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Scarborough RO, Bailey KE, Sri AE, Browning GF, Hardefeldt LY. Seeking simplicity, navigating complexity: How veterinarians select an antimicrobial drug, dose, and duration for companion animals. J Vet Intern Med 2024. [PMID: 39304497 DOI: 10.1111/jvim.17197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 09/04/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Minimizing harm from antimicrobials requires use of the narrowest spectrum drug, at an effective dose for the minimum effective duration. Many prescribers are not currently following these guidelines. To address suboptimal antimicrobial use, the underlying reasons must be understood. OBJECTIVES To identify factors influencing choices of antimicrobial drug, dose, and duration for companion animals. SUBJECTS Twenty-two veterinarians treating companion animals in Australia. Diversity of participants was deliberately sought. METHODS Semistructured interviews were conducted online. Two case studies were discussed, and then a range of broader questions was posed. Transcripts were analyzed thematically, using an inductive approach. RESULTS Few participants chose guideline-concordant management for the case studies. Prescribing choices were influenced by a complex array of factors associated with the clinical case, pet owner, drug, veterinarian, veterinary colleagues, and external factors. Key factors driving broad-spectrum antimicrobial use included a sense of safety, habit, ease of administering the drug (especially in cats), pharmaceutical marketing, and the self-perpetuating dispensary cycle. Many participants were concerned about antimicrobial resistance, but insufficiently informed about how to minimize this risk. Several participants believed that longer duration of treatment and ensuring patients finish a predetermined course would decrease the risk of antimicrobial resistance and improve clinical outcomes. CONCLUSIONS AND CLINICAL IMPORTANCE Veterinarians are engaged with the concept of antimicrobial stewardship, but face numerous practical barriers and require more information. In particular, improved education is needed on enhancing patient safety by minimizing both spectrum of activity and duration of treatment, and dispelling myths about "finishing the course."
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Affiliation(s)
- Ri O Scarborough
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute of Infection and Immunity, Melbourne, Victoria, Australia
| | - Kirsten E Bailey
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute of Infection and Immunity, Melbourne, Victoria, Australia
| | - Anna Ellen Sri
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute of Infection and Immunity, Melbourne, Victoria, Australia
| | - Glenn Francis Browning
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute of Infection and Immunity, Melbourne, Victoria, Australia
| | - Laura Y Hardefeldt
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute of Infection and Immunity, Melbourne, Victoria, Australia
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Rees CE, Proctor DW, Nguyen VNB, Ottrey E, Mattick KL. Realist analysis of qualitative data in health professions education research. MEDICAL EDUCATION 2024. [PMID: 39157923 DOI: 10.1111/medu.15482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/29/2024] [Accepted: 07/09/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Qualitative realist analysis is gaining in popularity in health professions education research (HPER) as part of theory-driven program evaluation. Although realist approaches such as syntheses and evaluations typically advocate mixed methods, qualitative data dominate currently. Various forms of qualitative analysis have been articulated in HPER, yet realist analysis has not. Although realist analysis is interpretive, it moves beyond description to explain generative causation employing retroductive theorising. Ultimately, it attempts to build and/or 'test' (confirm, refute or refine) theory about how, why, for whom, when and to what extent programs work using the context-mechanism-outcome configuration (CMOC) heuristic. This paper aims to help readers better critique, conduct and report qualitative realist analysis. REALIST ANALYSIS METHODS We describe four fundamentals of qualitative realist analysis: (1) simultaneous data collection/analysis; (2) retroductive theorising; (3) configurational analysis (involving iterative phases of identifying CMOCs, synthesising CMOCs into demi-regularities and translating demi-regularities into program theory); and (4) realist analysis quality (relevance, rigour, richness). Next, we provide a critical analysis of realist analyses employed in 15 HPER outputs-three evaluations and 12 syntheses. Finally, drawing on our understandings of realist literature and our experiences of conducting qualitative realist analysis (both evaluations and syntheses), we articulate three common analysis challenges (coding, consolidation and mapping) and strategies to mitigate these challenges (teamwork, reflexivity and consultation, use of data analysis software and graphical representations of program theory). CONCLUSIONS Based on our critical analysis of the literature and realist analysis experiences, we encourage researchers, peer reviewers and readers to better understand qualitative realist analysis fundamentals. Realist analysts should draw on relevant realist reporting standards and literature on realist analysis to improve the quality and reporting of realist analysis. Through better understanding the common challenges and mitigation strategies for realist analysis, we can collectively improve the quality of realist analysis in HPER.
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Affiliation(s)
- Charlotte E Rees
- School of Health Sciences, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Monash Centre for Scholarship in Health Education (MCSHE), Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | | | - Van N B Nguyen
- Monash Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Ella Ottrey
- Monash Centre for Scholarship in Health Education (MCSHE), Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Karen L Mattick
- University of Exeter Medical School, University of Exeter, Exeter, UK
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Fitzgerald I, Sahm LJ, Howe J, Maidment I, Wallace E, Crowley EK. Shared decision-making interventions in the choice of antipsychotic prescription in people living with psychosis (SHAPE): Protocol for a realist review. PLoS One 2024; 19:e0304626. [PMID: 39052681 PMCID: PMC11271866 DOI: 10.1371/journal.pone.0304626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 05/14/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Shared decision-making (SDM) has yet to be successfully adopted into routine use in psychiatric settings amongst people living with severe mental illnesses. Suboptimal rates of SDM are particularly prominent amongst patients with psychotic illnesses during antipsychotic treatment choices. Many interventions have been assessed for their efficacy in improving SDM within this context, although results have been variable and inconsistent. AIMS To generate an in-depth understanding of how, why, for whom, and to what extent interventions facilitating the application of SDM during antipsychotic treatment choices work and the impact of contextual factors on intervention effectiveness. METHODS This review will use realist review methodology to provide a causal understanding of how and why interventions work when implementing SDM during antipsychotic treatment choices. The cohort of interest will be those experiencing psychosis where ongoing treatment with an antipsychotic is clinically indicated. The review will take place over five stages; (1) Locating existing theories, (2) Searching for evidence, (3) Selecting articles, (4) Extracting and organising data and (5) Synthesizing evidence and drawing conclusions. An understanding of how and why interventions work will be achieved by developing realist programme theories on intervention effectiveness through iterative literature reviews and engaging with various stakeholder groups, including patient, clinician and carer representatives. DISCUSSION This is the first realist review aiming to identify generative mechanisms explaining how and why successful interventions aimed at improving SDM within the parameters outlined work and in which contexts desired outcomes are most likely to be achieved. Review findings will include suggestions for clinicians, policy and decision-makers about the most promising interventions to pursue and their ideal attributes.
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Affiliation(s)
- Ita Fitzgerald
- Pharmacy Department, St Patrick’s Mental Health Services, Dublin, Ireland
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - Laura J. Sahm
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
- Pharmacy Department, Mercy University Hospital, Cork, Ireland
| | - Jo Howe
- School of Pharmacy, College of Health and Life Sciences, Aston University, Birmingham, United Kingdom
| | - Ian Maidment
- School of Pharmacy, College of Health and Life Sciences, Aston University, Birmingham, United Kingdom
| | - Emma Wallace
- Department of General Practice, School of Medicine, University College Cork, Cork, Ireland
| | - Erin K. Crowley
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
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4
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Lansink C, Sinha B, Meessen N, Dekkers T, Beerlage-de Jong N. Why Do Physicians Prescribe Antibiotics? A Systematic Review of the Psycho-Socio-Organisational Factors Related to Potentially Inappropriate Prescribing of Antimicrobials in Europe. Infect Dis Rep 2024; 16:664-683. [PMID: 39195002 DOI: 10.3390/idr16040051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/29/2024] Open
Abstract
Purpose: Effective antimicrobial use enhances care quality and combats antibiotic resistance. Yet, non-guideline factors influence potentially inappropriate prescribing. This study explores psycho-socio-organisational factors in antimicrobial prescribing as perceived by physicians across primary, secondary, and tertiary care. Methods: Adhering to PRISMA guidelines, a systematic review was conducted using PubMed and Scopus databases from 1 January 2000, to 8 March 2023, with an update search until 30 January 2024. Inclusion criteria focused on studies in Europe exploring psycho-socio-organisational factors for antibiotic prescribing from physicians' perspectives in hospital, inpatient, or primary care settings. Exclusion criteria targeted out-of-office prescriptions or low-quality studies. To evaluate the latter, several quality and risk-of-bias checklists were used. Data were extracted on study characteristics, study design, and methods and identified determinants of antibiotic prescribing. Data was analysed using a narrative synthesis method. Results: Among 8370 articles, 58 met inclusion criteria, yielding 35 articles from 23 countries. Three main themes emerged: personal, psychological, and organisational factors, encompassing seven determinants including work experience, knowledge, guideline adherence, uncertainty management, perceived pressure, time constraints, and diagnostic resource availability. Uncertainty management was key, with work experience and knowledge mitigating it. No additional factors emerged in the updated search. Conclusion: Enhanced uncertainty management decreases perceived patient and/or parental pressure to prescribe antibiotics, contributing to reducing potentially inappropriate prescribing (PIP). Therefore, it is imperative to educate physicians on effectively managing uncertainty. Interventions to improve antibiotic prescribing should be tailored to the specific needs and preferences of the different prescribing physicians.
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Affiliation(s)
- Chiara Lansink
- Section of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
| | - Bhanu Sinha
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Nico Meessen
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Tessa Dekkers
- Section of Psychology, Health and Technology, Centre for eHealth and Wellbeing Research, University of Twente, 7500 AE Enschede, The Netherlands
| | - Nienke Beerlage-de Jong
- Section of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
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Yamaki J, Mikhail M, Beuttler R, Robinson P, Yücel E, Watanabe AH. Characterizing Antibiotic Regimen Modification Behavior, Patient Characteristics, and Outcomes for Patients with Gram-Negative Bacterial Infections, A Retrospective Single-Center Study. Antibiotics (Basel) 2024; 13:302. [PMID: 38666978 PMCID: PMC11047705 DOI: 10.3390/antibiotics13040302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/22/2024] [Accepted: 03/24/2024] [Indexed: 04/29/2024] Open
Abstract
Few studies describe the frequency of antibiotic regimen modification behaviors in the acute care setting. We sought to ascertain patient and treatment characteristics, details of regimen modification, and clinical outcomes with antibiotic modifications. This retrospective study included patients admitted to Hoag Memorial Hospital from 1 January 2019-31 March 2021 with a complicated infection caused by a Gram-negative organism resistant to extended-spectrum cephalosporins or with the potential for resistance (AmpC producers). A total of 400 patients were included. The predominant sources were bloodstream (33%), urine (26%), and respiratory (24%), including patients with multiple sources. The most isolated organisms were Pseudomonas spp. and ESBL-producing organisms, 38% and 34%, respectively. A total of 72% of patients had antibiotic regimen modifications to their inpatient antibiotic regimens. In patients where modifications occurred, the number ranged from one to six modifications. The most common reasons for modifications included a lack of patient response (14%), additional history reviewed (9%), and decompensation (7%). No difference in clinical outcomes was observed based on antibiotic modifications. The numerous changes in therapy observed may reflect the limitations in identifying patients with resistant organisms early on in admission. This highlights the need for more novel antibiotics and the importance of identifying patients at risk for resistant organisms.
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Affiliation(s)
- Jason Yamaki
- Department of Pharmacy Practice, Chapman University School of Pharmacy (CUSP), Irvine, CA 92618, USA; (M.M.); (R.B.)
- Hoag Memorial Hospital, Newport Beach, CA 92663, USA;
| | - Mirna Mikhail
- Department of Pharmacy Practice, Chapman University School of Pharmacy (CUSP), Irvine, CA 92618, USA; (M.M.); (R.B.)
| | - Richard Beuttler
- Department of Pharmacy Practice, Chapman University School of Pharmacy (CUSP), Irvine, CA 92618, USA; (M.M.); (R.B.)
| | | | - Emre Yücel
- Merck & Co., Inc., Rahway, NJ 07065, USA (A.H.W.)
