Public reporting as a prescriptions quality improvement measure in primary care settings in China: variations in effects associated with diagnoses

Evaluation of prescription review and feedback policy on rational antibiotic use in primary healthcare settings in Beijing, China: a qualitative study using the Theoretical Domains Framework and the behaviour change wheel

Objectives

To decelerate antibiotic resistance driven by inappropriate antibiotic prescribing, a prescription review and feedback (PRF) policy is implemented in primary healthcare institutions (PHIs) in Beijing, China. However, evaluation of PRF implementation in PHIs is scarce. This study aims to systematically identify the barriers and facilitators of PRF policy implementation to provide evidence for antimicrobial stewardship.

Methods

We conducted key informant interviews with 40 stakeholders engaged in the implementation of PRF in Beijing, including physicians, pharmacists and administrators. Interviews were audio recorded and transcribed verbatim. We coded the interview transcripts and mapped informant views to domains of the Theoretical Domains Framework. We then used a behaviour change wheel to suggest possible behavioural interventions.

Results

Procedural knowledge (Knowledge) and skills (Skill) of PRF were possessed by stakeholders. They felt responsible to promote the appropriate use of antibiotics (Social/professional role and identity) and believed that PRF could help to change inappropriate provider behaviours (Behavioural regulation) in prescribing antibiotics (Beliefs about consequences) under increased intention on antibiotic use (Stages of change). Moreover, informants called for a more unified review standard to enhance PRF implementation (Goals). Frequently identified barriers to PRF included inadequate capacity (Skill), using punishment mechanism (Behaviour regulation), reaching consistently lower antibiotic prescription rates (Goals), lack of resources (Environmental context and resources) and perceived pressure coming from patients (Social influences).

Conclusions

Stakeholders believed that PRF implementation promoted the rational use of antibiotics at PHIs in Beijing. Still, PRF was hampered by inconsistencies in review process and resources needed for PRF implementation.

Appropriate use of antibiotics for acute respiratory infections at primary healthcare facilities in China: a nationwide cross-sectional study from 2017 to 2019

Background

The appropriateness of antibiotic use for acute respiratory infections (ARIs) in Chinese primary healthcare facilities (PHFs) remained uncertain. We aimed to evaluate to what degree antibiotic prescribing for ARIs were aligned with guideline recommendations in primary settings across China.

Methods

We collected outpatient prescriptions from 262 Chinese PHFs in 27 cities of six provinces between 2017 and 2019. The appropriate antibiotic prescribing was defined as prescribing antibiotic classes that were recommended by Chinese clinical guidelines, if patients were prescribed antibiotics. We evaluated the magnitude of antibiotics prescribed for acute upper respiratory infections (AURIs), acute bronchitis, and community-acquired pneumonia (CAP) and their appropriateness.

Findings

Overall, 55.1% (87,684/159,150), 66.8% (30,836/46,153), and 68.5% (4615/6733) of outpatients with AURIs, acute bronchitis, and CAP treated at PHFs in China were prescribed with antibiotics. Of all antibiotic prescriptions, only 20.0% (17,542/87,684), 18.6% (5724/30,836) and 69.6% (3211/4615) used antibiotic classes that were recommended by the guidelines for AURIs, acute bronchitis, and CAP, respectively. Patients residing in the Chinese central region (17.0%, 15.4%, 69.3% for AURIs, acute bronchitis, and CAP, respectively) were less likely to be prescribed with antibiotics that were appropriately selected.

Interpretation

Unnecessary antibiotics were widely prescribed for patients with AURIs or acute bronchitis and most patients with ARIs did not receive guideline-recommended antibiotic classes in Chinese PHFs. Interventions to promote evidence-based treatment and the appropriate use of antibiotics are urgently needed at the primary level across China.

Funding

This work was supported by the National Natural Science Foundation of China [grant number 72074007, 81973294].

Does the market reward quality? Evidence from India

There are two salient facts about health care in low and middle-income countries; (1) the private sector plays an important role and (2) the care provided is often of poor quality. Despite these facts we know little about what drives quality of care in the private sector and why patients seek care from poor quality providers. We use two field studies in India that provide insight into this issue. First, we use a discrete choice experiment to show that patients strongly value technical quality. Second, we use standardized patients to show that better quality providers are not able to charge higher prices. Instead providers are able to charge higher prices for elements of quality that the patient can observe, which are less important for health outcomes. Future research should explore whether accessible information on technical quality of local providers can shift demand to higher quality providers and improve health outcomes.

