CREMARA currently has the following projects:
Mismatch between packaging and guideline quantities
This program tests whether the packaging of antibiotics aligns with guideline recommendations for duration and frequency of dose. We found they do not.
Changes in legislation are being contemplates by the PBAC – including restricting the expiry date of antibiotic prescriptions.
See McGuire et al
The ‘ideal” general practice’s antibiotic use
Current planning of targets for antibiotic use in Australia is hampered by any estimate of what is a reasonable use of antibiotics, and we have to rely and extrapolate on international comparisons. This project is undertaken with Helena Britt and colleagues at the University of Sydney’s BEACH program. We will interpret the guidelines to estimate the model-practice prescription of antibiotics, and compare them with current levels.
Shared Decision Making and Patient Decision Aids
It became clear that central to reducing antibiotic in primary care lies shared decision making (SDM). Australia falls behind many other western countries in adopting this method of introducing evidence to the consultation and sharing the decision making with the patient.
We have accordingly promoted SDM in the Australian literature (Hoffmann Med J Aust 2014;201:35-9), and through the NHMRC (Position Paper 2014).
We have undertaken a Cochrane review on SDM for antibiotic use in primary care consultations for acute respiratory infections (in press Coxeter 2015), that largely demonstrates they are effective.
Exploring the effect of prior beliefs of benefits and harms among the public find the benefits are over-estimated and the harms under-estimated (Hoffmann TC, Del Mar C. JAMA Int Med 2014;175:274-86). A similar review is underway about clinicians’ beliefs.
Similar findings are found among those with ARIs, (Hansen BMC Fam Pract 2015;16:82.
Prior beliefs are also important with respect to resistance (McCullough J Antimicrob Chemother 2015doi:10.1093/jac/dkv164), and a similar review about public beliefs that are soon to be published.
One way of delivering SDM is using tools such as patient decision aids (PtDAs). We have been funded by the Australian Commission on Safety and Quality in Health care (ACSQHC) to develop a set of PtDAs in acute respiratory infections. This fits with the work of 2 PhDs students: Peter Coxeter is undertaking a trial of these PtDAs to test their acceptability with consumers. Mina Bakhit will trial trial the PDAs to test their effect on antibiotic prescribing.
The ACSQHC has also provided funding to develop an educational module on SDM for several professional Colleges.
Widely used overseas, we have undertaken an update Cochrane review showing that delayed prescribing reduced antibiotic prescribing in primary care. It is a component of the GAPS study (see).
PhD student Lucy Sargent together with Amanda McCullough, John Lowe and Chris Del Mar are developing up a trial for Australia. This is preceded by qualitative work to assist the design of the intervention and gauge patients’ and GPs’ appetite for it.
Adverse effects of antibiotics
We hypothesise that adverse effects of antibiotics are under-represented in the decision making process. This may be in part to inadequate quantification of their adverse effects.
Accordingly we undertook a systematic review of these effects in the most common antibiotic used, amoxicillin (+/- clavulanate) – used for any indication (Gillies M, Can Med Assoc J 2014 cmaj 140848). Another Cochrane study is under way being led by Malene Hansen on macrolides.