Family Practice Advance Access originally published online on February 3, 2006
Family Practice 2006 23(2):175-179; doi:10.1093/fampra/cmi122
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Management of upper respiratory tract infections in Dutch general practice; antibiotic prescribing rates and incidences in 1987 and 2001
UMC Utrecht–Julius Centrum, PO Box 85500, 3508 GA Utrecht, The Netherlands and a NIVEL.
Correspondence to Maria Kuyvenhoven, UMC Utrecht–Julius Centrum, PO Box 85500, 3508 GA Utrecht, The Netherlands; Email: m.m.kuyvenhoven{at}umcutrecht.nl
Received 20 June 2005; Accepted 28 December 2005.
Kuyvenhoven M, van Essen G, Schellevis F and Verheij T. Management of upper respiratory tract infections in Dutch general practice; antibiotic prescribing rates and incidences in 1987 and 2001. Family Practice 2006; 23: 175–179.
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Abstract |
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Background and aim. This study aims to assess differences in antibiotic prescribing and incidence of Upper Respiratory Tract Infections (URTIs) between 1987 and 2001, before (1987) and after (2001) publication of Dutch guidelines on URTIs.
Design, setting and method. Data were collected in two national surveys: 96 general practices (n = 344 449 patients) in 1987 and 90 general practices (n = 358 008 patients) in 2001. Outcome measures were: (1) antibiotic prescribing rates for acute otitis media (AOM), common cold, sinusitis and acute tonsillitis; (2) number of antibiotic prescriptions per 1000 patients per year; (3) incidence rates per 1000 patients per year.
Results. Antibiotic prescribing rates in AOM and common cold were increased in 2001 compared to 1987 (from 27% to 48%; from 17% to 23%, respectively), while the rates for sinusitis and acute tonsillitis were about the same (72% and 70%; 74% and 72%, respectively). Except for AOM, the number of antibiotic prescriptions per 1000 patients decreased by 30% to 50%. As incidence rates of common cold, tonsillitis and sinusitis decreased, the decline in the total volume of antibiotic prescriptions per 1000 patients for these three categories has mainly to be attributed to a fall of incidence rates.
Conclusion. Antibiotic prescribing rates for URTIs have not declined between 1987 and 2001, but the volumes for common cold, sinusitis and tonsillitis have fallen down mainly attributable to declined incidences, which have probably been caused by a reduced inclination of patients to present respiratory illness to their GP. Prescribing antibiotics for AOM has increased.
Keywords. Family medicine, prescribing, respiratory medicine.
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Introduction |
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About 80% of antibiotic prescriptions for systemic use are prescribed in primary care with respiratory tract infections being the most common indication.1 These cases form a substantial workload for GPs. Based on the available evidence one can say that the vast majority of cases of common cold, acute otitis media (AOM), sore throat/tonsillitis, sinusitis and bronchitis does not benefit from antibiotic therapy.2–4 Although Dutch antibiotic rates are low compared with other European countries,5 even in The Netherlands up to 50% of antibiotic prescriptions for respiratory tract infections were assumed to be unnecessary.6 Overprescribing of antibiotics unnecessarily exposes patients to risk of side effects, encourages re-consulting for similar problems and enhances antimicrobial resistance.
Since the early 1990s the Dutch College of General Practitioners has published guidelines for diagnosis and management of Upper Respiratory Tract Infections (URTIs) (AOM: 19907; sore throat: 19908; and sinusitis: 19939). By defining clear indications for antimicrobial treatment these guidelines advocate a restrained antimicrobial policy for URTIs and advise no antibiotics for common cold. It is unknown whether these guidelines have been accompanied with a reduction in prescribing antibiotics. Information on the relation between publication of guidelines and prescription rates is fruitful to set up and target implementation strategies and quality assurance programmes.
In studying prescription rates, both number of prescriptions and incidence of diseases under study have to be taken into account. The aim of this study was therefore to examine differences in antibiotic prescribing and incidences of URTIs between 1987 and 2001. By means of the data of two National Surveys of General Practice, carried out before (1987) and after (2001) publication of the Dutch guidelines on AOM, sinusitis and acute sore throat, it was possible to study changes in antimicrobial management of URTIs in Dutch General Practice.
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Methods |
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Design
In this study results of two cross-sectional morbidity studies were compared: analysis of prescribing antibiotics and incidences in 1987 and 2001 was carried out with data derived from the First and Second Dutch National Survey of General Practice carried out by The Netherlands Institute for Health Services Research (NIVEL).10
First Dutch National Survey of General Practice; 1987
The first Dutch national survey of general practice (1987) included a randomly selected stratified sample of 161 GP's serving 334 449 patients. The GPs were divided into four groups of 40 physicians each. Each group was involved in the study for three consecutive months during the period 1 April 1987 and 31 March 1988. The study gave a fairly reliable impression of Dutch General Practice with regard to patients' as well as GP's characteristics.11 All contacts (visits, house calls, telephones and others) were recorded in terms of diagnoses and coded afterwards according to the format of the International Classification of Primary Care version 1 (ICPC-1). Prescriptions were registered in a direct link with contacts. Drugs were coded according to the anatomical therapeutic chemical (ATC) classification system used by the WHO (http://www.who.int/classifications/atcddd).
