Rationale Antibiotikaverordnung in der Humanmedizin

Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers

BACKGROUND

Previous studies have identified substantial regional variations in outpatient antibiotic prescribing in Germany, both in the paediatric and adult population. This indicates inappropriate antibiotic prescribing in some regions, which should be avoided to reduce antimicrobial resistance and potential side effects. The reasons for regional variations in outpatient antibiotic prescribing are not yet completely understood; socioeconomic and health care density differences between regions do not fully explain such differences. Here, we apply a behavioural perspective by adapting the Theoretical Domains Framework (TDF) to examine regional factors deemed relevant for outpatient antibiotic prescriptions by paediatricians and general practitioners.

METHODS

Qualitative study with guideline-based telephone interviews of 40 prescribers (paediatricians and general practitioners) in outpatient settings from regions with high and low rates of antibiotic prescriptions, stratified by urbanity. TDF domains formed the basis of an interview guide to assess region-level resources and barriers to rational antibiotic prescription behaviour. Interviews lasted 30-61 min (M = 45 min). Thematic analysis was used to identify thematic clusters, and relationships between themes were explored through proximity estimation.

RESULTS

Both paediatricians and general practitioners in low-prescribing regions reported supporting contextual factors (in particular good collegial networks, good collaboration with laboratories) and social factors (collegial support and low patient demand for antibiotics) as important resources. In high-prescribing regions, poor coordination between in-patient and ambulatory health services, lack of region-level information on antimicrobial resistance, few professional development opportunities, and regional variations in patient expectations were identified as barriers to rational prescribing behaviour.

CONCLUSIONS

Interventions targeting professional development, better collaboration structures with laboratories and clearer and user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates.

Decision support systems for antibiotic prescription in hospitals: a survey with hospital managers on factors for implementation

BACKGROUND

Inappropriate antimicrobial use, such as antibiotic intake in viral infections, incorrect dosing and incorrect dosing cycles, has been shown to be an important determinant of the emergence of antimicrobial resistance. Artificial intelligence-based decision support systems represent a potential solution for improving antimicrobial prescribing and containing antimicrobial resistance by supporting clinical decision-making thus optimizing antibiotic use and improving patient outcomes.

OBJECTIVE

The aim of this research was to examine implementation factors of artificial intelligence-based decision support systems for antibiotic prescription in hospitals from the perspective of the hospital managers, who have decision-making authority for the organization.

METHODS

An online survey was conducted between December 2022 and May 2023 with managers of German hospitals on factors for decision support system implementation. Survey responses were analyzed from 118 respondents through descriptive statistics.

RESULTS

Survey participants reported openness towards the use of artificial intelligence-based decision support systems for antibiotic prescription in hospitals but little self-perceived knowledge in this field. Artificial intelligence-based decision support systems appear to be a promising opportunity to improve quality of care and increase treatment safety. Along with the Human-Organization-Technology-fit model attitudes were presented. In particular, user-friendliness of the system and compatibility with existing technical structures are considered to be important for implementation. The uptake of decision support systems also depends on the ability of an organization to create a facilitating environment that helps to address the lack of user knowledge as well as trust in and skepticism towards these systems. This includes the training of user groups and support of the management level. Besides, it has been assessed to be important that potential users are open towards change and perceive an added value of the use of artificial intelligence-based decision support systems.

CONCLUSION

The survey has revealed the perspective of hospital managers on different factors that may help to address implementation challenges for artificial intelligence-based decision support systems in antibiotic prescribing. By combining factors of user perceptions about the systems´ perceived benefits with external factors of system design requirements and contextual conditions, the findings highlight the need for a holistic implementation framework of artificial intelligence-based decision support systems.

Comparative Analysis of Outpatient Antibiotic Prescribing in Early Life: A Population-Based Study Across Birth Cohorts in Denmark and Germany

INTRODUCTION

Comparing antibiotic prescribing between countries can provide important insights into potential needs of improving antibiotic stewardship programs. We aimed to compare outpatient antibiotic prescribing in early life between children born in Denmark and Germany.

METHODS

Using the Danish nationwide healthcare registries and a German claims database (GePaRD, ~ 20% population coverage), we included children born between 2004 and 2016, and followed them regarding outpatient antibiotic prescriptions until end of enrollment or the end of 2018. We then determined the median time to first antibiotic prescription. Based on all prescriptions in the first 2 years of life, we calculated the rate of antibiotic treatment episodes and for the children's first prescriptions in this period, we determined established quality indicators. All analyses were stratified by birth year and country.

RESULTS

In the 2016 birth cohorts, the median time to first antibiotic prescription was ~ 21 months in Denmark and ~ 28 in Germany; the rate of antibiotic treatment episodes per 1000 person-years was 537 in Denmark and 433 in Germany; the percentage of prescribed antibiotics with higher concerns regarding side effects and/or resistance potential was 6.2% in Denmark and 44.2% in Germany. In the 2016 birth cohorts, the age at first antibiotic prescription was 50-59% higher compared to the 2004 birth cohorts; the rate of antibiotic treatment episodes was 43-44% lower.

