Changing the Antibiotic Prescribing of General Practice Registrars through better adherence to antibiotic guidelines

The intervention in the ChAP study consists of three components: 1) access to two online learning modules, 2) a face-to-face interactive workshop, and 3) engagement of the registrar's supervisor. 1. The first component is a predisposing activity consisting of access to two of the three INternet TRaining for AntibiOtic use (INTRO) electronic modules (developed within the European Union funded GRACE study) adapted for the Australian context. The first module contains information about the epidemiology of respiratory infections in primary care, antibiotic use in Australia and worldwide, information about antimicrobial resistance, and evidence supporting the recommendations from clinical guidelines, with a special focus on the electronic Therapeutics Guidelines: Australia (Antibiotics) 2013 version (eTG:A). This module will take 10-30 minutes to complete depending on the level of perusal of the materials provided in the module. INTRO module 2 will not be used as it concerns CRP-testing which is currently not recommended in the Australian Therapeutic Guidelines. INTRO module 3 focuses on communication skills training through videos showing how a GP can use communication skills to elicit patient concerns and expectations, discuss the pros and cons of antibiotic treatment and the natural course of respiratory infections. The communication training takes 25-30 minutes to complete and is supported by a patient booklet that can be used in the consultation. The online modules will be made available to registrars to work through individually at a time prior to the face-to-face session. They will be given a time frame of 2 weeks in which to complete the modules. The face-to-face session will occur after completion of the electronic modules in order to maximise the potential for effectiveness. 2. The face-to-face component consists of a 1.5 hour workshop in group settings with approximately 100 registrars scheduled as part of the standard training program for GP registrars delivered at their Regional Training Provider (RTP, geographically-based providers of general practice vocational training in Australia). It is usual for not all eligible registrars to attend a given workshop, therefore this number is somewhat less than the number of registrars who will receive access to the online modules and be included in the Intention to Treat analysis, as outlined below. Prescribing data from the Registrars’ Clinical Encounters in Training (ReCEnT) study that reflects prescribing by the cohorts of registrars in the participating RTPs will be used in the educational session to personalise and reinforce the practical relevance and importance of the educational message. During these sessions, registrars will be asked to reflect on their group’s prescribing data and by means of clinical cases work through the main principles of rational prescribing of antibiotics for acute bronchitis/bronchiolitis and upper respiratory tract infections (URTIs) as outlined in eTG:A. Barriers to, and facilitators of, appropriate prescribing by registrars will be addressed. During the workshop there will be room for practising of the communication skills presented in the online modules. 3. Engagement of the supervisor is the focus of the third component of the intervention. For logistic reasons this engagement will be different in the two participating Regional Training Providers: in RTP 1 – supervisors will participate in face-to-face interactive workshops similar to those delivered to registrars; in RTP 2 – where these workshops are not practicable (because of the geographical distances between practices where registrars are located), each registrar will have a reinforcing one-on-one session with their clinical supervisor. The reinforcing activity in the second RTP consists of 3 to 4 structured cases that will be made available to the registrars and their supervisors for discussion in their routinely scheduled weekly one-on-one in-practice sessions over the following 4-6 weeks. These sessions usually take approximately 1 hour weekly. Supervisors will be given access to the online modules prior to these sessions in RTP2 and prior to the supervisor workshop in RTP1. The intervention will be delivered at different times in the participating RTPs, starting in November 2014 and expected to be completed by March 2015. The intervention period in RTP2 will be 6-8 weeks (from start of predisposing activity to completion of the reinforcing activity) and 2 weeks (from access to predisposing activity to face-to-face workshop) in RTP1. Participation in the online predisposing activity modules (INTRO 1 and 3) will be monitored by surveying registrars and supervisors. Presence at the face to face workshop is monitored by participants signing the attendance sheet. Reinforcing activity participation by RTP2 registrars and their supervisors will be surveyed after the intervention period.