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Kovács SD. Patient autonomy in the era of the sustainability crisis. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024; 27:399-405. [PMID: 38850497 PMCID: PMC11310236 DOI: 10.1007/s11019-024-10214-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 06/10/2024]
Abstract
In the realm of medical ethics, the foundational principle of respecting patient autonomy holds significant importance, often emerging as a central concern in numerous ethically complex cases, as authorizing medical assistance in dying or healthy limb amputation on patient request. Even though advocates for either alternative regularly utilize prima facie principles to resolve ethical dilemmas, the interplay between these principles is often the core of the theoretical frameworks. As the ramifications of the sustainability crisis become increasingly evident, there is a growing need to integrate awareness for sustainability into medical decision-making, thus reintroducing potential conflict with patient autonomy. The contention of this study is that the ethical standards established in the 20th century may not adequately address the challenges that have arisen in the 21st century. The author suggests an advanced perception of patient autonomy that prioritizes fostering patients' knowledge, self-awareness, and sense of responsibility, going beyond a sole focus on their intrinsic values. Empowering patients could serve as a tool to align patient autonomy, beneficence, and the aim to reduce resource consumption.
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Affiliation(s)
- Szilárd Dávid Kovács
- Institute of Behavioural Sciences, Semmelweis University, Budapest, 1089, Hungary.
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2
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Morkem R, Smith G, Knight B, Wong ST, Barber D. Understanding the impact of COVID-19 on antibiotic use in Canadian primary care: a matched-cohort study using EMR data. Antimicrob Resist Infect Control 2024; 13:76. [PMID: 38997756 PMCID: PMC11242630 DOI: 10.1186/s13756-024-01434-0] [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: 03/21/2024] [Accepted: 07/02/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Inappropriate or overuse of antibiotic prescribing in primary care highlights an opportunity for antimicrobial stewardship (AMS) programs aimed at reducing unnecessary use of antimicrobials through education, policies and practice audits that optimize antibiotic prescribing. Evidence from the early part of the pandemic indicates a high rate of prescribing of antibiotics for patients with COVID-19. It is crucial to surveil antibiotic prescribing by primary care providers from the start of the pandemic and into its endemic stage to understand the effects of the pandemic and better target effective AMS programs. METHODS This was a matched pair population-based cohort study that used electronic medical record (EMR) data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Participants included all patients that visited their primary care provider and met the inclusion criteria for COVID-19, respiratory tract infection (RTI), or non-respiratory or influenza-like-illness (negative). Four outcomes were evaluated (a) receipt of an antibiotic prescription; (b) receipt of a non-antibiotic prescription; (c) a subsequent primary care visit (for any reason); and (d) a subsequent primary care visit with a bacterial infection diagnosis. Conditional logistic regression was used to evaluate the association between COVID-19 and each of the four outcomes. Each model was adjusted for location (rural or urban), material and social deprivation, smoking status, alcohol use, obesity, pregnancy, HIV, cancer and number of chronic conditions. RESULTS The odds of a COVID-19 patient receiving an antibiotic within 30 days of their visit is much lower than for patients visiting for RTI or for a non-respiratory or influenza-like-illnesses (AOR = 0.08, 95% CI[0.07, 0.09] compared to RTI, and AOR = 0.43, 95% CI[0.38, 0.48] compared to negatives). It was found that a patient visit for COVID-19 was much less likely to have a subsequent visit for a bacterial infection at all time points. CONCLUSIONS Encouragingly, COVID-19 patients were much less likely to receive an antibiotic prescription than patients with an RTI. However, this highlights an opportunity to leverage the education and attitude change brought about by the public health messaging during the COVID-19 pandemic (that antibiotics cannot treat a viral infection), to reduce the prescribing of antibiotics for other viral RTIs and improve antibiotic stewardship.
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Affiliation(s)
- Rachael Morkem
- Department of Family Medicine, Queen's University, 220 Bagot St., Kingston, ON, K7L 5E9, Canada.
