Which interventions optimize antibiotic prescribing in primary care in England? A survey and Qualitative Comparative Analysis of NHS Integrated Care Boards.

Background: Optimizing antibiotic use is a UK Government priority. This study aimed to identify which combinations of interventions are associated with meeting primary care antibiotic prescribing targets in England's National Health Service, going beyond typical evaluations of individual interventions. Methods: Data on interventions implemented by Integrated Care Boards (ICBs) in England were collected via an online survey (October 2023 to January 2024). The survey gathered information about 61 interventions covering data monitoring, incentives, governance, staff training, guidance, diagnostics, decision support tools and public awareness-raising activities.The survey data were linked to ICB-level antibiotic prescribing data, analysed descriptively and through a set-theoretic approach (fuzzy-set Qualitative Comparative Analysis, fsQCA). Clusters of ICBs that used a common set of interventions and met prescribing targets were identified. The average prescribing rates were calculated for each cluster and compared with ICBs that did not implement those interventions. Results: Fifty-four responses were received from staff at 29 out of 42 ICBs (69%). Locally adapted prescribing guidance was used by all ICBs meeting targets. ICBs that monitored data and used incentives, guidance and/or challenged prescribers on their behaviour had the lowest prescribing. Implementing diagnostics, staff training or public awareness-raising interventions was not associated with lower prescribing. Conclusions: In a country that has been reducing antibiotic prescribing and implementing numerous antimicrobial stewardship interventions over the last decade, commissioning organizations that met policy targets were using combinations of a limited number of interventions by 2024. National and local efforts could therefore start prioritizing fewer interventions to further reduce prescribing.