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Howe J, MacPhee M, Duddy C, Habib H, Wong G, Jacklin S, Oduola S, Upthegrove R, Carlish M, Allen K, Patterson E, Maidment I. A realist review of medication optimisation of community dwelling service users with serious mental illness. BMJ Qual Saf 2023:bmjqs-2023-016615. [PMID: 38071586 DOI: 10.1136/bmjqs-2023-016615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/14/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI. OBJECTIVE Published literature and two stakeholder groups were employed to answer: What works for whom and in what circumstances to optimise medication use with people living with SMI in the community? METHODS A five-stage realist review was co-conducted with a lived experience group of individuals living with SMI and a practitioner group caring for individuals with SMI. An initial programme theory was developed. A formal literature search was conducted across eight bibliographic databases, and literature were screened for relevance to programme theory refinement. In total 60 papers contributed to the review. 42 papers were from the original database search with 18 papers identified from additional database searches and citation searches conducted based on stakeholder recommendations. RESULTS Our programme theory represents a continuum from a service user's initial diagnosis of SMI to therapeutic alliance development with practitioners, followed by mutual exchange of information, shared decision-making and medication optimisation. Accompanying the programme theory are 11 context-mechanism-outcome configurations that propose evidence-informed contextual factors and mechanisms that either facilitate or impede medication optimisation. Two mid-range theories highlighted in this review are supported decision-making and trust formation. CONCLUSIONS Supported decision-making and trust are foundational to overcoming stigma and establishing 'safety' and comfort between service users and practitioners. Avenues for future research include the influence of stigma and equity across cultural and ethnic groups with individuals with SMI; and use of trained supports, such as peer support workers. PROSPERO REGISTRATION NUMBER CRD42021280980.
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Affiliation(s)
- Jo Howe
- Pharmacy School, College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Maura MacPhee
- School of Nursing, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Claire Duddy
- Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hafsah Habib
- Pharmacy School, Aston University College of Health and Life Sciences, Birmingham, UK
| | - Geoff Wong
- Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon Jacklin
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
| | - Sheri Oduola
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Rachel Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK
- Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Max Carlish
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Katherine Allen
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Emma Patterson
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Ian Maidment
- Pharmacy School, College of Health and Life Sciences, Aston University, Birmingham, UK
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Mattick K, Goulding A, Carrieri D, Brennan N, Burford B, Vance G, Dornan T. Constraints and affordances for UK doctors-in-training to exercise agency: A dialogical analysis. MEDICAL EDUCATION 2023; 57:1198-1209. [PMID: 37293699 DOI: 10.1111/medu.15150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/09/2023] [Accepted: 05/26/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION The goal of medical education is to develop clinicians who have sufficient agency (capacity to act) to practise effectively in clinical workplaces and to learn from work throughout their careers. Little research has focused on experiences of organisational structures and the role of these in constraining or affording agency. The aim of this study was to identify priorities for organisational change, by identifying and analysing key moments of agency described by doctors-in-training. METHODS This was a secondary qualitative analysis of data from a large national mixed methods research programme, which examined the work and wellbeing of UK doctors-in-training. Using a dialogical approach, we identified 56 key moments of agency within the transcripts of 22 semi-structured interviews with doctors based across the UK in their first year after graduation. By analysing action within the key moments from a sociocultural theoretical perspective, we identified tangible changes that healthcare organisations can make to afford agency. RESULTS When talking about team working, participants gave specific descriptions of agency (or lack thereof) and used adversarial metaphors, but when talking about the wider healthcare system, their dialogue was disengaged and they appeared resigned to having no agency to shape the agenda. Organisational changes that could afford greater agency to doctors-in-training were improving induction, smoothing peaks and troughs of responsibility and providing a means of timely feedback on patient care. CONCLUSIONS Our findings identified some organisational changes needed for doctors-in-training to practise effectively and learn from work. The findings also highlight a need to improve workplace-based team dynamics and empower trainees to influence policy. By targeting change, healthcare organisations can better support doctors-in-training, which will ultimately benefit patients.
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Affiliation(s)
- Karen Mattick
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Anna Goulding
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Daniele Carrieri
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research, Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Bryan Burford
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Gillian Vance
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Tim Dornan
- Centre for Medical Education, Queen's University Belfast, Belfast, UK
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Chadborn T, Williams S, Jorgensen T, Price C, Buckel A, Altieri E. An approach for embedding behavioural science in antimicrobial resistance One Health research. J Infect Public Health 2023; 16 Suppl 1:134-140. [PMID: 37973498 DOI: 10.1016/j.jiph.2023.11.001] [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: 10/04/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023] Open
Abstract
Antimicrobial Resistance (AMR) is a global health emergency that threatens modern medicine and incurs great cost to human health. The World Health Organization as part of a quadripartite joint initiative with the Food and Agriculture Organization of the United Nations, World Organisation for Animal Health, and United Nations Environment Programme, has recently published a One Health Priority Research Agenda for AMR. In this article we present a multidisciplinary approach, proposed by behavioural science experts, One Health experts and AMR experts to support the implementation of the Priority Research Agenda. We review, using specific examples of complex interventions designed to tackle AMR in which behavioural science has been embedded, five main steps: Define - what behaviours are a priority in each context; Diagnose - What are the barriers and enablers to the behaviours prioritised? Design - what interventions exist and what new or enhanced interventions could work to tackle the barriers identified? and, Implement and Evaluate the intervention(s). The approach presented will be useful for funders and researchers who wish to incorporate methods, frameworks and insights from the behavioural sciences into research plans, proposals and protocols in relation to a multisectoral One Health agenda and produce findings that are more relevant to policymakers.
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Affiliation(s)
- Tim Chadborn
- Behavioural Insights Unit, World Health Organization (WHO), Switzerland.
| | - Simon Williams
- Behavioural Insights Unit, World Health Organization (WHO), Switzerland
| | - Tine Jorgensen
- AMR Unit, Communicable Diseases and Environment Division, World Health Organization (WHO EURO), Switzerland
| | - Cortney Price
- Office of Innovation (OIN), Food and Agriculture Organization of the United Nations (FAO), Kenya
| | - Anica Buckel
- Food and Agriculture Organization of the United Nations (FAO), Nairobi, Kenya
| | - Elena Altieri
- Behavioural Insights Unit, World Health Organization (WHO), Switzerland
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Graells T, Lambraki IA, Cousins M, Léger A, Henriksson PJG, Troell M, Carson CA, Parmley EJ, Majowicz SE, Wernli D, Jørgensen PS. Exploring the factors that contribute to the successful implementation of antimicrobial resistance interventions: a comparison of high-income and low-middle-income countries. Front Public Health 2023; 11:1230848. [PMID: 37900049 PMCID: PMC10612146 DOI: 10.3389/fpubh.2023.1230848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/13/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a challenge to modern medicine. Interventions have been applied worldwide to tackle AMR, but these actions are often not reported to peers or published, leading to important knowledge gaps about what actions are being taken. Understanding factors that influence the implementation of AMR interventions and what factors are relevant in low-middle-income countries (LMICs) and high-income countries (HICs) were the key objectives of this exploratory study, with the aim to identifying which priorities these contexts need. Methods A questionnaire was used to explore context, characteristics, and success factors or obstacles to intervention success based on participant input. The context was analyzed using the AMR-Intervene framework, and success factors and obstacles to intervention success were identified using thematic analysis. Results Of the 77 interventions, 57 were implemented in HICs and 17 in LMICs. Interventions took place in the animal sector, followed by the human sector. Public organizations were mainly responsible for implementation and funding. Nine themes and 32 sub-themes emerged as important for intervention success. The themes most frequently reported were 'behavior', 'capacity and resources', 'planning', and 'information'. Five sub-themes were key in all contexts ('collaboration and coordination', 'implementation', 'assessment', 'governance', and 'awareness'), two were key in LMICs ('funding and finances' and 'surveillance, antimicrobial susceptibility testing and preventive screening'), and five were key in HICs ('mandatory', 'multiple profiles', 'personnel', 'management', and 'design'). Conclusion LMIC sub-themes showed that funding and surveillance were still key issues for interventions, while important HIC sub-themes were more specific and detailed, including mandatory enforcement, multiple profiles, and personnel needed for good management and good design. While behavior is often underrated when implementing AMR interventions, capacity and resources are usually considered, and LMICs can benefit from sub-themes captured in HICs if tailored to their contexts. The factors identified can improve the design, planning, implementation, and evaluation of interventions.
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Affiliation(s)
- Tiscar Graells
- Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
| | - Irene A. Lambraki
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Melanie Cousins
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Anaïs Léger
- Global Studies Institute, University of Geneva, Genève, Switzerland
| | - Patrik J. G. Henriksson
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
- Beijer Institute of Ecological Economics, Royal Swedish Academy of Sciences, Stockholm, Sweden
- WorldFish, Penang, Malaysia
| | - Max Troell
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
- Beijer Institute of Ecological Economics, Royal Swedish Academy of Sciences, Stockholm, Sweden
| | - Carolee A. Carson
- Centre for Foodborne, Environmental and Zoonotic Infectious Diseases; Public Health Agency of Canada, Guelph, ON, Canada
| | - Elizabeth Jane Parmley
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Shannon E. Majowicz
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Didier Wernli
- Global Studies Institute, University of Geneva, Genève, Switzerland
| | - Peter Søgaard Jørgensen
- Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden
- Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden
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Lee S, Datta R. Frontiers in antimicrobial stewardship: antimicrobial use during end-of-life care. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e164. [PMID: 38028928 PMCID: PMC10644156 DOI: 10.1017/ash.2023.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Seohyuk Lee
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rupak Datta
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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McIntyre MT, Saha S, Morris AM, Lapointe-Shaw L, Tang T, Weinerman A, Fralick M, Agarwal A, Verma A, Razak F. Physician antimicrobial prescribing and patient outcomes on general medical wards: a multicentre retrospective cohort study. CMAJ 2023; 195:E1065-E1074. [PMID: 37604522 PMCID: PMC10442238 DOI: 10.1503/cmaj.221732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Variability in antimicrobial prescribing may indicate an opportunity for improvement in antimicrobial use. We sought to measure physician-level antimicrobial prescribing in adult general medical wards, assess the contribution of patient-level factors to antimicrobial prescribing and evaluate the association between antimicrobial prescribing and clinical outcomes. METHODS Using the General Medicine Inpatient Initiative (GEMINI) database, we conducted a retrospective cohort study of physician-level volume and spectrum of antimicrobial prescribing in adult general medical wards in 4 academic teaching hospitals in Toronto, Ontario, between April 2010 and December 2019. We stratified physicians into quartiles by hospital site based on volume of antimicrobial prescribing (days of therapy per 100 patient-days and antimicrobial-free days) and antibacterial spectrum (modified spectrum score). The modified spectrum score assigns a value to each antibacterial agent based on the breadth of coverage. We assessed patient-level differences among physician quartiles using age, sex, Laboratory-based Acute Physiology Score, discharge diagnosis and Charlson Comorbidity Index. We evaluated the association of clinical outcomes (in-hospital 30-day mortality, length of stay, intensive care unit [ICU] transfer and hospital readmission) with antimicrobial volume and spectrum using multilevel modelling. RESULTS The cohort consisted of 124 physicians responsible for 124 158 hospital admissions. The median physician-level volume of antimicrobial prescribing was 56.1 (interquartile range 51.7-67.5) days of therapy per 100 patient-days. We did not find any differences in baseline patient characteristics by physician prescribing quartile. The difference in mean prescribing between quartile 4 and quartile 1 was 15.8 days of therapy per 100 patient-days (95% confidence interval [CI] 9.6-22.0), representing 30% higher antimicrobial prescribing in the fourth quartile than the first quartile. Patient in-hospital deaths, length of stay, ICU transfer and hospital readmission did not differ by physician quartile. In-hospital mortality was higher among patients cared for by prescribers with higher modified spectrum scores (odds ratio 1.13, 95% CI 1.04-1.24). INTERPRETATION We found that physician-level variability in antimicrobial prescribing was not associated with differences in patient characteristics or outcomes in academic general medicine wards. These findings provide support for considering the lowest quartile of physician antimicrobial prescribing within each hospital as a target for antimicrobial stewardship.