| | - Glenys Smith
- Public Health Agency of Canada, Ottawa, ON, Canada
| | | | - Sabrina T Wong
- Centre for Health Services and Policy Research and School of Nursing, University of British Columbia, Vancouver, Canada
| | - David Barber
- Department of Family Medicine, Queen's University, 220 Bagot St., Kingston, ON, K7L 5E9, Canada
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Baillie EJ, Merlo G, Van Driel ML, Magin PJ, Hall L. Early-career general practitioners' antibiotic prescribing for acute infections: a systematic review. J Antimicrob Chemother 2024; 79:512-525. [PMID: 38252922 PMCID: PMC10904722 DOI: 10.1093/jac/dkae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Antimicrobial resistance is a worldwide threat, exacerbated by inappropriate prescribing. Most antibiotic prescribing occurs in primary care. Early-career GPs are important for the future of antibiotic prescribing and curbing antimicrobial resistance. OBJECTIVES To determine antibiotic prescribing patterns by early-career GPs for common acute infections. METHODS A systematic literature search was conducted using PubMed, Embase and Scopus. Two authors independently screened abstracts and full texts for inclusion. Primary outcomes were antibiotic prescribing rates for common acute infections by GPs with experience of 10 years or less. Secondary outcomes were any associations between working experience and antibiotic prescribing. RESULTS Of 1483 records retrieved, we identified 41 relevant studies. Early-career GPs were less likely to prescribe antibiotics compared with their more experienced colleagues (OR range 0.23-0.67). Their antibiotic prescribing rates for 'any respiratory condition' ranged from 14.6% to 52%, and for upper respiratory tract infections from 13.5% to 33%. Prescribing for acute bronchitis varied by country, from 15.9% in Sweden to 26% in the USA and 63%-73% in Australia. Condition-specific data for all other included acute infections, such as sinusitis and acute otitis media, were limited to the Australian context. CONCLUSIONS Early-career GPs prescribe fewer antibiotics than later-career GPs. However, there are still significant improvements to be made for common acute conditions, as their prescribing is higher than recommended benchmarks. Addressing antimicrobial resistance requires an ongoing worldwide effort and early-career GPs should be the target for long-term change.
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Affiliation(s)
- Emma J Baillie
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Greg Merlo
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Mieke L Van Driel
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, QLD, 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
| | - Lisa Hall
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
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Tandon P, Brown KA, Daneman N, Langford BJ, Leung V, Friedman L, Schwartz KL. Variability in changes in physician outpatient antibiotic prescribing from 2019 to 2021 during the COVID-19 pandemic in Ontario, Canada. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e171. [PMID: 38028902 PMCID: PMC10644162 DOI: 10.1017/ash.2023.433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 12/01/2023]
Abstract
Objective To evaluate inter-physician variability and predictors of changes in antibiotic prescribing before (2019) and during (2020/2021) the coronavirus disease 2019 (COVID-19) pandemic. Methods We conducted a retrospective cohort analysis of physicians in Ontario, Canada prescribing oral antibiotics in the outpatient setting between January 1, 2019 and December 31, 2021 using the IQVIA Xponent data set. The primary outcome was the change in the number of antibiotic prescriptions between the prepandemic and pandemic period. Secondary outcomes were changes in the selection of broad-spectrum agents and long-duration (>7 d) antibiotic use. We used multivariable linear regression models to evaluate predictors of change. Results There were 17,288 physicians included in the study with substantial inter-physician variability in changes in antibiotic prescribing (median change of -43.5 antibiotics per physician, interquartile range -136.5 to -5.0). In the multivariable model, later career stage (adjusted mean difference [aMD] -45.3, 95% confidence interval [CI] -52.9 to -37.8, p < .001), family medicine (aMD -46.0, 95% CI -62.5 to -29.4, p < .001), male patient sex (aMD -52.4, 95% CI -71.1 to -33.7, p < .001), low patient comorbidity (aMD -42.5, 95% CI -50.3 to -34.8, p < .001), and high prescribing to new patients (aMD -216.5, 95% CI -223.5 to -209.5, p < .001) were associated with decreases in antibiotic initiation. Family medicine and high prescribing to new patients were associated with a decrease in selection of broad-spectrum agents and prolonged antibiotic use. Conclusions Antibiotic prescribing changed throughout the COVID-19 pandemic with overall decreases in antibiotic initiation, broad-spectrum agents, and prolonged antibiotic courses with inter-physician variability. These findings present opportunities for community antibiotic stewardship interventions.
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Affiliation(s)
- Pranav Tandon
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - Kevin A. Brown
- Public Health Ontario, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, ON, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | - Bradley J. Langford
- Public Health Ontario, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, ON, Canada
- Toronto East Health Network, Toronto, ON, Canada
| | | | - Kevin L. Schwartz
- Public Health Ontario, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Unity Health Toronto, Toronto, ON, Canada
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Ingalls EM, Veillette JJ, Olson J, May SS, Dustin Waters C, Gelman SS, Vargyas G, Hutton M, Tinker N, Fontaine GV, Foster RA, Stallsmith J, Earl A, Buckel WR, Vento TJ. Impact of a Multifaceted Intervention on Antibiotic Prescribing for Cystitis and Asymptomatic Bacteriuria in 23 Community Hospital Emergency Departments. Hosp Pharm 2023; 58:401-407. [PMID: 37360208 PMCID: PMC10288455 DOI: 10.1177/00185787231159578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
Background: Urinary tract infections (UTIs) are over-diagnosed and over-treated in the emergency department (ED) leading to unnecessary antibiotic exposure and avoidable side effects. However, data describing effective large-scale antimicrobial stewardship program (ASP) interventions to improve UTI and asymptomatic bacteriuria (ASB) management in the ED are lacking. Methods: We implemented a multifaceted intervention across 23 community hospital EDs in Utah and Idaho consisting of in-person education for ED prescribers, updated electronic order sets, and implementation/dissemination of UTI guidelines for our healthcare system. We compared ED UTI antibiotic prescribing in 2021 (post-intervention) to baseline data from 2017 (pre-intervention). The primary outcomes were the percent of cystitis patients prescribed fluoroquinolones or prolonged antibiotic durations (>7 days). Secondary outcomes included the percent of patients treated for UTI who met ASB criteria, and 14-day UTI-related readmissions. Results: There was a significant decrease in prolonged treatment duration for cystitis (29% vs 12%, P < .01) and treatment of cystitis with a fluoroquinolone (32% vs 7%, P < .01). The percent of patients treated for UTI who met ASB criteria did not change following the intervention (28% pre-intervention versus 29% post-intervention, P = .97). A subgroup analysis indicated that ASB prescriptions were highly variable by facility (range 11%-53%) and provider (range 0%-71%) and were driven by a few high prescribers. Conclusions: The intervention was associated with improved antibiotic selection and duration for cystitis, but future interventions to improve urine testing and provide individualized prescriber feedback are likely needed to improve ASB prescribing practice.
