letters.

SD   16/09/2020 1:15:49 PM

A prescription denied to patient due to fear instilled by letter into GP may result in deterioration of an infection or even an ED presentation after that. Lesser prescriptions does not necessarily mean better care. It’s people we treat rather than stats. Looking at large number if reduced prescriptions, many people may be missing out on their treatment.

Dr Natalie Alexandra Cook   16/09/2020 5:26:10 PM

delayed prescribing spreading bacterial infection in the community? sick leave 5 days a year for workers doesnt help with ''lets wait and see if in 1-2 wks its over''

Dr Wakinyjan Tabart   16/09/2020 7:53:49 PM

i am definitely trying to cut down on antibiotic prescribing, but more due to learning more about the importance of a healthy gut microbiota, and the harm of antibiotics on the gut, and its relationship to all aspects of health.

Dr James Scandrett Brown   7/12/2021 6:00:24 AM

Non prescription of antibiotics contributes with gout to the to the dialysis industry

Dr James Scandrett Brown   7/12/2021 6:03:25 AM

Hospital use of antibiotics far exceeds in contribution to resistance as shown by primary practice cultures which show resistance to antibiotics never used in non emergency primary care