CONCLUSIONS

Infants in Denmark received antibiotics markedly earlier and more frequently than in Germany, while quality indicators of antibiotic prescribing were more favorable in Denmark. Although both countries experienced positive changes towards more rational antibiotic prescribing in early life, our findings suggest potential for further improvement. This particularly applies to prescribing antibiotics with a lower potential for side effects and/or resistance in Germany.

[Factors influencing the implementation of AI-based decision support systems for antibiotic prescription in hospitals: a qualitative analysis from the perspective of health professionals]

BACKGROUND

Decision support systems based on artificial intelligence might optimize antibiotic prescribing in hospitals and prevent the development of antimicrobial resistance. The aim of this study was to identify impeding and facilitating factors for successful implementation from the perspective of health professionals.

METHODS

Problem-centered individual interviews were conducted with health professionals working in hospitals. Data evaluation was based on the structured qualitative content analysis according Kuckartz.

RESULTS

Attitudes of health professionals were presented along the Human-Organization -Technology-fit model. Technological and organizational themes were the most important factors for system implementation. Especially, compatibility with existing systems and user-friendliness were seen to play a major role in successful implementation. Additionally, the training of potential users and the technical equipment of the organization were considered essential. Finally, the importance of promoting technical skills of potential users in the long term and creating trust in the benefits of the system were highlighted.

CONCLUSION

The identified factors provide a basis for prioritizing and quantifying needs and attitudes in a next step. It becomes clear that, beside technological factors, attention to context-specific and user-related conditions are of fundamental importance to ensure successful implementation and system trust in the long term.

Factors influencing the implementation of decision support systems for antibiotic prescription in hospitals: a systematic review

BACKGROUND

Antibiotic resistance is a major health threat. Inappropriate antibiotic use has been shown to be an important determinant of the emergence of antibiotic resistance. Decision support systems for antimicrobial management can support clinicians to optimize antibiotic prescription.

OBJECTIVE

The aim of this systematic review is to identify factors influencing the implementation of decision support systems for antibiotic prescription in hospitals.

METHODS

A systematic search of factors impeding or facilitating successful implementation of decision support systems for antibiotic prescription was performed in January 2022 in the databases PubMed, Web of Science and The Cochrane Library. Only studies were included which comprised decision support systems in hospitals for prescribing antibiotic therapy, published in English with a qualitative, quantitative or mixed-methods study design and between 2011 and 2021. Factors influencing the implementation were identified through text analysis by two reviewers.

RESULTS

A total of 14 publications were identified matching the inclusion criteria. The majority of factors relate to technological and organizational aspects of decision support system implementation. Some factors include the integration of the decision support systems into existing systems, system design, consideration of potential end-users as well as training and support for end-users. In addition, user-related factors, like user attitude towards the system, computer literacy and prior experience with the system seem to be important for successful implementation of decision support systems for antibiotic prescription in hospitals.

CONCLUSION

The results indicate a broad spectrum of factors of decision support system implementation for antibiotic prescription and contributes to the literature by identifying important organizational as well as user-related factors. Wider organizational dimensions as well as the interaction between user and technology appear important for supporting implementation.

Implementation fidelity in a multifaceted program to foster rational antibiotics use in primary care: an observational study

BACKGROUND

The ARena study (Sustainable Reduction of Antimicrobial Resistance in German Ambulatory Care) is a three-arm, cluster randomized trial to evaluate a multifaceted implementation program in a German primary care setting. In the context of a prospective process evaluation conducted alongside ARena, this study aimed to document and explore fidelity of the implementation program.

METHODS

This observational study is based on data generated in a three-wave survey of 312 participating physicians in the ARena program and attendance documentation. Measures concerned persistence of participation in the ARena program and adherence to intervention components (thematic quality circles, e-learning, basic expenditure reimbursements, additional bonus payments and a computerized decision support system). Participants' views on five domains of the implementation were also measured. Binary logistic and multiple linear regression analyses were used to explore which views on the implementation were associated with participants' adherence to quality circles and use of additional bonus compensation.

RESULTS

The analysis of fidelity showed overall high persistence of participation in the intervention components across the three intervention arms (90,1%; 97,9%; 92,9%). 96.4% of planned quality circles were delivered to study participants and, across waves, 30.4% to 93% of practices participated; 56.1% of physicians attended the maximum of four quality circles. 84% of the practices (n = 158) with a minimum of one index patient received a performance-based additional bonus payment at least once. In total, bonus compensation was triggered for 51.8% of affected patients. Participation rate for e-learning (a prerequisite for reimbursement of project-related expenditure) covered 90.8% of practices across all intervention arms, with the highest rate in arm II (96.5%). Uptake of expenditure reimbursement was heterogeneous across study arms, with a mean rate of 86.5% (89.1% in arm I, 96.4% in arm II and 74.1% in arm III). Participants' views regarding participant responsiveness (OR = 2.298) 95% CI [1.598, 3.305] and Context (OR = 2.146) 95% CI [1.135, 4.055] affected additional bonus payment. Participants' views on participant responsiveness (Beta = 0.718) 95% CI [0.479, 0.957], Context (Beta = 0.323) 95% CI [0.055, 0.590] and Culture of shared decision-making (Beta = -0.334) 95% CI [-0.614, -0.053] affected quality circle attendance.

