An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial

Practical help for specifying the target difference in sample size calculations for RCTs: the DELTA2 five-stage study, including a workshop

BACKGROUND

The randomised controlled trial is widely considered to be the gold standard study for comparing the effectiveness of health interventions. Central to its design is a calculation of the number of participants needed (the sample size) for the trial. The sample size is typically calculated by specifying the magnitude of the difference in the primary outcome between the intervention effects for the population of interest. This difference is called the 'target difference' and should be appropriate for the principal estimand of interest and determined by the primary aim of the study. The target difference between treatments should be considered realistic and/or important by one or more key stakeholder groups.

OBJECTIVE

The objective of the report is to provide practical help on the choice of target difference used in the sample size calculation for a randomised controlled trial for researchers and funder representatives.

METHODS

The Difference ELicitation in TriAls2 (DELTA2) recommendations and advice were developed through a five-stage process, which included two literature reviews of existing funder guidance and recent methodological literature; a Delphi process to engage with a wider group of stakeholders; a 2-day workshop; and finalising the core document.

RESULTS

Advice is provided for definitive trials (Phase III/IV studies). Methods for choosing the target difference are reviewed. To aid those new to the topic, and to encourage better practice, 10 recommendations are made regarding choosing the target difference and undertaking a sample size calculation. Recommended reporting items for trial proposal, protocols and results papers under the conventional approach are also provided. Case studies reflecting different trial designs and covering different conditions are provided. Alternative trial designs and methods for choosing the sample size are also briefly considered.

CONCLUSIONS

Choosing an appropriate sample size is crucial if a study is to inform clinical practice. The number of patients recruited into the trial needs to be sufficient to answer the objectives; however, the number should not be higher than necessary to avoid unnecessary burden on patients and wasting precious resources. The choice of the target difference is a key part of this process under the conventional approach to sample size calculations. This document provides advice and recommendations to improve practice and reporting regarding this aspect of trial design. Future work could extend the work to address other less common approaches to the sample size calculations, particularly in terms of appropriate reporting items.

FUNDING

Funded by the Medical Research Council (MRC) UK and the National Institute for Health Research as part of the MRC-National Institute for Health Research Methodology Research programme.

The Effectiveness of Online Course Intervention to Improve Knowledge of Antimicrobial Resistance among Dental Students, in Comparison to Reference Group Using a Randomized Controlled Trial

AIM

This study aimed to assess the effectiveness of a recognised antimicrobial resistance (AMR) online module on knowledge and perception among dental students, using a randomised controlled trial study design.

METHODS

Dental students (n = 64, aged 21-25 years) in clinical years agreed to participate in this triple-blinded, parallel, randomised controlled trial. There were 34 students in the study group and 30 students in the control group. The study group participated in an online course covering information about AMR, while students in the control group received another online course about microorganisms in dentistry. Both groups were assessed three times using online questionnaires: before the intervention (T1), after the intervention (T2), and two months later (T3). Each one of T1, T2 and T3 had 22 questions. The questions were repeated each time in T1, T2, and T3 asking about AMR but with different question format, to avoid the possibility of students to memorise the answers.

RESULTS

The mean (m) of correct answers for all students on T1 was 12.56, with standard deviation (SD) of 3.2. On T2, m = 14.03 and SD = 3.85, and on T3, m = 14.36 and SD = 3.71. Scores ranged from 0 to 22. The participants in the study and control groups showed significant score improvements from T1 to T2, immediately after the intervention, but there was no significant difference between T2 and T3. The study group students' scores did not improve significantly from T1 to T3, in contrast to the control group students' scores. More importantly, there was no significant difference in improvement from T1 to T2 when comparing the study and control groups.

CONCLUSION

Online courses might not be reliable learning methods for ensuring the optimal levels of AMR knowledge that are needed by dental practitioners.

Clinical performance comparators in audit and feedback: a review of theory and evidence

BACKGROUND

Audit and feedback (A&F) is a common quality improvement strategy with highly variable effects on patient care. It is unclear how A&F effectiveness can be maximised. Since the core mechanism of action of A&F depends on drawing attention to a discrepancy between actual and desired performance, we aimed to understand current and best practices in the choice of performance comparator.