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Affiliation(s)
| | - John J. Veillette
- Intermountain Medical Center, Murray, UT, USA
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Murray, UT, USA
| | - Jared Olson
- Primary Children’s Hospital, Salt Lake City, UT, USA
- University of Utah, Salt Lake City, UT, USA
| | - Stephanie S. May
- Intermountain Medical Center, Murray, UT, USA
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Murray, UT, USA
| | | | - Stephanie S. Gelman
- Intermountain Medical Center, Murray, UT, USA
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Murray, UT, USA
| | - George Vargyas
- Intermountain Medical Center Emergency Department, Murray, UT, USA
| | | | - Nick Tinker
- Intermountain Medical Center, Murray, UT, USA
| | | | | | - Jena Stallsmith
- Primary Children’s Hospital, Salt Lake City, UT, USA
- University of Utah, Salt Lake City, UT, USA
| | - Ali Earl
- St. George Regional Hospital, St. George, UT, USA
| | | | - Todd J. Vento
- Intermountain Medical Center, Murray, UT, USA
- Infectious Diseases Telehealth Service, Intermountain Healthcare, Murray, UT, USA
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Schwartz KL, Xu AXT, Alderson S, Bjerrum L, Brehaut J, Brown BC, Bucher HC, De Sutter A, Francis N, Grimshaw J, Gunnarsson R, Hoye S, Ivers N, Lecky DM, Lindbæk M, Linder JA, Little P, Michalsen BO, O'Connor D, Pulcini C, Sundvall PD, Lundgren PT, Verbakel JY, Verheij TJ. Best practice guidance for antibiotic audit and feedback interventions in primary care: a modified Delphi study from the Joint Programming Initiative on Antimicrobial resistance: Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN). Antimicrob Resist Infect Control 2023; 12:72. [PMID: 37516892 PMCID: PMC10387210 DOI: 10.1186/s13756-023-01279-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/21/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND Primary care is a critical partner for antimicrobial stewardship efforts given its high human antibiotic usage. Peer comparison audit and feedback (A&F) is often used to reduce inappropriate antibiotic prescribing. The design and implementation of A&F may impact its effectiveness. There are no best practice guidelines for peer comparison A&F in antibiotic prescribing in primary care. OBJECTIVE To develop best practice guidelines for peer comparison A&F for antibiotic prescribing in primary care in high income countries by leveraging international expertise via the Joint Programming Initiative on Antimicrobial Resistance-Primary Care Antibiotic Audit and Feedback Network. METHODS We used a modified Delphi process to achieve convergence of expert opinions on best practice statements for peer comparison A&F based on existing evidence and theory. Three rounds were performed, each with online surveys and virtual meetings to enable discussion and rating of each best practice statement. A five-point Likert scale was used to rate consensus with a median threshold score of 4 to indicate a consensus statement. RESULTS The final set of guidelines include 13 best practice statements in four categories: general considerations (n = 3), selecting feedback recipients (n = 1), data and indicator selection (n = 4), and feedback delivery (n = 5). CONCLUSION We report an expert-derived best practice recommendations for designing and evaluating peer comparison A&F for antibiotic prescribing in primary care. These 13 statements can be used by A&F designers to optimize the impact of their quality improvement interventions, and improve antibiotic prescribing in primary care.
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Affiliation(s)
- Kevin L Schwartz
- Public Health Ontario, 480 University Ave, Ste 300, Toronto, ON, M5G 1V2, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
- Unity Health Toronto, Toronto, Canada.
