ENORM - Educational intervenetion in NORwegian Municipalities for antibiotic treatment in line with guidelines

Antimicrobial resistance is a growing threat to public health. Any use of antibiotics increases the risk of adverse clinical effects of antimicrobial resistance. Antibiotics should be used only when there is reason to believe that they will provide an important and positive effect. About 80% of all antibiotics in Norway are prescribed in general practice, and studies have shown that a significant proportion of this is used in cases where antibiotics are not expected to give any important effect. Quality improvement programmes facing general practitioners (GPs) result in a lower and more appropriate prescribing of antibiotics, but such programmes are expensive, and so far they have not been implemented nationally. In the project ENORM - Educational intervention in Norwegian Municipalities for antibiotic treatment in line with guidelines, we want to develop and test a quality improvement programme that easily can be offered to all GPs in Norway. The idea is to create the programme so simple and inexpensive that it becomes attractive both for doctors and health authorities. To achieve this, we will use individuals and entities that already have a role and a responsibility in the fight against antimicrobial resistance; municipal doctors, NorPD (The Norwegian Prescription Database), and SKIL (The Norwegian Quality Centre for Outpatient Clinics). The preparation of the quality improvement programme will be guided by qualitative studies among municipal doctors and general practitioners. By October 2018, the quality improvement project has been fully developed, following the input of municipal doctors and general practitioners. The project consists of a 15-hour clinical course, divided into three e-learning courses and three group meetings. Two personal antibiotic prescribing reports are prepared - one before the start of the course, and another after six months, to allow participants to see if they have changed their prescribing practices. Discussion about these reports is the main content of the group meetings. The group meetings are spread over time so that the entire course is conducted in about eight months. 30 randomly selected municipalities have been invited to participate in a comparative study to explore the impact of the course. Almost all municipal doctors from the invited municipalities attended the start-up meeting at in February 2017. Then the municipal doctors have invited the local general practitioners to attend the course. Approximately 70% of all general practitioners in the invited municipalities have signed up for the course. All these GPs are now finished with the course, and we are investigating whether the antibiotics use in the 30 participating municipalities differs from the antibiotics use in 30 randomly selected control municipalities. A qualitative study on GPs' attitudes towards municipal doctors engaging in quality work vis-à-vis the GPs has been published, and a qualitative study on the municipal doctors' attitudes towards engaging in quality work is about to be published. The ENORM course is already offered countywide to all the country's GPs. By the end of 2020, it is expected that around half of the country's GPs will have participated in the course.

Prosjektet har involvert kommuneleger som mediatorer for kvalitetsarbeid i allmennpraksis. Dette har vist seg å være en suksess. Kommunelegene engasjeres nå i RAK-prosjektet, som altså er en nasjonal implementering av kurset som er laget i ENROM-prosjektet. Prosjektet har benyttet registerdata i kvalitetsarbeid i allmennpraksis. Dette har også vist seg å være en suksess. Registerdata benyttes nå i RAK-prosjektet. Flere andre prosjekter under planlegging skal benytte registerdata i kvalitetsarbeid. I prosjektet er det laget et kvalitetsforbedringsopplegg som kombinerer e-læringskurs, gruppemøter og individuell kvalitetsdatarapport. Som følge av prosjektet brukes nå dette opplegget i RAK-prosjektet. Andre prosjekter under planlegging skal også benytte dette opplegget.

ENORM - Educational intervenetion in NORwegian Municipalities for antibiotic treatment in line with guidelines Antimicrobial resistance is an increasing challenge to society in both human and economic terms. The two major strategies to withstand this ch allenge are: 1) Minimizing the use of antibiotics. 2) Hygienic actions against spread of resistant bacteria. Most of the consumed antibiotics are prescribed by general practitioners (GPs) for respiratory and urinary tract infections, and a large proportio n of this prescribing is not in line with national guidelines. The objective of this trial is to evaluate the effect of an easy-to-perform intervention towards Norwegian GPs for antibiotics use more in line with the national guidelines. Specifically, we will evaluate, at the municipality level, - total amount of dispensed antibiotics - the rate of dispensed penicillin V in relation to amoxicillin, macrolides and doxycykline - the rate of dispensed ciprofloxacin in relation to trimetoprim, pivmecillinam and furadantin The intervention will make use of established and self-financed entities: The municipalities Medical Officer for Health, Continous Medical Education (CME) groups, and the Norwegian Prescription Database. The multi-faceted intervention wil l approach the GPs through their CME groups in the highest prescribing Norwegian municipalities, and contains facets used in a previous, successful trial from our research group: outreach visits, audit and feedback on GPs own prescription patterns togethe r with peers, computerized pop-up reminder, patient leaflets and recommendation of delayed prescribing. The intervention will be easy to convert into a course available for all Norwegian GPs, with hardly any additional costs, which presumably may result in a large and clinically relevant national improvement in antibiotic prescribing.