METHODS

We described current choices for performance comparators by conducting a secondary review of randomised trials of A&F interventions and identifying the associated mechanisms that might have implications for effective A&F by reviewing theories and empirical studies from a recent qualitative evidence synthesis.

RESULTS

We found across 146 trials that feedback recipients' performance was most frequently compared against the performance of others (benchmarks; 60.3%). Other comparators included recipients' own performance over time (trends; 9.6%) and target standards (explicit targets; 11.0%), and 13% of trials used a combination of these options. In studies featuring benchmarks, 42% compared against mean performance. Eight (5.5%) trials provided a rationale for using a specific comparator. We distilled mechanisms of each comparator from 12 behavioural theories, 5 randomised trials, and 42 qualitative A&F studies.

CONCLUSION

Clinical performance comparators in published literature were poorly informed by theory and did not explicitly account for mechanisms reported in qualitative studies. Based on our review, we argue that there is considerable opportunity to improve the design of performance comparators by (1) providing tailored comparisons rather than benchmarking everyone against the mean, (2) limiting the amount of comparators being displayed while providing more comparative information upon request to balance the feedback's credibility and actionability, (3) providing performance trends but not trends alone, and (4) encouraging feedback recipients to set personal, explicit targets guided by relevant information.

Improving primary care Access in Context and Theory (I-ACT trial): a theory-informed randomised cluster feasibility trial using a realist perspective

Background

Primary care access can be challenging for older, rural, socio-economically disadvantaged populations. Here we report the I-ACT cluster feasibility trial which aims to assess the feasibility of trial design and context-sensitive intervention to improve primary care access for this group and so expand existing theory.

Methods

Four general practices were recruited; three randomised to intervention and one to usual care. Intervention practices received £1500, a support manual and four meetings to develop local, innovative solutions to improve the booking system and transport.

Patients aged over 64 years old and without household car access were recruited to complete questionnaires when booking an appointment or attending the surgery. Outcome measures at 6 months included: self-reported ease of booking an appointment and transport; health care use; patient activation; capability; and quality of life. A process evaluation involved observations and interviews with staff and participants.

Results

Thirty-four patients were recruited (26 female, eight male, mean age 81.6 years for the intervention group and 79.4 for usual care) of 1143 invited (3% response rate). Most were ineligible because of car access. Twenty-nine participants belonged to intervention practices and five to usual care. Practice-level data was available for all participants, but participant self-reported data was unavailable for three. Fifty-six appointment questionnaires were received based on 150 appointments (37.3%).

Practices successfully designed and implemented the following context-sensitive interventions: Practice A: a stacked telephone system and promoting community transport; Practice B: signposting to community transport, appointment flexibility, mobility scooter charging point and promoting the role of receptionists; and Practice C: local taxi firm partnership and training receptionists. Practices found the process acceptable because it gave freedom, time and resource to be innovative or provided an opportunity to implement existing ideas. Data collection methods were acceptable to participants, but some found it difficult remembering to complete booking and appointment questionnaires. Expanded theory highlighted important mechanisms, such as reassurance, confidence, trust and flexibility.

Conclusions

Recruiting older participants without access to a car proved challenging. Retention of participants and practices was good but only about a third of appointment questionnaires were returned. This study design may facilitate a shift from one-size-fits-all interventions to more context-sensitive interventions.

Trial registration

ISRCTN18321951, Registered on 6 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3299-2) contains supplementary material, which is available to authorized users.

