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Harrigan JJ, Hamilton KW, Cressman L, Bilker WB, Degnan KO, David MZ, Tran D, Pegues DA, Dutcher L. Antibiotic Prescribing Patterns for Respiratory Tract Illnesses Following the Conclusion of an Education and Feedback Intervention in Primary Care. Clin Infect Dis 2024; 78:1120-1127. [PMID: 38271275 DOI: 10.1093/cid/ciad754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND A study previously conducted in primary care practices found that implementation of an educational session and peer comparison feedback was associated with reduced antibiotic prescribing for respiratory tract diagnoses (RTDs). Here, we assess the long-term effects of this intervention on antibiotic prescribing following cessation of feedback. METHODS RTD encounters were grouped into tiers based on antibiotic prescribing appropriateness: tier 1, almost always indicated; tier 2, possibly indicated; and tier 3, rarely indicated. A χ2 test was used to compare prescribing between 3 time periods: pre-intervention, intervention, and post-intervention (14 months following cessation of feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between period and prescribing. RESULTS We analyzed 260 900 RTD encounters from 29 practices. Antibiotic prescribing was more frequent in the post-intervention period than in the intervention period (28.9% vs 23.0%, P < .001) but remained lower than the 35.2% pre-intervention rate (P < .001). In multivariable analysis, the odds of prescribing were higher in the post-intervention period than the intervention period for tier 2 (odds ratio [OR], 1.19; 95% confidence interval [CI]: 1.10-1.30; P < .05) and tier 3 (OR, 1.20; 95% CI: 1.12-1.30) indications but was lower compared to the pre-intervention period for each tier (OR, 0.66; 95% CI: 0.59-0.73 tier 2; OR, 0.68; 95% CI: 0.61-0.75 tier 3). CONCLUSIONS The intervention effects appeared to last beyond the intervention period. However, without ongoing provider feedback, there was a trend toward increased prescribing. Future studies are needed to determine optimal strategies to sustain intervention effects.
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Affiliation(s)
- James J Harrigan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Keith W Hamilton
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Warren B Bilker
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kathleen O Degnan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael Z David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Mozes I, Baron-Epel O, Heymann A. Impact of Remote Medical Devices on Utilization of Medical Services in Pediatric Patients with Upper Respiratory Infections: A Retrospective Study. Health Informatics J 2024; 30:14604582241233996. [PMID: 38587170 DOI: 10.1177/14604582241233996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Background: Remote mobile examination devices in telemedicine are a new technology in healthcare. Objective: To assess the utilization of visits using remote medical devices. Methods: A retrospective analysis of follow-up visits, referrals, laboratory testing and antibiotic prescriptions of 470,845 children's video visits with and without remote medical examination device and in-clinic visits. Results: Rates of follow-up visits, referrals and laboratory tests were higher in video visits compared to visit with medical device (OR of 1.27, 1.08, 1.93 respectfully). For in-clinic visits, rates of follow-up were lower but higher for referrals to subspecialists and laboratory test referrals when compared to telemedicine. Antibiotic prescriptions were provided at a lower rate in video visits compared to visits with a medical device (OR = 0.48) and in-clinic visits. Conclusions: Incorporating a remote medical device may reduce follow up visits, referrals and laboratory tests compared to a video visit without a device. The prevalence of antibiotic prescriptions did not escalate in telemedicine consultations.
