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Stalteri Mastrangelo R, Hajizadeh A, Piggott T, Loeb M, Wilson M, Lozano LEC, Roldan Y, El-Khechen H, Miroshnychenko A, Thomas P, Schünemann HJ, Nieuwlaat R. In-Hospital Macro-, Meso-, and Micro-Drivers and Interventions for Antibiotic Use and Resistance: A Rapid Evidence Synthesis of Data from Canada and Other OECD Countries. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2022; 2022:5630361. [PMID: 35509517 PMCID: PMC9061047 DOI: 10.1155/2022/5630361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 11/23/2021] [Accepted: 01/07/2022] [Indexed: 06/14/2023]
Abstract
Hospitals continue to face challenges in reducing incorrect antibiotic use due to social and cultural factors at the level of the health system, the care facility, the provider, and the patient. The objective of this paper is to highlight the social and cultural drivers of antimicrobial use and resistance and targeted interventions for secondary and tertiary care settings in Canada and other OECD countries. This paper is an extension of the synthesis conducted for the Public Health Agency of Canada's 2019 Spotlight Report: Preserving Antibiotics Now and Into the Future. We conducted a systematic review with a few modifications to meet rapid timelines. We conducted a search in Ovid MEDLINE and McMaster University's evidence databases for systematic reviews and then for individual Canadian studies. To cast a wider net, we searched OECD organization websites and screened reference lists from systematic reviews. We synthesized the evidence narratively and categorized the evidence into macro-, meso-, and microlevel. A total of 70 studies were (a) from OCED countries and summarized evidence of potential sociocultural antimicrobial resistance and use barriers or facilitators and/or interventions addressing these challenges; (b) systematic reviews with 50% of included studies that are situated in secondary and tertiary settings; and (c) published in Canada's two official languages, English and French. We found that hospital structures and policies may influence antibiotic utilization and variations in antimicrobial management. Microlevel factors may sway inappropriate prescribing among clinicians. The amount and type of antibiotics used may affect resistance rates. Interventions were mainly comprised of antibiotic stewardship and training that modify clinician behavior and that educate patients and carers. This evidence synthesis illustrates the various drivers of, and interventions for, antimicrobial use and resistance at the macro-, meso-, and microlevel in secondary and tertiary settings. We demonstrate that upstream drivers may lead to downstream events that influence antimicrobial resistance.
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Affiliation(s)
- Rosa Stalteri Mastrangelo
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Anisa Hajizadeh
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Departments of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, ON, Canada
| | - Michael Wilson
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Luis Enrique Colunga Lozano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton, ON, Canada
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton, ON, Canada
| | - Hussein El-Khechen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Anna Miroshnychenko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Priya Thomas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Holger J. Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton, ON, Canada
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Poutanen R, Virta T, Heikkilä P, Pauniaho S, Csonka P, Korppi M, Renko M, Palmu S. National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed. Acta Paediatr 2021; 110:1594-1600. [PMID: 33247995 DOI: 10.1111/apa.15692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/18/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022]
Abstract
AIM Our aim was to evaluate the impact of the 2014 Finnish Current Care Guidelines for paediatric lower respiratory tract infections (LRTIs), particularly on taking of chest radiographs. METHODS This study used official national data and regional (Pirkanmaa) data on children aged 0-16 years who underwent chest radiographs in 2011 and 2015. We also collected data for LRTI diagnoses from local registers, including prescribed antibiotics and taking of chest radiographs. The local cohort comprised children aged 0-15 who presented to the primary care emergency room or to the hospital emergency department (Tampere university hospital) in November-December 2012-2015. RESULTS Chest radiographs for Finnish children aged 0-16 fell from 2011 to 2015: by 15.9% nationally and by 16.9% in Pirkanmaa. When asylum seekers with chest radiographs for tuberculosis screening were excluded, the estimated national reduction was 29.9%. In the local cohort, chest radiographs increased from 82 to 139 (69.5%) between 2012/2013 and 2014/2015 as the occurrence of community-acquired pneumonia (CAP) increased. However, the proportion of patients with CAP who had chest radiograph taken tended to decrease from 84.6% to 71.3% (p = 0.078). CONCLUSION Decreases in national and regional chest imaging trends were observed after the 2014 guidance for children`s LRTI was introduced.
