Evaluation of clinicians' knowledge, attitudes, and planned behaviors related to an intervention to improve acute respiratory infection management

Antimicrobial stewardship strategy implementation and impact in acute care spinal cord injury and disorder units

CONTEXT

Antimicrobial Stewardship Programs (ASPs) are crucial to optimizing antibiotic use. ASPs are implemented in the Veterans Health Administration (VAs), but they do not target the needs of populations at high risk for resistant infections, such as spinal cord injury and disorder (SCI/D).

OBJECTIVE

The goal of this study was to assess key ASP leader and SCI/D clinicians' perceived level of implementation and impact of 33 Antimicrobial Stewardship (AS) strategies.

METHOD

SCI/D clinicians and ASP leaders across 24 VA facilities with SCI/D units were surveyed. Participants rated their perceived level of impact ("high", "mild", "low") and perceived level of implementation ("not", "partially", "fully") for 33 AS strategies in SCI/D units in VAs. Strategies were grouped into core elements which they support. We conducted a Fisher's exact test to assess differences between respondent perceptions based on role (SCI/D clinicians versus ASP leaders).

RESULTS

AS strategy implementation varied across VA facilities. Of the AS strategies, pre-authorization was perceived to be highly impactful (78%) and fully implemented (82%). SCI/D clinicians and ASP leaders rated AS strategies differently such that SCI/D clinicians were less aware of implementation of AS strategies related to reporting requirements; further, SCI/D clinicians rated strategies which guide treatment duration and which limit C. difficile antibiotic exposure as more impactful than ASP leaders. Ratings for facility-wide and SCI/D unit ratings did not significantly differ for impact or implementation.

CONCLUSION

Implementation practices varied across VA facilities. Future work should implement highly impactful AS strategies according to facility and unit needs.

Antibiotic Prescribing Decisions for Upper Respiratory Tract Infections Among Primary Healthcare Physicians in China: A Mixed-Methods Approach Based on the Theory of Planned Behavior

Objectives: In China, primary healthcare (PHC) facilities have high antibiotic prescribing rates for upper respiratory tract infections (URTIs), which are primarily viral and self-limited. This study aimed to identify the main factors influencing PHC physicians' antibiotic decisions for URITs based on the theory of planned behavior. Methods: A convergent mixed-methods study was conducted at 30 PHC facilities across Shaanxi Province, China. A total of 108 PHC physicians completed a five-point Likert Scale questionnaire focused on behavioral components of antibiotic prescribing, including attitudes, subjective norms, perceived behavioral control, belief in past experiences, and prescribing intentions. Twenty-two physicians participated in semi-structured interviews. Results: Respondents had a good awareness of AMR (Mean = 4.49) and a weak belief regarding the benefit of antibiotics (Mean = 2.34). The mean score for subjective norms was 3.36, and respondents had good control over their prescribing behavior (Mean = 4.00). A reliance on past prescribing experiences was observed (Mean = 3.34), and physicians' antibiotic prescribing intention was 3.40 on average. Multiple linear regression revealed that physicians showing a more favorable attitude towards antibiotics (p = 0.042) and relying more on their past experiences (p = 0.039) had a higher antibiotic prescribing intention. Qualitative interviews indicated that most physicians would consider prescribing antibiotics when facing diagnostic uncertainty. Low utilization of diagnostic tests, limited effectiveness of training programs, inadequate knowledge of guidelines, and lack of feedback on antibiotic prescriptions all contributed to antibiotic overprescribing. Conclusions: PHC physicians in China demonstrated strong intentions to prescribe antibiotics for URTIs when facing diagnostic uncertainty. Beliefs about antibiotics and previous prescribing behavior were significantly linked to prescribing intentions. Multifaceted interventions that focus on facilitating diagnostic tests, improving the quality of training, effectively implementing clinical guidelines, and providing practical feedback on antibiotic prescriptions may help reduce antibiotic overprescribing in China's PHC facilities.

Adaptation and validation of an antibiotic prescribing, peer comparison metric for respiratory tract diagnoses in walk-in clinics: a mixed-methods analysis

Objective

Antibiotic overuse is common across walk-in clinics, but it is unclear which stewardship metrics are most effective for audit and feedback. In this study, we assessed the validity of a metric that captures antibiotic prescribing for respiratory tract diagnoses (RTDs).