Reinvigorating stagnant science: implementation laboratories and a meta-laboratory to efficiently advance the science of audit and feedback

Audit and feedback (A&F) is a commonly used quality improvement (QI) approach. A Cochrane review indicates that A&F is generally effective and leads to modest improvements in professional practice but with considerable variation in the observed effects. While we have some understanding of factors that enhance the effects of A&F, further research needs to explore when A&F is most likely to be effective and how to optimise it. To do this, we need to move away from two-arm trials of A&F compared with control in favour of head-to-head trials of different ways of providing A&F. This paper describes implementation laboratories involving collaborations between healthcare organisations providing A&F at scale, and researchers, to embed head-to-head trials into routine QI programmes. This can improve effectiveness while producing generalisable knowledge about how to optimise A&F. We also describe an international meta-laboratory that aims to maximise cross-laboratory learning and facilitate coordination of A&F research.

Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice

BACKGROUND

Most antibiotic use in the United States occurs in the outpatient setting, and 10% of these prescriptions are generated by dentists. The development of comprehensive antibiotic stewardship programs (ASPs) in the dental setting is nascent, and therefore we describe the implementation of a dental ASP.

METHODS

A collaborative team of dentist, pharmacist, and physician leaders conducted a baseline needs assessment and literature evaluation to identify opportunities to improve antibiotic prescribing by dentists within Illinois' largest oral health care provider for Medicaid recipients. A multimodal intervention was implemented that included patient and provider education, clinical guideline development, and an assessment of the antibiotic prescribing rate per urgent care visit before and after the educational interventions.

RESULTS

We identified multiple needs, including standardization of antibiotic prescribing practices for patients with acute oral infections in the urgent care clinics. A 72.9% decrease in antibiotic prescribing was observed in urgent care visits after implementation of our multimodal intervention (preintervention urgent care prescribing rate, 8.5% [24/283]; postintervention, 2.3% [8/352]; P < .001).

CONCLUSIONS

We report the successful implementation of a dental ASP that is concordant with the Centers for Disease Control and Prevention Core Elements of Antibiotic Stewardship in the Outpatient Setting. Our approach may be adapted to other dental practices to improve antibiotic prescribing.

Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial

OBJECTIVES

To evaluate the effectiveness and safety at population scale of electronically delivered prescribing feedback and decision support interventions at reducing antibiotic prescribing for self limiting respiratory tract infections.

DESIGN

Open label, two arm, cluster randomised controlled trial.

SETTING

UK general practices in the Clinical Practice Research Datalink, randomised between 11 November 2015 and 9 August 2016, with final follow-up on 9 August 2017.

PARTICIPANTS

79 general practices (582 675 patient years) randomised (1:1) to antimicrobial stewardship (AMS) intervention or usual care.

INTERVENTIONS

AMS intervention comprised a brief training webinar, automated monthly feedback reports of antibiotic prescribing, and electronic decision support tools to inform appropriate prescribing over 12 months. Intervention components were delivered electronically, supported by a local practice champion nominated for the trial.

MAIN OUTCOME MEASURES

Primary outcome was the rate of antibiotic prescriptions for respiratory tract infections from electronic health records. Serious bacterial complications were evaluated for safety. Analysis was by Poisson regression with general practice as a random effect, adjusting for covariates. Prespecified subgroup analyses by age group were reported.

RESULTS

The trial included 41 AMS practices (323 155 patient years) and 38 usual care practices (259 520 patient years). Unadjusted and adjusted rate ratios for antibiotic prescribing were 0.89 (95% confidence interval 0.68 to 1.16) and 0.88 (0.78 to 0.99, P=0.04), respectively, with prescribing rates of 98.7 per 1000 patient years for AMS (31 907 prescriptions) and 107.6 per 1000 patient years for usual care (27 923 prescriptions). Antibiotic prescribing was reduced most in adults aged 15-84 years (adjusted rate ratio 0.84, 95% confidence interval 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 patients (95% confidence interval 40 to 200). There was no evidence of effect for children younger than 15 years (adjusted rate ratio 0.96, 95% confidence interval 0.82 to 1.12) or people aged 85 years and older (0.97, 0.79 to 1.18); there was also no evidence of an increase in serious bacterial complications (0.92, 0.74 to 1.13).

CONCLUSIONS

Electronically delivered interventions, integrated into practice workflow, result in moderate reductions of antibiotic prescribing for respiratory tract infections in adults, which are likely to be of importance for public health. Antibiotic prescribing to very young or old patients requires further evaluation.

