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Antibiotic decision making in surgical intensive care: a qualitative analysis. J Hosp Infect 2020; 104:158-164. [PMID: 31505223 DOI: 10.1016/j.jhin.2019.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/02/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Antibiotic use in hospitals is high, particularly in surgical specialty and intensive care units. Antimicrobial stewardship programmes (ASPs) are increasingly intervening in antibiotic use by surgeons and intensivists. However, there is limited information on the features which characterize antibiotic decision making in the surgical intensive care unit (SICU), an area in hospital practice where critically ill surgery patients can be kept under close observation. AIM To explore the features which characterize antibiotic decision making in the SICU. METHODS A total of 160 h of ethnographic observation and 10 semi-structured interviews were conducted at two teaching hospitals in the USA. Data were analysed using thematic coding. FINDINGS Three key characteristics of SICU practice with regard to antibiotic use were identified: (1) physical proximity makes SICU clinicians acutely aware of changes in patient status; (2) communication of patient status relies on active involvement by SICU clinicians; (3) SICU clinicians have contested and variable autonomy over antibiotic decisions. CONCLUSIONS Antibiotic decision making in the SICU is a complex process involving multiple clinician teams with varying levels of physical proximity to and autonomy over patient cases. This study found that the SICU clinician team has increased physical proximity to patient cases but little autonomy over antibiotic decisions. If these characteristics are not considered, antimicrobial stewardship (AMS) interventions may have diminished success in addressing high levels of the antibiotic use in the SICU.
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Anstey Watkins J, Wagner F, Xavier Gómez-Olivé F, Wertheim H, Sankoh O, Kinsman J. Rural South African Community Perceptions of Antibiotic Access and Use: Qualitative Evidence from a Health and Demographic Surveillance System Site. Am J Trop Med Hyg 2020; 100:1378-1390. [PMID: 30994091 PMCID: PMC6553901 DOI: 10.4269/ajtmh.18-0171] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Knowledge and practices of rural South African populations with regard to antibiotic access and use (ABACUS) remain understudied. By using the case of four villages in the north east of the country, our aim was to investigate popular notions and social practices related to antibiotics to inform patient-level social interventions for appropriate antibiotic use. To achieve this, we investigated where community members (village residents) were accessing and sourcing medication, and what they understood antibiotics and antibiotic resistance (ABR) to be. Embedded within the multicountry ABACUS project, this qualitative study uses interviews and focus group discussions. A sample of 60 community members was recruited from the Agincourt Health and Demographic Surveillance System, situated in Mpumalanga Province, from April to August, 2017. We used the five abilities of seek, reach, pay, perceive, and engage in access to healthcare as proposed by Levesque’s “Access to Healthcare” framework. Respondents reported accessing antibiotics prescribed from legal sources: by nurses at the government primary healthcare clinics or by private doctors dispensed by private pharmacists. No account of the illegal purchasing of antibiotics was described. There was a mix of people who finished their prescription according to the instructions and those who did not. Some people kept antibiotics for future episodes of infection. The concept of “ABR” was understood by some community members when translated into related Xitsonga words because of knowledge tuberculosis and HIV/AIDS treatment regimens. Our findings indicate that regulation around the sale of antibiotics is enforced. Safer use of antibiotics and why resistance is necessary to understand need to be instilled. Therefore, context-specific educational campaigns, drawing on people’s understandings of antibiotics and informed by the experiences of other diseases, may be an important and deployable means of promoting the safe use of antibiotics.
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Affiliation(s)
- Jocelyn Anstey Watkins
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
| | - Fezile Wagner
- Medical Research Council, Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francesc Xavier Gómez-Olivé
- Medical Research Council, Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Heiman Wertheim
- Department of Medical Microbiology, Radboudumc Center for Infectious Diseases, Nijmegen, The Netherlands.,Nuffield Department of Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, United Kingdom.,Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Osman Sankoh
- Statistics Sierra Leone, Freetown, Sierra Leone.,International Network for the Demographic Evaluation of Populations and their Health (INDEPTH) Network, Accra, Ghana.,Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - John Kinsman
- Department of Public Health Sciences, Global Health (Division of International Health - IHCAR), Karolinska Institutet, Stockholm, Sweden.,Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health (Umeå Centre for Global Health Research), Umeå University, Umeå, Sweden
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Rynkiewich K. Finding "What's Wrong With Us": Antibiotic Prescribing Practice Among Physicians in the United States. FRONTIERS IN SOCIOLOGY 2020; 5:5. [PMID: 33869414 PMCID: PMC8022448 DOI: 10.3389/fsoc.2020.00005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 01/27/2020] [Indexed: 05/15/2023]
Abstract
Antibiotic stewardship-or the responsible use of antibiotics-has been touted as a solution to the problem of antibiotic resistance. Antibiotic stewardship in medical institutions attempts to change the antibiotic prescribing "behaviors" and "habits" of physicians. Interventions abound targeting "problem prescribers," or those physicians whose practice is out of line with physician peers. Thus, the locus of decision-making in antibiotic prescribing is thought to be the found with the individual physician. Based on 18 months of participant observation and in-depth interviewing of antibiotic-prescribing physicians at two medical institutions in the United States, this paper will question notions of antibiotic stewardship that center on individual "behaviors" and "habits." Many physicians have taken to heart a reductionist approach in studies of antibiotic prescribing, including several physicians I encountered during research who enthusiastically located the benefit of my research in the ability to identify "what's wrong with us." In this paper, I use two representative ethnographic case studies to argue that antibiotic stewardship interventions aimed at identifying and correcting "bad" physician practice limit the possibilities of understanding the social dynamics of the institution. Through an analysis of everyday encounters in the hospital setting, I show how decision-making in antibiotic prescribing can more productively be located between and among institutions, physicians, patient charts, and other hospital-based staff members (e.g., pharmacists, nurses). By demonstrating that antibiotic prescribing is a collective practice occurring through engagement with social and material surroundings, I argue that we can better account for the weighted ways in which social action and relations unfold over time.