Reporting of costs and economic impacts in randomized trials of de-implementation interventions for low-value care: a systematic scoping review

BACKGROUND

De-implementation of low-value care can increase health care sustainability. We evaluated the reporting of direct costs of de-implementation and subsequent change (increase or decrease) in health care costs in randomized trials of de-implementation research.

METHODS

We searched MEDLINE and Scopus databases without any language restrictions up to May 2021. We conducted study screening and data extraction independently and in duplicate. We extracted information related to study characteristics, types and characteristics of interventions, de-implementation costs, and impacts on health care costs. We assessed risk of bias using a modified Cochrane risk-of-bias tool.

RESULTS

We screened 10,733 articles, with 227 studies meeting the inclusion criteria, of which 50 included information on direct cost of de-implementation or impact of de-implementation on health care costs. Studies were mostly conducted in North America (36%) or Europe (32%) and in the primary care context (70%). The most common practice of interest was reduction in the use of antibiotics or other medications (74%). Most studies used education strategies (meetings, materials) (64%). Studies used either a single strategy (52%) or were multifaceted (48%). Of the 227 eligible studies, 18 (8%) reported on direct costs of the used de-implementation strategy; of which, 13 reported total costs, and 12 reported per unit costs (7 reported both). The costs of de-implementation strategies varied considerably. Of the 227 eligible studies, 43 (19%) reported on impact of de-implementation on health care costs. Health care costs decreased in 27 studies (63%), increased in 2 (5%), and were unchanged in 14 (33%).

CONCLUSION

De-implementation randomized controlled trials typically did not report direct costs of the de-implementation strategies (92%) or the impacts of de-implementation on health care costs (81%). Lack of cost information may limit the value of de-implementation trials to decision-makers.

TRIAL REGISTRATION

OSF (Open Science Framework): https://osf.io/ueq32 .

Inappropriate antibiotic prescribing in primary healthcare facilities in China: a nationwide survey, 2017-2019

OBJECTIVES

We aimed to generate comprehensive estimates of the appropriateness of outpatient antibiotic prescriptions at primary healthcare facilities (PHFs) in China.

METHODS

Between 2017 and 2019, we collected outpatient-visit prescriptions from 269 Chinese PHFs in 31 cities located in 6 provinces. Conditions that resulted in antibiotic use were classified into appropriate, potentially appropriate, and inappropriate using a well-established classification approach. We then assessed the magnitude, appropriateness, and costs of antibiotic prescribing, overall and by antibiotic classification group, diagnostic categories, and patient characteristics.

RESULTS

Of all eligible 209 662 antibiotic prescriptions, 147 758 (70.5%) were inappropriate, which accounted for 66.8% (558.0/835.3 thousand US dollars) of costs for antibiotics. Upper respiratory tract infections, acute bronchitis, and non-infectious gastroenteritis were responsible for 68.9% (101 744/147 758) of inappropriately antibiotic prescriptions. High inappropriate antibiotic prescribing rates were observed among children aged 0-5 years (78.5% (21 049/26 799)) and patients living in economically undeveloped areas (77.5% (38 430/49 587)). A total of 256 474 individual antibiotics were prescribed, of which 82.2% (210 885/256 474) were broad-spectrum antibiotics, with second-generation cephalosporins (15.1% (38 705/256 474)) and third-generation cephalosporins (14.6% (37 491/256 474)) being the most commonly prescribed subgroups.

DISCUSSION

Our findings highlight the excessive and inappropriate use of antibiotics in Chinese PHFs pending multidimensional efforts.

Identifying key influences on antibiotic use in China: a systematic scoping review and narrative synthesis

INTRODUCTION

The inappropriate use of antibiotics is a key driver of antimicrobial resistance. In China, antibiotic prescribing and consumption exceed recommended levels and are relatively high internationally. Understanding the influences on antibiotic use is essential to informing effective evidence-based interventions. We conducted a scoping review to obtain an overview of empirical research about key behavioural, cultural, economic and social influences on antibiotic use in China.

METHODS

Searches were conducted in Econlit, Medline, PsycINFO, Social Science citation index and the Cochrane Database of Systematic Reviews for the period 2003 to early 2018. All study types were eligible including observational and intervention, qualitative and quantitative designs based in community and clinical settings. Two authors independently screened studies for inclusion. A data extraction form was developed incorporating details on study design, behaviour related to antibiotic use, influences on behaviour and information on effect (intervention studies only).