| | - Alice X T Xu
- Public Health Ontario, 480 University Ave, Ste 300, Toronto, ON, M5G 1V2, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sarah Alderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Oaklands Health Centre, Holmfirth, UK
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jamie Brehaut
- Centre for Practice-Changing Research (CPCR), Ottawa Hospital Research Institute, Ottawa, Canada
| | - Benjamin C Brown
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Heiner C Bucher
- Division of Clinical Epidemiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - An De Sutter
- Department of Public Health and Primary Care, Center for Family Medicine UGent, Ghent University, Ghent, Belgium
| | - Nick Francis
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Jeremy Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Ronny Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | - Sigurd Hoye
- Department of General Practice, Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Noah Ivers
- Women's College Hospital, Toronto, Canada
| | - Donna M Lecky
- Primary Care and Interventions Unit, UK Health Security Agency, Gloucester, England
| | - Morten Lindbæk
- Department of General Practice, Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Jeffrey A Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Paul Little
- Primary Care Research Centre, University of Southampton, Southampton, England
| | - Benedikte Olsen Michalsen
- Department of General Practice, Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Celine Pulcini
- APEMAC, Université de Lorraine, Nancy, France
- CHRU-Nancy, Centre regional en antibiotherapie de la region Grand Est AntibioEst, Université de Lorraine, Nancy, France
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | | | - Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Louvain, Belgium
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Simeoni M, Saragosa M, Laur C, Desveaux L, Schwartz K, Ivers N. Coping with ‘the grey area’ of antibiotic prescribing: a theory-informed qualitative study exploring family physician perspectives on antibiotic prescribing. BMC PRIMARY CARE 2022; 23:188. [PMID: 35902821 PMCID: PMC9330951 DOI: 10.1186/s12875-022-01806-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 07/20/2022] [Indexed: 11/21/2022]
Abstract
Background Unnecessary antibiotic use is associated with adverse side effects and rising rates of resistance at the individual and population level. This study used a theory-informed approach to identify potentially modifiable determinants of antibiotic prescribing for patients presenting to primary care with upper respiratory tract infection symptoms. Methods Qualitative interviews were conducted with primary care physicians in Ontario, Canada who were identified as medium- or high-volume antibiotic prescribers (high volume defined as top 20th percentile versus “medium” defined as 40th to 60th percentile). The interview guide and analysis were informed by the Theoretical Domains Framework. Each interview was coded by two research team members. Sampling and analysis continued until thematic saturation was achieved. Results Twenty family physicians were interviewed. Physicians felt that many decisions about prescribing for upper respiratory tract infection symptoms were straightforward (i.e., black and white). However, intention to avoid prescribing in cases where an antibiotic was not indicated clinically did not always align with the provider action or expectation of the patient. Clinical decisions were influenced by the Theoretical Domain Framework domains that were both internal to the physician (Knowledge, Skills, Social/Professional Role, and Belief about Capabilities) and external to the physician (Social Influence, Belief about Consequences, Reinforcement, Emotions, and Behavioural Regulation). The Environmental Context and Resources played a key role. Physicians reported significant differences in their approach to antibiotic prescribing within episodic (walk-in) or continuity of care settings, as the presence (or not) of longitudinal physician–patient relationships seemed to moderate the role of these factors on the decision-making process in cases of uncertainty. Conclusions Antibiotic prescribing in primary care is a complex decision-making process in which context may outweigh biology during encounters featuring clinical uncertainty. Differential skill in handling uncertainty and tactics used to operationalize guideline recommendations in the real world seems to contribute to observed variation in prescribing patterns, as much or more than differences in knowledge of best practices. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01806-8.
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Gouin KA, Fleming-Dutra KE, Tsay S, Bizune D, Hicks LA, Kabbani S. Identifying higher-volume antibiotic outpatient prescribers using publicly available medicare part D data - United States, 2019. Am J Transplant 2022; 22:1266-1270. [PMID: 35373523 DOI: 10.1111/ajt.16653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Clifton, New Jersey
| | - Sharon Tsay
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Clifton, New Jersey
| | - Destani Bizune
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Clifton, New Jersey
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Clifton, New Jersey
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Clifton, New Jersey
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Gouin KA, Fleming-Dutra KE, Tsay S, Bizune D, Hicks LA, Kabbani S. Identifying Higher-Volume Antibiotic Outpatient Prescribers Using Publicly Available Medicare Part D Data - United States, 2019. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2022; 71:202-205. [PMID: 35143465 PMCID: PMC8830623 DOI: 10.15585/mmwr.mm7106a3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Antibiotic prescribing can lead to adverse drug events and antibiotic resistance, which pose ongoing urgent public health threats (1). Adults aged ≥65 years (older adults) are recipients of the highest rates of outpatient antibiotic prescribing and are at increased risk for antibiotic-related adverse events, including Clostridioides difficile and antibiotic-resistant infections and related deaths (1). Variation in antibiotic prescribing quality is primarily driven by prescribing patterns of individual health care providers, independent of patients' underlying comorbidities and diagnoses (2). Engaging higher-volume prescribers (the top 10% of prescribers by antibiotic volume) in antibiotic stewardship interventions, such as peer comparison audit and feedback in which health care providers receive data on their prescribing performance compared with that of other health care providers, has been effective in reducing antibiotic prescribing in outpatient settings and can be implemented on a large scale (3-5). This study analyzed data from the Centers for Medicare & Medicaid Services (CMS) Part D Prescriber Public Use Files (PUFs)* to describe higher-volume antibiotic prescribers in outpatient settings compared with lower-volume prescribers (the lower 90% of prescribers by antibiotic volume). Among the 59.4 million antibiotic prescriptions during 2019, 41% (24.4 million) were prescribed by the top 10% of prescribers (69,835). The antibiotic prescribing rate of these higher-volume prescribers (680 prescriptions per 1,000 beneficiaries) was 60% higher than that of lower-volume prescribers (426 prescriptions per 1,000 beneficiaries). Identifying health care providers responsible for a higher volume of antibiotic prescribing could provide a basis for additional assessment of appropriateness and outreach. Public health organizations and health care systems can use publicly available data to guide focused interventions to optimize antibiotic prescribing to limit the emergence of antibiotic resistance and improve patient outcomes.