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Affiliation(s)
- Mark T McIntyre
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont.
| | - Sudipta Saha
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Andrew M Morris
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Lauren Lapointe-Shaw
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Terence Tang
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Adina Weinerman
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Michael Fralick
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Arnav Agarwal
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Amol Verma
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Fahad Razak
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
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12
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Goedegebuur J, Abbel D, Accassat S, Achterberg WP, Akbari A, Arfuch VM, Baddeley E, Bax JJ, Becker D, Bergmeijer B, Bertoletti L, Blom JW, Calvetti A, Cannegieter SC, Castro L, Chavannes NH, Coma-Auli N, Couffignal C, Edwards A, Edwards M, Enggaard H, Font C, Gava A, Geersing GJ, Geijteman ECT, Greenley S, Gregory C, Gussekloo J, Hoffmann I, Højen AA, van den Hout WB, Huisman MV, Jacobsen S, Jagosh J, Johnson MJ, Jørgensen L, Juffermans CCM, Kempers EK, Konstantinides S, Kroder AF, Kruip MJHA, Lafaie L, Langendoen JW, Larsen TB, Lifford K, van der Linden YM, Mahé I, Maiorana L, Maraveyas A, Martens ESL, Mayeur D, van Mens TE, Mohr K, Mooijaart SP, Murtagh FEM, Nelson A, Nielsen PB, Ording AG, Ørskov M, Pearson M, Poenou G, Portielje JEA, Raczkiewicz D, Rasmussen K, Trinks-Roerdink E, Schippers I, Seddon K, Sexton K, Sivell S, Skjøth F, Søgaard M, Szmit S, Trompet S, Vassal P, Visser C, van Vliet LM, Wilson E, Klok FA, Noble SIR. Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool. Thromb Res 2023; 228:54-60. [PMID: 37276718 DOI: 10.1016/j.thromres.2023.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs. METHODS The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe. RESULTS SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life. CONCLUSIONS We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.
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Affiliation(s)
- J Goedegebuur
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Abbel
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - S Accassat
- Department of Vascular and Therapeutical Medicine, University Hospital of Saint-Etienne, Saint-Étienne, France
| | - W P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - A Akbari
- Swansea University, Swansea, Wales, United Kingdom
| | - V M Arfuch
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - E Baddeley
- Cardiff University, Cardiff, United Kingdom
| | - J J Bax
- Department of Medicine - Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Becker
- University Medical Center Mainz, Mainz, Germany
| | | | - L Bertoletti
- Department of Vascular and Therapeutical Medicine, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - J W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - A Calvetti
- Assistance Publique-Hopitaux de Paris, Paris, France
| | - S C Cannegieter
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - L Castro
- Vall d'Hebron Research Institute, Barcelona, Spain
| | - N H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - N Coma-Auli
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - C Couffignal
- Hôpital Louis Mourier, APHP, Assistance Publique-Hopitaux de Paris, Paris, France
| | - A Edwards
- Cardiff University, Cardiff, United Kingdom
| | - M Edwards
- Cardiff University, Cardiff, United Kingdom
| | - H Enggaard
- Aalborg University Hospital, Aalborg, Denmark
| | - C Font
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - A Gava
- Societa per l'Assistenza al Malato Oncologico Terminale Onlus (S.A.M.O.T.) Ragusa Onlus, Ragusa, Italy
| | - G J Geersing
- Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht, the Netherlands
| | - E C T Geijteman
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - S Greenley
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - C Gregory
- Cardiff University, Cardiff, United Kingdom
| | - J Gussekloo
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - I Hoffmann
- Hôpital Bichat, APHP, Assistance Publique-Hopitaux de Paris, Paris, France
| | - A A Højen
- Aalborg University Hospital, Aalborg, Denmark
| | - W B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S Jacobsen
- Aalborg University Hospital, Aalborg, Denmark
| | - J Jagosh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - M J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - L Jørgensen
- Aalborg University Hospital, Aalborg, Denmark
| | - C C M Juffermans
- Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | - E K Kempers
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - A F Kroder
- Todaytomorrow, Rotterdam, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - L Lafaie
- Department of Geriatrics and Gerontology, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | | | - T B Larsen
- Aalborg University Hospital, Aalborg, Denmark
| | - K Lifford
- Cardiff University, Cardiff, United Kingdom
| | - Y M van der Linden
- Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands; Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - I Mahé
- Department of Innovative Therapies in Haemostasis, Hôpital Louis Mourier, APHP, Paris, France
| | - L Maiorana
- Societa per l'Assistenza al Malato Oncologico Terminale Onlus (S.A.M.O.T.) Ragusa Onlus, Ragusa, Italy
| | - A Maraveyas
- Clinical Sciences Centre Hull York Medical School University of Hull, Hull, United Kingdom
| | - E S L Martens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - D Mayeur
- Centre Georges-François Leclerc, Dijon, France
| | - T E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - K Mohr
- University Medical Center Mainz, Mainz, Germany
| | - S P Mooijaart
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - F E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - A Nelson
- Cardiff University, Cardiff, United Kingdom
| | - P B Nielsen
- Aalborg University Hospital, Aalborg, Denmark
| | - A G Ording
- Aalborg University Hospital, Aalborg, Denmark
| | - M Ørskov
- Aalborg University Hospital, Aalborg, Denmark
| | - M Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - G Poenou
- Department of Vascular and Therapeutical Medicine, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - J E A Portielje
- Department of Medicine - Internal medicine and Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Raczkiewicz
- Department of Medical Statistics, School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - K Rasmussen
- Aalborg University Hospital, Aalborg, Denmark
| | - E Trinks-Roerdink
- Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - K Seddon
- Wales Cancer Research Centre, Cardiff, UK
| | - K Sexton
- Cardiff University, Cardiff, United Kingdom
| | - S Sivell
- Cardiff University, Cardiff, United Kingdom
| | - F Skjøth
- Aalborg University Hospital, Aalborg, Denmark
| | - M Søgaard
- Aalborg University Hospital, Aalborg, Denmark
| | - S Szmit
- Department of Cardio-Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - S Trompet
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - P Vassal
- Department of Vascular and Therapeutical Medicine, University Hospital of Saint-Etienne, Saint-Étienne, France
| | - C Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - L M van Vliet
- Department of Health, Medicine and Neuropsychology, Leiden University, Leiden, the Netherlands
| | - E Wilson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Turner R, Hart J, Ashiru-Oredope D, Atkins L, Eades C, Felton T, Howlett E, Rice S, Shallcross L, Lorencatto F, Byrne-Davis L. A qualitative interview study applying the COM-B model to explore how hospital-based trainers implement antimicrobial stewardship education and training in UK hospital-based care. BMC Health Serv Res 2023; 23:770. [PMID: 37468860 DOI: 10.1186/s12913-023-09559-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/16/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a major global health threat caused by the inappropriate use of antimicrobials in healthcare and other settings. Antimicrobial stewardship (AMS) is a broad multi-component health services intervention that promotes and monitors the judicious use of antimicrobials to preserve their future effectiveness. A main component of AMS is education and training (E&T). However, there are often discrepancies in how such interventions are implemented and delivered in hospital-based care. The aim of this study was to explore the factors influencing the implementation of AMS E&T in UK hospitals. METHODS Semi-structured interviews were carried out with AMS E&T trainers in UK hospitals. The interview schedule was developed using the Capability, Opportunity, Motivation = Behaviour (COM-B) model. Participants were identified via professional networks and social media. Interviews were analysed using inductive thematic analysis, followed by deductive analysis using the COM-B model as a framework. RESULTS A total of 34 participants (26 antimicrobial pharmacists, 3 nurses, 1 advanced clinical practitioner, 2 infectious disease consultants, 1 microbiologist and 1 clinical scientist). responsible for designing, implementing and evaluating AMS E&T in UK hospitals (five from Northern Ireland, four from Wales, two from Scotland and 23 from England) took part in virtual interviews. Key themes were: (1) The organisational context, including system-level barriers to AMS included competing organisational targets (Reflective motivation and physical opportunity) and the impact of the COVID-19 pandemic on activity (Physical opportunity); (2) Healthcare professionals' roles and the wider multi-disciplinary team, such that AMS roles were defined and addressed poorly in E&T (Social opportunity); and (3) The individual perception of the need for AMS E&T in hospital-based care, manifest in a perceived lack of conviction of the wider threat of AMR and the resulting need for AMS E&T (Reflective motivation). CONCLUSION This study has identified factors influencing implementation of AMS E&T in UK hospitals and further identified where implemented, AMS E&T did not address real-world challenges. Current AMS E&T needs to be optimised to elicit practice change, with recommendations including training and engaging the wider work-force and drawing upon theoretically-informed intervention development frameworks to inform AMS E&T to better target AMS behaviour change.
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Affiliation(s)
- Rebecca Turner
- Division of Psychology and Mental Health, Faculty of Biology, Medicine & Health, the University of Manchester, Manchester, UK.
| | - Jo Hart
- Division of Medical Education, Faculty of Biology, Medicine & Health, the University of Manchester, Manchester, UK
| | | | - Lou Atkins
- Centre for Behaviour Change, University College London, London, UK
| | - Christopher Eades
- Department of Infectious Diseases, Manchester University NHS Foundation Trust, Manchester, UK
| | - Tim Felton
- Department of Critical Care Medicine, Wythenshawe Hospital, Manchester University NHS Foundation, Manchester, UK
| | - Emily Howlett
- Vocal, Manchester University NHS Foundation Trust, Manchester, UK
| | - Stephen Rice
- Population Health Sciences Institute, Faculty of Medical Sciences, the University of Newcastle Upon, Tyne, UK
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London, UK
| | | | - Lucie Byrne-Davis
- Division of Medical Education, Faculty of Biology, Medicine & Health, the University of Manchester, Manchester, UK
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Jager A, Wong G, Papoutsi C, Roberts N. The usage of data in NHS primary care commissioning: a realist review. BMC Med 2023; 21:236. [PMID: 37400837 DOI: 10.1186/s12916-023-02949-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/19/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Primary care has been described as the 'bedrock' of the National Health Service (NHS) accounting for approximately 90% of patient contacts but is facing significant challenges. Against a backdrop of a rapidly ageing population with increasingly complex health challenges, policy-makers have encouraged primary care commissioners to increase the usage of data when making commissioning decisions. Purported benefits include cost savings and improved population health. However, research on evidence-based commissioning has concluded that commissioners work in complex environments and that closer attention should be paid to the interplay of contextual factors and evidence use. The aim of this review was to understand how and why primary care commissioners use data to inform their decision making, what outcomes this leads to, and understand what factors or contexts promote and inhibit their usage of data. METHODS We developed initial programme theory by identifying barriers and facilitators to using data to inform primary care commissioning based on the findings of an exploratory literature search and discussions with programme implementers. We then located a range of diverse studies by searching seven databases as well as grey literature. Using a realist approach, which has an explanatory rather than a judgemental focus, we identified recurrent patterns of outcomes and their associated contexts and mechanisms related to data usage in primary care commissioning to form context-mechanism-outcome (CMO) configurations. We then developed a revised and refined programme theory. RESULTS Ninety-two studies met the inclusion criteria, informing the development of 30 CMOs. Primary care commissioners work in complex and demanding environments, and the usage of data are promoted and inhibited by a wide range of contexts including specific commissioning activities, commissioners' perceptions and skillsets, their relationships with external providers of data (analysis), and the characteristics of data themselves. Data are used by commissioners not only as a source of evidence but also as a tool for stimulating commissioning improvements and as a warrant for convincing others about decisions commissioners wish to make. Despite being well-intentioned users of data, commissioners face considerable challenges when trying to use them, and have developed a range of strategies to deal with 'imperfect' data. CONCLUSIONS There are still considerable barriers to using data in certain contexts. Understanding and addressing these will be key in light of the government's ongoing commitments to using data to inform policy-making, as well as increasing integrated commissioning.
