Antibiotic prescribing during office hours and out-of-hours: a comparison of quality and quantity in primary care in the Netherlands

Abstract

Background: Unnecessary and non-first-choice antibiotic prescribing is a significant problem in primary care. It is often argued that irrational prescribing is higher during out-of-hours (OOH) consultations.

Aim: To obtain insight into the quantity and quality of OOH antibiotic prescribing for commonly presented infectious diseases.

Design and setting: Two two-way comparisons of 1) nationally dispensed antibiotics during office hours and OOH care, using data from the Dutch Foundation of Pharmaceutical Statistics, and 2) regional prescribing quality data from 45 primary care practices from Utrecht and its vicinity, and two large OOH services in Utrecht and Woerden.

Method: From the national data, yearly dispensed antibiotics were analysed per prescriber type, with respect to time (office hours or OOH) of prescription, types of antibiotics, and patients' age group. Regional prescribing rates, choice of antibiotic, and appropriateness of prescribing were compared for otitis media, sinusitis, tonsillitis, bronchitis, cystitis, and impetigo. Appropriateness was assessed by comparing all relevant information from medical files with the guideline recommendations.

Results: Only 6% of GP-prescribed antibiotics were prescribed OOH. OOH, cystitis and acute otitis media presented most often. First-choice prescribing was comparable for the two settings, whereas prescribing rates were higher OOH, with comparatively more amoxicillin(/clavulanate). The appropriateness evaluation, however, revealed that overprescribing was comparable, or even lower than, for daily practice.

Conclusion: The suggestion that OOH antibiotic prescribing quality is worse than in daily practice does not seem founded. The higher OOH prescribing rates can be explained by a different population of presenting patients. The appropriateness of prescribing rather than prescribing rates, therefore, should be used to determine quality.

Keywords: antibiotics; drug prescribing; infectious disease; out-of-hours service; prescribing quality; primary care.

Figure 1.

Dispensed antibiotics per prescriber, split for office hours and out-of-hours prescribing. These national data were derived from community pharmacies via the SFK. Absolute numbers of dispensed antibiotics are shown, in total and per prescriber; others refer to dentists, nursing home practitioners, and public health practitioners. SFK = Dutch Foundation of Pharmaceutical Statistics.

Figure 2.

Types of antibiotics prescribed by GPs during office and out-of-hours contacts. These national data were obtained from the SFK. Of all GP-prescribed antibiotics (J01 at the ATC4 or 5 level), their relative contribution as a percentage was determined for office hours and out-of-hours prescribing. SFK = Dutch Foundation of Pharmaceutical Statistics.

Figure 3.

Appropriateness of (non-)antibiotic management in out-of-hours care. Data are from Primair patient files. Per indication, all available information of 100 consultations were compared with the prescribing guidelines (Appendix 1). The numbers of (in-)appropriate (non-)antibiotic prescriptions are shown, and the percentages of overprescription are given.