Second Dutch National Survey of General Practice; 2001
The second survey (2001) included 195 GPs in 104 practices serving 400 912 patients (mid-time population). They registered data about all patient contacts during 12 months.12 Characteristics of patients, GPs and practices did not differ from the total population of Dutch inhabitants and practices, except for type of practice: solo practices were underrepresented in the study population. So this study too, gave a representative impression of morbidity and prescribing habits in Dutch General Practice.12 For this study 14 out of the 104 practices were excluded for inadequate registration of contacts and prescriptions (10 practices) and software problems in registration (4 practices). So, analyses pertained to 186 GP's serving 358 008 patients. Morbidity presented was recorded in the ICPC format. Prescriptions and referrals were registered in a separate database. Prescribing rates and the frequency of referral to medical specialists were calculated by linking prescription data with contacts (visits, house calls, telephones and others) based on ICPC codes of contacts, dates and patient identification. Drugs were coded according to ATC classification.
Outcome measures
Outcome measures were as follows:
- Antibiotic prescribing rates: the proportion of episodes of URTIs in which an antimicrobial drug (ATC code J 01) was prescribed for (contact-based prescribing rate) AOM (ICPC code: H71), common cold (R74), acute/chronic sinusitis (R75) and acute tonsillitis (R76). The rates were calculated for first contacts, while 95% of the episodes of URTIs contained one contact and guidelines apply best to first contacts;
- Number of antibiotic prescriptions per 1000 patients per year for URTIs; and
- Incidence of URTIs: in 1987 incidence was calculated per 1000 patients per year by means of a 4-fold increase of incidences per 3 months,13 while in 2001 incidence was calculated per 1000 patients per year.14
Data processing and analysis
1987. The number of contacts and the contact-based antibiotic prescription rates were derived from an earlier paper in this journal,15 while incidence rates were derived from the morbidity report of the first survey.13 Number of prescriptions and incidences were calculated per 1000 patients per year by means of a 4-fold increase of prescription and incidences per 3 months.
2001. The antibiotic prescription rates were calculated by linking the first contacts of new episodes with the prescription database based on ICPC codes, dates and patient level. The incidence rates were derived from the morbidity report of the second survey.14 Incidence rates were not standardized for age and gender by the NIVEL, because of samples' correspondence with the Dutch population.
Analysis. Differences between 1987 and 2001 were calculated for the four URTIs separately for antibiotic prescribing rates and for the total number of prescriptions per 1000 patients per year (differences; 95% CI). Next, incidence rates for 1987 and 2001 were derived from the respective studies and differences in incidence rates were calculated.
Data were analysed with SSPS-X program (frequencies) and the CIA program (difference in proportions; 95% CI).16
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Results |
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The contact-based antibiotic prescribing rate for AOM increased from 27% in 1987 to 48% in 2001 and a smaller increase was present for common cold (from 17% in 1987 to 23% in 2001) (Table 1). The rates were about the same in both years for sinusitis (1987: 72% and 2001: 70%) and acute tonsillitis (1987: 74% and 2001: 72%). In 3% of all episodes of URTIs patients were referred to a medical specialist in 1987 as well as in 2001.
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For AOM, increase in the total number of antibiotic prescriptions per 1000 patients per year was smaller than that of the contact-based prescription rate for AOM (1987: 5.8 to 2001: 6.8; Table 1), mainly attributable to decline of incidence of AOM from 26.8 per 1000 patients in 1987 to 16.3 per 1000 patients in 2001 (Table 2). The total number of antibiotic prescriptions per 1000 patients for the remaining three diseases declined: for common cold (from 16.8 to 10.7 prescriptions per 1000 patients), for sinusitis (from 21.3 to 14.5 per 1000 patients) and for acute tonsillitis (from 15.0 to 6.7 per 1000 patients per year). Since incidence rates of common cold and acute tonsillitis decreased
60%, and incidence rates of sinusitis 30% (Table 2), the decline in the total volume of antibiotic prescriptions per 1000 patients for these three categories might be attributed to a fall of incidence rates between 1987 and 2001.
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Discussion |
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Summary of main findings
Antibiotic prescribing rates for AOM and common cold were higher in 2001 compared with 1987 and the rates for sinusitis and acute tonsillitis were about the same for both years. However, the total volume of antibiotic prescriptions per 1000 patients per year prescribed for common cold, sinusitis and acute tonsillitis did decrease, mainly because of a reduction of incidences of these infections in general practice. The volume of antibiotic prescribing for AOM slightly increased.