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Affiliation(s)
- Alexandra Jager
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, Medical Sciences, University of Oxford, Oxford, UK
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Rynkiewich K, Gole S, Won S, Schwartz DN. Cultures of antibiotic prescribing in medical intensive care. Soc Sci Med 2023; 324:115834. [PMID: 37003024 DOI: 10.1016/j.socscimed.2023.115834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 04/03/2023]
Abstract
Antimicrobial resistance (AMR) continues to present a challenge to international healthcare systems and structures of public health. The focus on optimizing antibiotic prescribing in human populations has challenged healthcare systems charged with making responsible their physician-prescribers. In the United States, physicians in almost every specialty and role use antibiotics as part of their therapeutic armamentariums. In United States hospitals, most patients are administered antibiotics during their stay. Therefore, antibiotic prescribing and utilization is a commonly accepted part of medical practice. In this paper, we utilize social science work on antibiotic prescribing to examine a critical space of care in United States hospital settings. From March to August 2018, we used ethnographic methods to study hospital-based medical intensive care unit physicians at the offices and hospital floors they frequent in two urban United States teaching hospitals. We focused on eliciting the interactions and discussions surrounding antibiotic decision-making that are uniquely influenced by the context of medical intensive care units. We argue that antibiotic use in the medical intensive care units under study was shaped by urgency, hierarchy, and uncertainty representative of the medical intensive care unit's role within the larger hospital system. We conclude that by studying the culture of antibiotic prescribing in medical intensive care units, we can see more clearly both the vulnerability of the looming antimicrobial resistance crisis and by contrast the perceived insignificance of stewarding antibiotic use when considered alongside the fragility of life amidst acute medical concerns regularly experienced in the unit.
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Affiliation(s)
| | - Sarin Gole
- Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, NB5, Cleveland, OH 44195, USA
| | - Sarah Won
- Department of Internal Medicine, Rush Medical College, USA
| | - David N Schwartz
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, USA
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Owens R, Bamford K, Pinion S, Garry E, Cranmer E, Pearce C, Wint HH, Gill S, Philips R, Khan A, Roy Bentley S, Roberts N, Keating B, Askaroff N, Morphew M, Orr C, Mouket T, Pope K, Powell N. Assessment of the appropriateness of antibiotic prescribing in an acute UK hospital using a national audit tool: a single centre retrospective survey. Eur J Hosp Pharm 2023:ejhpharm-2022-003569. [PMID: 37117009 DOI: 10.1136/ejhpharm-2022-003569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/28/2023] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION Antibiotic use drives antibiotic resistance. The UK antimicrobial resistance (AMR) strategy aims to reduce antibiotic use. We aimed to quantify excess antibiotic use in a district general hospital in south-west England. METHODS Medical patients discharged in August 2020 who had received antibiotics were included. An audit tool of antibiotic prescribing appropriateness was used to collect relevant clinical information regarding each patient case. The appropriateness of antibiotic use was then determined by two infection specialists and excess days of therapy (DOTs) calculated. RESULTS 647 patients were discharged in August 2020. Of the 1658 antibiotic DOTs for the 184 patients reviewed, 403 (24%) were excess DOTs. The excess antibiotic DOTs were prescribed in 92 patients (50%); 112/403 (27.8%) excess DOTs originated at the initiation of antibiotic therapy (time point A); 184/403 (45.7%) of excess DOTs occurred at the antibiotic review pre-72 hours (time point B); and 107/403 (26.6%) of excess DOTs were due to protracted antibiotic courses (time point C). CONCLUSION 24% of antibiotic DOTs were deemed unnecessary. The greatest opportunity to reduce antibiotic use safely was the pre-72 hours antibiotic review, which may provide a target for reducing excess antimicrobial therapy in line with the national AMR strategy.
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Affiliation(s)
- Rhys Owens
- Emergency Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Kathy Bamford
- Medical Microbiology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Sophie Pinion
- Anaesthetics, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Emma Garry
- Department of Obstetrics and Gynaecology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Emily Cranmer
- Eldercare, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Catharine Pearce
- Respiratory department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Htet Htet Wint
- Neurology department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Simon Gill
- Respiratory department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Ryan Philips
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Adnan Khan
- Eldercare, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Selina Roy Bentley
- Enhanced Perioperative Care Unit, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Neil Roberts
- University Hositals Plymouth NHS Trust, Plymouth, UK
| | | | - Natasha Askaroff
- Oncology Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Megan Morphew
- Oncology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Charles Orr
- Emergency Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Tarek Mouket
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Katherine Pope
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospital NHS Trust, Cornwall, UK
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Duddy C, Wong G. Grand rounds in methodology: when are realist reviews useful, and what does a 'good' realist review look like? BMJ Qual Saf 2023; 32:173-180. [PMID: 36585019 DOI: 10.1136/bmjqs-2022-015236] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/07/2022] [Indexed: 01/01/2023]
Abstract
Research in the quality and safety field often necessitates an approach that supports the development of an in-depth understanding of how a complex phenomenon occurs, or how an intervention works. Realist review is an increasingly popular form of evidence synthesis that provides a theory-driven, interpretive approach to secondary research. Realist reviews offer quality and safety researchers the opportunity to draw on diverse types of evidence to develop explanatory theory about how, when and for whom interventions 'work' or outcomes occur. The approach is flexible, iterative and practical, typically drawing on the experience of policymakers, practitioners and patients throughout the review. With the increasing use of realist reviews, some common misconceptions about the approach have become evident in the literature. This paper introduces what is involved when planning and conducting a realist review, and where the approach can offer most value, as well as outlining common challenges that researchers may face when adopting the approach, and recommended solutions. Our aim is to support researchers who are considering conducting a realist review to understand the key principles and concepts involved, and how they can go about producing high-quality work.
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Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Knowledge, Attitudes and Practice Regarding Antibiotic Prescription by Medical Interns: A Qualitative Study in Spain. Antibiotics (Basel) 2023; 12:antibiotics12030457. [PMID: 36978321 PMCID: PMC10044181 DOI: 10.3390/antibiotics12030457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Antibiotic resistance is an issue of growing importance in the public health sphere. Medical interns are of great relevance when it comes to the source of this problem. This study therefore sought to ascertain which factors influence the management of antibiotic therapy by this population, in order to pinpoint the possible causes of misprescribing habits. We conducted a qualitative study based on focus group techniques, with groups consisting of medical interns from the Santiago de Compostela Clinical University Teaching Hospital. Our study identified factors which the participants considered to be determinants of antibiotic use and their relationship with the appearance of resistance. The single most repeated factor was the influence of the attending physician’s judgement; other factors included a high healthcare burden or prescribing inertia. This stage is an opportunity to correct misprescribing habits, by implementing educational interventions aimed at modifying the identified factors.
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Noble C, Mattick K. From health advocacy to collective action. MEDICAL EDUCATION 2023. [PMID: 36760185 DOI: 10.1111/medu.15029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Christy Noble
- Academy for Medical Education, Medical School, The University of Queensland, Brisbane, Queensland, Australia
| | - Karen Mattick
- Department of Health and Community Sciences, Medical School, University of Exeter, Exeter, UK
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20
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Calvo-Villamañán A, San Millán Á, Carrilero L. Tackling AMR from a multidisciplinary perspective: a primer from education and psychology. Int Microbiol 2023; 26:1-9. [PMID: 36224500 PMCID: PMC9556281 DOI: 10.1007/s10123-022-00278-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 09/06/2022] [Accepted: 09/12/2022] [Indexed: 01/06/2023]
Abstract
Antimicrobial resistance (AMR) is currently one of the most concerning threats in public health. The efforts to tackle the problem require a global One Health approach, using multidisciplinary approaches and a thorough understanding of the topic both by the general public and the experts. Currently, the lack of a shared mental model of the problem, the absence of a sense of responsibility amongst the different actors and a deficient education on the topic burden the efforts to slow down the emergency and spread of antimicrobial resistant infections. We here propose a multidisciplinary approach to tackle the AMR problem, taking into consideration not only the input from the biological and medical sciences but also the input from the social sciences. Specifically, we suggest strategies from education and psychology to increase awareness about antimicrobial resistance and to implement more effective interventions. Finally, we advocate for a comprehensive and a solidaristic model as the only solution for a problem which knows no borders. As such, political will and international cooperation will be key to achieve the desired change in antibiotic resistance trend.
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Affiliation(s)
- Alicia Calvo-Villamañán
- grid.428469.50000 0004 1794 1018Department of Microbial Biotechnology, Centro Nacional de Biotecnología–CSIC, 28049 Madrid, Spain
| | - Álvaro San Millán
- grid.428469.50000 0004 1794 1018Department of Microbial Biotechnology, Centro Nacional de Biotecnología–CSIC, 28049 Madrid, Spain
| | - Laura Carrilero
- grid.11835.3e0000 0004 1936 9262School of Biosciences, The University of Sheffield, Western Bank, Sheffield, S10 2TN UK
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21
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Chu A, Kumar A, Depoorter G, Franklin BD, McLeod M. Learning from electronic prescribing errors: a mixed methods study of junior doctors' perceptions of training and individualised feedback data. BMJ Open 2022; 12:e056221. [PMID: 36549720 PMCID: PMC9772675 DOI: 10.1136/bmjopen-2021-056221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To explore the views of junior doctors towards (1) electronic prescribing (EP) training and feedback, (2) readiness for receiving individualised feedback data about EP errors and (3) preferences for receiving and learning from EP feedback. DESIGN Explanatory sequential mixed methods study comprising quantitative survey (phase 1), followed by interviews and focus group discussions (phase 2). SETTING Three acute hospitals of a large English National Health Service organisation. PARTICIPANTS 25 of 89 foundation year 1 and 2 doctors completed the phase 1 survey; 5 participated in semi-structured interviews and 7 in a focus group in phase 2. RESULTS Foundation doctors in this mixed methods study reported that current feedback provision on EP errors was lacking or informal, and that existing EP training and resources were underused. They believed feedback about prescribing errors to be important and were keen to receive real-time, individualised EP feedback data. Feedback needed to be in manageable amounts, motivational and clearly signposting how to learn or improve. Participants wanted feedback and better training on the EP system to prevent repeating errors. In addition to individualised EP error data, they were positive about learning from general prescribing errors and aggregated EP data. However, there was a lack of consensus about how best to learn from statistical data. Potential limitations identified by participants included concern about how the data would be collected and whether it would be truly reflective of their performance. CONCLUSIONS Junior doctors would value feedback on their prescribing, and are keen to learn from EP errors, develop their clinical prescribing skills and use the EP interface effectively. We identified preferences for EP technology to enable provision of real-time data in combination with feedback to support learning and potentially reduce prescribing errors.
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Affiliation(s)
- Ann Chu
- Faculty Education Office, Imperial College London, London, UK
| | - Arika Kumar
- Department of Pharmacy, Imperial College Healthcare NHS Trust, London, UK
- UCL School of Pharmacy, London, UK
| | | | - Bryony Dean Franklin
- Department of Pharmacy, Imperial College Healthcare NHS Trust, London, UK
- UCL School of Pharmacy, London, UK
| | - Monsey McLeod
- Department of Pharmacy, Imperial College Healthcare NHS Trust, London, UK
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22
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Hidano A, Holt H, Durrance-Bagale A, Tak M, Rudge JW. Exploring why animal health practices are (not) adopted among smallholders in low and middle-income countries: a realist framework and scoping review protocol. Front Vet Sci 2022; 9:915487. [PMID: 35968008 PMCID: PMC9372438 DOI: 10.3389/fvets.2022.915487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/29/2022] [Indexed: 11/29/2022] Open
Abstract
Background Improving livestock health is considered critical to address poverty, malnutrition and food insecurity in low- and middle-income countries (LMICs). Modifications of livestock management practices is also increasingly recognized as an important strategy to mitigate global threats such as climate change and novel disease emergence. Smallholders are, however, under various constraints which prohibit them from altering health practices for livestock and little is known about how the adoption of these practices may be promoted. The proposed scoping review aims to systematically map evidence around "what practices are (not) adopted by smallholders under what circumstances, how and why?." Method and analysis We conducted initial scoping searches to broadly define types of animal health practices relevant for smallholders in LMICs and formulated search terms. A scoping review protocol was designed and registered. A systematic literature search will be conducted using electronic databases including CAB Abstract, Scopus, MEDLINE, EMBASE, and Web of Science Core Collection. Gray literature will be searched from AGRIS and Standards for Supporting Agricultural Livelihoods in Emergencies. Articles in English, pertaining to the animal health practices considered highly relevant will be considered eligible for inclusion. Articles will be screened at two stages by two independent reviewers; screening of titles, abstracts, and keywords, followed by full-article screening. The first reviewer will review 100% of the articles at both stages. The second reviewer will review a random sample of 20% of the articles at both stages. Any disagreements will be resolved using inputs from the third reviewer. A thematic analysis will be conducted to catalog contexts and mechanisms for adoption and discussed under a realist framework. Discussion Understanding of the mechanisms underlying the adoption of animal health practices by livestock smallholders in LMICs is crucial for successful implementation of interventions including those which are based on a One Health approach. This review will identify the extent of this knowledge across disciplines and inform future research priorities for the design of effective and feasible interventions which can contribute toward Sustainable Development Goal 2. Registration This protocol is registered within the Open Science Framework (https://doi.org/10.17605/OSF.IO/FUQAX).
