Impact of a public commitment charter, a non-prescription pad and an antibiotic information leaflet to improve antibiotic prescription among general practitioners: A randomised controlled study.

BACKGROUND: This study evaluated the effect of a multifaceted antibiotic stewardship intervention on the overall prescription of systemic antibiotics in primary care. Secondary objectives evaluated the effect on the prescription of broad-spectrum antibiotics and the seasonal variation of both total antibiotic and quinolone prescriptions, as a proxy for unnecessary prescribing. METHODS: This pragmatic, randomised, controlled, before-after intervention study was conducted among general practitioners (GPs) who over prescribe antibiotics in Lorraine, France (Intervention group, n = 109; Control group, n = 236; Before period, 01/10/2017-30/09/2018; After period, 01/10/2018-30/09/2019). The intervention included a public commitment charter, a patient information leaflet and a non-prescription pad. Health Insurance data was obtained to calculate overall and broad-spectrum prescription rate (defined daily doses/1000 consultations) and the seasonal variation of prescriptions (%), by period. The intervention effect was measured with general linear mixed models including three independent variables (group, period and group x period interaction). RESULTS: Overall, compared to the Before period, GPs in both groups prescribed significantly fewer systemic antibiotics (p < 0.001) and broad-spectrum antibiotics (p < 0.001) after the intervention was implemented. However, the group x period interaction did not show any evidence that the intervention had an effect on these outcomes. Nevertheless, the intervention did result in a trend towards less seasonal variation in total systemic antibiotic prescription (p = 0.052). CONCLUSIONS: A tendency towards an effect of the intervention to reduce unnecessary antibiotic prescribing during winter months was observed. No effect was observed on the overall volume of systemic antibiotic prescription. This study invites discussion about the challenges faced when evaluating non-pharmacological interventions in primary care.

Risk of readmission and death after hospitalization for worsening heart failure: Role of post-discharge follow-up visits in a real-world study from the Grand Est Region of France.

AIMS: Patients who experience hospitalizations due to heart failure (HF) face a significant risk of readmission and mortality. Our objective was to evaluate whether the risk of hospitalization and mortality following discharge from HF hospitalization differed based on adherence to the outpatient follow-up (FU) protocol comprising an appointment with a general practitioner (GP) within 15 days, a cardiologist within 2 months or both (termed combined FU). METHODS AND RESULTS: We studied all adults admitted for a first HF hospitalization from 2016 to 2020 in France's Grand Est region. Association between adherence to outpatient FU and outcomes were assessed with time-dependent survival analysis model. Among 67 476 admitted patients (mean age 80.3 ± 11.3 years, 53% women), 62 156 patients (92.2%) were discharged alive and followed for 723 (317-1276) days. Combined FU within 2 months was used in 21.1% of patients, with lower rates among >85 years, women, and those with higher comorbidity levels (p < 0.0001 for all). Combined FU was associated with a lower 1-year death or rehospitalization (adjusted hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.88-0.94, p < 0.0001) mostly related to lower mortality (adjusted HR 0.65, 95% CI 0.62-0.68, p < 0.0001) whereas HF readmission was higher (adjusted HR 1.19, 95% CI 1.15-1.24, p < 0.0001). When analysing components of combined FU separately, 1-year mortality was more related to cardiologist FU (HR 0.65, 95% CI 0.62-0.67, p < 0.0001), than GP FU (HR 0.87, 95% CI 0.85-0.90, p < 0.0001). CONCLUSION: Combined FU is carried out in a minority of patients following HF hospitalization, yet it is linked to a substantial reduction in 1-year mortality, albeit at the expense of an increase in HF hospitalizations.

Selection of proxy indicators estimating the appropriateness of antibiotic prescriptions in general practice: a national consensus procedure in France.

Background: GPs are responsible for more than 70% of outpatient antibiotic prescriptions in France. Metrics are important antibiotic stewardship tools that can be used to set targets for improvement and to give feedback to professionals and stakeholders. Objectives: The primary objective of the present study was to select a set of proxy indicators (PIs) based on 10 previously developed PIs, to estimate the appropriateness of antibiotic prescriptions by GPs. The secondary objective was to evaluate the clinimetric properties of the selected PIs. Methods: A RAND-modified Delphi consensus procedure was conducted with a multidisciplinary panel of stakeholders. This procedure consisted of two successive online surveys with a consensus meeting in between. Clinimetric properties (measurability, applicability and potential room for improvement) were evaluated for the PIs selected through the consensus procedure, using 2022 Regional Health Insurance data. Results: Seventeen experts participated in the first-round survey and 14 in the second-round. A final set of 12 PIs was selected. Among the 10 initial PIs, 3 were selected without modification and 7 were modified and selected. Moreover, two newly suggested PIs were selected. Ten of the 12 PIs presented good clinimetric properties. Conclusions: The 12 selected PIs cover the main situations responsible for inappropriate and unnecessary use of antibiotics in general practice. These PIs, easily calculable using routinely collected health insurance reimbursement data, might be used to give feedback to prescribers and stakeholders and help improve antibiotic prescriptions in primary care.

French general practitioners' and patients' acceptability of a public commitment charter and patient information leaflets targeting unnecessary antibiotic use: a qualitative study.

BACKGROUND: The 'AntibioCharte' randomised controlled study aimed at assessing the impact of a multifaceted antibiotic stewardship intervention targeting French general practitioners with higher-than-average antibiotic use. The intervention included a public commitment charter signed by the general practitioner, a non-prescription pad, and a patient information leaflet. OBJECTIVES: We conducted a qualitative study to evaluate general practitioners' fidelity in the intervention and its acceptability by patients and general practitioners. METHODS: This investigation was performed in northeastern France from July 2019 to May 2020, among the AntibioCharte intervention group after a 1-year implementation period. General practitioners' fidelity in the charter was assessed by direct observations; general practitioners' fidelity in the other tools, and acceptability of both general practitioners and patients were assessed through semi-structured face-to-face individual interviews. RESULTS: Twenty-seven general practitioners and 14 patients participated. General practitioners' fidelity varied according to the tool: the charter was clearly displayed in most waiting rooms; the non-prescription pad was used throughout the intervention period by most general practitioners while the leaflet was used by fewer general practitioners. Both general practitioners and patients found the charter's content and form relevant, but few general practitioners felt themselves publicly engaged. The waiting room may not be appropriate to display the charter as some general practitioners forgot it and patients did not always read the displayed documents. General practitioners appreciated the pad and found that it could help them change their practices. It was perceived as a good tool to educate patients and manage their expectations for antibiotics. Patients appreciated the pad too, especially information on the infections' symptoms and their duration. Still, some patients feared that it could encourage doctors not to prescribe antibiotics. Unlike general practitioners, who considered the leaflet redundant with the information given during the consultation, patients found it useful to raise awareness on antibiotics' specificities and risks, and remind them of good practices. CONCLUSIONS: The AntibioCharte intervention was overall well accepted by general practitioners and patients. The non-prescription pad was the best perceived tool. Trial registration number ClinicalTrials.gov: NCT04562571.