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

The intervention in the ChAP study consists of four components: 1) access to two online learning modules, 2) an online webinar, 3) frameworks for case-based education sessions for the GP registrar and their supervisor, and 4) provision of posters for the registrars'/supervisors' clinics. 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 in 2015 and updated in 2021. 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) 2019 version (eTG:A). This module will take 15-30 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 the provision of a patient booklet and leaflet 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 webinar. They will be given a time frame of 2 weeks in which to complete the modules. The webinar will occur after completion of the electronic modules in order to maximise the potential for effectiveness. 2. The webinar component consists of a 70-minute online session, accessible for all registrars in the intervention group. This is scheduled to be added as part of the standard training program for GP registrars delivered at GP Synergy, their Regional Training Organisation (RTO, geographically-based providers of general practice vocational training in Australia). The webinar will be facilitated by a GP who is also part of the study team (Prof Parker Magin). It is usual for not all eligible registrars to attend a given training opportunity, therefore the number attending the webinar is anticipated to be somewhat less than the number of registrars who will receive access to the online modules. All, however, will be included in an Intention-to-treat analysis (see below). Prescribing data from the Registrars’ Clinical Encounters in Training (ReCEnT) study that includes recording of prescribing by the cohorts of registrars in the participating RTOs 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 prescribing data and by means of clinical cases work through the main principles of rational prescribing of antibiotics for non-pneumonia acute respiratory tract infections (ARTIs) using the management of acute bronchitis/bronchiolitis as outlined in eTG:A, as an exemplar. Barriers to, and facilitators of, appropriate prescribing by registrars will be addressed. 3. Engagement of the supervisor is the focus of the third component of the intervention. Supervisors will be invited to participate in a 60-minute webinar similar to that delivered to registrars and prior to the registrar webinar. The webinar will be facilitated by a GP who is also part of the study team (Prof. Parker Magin). They will also have access to the online modules 2 weeks prior to their webinar. All supervisors will be provided with a structured framework for an educational session with their registrars. This framework will be based on 3 to 4 structured cases. The education session will be delivered (at the supervisor’s discretion) for discussion in their routinely scheduled weekly one-on-one in-practice teaching sessions over the following 6 weeks. These sessions usually take approximately 1 hour weekly. Supervisors will be given access to the online modules prior to their webinar. 4. All teaching practices in the intervention RTO (GP Synergy) will be emailed an electronic copy of a waiting room/treatment room poster adapted from that used in the GAPS study of antibiotic stewardship conducted in Queensland (see Avent et al. BMC Family Practice 2016). Information booklets for use with patients are available through the electronic Therapeutic Guidelines (eTG) (all registrars and teaching practices have access to eTG). The intervention will be delivered in July 2021. The intervention period will be 6 weeks (from the start of the predisposing activity to completion of the reinforcing activity, including attendance at the webinar). Registrar participation in the online predisposing activity modules (INTRO 1 and 3) will be monitored by surveying registrars and supervisors with a short questionnaire on completion of INTRO module 3. Presence at the webinar is monitored by the webinar host electronically.