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Sawyer JM, Sallnow L, Kupeli N, Stone P, Sampson EL. Social networks, social capital and end-of-life care for people with dementia: a realist review. BMJ Open 2019; 9:e030703. [PMID: 31822539 PMCID: PMC6924787 DOI: 10.1136/bmjopen-2019-030703] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES (1) To develop an understanding of how social capital may be conceptualised within the context of end-of-life care and how it can influence outcomes for people with dementia and their families with specific reference to the context and mechanisms that explain observed outcomes. (2) To produce guidance for healthcare systems and researchers to better structure and design a public health approach to end-of-life care for people with dementia. DESIGN A realist review. DATA SOURCES MEDLINE, EMBASE, CINAHL and grey literature. ANALYSIS We conceptualised social capital as a complex intervention and, in order to understand how change is generated, used realist evaluation methods to create different configurations of context, mechanism and outcomes. We conducted an iterative search focusing on social capital, social networks and end-of-life care in dementia. All study designs and outcomes were screened and analysed to elicit explanations for a range of outcomes identified. Explanations were consolidated into an overarching programme theory that drew on substantive theory from the social sciences and a public health approach to palliative care. RESULTS We identified 118 articles from 16 countries ranging from 1992 to 2018. A total of 40 context-mechanism-outcome configurations help explain how social capital may influence end-of-life care for people with dementia. Such influence was identified within five key areas. These included: (1) socially orientating a person with dementia following diagnosis; (2) transitions in the physical environment of care; (3) how the caregiving experience is viewed by those directly involved with it; (4) transition of a person with dementia into the fourth age; (5) the decision making processes underpinning such processes. CONCLUSION This review contributes to the dispassionate understanding of how complex systems such as community and social capital might be viewed as a tool to improve end-of-life care for people with dementia. PROSPERO REGISTRATION NUMBER CRD42018084524.
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Affiliation(s)
- Joseph M Sawyer
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Libby Sallnow
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Camden, Islington ELiPSe and UCLH & HCA Palliative Care Service, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
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Wilcock M, Powell N, Sandoe J. A UK hospital survey to explore healthcare professional views and attitudes to patients incorrectly labelled as penicillin allergic: an antibiotic stewardship patient safety project. Eur J Hosp Pharm 2019; 26:329-333. [PMID: 31798856 PMCID: PMC6855872 DOI: 10.1136/ejhpharm-2017-001451] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 04/26/2018] [Accepted: 05/01/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To ascertain the views, beliefs and attitudes of hospital staff to incorrect penicillin allergy records in order to determine healthcare worker motivation for the implementation of a penicillin de-labelling antibiotic stewardship intervention at the study hospital. METHODS An electronic questionnaire (SurveyMonkey) was distributed to medical, nursing and pharmacy staff at a 750-bed teaching district general hospital with no specialist allergy service. RESULTS 193 staff responded (58% medical, 31% nursing and 11% pharmacy). Virtually all staff had encountered patients who believed themselves to be penicillin allergic, but felt the patient's belief to be erroneous. The potential negative consequences of an incorrectly assigned penicillin allergy label were acknowledged by the majority of respondents. In total, 188/190 (99%) of staff thought patients having an incorrect allergy status to penicillin was a problem and required a solution. Staff reported they would feel confident using a validated evidence-based question tool to de-label patients incorrectly labelled as penicillin allergic if the process was supported by Trust management, although many still felt apprehensive about de-labelling patients for fear of patient harm through inappropriate de-labelling. CONCLUSIONS A penicillin allergy de-labelling intervention would be well supported by healthcare workers at the study hospital, demonstrating a receptive environment for this behavioural change intervention. Further exploration of the barriers and levers to introducing an intervention is required using behavioural change methodology in order to design a successful de-labelling intervention.
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Affiliation(s)
- Michael Wilcock
- Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospitals NHS Trust, Truro, UK
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Byrne MK, Miellet S, McGlinn A, Fish J, Meedya S, Reynolds N, van Oijen AM. The drivers of antibiotic use and misuse: the development and investigation of a theory driven community measure. BMC Public Health 2019; 19:1425. [PMID: 31666056 PMCID: PMC6822443 DOI: 10.1186/s12889-019-7796-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/16/2019] [Indexed: 11/23/2022] Open
Abstract
Background Antimicrobial resistance is a global public health concern, with extensive associated health and economic implications. Actions to slow and contain the development of resistance are imperative. Despite the fact that overuse and misuse of antibiotics are highlighted as major contributing factors to this resistance, no sufficiently validated measures aiming to investigate the drivers behind consumer behaviour amongst the general population are available. The objective of this study was to develop and investigate the psychometric properties of an original, novel and multiple-item questionnaire, informed by the Theory of Planned Behaviour, to measure factors contributing to self-reported antibiotic use within the community. Method A three-phase process was employed, including literature review and item generation; expert panel review; and pre-test. Investigation of the questionnaire was subsequently conducted through a cross-sectional, anonymous survey. Orthogonal principal analysis with varimax rotation, cronbach alpha and linear mixed-effects modelling analyses were conducted. A 60 item questionnaire was produced encompassing demographics, social desirability, three constructs of the Theory of Planned Behaviour including: attitudes and beliefs; subjective norm; perceived behavioural control; behaviour; and a covariate – knowledge. Results Three hundred seventy-three participants completed the survey. Eighty participants (21%) were excluded due to social desirability concerns, with data from the remaining 293 participants analysed. Results showed modest but acceptable levels of internal reliability, with high inter-item correlations within each construct. All four variables and the outcome variable of antibiotic use behaviour comprised four items with the exception of social norms, for which there were two items, producing a final 18 item questionnaire. Perceived behavioural control, social norms, the interaction between attitudes and beliefs and knowledge, and the presence of a healthcare worker in the family were all significant predictors of antibiotic use behaviour. All other predictors tested produced a nonsignificant relationship with the outcome variable of self-reported antibiotic use. Conclusion This study successfully developed and validated a novel tool which assesses factors influencing community antibiotic use and misuse. The questionnaire can be used to guide appropriate intervention strategies to reduce antibiotic misuse in the general population. Future research is required to assess the extent to which this tool can guide community-based intervention strategies.
