Assessing Reduction of Antibiotic Prescribing for Acute, Non-Complicated Infections in Primary Care in Germany: Multi-Step Outcome Evaluation in the Cluster-Randomized Trial ARena

Abstract

The three-armed cluster-randomized trial ARena (sustainable reduction of antibiotic-induced antimicrobial resistance) aimed to foster appropriate antibiotic use and reduce overprescribing in German ambulatory care to counter antibiotic resistance. Multi-faceted interventions targeted primary care physicians, teams and patients. This study examined the effectiveness of the implementation program. ARena was conducted in 14 primary care networks with 196 practices. All arms received data-based feedback on antibiotics prescribing and quality circles. Arms II and III received different add-on components each. Primary outcome examined is the prescribing rate for systemic antibiotics for cases with non-complicated acute infections (upper respiratory tract, bronchitis, sinusitis, tonsillitis, otitis media). Secondary outcomes refer to the prescribing of quinolones and guideline-recommended antibiotics. Based on pseudonymized quarterly claims data, mixed logistic regression models examined pre-post intervention antibiotic prescribing rate changes and compared to matched standard care. A significant rate reduction (arm I 11.7%; arm II 9.9%; arm III 12.7%) and significantly lower prescribing rates were observed for all arms (20.1%, 18.9% and 23.6%) compared to matched standard care (29.4%). Fluoroquinolone prescribing was reduced in all intervention arms and rates for recommended substances generally increased. No significant post-interventional difference between intervention arms was detected. Findings indicate implementation program impact compared to standard care.

Contextual factors influencing physicians’ perception of antibiotic prescribing in primary care in Germany — a prospective observational study

“…The detected effect could also support the assumption of the project's implementation strategy, which specifically targeted knowledge deficits regarding antibiotics and AMR as well as physicians’ awareness regarding their own prescribing routines. Confirming this assumption, the outcome evaluation of the ARena project observed a significant reduction of antibiotic prescribing in the intervention arms in a pre-post comparison and compared to matched standard care, suggesting that the implementation program had impact on professional practice [ 14 , 15 ].…”

“…The evaluation research covers both an outcome and a process evaluation. Detailed descriptions of the project and the intervention components [ 6 ], the process evaluation, [ 13 ], and the outcome evaluation [ 14 , 15 ] were published elsewhere. See Additional file 1 for description of the study design and the process evaluation design in ARena and a brief description of intervention components.…”

Implementation fidelity in a multifaceted program to foster rational antibiotics use in primary care: an observational study

“…1. Detailed sociodemographic characteristics of included cases, sample size calculation, information about relevant data protection as well as outcomes of the ARena trial regarding a sustainable reduction of antimicrobial resistance in German ambulatory care have been reported elsewhere [ 37 , 38 ]. All routinely collected claims data relevant for the ARena trial were stored on secure servers at the aQua institute, Göttingen, Germany and were analyzed by a qualified statistitian.…”

Making implementation science more efficient: capitalizing on opportunities beyond the field

“…An example of such a SWAT can be found in the ARENA project, which was a quality improvement project to reduce unnecessary use of antibiotics in respiratory tract infections [ 11 ]. Whilst all primary care practices in the project received additional reimbursement, training and feedback on prescribing patterns, one group also received interventions for practice assistants and another group received also received a computerized decision support tool.…”