TRIAL REGISTRATION

ISRCTN95232781.

Detecting change in comparison to peers in NHS prescribing data: a novel application of cumulative sum methodology

Background

The widely used OpenPrescribing.net service provides standard measures which compare prescribing of Clinical Commissioning Groups (CCGs) and English General Practices against that of their peers. Detecting changes in prescribing behaviour compared with peers can help identify missed opportunities for medicines optimisation. Automating the process of detecting these changes is necessary due to the volume of data, but challenging due to variation in prescribing volume for different measures and locations. We set out to develop and implement a method of detecting change on all individual prescribing measures, in order to notify CCGs and practices of such changes in a timely manner.

Methods

We used the statistical process control method CUSUM to detect prescribing behaviour changes in relation to population trends for the individual standard measures on OpenPrescribing. Increases and decreases in percentile were detected separately, using a multiple of standard deviation as the threshold for detecting change. The algorithm was modified to continue re-triggering when trajectory persists. It was deployed, user-tested, and summary statistics generated on the number of alerts by CCG and practice.

Results

The algorithm detected changes in prescribing for 32 prespecified measures, across a wide range of CCG and practice sizes. Across the 209 English CCGs, a mean of 2.5 increase and 2.4 decrease alerts were triggered per CCG, per month. For the 7578 practices, a mean of 1.3 increase and 1.4 decrease alerts were triggered per practice, per month.

Conclusions

The CUSUM method appears to effectively discriminate between random noise and sustained change in prescribing behaviour. This method aims to allow practices and CCGs to be informed of important changes quickly, with a view to improve their prescribing behaviour. The number of alerts triggered for CCGs and practices appears to be appropriate. Prescribing behaviour after users are alerted to changes will be monitored in order to assess the impact of these alerts.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0642-6) contains supplementary material, which is available to authorized users.

Dentists' prescribing of antibiotics and opioids to Medicare Part D beneficiaries: Medications of high impact to public health

BACKGROUND

Gaining a better understanding of dental prescribing can help identify opportunities for intervention regarding optimal medication use. The purpose of this study is to characterize opioid and antibiotic prescribing patterns of dentists in the United States for Medicare Part D beneficiaries.

METHODS

The authors conducted a retrospective cross-sectional analysis of national 2014 Medicare Part D Prescriber Public Use File data. Providers in the data set with dental-related disciplines were included (n = 99,797). Outcomes of interest were mean days' supply and mean number of claims reported per claim, beneficiary, and prescriber discipline.

RESULTS

Of the 6,724,372 dental prescription claims submitted, 3,947,848 (58.7%) and 1,312,796 (19.5%) were for antibiotics and opioids, respectively. Sixty-nine percent of dentists in the highest quartile of opioid prescribers were also in the highest quartile of antibiotic prescribers (r² = 0.7778; P < .01). The mean (standard deviation) days' supply per claim was 6.9 (5.3) days (range, 1-90 days) for antibiotics and 3.6 (2.0) days (range, 1-44.5 days) for opioids. Of the 33,348 dental providers who prescribed opioids, 18,971 (56.9%) prescribed a mean opioid days per claim greater than the recommended duration of 3 days for acute pain.

CONCLUSION

Opioids and antibiotics are the medications most prescribed by dentists. On the basis of national recommendations and results of studies from other countries, the length of therapy prescribed may be excessive. Further studies should be conducted to assess appropriateness of dental prescriptions.

PRACTICAL IMPLICATIONS

Dentistry should be considered for antibiotic and opioid stewardship interventions along with medicine.

What are the 'active ingredients' of interventions targeting the public's engagement with antimicrobial resistance and how might they work?

Objectives

Changing public awareness of antimicrobial resistance (AMR) represents a global public health priority. A systematic review of interventions that targeted public AMR awareness and associated behaviour was previously conducted. Here, we focus on identifying the active content of these interventions and explore potential mechanisms of action.