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Affiliation(s)
- Mitchell K Byrne
- School of Psychology, University of Wollongong, Building 41, Northfields Ave, Wollongong, NSW, 2522, Australia. .,Wollongong Antimicrobial Resistance Research Alliance (WARRA), Wollongong, New South Wales, Australia. .,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia.
| | - Sebastien Miellet
- School of Psychology, University of Wollongong, Building 41, Northfields Ave, Wollongong, NSW, 2522, Australia.,Wollongong Antimicrobial Resistance Research Alliance (WARRA), Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
| | - Anica McGlinn
- School of Psychology, University of Wollongong, Building 41, Northfields Ave, Wollongong, NSW, 2522, Australia
| | - Janaye Fish
- Wollongong Antimicrobial Resistance Research Alliance (WARRA), Wollongong, New South Wales, Australia.,Research Department, Illawarra Shoalhaven Local Health District, New South Wales, Australia.,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
| | - Shahla Meedya
- Wollongong Antimicrobial Resistance Research Alliance (WARRA), Wollongong, New South Wales, Australia.,School of Nursing, University of Wollongong, Wollongong, New South Wales, Australia
| | - Nina Reynolds
- Wollongong Antimicrobial Resistance Research Alliance (WARRA), Wollongong, New South Wales, Australia.,School of Management, Operations and Marketing, University of Wollongong, Wollongong, New South Wales, Australia
| | - Antoine M van Oijen
- Wollongong Antimicrobial Resistance Research Alliance (WARRA), Wollongong, New South Wales, Australia.,Molecular Horizons Institute and School of Chemistry and Biomolecular Science, University of Wollongong, Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
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Parker H, Farrell O, Bethune R, Hodgetts A, Mattick K. Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation. Br J Clin Pharmacol 2019; 85:2405-2413. [PMID: 31313340 PMCID: PMC6783579 DOI: 10.1111/bcp.14065] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/19/2019] [Accepted: 07/01/2019] [Indexed: 11/29/2022] Open
Abstract
Aims To develop and evaluate a feasible, authentic pharmacist‐led prescribing feedback intervention for doctors‐in‐training, to reduce prescribing errors. Methods This was a mixed methods study. Sixteen postgraduate doctors‐in training, rotating though the surgical assessment unit of 1 UK hospital, were filmed taking a medication history with a patient and prescribing medications. Each doctor reviewed their video footage and made plans to improve their prescribing, supported by feedback from a pharmacist. Quantitative data in the form of prescribing error prevalence data were collected on 1 day per week before, during and after the intervention period (between November 2015 and March 2017). Qualitative data in the form of individual semi‐structured interviews were collected with a subset of participants, to evaluate their experience. Quantitative data were analysed using a statistical process chart and qualitative data were transcribed and analysed thematically. Results During the data collection period, 923 patient drug charts were reviewed by pharmacists who identified 1219 prescribing errors overall. Implementation of this feedback approach was associated with a statistically significant reduction in the mean number of prescribing errors, from 19.0/d to 11.7/d (estimated to equate to 38% reduction; P < .0001). Pharmacist‐led video‐stimulated prescribing feedback was feasible and positively received by participants, who appreciated the reinforcement of good practice as well as the opportunity to reflect on and improve practice. Conclusions Feedback to doctors‐in‐training tends to be infrequent and often negative, but this feasible feedback strategy significantly reduced prescribing errors and was well received by the target audience as a supportive developmental approach.
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Affiliation(s)
- Hazel Parker
- Pharmacy Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Odran Farrell
- Pharmacy Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Rob Bethune
- Exeter Surgical Health Service Research Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Ali Hodgetts
- Pharmacy Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Karen Mattick
- University of Exeter Medical School, University of Exeter, Exeter, UK
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Adhikari B, Vincent R, Wong G, Duddy C, Richardson E, Lavery JV, Molyneux S. A realist review of community engagement with health research. Wellcome Open Res 2019; 4:87. [PMID: 31289754 PMCID: PMC6611131 DOI: 10.12688/wellcomeopenres.15298.2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2019] [Indexed: 01/04/2023] Open
Abstract
Introduction: Community engagement is increasingly recognized as a critical aspect of global health. Recent years have seen an expansion of community engagement activities linked to health research, but debates and inconsistencies remain about the aims of different types of engagement, mechanisms underpinning their implementation and impact, and influential contextual factors. Greater commitment to and consistency around community engagement by health research programs, implementers and funders requires a more coherent evidence base. This realist review is designed to improve our understanding of how and why community engagement contributes to intended and unintended outcomes (including research and ethical outcomes) in different contexts. Given the breadth and diversity of the literature on community engagement in health research, the review will initially focus on malaria research in low- and middle-income countries (LMICs) and draw on wider global health literature where needed. Methods and analysis: Community engagement in practice is often a complex set of interventions. We will conduct a realist review - a theory driven approach to evidence synthesis - to provide explanations for how and why community engagement with health research produces the pattern of outcomes observed across different contexts of application. We will consolidate evidence from a range of documents, including qualitative, quantitative and mixed method studies. The review will follow several stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesizing and refining the programme theory, and reiteration of these steps as needed. Ethics and dissemination: A formal ethics review is not required for this literature review. Findings will be disseminated in a peer reviewed journal, through national and international conferences, and through a set of short briefings tailored for audiences with an interest in community engagement. Outputs and presentations will be informed by and feed into our network of community engagement experts. PROSPERO registration number: CRD42019125687.
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Affiliation(s)
- Bipin Adhikari
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX1 3SY, UK
| | - Robin Vincent
- Robin Vincent Learning and Evaluation Limited, Sheffield, UK
| | - Geoff Wong
- Nuffield Department of Primary Health Care Services, University of Oxford, Oxford, OX2 6GG, UK
| | - Claire Duddy
- Nuffield Department of Primary Health Care Services, University of Oxford, Oxford, OX2 6GG, UK
| | - Emma Richardson
- Centre for Ethical, Social & Cultural Risk, St Michael's Hospital, Toronto, ON M5B 1W8, Canada
| | - James V. Lavery
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, 30322, USA
- Center for Ethics, Emory University, Altanta, Georgia, 30322, USA
| | - Sassy Molyneux
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX1 3SY, UK
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, University of Oxford, Kilifi, 80108, Kenya
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Luetsch K, Twigg M, Rowett D, Wong G. In search for gold - The relevance of realist reviews and evaluations to pharmacy research and policy development. Res Social Adm Pharm 2019; 16:836-839. [PMID: 31303478 DOI: 10.1016/j.sapharm.2019.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/02/2019] [Indexed: 10/26/2022]
Abstract
Pharmacy services and programs can be regarded as complex interventions which are developed and implemented within the open, complex system of overall healthcare. Realist research considers matters of complexity and provides insights into what programs and interventions work, why and in which contexts. Based on the philosophy of science of critical realism, realist evaluations and realist reviews generate causative explanations which inform pharmacy practitioners, educators and policy makers in which context programs and services achieve particular outcomes. This more nuanced understanding of how pharmacy services contribute to overall healthcare provides guidance for the refinement and targeting of programs, interventions and practice models. This article outlines key aspects of realist research approaches and provides insight into how realism can contribute to research in and the practice of pharmacy.