Design

We performed a mixed-methods study to evaluate an RTD metric, which quantified the frequency at which a provider prescribed antibiotics for RTD visits after excluding visits with complicating factors.

Setting

Seven walk-in clinics across an integrated healthcare system.

Participants

We included clinic visits during 2018-2022. We also conducted 17 semi-structured interviews with 10 unique providers to assess metric acceptability.

Results

There were 331,496 visits; 120,937 (36.5%) met RTD criteria and 44,382 (36.7%) of these received an antibiotic. Factors associated with an increased odds of antibiotic use for RTDs included patient age ≥ 65 (OR = 1.40; 95% CI 1.30-1.51), age 0-17 (1.55, 95% CI 1.50-1.60), and ≥1 comorbidity (OR = 1.22; 95% CI = 1.15-1.29). After stratifying providers by their antibiotic-prescribing frequency for RTDs, patient case-mix was similar across tertiles. However, the highest tertile of prescribers more frequently coded suppurative otitis media and more frequently prescribed antibiotics for antibiotic-nonresponsive conditions (eg, viral infections). There was no correlation between antibiotic prescribing for RTDs and the frequency of return visits (r = 0.01, P = 0.96). Interviews with providers demonstrated the acceptability of the metric as an assessment tool.

Conclusion

A provider-level metric that quantifies the frequency of antibiotic prescribing for all RTDs has both construct and face validity. Future studies should assess whether this type of metric is an effective feedback tool.

Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration

BACKGROUND

Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration.

METHODS

We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process.

RESULTS

We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal.

CONCLUSIONS

The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.

Factors influencing antibiotic prescribing by nurse practitioners: A quantitative pilot study using the theory of planned behavior

BACKGROUND

The overuse of antibiotics contributes to the development of antibiotic resistance (AR) and exposes patients to potential antibiotic-related harm. Nurse practitioners (NPs) are well positioned to optimize antibiotic use; however, little is known about the factors influencing NP prescribing behaviors.

PURPOSE

Describe the knowledge, attitude, subjective norms, and perceived behavioral control in prescribing antibiotics among NPs practicing at a large university-affiliated health care system in the northeast United States.

METHODOLOGY

This was a cross-sectional online anonymous survey using the Theory of Planned Behavior. Descriptive statistics were used to describe the sample. Nonparametric tests were used to examine differences in the dependent variables by demographic characteristics.

RESULTS

One hundred seventy-four of 618 NPs (28%) completed the survey. Almost all considered AR a problem in the United States, but only half considered it a problem in their health care setting. More than half indicated they prescribed antibiotics less than 25% of the time in daily practice. Most were confident in making antibiotic prescribing decisions. There was a positive relationship between years of experience as NPs and their confidence in making antibiotic prescribing decisions ( p < .003) and an inverse relationship between years of experience as NPs and asking for advice from physicians or pharmacists when prescribing antibiotics ( p < .002).

CONCLUSION/IMPLICATIONS

With increasing numbers of NPs managing infectious diseases and prescribing antibiotics, these findings will inform interventions to support appropriate prescribing behaviors.

Assessment of factors influencing physicians' intention to prescribe transfusion using the theory of planned behavior

BACKGROUND

Blood shortage is a persistent problem affecting Taiwan's health-care system. The theory of planned behavior (TPB) has been commonly used in studies of health advocacy. The purpose of this study was to develop a questionnaire measuring clinicians' intention to prescribe transfusion based on the TPB.

METHOD

A questionnaire comprising 15 items for assessing clinicians' intention to prescribe blood transfusion was developed, and it collected demographic characteristics, tested patient blood management (PBM) and perceived knowledge of PBM. Furthermore, the questionnaire contained four subscales related to the TPB. A total of 129 clinicians participated in this pilot study between July and December2020. Item analysis and exploratory factor analysis were conducted to examine the validity and reliability of this measurement instrument.

RESULTS

The results indicated no statistically significant correlations between the demographic characteristics and PBM test scores. Regarding perceived knowledge, the results of a one-way analysis of variance revealed that the effect of age, hierarchy of doctors, and education level were significant. In terms of subjective norms, a significant effect on education level was noted [t (129) = 2.28, p < 0.05], with graduate school graduates receiving higher scores than college graduates. An analysis of variance demonstrated the effects of hierarchy, education level, and medical specialty on perceived behavioral control. The results of the regression analyses revealed that perceived knowledge (β = 0.32, p < 0.01) and subjective norms (β = 0.22, p < 0.05) were significantly related to clinicians' behavioral intentions.

