Summary
Of all GP-prescribed antibiotics, only 6% were prescribed OOH. Comparatively more amoxicillin and amoxicillin/clavulanate were prescribed; amoxicillin, as children more often present at OOH,23 and higher amoxicillin/clavulanate use was specifically seen for tonsillitis, cystitis, and impetigo (Table 2). Overall, OOH first-choice prescribing was comparable with office hours prescribing. And, although prescribing rates, especially for sinusitis, tonsillitis, and cystitis, were higher for OOH, overprescribing was comparable, or even lower than had been determined in a previous study for daily practice.1
Oral antibiotics have a limited effectiveness in treatment of RTI and ear infections. With risk factors, for a severe infection, or pneumonia, the benefits of antibiotic treatment offset the risk of harm. A confirmed urinary tract infection is treated effectively with antibiotics, although there is evidence that a wait-and-see policy can be appropriate for uncomplicated cystitis.4 Topical antibiotics are effective for impetigo; oral antibiotics are indicated only for extensive disease with general illness and insufficient effect of topical treatment.
For various reasons, like time pressure, no personal relationship with the patient, and the organisation of emergency care, it was suspected that OOH antibiotic prescribing quality was lower. Indeed, prescribing rates for all indications were higher OOH. When interpreting this, however, one should be aware that the patient population presenting at OOH differs from daily practice. First, a different triage system is used: the OOH system aims to select patients with urgent problems that cannot wait until the next day for evaluation by the patient’s own GP. As a result, more severe illness will be presented in OOH, with a higher likelihood of requiring antibiotics.24,25 Second, comparatively more young children23 and patients aged >75 years present at OOH; patients in these age categories could belong to risk groups. Third, the threshold to contact the OOH service is higher than contacting own GP during office hours. Therefore, higher prescription rates do not necessarily implicate more irrational prescribing.
A previous Dutch study showed office hours overprescribing for AOM, sinusitis, tonsillitis, and bronchitis of, respectively, 4%, 50%, 53%, and 69%.1 OOH, the present study found lower overprescribing for sinusitis, tonsillitis, and bronchitis. Only AOM overprescribing was higher OOH. According to the Dutch AOM guideline, antibiotic treatment can be considered for patients with non-reducing complaints for 3 days. When disease duration was not specifically mentioned in the patient file and no other antibiotic prescribing criterion was present, the present study classified prescribing as inappropriate. This missing information might have resulted in an overestimation. Alternatively, there might really be more irrational prescribing for children with AOM. GPs might ‘give in’ to antibiotic treatment more easily as they lack time for communicating their non-treatment considerations with the concerned parent.
For cystitis, the daytime prescribing rate was around 60%, in agreement with a previous study.3 This seems low as, according to the guideline, antibiotic treatment is indicated for confirmed cystitis. Patients might choose a wait-and-see policy, or the diagnosis and/or prescription might have been inappropriately registered. GPs and practice assistants are both involved in the management of females with suspected urinary tract infection, which might decrease proper coding. The higher OOH prescribing rate is not alarming, as there was hardly any overprescribing. This indicates that GPs and nurses followed the guideline and only prescribed antibiotics after urine testing. Overprescribing for impetigo seems low, but could not be compared with daytime data, as these were not available.
Strengths and limitations
To the authors’ knowledge this is the first study evaluating OOH antibiotic prescribing quantity and quality, as well as the appropriateness of prescribing for the most often presented infectious diseases in primary care. The main strength of this study is that for the main infections all office hours were analysed and OOH contacts from 1 complete year were analysed. Data were retrieved from the same region in the Netherlands. This is important for a valid quality comparison, as antibiotic use varies throughout the country.26 As routine care data were used, GPs were not aware of the analysis of their prescribing behaviour. Second, the appropriateness of prescribing, using guideline benchmarking, has not been studied before for OOH care. By benchmarking all available patient and disease characteristics to the guidelines, it has been shown that higher prescribing rates do not go hand-in-hand with more irrational prescribing.
The following limitations must be acknowledged. First, in determining of overprescribing during office hours, a registration form was used to capture all relevant patient and disease characteristics.1 For OOH overprescribing, information from the patient files was used. This harbours the risk of missing relevant information, as GPs might not have registered all relevant items from the guideline. It was noted, however, that GPs tended to file extensive information during OOH, with the aim of informing the patient’s own GP. When specific information was not provided, it was regarded as absent; this might have overestimated overprescribing in this setting. Second, the analysis of OOH overprescribing was done 1–2 years later than the office hours registration. In this period, however, antibiotic use for RTIs was very stable in the Netherlands,26,27 and guideline recommendations for antibiotic treatment did not change. Third, the data were retrieved by selecting for ICPC codes. There is no reason to assume that ICPC coding was done differently in the two settings, as in the Netherlands OOH services are done by GPs.
Comparison with existing literature
Another Dutch study showed that adherence to antibiotic prescribing guidelines was 69% in OOH care; overtreatment was mostly seen for sinusitis and sore throat.25 Prescribing rates and types of antibiotics were not presented, and the data from that study were not compared with daytime practice. In the present study, using all free text from patient records, higher OOH guideline adherence was found. In two other low-prescribing countries, Denmark and Norway, high small -spectrum prescribing during OOH9 and comparable prescribing between the two settings were found as well.14 In Belgium, a high prescribing country, prescribing quality indicator outcomes for seven acute infections also revealed similar outcomes for the two settings.16 Although medical appropriateness was not determined in these studies, the results do point towards a similar quality in office hours and OOH care.
In Norway, an intervention in an OOH service using peer academic detailing did not affect prescribing rates, but did reduce macrolide and lincosamide prescribing.7
Implications for practice
It seems that the OOH triage, which specifically aims to select urgent cases and to prevent complications, results in a patient population with more severe disease. The low threshold to consult a GP during the daytime is valued in Dutch primary care, but also results in patients consulting with mild, self-limiting disease. OOH triage might be an inspirational model to adapt daytime triage to reassure patients with self-limiting disease on the phone, and to stimulate self-management. This could help to decrease antibiotic overprescribing.
In conclusion, the quality of antibiotic prescribing during OOH is comparable, or even slightly better than, in daily practice. Given the numbers of dispensed antibiotics during OOH (6%), the generally correct choice of antibiotic, and the non-excessive rates of irrational prescribing, Dutch antibiotic-related problems cannot be attributed to management at OOH services.
