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Improve the uptake and SusTainability of Effective interventions to promote Prudent antibiotic Use in Primary care (STEP-UP)

Antimicrobial resistance is a key threat to patient safety. It is driven by antibiotic use. In the UK, GPs prescribe ~75% of all antibiotics. Under 20% of these prescriptions will benefit patients, but they all increase the number of microbes that are resistant to antibiotics, and can cause side-effects.

Research studies have tested many ways to help GPs prescribe fewer antibiotics to patients who are unlikely to benefit. These have included training and strategies like ‘back-up’ prescriptions for patients to use if symptoms get worse. Many have worked well and GPs using them have prescribed fewer antibiotics. The problem is that GPs not taking part in the research have not started using them, so very little has changed overall.

Government policies have also been introduced to give general practices more money if doctors prescribe fewer antibiotics to patients who are unlikely to benefit. This cost millions of pounds, and reduced antibiotic use, but it is not clear how promising extra money actually made changes happen.

Lastly, when researchers test a new diagnostic tool or training package, they don’t just ask whether it works, but how much it would cost the NHS to use widely. Working out ‘value for money’ balances costs now against potential benefits and risks in the future. Antibiotics are so cheap (usually under £1 for a course) that most analyses suggest everyone should always get antibiotics. The problem is that we don’t have good ways to include the enormous threat that resistance poses in the future in these cost-benefit calculations.

Together, this means that we spend lots of time and money looking for new ‘magic bullets’ to reduce antibiotic prescribing, without getting the most from what we already know can work, but is not used. We need to know why effective strategies aren’t used and improve them so they are used regularly in every-day care.

This project aims first to understand in more detail how the strategies that previous studies have shown reduce antibiotic prescribing were working. We need to do this because ‘common sense’ ideas are often wrong: different people react in different ways to the same situation and what researchers think is going on is often not the case. This will help us come up with ways to make existing strategies more attractive and easier to use every day. This will increase their uptake across England, meaning we can continue to reduce unnecessary antibiotic use and the threat of antibiotic resistance.

We will investigate 4 different, carefully chosen, areas.

  • Incentivising general practices: evaluating an England-wide policy to pay general practices to reduce unnecessary antibiotic use
  • Changes to the system: exploring ‘delayed prescribing’ where GPs give a prescription that patients can ‘cash-in’ if their symptoms get worse
  • Upskilling GPs: investigating ways to help GPs explain to patients when antibiotics are not needed
  • Better-informing decision-makers: assessing how we balance the health and cost impact of antibiotic use now vs resistance in the future, and how we determine cost-effectiveness of changes in antibiotic use

In each area, we will run detailed studies to find out exactly what the barriers are to using effective strategies, and work out ways to overcome them. These will include studies with clinical commissioning groups, with GPs, nurse prescribers, practice managers and patients. We will then develop new ways to improve strategies, in partnership with different types of healthcare professionals and patients. We will test these enhancements in an implementation study. We will also develop and apply new economic evaluation research methods to assess value for money.

Our team covers expertise in health psychology, health economics, biostatistics, primary care, pharmacy and clinical epidemiology. It also provides the opportunity for younger researchers to take leadership roles whilst being supported by more experienced colleagues.

STEP-UP started on 1 August 2017 and will run for 4 years. It is a collaboration between the University of Oxford, Imperial College London and the University of Southampton, and brings together the two NIHR Antimicrobial Resistance Health Protection Research Units at Oxford and Imperial, in collaboration with Public Health England, bringing together a multi-disciplinary team with expertise in health psychology, health economics, primary care, statistics, and clinical epidemiology.