CONCLUSIONS

This study revealed that factors affecting clinicians' blood transfusion management can be explained using the TPB-based questionnaire. This study demonstrated that physicians' perceptions of whether most people approve of PBM and their self-assessment of their PBM knowledge affect their intentions to proceed with PBM. According to this finding, a support system among physicians must be established and maintained to increase physicians' confidence in promoting PBM.

Association of antibiotics with veteran visit satisfaction and antibiotic expectations for upper respiratory tract infections

BACKGROUND AND OBJECTIVE

Veterans' Affairs (VA) healthcare providers perceive that Veterans expect and base visit satisfaction on receiving antibiotics for upper respiratory tract infections (URIs). No studies have tested this hypothesis. We sought to determine whether receiving and/or expecting antibiotics were associated with Veteran satisfaction with URI visits.

METHODS

This cross-sectional study included Veterans evaluated for URI January 2018-December 2019 in an 18-clinic ambulatory VA primary-care system. We evaluated Veteran satisfaction via the Patient Satisfaction Questionnaire Short Form (RAND Corporation), an 18-item 5-point Likert scale survey. Additional items assessed Veteran antibiotic expectations. Antibiotic receipt was determined via medical record review. We used multivariable regression to evaluate whether antibiotic receipt and/or Veteran antibiotic expectations were associated with satisfaction. Subgroup analyses focused on Veterans who accurately remembered antibiotic prescribing during their URI visit.

RESULTS

Of 1,329 eligible Veterans, 432 (33%) participated. Antibiotic receipt was not associated with differences in mean total satisfaction (adjusted score difference, 0.6 points; 95% confidence interval [CI], -2.1 to 3.3). However, mean total satisfaction was lower for Veterans expecting an antibiotic (adjusted score difference -4.4 points; 95% CI -7.2 to -1.6). Among Veterans who accurately remembered the visit and did not receive an antibiotic, those who expected an antibiotic had lower mean satisfaction scores than those who did not (unadjusted score difference, -16.6 points; 95% CI, -24.6 to -8.6).

CONCLUSIONS

Veteran expectations for antibiotics, not antibiotic receipt, are associated with changes in satisfaction with outpatient URI visits. Future research should further explore patient expectations and development of patient-centered and provider-focused interventions to change patient antibiotic expectations.

Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review

BACKGROUND

There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care.

METHODS

We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review.

RESULTS

Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently.

CONCLUSIONS

This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.

Autonomy, power dynamics and antibiotic use in primary healthcare: A qualitative study

Antibiotic resistance is a global health concern. Although numerous strategies have tried to reduce inadequate antibiotic prescribing, antibiotics are still prescribed in 60% of acute lower respiratory tract infections (ALRTIs) cases in Catalonia (Spain). This study aims to explore service users' experiences of ALRTIs, the quality and access to healthcare services, and health education. Selective purposive sampling was carried out, based on a prior definition of participant characteristics. These were sex, age, ethnicity, date of the last ALRTI, number of ALRTIs in the last year, and treatments received. Participants with a previous diagnosis of ALRTIs were recruited from three primary health care centres in Barcelona and one in Tarragona. Twenty-nine interviews were conducted between April and June 2019. A content thematic analysis was performed. Three themes were identified: 1) risk perceptions and help-seeking; 2) treatment preferences and antibiotic use; and 3) relationship dynamics and communication with healthcare professionals. Accounts of service users' sense of autonomy towards their health and power dynamics within the healthcare system were apparent. Supporting service users to become reliable, subjective and agentic experts of their health and bodies could help them to voice their healthcare agendas. Power structures embedded within healthcare, political and economic institutions should be challenged so that healthcare services can be co-developed (with service users) and based on service users' autonomy and horizontal relationships. Special consideration should be paid to the intersection of social vulnerabilities. A concordance approach to prescribing could be key to improve the responsible use of antibiotics and to contribute to the prevention of AMR in primary healthcare. The marketisation of health, and the increased demands of private healthcare in Spain due to the financial pressures on public healthcare as a consequence of the financial crisis of 2008 and the COVID-19 pandemic, are a risk for promoting adequate antibiotic prescribing and use. Trial registration The ISAAC-CAT study has been registered in the NCT registry, ID: NCT03931577.