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Affiliation(s)
- Karen Luetsch
- School of Pharmacy, The University of Queensland, 20 Cornwall St, Woolloongabba, Qld, 4102, Australia.
| | - Michael Twigg
- School of Pharmacy, University of East Anglia, Norwich, NR47TJ, United Kingdom
| | - Debra Rowett
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA, 5000, Australia.
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, United Kingdom.
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Rivas C, Vigurs C, Cameron J, Yeo L. A realist review of which advocacy interventions work for which abused women under what circumstances. Cochrane Database Syst Rev 2019; 6:CD013135. [PMID: 31254283 PMCID: PMC6598804 DOI: 10.1002/14651858.cd013135.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intimate partner abuse (including coercive control, physical, sexual, economic, emotional and economic abuse) is common worldwide. Advocacy may help women who are in, or have left, an abusive intimate relationship, to stop or reduce repeat victimisation and overcome consequences of the abuse. Advocacy primarily involves education, safety planning support and increasing access to different services. It may be stand-alone or part of other services and interventions, and may be provided within healthcare, criminal justice, social, government or specialist domestic violence services. We focus on the abuse of women, as interventions for abused men require different considerations. OBJECTIVES To assess advocacy interventions for intimate partner abuse in women, in terms of which interventions work for whom, why and in what circumstances. SEARCH METHODS In January 2019 we searched CENTRAL, MEDLINE, 12 other databases, two trials registers and two relevant websites. The search had three phases: scoping of articles to identify candidate theories; iterative recursive search for studies to explore and fill gaps in these theories; and systematic search for studies to test, confirm or refute our explanatory theory. SELECTION CRITERIA Empirical studies of any advocacy or multi-component intervention including advocacy, intended for women aged 15 years and over who were experiencing or had experienced any form of intimate partner abuse, or of advocates delivering such interventions, or experiences of women who were receiving or had received such an intervention. Partner abuse encompasses coercive control in the absence of physical abuse. For theory development, we included studies that did not strictly fit our original criteria but provided information useful for theory development. DATA COLLECTION AND ANALYSIS Four review authors independently extracted data, with double assessment of 10% of the data, and assessed risk of bias and quality of the evidence. We adopted RAMESES (Realist and meta-narrative evidence syntheses: evolving standards) standards for reporting results. We applied a realist approach to the analysis. MAIN RESULTS We included 98 studies (147 articles). There were 88 core studies: 37 focused on advocates (4 survey-based, 3 instrument development, 30 qualitative focus) and seven on abused women (6 qualitative studies, 1 survey); 44 were experimental intervention studies (some including qualitative evaluations). Ten further studies (3 randomised controlled trials (RCTs), 1 intervention process evaluation, 1 qualitative study, 2 mixed methods studies, 2 surveys of women, and 1 mixed methods study of women and staff) did not fit the original criteria but added useful information, as befitting a realist approach. Two studies are awaiting classification and three are ongoing.Advocacy interventions varied considerably in contact hours, profession delivering and setting.We constructed a conceptual model from six essential principles based on context-mechanism-outcome (CMO) patterns.We have moderate and high confidence in evidence for the importance of considering both women's vulnerabilities and intersectionalities and the trade-offs of abuse-related decisions in the contexts of individual women's lives. Decisions should consider the risks to the woman's safety from the abuse. Whether actions resulting from advocacy increase or decrease abuse depends on contextual factors (e.g. severity and type of abuse), and the outcomes the particular advocacy intervention is designed to address (e.g. increasing successful court orders versus decreasing depression).We have low confidence in evidence regarding the significance of physical dependencies, being pregnant or having children. There were links between setting (high confidence), and potentially also theoretical underpinnings of interventions, type, duration and intensity of advocacy, advocate discipline and outcomes (moderate and low confidence). A good therapeutic alliance was important (high confidence); this alliance might be improved when advocates are matched with abused women on ethnicity or abuse experience, exercise cultural humility, and remove structural barriers to resource access by marginalised women. We identified significant challenges for advocates in inter-organisational working, vicarious traumatisation, and lack of clarity on how much support to give a woman (moderate and high confidence). To work effectively, advocates need ongoing training, role clarity, access to resources, and peer and institutional support.Our provisional model highlights the complex way that factors combine and interact for effective advocacy. We confirmed the core ingredients of advocacy according to both women and advocates, supported by studies and theoretical considerations: education and information on abuse; rights and resources; active referral and liaising with other services; risk assessment and safety planning. We were unable to confirm the impact of complexity of the intervention (low confidence). Our low confidence in the evidence was driven mostly by a lack of relevant studies, rather than poor-quality studies, despite the size of the review. AUTHORS' CONCLUSIONS Results confirm the core ingredients of advocacy and suggest its use rests on sound theoretical underpinnings. We determined the elements of a good therapeutic alliance and how it might be improved, with a need for particular considerations of the factors affecting marginalised women. Women's goals from advocacy should be considered in the contexts of their personal lives. Women's safety was not necessarily at greatest risk from staying with the abuser. Potentially, if undertaken for long enough, advocacy should benefit an abused woman in terms of at least one outcome providing the goals are matched to each woman's needs. Some outcomes may take months to be determined. Where abuse is severe, some interventions may increase abuse. Advocates have a challenging role and must be supported emotionally, through provision of resources and through professional training, by organisations and peers.Future research should consider the different principles identified in this review, and study outcomes should be considered in relation to the mechanisms and contexts elucidated. More longitudinal evidence is needed. Single-subject research designs may help determine exactly when effect no longer increases, to determine the duration of longitudinal work, which will likely differ for vulnerable and marginalised women. Further work is needed to ascertain how to tailor advocacy interventions to cultural variations and rural and resource-poor settings. The methods used in the included studies may, in some cases, limit the applicability and completeness of the data reported. Economic analyses are required to ascertain if resources devoted to advocacy interventions are cost-effective in healthcare and community settings.