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Affiliation(s)
- Arata Hidano
- Communicable Disease Policy Research Group, Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United kingdom
| | - Hannah Holt
- Communicable Disease Policy Research Group, Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United kingdom
- Veterinary Epidemiology, Economics and Public Health Group, Royal Veterinary College, London, United Kingdom
| | - Anna Durrance-Bagale
- Communicable Disease Policy Research Group, Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United kingdom
| | - Mehroosh Tak
- Veterinary Epidemiology, Economics and Public Health Group, Royal Veterinary College, London, United Kingdom
| | - James W. Rudge
- Communicable Disease Policy Research Group, Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United kingdom
- Faculty of Public Health, Mahidol University, Bangkok, Thailand
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23
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Tipping the balance: A systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings. PLoS One 2022; 17:e0271454. [PMID: 35857810 PMCID: PMC9299309 DOI: 10.1371/journal.pone.0271454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 07/01/2022] [Indexed: 11/19/2022] Open
Abstract
Surgical specialties account for a high proportion of antimicrobial use in hospitals, and misuse has been widely reported resulting in unnecessary patient harm and antimicrobial resistance. We aimed to synthesize qualitative studies on surgical antimicrobial prescribing behavior, in hospital settings, to explain how and why contextual factors act and interact to influence practice. Stakeholder engagement was integrated throughout to ensure consideration of varying interpretive repertoires and that the findings were clinically meaningful. The meta-ethnography followed the seven phases outlined by Noblit and Hare. Eight databases were systematically searched without date restrictions. Supplementary searches were performed including forwards and backwards citation chasing and contacting first authors of included papers to highlight further work. Following screening, 14 papers were included in the meta-ethnography. Repeated reading of this work enabled identification of 48 concepts and subsequently eight overarching concepts: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment. The overarching concepts interacted to varying degrees but there was no consensus among stakeholders regarding an order of importance. Further abstraction of the overarching concepts led to the development of a conceptual model and a line-of-argument synthesis, which posits that social and structural mediators influence individual complex antimicrobial judgements and currently skew practice towards increased and unnecessary antimicrobial use. Crucially, our model provides insights into how we might ‘tip the balance’ towards more evidence-based antimicrobial use. Currently, healthcare workers deploy antimicrobials across the surgical pathway as a safety net to allay fears, reduce uncertainty and risk, and to mitigate against personal blame. Our synthesis indicates that prescribing is unlikely to change until the social and structural mediators driving practice are addressed. Furthermore, it suggests that research specifically exploring the context for effective and sustainable quality improvement stewardship initiatives in surgery is now urgent.
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Studying Factors Affecting Success of Antimicrobial Resistance Interventions through the Lens of Experience: A Thematic Analysis. Antibiotics (Basel) 2022; 11:antibiotics11050639. [PMID: 35625282 PMCID: PMC9137464 DOI: 10.3390/antibiotics11050639] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/02/2022] [Accepted: 05/03/2022] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial resistance (AMR) affects the environment, and animal and human health. Institutions worldwide have applied various measures, some of which have reduced antimicrobial use and AMR. However, little is known about factors influencing the success of AMR interventions. To address this gap, we engaged health professionals, designers, and implementers of AMR interventions in an exploratory study to learn about their experience and factors that challenged or facilitated interventions and the context in which interventions were implemented. Based on participant input, our thematic analysis identified behaviour; institutional governance and management; and sharing and enhancing information as key factors influencing success. Important sub-themes included: correct behaviour reinforcement, financial resources, training, assessment, and awareness of AMR. Overall, interventions were located in high-income countries, the human sector, and were publicly funded and implemented. In these contexts, behaviour patterns strongly influenced success, yet are often underrated or overlooked when designing AMR interventions. Improving our understanding of what contributes to successful interventions would allow for better designs of policies that are tailored to specific contexts. Exploratory approaches can provide encouraging results in complex challenges, as made evident in our study. Remaining challenges include more engagement in this type of study by professionals and characterisation of themes that influence intervention outcomes by context.
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Yardley S, Francis SA, Dean Franklin B, Ogden M, Kajamaa A, Mattick K. Getting palliative medications right across the contexts of homes, hospitals and hospices: protocol to synthesise scoping review and ethnographic methods in an activity theory analysis. BMJ Open 2022; 12:e061754. [PMID: 35301215 PMCID: PMC8932278 DOI: 10.1136/bmjopen-2022-061754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Prescribing and medication use in palliative care is a multistep process. It requires systems coordination and is enacted through activities of patients, informal carers and professionals. This study compares practice to idealised descriptions of what should happen; identifying when, how and why process disturbances impact on quality and safety. Our objectives are to:Document an intended model (phase 1, scoping review).Refine the model with study of practice (phase 2, ethnography).Use the model to pinpoint 'hot' (viewed as problematic by participants) and 'cold' spots (observed as problematic by researchers) within or when patients move across three contexts-hospice, hospital and community (home).Create learning recommendations for quality and safety targeted at underlying themes and contributing factors. METHODS AND ANALYSIS The review will scope Ovid Medline, CINAHL and Embase, Google Scholar and Images-no date limits, English language only. The Population (palliative), Concept (medication use), Context (home, hospice, hospital) framework defines inclusion/exclusion criteria. Data will be extracted to create a model illustrating how processes ideally occur, incorporating multiple steps of typical episodes of prescribing and medication use for symptom control. Direct observations, informal conversations around acts of prescribing and medication use, and semistructured interviews will be conducted with a purposive sample of patients, carers and professionals. Drawing on activity theory, we will synthesise analysis of both phases. The analysis will identify when, how and why activities affect patient safety and experience. Generating a rich multivoiced understanding of the process will help identify meaningful targets for improvement. ETHICS AND DISSEMINATION Ethical approval granted by the Camden & Kings Cross NHS Regional Ethics Committee (21/LO/0459). A patient and public involvement (PPI) coinvestigator, a multiprofessional steering group and a PPI engagement group are working with the research team. Dissemination of findings is planned through peer-reviewed publications and a stakeholder (policymakers, commissioners, clinicians, researchers, public) report/dissemination event.
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Affiliation(s)
- Sarah Yardley
- Marie Curie Palliative Care Research Department, University College London, London, UK
- Central & North West London NHS Foundation Trust, London, London
| | - Sally-Anne Francis
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Bryony Dean Franklin
- University College London School of Pharmacy, London, UK
- Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK
| | - Margaret Ogden
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Anu Kajamaa
- Faculty of Education, University of Oulu, Oulu, Finland
| | - Karen Mattick
- College of Medicine & Health, University of Exeter, Exeter, UK
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Cresswell K, Hinder S, Sheikh A, Pontefract S, Watson N, Price D, Heed A, Coleman J, Ennis H, Beggs J, Chuter A, Williams R. ePrescribing-based antimicrobial stewardship practices in an English National Health service hospital: a qualitative interview study (Preprint). JMIR Form Res 2022. [DOI: 10.2196/37863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Golding SE, Higgins HM, Ogden J. Assessing Knowledge, Beliefs, and Behaviors around Antibiotic Usage and Antibiotic Resistance among UK Veterinary Students: A Multi-Site, Cross-Sectional Survey. Antibiotics (Basel) 2022; 11:256. [PMID: 35203857 PMCID: PMC8868437 DOI: 10.3390/antibiotics11020256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/06/2022] [Accepted: 02/09/2022] [Indexed: 01/21/2023] Open
Abstract
Antimicrobial resistance (AMR) is a profound threat to human and animal health. Antimicrobial prescribing behaviours are influenced by psychological factors such as knowledge, beliefs, and emotions. As future antimicrobial prescribers, it is important to understand beliefs about AMR and stewardship among veterinary (vet) students. This cross-sectional online survey assessed vet students' self-reported behavior, knowledge, and beliefs in specific relation to antibiotic resistance (ABR) and antibiotic usage. Participants were early years (first- and second-year; n = 460) and later-years (third- and fourth-year; n = 113) undergraduate vet students from three UK universities. Self-reported antibiotic-related behaviors were responsible among most students. Knowledge about ABR and stewardship was moderate among early years students and good among later years students. Vet students typically believed that vets had less responsibility for both causing and preventing ABR than other groups (animal owners, human medics, and the public). This study offers evidence that vet students (along with other groups) tend to lay greater responsibility for ABR/AMR outside of their own profession, which may impact their future prescribing behaviors. It is vital that AMR and antimicrobial stewardship are embedded across veterinary curricula, and that the One Health nature of the challenge posed by AMR is emphasized to encourage shared responsibility across all stakeholder groups, thereby helping to reduce 'other-blaming' for AMR.
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Affiliation(s)
- Sarah E. Golding
- School of Psychology, Faculty of Health and Medical Sciences, Stag Hill Campus, University of Surrey, Guildford GU2 7XH, UK;
| | - Helen M. Higgins
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Neston, Cheshire CH64 7TE, UK;
| | - Jane Ogden
- School of Psychology, Faculty of Health and Medical Sciences, Stag Hill Campus, University of Surrey, Guildford GU2 7XH, UK;
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Hampton T, Ogden J, Higgins HM. Understanding doctors' emergency department antibiotic prescribing decisions in children with respiratory symptoms in the UK: a qualitative study. BMJ Open 2021; 11:e051561. [PMID: 34930732 PMCID: PMC8688728 DOI: 10.1136/bmjopen-2021-051561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Exploration of the factors that influence hospital doctors' antibiotic prescribing decisions when treating children with respiratory symptoms in UK emergency departments. METHODS A qualitative study using semistructured interviews based on a critical incident technique with 21 physicians of different grades and specialties that treat children in the UK. Interviews were audio-recorded then transcribed verbatim and analysed using thematic analysis. RESULTS Four themes were identified. These themes illustrate factors which influence clinician prescribing. The three principal themes were authorities, pressures and risk. The fourth transcending theme that ran through all themes was clinician awareness and complicity ('knowing but still doing'). CONCLUSIONS Hospital doctors prescribe antibiotics even when they know they should not. This appears to be due to the influence of those in charge or external pressures experienced while weighing up the immediate and longer term risks but clinicians do this with full insight into their actions. These findings have implications for invested parties seeking to develop future antimicrobial stewardship programmes. It is recommended that stewardship interventions acknowledge and target these themes which may in turn facilitate behaviour change and antimicrobial prescribing practice in emergency departments.
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Affiliation(s)
- Thomas Hampton
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jane Ogden
- School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Helen Mary Higgins
- Department of Livestock and One Health, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
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Ahmadyar M, Rai T, Daly B, Wong G. Improving access of young adults with experience of homelessness to primary care dental services in the UK: A realist synthesis. Community Dent Oral Epidemiol 2021; 50:437-444. [PMID: 34651327 DOI: 10.1111/cdoe.12695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/25/2021] [Accepted: 09/05/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To understand why, how and under what circumstances interventions lead to improved access of young adults with experience of homelessness (YAEH) to primary care dental services in the UK. METHODS We followed a realist, theory-driven methodology. It involved locating existing theories, searching for evidence, document selection, data extraction/appraisal and evidence synthesis. We searched scientific databases and grey literature sources. We used these data and relevant substantive theories to develop explanations of how, why and under what circumstances interventions lead to desired outcomes. We presented these explanations in the form of context-mechanism-outcome configurations (CMOCs). The CMOCs were incorporated in an overarching programme theory, which was iteratively developed and refined throughout the realist synthesis. RESULTS We used 106 scientific and 18 grey literature records to synthesize 61 CMOCs. Our revised programme theory highlights the importance of four main considerations: 'preparing a service', 'producing and disseminating information', 'outreach activities' and 'facilitating interactions'. When designing dental programmes for YAEH, we recommend considering the importance of prior service planning (including resourcing of emergency dental care, training staff and incorporating safety measures), creating positive experiences, flexibility, patient-centeredness, being informative and reassuring, creating an enabling environment (including strong communication, building rapport and avoiding negative judgements), having realistic expectations and designing services that empower patients. CONCLUSIONS Improving dental access of YAEH requires attention to multiple levels. Services can achieve positive outcomes by understanding the complexity of YAEH lives, and creating contextual circumstances that encourage their attendance.