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Affiliation(s)
- Inbal Mozes
- School of Public Health, Haifa University, Haifa, Israel
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Sanchez GV, Kabbani S, Tsay SV, Bizune D, Hersh AL, Luciano A, Hicks LA. Antibiotic Stewardship in Outpatient Telemedicine: Adapting Centers for Disease Control and Prevention Core Elements to Optimize Antibiotic Use. Telemed J E Health 2024; 30:951-962. [PMID: 37856146 DOI: 10.1089/tmj.2023.0229] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
The rapid expansion of telemedicine has highlighted challenges and opportunities to improve antibiotic use and effectively adapt antibiotic stewardship best practices to outpatient telemedicine settings. Antibiotic stewardship integration into telemedicine is essential to optimize antibiotic prescribing for patients and ensure health care quality. We performed a narrative review of published literature on antibiotic prescribing and stewardship in outpatient telemedicine to inform the adaptation of the Core Elements of Outpatient Antibiotic Stewardship framework to outpatient telemedicine settings. Our narrative review suggests that in-person antibiotic stewardship interventions can be adapted to outpatient telemedicine settings. We present considerations for applying the Core Elements of Outpatient Antibiotic Stewardship to outpatient telemedicine which builds upon growing evidence describing care delivery and quality improvement in this setting. Additional applied implementation research is necessary to inform the application of effective, sustainable, and equitable antibiotic stewardship interventions across the spectrum of outpatient telemedicine.
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Affiliation(s)
- Guillermo V Sanchez
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon V Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Destani Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adam L Hersh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Angelina Luciano
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Baillie EJ, Merlo G, Biezen R, Peprah Boaitey K, Magin PJ, van Driel ML, Hall L. Diagnosis and management of acute infections during telehealth consultations in Australian general practice: a qualitative study. BJGP Open 2024; 8:BJGPO.2023.0142. [PMID: 38092442 PMCID: PMC11169986 DOI: 10.3399/bjgpo.2023.0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/13/2023] [Accepted: 11/24/2023] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND The use of telehealth has increased dramatically since the beginning of the COVID-19 pandemic. Little is known about how GPs manage acute infections during telehealth, and the potential impact on antimicrobial stewardship. AIM To explore the experiences and perceptions of GP trainees' and supervisors' use of telehealth, and how it influences their management of acute infections. DESIGN & SETTING Australian GP registrars (trainees) and supervisors were recruited via email through their training organisations. Semi-structured interviews with 18 participants were conducted between July and August 2022. METHOD Interviews were transcribed verbatim and analysed using a reflexive thematic approach. RESULTS We identified six overall themes. 1. Participants experienced impaired diagnostic capacity during telehealth consultations. 2. Attempts to improve diagnostic acuity included various methods, such as having patients self-examine. 3. The management of clinical uncertainty frequently entailed referring patients for in-person assessment, overinvestigating, or overtreating. 4. Antibiotic prescribing decisions during telehealth were informed by less information than were in-person consults, with varying impact. 5. Participants believed that other GPs improperly prescribed antibiotics during telehealth. 6. Supervisors believed that registrars hadn't developed the knowledge or skills to determine when conditions could be managed appropriately via telehealth. CONCLUSION Telehealth has potential for reducing transmission of acute infections and increasing access to healthcare. However, the implications of GPs, especially less experienced GPs, making diagnoses with less certainty, and consequently compromising antimicrobial stewardship, are a concern. Patient self-assessment tools may improve outcomes of telehealth consultations for acute infections.
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Affiliation(s)
- Emma J Baillie
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, QL, Australia
| | - Gregory Merlo
- Healthcare Improvement Unit, Queensland Health, Bowen Hills, Brisbane, QL, Australia
| | - Ruby Biezen
- Department of General Practice, The University of Melbourne, Melbourne, VI, Australia
| | - Kwame Peprah Boaitey
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QL, Australia
| | - Parker J Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- GP Training Research Department, Royal Australian College of General Practitioners, Callaghan, NSW, Australia
| | - Mieke L van Driel
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, QL, Australia
| | - Lisa Hall
- School of Public Health, The University of Queensland, Brisbane, QL, Australia
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Wattles BA, Jawad KS, Feygin YF, Stahl JD, Vidwan NK, Stevenson MD, Kong M, Smith MJ. Quality of antibiotic prescribing to children through the coronavirus disease 2019 (COVID-19) pandemic. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e94. [PMID: 36483376 PMCID: PMC9726595 DOI: 10.1017/ash.2022.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/11/2022] [Accepted: 05/11/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To describe pediatric outpatient visits and antibiotic prescribing during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN An observational, retrospective control study from January 2019 to October 2021. SETTING Outpatient clinics, including 27 family medicine clinics, 27 pediatric clinics, and 26 urgent or prompt care clinics. PATIENTS Children aged 0-19 years receiving care in an outpatient setting. METHODS Data were extracted from the electronic health record. The COVID-19 era was defined as April 1, 2020, to October 31, 2021. Virtual visits were identified by coded encounter or visit type variables. Visit diagnoses were assigned using a 3-tier classification system based on appropriateness of antibiotic prescribing and a subanalysis of respiratory visits was performed to compare changes in the COVID-19 era compared to baseline. RESULTS Through October 2021, we detected an overall sustained reduction of 18.2% in antibiotic prescribing to children. Disproportionate changes occurred in the percentages of antibiotic visits in respiratory visits for children by age, race or ethnicity, practice setting, and prescriber type. Virtual visits were minimal during the study period but did not result in higher rates of antibiotic visits or in-person follow-up visits. CONCLUSIONS These findings suggest that reductions in antibiotic prescribing have been sustained despite increases in outpatient visits. However, additional studies are warranted to better understand disproportionate rates of antibiotic visits.