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Affiliation(s)
- Carol Rivas
- University College LondonDepartment of Social Science, UCL Institute of Education18 Woburn SquareLondonUKWC1H 0NR
| | - Carol Vigurs
- University College LondonDepartment of Social Science, UCL Institute of Education18 Woburn SquareLondonUKWC1H 0NR
| | - Jacqui Cameron
- The University of MelbourneDepartment of Social Work, Melbourne School of Health SciencesMelbourneVICAustralia
- Finders UniversityNational Centre for Education and Training on Addiction (NCETA)AdelaideSouth AustraliaAustralia
| | - Lucia Yeo
- University College LondonDepartment of Social Science, UCL Institute of Education18 Woburn SquareLondonUKWC1H 0NR
- KK Women's and Children's HospitalDepartment of Child DevelopmentSingaporeSingapore229899
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Howard-Anderson J, Schwab KE, Chang S, Wilhalme H, Graber CJ, Quinn R. Internal medicine residents' evaluation of fevers overnight. Diagnosis (Berl) 2019; 6:157-163. [PMID: 30875319 PMCID: PMC6541517 DOI: 10.1515/dx-2018-0066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 02/12/2019] [Indexed: 01/01/2023]
Abstract
Background Scant data exists to guide the work-up for fever in hospitalized patients, and little is known about what diagnostic tests medicine residents order for such patients. We sought to analyze how cross-covering medicine residents address fever and how sign-out systems affect their response. Methods We conducted a prospective cohort study to evaluate febrile episodes that residents responded to overnight. Primary outcomes included diagnostic tests ordered, if an in-person evaluation occurred, and the effect of sign-out instructions that advised a "full fever work-up" (FFWU). Results Investigators reviewed 253 fevers in 155 patients; sign-out instructions were available for 204 fevers. Residents evaluated the patient in person in 29 (11%) episodes. The most common tests ordered were: blood cultures (48%), urinalysis (UA) with reflex culture (34%), and chest X-ray (30%). If the sign-out advised an FFWU, residents were more likely to order blood cultures [odds ratio (OR) 14.75, 95% confidence interval (CI) 7.52-28.90], UA with reflex culture (OR 12.07, 95% CI 5.56-23.23), chest X-ray (OR 16.55, 95% CI 7.03-39.94), lactate (OR 3.33, 95% CI 1.47-7.55), and complete blood count (CBC) (OR 3.16, 95% CI 1.17-8.51). In a multivariable regression, predictors of the number of tests ordered included hospital location, resident training level, timing of previous blood culture, in-person evaluation, escalation to a higher level of care, and sign-out instructions. Conclusions Sign-out instructions and a few patient factors significantly impacted cross-cover resident diagnostic test ordering for overnight fevers. This practice can be targeted in resident education to improve diagnostic reasoning and stewardship.
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Affiliation(s)
- Jessica Howard-Anderson
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA 30303, USA
| | - Kristin E. Schwab
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Sandy Chang
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Holly Wilhalme
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, CA, USA
| | - Christopher J. Graber
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; and Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Roswell Quinn
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; and Hospitalist Division of the Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Kajamaa A, Mattick K, Parker H, Hilli A, Rees C. Trainee doctors' experiences of common problems in the antibiotic prescribing process: an activity theory analysis of narrative data from UK hospitals. BMJ Open 2019; 9:e028733. [PMID: 31189683 PMCID: PMC6576120 DOI: 10.1136/bmjopen-2018-028733] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/25/2019] [Accepted: 05/15/2019] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Prescribing antibiotics is an error-prone activity and one of the more challenging responsibilities for doctors in training. The nature and extent of challenges experienced by them at different stages of the antibiotic prescribing process are not well described, meaning that interventions may not target the most problematic areas. OBJECTIVES Our aim was to explore doctors in training experiences of common problems in the antibiotic prescribing process using cultural-historical activity theory (CHAT). Our research questions were as follows: What are the intended stages in the antibiotic prescribing process? What are the challenges and where in the prescribing process do these occur? METHODS We developed a process model based on how antibiotic prescribing is intended to occur in a 'typical' National Health Service hospital in the UK. The model was first informed by literature and refined through consultation with practising healthcare professionals and medical educators. Then, drawing on CHAT, we analysed 33 doctors in training narratives of their antibiotic prescribing experiences to identify and interpret common problems in the process. RESULTS Our analysis revealed five main disturbances commonly occurring during the antibiotic prescribing process: consultation challenges, lack of continuity, process variation, challenges in patient handover and partial loss of object. Our process model, with 31 stages and multiple practitioners, captures the complexity, inconsistency and unpredictability of the process. The model also highlights 'hot spots' in the process, which are the stages that doctors in training are most likely to have difficulty navigating. CONCLUSIONS Our study widens the understanding of doctors in training prescribing experiences and development needs regarding the prescribing process. Our process model, identifying the common disturbances and hot spots in the process, can facilitate the development of antibiotic prescribing activities and the optimal design of interventions to support doctors in training.
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Affiliation(s)
- Anu Kajamaa
- Faculty of Educational Sciences, University of Helsinki, Finland
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Hazel Parker
- Pharmacy Department, Royal Devon & Exeter Hospital, Exeter, UK
| | - Angelique Hilli
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Charlotte Rees
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
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Adhikari B, Vincent R, Wong G, Duddy C, Richardson E, Lavery JV, Molyneux S. A realist review of community engagement with health research. Wellcome Open Res 2019; 4:87. [PMID: 31289754 PMCID: PMC6611131 DOI: 10.12688/wellcomeopenres.15298.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2019] [Indexed: 09/07/2023] Open
Abstract
Introduction: Community engagement is increasingly recognized as a critical aspect of global health. Recent years have seen an expansion of community engagement activities linked to health research, but debates and inconsistencies remain about the aims of different types of engagement, mechanisms underpinning their implementation and impact, and influential contextual factors. Greater commitment to and consistency around community engagement by health research programs, implementers and funders requires a more coherent evidence base. This realist review is designed to improve our understanding of how and why community engagement contributes to intended and unintended outcomes (including research and ethical outcomes) in different contexts. Given the breadth and diversity of the literature on community engagement in health research, the review will initially focus on malaria research in low- and middle-income countries (LMICs) and draw on wider global health literature where needed. Methods and analysis: Community engagement in practice is often a complex set of interventions. We will conduct a realist review - a theory driven approach to evidence synthesis - to provide explanations for how and why community engagement with health research produces the pattern of outcomes observed across different contexts of application. We will consolidate evidence from a range of documents, including qualitative, quantitative and mixed method studies. The review will follow several stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesizing and refining the programme theory, and reiteration of these steps as needed. Ethics and dissemination: A formal ethics review is not required for this literature review. Findings will be disseminated in a peer reviewed journal, through national and international conferences, and through a set of short briefings tailored for audiences with an interest in community engagement. Outputs and presentations will be informed by and feed into our network of community engagement experts. PROSPERO registration number: CRD42019125687.