RESULTS

Intervention studies increased markedly from 2014, and largely focused on the impact of national policy and practice directives on antibiotic use in secondary and tertiary healthcare contexts in China. Most studies used pragmatic designs, such as before and after comparisons. Influences on antibiotic use clustered under four themes: antibiotic prescribing; adherence to antibiotics; self-medicating behaviour and over-the-counter sale of antibiotics. Many studies highlighted the use of antibiotics without a prescription for common infections, which was facilitated by availability of left-over medicines and procurement from local pharmacies.

CONCLUSIONS

Interventions aimed at modifying antibiotic prescribing behaviour show evidence of positive impact, but further research using more robust research designs, such as randomised trials, and incorporating process evaluations is required to better assess outcomes. The effect of national policy at the primary healthcare level needs to be evaluated and further exploration of the influences on antibiotic self-medicating is required to develop interventions that tackle this behaviour.

Effects of Volume-Price Contracts on Pharmaceutical Prices: A Retrospective Comparative Study of Public Hospitals in Hubei of China

Background: Pharmaceutical expenditure has been increasing worldwide. Many countries have attempted to contain the increase through collective bargaining, including in China. In 2015, the Chinese government introduced a new policy to empower regional governments to reduce pharmaceutical prices through its existing tendering system which enables a lower price for products with higher procurement volumes. Xiangyang municipality in Hubei province took a lead in piloting this initiative. Objectives: This study aimed to evaluate the effects of the volume-price contract initiative on pharmaceutical price procured by the public hospitals in Xiangyang. Methods: A retrospective comparative design was adopted. The price of cardiovascular medicines (349 products under 164 International Nonproprietary Names) procured by the public hospitals in Xiangyang was compared with those procured in Yichang municipality in Hubei. A total of 15,921 procurement records over the period from January 2017 to December 2018 were examined (Xiangyang started the volume-price contract initiative in January 2018). Generalized linear regression models with a difference-in-differences approach which could reflect the differences between the two cities between January 2018 and December 2018 were established to test the effects of the volume-price contract initiative on pharmaceutical prices. Results: On average, the procurement price for cardiovascular medicines adjusted by defined daily dosage in Xiangyang dropped by 41.51%, compared with a 0.22% decrease in Yichang. The difference-in-differences results showed that the volume-price contract initiative resulted in a 36.24% drop (p = 0.006) in the price (30.23% for the original brands, p = 0.008), in addition to the therapeutic competition effect (31.61% reduction in the price, p = 0.002). The top 100 domestic suppliers were highly responsive to the initiative (82.80% drop in the price, p = 0.001). Conclusion: The volume-price contract initiative has the potential to bring down the price of pharmaceutical supplies. Higher responses from the domestic suppliers are evident.

Outpatient Antibiotic Prescribing Patterns and Appropriateness for Children in Primary Healthcare Settings in Beijing City, China, 2017-2019

(1) Background: Few studies have focused on antibiotic use and appropriateness in children in primary health institutions (PHIs). This study aimed to identify the patterns and appropriateness of antibiotic use for children in PHIs in Beijing, China. (2) Methods: Outpatient prescriptions of 327 PHIs from 2017 to 2019 for patients <18 years old were collected. Prescriptions were described using quantity indicators. Antibiotics were categorized according to ATC classification J01 and Access, Watch, Reserve grouping. Appropriateness was reviewed by experts using three subtypes of irrational prescriptions (irregular, inappropriate, and abnormal). (3) Results: 20,618 prescriptions were collected in total. The antibiotic prescription rate (APR) was 15.1% (N = 3113). Among antibiotic prescriptions, J01FA Macrolides were the most used (N = 1068, 34.9%). The Watch group constituted 89.0% (N = 2818) of total antibiotic use. Bronchitis (N = 1059, 35.2%) was the most common diagnosis. A total of 292 instances of irrational antibiotic use were identified, with inappropriate prescriptions being the most prevalent subtype (N = 233, 79.8%). (4) Conclusion: Although APR for children in PHIs in Beijing was relatively low, the pattern of antibiotic use differed from other countries. Further studies are needed to optimize antibiotic use for children in PHIs under different levels of economic development.

Outpatient prescribing pattern for acute bronchitis in primary healthcare settings in China

Inappropriate prescribing for acute bronchitis in primary healthcare settings (PHSs) is commonly seen worldwide. Here we describe the prescribing patterns and antibiotic use for acute bronchitis in PHSs across China. We conduct a nationwide cross-sectional survey to collect outpatient prescriptions from PHSs in 2017. Patients diagnosed with acute bronchitis without other infections are eligible for this study. Generalized estimating equations are used for analysis. Overall, 10,678 prescriptions for acute bronchitis from 214 institutions are included. The antibiotic prescription rate is 44.5% for total prescriptions, and differs significantly by region and urban/rural status (p < 0.05). Among all single-antibiotic prescriptions, 91.5% are broad-spectrum. Two-thirds of the prescriptions contain medicines for symptom management. The overall guideline compliance rate of acute bronchitis treatment for adults is 31.0%. Prescribing antibiotics, especially broad-spectrum ones, for acute bronchitis is commonly observed in Chinese PHSs. Targeted interventions are urgently needed for Chinese primary clinicians, especially in western rural areas.