Methods

The project took a novel approach to intervention mapping utilizing the following steps: (1) an exploration of explicit and tacit theory and theoretical constructs within the interventions using the Theoretical Domains Framework (TDFv2), (2) retrospective coding of behaviour change techniques (BCTs) using the BCT Taxonomy v1, and (3) an investigation of coherent links between the TDF domains and BCTs across the interventions.

Results

Of 20 studies included, only four reported an explicit theoretical basis to their intervention. However, TDF analysis revealed that nine of the 14 TDF domains were utilized, most commonly ‘Knowledge’ and ‘Environmental context and resources’. The BCT analysis showed that all interventions contained at least one BCT, and 14 of 93 (15%) BCTs were coded, most commonly ‘Information about health consequences’, ‘Credible source’, and ‘Instruction on how to perform the behaviour’.

Conclusions

We identified nine relevant TDF domains and 14 BCTs used in these interventions. Only 15% of BCTs have been applied in AMR interventions thus providing a clear opportunity for the development of novel interventions in this context. This methodological approach provides a useful way of retrospectively mapping theoretical constructs and BCTs when reviewing studies that provide limited information on theory and intervention content.

Assessment of inappropriate antibiotic prescribing among a large cohort of general dentists in the United States

BACKGROUND

The purpose of this study was to assess dental antibiotic prescribing trends over time, to quantify the number and types of antibiotics dentists prescribe inappropriately, and to estimate the excess health care costs of inappropriate antibiotic prescribing with the use of a large cohort of general dentists in the United States.

METHODS

We used a quasi-Poisson regression model to analyze antibiotic prescriptions trends by general dentists between January 1, 2013, and December 31, 2015, with the use of data from Express Scripts Holding Company, a large pharmacy benefits manager. We evaluated antibiotic duration and appropriateness for general dentists. Appropriateness was evaluated by reviewing the antibiotic prescribed and the duration of the prescription.

RESULTS

Overall, the number and rate of antibiotic prescriptions prescribed by general dentists remained stable in our cohort. During the 3-year study period, approximately 14% of antibiotic prescriptions were deemed inappropriate, based on the antibiotic prescribed, antibiotic treatment duration, or both indicators. The quasi-Poisson regression model, which adjusted for number of beneficiaries covered, revealed a small but statistically significant decrease in the monthly rate of inappropriate antibiotic prescriptions by 0.32% (95% confidence interval, 0.14% to 0.50%; P = .001).

CONCLUSIONS

Overall antibiotic prescribing practices among general dentists in this cohort remained stable over time. The rate of inappropriate antibiotic prescriptions by general dentists decreased slightly over time.

PRACTICAL IMPLICATIONS

From these authors' definition of appropriate antibiotic prescription choice and duration, inappropriate antibiotic prescriptions are common (14% of all antibiotic prescriptions) among general dentists. Further analyses with the use of chart review, administrative data sets, or other approaches are needed to better evaluate antibiotic prescribing practices among dentists.

The knowledge mobilisation challenge: does producing evidence lead to its adoption within dentistry?

The transfer of evidence into clinical practice is the ultimate aim of those engaged in health research. But is this a process that occurs naturally? Can health researchers take it for granted that the evidence they produce will be embraced by clinicians and incorporated into their everyday practice? In this article, we use the example of oral healthcare in dependent older people and the issue of antibiotic prescribing by GDPs to illustrate the fact that successful knowledge transfer between researchers and practitioners cannot be automatically assumed. What is needed, so we argue, are certain tools to facilitate the knowledge transfer, exchange and implementation process. These tools may take the form of human intermediaries, who can occupy the space in between the worlds of research and practice, acting as brokers to mobilise knowledge, or through the establishment of communities of practice. We outline both of these approaches here as a potential solution to the problem of knowledge mobilisation in dentistry.

Explaining family physicians' beliefs about antibiotic prescription

Background

Antibiotics are among those drugs prescribed abundantly in hospitals due to their high efficiency. However, excessive, non-logical and unnecessary use of antibiotics regardless of physicians' recommendations is considered as a challenge.