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10
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Simon M, Thilly N, Pereira O, Pulcini C. Factors associated with the appropriateness of antibiotics prescribed in French general practice: a cross-sectional study using reimbursement databases. Clin Microbiol Infect 2021; 28:609.e1-609.e6. [PMID: 34500079 DOI: 10.1016/j.cmi.2021.08.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/24/2021] [Accepted: 08/29/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Identifying characteristics associated with the appropriateness of antibiotic prescriptions is useful to guide antibiotic stewardship interventions. Proxy indicators estimating the appropriateness of antibiotic prescriptions at the general practitioner (GP) level have recently been validated. Our objectives were to identify (a) clusters of GPs according to their appropriateness score based on these proxy indicator results, and (b) GPs', patients' and practices' characteristics associated with inappropriate prescriptions. METHODS We conducted a cross-sectional observational study analysing antibiotics prescribed by GPs in one large French region in 2019, using the Health Insurance databases. We identified clusters of GPs according to their appropriateness score calculated from ten proxy indicators' results. We then analysed the association between the clusters with more inappropriate practices compared with the one with less inappropriate practices, and GPs', patients', and practices' characteristics. We performed bivariate and multivariable analyses using logistic polytomous regressions. RESULTS We included 4819 GPs who were grouped into three clusters. GPs who belong to the clusters with more inappropriate practices were more likely to practice in certain geographical area, to be male, not to have a particular medical practice, to be practicing for longer, to have more patients and consultations, to have a higher proportion of elderly patients, and to prescribe more drugs, more antibiotics and a higher proportion of broad-spectrum antibiotics. CONCLUSION We identified clusters of practice as well as factors associated with the appropriateness of antibiotic prescriptions, using routinely collected data. This might help to guide antibiotic stewardship interventions.
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Affiliation(s)
- Maïa Simon
- Université de Lorraine, APEMAC, Nancy, France
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Département Méthodologie, Promotion, Investigation, Nancy, France
| | - Ouarda Pereira
- Direction Régionale du Service Médical (DRSM) Grand Est, Strasbourg, France
| | - Céline Pulcini
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Département de Maladies Infectieuses, Nancy, France.
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11
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Schwartz KL, Ivers N, Langford BJ, Taljaard M, Neish D, Brown KA, Leung V, Daneman N, Alloo J, Silverman M, Shing E, Grimshaw JM, Leis JA, Wu JHC, Garber G. Effect of Antibiotic-Prescribing Feedback to High-Volume Primary Care Physicians on Number of Antibiotic Prescriptions: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:1165-1173. [PMID: 34228086 PMCID: PMC8261687 DOI: 10.1001/jamainternmed.2021.2790] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/27/2021] [Indexed: 01/07/2023]
Abstract
Importance Antibiotic overuse contributes to adverse drug effects, increased costs, and antimicrobial resistance. Objective To evaluate peer-comparison audit and feedback to high-prescribing primary care physicians (PCPs) and assess the effect of targeted messaging on avoiding unnecessary antibiotic prescriptions and avoiding long-duration prescribing. Design, Setting, and Participants In this 3-arm randomized clinical trial, administrative data collected from IQVIA's Xponent database were used to recruit the highest quartile of antibiotic-prescribing PCPs (n = 3500) in Ontario, Canada. Interventions Physicians were randomized 3:3:1 to receive a mailed letter sent in December 2018 addressing antibiotic treatment initiation (n = 1500), a letter addressing prescribing duration (n = 1500), or no letter (control; n = 500). Outliers at the 99th percentile at baseline for each arm were excluded from analysis. Main Outcomes and Measures The primary outcome was total number of antibiotic prescriptions over 12 months postintervention. Secondary outcomes were number of prolonged-duration prescriptions (>7 days) and antibiotic drug costs (in Canadian dollars). Robust Poisson regression controlling for baseline prescriptions was used for analysis. Results Of the 3465 PCPs included in analysis, 2405 (69.4%) were male, and 2116 (61.1%) were 25 or more years from their medical graduation. At baseline, PCPs receiving the antibiotic initiation letter and duration letter prescribed an average of 988 and 1000 antibiotic prescriptions, respectively; at 