The learning environment is important.
1. Groups of about 15 seem good. A mix of GPs, nurse prescribers, pharmacists with access to data, and 'infection experts' seems to work well.
2. Clinical leasdership is important. This is not about being heroic. It's about having someone stand up and say "This matters, and as a group we agree this matters". It is important that this sentiment comes from those 'doing the work'. Experts need to be invited in, as part of the dialogue, not as the solution. Without this, most education is perhaps verging on the pointless. I'm sure there is a literature on this.
3. All participants need to feel 'safe' and able to contribute to any discussion in a non-judgemental way
Data and cases get you started and can build trust and common purpose
4. Practice data is a good way to start any discussion. Continuous ranking data relative to peers is probably a better way of tracking changes in prescribing habits than actual items per STAR-PU. The latter is too sensitive to seasonal and secular trends, and other external forces (eg. guidelines).
Graph showing rolling 12 month average rank of one practice vs peers
5. Individual prescribing data is a good way to continue discussion. GP prescribing systems allow this to be cut in many ways - by sex, age, type of antibiotic, time of week, phone vs face to face. This is a good way to start exploring beliefs. Be very careful about drawing any conclusions at this stage. People will get defensive if you are not careful. You just want to get interest at this stage, There are many valid reasons for variation in prescribing patterns. There are also many ways to explain away variation - you need to be careful!
6. Serious untoward events, or other 'interesting' cases, or a good way to 'reground' the discussion in 'what matters' to the patient.
Using expert opinion to guide discussion
7. The role of the 'expert' is perhaps just to facilitate discussion. Frankly, those 'doing the work' are far more aware of what the issues are.
8. The 'expert' must provide information that is salient. So for GPs these are things like : "What will this do to my workload?"; "Is it safe?"; "What will my patients think?"
9. The 'expert' can help define the unknown knowns, the known unknowns and the unknown unknowns. A lot of primary care happens in this space - and exploring it can be a rich experience for all.
So it feels this is where we got to today. The next step is to form a smaller group of nurse prescribers and GPs and do some case reviews. I think we need to focus on a specific topic. For instance, why is flucloxacillin prescribing so seasonal? Are people misdiagnosing the erythema of insect bites as cellulitis? Or are there other reasons for seasonality that we haven't thought about? Or, why are we prescribing so many antibiotics to women aged 20-39? Can we find better strategies for helping them manage without antibiotics? Or do we feel particularly sorry for harassed young mothers, and just want to 'do something', even though we know it won't help?
I think we need to invent a structure for this peer-led case review that is helpful for driving improvement. I think this could take the same structure we are using to drive improvement in diagnostics (see other blogs). It has to avoid being process focussed, it needs to reflect the real uncertainties in this area, and it needs to be a method for promoting improvement rather than compliance. Something like :
Clean start
1. Do we think antibiotics were indicated? (Almost definitely / probably / possibly / almost definitely not).
2. Do we think the antibiotics were appropriate (ie treating likely pathogens) - (Almost definitely / probably / possibly / almost definitely not).
3. Do we understand the 'red flags' for this condition and did the patient know these?
Clean continuation
4. Do we think diagnostics were used optimally?
5. Do we think antibiotics were given for a reasonable duration (Almost definitely / probably / possibly / almost definitely not).
6. Do we think antibiotics should have been modified at any point? (Almost definitely / probably / possibly / almost definitely not).
Clean stop
7. Do we think the patient knows how to manage this condition in the future, if appropriate?
8. Does the patient know what they have to do to prevent recurrence?
9. Have we done everything to prevent recurrence (eg. vaccinate)?
Not sure how contrived they are, or whether there are bigger things, but structure and method for doing this feels important. We then have measures that we can use to experiment with improvement. For instance, does having better guidance for patients and their carers make any difference to any of these measures?
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