Objectives

The aim of this study was to explain family physicians' beliefs about antibiotic prescription in Ahvaz.

Methods

This study is part of a content-analysis qualitative research conducted in Ahvaz in 2016. Study subjects were selected according to purposive sampling and data collection continued to data saturation. Required data were collected using semi-structured in-depth interviews with participation of eight subjects. Data analysis was conducted along with conducting interviews using constant comparison analysis, and it continued to the last interview. Strength and accuracy of data were investigated by experts and participants.

Results

From data analysis, four major categories were extracted that were composed of 20 subcategories. They were 1) expected outcomes of antibiotics (perceived pros and cons); 2) perceived pressure to follow others' opinions; 3) the level of access to antibiotics; and 4) individual's perception for prescription.

Conclusion

Findings of this study showed that various factors affect physicians' decisions to prescribe antibiotics and it is emphasized to consider these factors.

An evaluation of dental antibiotic prescribing practices in the United States

BACKGROUND

Antibiotic prescribing practices among general dentists and dental specialists in the United States remains poorly understood. The purpose of this study was to compare prescribing practices across dental specialties, evaluate the duration of antibiotics dentists prescribed, and determine variation in antibiotic selection among dentists.

METHODS

The authors performed a retrospective cross-sectional analysis of dental care provider specialties linked to deidentified antibiotic claims data from a large pharmacy benefits manager during the 2015 calendar year.

RESULTS

As a group, general dentists and dental specialists were responsible for more than 2.9 million antibiotic prescriptions, higher than levels for several other medical and allied health care provider specialties. Antibiotic treatment duration generally was prolonged and commonly included broad-spectrum agents, such as amoxicillin clavulanate and clindamycin. Although amoxicillin was the most commonly prescribed antibiotic among all dental specialties, there was substantial variation among other antibiotics each specialty selected. The most common antibiotic treatment durations were 7 and 10 days.

CONCLUSIONS

This study's results demonstrate that dentists frequently prescribe antibiotics for prolonged periods and often use broad-spectrum antibiotics. Further studies are necessary to evaluate the appropriateness of these antibiotic prescribing patterns.

PRACTICAL IMPLICATIONS

The clinically significant variation in antibiotic selection and treatment duration identified among all dental specialties in this study population implies that further research and guidance into the treatment of dental infections is necessary to improve and standardize antibiotic prescribing practices.

The effect of interventions aiming to optimise the prescription of antibiotics in dental care-A systematic review

BACKGROUND

Abundant evidence in dentistry suggests that antibiotics are prescribed despite the existence of guidelines aiming to reduce the development of antibiotic resistance. This review investigated (1) which type of interventions aiming to optimise prescription of antibiotics exist in dentistry, (2) the effect of these interventions and (3) the specific strengths and limitations of the studies reporting on these interventions.

METHOD

Literature search was based on Medline, Embase, Global Health, Cochrane CENTRAL, ClinicalTrials.gov and Current Controlled Trials. Studies with one of the two primary outcomes were included: (1) The number of antibiotics prescribed and/or (2) the accuracy of the prescription, commonly measured as a percentage of adherence to local clinical guidelines.

RESULTS

Nine studies met these inclusion criteria. Five studies reported on the prescription of antibiotics in primary dental care and four studies focused on outpatient dental care. Interventions used in primary dental care included a combination of audit, feedback, education, local consensus, dissemination of guidelines and/or academic detailing. Trials in the outpatient setting made use of expert panel discussions, educational feedback on previous acts of prescribing, the dissemination of guidelines and the establishment of internal guidelines. All studies successfully reduced the number of antibiotics prescribed and/or increased the accuracy of the prescription. However, most studies were confounded by a high risk of selection bias, selective outcome reporting and high variance across study groups. In particular, information relating to study design and methodology was insufficient. Only three studies related the prescriptions to the number of patients treated with antibiotics.