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Affiliation(s)
- Roope Poutanen
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Tuija Virta
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Paula Heikkilä
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Satu‐Liisa Pauniaho
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
| | - Peter Csonka
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
- Terveystalo Healthcare Tampere Finland
| | - Matti Korppi
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Marjo Renko
- Department of Paediatrics Kuopio University HospitalUniversity of Eastern Finland Kuopio Finland
| | - Sauli Palmu
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
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Weinstein SJ, House SA, Chang CH, Wasserman JR, Goodman DC, Morden NE. Small geographic area variations in prescription drug use. Pediatrics 2014; 134:563-70. [PMID: 25113303 DOI: 10.1542/peds.2013-4250] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite the frequency of pediatric prescribing little is known about practice differences across small geographic regions and payer type (Medicaid and commercial). OBJECTIVE The goal of this research was to quantify variation in prescription drug use among northern New England children. METHODS Northern New England, all-payer administrative data (2007-2010) permitted study of prescriptions for 949 821 children ages 0 to 17 years (1.75 million person-years [PYs]; 54% Medicaid, 46% commercial). Age- and gender adjusted overall and drug group-specific prescription use was quantified according to payer type (Medicaid or commercial) and within payer type across 69 hospital service areas (HSAs). We measured prescription fills per PY (rate) and annual, mean percentage of the population with any drug group-specific fills (prevalence). RESULTS Overall mean annual prescriptions per PY were 3.4 (commercial) and 5.5 (Medicaid). Generally, these payer type differences were smaller than HSA-level variation within payer type. HSA-level rates of attention-deficit/hyperactivity disorder drug use (5th-95th percentile) varied twofold in Medicaid and more than twofold in commercially insured children; HSA-level antidepressant use varied more than twofold within each payer type. Antacid use varied threefold across HSAs and was highest in infants where commercial use paradoxically exceeded Medicaid. Prevalence of drug use varied as much as rates across HSAs. CONCLUSIONS Prescription use was higher among Medicaid-insured than commercially insured children. Regional variation generally exceeded payer type differences, especially for drugs used in situations of diagnostic and therapeutic uncertainty. Efforts should advance best pediatric prescribing discussions and shared decision-making.
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Affiliation(s)
| | - Samantha A House
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Chiang-Hua Chang
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire;Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire;The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire; andDepartment of Community and Family Medicine Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jared R Wasserman
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire; and
| | - David C Goodman
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire; and Department of Community and Family Medicine Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Nancy E Morden
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire; and Department of Community and Family Medicine Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
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Florin TA, French B, Zorc JJ, Alpern ER, Shah SS. Variation in emergency department diagnostic testing and disposition outcomes in pneumonia. Pediatrics 2013; 132:237-44. [PMID: 23878049 DOI: 10.1542/peds.2013-0179] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To describe the variability across hospitals in diagnostic test utilization for children diagnosed with community-acquired pneumonia (CAP) during emergency department (ED) evaluation and to determine if test utilization is associated with hospitalization and ED revisits. METHODS We conducted a retrospective cohort study of children aged 2 months to 18 years with ED visits resulting in CAP diagnoses from 2007 to 2010 who were seen at 36 hospitals contributing data to the Pediatric Health Information System. Children with complex chronic conditions, recent hospitalization, trauma, aspiration, or perinatal infection were excluded. Primary outcomes included diagnostic testing, hospitalization, and 3-day ED revisit rates across hospitals. We examined variation in diagnostic testing among hospitals by using multivariable mixed-effects logistic regression. RESULTS A total of 100,615 ED visits were analyzed. Complete blood count (median: 28.7%), blood culture (27.9%), and chest radiograph (75.7%) were the most commonly ordered ED diagnostic tests. After adjustment for patient characteristics, significant variation (P < .001) was found for each test examined across hospitals. High test-utilizing hospitals had increased odds of hospitalization compared with low-utilizing hospitals (odds ratio: 1.86 [95% confidence interval: 1.17-2.94]; P = .008). However, differences in the odds of ED revisit between the low- and high-utilizing hospitals were not significant (odds ratio: 1.21 [95% confidence interval: 0.97-1.51]; P = .09). CONCLUSIONS Emergency departments that use more testing in diagnosing CAP have higher hospitalization rates than lower-utilizing EDs. However, ED revisit rates were not significantly different between high- and low-utilizing EDs. These results suggest an opportunity to reduce diagnostic testing for CAP without negatively affecting outcomes.
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Affiliation(s)
- Todd A Florin
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio 45229, USA.
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Johnson LW, Robles J, Hudgins A, Osburn S, Martin D, Thompson A. Management of bronchiolitis in the emergency department: impact of evidence-based guidelines? Pediatrics 2013; 131 Suppl 1:S103-9. [PMID: 23457145 DOI: 10.1542/peds.2012-1427m] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Recent practice guidelines from the American Academy of Pediatrics recommend limiting use of bronchodilators, corticosteroids, antibiotics, and diagnostic testing for patients with bronchiolitis. We sought to determine the association of the evidence-based guidelines with bronchiolitis care in the emergency department (ED). METHODS We analyzed data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED visits. We compared utilization for patient visits before and after the publication of the guidelines. We used logistic regression to determine the association of the availability of the guidelines with resource utilization. RESULTS Bronchodilators were used in 53.8% of patient visits with no differences noted after the introduction of the guidelines (53.6% vs 54.2%, P = .91). Systemic steroids were used in 20.4% of patient visits, and antibiotics were given in 33.2% of visits. There were no changes in the frequency of corticosteroid (21.9% vs 17.8%, P = .31) or antibiotic (33.6% vs 29.7%, P = .51) use. There was an associated decrease in use of chest x-rays (65.3% vs 48.6%, P = .005). This association remained significant after adjusting for patient and hospital characteristics with an adjusted odds ratio of 0.41 (95% confidence interval 0.26-0.67). CONCLUSIONS For patients seen in the ED with bronchiolitis, utilization of diagnostic imaging has decreased with the availability of the American Academy of Pediatrics practice guidelines. However, there has not been an associated decrease in use of nonrecommended therapies. Targeted efforts will likely be required to change practice significantly.
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Affiliation(s)
- Lara W Johnson
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA.
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