Antibiotic prescribing in a clinician-first telephone triage setting in a general practice

In May 2016, a general practice with around 16,000 registrants introduced a clinician-first triage system, which moved the practice’s more traditional face-to-face approach to one in which the majority of the consultations were conducted over the telephone. As a result, many prescriptions have been issued remotely, including those for antibiotics. As part of the National Institute for Health and Care Excellence’s (NICE) scholarship programme, a project was initiated to measure the impact of telephone triage in the practice on the quantity and quality of antibiotic prescribing, and to implement national guidelines^{[1]
,[2]
,[3]}
to improve the practice’s antibiotic prescribing.

A search was completed on the total number of antibiotic prescriptions issued in October, November and December 2015 (pre-telephone triage) and 2016 (post-telephone triage), respectively, for commonly used oral antibiotics based on Public Health England (PHE) guidelines^[3]
. A total of 10% of the samples were reviewed based on NICE antimicrobial stewardship quality standards^[2]
1, 2 and 3, respectively. The durations of antibiotic courses prescribed were also recorded. As part of an action plan, local prescribers’ awareness was raised on the aforementioned national guidelines and a prescribing duration default setting was added to the general practice system, before a re-audit was conducted in the same period in 2017.

Telephone triage did not impact the quantity of antibiotic prescribing (n₂₀₁₅=2147, n₂₀₁₆=2042, n₂₀₁₇=2061, p_2015vs2016>0.05, p_2016vs2017>0.05), although the proportion of antibiotics prescribed over the phone increased significantly (Δ%_2016-2015=18.92, P<0.05).

In 2015 and 2016, most antibiotics were prescribed for seven days (%₂₀₁₅=66.54, %₂₀₁₆=69.53). The proportion of five-day prescriptions (%₂₀₁₅=10.66, %₂₀₁₆=10.94) and three-day prescriptions (%₂₀₁₅=5.88, %₂₀₁₆=5.86) was low. After the primary audit and completion of the action plan, a statistically significant reduction (Δ%_2017-2016=27.33, P<0.05) in seven-day antibiotic prescribing was observed in 2017.

The use of deferred antibiotics was low (%₂₀₁₅=4.72, %₂₀₁₆=5.13, %₂₀₁₇=6.14). Duration of prescribing, especially for liquid antibiotics, was not clearly stated, with only two instances in which the duration was indicated over the three years reviewed. A small number of prescriptions were given without a diagnosis being clearly recorded %₂₀₁₅=2.95, %₂₀₁₆=3.54 and %₂₀₁₇=2.27). On the other hand, the amount of advice given when antibiotics were being prescribed had increased significantly since the introduction of telephone triage (Δ%_2017-2015=19.09, P<0.05).

Many GPs are trialling telephone triage as a way of managing workload. However, Campbell et al.
^[4]
found that triage was associated with a 33% increase in the number of contacts for each clinician, compared with usual care. Newbould et al
^[5]
corroborate this finding in their own work. This sentiment is shared in the practice but it is reassuring, from an antimicrobial stewardship perspective, that the number of antibiotics prescribed remained stable despite the increased workload.

Smieszek et al
^[6]
suggested that between 8.8% and 23.1% of antibiotic prescribing in England is inappropriate, but the same group of researchers admitted that defining the appropriateness or the quality of antibiotic prescribing is difficult^[7]
. Assuming that good antibiotic prescribing means having appropriate advice when prescribing, the practice’s quality of prescribing can be improved by using deferred prescription when clinical indication is not clear, and using antibiotics for the shortest possible duration with clear clinical indication and duration recorded, as suggested by NICE guidelines^[1],[2]
.

Holding to the aforementioned assumptions, there is still room for improvement at the practice. There is low use of deferred prescribing, which, unfortunately, is in line with the national picture^[8]
, despite Little et al
^[9]
showing that deferred antibiotic prescribing is an effective strategy to reduce antibiotic use. There is also poor record keeping, as shown by a number of antibiotic prescriptions given with no diagnosis or duration recorded.

On a brighter note, setting a default duration for commonly used antibiotics on the general practice’s computer system (as suggested by PHE guidelines^[3]
) resulted in a significant reduction in seven-day antibiotic prescriptions. However, it is difficult to determine if the awareness campaign with local prescribers contributed to the changes in prescribing parameters between 2016 and 2017. Nevertheless, raising awareness is still an important step in encouraging the appropriate use of antibiotics.

Methodologically, the use of a 10% sample size was convenient but may not represent the true picture; results from this study should be interpreted with this limitation in mind. In addition, the project looked at retrospective data entered on to patient’s notes; the quality of those data collected and the eventual results will only be as good as the data that were entered at the time of consultation.

In conclusion, telephone triage did not affect the quantity or quality of antibiotic prescribing. The quality of antibiotic prescribing in general practice can be improved by following the five Ds:

• Diagnosis recorded;
• Duration stated;
• Delayed prescribing promoted;
• Default duration set on computer system;
• Disseminating the knowledge with prescribers and patients.

Min Ven Teo, primary care pharmacist, The College Practice, Maidstone