CONCLUSIONS

This systematic review was able to offer conclusions which took the limitations of the investigated studies into account. Unfortunately, few studies could be included and many of these studies were confounded by a low quality of scientific reporting and lack of information regarding study methodology. High-quality research with objective and standardised outcome reporting, longer periods of follow-up, rigorous methodology and adequate standard of study reporting is urgently needed.

Advancing the literature on designing audit and feedback interventions: identifying theory-informed hypotheses

BACKGROUND

Audit and feedback (A&F) is a common strategy for helping health providers to implement evidence into practice. Despite being extensively studied, health care A&F interventions remain variably effective, with overall effect sizes that have not improved since 2003. Contributing to this stagnation is the fact that most health care A&F interventions have largely been designed without being informed by theoretical understanding from the behavioral and social sciences. To determine if the trend can be improved, the objective of this study was to develop a list of testable, theory-informed hypotheses about how to design more effective A&F interventions.

METHODS

Using purposive sampling, semi-structured 60-90-min telephone interviews were conducted with experts in theories related to A&F from a range of fields (e.g., cognitive, health and organizational psychology, medical decision-making, economics). Guided by detailed descriptions of A&F interventions from the health care literature, interviewees described how they would approach the problem of designing improved A&F interventions. Specific, theory-informed hypotheses about the conditions for effective design and delivery of A&F interventions were elicited from the interviews. The resulting hypotheses were assigned by three coders working independently into themes, and categories of themes, in an iterative process.

RESULTS

We conducted 28 interviews and identified 313 theory-informed hypotheses, which were placed into 30 themes. The 30 themes included hypotheses related to the following five categories: A&F recipient (seven themes), content of the A&F (ten themes), process of delivery of the A&F (six themes), behavior that was the focus of the A&F (three themes), and other (four themes).

CONCLUSIONS

We have identified a set of testable, theory-informed hypotheses from a broad range of behavioral and social science that suggest conditions for more effective A&F interventions. This work demonstrates the breadth of perspectives about A&F from non-healthcare-specific disciplines in a way that yields testable hypotheses for healthcare A&F interventions. These results will serve as the foundation for further work seeking to set research priorities among the A&F research community.

Trends in antibiotic prescribing by dental practitioners in Germany

PURPOSE

To analyze the structure of antibiotic prescriptions by dentists in Germany during a time-period of four years in relation to medical antibiotic prescriptions.

MATERIALS AND METHODS

We collected nationwide data from all statutory health insurances on dental prescriptions of systemic antibiotics from 2012 to 2015. The annual reports of the "Research Institute for Local Health Care Systems" (WIdO, Berlin) provided the basis for this longitudinal data base analysis. The types of antibiotics, the number of prescriptions and the prescribed 'defined daily doses' (DDD) were analyzed. The results were compared to antibiotic prescriptions of German physicians.

RESULTS

An average of 8.8% per year of all antibiotic prescriptions is issued by dentists. The mostly prescribed antibiotic is amoxicillin. The share of amoxicillin on all dental prescriptions increased from 35.6% in 2012 to 45.8% in 2015 (p < 0.01). About three-quarters of all dentally prescribed DDD can be attributed to amoxicillin and clindamycin. On the part of the physicians the proportion of clindamycin is 18 fold lower than in the dental field.

CONCLUSIONS

Dental and medical antibiotic prescriptions in Germany show statistically significant differences regarding the shares of the prescribed antibiotics. In an international comparison the high proportion of Clindamycin in Germany is noticeable.

Disparities in Feedback Provision to Emergency Medical Services Professionals

INTRODUCTION

Feedback to EMS professionals is a critical component for optimizing patient care and outcomes in the prehospital setting. There is a paucity of data concerning the feedback received by prehospital providers.

OBJECTIVES

The objective of this study was to describe the prevalence of feedback received by EMS professionals in the past 30 days including the types, sources, modes, and utility of feedback. The secondary objective was to identify factors associated with receiving any feedback and, specifically, feedback regarding medical care provided.

METHODS

This was a cross-sectional survey examining currently practicing nationally certified EMS patient care providers (EMT or higher) in non-military and non-tribal settings. Data were collected on provider characteristics along with feedback received. Descriptive statistics were calculated, and multivariable logistic regression models were constructed to assess the relationship between EMS provider characteristics and receiving feedback. A non-respondent survey was administered to assess for non-response bias.