Mechanisms and impact of public reporting on physicians and hospitals' performance: A systematic review (2000-2020)

BACKGROUND

Public performance reporting (PPR) of physician and hospital data aims to improve health outcomes by promoting quality improvement and informing consumer choice. However, previous studies have demonstrated inconsistent effects of PPR, potentially due to the various PPR characteristics examined. The aim of this study was to undertake a systematic review of the impact and mechanisms (selection and change), by which PPR exerts its influence.

METHODS

Studies published between 2000 and 2020 were retrieved from five databases and eight reviews. Data extraction, quality assessment and synthesis were conducted. Studies were categorised into: user and provider responses to PPR and impact of PPR on quality of care.

RESULTS

Forty-five studies were identified: 24 on user and provider responses to PPR, 14 on impact of PPR on quality of care, and seven on both. Most of the studies reported positive effects of PPR on the selection of providers by patients, purchasers and providers, quality improvement activities in primary care clinics and hospitals, clinical outcomes and patient experiences.

CONCLUSIONS

The findings provide moderate level of evidence to support the role of PPR in stimulating quality improvement activities, informing consumer choice and improving clinical outcomes. There was some evidence to demonstrate a relationship between PPR and patient experience. The effects of PPR varied across clinical areas which may be related to the type of indicators, level of data reported and the mode of dissemination. It is important to ensure that the design and implementation of PPR considered the perspectives of different users and the health system in which PPR operates in. There is a need to account for factors such as the structural characteristics and culture of the hospitals that could influence the uptake of PPR.

Antibiotic Sales in Primary Care in Hubei Province, China: An Analysis of 2012-2017 Procurement Records

The over-use of antibiotics has been identified as a major global challenge, where there is insufficient knowledge about the use of antibiotics in primary healthcare settings, especially at a population level. This study aims to investigate the trends and patterns of antibiotic sales in primary care in Hubei, China over a six-year period from 2012 to 2017. Antibiotic sales were expressed with Defined Daily Doses per 1000 inhabitants per day (DIDs) and compared with European countries using the 12 quality indicators proposed by the scientific advisory board of the European Surveillance of Antimicrobial Consumption (ESAC) project. Antibiotic sales increased from 12.8 DID in 2012 to 15.3 DID in 2013, and then declined afterwards. The most commonly used antibiotics, J01C (beta-lactam antimicrobials, penicillins), accounted for 40.5% of total antibiotic sales. Parenteral administration of antibiotics accounted for over 50% of total antibiotic sales. Total antibiotic sales were almost on a par with the 31 European countries monitored by the ESAC project, but cephalosporin sales were higher than at least three quarters of the compared countries, resulting in a significant higher proportion of third-generation cephalosporin consumption (13.8–19.43%). The relative consumption of Fluoroquinolone (9.26–9.89%) was also higher than at least half of the compared countries. There is a lack of robust evidence to show that antibiotic consumption in primary care is lower in Hubei compared with other countries. The preference of clinicians in China to use broad-spectrum and parenteral antibiotics deserves further study and policy attention.

Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems

This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies.

Sino-Australian University Partnership in Health Management Education

This paper outlines a successful partnership program between La Trobe University in Melbourne Australia, and Harbin Medical University in Harbin, China. These two universities have been collaborating for more than 15 years to provide a comprehensive Master of Health Administration program that adapts the Australian curriculum to meet the rapidly increasing need for qualified health services managers throughout China. This paper describes the mechanisms by which the joint programs were developed and how the two universities work together in partnership to continually improve the program components and outcomes, taking into account the significant differences in context and cultures. Since 2001, La Trobe University has enrolled about 1000 Chinese health services managers, with 721 completing a Master's degree, who are now having increasing influence on the reforms of the Chinese health care system. The partnership has enriched Australian knowledge of Chinese culture and values, as well as the Chinese health system and health policies, as evidenced by the large volume of joint publications. The profession of health management has been substantially strengthened in China, and working together, Chinese and Australian academics have had demonstrated impact on enhancing the reforms of the Chinese public health system. Further studies, with sufficient funds for data collection, are needed to evaluate the long-term impacts of transnational programs on academic and health system development in China.