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Affiliation(s)
- Maryam Ahmadyar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tanvi Rai
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Blanaid Daly
- Dublin Dental University Hospital, Trinity College Dublin, Dublin 2, Ireland
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Hand KS, Clancy B, Allen M, Mayes A, Patel Y, Latter SM. 'It makes life so much easier'-experiences of users of the MicroGuide™ smartphone app for improving antibiotic prescribing behaviour in UK hospitals: an interview study. JAC Antimicrob Resist 2021; 3:dlab111. [PMID: 34632385 PMCID: PMC8496772 DOI: 10.1093/jacamr/dlab111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/17/2021] [Indexed: 11/12/2022] Open
Abstract
Objectives To understand the impact on prescribing behaviour of an antimicrobial therapy
guidelines smartphone app, in widespread use in hospitals in the UK. Methods Twenty-eight doctors and five nurse prescribers from four purposively
selected hospitals in the UK participated in behavioural theory-informed
semi-structured interviews about their experiences of using the
MicroGuide™ smartphone app. Data were analysed using a thematic
content analysis. Results Five themes emerged from the interview data: convenience and accessibility;
validation of prescribing decisions; trust in app content; promotion of
antimicrobial stewardship; and limitations and concerns. Participants
appreciated the perceived convenience, accessibility and timesaving
attributes of the app, potentially contributing to more prompt treatment of
patients with time-critical illness. The interviewees also reported finding
it reassuring to use the app to support decision-making and to validate
existing knowledge. They trusted the app content authored by local experts
and considered it to be evidence-based and up-to-date. This was believed to
result in fewer telephone calls to the microbiology department for advice.
Participants recognized the value of the app for supporting the goals of
antimicrobial stewardship by promoting the responsible and proportionate use
of antimicrobials. Finally, a number of limitations of the app were
reported, including the risk of de-skilling trainees, cultural problems with
using smartphones in clinical environments and software technical
problems. Conclusions The MicroGuide app was valued as a means of addressing an unmet need for
updated, concise, trustworthy specialist information in an accessible format
at the bedside to support safe and effective antimicrobial prescribing.
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Affiliation(s)
- Kieran S Hand
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Bridget Clancy
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Mike Allen
- Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, UK
| | - Amazigom Mayes
- Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, UK
| | - Yash Patel
- Merck Sharp & Dohme Limited, Hertford Road, Hoddesdon, UK
| | - Susan M Latter
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
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Rana D, Westrop S, Germeni E, McGarty A, Ells L, Lally P, McEwan M, Melville C, Harris L, Wu O. Understanding the effectiveness and underlying mechanisms of lifestyle modification interventions in adults with learning disabilities: protocol for a mixed-methods systematic review. Syst Rev 2021; 10:251. [PMID: 34544482 PMCID: PMC8453997 DOI: 10.1186/s13643-021-01808-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 09/03/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Adults with learning disabilities have an increased disposition to unhealthy lifestyle behaviours which often occur simultaneously. Existing studies focus on complex interventions targeting unhealthy diet, physical inactivity, sedentary behaviour, smoking, and alcohol use to reduce health risks experienced. It is essential to understand how well these interventions work, what works, for whom, in what context and why. This study aims to investigate the effectiveness and underlying mechanisms of lifestyle modification interventions for adults with learning disabilities. METHODS This is a mixed-methods systematic review consisting of a network meta-analysis (NMA) and realist synthesis. Electronic databases (ASSIA, CINAHL, EMBASE, MEDLINE, and PsycINFO) will be searched from inception to 14 January 2021 with no language restriction. Additionally, trial registries, grey literature databases and references lists will be searched. Studies related to lifestyle modification interventions on the adult population (>18 years) with learning disabilities will be eligible for inclusion. Two independent researchers will screen studies, extract data and assess its quality and risk of bias using the Cochrane Collaboration's Risk of Bias Assessment Tool (RoB Version 2) and ROBINS-I. The strength of the body of evidence will be assessed based on the GRADE approach. The NMA will incorporate results from RCTs and quasi-experimental studies to estimate the effectiveness of various lifestyle interventions. Where appropriate, a component NMA (CNMA) will be used to estimate effectiveness. The realist synthesis will complement and explain the findings of NMA and CNMA by including additional qualitative and mixed-methods studies. Studies will be included based on their relevance to the programme theory and the rigour of their methods, as determined by quality appraisal tools appropriate to the study design. Results from both syntheses will be incorporated into a logic model. DISCUSSION The paucity of population-specific lifestyle interventions contributes to the challenges of behaviour change in adults with learning disabilities. This study will provide an evidence-base from which various stakeholders can develop effective interventions for adults with learning disabilities. The evidence will also help prioritise and inform research recommendations for future primary research so that people with learning disabilities live happier, healthier and longer lives. TRIAL REGISTRATION PROSPERO CRD 42020223290.
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Affiliation(s)
- Dikshyanta Rana
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, G12 8RZ UK
| | - Sophie Westrop
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, G12 8RZ UK
| | - Evi Germeni
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, G12 8RZ UK
| | - Arlene McGarty
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, G12 8RZ UK
| | - Louisa Ells
- School of Clinical and Applied Sciences, Leeds Beckett University, City Campus, Leeds, LS1 3HE UK
| | - Phillippa Lally
- UCL Institute of Epidemiology and Health Care, University College London, London, WC1E 6BT UK
| | | | - Craig Melville
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, G12 8RZ UK
| | - Leanne Harris
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, G31 2ER UK
| | - Olivia Wu
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, G12 8RZ UK
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Wojcik G, Ring N, McCulloch C, Willis DS, Williams B, Kydonaki K. Understanding the complexities of antibiotic prescribing behaviour in acute hospitals: a systematic review and meta-ethnography. ACTA ACUST UNITED AC 2021; 79:134. [PMID: 34301332 PMCID: PMC8299683 DOI: 10.1186/s13690-021-00624-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/30/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Antimicrobial resistance poses a serious global public health threat. Hospital misuse of antibiotics has contributed to this problem and evidence-based interventions are urgently needed to change inappropriate prescribing practices. This paper reports the first theoretical stage of a longer-term project to improve antibiotic prescribing in hospitals through design of an effective behaviour-change intervention. METHODS Qualitative synthesis using meta-ethnography of primary studies reporting doctors' views and experiences of antibiotic prescribing in hospitals for example, their barriers to appropriate prescribing. Twenty electronic databases were systematically searched over a 10-year period and potential studies screened against eligibility criteria. Included studies were quality-appraised. Original participant quotes and author interpretations were extracted and coded thematically into NVivo. All study processes were conducted by two reviewers working independently with findings discussed with the wider team and key stakeholders. Studies were related by findings into clusters and translated reciprocally and refutationally to develop a new line-of-argument synthesis and conceptual model. Findings are reported using eMERGe guidance. RESULTS Fifteen papers (13 studies) conducted between 2007 and 2017 reporting the experiences of 336 doctors of varying seniority working in acute hospitals across seven countries, were synthesised. Study findings related in four ways which collectively represented multiple challenges to appropriate antibiotic medical prescribing in hospitals: loss of ownership of prescribing decisions, tension between individual care and public health concerns, evidence-based practice versus bedside medicine, and diverse priorities between different clinical teams. The resulting new line-of-argument and conceptual model reflected how these challenges operated on both micro- and macro-level, highlighting key areas for improving current prescribing practice, such as creating feedback mechanisms, normalising input from other specialties and reducing variation in responsibility for antibiotic decisions. CONCLUSIONS This first meta-ethnography of doctors` experiences of antibiotic prescribing in acute hospital settings has enabled development of a novel conceptual model enhancing understanding of appropriate antibiotic prescribing. That is, hospital antibiotic prescribing is a complex, context-dependent and dynamic process, entailing the balancing of many tensions. To change practice, comprehensive efforts are needed to manage failures in communication and information provision, promote distribution of responsibility for antibiotic decisions, and reduce fear of consequences from not prescribing. TRIAL REGISTRATION PROSPERO registration: CRD42017073740 .
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Affiliation(s)
- Gosha Wojcik
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK.
| | - Nicola Ring
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
| | - Corrienne McCulloch
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh Royal Infirmary, EH16 4SA, Edinburgh, UK
| | - Diane S Willis
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
| | - Brian Williams
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
| | - Kalliopi Kydonaki
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
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Hamill LM, Bonnett J, Baxter MF, Kreutz M, Denny KJ, Keijzers G. Antimicrobial Prescribing in the Emergency Department; Who Is Calling the Shots? Antibiotics (Basel) 2021; 10:antibiotics10070843. [PMID: 34356764 PMCID: PMC8300735 DOI: 10.3390/antibiotics10070843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: Inappropriate antimicrobial prescribing in the emergency department (ED) can lead to poor outcomes. It is unknown how often the prescribing clinician is guided by others, and whether prescriber factors affect appropriateness of prescribing. This study aims to describe decision making, confidence in, and appropriateness of antimicrobial prescribing in the ED. Methods: Descriptive study in two Australian EDs using both questionnaire and medical record review. Participants were clinicians who prescribed antimicrobials to patients in the ED. Outcomes of interest were level of decision-making (self or directed), confidence in indication for prescribing and appropriateness (5-point Likert scale, 5 most confident). Appropriateness assessment of the prescribing event was by blinded review using the National Antibiotic Prescribing Survey appropriateness assessment tool. All analyses were descriptive. Results: Data on 88 prescribers were included, with 61% making prescribing decisions themselves. The 39% directed by other clinicians were primarily guided by more senior ED and surgical subspecialty clinicians. Confidence that antibiotics were indicated (Likert score: 4.20, 4.35 and 4.35) and appropriate (Likert score: 4.07, 4.23 and 4.29) was similar for juniors, mid-level and senior prescribers, respectively. Eighty-five percent of prescriptions were assessed as appropriate, with no differences in appropriateness by seniority, decision-making or confidence. Conclusions: Over one-third of prescribing was guided by senior ED clinicians or based on specialty advice, primarily surgical specialties. Prescriber confidence was high regardless of seniority or decision-maker. Overall appropriateness of prescribing was good, but with room for improvement. Future qualitative research may provide further insight into the intricacies of prescribing decision-making.
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Affiliation(s)
- Laura M. Hamill
- Department of Emergency Medicine, Christchurch Hospital, Canterbury DHB, Christchurch 8011, New Zealand;
| | - Julia Bonnett
- School of Medicine, Griffith University, Gold Coast, QLD 4215, Australia; (J.B.); (M.F.B.); (M.K.)
| | - Megan F. Baxter
- School of Medicine, Griffith University, Gold Coast, QLD 4215, Australia; (J.B.); (M.F.B.); (M.K.)
| | - Melina Kreutz
- School of Medicine, Griffith University, Gold Coast, QLD 4215, Australia; (J.B.); (M.F.B.); (M.K.)
| | - Kerina J. Denny
- Department of Intensive Care, Gold Coast University Hospital, Gold Coast, QLD 4215, Australia;
| | - Gerben Keijzers
- School of Medicine, Griffith University, Gold Coast, QLD 4215, Australia; (J.B.); (M.F.B.); (M.K.)