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Affiliation(s)
- Bethany A. Wattles
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kahir S. Jawad
- Norton Children’s Research Institute Affiliated with University of Louisville School of Medicine, Louisville, Kentucky
| | - Yana F. Feygin
- Norton Children’s Research Institute Affiliated with University of Louisville School of Medicine, Louisville, Kentucky
| | - J. Drew Stahl
- Department of Pharmacy, Norton Children’s Hospital, Louisville, Kentucky
| | - Navjyot K. Vidwan
- Norton Children’s and University of Louisville School of Medicine, Department of Pediatrics, Louisville, Kentucky
| | - Michelle D. Stevenson
- Norton Children’s and University of Louisville School of Medicine, Department of Pediatrics, Louisville, Kentucky
| | - Maiying Kong
- Department of Bioinformatics and Biostatistics, University of Louisville School for Public Health and Information Sciences, Louisville, Kentucky
| | - Michael J. Smith
- Department of Pediatrics and Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University Medical Center, Durham, North Carolina
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Opportunities and challenges in improving antimicrobial use during the era of telehealth expansion: A narrative review. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e26. [PMID: 36168461 PMCID: PMC9495641 DOI: 10.1017/ash.2021.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/11/2021] [Indexed: 11/24/2022]
Abstract
Efforts to improve antimicrobial prescribing are occurring within a changing healthcare landscape, which includes the expanded use of telehealth technology. The wider adoption of telehealth presents both challenges and opportunities for promoting antimicrobial stewardship. Telehealth provides 2 avenues for remote infectious disease (ID) specialists to improve inpatient antimicrobial prescribing: telehealth-supported antimicrobial stewardship and tele-ID consultations. Those 2 activities can work separately or synergistically. Studies on telehealth-supported antimicrobial stewardship have reported a reduction in inpatient antimicrobial prescribing, cost savings related to less antimicrobial use, a decrease in Clostridioides difficile infections, and improved antimicrobial susceptibility patterns for common organisms. Tele-ID consultation is associated with fewer hospital transfers, a shorter length of hospital stay, and decreased mortality. The implementation of these activities can be flexible depending on local needs and available resources, but several barriers may be encountered. Opportunities also exist to improve antimicrobial use in outpatient settings. Telehealth provides a more rapid mechanism for conducting outpatient ID consultations, and increasing use of telehealth for routine and urgent outpatient visits present new challenges for antimicrobial stewardship. In primary care, urgent care, and emergency care settings, unnecessary antimicrobial use for viral acute respiratory tract infections is common during telehealth encounters, as is the case for fact-to-face encounters. For some diagnoses, such as otitis media and pharyngitis, antimicrobials are further overprescribed via telehealth. Evidence is still lacking on the optimal stewardship strategies to improve antimicrobial prescribing during telehealth encounters in ambulatory care, but conventional outpatient stewardship strategies are likely transferable. Further work is warranted to fill this knowledge gap.
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