Impact of public release of performance data on the behaviour of healthcare consumers and providers

BACKGROUND

It is becoming increasingly common to publish information about the quality and performance of healthcare organisations and individual professionals. However, we do not know how this information is used, or the extent to which such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers, and purchasers.

OBJECTIVES

To estimate the effects of public release of performance data, from any source, on changing the healthcare utilisation behaviour of healthcare consumers, providers (professionals and organisations), and purchasers of care. In addition, we sought to estimate the effects on healthcare provider performance, patient outcomes, and staff morale.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trials registers on 26 June 2017. We checked reference lists of all included studies to identify additional studies.

SELECTION CRITERIA

We searched for randomised or non-randomised trials, interrupted time series, and controlled before-after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or professionals. Each study had to report at least one main outcome related to selecting or changing care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers, and healthcare purchasers), performance data, main outcomes (choice of healthcare provider, and improvement by means of changes in care), and other outcomes (awareness, attitude, knowledge of performance data, and costs). Given the substantial degree of clinical and methodological heterogeneity between the studies, we presented the findings for each policy in a structured format, but did not undertake a meta-analysis.

MAIN RESULTS

We included 12 studies that analysed data from more than 7570 providers (e.g. professionals and organisations), and a further 3,333,386 clinical encounters (e.g. patient referrals, prescriptions). We included four cluster-randomised trials, one cluster-non-randomised trial, six interrupted time series studies, and one controlled before-after study. Eight studies were undertaken in the USA, and one each in Canada, Korea, China, and The Netherlands. Four studies examined the effect of public release of performance data on consumer healthcare choices, and four on improving quality.There was low-certainty evidence that public release of performance data may make little or no difference to long-term healthcare utilisation by healthcare consumers (3 studies; 18,294 insurance plan beneficiaries), or providers (4 studies; 3,000,000 births, and 67 healthcare providers), or to provider performance (1 study; 82 providers). However, there was also low-certainty evidence to suggest that public release of performance data may slightly improve some patient outcomes (5 studies, 315,092 hospitalisations, and 7502 providers). There was low-certainty evidence from a single study to suggest that public release of performance data may have differential effects on disadvantaged populations. There was no evidence about effects on healthcare utilisation decisions by purchasers, or adverse effects.

AUTHORS' CONCLUSIONS

The existing evidence base is inadequate to directly inform policy and practice. Further studies should consider whether public release of performance data can improve patient outcomes, as well as healthcare processes.

Effects of prescription restrictive interventions on antibiotic procurement in primary care settings: a controlled interrupted time series study in China

Background

The overuse of antibiotics has been identified as a major challenge in regard to the rational prescription of medicines in low and middle income countries. Extensive studies on the effectiveness of persuasive interventions, such as guidelines have been undertaken. There is a dearth of research pertaining to the effects of restrictive interventions. This study aimed to evaluate the impacts of prescription restrictions in relation to types and administration routes of antibiotics on antibiotic procurement in primary care settings in China.

Methods

Data were drawn from the monthly procurement records of medicines for primary care institutions in Hubei province over a 31-month period from May 2011 to November 2013. We analyzed the monthly procurement volume and costs of antibiotics. Interrupted time series analyses with a difference-in-difference approach were performed to evaluate the effect of the restrictive intervention (started in August 2012) on antibiotic procurement in comparison with those for cardiovascular conditions. Sensitivity tests were performed by replacing outliers using a simple linear interpolation technique.

Results

Over the entire study period, antibiotics accounted for 33.65% of the total costs of medicines procured for primary care institutions: mostly non-restricted antibiotics (86.03%) and antibiotics administered through parenteral routes (79.59%). On average, 17.14 million defined daily doses (DDDs) of antibiotics were procured per month, with the majority (93.09%) for non-restricted antibiotics and over half (52.38%) for parenteral administered antibiotics. The restrictive intervention was associated with a decline in the secular trend of costs for non-restricted oral antibiotics (− 0.36 million Yuan per month, p = 0.029), and for parenteral administered restricted antibiotics (− 0.28 million Yuan per month, p = 0.019), as well as a decline in the secular trend of procurement volume for parenteral administered non-restricted antibiotics (− 0.038 million DDDs per month, p = 0.05).

Conclusions

Restrictive interventions are effective in reducing the procurement of antibiotics. However, the effect size is relatively small and antibiotic consumptions remain high, especially parenteral administered antibiotics.