CONCLUSION

This study showed an overall high fidelity to the implementation program. Participants' views on the implementation were associated with degree of intervention fidelity.

TRIAL REGISTRATION

ISRCTN, ISRCTN58150046.

Barriers to rational antibiotic prescription in Iran: a descriptive qualitative study

Introduction

Rational antibiotic prescription (RAP) refers to the purposeful and appropriate antibiotic prescription with correct dose and course to produce the most possible benefits and less possible side effects. Identification and management of the barriers to RAP can help promote RAP. The aim of the study was to explore the barriers to RAP in Iran.

Methods

This descriptive qualitative study was conducted in 2021 on 46 physicians (including general physicians, specialists, and subspecialists), pharmacologists, microbiologists, and nurses. Participants were purposefully selected from five specialty and subspecialty hospitals in Isfahan, Iran, and the Treatment Administration of Isfahan University of Medical Sciences, Isfahan, Iran. Data were collected via semi-structured interviews and were analyzed via conventional content analysis.

Results

The barriers to RAP in Iran came into sixteen subcategories and four main categories, namely physicians’ limited professional competence (with six subcategories), poor informational and functional resources (with four subcategories), ineffective supervision of RAP (with three subcategories), and inappropriate context for RAP (with three subcategories). The subcategories of these categories were physicians’ limited professional knowledge, physicians’ poor attitude towards RAP, physicians’ routine-based practice instead of evidence-based practice, physicians’ limited accountability, physicians’ fear over the legal consequences of not prescribing antibiotics, physicians’ financial motives, limited access to quality educational materials, poor in-service training for physicians, lack of culturally appropriate guidelines, inefficiency of the stewardship committee, limited supervision of physicians’ performance, ineffective managerial supervision, limited supervision of sampling for antimicrobial susceptibility testing, sociocultural factors contributing to irrational antibiotic prescription, poor adherence of insurance companies to their financial commitments, and financial incentives of pharmaceutical companies for physicians.

Conclusion

The barriers to RAP are different and complex and include physician-related, resource-related, supervision-related, and contextual factors. Physicians with limited professional competence, limited access to resources, and limited supervision will have problems in RAP. Effective management of the barriers to RAP can promote RAP and minimize irrational antibiotic prescription and its consequences, chiefly antimicrobial resistance.

[Inadequate antibiotic prescribing and areas for improvement]

Inadequate antibiotic prescribing has been observed in many settings both in hospitals as well as in primary care. Most often there is uncertainty about the indication for antibiotic treatment itself, prescribers are reluctant to deescalate, and therapy duration is too long which results most often in overprescribing. The burden of overprescribing is difficult to estimate, but many studies in the hospital setting report a rate of approximately 30 % of inadequate prescribing - with wide variation. Over- but also underprescribing of antimicrobial agents is a serious patient safety issue that needs to be addressed in specific programmes at different levels of the healthcare system. Interventional studies have shown that programmes implementing or intensifying audit and feedback with clinical reevaluation by experts can be very efficient to reduce inadequate prescribing.

[Organisational and staff requirements for antimicrobial stewardship activities in hospitals : Position paper of the Commission on Anti-Infectives, Resistance and Therapy (Commission ART) at the Robert Koch Institute, with advice from professional associations]

Increased awareness of the rising antimicrobial resistance problem and impending loss of suitable treatment options for infectious diseases have changed patient care. Antimicrobial/antibiotic stewardship (ABS) activities aiming to optimize antimicrobial treatment were specified in international (WHO, ECDC) and national programmes and evidence-based practice guidelines. In Germany, ABS in hospitals is enshrined in the Infection Protection Act §23 and in a national guideline. The position paper presents the goals and tasks of ABS as well as the necessary organisational and staff requirements.Qualified training and education, mandates and support from hospital directors, and the provision of sufficient resources are essential prerequisites for the successful work of the ABS team. The ABS team should work hospital-wide across clinical services. Their main tasks are developing and implementing an ABS programme tailored to local needs and the conditions of the hospital, taking into account anti-infective drug prescribing, the resistance situation and case mix. Their tasks also include drafting and implementing in-house recommendations for diagnosis, prophylaxis and treatment of important infectious diseases. The ABS team should be interdisciplinary and include specially qualified doctors and pharmacists. Doctors commissioned for ABS should support this team and take the department-specific concerns into account. The document specifies a minimum ABS staff of one full-time equivalent (FTE) per 500 beds. Depending on the case mix and specialties, additional staff may be required. It proposes that there should be 0.1 FTE doctors commissioned for ABS per 100 beds.