Strengths and limitations of the study
These results were based on GP morbidity and prescription records of the First and Second National Survey of General Practice. In both surveys patients' and GP's characteristics did not differ from those in the total population of Dutch inhabitants and GPs. Next to these findings no differences in practice style were shown to be present between GPs participating in this registration network and those who were not.17 So, both surveys are supposed to validly represent patients' morbidity and GPs' prescribing behaviour.11,12 The fact that episodes and prescriptions in the second survey had to be linked to each other could be criticized. However, we found about the same prescription rates in two other studies in Dutch general practices (84 GPs and 68 practices, respectively) in 2001.18
Comparison with existing literature
Our results are in line with studies relating to the UK and the USA19–22; Fleming et al.23 showed that a reduction in incidence of respiratory tract infections between 1995 and 2000 could be assumed to be the main reason for a decline in antibiotic prescribing in the UK rather than a changing prescribing threshold for antibiotics per se. In the USA contact-based rates as well as population-based rates in outpatient care have declined.22 However, in addition to this decline, a reduction of use of older and narrow-spectrum antibiotics has been accompanied by an increase of newer and broader types of antibiotics in the USA.22 The latter trend has been shown to be present in The Netherlands as well.1
The decrease of incidence of AOM, common cold and sinusitis can slightly be attributed to a shift in diagnostic preferences and coding practices of GPs; the incidence of earache (H01) increased from 1.2 to 4.2 per 1000 patients per year and the incidence of nasal congestion and sinus complaints (R07 and R09 combined) increased from 1.6 to 5.3 per 1000 patients per year. However, the decrease of acute tonsillitis (–14.1 per 1000 patients per year) has been accompanied with an increase in throat and tonsil complaints (R21 and R22 combined) from 1.4 to 13.5 per 1000 patients per year with a prescribing rate of 14%.
We wonder whether the decrease of incidence of AOM, common cold and sinusitis has been caused by a reduction of illness in the population or by a reduced inclination of patients to present respiratory illnesses to their GP. This latter suggestion is corroborated for children with earache by Otters et al.24 So, we hypothesize that GPs' growing reluctance to prescribe antibiotics and their tendency to inform patients about ineffectiveness of antimicrobial management in these cases have reduced patients' inclination to consult their GPs with these illnesses, but we cannot confirm one of the two hypotheses and possibly there is a concurrent trend among medical professionals and patients.
The rise of antibiotic prescribing in AOM is surprising; first, it is possible that relatively more severe cases consulted their GP in 2001 compared with 1987 because of the lowering inclination of patients to present earache to their GP. And so the antibiotic prescribing rate increased. However, the total volume of antibiotics prescribed per 1000 patients for AOM is somewhat higher in 2001 than in 1987. So, it is also possible, that Dutch GP's are more inclined to prescribe antibiotics for AOM compared with 15 years ago. About the same findings were shown for children with AOM by Otters et al.24
Implications for future research and practice
Further investigation of physicians' and patients' characteristics that are at risk of unnecessary antibiotic prescribing is needed to develop quality assurance programmes aimed at reducing unnecessary or inappropriate prescribing. Such programmes can be effective even in a low prescribing country as The Netherlands, as has been shown in a recent study about the effectiveness of a group education programme with a consensus procedure about indications and first choice drugs combined with a communication skills training, monitoring and feedback procedures.25
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Conclusion |
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The antibiotic prescribing rate and the volume of antibiotics prescribed for AOM has increased since 1987, while the total volume of antibiotics prescribed for common cold, sinusitis and acute tonsillitis in 2001 is lower than in 1987. This latter reduction has mainly to be attributed to a decline in incidence rates and partly to a shift in diagnostic and coding practice of GPs. In general, patients with URTIs nowadays do contact their GP less frequently than before. Possibly the publication of guidelines in the 1990s have indirectly induced a lowering of the threshold to consult the doctor for URTIs and possibly there is a concurrent trend among medical professionals and patients.
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Acknowledgments |
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We gratefully thank all GPs and patients who voluntarily participated in the First and Second Dutch National Survey of General Practice and Peter Zuithoff and Nicole Boekema for their data-management activities.
Funding: none
Competing interests: none of the authors had any conflicting interests.
Contributors: MK is the guarantor of this study and paper. GAvE and TJMV participated in analysis, interpretation and reporting results. FS coordinated the Second Dutch National Survey on General Practice and contributed to design, analysis and reporting results.
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References |
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1 Kuyvenhoven MM, van Balen FA, Verheij TJ. Outpatient antibiotic prescription from 1992 to 2001 in The Netherlands. J Antimicrob Chemother 2003; 52: 675–678.