12 months postintervention, these PCPs prescribed an average of 849 and 851 antibiotic prescriptions, respectively. For the primary outcome of total antibiotic prescriptions 12 months postintervention, there was no statistically significant difference in total antibiotic use between PCPs who received the initiation letter compared with controls (relative risk [RR], 0.96; 97.5% CI, 0.92-1.01; P = .06) and a small statistically significant difference for the duration letter compared with controls (RR, 0.95; 97.5% CI, 0.91-1.00; P = .01). For PCPs receiving the duration letter, this corresponds to an average of 42 fewer antibiotic prescriptions over 12 months. There was no statistically significant difference between the letter arms. For the initiation letter, compared with controls there was an RR of 0.98 (97.5% CI, 0.93-1.03; P = .42) and 0.97 (97.5% CI, 0.92-1.02; P = .19) for the outcomes of prolonged-duration prescriptions and antibiotic drug costs, respectively. At baseline, PCPs who received the duration letter prescribed an average of 332 prolonged-duration prescriptions with $14 470 in drug costs. There was an 8.1% relative reduction (RR, 0.92; 97.5% CI, 0.87-0.97; P < .001) in prolonged-duration prescriptions, and a 6.1% relative reduction in antibiotic drug costs (RR, 0.94; 97.5% CI, 0.89-0.99; P = .01). This corresponds to an average of 24 fewer prolonged-duration prescriptions and $771 in drug cost savings per PCP over 12 months. Conclusions and Relevance In this randomized clinical trial, a single mailed letter to the highest-prescribing PCPs in Ontario, Canada providing peer-comparison feedback, including messaging on limiting antibiotic-prescribing durations, led to statistically significant reductions in total and prolonged-duration antibiotic prescriptions, as well as drug costs. Trial Registration ClinicalTrials.gov Identifier: NCT03776383.
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Affiliation(s)
- Kevin L. Schwartz
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Unity Health Toronto, Toronto, Ontario, Canada
| | - Noah Ivers
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bradley J. Langford
- Public Health Ontario, Toronto, Ontario, Canada
- Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Kevin A. Brown
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Javed Alloo
- Section on General and Family Practice, Ontario Medical Association, Toronto, Ontario, Canada
- Ontario College of Family Physicians, Toronto, Ontario
| | - Michael Silverman
- Division of Infectious Diseases, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Emily Shing
- Public Health Ontario, Toronto, Ontario, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jerome A. Leis
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Gary Garber
- Public Health Ontario, Toronto, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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12
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Leung V, Langford BJ, Ha R, Schwartz KL. Metrics for evaluating antibiotic use and prescribing in outpatient settings. JAC Antimicrob Resist 2021; 3:dlab098. [PMID: 34286273 PMCID: PMC8287042 DOI: 10.1093/jacamr/dlab098] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Antimicrobial stewardship interventions in outpatient settings are diverse and a variety of outcomes have been used to evaluate these efforts. This narrative review describes, compares and provides specific examples of antibiotic use and other prescribing measures to help antimicrobial stewards better understand, interpret and implement metrics for this setting. A variety of data have been used including those generated from drug sales, prescribing and dispensing activities, however data generated closest to when an individual patient consumes an antibiotic is usually more accurate for estimating antibiotic use. Availability of data is often dependent on context such as information technology infrastructure and the healthcare system under consideration. While there is no ideal antibiotic use or prescribing metric for evaluating antimicrobial stewardship activities in the outpatient setting, the intervention of interest and available data sources are important factors. Common metrics for estimating antimicrobial use include DDD per 1000 inhabitants per day (DID) and days of therapy per 1000 inhabitants/day (DOTID). Other prescribing metrics such as antibiotic prescribing rate (APR), proportion of prescriptions containing an antibiotic, proportion of prolonged antibiotic courses prescribed, estimated appropriate APR and quality indicators are used to assess specific aspects of antimicrobial prescribing behaviour such as initiation, selection, duration and appropriateness. Understanding the context of prescribing practices helps to ensure feasibility and relevance when implementing metrics and targets for improvement in the outpatient setting.