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Affiliation(s)
- Bipin Adhikari
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX1 3SY, UK
| | - Robin Vincent
- Robin Vincent Learning and Evaluation Limited, Sheffield, UK
| | - Geoff Wong
- Nuffield Department of Primary Health Care Services, University of Oxford, Oxford, OX2 6GG, UK
| | - Claire Duddy
- Nuffield Department of Primary Health Care Services, University of Oxford, Oxford, OX2 6GG, UK
| | - Emma Richardson
- Centre for Ethical, Social & Cultural Risk, St Michael's Hospital, Toronto, ON M5B 1W8, Canada
| | - James V. Lavery
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, 30322, USA
- Center for Ethics, Emory University, Altanta, Georgia, 30322, USA
| | - Sassy Molyneux
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX1 3SY, UK
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, University of Oxford, Kilifi, 80108, Kenya
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Papoutsi C, Colligan G, Hagell A, Hargreaves D, Marshall M, Vijayaraghavan S, Greenhalgh T, Finer S. Promises and Perils of Group Clinics for Young People Living With Diabetes: A Realist Review. Diabetes Care 2019; 42:705-712. [PMID: 31010940 DOI: 10.2337/dc18-2005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 02/22/2019] [Indexed: 02/03/2023]
Abstract
Group clinics are becoming popular as a new care model in diabetes care. This evidence synthesis, using realist review methodology, examined the role of group clinics in meeting the complex needs of young people living with diabetes. Following Realist And Meta-narrative Evidence Synthesis-Evolving Standards (RAMESES) quality standards, we conducted a systematic search across 10 databases. A total of 131 articles met inclusion criteria and were analyzed to develop theoretically informed explanations of how and why group clinics could work (or not) for young people with diabetes. Models of group-based care in the literature varied significantly and incorporated different degrees of clinical and educational content. Our analysis identified four overarching principles that can be applied in different contexts to drive sustained engagement of young people in group clinics: 1) emphasizing self-management as practical knowledge; 2) developing a sense of affinity between patients; 3) providing safe, developmentally appropriate care; and 4) balancing group and individual needs. Implementation of group clinics was not always straightforward; numerous adjustments to operational and clinical processes were required to establish and deliver high-quality care. Group clinics for young people with diabetes offer the potential to complement individualized care but are not a panacea and may generate as well as solve problems.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, U.K
| | - Grainne Colligan
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, U.K
| | - Ann Hagell
- Association for Young People's Health, London, U.K
| | - Dougal Hargreaves
- Department of Primary Care and Public Health, Imperial College London, London, U.K
| | - Martin Marshall
- Department of Primary Care and Population Health, University College London, London, U.K
| | | | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, U.K
| | - Sarah Finer
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, U.K. .,Barts Health NHS Trust, London, U.K
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Mattick K, Brennan N, Briscoe S, Papoutsi C, Pearson M. Optimising feedback for early career professionals: a scoping review and new framework. MEDICAL EDUCATION 2019; 53:355-368. [PMID: 30828874 DOI: 10.1111/medu.13794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/10/2018] [Accepted: 11/19/2018] [Indexed: 06/09/2023]
Abstract
CONTEXT Meta-analyses have shown that feedback can be a powerful intervention to increase learning and performance but there is significant variability in impact. New trials are adding little to the question of whether feedback interventions are effective, so the focus now is how to optimise the effect. Early career professionals (ECPs) in busy work environments are a particularly important target group. This literature review aimed to synthesise information to support the optimal design of feedback interventions for ECPs. METHODS We undertook a scoping literature review, using search terms such as 'feedback' and 'effectiveness' in MEDLINE, MEDLINE-In-Process, PsycINFO, CINAHL, Education Research Complete, Education Resources Information Center, the Cochrane Database of Systematic Reviews, the Social Sciences Citation Index and Applied Social Sciences Index and Abstracts, to identify empirical studies describing feedback interventions in busy workplaces published in English since 1990. We applied inclusion criteria to identify studies for the mapping stage and extracted key data to inform the next stage. We then selected a subset of papers for the framework development stage, which were subjected to a thematic synthesis by three authors, leading to a new feedback framework and a modified version of feedback intervention theory specifically for ECPs. RESULTS A total of 80 studies were included in the mapping stage, with roughly equal studies from hospital settings and school classrooms, and 17 papers were included in the framework development stage. The feedback framework comprised three main categories (audit, feedback and goal setting) and 22 subcategories. The review highlighted the limited empirical research focusing solely on feedback for ECPs, which was surprising given the particular nuances in feedback for ECPs identified through this study. CONCLUSIONS We offer the feedback framework to optimise the design of future feedback interventions for early career professionals and encourage future feedback research to move away from generic models and tailor work to specific target audiences.