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD 4215, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD 4215, Australia
- Correspondence:
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Eaton G, Wong G, Tierney S, Roberts N, Williams V, Mahtani KR. Understanding the role of the paramedic in primary care: a realist review. BMC Med 2021; 19:145. [PMID: 34167541 PMCID: PMC8229679 DOI: 10.1186/s12916-021-02019-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/28/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Since 2002, paramedics have been working in primary care within the United Kingdom (UK), a transition also mirrored within Australia, Canada and the USA. Recent recommendations to improve UK NHS workforce capacities have led to a major push to increase the numbers of paramedics recruited into primary care. However, gaps exist in the evidence base regarding how and why these changes would work, for whom, in what context and to what extent. To understand the ways in which paramedics impact (or not) the primary care workforce, we conducted a realist review. METHODS A realist approach aims to provide causal explanations through the generation and articulation of contexts, mechanisms and outcomes. Our search of electronic databases was supplemented with Google and citation checking to locate grey literature including news items and workforce reports. Included documents were from the UK, Australia, Canada and the Americas-countries within which the paramedic role within primary care is well established. RESULTS Our searches resulted in 205 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) within a final programme theory. Our results outline that paramedics are more likely to be effective in contributing to primary care workforces when they are supported to expand their existing role through formal education and clinical supervision. We also found that unless paramedics were fully integrated into primary care services, they did not experience the socialisation needed to build trusting relationships with patients or physicians. Indeed, for patients to accept paramedics in primary care, their role and its implications for their care should be outlined by a trusted source. CONCLUSIONS Our realist review highlights the complexity surrounding the introduction of paramedics into primary care roles. As well as offering an insight into understanding the paramedic professional identity, we also discuss the range of expectations this professional group will face in the transition to primary care. These expectations come from patients, general practitioners (family physicians) and paramedics themselves. This review is the first to offer insight into understanding the impact paramedics may have on the international primary care workforce and shaping how they might be optimally deployed.
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Affiliation(s)
- Georgette Eaton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stephanie Tierney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | | | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Duncan EM, Charani E, Clarkson JE, Francis JJ, Gillies K, Grimshaw JM, Kern WV, Lorencatto F, Marwick CA, McEwen J, Möhler R, Morris AM, Ramsay CR, Rogers Van Katwyk S, Rzewuska M, Skodvin B, Smith I, Suh KN, Davey PG. A behavioural approach to specifying interventions: what insights can be gained for the reporting and implementation of interventions to reduce antibiotic use in hospitals? J Antimicrob Chemother 2021; 75:1338-1346. [PMID: 32016346 PMCID: PMC7177472 DOI: 10.1093/jac/dkaa001] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/27/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023] Open
Abstract
Background Reducing unnecessary antibiotic exposure is a key strategy in reducing the development and selection of antibiotic-resistant bacteria. Hospital antimicrobial stewardship (AMS) interventions are inherently complex, often requiring multiple healthcare professionals to change multiple behaviours at multiple timepoints along the care pathway. Inaction can arise when roles and responsibilities are unclear. A behavioural perspective can offer insights to maximize the chances of successful implementation. Objectives To apply a behavioural framework [the Target Action Context Timing Actors (TACTA) framework] to existing evidence about hospital AMS interventions to specify which key behavioural aspects of interventions are detailed. Methods Randomized controlled trials (RCTs) and interrupted time series (ITS) studies with a focus on reducing unnecessary exposure to antibiotics were identified from the most recent Cochrane review of interventions to improve hospital AMS. The TACTA framework was applied to published intervention reports to assess the extent to which key details were reported about what behaviour should be performed, who is responsible for doing it and when, where, how often and with whom it should be performed. Results The included studies (n = 45; 31 RCTs and 14 ITS studies with 49 outcome measures) reported what should be done, where and to whom. However, key details were missing about who should act (45%) and when (22%). Specification of who should act was missing in 79% of 15 interventions to reduce duration of treatment in continuing-care wards. Conclusions The lack of precise specification within AMS interventions limits the generalizability and reproducibility of evidence, hampering efforts to implement AMS interventions in practice.
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Affiliation(s)
- Eilidh M Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Esmita Charani
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Faculty of Medicine, Imperial College London, London, UK
| | - Janet E Clarkson
- Schools of Dentistry, University of Dundee, Dundee, UK & University of Manchester, Manchester, UK, NHS Education for Scotland, Scotland
| | - Jill J Francis
- School of Health Sciences, City University of London, London, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada and Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Winfried V Kern
- University of Freiburg Medical Center and Faculty of Medicine, Department of Medicine II/Infectious Diseases, Freiburg im Breisgau, Germany
| | | | - Charis A Marwick
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Scotland, UK
| | | | - Ralph Möhler
- Department of Health Services Research and Nursing Science, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Andrew M Morris
- Sinai Health System, University Health Network and University of Toronto, Toronto, Canada
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | | | - Magdalena Rzewuska
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Brita Skodvin
- Norwegian Advisory Unit for Antibiotic Use in Hospitals, Haukeland University Hospital, Bergen, Norway
| | - Ingrid Smith
- Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
| | - Kathryn N Suh
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter G Davey
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Scotland, UK
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Maugeri IP, Brimblecombe J, Choi TST, Kleve S, Palermo C. For whom and under what circumstances do nutrition-education cooking interventions work: a realist synthesis. Nutr Rev 2021; 79:479-493. [PMID: 32443146 DOI: 10.1093/nutrit/nuaa021] [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] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To explore for whom and under what circumstances nutrition-education cooking interventions affect nutrition outcomes in adults. METHODS A realist synthesis was undertaken. The CINAHL, Ovid Medline, Scopus, and Web of Science databases were searched for literature published between 1980 and 2019, using the terms "cook" and "intervention" and their synonyms; 5759 articles were identified. Grey literature was sourced for further additional program context. A total of 23 articles (n = 11 programs) met inclusion criteria for analysis. Program data were coded in duplicate for context, outcome, and mechanism configurations, and used to build a refined program theory. RESULTS Nutrition-education cooking interventions targeted at low-socioeconomic-status and marginalized populations produced a range of positive nutrition outcomes. Outcomes were observed when the program involved hands-on cooking and a skilled facilitator coupled with individual self-efficacy, knowledge gain, family support, and an expectation of positive health outcomes. CONCLUSION These findings highlight key program components to achieve improvements in nutrition and important recommendations for nutrition-education cooking interventions.
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Affiliation(s)
- Isabella P Maugeri
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia
| | - Julie Brimblecombe
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia.,Honorary Fellow of the Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Tammie S T Choi
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia
| | - Sue Kleve
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia
| | - Claire Palermo
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia
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Golding SE, Ogden J, Higgins HM. Examining the Effect of Context, Beliefs, and Values on UK Farm Veterinarians' Antimicrobial Prescribing: A Randomized Experimental Vignette and Cross-Sectional Survey. Antibiotics (Basel) 2021; 10:445. [PMID: 33921073 PMCID: PMC8071438 DOI: 10.3390/antibiotics10040445] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 12/28/2022] Open
Abstract
Antimicrobial resistance (AMR) is a pressing threat to public and animal health. There is evidence that antimicrobial prescribing and stewardship behaviors by veterinarians (vets) are influenced by non-clinical factors, such as psychological, social, and environmental factors. This study explored the role of context, beliefs, and values on vets' antimicrobial prescribing decisions. UK-based practicing farm vets (n = 97) were recruited to an online study. Using an experimental vignette methodology, vets were randomly assigned across four conditions, to examine the effects of different contexts (pressure on farm economics, the farmer, or the vet-farmer relationship, compared to a control condition) on vets' likelihood of prescribing antibiotics. Vets' beliefs about different groups' responsibility for causing and preventing AMR and vets' values were also measured. Key findings were that context alone, values, and beliefs about groups' responsibilities for causing AMR were not predictive of vets' likelihood of prescribing antibiotics. However, vets' beliefs about groups' responsibilities for preventing AMR were predictive of an increased likelihood of prescribing antibiotics, when vets were exposed to the experimental condition of the vignette in which the vet-farmer relationship was under pressure. Farm vets also believed that different groups have different levels of responsibility for causing and preventing AMR. Results should be interpreted cautiously, given the smaller than planned for sample size, and the possibility for both false negatives and false positives. Further research is needed to explore how these findings could inform antimicrobial stewardship interventions in veterinary medicine.
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Affiliation(s)
- Sarah E. Golding
- School of Psychology, Faculty of Health and Medical Sciences, Stag Hill Campus, University of Surrey, Guildford GU2 7XH, UK;
| | - Jane Ogden
- School of Psychology, Faculty of Health and Medical Sciences, Stag Hill Campus, University of Surrey, Guildford GU2 7XH, UK;
| | - Helen M. Higgins
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Neston, Cheshire CH64 7TE, UK;
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Hoverd E, Staniszewska S, Dale J. The informed consent process in health research with under-served populations: a realist review protocol. Syst Rev 2021; 10:103. [PMID: 33836834 PMCID: PMC8034278 DOI: 10.1186/s13643-021-01652-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The informed consent process aims to provide potential participants with information about health research that enables them to make an informed decision as to whether they choose to participate, or not. However, it remains unclear as to whether the process is effective for those who are under-served in health research. It is a pivotal issue within health research that the diversity of people who participate is broadened. The National Institute for Health Research (NIHR) pledges to support equality, diversity and inclusion, actively creating opportunities for all citizens whom are eligible, to take part in health research. METHODS In order to understand how the informed consent process for under-served populations in health research works, under what circumstances and in what respects, a realist review approach will be undertaken. Searches will be carried out using electronic databases (EMBASE, MEDLINE, Web of Science and PsycINFO), along with selected websites and grey literature. Development of initial rough programme theory(ies) will lead to a more refined programme theory that will provide an explanation of context, mechanism and outcomes. Stakeholder involvement by NIHR (Public) Research Champions, health professionals and clinical academics will provide expert opinion about concepts and programme theory. DISCUSSION Findings of this realist review will highlight how the informed consent process in health research affects the experience and decision-making process of potential participants from under-served populations. They will be written up in accordance with RAMESES guidelines and disseminated to patients and the public, health researchers, health professionals and policymakers through peer-reviewed publication, presentations and discussions. The review will contribute to our understanding of the mechanisms that cause both positive and negative outcomes in the informed consent process for those whom are often under-represented in health research to inform policy, study design and delivery.
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Affiliation(s)
- Eleanor Hoverd
- CRN West Midlands Primary Care/Unit of Academic Primary Care, Warwick Medical School, Warwick University, Gibbet Hill Rd, Coventry, CV4 7AL England
| | - Sophie Staniszewska
- Warwick Research in Nursing, Warwick Medical School, Warwick University, Coventry, England
| | - Jeremy Dale
- Unit of Academic Primary Care, Warwick Medical School, Warwick University, Coventry, England
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Dixon S, Duddy C, Harrison G, Papoutsi C, Ziebland S, Griffiths F. Conversations about FGM in primary care: a realist review on how, why and under what circumstances FGM is discussed in general practice consultations. BMJ Open 2021; 11:e039809. [PMID: 33753429 PMCID: PMC7986780 DOI: 10.1136/bmjopen-2020-039809] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/11/2020] [Accepted: 11/09/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Little is known about the management of female genital mutilation (FGM) in primary care. There have been significant recent statutory changes relevant to general practitioners (GPs) in England, including a mandatory reporting duty. We undertook a realist synthesis to explore what influences how and when GPs discuss FGM with their patients. SETTING Primary care in England. DATA SOURCES Realist literature synthesis searching 10 databases with terms: GPs, primary care, obstetrics, gynaecology, midwifery and FGM (UK and worldwide). Citation chasing was used, and relevant grey literature was included, including searching FGM advocacy organisation websites for relevant data. Other potentially relevant literature fields were searched for evidence to inform programme theory development. We included all study designs and papers that presented evidence about factors potentially relevant to considering how, why and in what circumstances GPs feel able to discuss FGM with their patients. PRIMARY OUTCOME MEASURE This realist review developed programme theory, tested against existing evidence, on what influences GPs actions and reactions to FGM in primary care consultations and where, when and why these influences are activated. RESULTS 124 documents were included in the synthesis. Our analysis found that GPs need knowledge and training to help them support their patients with FGM, including who may be affected, what needs they may have and how to talk sensitively about FGM. Access to specialist services and guidance may help them with this role. Reporting requirements may complicate these conversations. CONCLUSIONS There is a pressing need to develop (and evaluate) training to help GPs meet FGM-affected communities' health needs and to promote the accessibility of primary care. Education and resources should be developed in partnership with community members. The impact of the mandatory reporting requirement and the Enhanced Dataset on healthcare interactions in primary care warrants evaluation. PROSPERO REGISTRATION NUMBER CRD42018091996.