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Affiliation(s)
- Valerie Leung
- Public Health Ontario, ON, Canada
- Toronto East Health Network, Michael Garron Hospital, ON, Canada
| | - Bradley J Langford
- Public Health Ontario, ON, Canada
- Hotel Dieu Shaver Health and Rehabilitation Centre, ON, Canada
| | - Rita Ha
- North York Family Health Team, ON, Canada
| | - Kevin L Schwartz
- Public Health Ontario, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, ON, Canada
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13
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Livorsi DJ, Nair R, Dysangco A, Aylward A, Alexander B, Smith MW, Kouba S, Perencevich EN. Using Audit and Feedback to Improve Antimicrobial Prescribing in Emergency Departments: A Multicenter Quasi-Experimental Study in the Veterans Health Administration. Open Forum Infect Dis 2021; 8:ofab186. [PMID: 34113685 DOI: 10.1093/ofid/ofab186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background In this pilot trial, we evaluated whether audit-and-feedback was a feasible strategy to improve antimicrobial prescribing in emergency departments (EDs). Methods We evaluated an audit-and-feedback intervention using a quasi-experimental interrupted time-series design at 2 intervention and 2 matched-control EDs; there was a 12-month baseline, 1-month implementation, and 11-month intervention period. At intervention sites, clinicians received (1) a single, one-on-one education about antimicrobial prescribing for common infections and (2) individualized feedback on total and condition-specific (uncomplicated acute respiratory infection [ARI]) antimicrobial use with peer-to-peer comparisons at baseline and every quarter. The primary outcome was the total antimicrobial-prescribing rate for all visits and was assessed using generalized linear models. In an exploratory analysis, we measured antimicrobial use for uncomplicated ARI visits and manually reviewed charts to assess guideline-concordant management for 6 common infections. Results In the baseline and intervention periods, intervention sites had 28 016 and 23 164 visits compared to 33 077 and 28 835 at control sites. We enrolled 27 of 31 (87.1%) eligible clinicians; they acknowledged receipt of 33.3% of feedback e-mails. Intervention sites compared with control sites had no absolute reduction in their total antimicrobial rate (incidence rate ratio = 0.99; 95% confidence interval, 0.98-1.01). At intervention sites, antimicrobial use for uncomplicated ARIs decreased (68.6% to 42.4%; P < .01) and guideline-concordant management improved (52.1% to 72.5%; P < .01); these improvements were not seen at control sites. Conclusions At intervention sites, total antimicrobial use did not decrease, but an exploratory analysis showed reduced antimicrobial prescribing for viral ARIs. Future studies should identify additional targets for condition-specific feedback while exploring ways to make electronic feedback more acceptable.
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Affiliation(s)
- Daniel J Livorsi
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Rajeshwari Nair
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Andrew Dysangco
- Indiana University School of Medicine and the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Andrea Aylward
- Sioux Falls VA Health Care System, Sioux Falls, South Dakota, USA
| | - Bruce Alexander
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Matthew W Smith
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Sammantha Kouba
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Eli N Perencevich
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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14
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Langford BJ, Chen C, Daneman N, Brown KA, Gomes T, Johnstone J, Wu J, Leung V, Garber G, Schwartz KL. Concordance between high antibiotic prescribing and high opioid prescribing among primary care physicians: a cross-sectional study. CMAJ Open 2021; 9:E175-E180. [PMID: 33688025 PMCID: PMC8034295 DOI: 10.9778/cmajo.20200122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Antimicrobial resistance and opioid misuse both present major public health challenges, and identifying high prescribers of both of these agents can help provide a common target for intervention. We sought to determine the association between being a high prescriber of antibiotics and being a high prescriber of opioids in the primary care setting. METHODS We performed a cross-sectional study of the antibiotic- and opioid-prescribing habits of primary care physicians in Ontario, Canada between Mar. 1, 2017, and Feb. 28, 2018, using administrative databases. We defined high prescribers as the top quartile of antibiotic or opioid prescribers using 3 antibiotic-prescribing metrics (prescriptions per patient visit, proportion of prescriptions that were broad spectrum and proportion of prescriptions > 8 d) and 3 opioid-prescribing metrics (prescriptions per patients seen, proportion of prescriptions > 90 mg of morphine equivalents and proportion of prescriptions > 28 d). We tabulated agreement between prescribing metrics using the κ statistic. RESULTS We included 9994 physicians. We observed minimal overlap between high antibiotic initiation and high opioid initiation (618 physicians [6.2%]) (κ = 0.00, 95% confidence interval -0.02 to 0.02). There was slight agreement between the antibiotic-prescribing indices and between the opioid-prescribing indices (within-class, range of κ 0.05 to 0.18). There was slight disagreement to slight agreement across antibiotic- and opioid-prescribing metrics (between-class, range of κ -0.09 to 0.16). INTERPRETATION Among primary care physicians, there was a lack of association between high antibiotic prescribing and high opioid prescribing. Our findings suggest that separate tailored approaches to antibiotic and opioid stewardship strategies are needed.
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Affiliation(s)
- Bradley J Langford
- Public Health Ontario (Langford, Chen, Daneman, Brown, Johnstone, Wu, Leung, Garber, Schwartz), Toronto, Ont.; Hotel Dieu Shaver Health and Rehabilitation Centre (Langford), St. Catharines, Ont.; ICES Central (Chen, Gomes, Schwartz); Sunnybrook Health Sciences Centre (Daneman); Dalla Lana School of Public Health (Brown, Schwartz), University of Toronto; Keenan Research Centre of the Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; Sinai Health System (Johnstone); Michael Garron Hospital (Leung), Toronto East Health Network, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.
