A complex intervention to reduce antibiotic prescribing in rural China: a cluster randomised controlled trial

Xingrong Shen; Beth Stuart; Enci Cui; Rong Liu; Tingting Zhang; Jing Chai; Wenjuan Cong; Xiaowen Hu; Isabel Oliver; Guiqing Yao; Paul Little; Helen Lambert; Lucy Yardley; Christie Cabral; Debin Wang

doi:10.1016/j.lanwpc.2024.101236

A complex intervention to reduce antibiotic prescribing in rural China: a cluster randomised controlled trial

Lancet Reg Health West Pac. 2024 Nov 6:53:101236. doi: 10.1016/j.lanwpc.2024.101236. eCollection 2024 Dec.

Authors

Xingrong Shen^{1

2}, Beth Stuart³, Enci Cui¹, Rong Liu¹, Tingting Zhang⁴, Jing Chai¹, Wenjuan Cong⁴, Xiaowen Hu⁵, Isabel Oliver^{6

7}, Guiqing Yao⁸, Paul Little⁹, Helen Lambert⁴, Lucy Yardley^{10

11}, Christie Cabral⁴, Debin Wang^{1

2}

Affiliations

¹ School of Health Service Management, Anhui Medical University, Hefei Anhui 230032, China.
² Center for Operational Health Service Research, Anhui Medical University, Hefei Anhui 230032, China.
³ Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, London, UK.
⁴ Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
⁵ Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, Anhui, China.
⁶ UK Health Security Agency, Bristol, UK.
⁷ National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) on Behavioural Science and Evaluation at the University of Bristol, Bristol, UK.
⁸ Department of Health Sciences, University of Leicester, Leicester, England, UK.
⁹ Primary Care Research Centre, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SO16 5ST, UK.
¹⁰ School of Psychological Science, University of Bristol, 12A Priory Rd, Bristol, BS8 1TU, UK.
¹¹ School of Psychology, University of Southampton, Building 44 Highfield Campus, Southampton, SO17 1BJ, UK.

Abstract

Background: Excessive use of antibiotics is a widespread problem. We aim to evaluate the efficacy of a multifaceted intervention for reducing antibiotic use in patients with respiratory tract infections (RTIs).

Methods: In this two-arm cluster randomized controlled trial, we enrolled patients aged 18+ with symptomatic RTIs at 40 township health centers (THCs) selected from 10 counties in Anhui, China. The THCs were randomized using an online tool ('Sealed Envelope') to intervention or usual care (1:1 ratio), stratified by baseline antibiotic prescribing and with random block sizes (4 or 6). The intervention had five components: a half-day clinician training, a WeChat-based peer support group, a decision aid, a poster commitment letter and a patient leaflet. The primary outcome was whether antibiotics were prescribed at the index consultation. Secondary measures included defined daily dose (DDD), illness recovery rate, re-visits to other care-givers or retail pharmacies and incremental cost-effectiveness ratio (ICER). These measures were analyzed using generalized linear mixed modeling controlling for clustering. The study was registered as ISRCTN30652037.

Findings: Between December 2021 and September 2022, 1053 patients were recruited (intervention, 21 THCs, n = 552; control, 19 THCs, n = 501), using consecutive sampling. Antibiotic prescribing rate was 55.25% and 66.67% in the intervention and control arms (Odds ratio 0.52, 95% confidence interval [CI]: 0.27, 0.98; p = 0.044). The intervention group also had lower, significant or non-significant, differences for other markers of antibiotic use: DDD (1.57 vs 2.75); prescriptions of two or more types of antibiotics (9.78% vs 11.58%); obtaining antibiotics from retail pharmacies (3.68% vs 5.78) or from other clinics (2.70% vs 4.05%). The intervention resulted in a cost reduction of 9.265 RMB (1.471 USD) per consultation episode and an ICER of -7769.98 RMB or -1233.33 USD/QALYs. The intervention did not encounter any major adverse event.

Interpretation: The intervention package was effective and cost-effective in reducing antibiotics prescribing without adverse effects.

Funding: The trial was supported by National Natural Science Foundation of China (No. 81861138049) and United Kingdom Research Innovation (No. MR/S013717/1).

Keywords: Antibiotics; China; Cluster randomised controlled trial; Prescribing; Primary care; Respiratory infection.