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Affiliation(s)
- Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Simon Briscoe
- Exeter HS&DR Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Francis-Graham S, Ekeke NA, Nelson CA, Lee TY, Haj SE, Rhodes T, Vindrola C, Colbourn T, Rosenberg W. Understanding how, why, for whom, and under what circumstances opt-out blood-borne virus testing programmes work to increase test engagement and uptake within prison: a rapid-realist review. BMC Health Serv Res 2019; 19:152. [PMID: 30849986 PMCID: PMC6408812 DOI: 10.1186/s12913-019-3970-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 02/21/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Prisons represent a unique opportunity to diagnose blood-borne viruses. Opt-out testing is receiving increasing interest, as a result of mounting evidence to suggest that the manner in which a test offer is delivered, affects test uptake. Although the effectiveness of opt-out testing within the prison setting has been established, robust explanations are required for the variation in outcomes reported. METHODS Rapid-realist review methodology was used to synthesise the literature on prison-based opt-out testing. The review was carried out in three phases. Phase one: An expert panel provided literature relevant to the implementation of opt-out testing within the English prison estate. Unstructured searches were also conducted to identify other social programmes where "opt-out" had been used to increase uptake. Phase two: a systematic search of six peer-review and five grey literature databases was carried out to identify empirical data on opt-out testing within the prison setting. Phase three: Additional non-exhaustive searches were carried out to identify literature that reinforced emergent concepts. The development of programme theory took place with each iteration and was validated in consultation with stakeholders. RESULTS Programme theory was constructed for two outcomes: the proportion of intake offered a test and the proportion offered that accepted testing. The proportion of intake offered testing was influenced by the timing of the test offer, which was often delayed due to barriers to prisoner access. The decision to accept testing was influenced by concerns about confidentiality, fear of a positive diagnosis, a prisoner's personal interpretation of risk, discomfort with invasive procedures, trust in healthcare, and the fidelity of the opt-out offer. CONCLUSIONS This review identified important implementation considerations that moderate the effectiveness of opt-out testing programmes. It also highlighted a lack of appreciation for the theoretical underpinnings of opt-out programmes and tension around how to implement testing in a manner that adheres to both default theory and informed consent. It is anticipated that results will be used to inform the design and implementation of subsequent versions of these programmes, as well as catalyse further in-depth analysis into their operation within the unique context of prison. REVIEW REGISTRATION CRD42017068342 .
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Affiliation(s)
- Seth Francis-Graham
- The National Institute for Health Research: Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
- The Institute for Global Health, University College London, London, UK
- The Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | | | | | - Tin Yan Lee
- The Chinese University of Hong Kong, Hong Kong, China
| | | | - Tim Rhodes
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, the London School of Hygiene and Tropical Medicine, London, UK
| | - Cecilia Vindrola
- The Institute of Epidemiology & Health, University College London, London, UK
| | - Tim Colbourn
- The Institute for Global Health, University College London, London, UK
| | - William Rosenberg
- The National Institute for Health Research: Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- The Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
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Smoke SM, Centrella M, Grigoriu A, Brust-Sisti L. Antibiotic Decision-Making Among Medical Residents, Medical Students, and Nurse Practitioners: A Single-Center Survey. J Pharm Pract 2019; 32:372-374. [PMID: 30595078 DOI: 10.1177/0897190018821265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Steven M Smoke
- 1 Department of Pharmacy, Jersey City Medical Center, Jersey City, NJ, USA
| | - Michelle Centrella
- 1 Department of Pharmacy, Jersey City Medical Center, Jersey City, NJ, USA
| | - Adriana Grigoriu
- 2 Department of Medicine, Jersey City Medical Center, Jersey City, NJ, USA
| | - Lindsay Brust-Sisti
- 1 Department of Pharmacy, Jersey City Medical Center, Jersey City, NJ, USA.,3 Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
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69
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Price T, Brennan N, Cleland J, Prescott-Clements L, Wanner A, Withers L, Wong G, Archer J. Remediating doctors' performance to restore patient safety: a realist review protocol. BMJ Open 2018; 8:e025943. [PMID: 30373784 PMCID: PMC6224734 DOI: 10.1136/bmjopen-2018-025943] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Underperformance by doctors poses a risk to patient safety. Remediation is an intervention designed to remedy underperformance and return a doctor to safe practice. Remediation is widely used across healthcare systems globally, and has clear implications for both patient safety and doctor retention. Yet, there is a poor evidence base to inform remediation programmes. In particular, there is a lack of understanding as to why and how a remedial intervention may work to change a doctor's practice. The aim of this research is to identify why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to support patient safety. METHODS AND ANALYSIS Realist review is an approach to evidence synthesis that seeks to develop programme theories about how an intervention works to produce its effects. The initial search strategy will involve: database and grey literature searching, citation searching and contacting authors. The evidence search will be extended as the review progresses and becomes more focused on the development of specific aspects of the programme theory. The development of the programme theory will involve input from a stakeholder group consisting of professional experts in the remediation process and patient representatives. Evidence synthesis will use a realist logic of analysis to interrogate data in order to develop and refine the initial programme theory into a more definitive realist programme theory of how remediation works. The study will follow and be reported according to Realist And Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES). ETHICS AND DISSEMINATION Ethical approval is not required. Our dissemination strategy will include input from our stakeholder group. Customised outputs will be developed using the knowledge-to-action cycle framework, and will be targeted to: policy-makers; education providers and regulators, the National Health Service, doctors and academics. PROSPERO REGISTRATION NUMBER CRD42018088779.
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Affiliation(s)
- Tristan Price
- Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Nicola Brennan
- Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Jennifer Cleland
- Institute of Education for Medical and Dental Sciences, School of Medicine, Dentistry and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | - Amanda Wanner
- NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC), University of Plymouth, Plymouth, UK
| | | | - Geoff Wong
- Nuffield Department of Primary Care, Health Sciences, University of Oxford, Oxford, UK
| | - Julian Archer
- Medicine and Dentistry, University of Plymouth, Plymouth, UK
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Colliers A, Coenen S, Remmen R, Philips H, Anthierens S. How do general practitioners and pharmacists experience antibiotic use in out-of-hours primary care? An exploratory qualitative interview study to inform a participatory action research project. BMJ Open 2018; 8:e023154. [PMID: 30269072 PMCID: PMC6169767 DOI: 10.1136/bmjopen-2018-023154] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
RATIONALE Antibiotics (ABs) are one of the most prescribed medications in out-of-hours (OOH) care in Belgium. Developing a better understanding of why ABs are prescribed in this setting is essential to improve prescribing habits. OBJECTIVES To assess AB prescribing and dispensing challenges for general practitioners (GPs) and pharmacists in OOH primary care, and to identify context-specific elements that can help the implementation of behaviour change interventions to improve AB prescribing in this setting. DESIGN This is an exploratory qualitative study using semistructured interviews. This study is part of a participatory action research project. SETTING AND PARTICIPANTS Participants include 17 GPs and 1 manager, who work in a Belgian OOH general practitioners cooperative (GPC), and 5 pharmacists of the area covered by the GPC. The GPC serves a population of more than 187 000 people. RESULTS GPs feel the threshold to prescribe AB in OOH care is lower in comparion to office hours. GPs and pharmacists talk about the difference in their professional identity in OOH (they define their task differently, they feel more isolated, insecure, have the need to please and so on), type of patients (unknown patients, vulnerable patients, other ethnicities, demanding patients and so on), workload (they feel time-pressured) and lack of diagnostic tools or follow-up. They are aware of the problem of AB overprescribing, but they do not feel ownership of the problem. CONCLUSION The implementation of behaviour change interventions to improve AB prescribing in OOH primary care has to take these context specifics into account and could involve interprofessional collaboration between GPs and pharmacists. TRIAL REGISTRATION NUMBER NCT03082521; Pre-results.