| | - Cynthia Chen
- Public Health Ontario (Langford, Chen, Daneman, Brown, Johnstone, Wu, Leung, Garber, Schwartz), Toronto, Ont.; Hotel Dieu Shaver Health and Rehabilitation Centre (Langford), St. Catharines, Ont.; ICES Central (Chen, Gomes, Schwartz); Sunnybrook Health Sciences Centre (Daneman); Dalla Lana School of Public Health (Brown, Schwartz), University of Toronto; Keenan Research Centre of the Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; Sinai Health System (Johnstone); Michael Garron Hospital (Leung), Toronto East Health Network, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Nick Daneman
- Public Health Ontario (Langford, Chen, Daneman, Brown, Johnstone, Wu, Leung, Garber, Schwartz), Toronto, Ont.; Hotel Dieu Shaver Health and Rehabilitation Centre (Langford), St. Catharines, Ont.; ICES Central (Chen, Gomes, Schwartz); Sunnybrook Health Sciences Centre (Daneman); Dalla Lana School of Public Health (Brown, Schwartz), University of Toronto; Keenan Research Centre of the Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; Sinai Health System (Johnstone); Michael Garron Hospital (Leung), Toronto East Health Network, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Kevin A Brown
- Public Health Ontario (Langford, Chen, Daneman, Brown, Johnstone, Wu, Leung, Garber, Schwartz), Toronto, Ont.; Hotel Dieu Shaver Health and Rehabilitation Centre (Langford), St. Catharines, Ont.; ICES Central (Chen, Gomes, Schwartz); Sunnybrook Health Sciences Centre (Daneman); Dalla Lana School of Public Health (Brown, Schwartz), University of Toronto; Keenan Research Centre of the Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; Sinai Health System (Johnstone); Michael Garron Hospital (Leung), Toronto East Health Network, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Tara Gomes
- Public Health Ontario (Langford, Chen, Daneman, Brown, Johnstone, Wu, Leung, Garber, Schwartz), Toronto, Ont.; Hotel Dieu Shaver Health and Rehabilitation Centre (Langford), St. Catharines, Ont.; ICES Central (Chen, Gomes, Schwartz); Sunnybrook Health Sciences Centre (Daneman); Dalla Lana School of Public Health (Brown, Schwartz), University of Toronto; Keenan Research Centre of the Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; Sinai Health System (Johnstone); Michael Garron Hospital (Leung), Toronto East Health Network, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Jennie Johnstone
- Public Health Ontario (Langford, Chen, Daneman, Brown, Johnstone, Wu, Leung, Garber, Schwartz), Toronto, Ont.; Hotel Dieu Shaver Health and Rehabilitation Centre (Langford), St. Catharines, Ont.; ICES Central (Chen, Gomes, Schwartz); Sunnybrook Health Sciences Centre (Daneman); Dalla Lana School of Public Health (Brown, Schwartz), University of Toronto; Keenan Research Centre of the Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; Sinai Health System (Johnstone); Michael Garron Hospital (Leung), Toronto East Health Network, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Julie Wu
- Public Health Ontario (Langford, Chen, Daneman, Brown, Johnstone, Wu, Leung, Garber, Schwartz), Toronto, Ont.; Hotel Dieu Shaver Health and Rehabilitation Centre (Langford), St. Catharines, Ont.; ICES Central (Chen, Gomes, Schwartz); Sunnybrook Health Sciences Centre (Daneman); Dalla Lana School of Public Health (Brown, Schwartz), University of Toronto; Keenan Research Centre of the Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; Sinai Health System (Johnstone); Michael Garron Hospital (Leung), Toronto East Health Network, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Valerie Leung
- Public Health Ontario (Langford, Chen, Daneman, Brown, Johnstone, Wu, Leung, Garber, Schwartz), Toronto, Ont.; Hotel Dieu Shaver Health and Rehabilitation Centre (Langford), St. Catharines, Ont.; ICES Central (Chen, Gomes, Schwartz); Sunnybrook Health Sciences Centre (Daneman); Dalla Lana School of Public Health (Brown, Schwartz), University of Toronto; Keenan Research Centre of the Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; Sinai Health System (Johnstone); Michael Garron Hospital (Leung), Toronto East Health Network, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Gary Garber
- Public Health Ontario (Langford, Chen, Daneman, Brown, Johnstone, Wu, Leung, Garber, Schwartz), Toronto, Ont.; Hotel Dieu Shaver Health and Rehabilitation Centre (Langford), St. Catharines, Ont.; ICES Central (Chen, Gomes, Schwartz); Sunnybrook Health Sciences Centre (Daneman); Dalla Lana School of Public Health (Brown, Schwartz), University of Toronto; Keenan Research Centre of the Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; Sinai Health System (Johnstone); Michael Garron Hospital (Leung), Toronto East Health Network, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Kevin L Schwartz
- Public Health Ontario (Langford, Chen, Daneman, Brown, Johnstone, Wu, Leung, Garber, Schwartz), Toronto, Ont.; Hotel Dieu Shaver Health and Rehabilitation Centre (Langford), St. Catharines, Ont.; ICES Central (Chen, Gomes, Schwartz); Sunnybrook Health Sciences Centre (Daneman); Dalla Lana School of Public Health (Brown, Schwartz), University of Toronto; Keenan Research Centre of the Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; Sinai Health System (Johnstone); Michael Garron Hospital (Leung), Toronto East Health Network, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
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