RESULTS

Responses from 32,314 EMS providers were received (response rate = 10.4%) with 15,766 meeting inclusion criteria. In the 30 days preceding the survey, 69.4% (n = 10,924) of respondents received at least one type of feedback with 54.7% (n = 8,592) reporting receiving medical care feedback. Multivariable logistic regression modeling indicated that higher certification level, fewer years of experience in EMS, working for a hospital-based agency, air medical service, and higher weekly call volumes were significantly associated with increased odds of having received at least one type of feedback, and specifically medical care feedback. Additionally, providing primarily medical/convalescent transport and more years of EMS experience were significantly associated with decreased odds of receiving feedback.

CONCLUSION

Feedback to EMS providers is critical to improving prehospital care. In this study, nearly a third of providers did not receive any feedback in a 30-day period, and nearly half reported not receiving medical care feedback. Disparities in the frequency of feedback exist between different provider levels and service settings, while reported feedback decreased with years of experience in the profession. Future work is needed to assess the content of feedback and role in improving patient care and safety.

How can Multi-Professional Education Support Better Stewardship?

Antimicrobial stewardship is widely accepted as an efficient strategy to combat the growing threat of antimicrobial resistance. Education is one of the cornerstones of successful antimicrobial stewardship programs. There is also general agreement that antimicrobial stewardship is a team effort that must involve the whole continuum of healthcare workers. Providing adequate education for all different professionals although challenging is deemed crucial to achieve good results. This paper reviews the different strategies available to educate the multiple healthcare workers, discusses how education can improve antimicrobial stewardship programs and outlines some of the challenges faced and research gaps that need to be addressed in order to improve education in this field.

Combined use of the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF): a systematic review

Background

Over 60 implementation frameworks exist. Using multiple frameworks may help researchers to address multiple study purposes, levels, and degrees of theoretical heritage and operationalizability; however, using multiple frameworks may result in unnecessary complexity and redundancy if doing so does not address study needs. The Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF) are both well-operationalized, multi-level implementation determinant frameworks derived from theory. As such, the rationale for using the frameworks in combination (i.e., CFIR + TDF) is unclear. The objective of this systematic review was to elucidate the rationale for using CFIR + TDF by (1) describing studies that have used CFIR + TDF, (2) how they used CFIR + TDF, and (2) their stated rationale for using CFIR + TDF.

Methods

We undertook a systematic review to identify studies that mentioned both the CFIR and the TDF, were written in English, were peer-reviewed, and reported either a protocol or results of an empirical study in MEDLINE/PubMed, PsycInfo, Web of Science, or Google Scholar. We then abstracted data into a matrix and analyzed it qualitatively, identifying salient themes.

Findings

We identified five protocols and seven completed studies that used CFIR + TDF. CFIR + TDF was applied to studies in several countries, to a range of healthcare interventions, and at multiple intervention phases; used many designs, methods, and units of analysis; and assessed a variety of outcomes. Three studies indicated that using CFIR + TDF addressed multiple study purposes. Six studies indicated that using CFIR + TDF addressed multiple conceptual levels. Four studies did not explicitly state their rationale for using CFIR + TDF.

Conclusions

Differences in the purposes that authors of the CFIR (e.g., comprehensive set of implementation determinants) and the TDF (e.g., intervention development) propose help to justify the use of CFIR + TDF. Given that the CFIR and the TDF are both multi-level frameworks, the rationale that using CFIR + TDF is needed to address multiple conceptual levels may reflect potentially misleading conventional wisdom. On the other hand, using CFIR + TDF may more fully define the multi-level nature of implementation. To avoid concerns about unnecessary complexity and redundancy, scholars who use CFIR + TDF and combinations of other frameworks should specify how the frameworks contribute to their study.

Trial registration

PROSPERO CRD42015027615

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0534-z) contains supplementary material, which is available to authorized users.