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Affiliation(s)
- Annelies Colliers
- Department of General Practice - Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Samuel Coenen
- Department of General Practice - Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Vaccine and Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Department of Epidemiology and Social Medicine (ESOC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Roy Remmen
- Department of General Practice - Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Hilde Philips
- Department of General Practice - Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Sibyl Anthierens
- Department of General Practice - Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
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Lévin C, Thilly N, Dousak M, Beraud G, Klesnik M, Uhan S, Nathwani D, Beovic B, Pulcini C. Perceptions, attitudes, and practices of French junior physicians regarding antibiotic use and resistance. Med Mal Infect 2018; 49:241-249. [PMID: 30266431 DOI: 10.1016/j.medmal.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 12/08/2017] [Accepted: 09/05/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the perceptions, attitudes, and practices of French junior physicians regarding antibiotic use and resistance, and then to identify the characteristics of junior physicians associated with appropriate practices of antibiotic use. METHOD European junior physicians received an email invitation to complete a 49 item web questionnaire between September 2015 and January 2016. We present the French data. Multivariate regression models were used to identify the characteristics of junior physicians associated with appropriate prescription practices and with consideration of the antibiotic prescription consequences. RESULTS The questionnaire was completed by 641 junior physicians: family medicine (37%), other medical specialties (e.g., pediatrics, internal medicine, neurology: 45%), surgical specialties (11%), and anesthesiology-intensive care specialty (7%). Most respondents (93%) declared being aware of the risk of bacterial resistance and 41% acknowledged prescribing antibiotics more often than necessary. Two factors were independently associated with appropriate prescription practices: a high perceived level of education on antibiotic use (OR=1.51; 95% CI [1.01-2.30]) and a medical specialty (OR=1.69; 95% CI [1.16-2.46]). Factors independently associated with taking into account adverse events of antibiotics were a good perceived knowledge of antibiotics (OR=3.71; 95% CI [2.09-6.61]), and a high perceived education level on antibiotics (OR=1.70; 95% CI [1.11-2.58]). CONCLUSION Our data can help better define interventions targeting junior physicians in antibiotic stewardship programs.
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Affiliation(s)
- C Lévin
- EA 4360 APEMAC, faculté de médecine de Nancy, université de Lorraine, 9, avenue de la Fôret-de-Haye, BP 20199, 54505 Nancy, France.
| | - N Thilly
- EA 4360 APEMAC, faculté de médecine de Nancy, université de Lorraine, 9, avenue de la Fôret-de-Haye, BP 20199, 54505 Nancy, France; Centre hospitalier universitaire de Nancy, plateforme d'aide à la recherche clinique, 54000 Nancy, France
| | - M Dousak
- Faculty of Social Sciences, University of Ljubljana, Slovenia
| | - G Beraud
- Santé des populations et pratiques optimales en santé, centre de recherche du CHU de Québec-Université Laval, hôpital Saint-Sacrement, Québec, Canada; Service de médecine interne et maladies infectieuses, centre hospitalier universitaire de Poitiers, 86021 Poitiers, France; Censtat, Interuniversity Institute for Biostatistics and statistical Bioinformatics, Hasselt University, Hasselt, Belgique
| | - M Klesnik
- Department of Infectious Disease, University Medical Centre, Ljubljana, Slovenia
| | - S Uhan
- Faculty of Social Sciences, University of Ljubljana, Slovenia
| | - D Nathwani
- Infection Unit, Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - B Beovic
- Department of Infectious Disease, University Medical Centre, Ljubljana, Slovenia
| | - C Pulcini
- EA 4360 APEMAC, faculté de médecine de Nancy, université de Lorraine, 9, avenue de la Fôret-de-Haye, BP 20199, 54505 Nancy, France; Service de maladies infectieuses et tropicales, université de Lorraine, CHRU de Nancy, 54000 Nancy, France
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Duddy C, Wong G. Explaining variations in test ordering in primary care: protocol for a realist review. BMJ Open 2018; 8:e023117. [PMID: 30209159 PMCID: PMC6144329 DOI: 10.1136/bmjopen-2018-023117] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/29/2018] [Accepted: 08/10/2018] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Studies have demonstrated the existence of significant variation in test-ordering patterns in both primary and secondary care, for a wide variety of tests and across many health systems. Inconsistent practice could be explained by differing degrees of underuse and overuse of tests for diagnosis or monitoring. Underuse of appropriate tests may result in delayed or missed diagnoses; overuse may be an early step that can trigger a cascade of unnecessary intervention, as well as being a source of harm in itself. METHODS AND ANALYSIS This realist review will seek to improve our understanding of how and why variation in laboratory test ordering comes about. A realist review is a theory-driven systematic review informed by a realist philosophy of science, seeking to produce useful theory that explains observed outcomes, in terms of relationships between important contexts and generative mechanisms.An initial explanatory theory will be developed in consultation with a stakeholder group and this 'programme theory' will be tested and refined against available secondary evidence, gathered via an iterative and purposive search process. This data will be analysed and synthesised according to realist principles, to produce a refined 'programme theory', explaining the contexts in which primary care doctors fail to order 'necessary' tests and/or order 'unnecessary' tests, and the mechanisms underlying these decisions. ETHICS AND DISSEMINATION Ethical approval is not required for this review. A complete and transparent report will be produced in line with the RAMESES standards. The theory developed will be used to inform recommendations for the development of interventions designed to minimise 'inappropriate' testing. Our dissemination strategy will be informed by our stakeholders. A variety of outputs will be tailored to ensure relevance to policy-makers, primary care and pathology practitioners, and patients. PROSPERO REGISTRATION NUMBER CRD42018091986.
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Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
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