2 Arroll B, Kenealy T. Antibiotics for the common cold. Cochrane Database Syst Rev 2002; CD000247, Review.
3 Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev 2000; CD000023, Review
4 Glasziou PP, Hayem M, Del Mar CB. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2000; CD000219, Review
5 Cars O, Molstad S, Melander S. Variation in antibiotic use in the European Union. Lancet 2001; 357: 1851–1853.[CrossRef][Web of Science][Medline]
6 de Melker RA. Effectiviteit van antibiotica bij veel voorkomende luchtweginfecties in de huisartspraktijk. [Efficacy of antibiotics in frequently occurring airway infections in family practice]. Ned Tijdschr Geneeskd 1998; 142: 452–456.[Medline]
7 Appelman CLM, van Balen FAM, van de Lisdonk EH, van Weert HCLM, Eizenga WH. NHG standaard Otitis Media Acuta (eerste herziening). [Guideline ‘Acute Otitis Media’ from the Dutch College of General Practitioners, first revision]. Huisarts Wet 1999; 33: 242–245.
8 Dagnelie CF, Zwart S, Balder FA, Romeijnders ACM, Geijer RMM. De NHG-standaard Acute keelpijn, eerste herziening. [Guideline ‘Acute sore throat’ from the Dutch College of General Practitioners, first revision]. Huisarts Wet 1999; 42: 271–278.
9 de Bock GH, van Duijn NP, Dagnelie CF et al. NHG-standaard Sinusitis [Guideline ‘Sinusitis’ from the Dutch College of General Practitioners]. Huisarts Wet 1993; 36: 255–257.
10 Sheldon T. Dutch GPs treat more patients and in less time than 20 years ago. BMJ 2004; 328: 976.
11 Foets M, Van der Velden J, De Bakker DH. The Dutch National Survey of Morbidity and Interventions in General Practice. Study Design. Utrecht, The Netherlands. Nivel, In 1992.
12 Westert GP, Schellevis FG, de Bakker DH, Groenewegen PP, Bensing JM, van der Zee J. Monitoring health inequalities through General Practice: the Second Dutch National Study of General Practice. Eur J Public Health 2005; 15: 59–65.
13 Velden J van der, Bakker DJ de, Claessens AAMC, Schellevis FG. Een nationale studie naar ziekten en verrichtingen in de huisartspraktijk. Basisrapport: morbiditeit in de huisartspraktijk. Utrecht, Nivel, 1991.
14 Linden MW van der, Westert GP, Bakker DH de, Schellevis FG Tweede nationale studie naar ziekten en verrichtingen in de huisartspraktijk. Klachten en aandoeningen in de bevolking en in de huisartspraktijk. Utrecht/Bilthoven: Nivel/RIVM; 2004.
15 Melker RA de, Kuyvenhoven MM. Management of upper respiratory tract infections in Dutch family practice. J Fam Pract 1994; 38: 353–357.[Web of Science][Medline]
16 Gardner MJ, Altman DG Statistics with confidence. Confidence intervals and statistical guidelines. London: BMJ; 1989.
17 Westert GP, Hoonhout LHF, de Bakker DH, van den Hoogen HJM, Schellevis FG. Huisartsen met en zonder elektronisch dossier: weinig verschil in medisch handelen. Huisarts Wet 2002; 45: 58–62.
18 Akkerman AE, Kuyvenhoven MM, van der Wouden H, Verheij JTM, Het voorschrijven van antibiotica door de huisarts bij luchtweginfecties, astma en COPD (Prescribing antibiotics by general practitioners in cases of rti's, astma and COPD) (in Dutch). Utrecht 2004 (A confidential report for the Health Care Insurance Board, Diemen, The Netherlands)
19 Majeed A, Moser K. Age- and sex-specific antibiotic prescribing in general practice in England and Wales in 1996. Br J Gen Pract 1999; 49: 735–736.[Web of Science][Medline]
20 Majeed A, Wrigley T. Antibiotic prescribing rates in England are falling. BMJ 2002; 325: 340.
21 McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA 2002; 287: 3096–3102.
22 Steinman MA, Gonzales R, Linder JA, Landefeld CS. Changing use of antibiotics in community-based outpatient practice, 1991–1999. Ann Intern Med 2003; 138: 525–533.
23 Fleming DM, Ross AM, Cross KW, Kendall H. The reducing incidence of respiratory tract infection and its relation to antibiotic prescribing. Brit J Gen Pract 2003; 53: 778–783.
24 Otters H, van der Wouden H, Schellevis F. Respiratory infection and antibiotic prescribing rates. Brit J Gen Pract 2004; 54: 132–133.
25 Welschen I, Kuyvenhoven MM, Hoes AW, Verheij TJM. Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract infections in primary care: randomised controlled trial. BMJ 2004; 329: 431–443.
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