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Affiliation(s)
- Sharon Dixon
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Frances Griffiths
- Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
- Warwick Medical School, University of Warwick, Coventry, UK
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Lavigne SH, Louis S, Rankin SC, Zaoutis TE, Szymczak JE. How companion animal veterinarians in the United States perceive financial constraints on antibiotic decision-making. Vet Rec 2021; 188:e62. [PMID: 34143461 DOI: 10.1002/vetr.62] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/03/2020] [Accepted: 12/24/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND The misuse of antibiotics is a persistent problem in both human and veterinary medicine. While complex social and behavioural factors drive inappropriate use in human medicine, less is known about factors that impact antibiotic use in companion animal medicine. OBJECTIVE To identify the perceptions that veterinarians practicing companion animal medicine hold about the influence of financial considerations on antibiotic use. METHODS Semi-structured qualitative interviews were conducted with veterinarians practicing companion animal medicine in a major metropolitan area in the Eastern United States. Respondents were sampled purposefully, and data were analysed using a thematic analysis approach. RESULTS Interviews were conducted with 36 veterinarians from 19 practices. Veterinarians believed that their clients' willingness to pay for diagnostic testing or treatment interfered with their ability to make appropriate decisions about antibiotic use. Concerns over antibiotic expiration and subsequent financial losses limited which antibiotics veterinarians stocked. Some veterinarians feared that restricting antibiotic use to appropriate uses could harm their business and lead to economic euthanasia of their patients. CONCLUSIONS Veterinarians perceive that financial factors can impede their ability to appropriately prescribe antibiotics. Interventions that address the financial aspects of prescribing have the potential to improve antibiotic decision-making in veterinary medicine.
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Affiliation(s)
- Sondra H Lavigne
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Souci Louis
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shelley C Rankin
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Theoklis E Zaoutis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Paediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Wagner CE, Prentice JA, Saad-Roy CM, Yang L, Grenfell BT, Levin SA, Laxminarayan R. Economic and Behavioral Influencers of Vaccination and Antimicrobial Use. Front Public Health 2020; 8:614113. [PMID: 33409264 PMCID: PMC7779682 DOI: 10.3389/fpubh.2020.614113] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
Despite vast improvements in global vaccination coverage during the last decade, there is a growing trend in vaccine hesitancy and/or refusal globally. This has implications for the acceptance and coverage of a potential vaccine against COVID-19. In the United States, the number of children exempt from vaccination for “philosophical belief-based” non-medical reasons increased in 12 of the 18 states that allowed this policy from 2009 to 2017 (1). Meanwhile, the overuse and misuse of antibiotics, especially in young children, have led to increasing rates of drug resistance that threaten our ability to treat infectious diseases. Vaccine hesitancy and antibiotic overuse exist side-by-side in the same population of young children, and it is unclear why one modality (antibiotics) is universally seen as safe and effective, while the other (vaccines) is seen as potentially hazardous by some. In this review, we consider the drivers shaping the use of vaccines and antibiotics in the context of three factors: individual incentives, risk perceptions, and social norms and group dynamics. We illustrate how these factors contribute to the societal and individual costs of vaccine underuse and antimicrobial overuse. Ultimately, we seek to understand these factors that are at the nexus of infectious disease epidemiology and social science to inform policy-making.
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Affiliation(s)
- Caroline E Wagner
- Department of Bioengineering, McGill University, Montreal, QC, Canada
| | - Joseph A Prentice
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, United States
| | - Chadi M Saad-Roy
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, United States.,Lewis-Sigler Institute for Integrative Genomics, Princeton University, Princeton, NJ, United States
| | - Luojun Yang
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, United States
| | - Bryan T Grenfell
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, United States.,Princeton School of Public and International Affairs, Princeton University, Princeton, NJ, United States.,Fogarty International Center, National Institutes of Health, Bethesda, MD, United States
| | - Simon A Levin
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, United States.,Princeton Environmental Institute, Princeton University, Princeton, NJ, United States
| | - Ramanan Laxminarayan
- Princeton Environmental Institute, Princeton University, Princeton, NJ, United States.,Center for Disease Dynamics, Economics & Policy, Washington, DC, United States
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Cameron J, Humphreys C, Kothari A, Hegarty K. Exploring the knowledge translation of domestic violence research: A literature review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:1898-1914. [PMID: 32614128 DOI: 10.1111/hsc.13070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 05/21/2020] [Accepted: 05/28/2020] [Indexed: 06/11/2023]
Abstract
There is growing recognition of the links between knowledge translation, policy and practice, particularly in the domestic violence research area. A literature review applying a systematic approach with a realist lens was the preferred methodology. The review answered the following question: What are the mechanisms of change in research networks which 'work' to support knowledge translation? A search of eight electronic databases for articles published between 1960 and 2018 was completed, with 2,999 records retrieved, 2,869 records excluded and 130 full-text articles screened for final inclusion in the review. The inclusion criteria were purposefully broad, including any study design or data source (including grey literature) with a focus on domestic violence knowledge translation. The analysis of included studies using a realist lens identified the mechanisms of change to support knowledge translation. A disaggregation of the included studies identified five theories focused on the following outcomes: (1) develop key messages, (2) flexible evidence use, (3) strengthen partnerships, (4) capacity building and (5) research utilisation. This review adds to our understanding of knowledge translation of domestic violence research. The mechanisms of change identified may support knowledge translation of research networks. Further research will focus on exploring the potential application of these program theories with a research network.
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Affiliation(s)
- Jacqui Cameron
- Department of Social Work, The University of Melbourne, Melbourne, Vic, Australia
- School of Health and Society, University of Wollongong, Wollongong, NSW, Australia
| | - Cathy Humphreys
- Department of Social Work, The University of Melbourne, Melbourne, Vic, Australia
| | - Anita Kothari
- School of Health Studies, University of Western Ontario, London, Canada
| | - Kelsey Hegarty
- Department of General Practice, The University of Melbourne, Melbourne, Vic, Australia
- Royal Women's Hospital, Melbourne, Vic, Australia
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Parker H, Frost J, Britten N, Robinson S, Mattick K. Understanding surgical antimicrobial prescribing behaviour in the hospital setting: a systematic review and meta-ethnography protocol. Syst Rev 2020; 9:236. [PMID: 33038928 PMCID: PMC7548039 DOI: 10.1186/s13643-020-01477-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/08/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Surgical specialities use extensive amounts of antimicrobials, and misuse has been widely reported, making them a key target for antimicrobial stewardship initiatives. Interventions informed by, and tailored to, a clear understanding of the contextual barriers to appropriate antimicrobial use are more likely to successfully improve practice. However, this approach has been under utilised. Our aim is to synthesise qualitative studies on surgical antimicrobial prescribing behaviour (APB) in hospital settings to explain how and why contextual factors act and interact to influence APB amongst surgical teams. We will develop new theory to advance understanding and identify knowledge gaps to inform further research. METHODS The meta-ethnography will follow the seven-phase method described by Noblit and Hare. We will conduct a comprehensive search using eight databases (AMED, CINAHL, EMBASE, MEDLINE, MEDLINE-in-process, Web of Science, Cochrane Library and PsycINFO) with no date restrictions; forwards and backwards citation searches; and contacting first authors of relevant papers. Studies will be dual screened and included if they use recognised qualitative methods and analysis; focus on contextual factors associated with surgical APB within hospital settings; are available in full in English; and are relevant to the research question. Any disagreements between reviewers will be resolved through discussion to reach consensus. Included studies will be read repeatedly to illuminate key concepts and the relationship between key concepts across studies. Then, key concepts will be sorted into conceptual categories or 'piles' which will be further abstracted to form a conceptual framework explaining surgical APB. During the synthesis, emerging interpretations will be discussed with stakeholders (including authors of included studies where possible; surgical and stewardship practitioners; and patient representatives) to ensure new knowledge is meaningful. DISCUSSION This research has several strengths: (1) the protocol has been written with reference to established guidance maximising rigour and transparency; (2) the multi-disciplinary research team bring varied interpretative repertoires and relevant methodological skills; and (3) stakeholders will be involved to ensure that findings are relevant, and disseminated via suitable channels, to support improved patient care. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020184343.
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Affiliation(s)
- Hazel Parker
- Pharmacy Department, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK.
| | - Julia Frost
- South Cloisters, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Nicky Britten
- South Cloisters, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Sophie Robinson
- South Cloisters, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Karen Mattick
- South Cloisters, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
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Abrams R, Park S, Wong G, Rastogi J, Boylan AM, Tierney S, Petrova M, Dawson S, Roberts N. Lost in reviews: Looking for the involvement of stakeholders, patients, public and other non-researcher contributors in realist reviews. Res Synth Methods 2020; 12:239-247. [PMID: 32985074 DOI: 10.1002/jrsm.1459] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 09/07/2020] [Accepted: 09/24/2020] [Indexed: 12/31/2022]
Abstract
The involvement of non-researcher contributors (eg, stakeholders, patients and the public, decision and policy makers, experts, lay contributors) has taken a variety of forms within evidence syntheses. Realist reviews are a form of evidence synthesis that involves non-researcher contributors yet this practice has received little attention. In particular, the role of patient and public involvement (PPI) has not been clearly documented. This review of reviews describes the ways in which contributor involvement, including PPI, is documented within healthcare realist reviews published over the last five years. A total of 448 papers published between 2014 and 2019 were screened, yielding 71 full-text papers included in this review. Statements about contributor involvement were synthesized across each review using framework analysis. Three themes are described in this article including nomenclature, nature of involvement, and reporting impact. Papers indicate that contributor involvement in realist reviews refers to stakeholders, experts, or advisory groups (ie, professionals, clinicians, or academics). Patients and the public are occasionally subsumed into these groups and in doing so, the nature and impact of their involvement become challenging to identify and at times, is lost completely. Our review findings indicate a need for the realist review community to develop guidance to support researchers in their future collaboration with contributors, including patients and the public.
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Affiliation(s)
- Ruth Abrams
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, England
| | - Sophie Park
- Department of Primary care and population health, UCL, London, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Juhi Rastogi
- Department of Primary care and population health, UCL, London, UK
| | - Anne-Marie Boylan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stephanie Tierney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mila Petrova
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Shoba Dawson
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
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Sriranjan AN, Abrams R, Wong G, Park S. Towards an understanding of GPs' viewpoint on diagnosing postnatal depression in general practice: a small-scale realist evaluation. Prim Health Care Res Dev 2020; 21:e42. [PMID: 33032675 PMCID: PMC7576521 DOI: 10.1017/s1463423620000316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 05/03/2020] [Accepted: 07/10/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Less than half of postnatal depression cases are identified in routine clinical assessment. Guidelines and current literature suggest that general practitioners (GPs) may have an opportunistic role in detecting postnatal depression due to their early contact and existing rapport with many new mothers. There is limited research on the diagnostic approaches chosen by GPs in different GP-patient contexts. Our small-scale study evaluates the thought processes of seven GPs based in one practice when forming a clinical diagnosis of postnatal depression under different contexts. METHODS Seven GP participants were interviewed using case vignettes about postnatal depression, based on an adapted Johari's window framework. A realist approach to analysis was undertaken with the intention of understanding GPs' responses to different situations. Context-mechanism-outcome configurations were constructed, and a programme theory was formed to consolidate the findings. FINDINGS Findings suggest that diagnoses may be a clinician-led or collaborative process between GP and patient. In collaborative contexts, stigmatising views were addressed by GPs, time for self-reflection was encouraged and mothers' views were accounted for. Clinician-led diagnoses often occurred in contexts where there was a lack of acknowledgement of symptoms on behalf of the patient or where safety was a concern. The personal and clinical experience of GPs themselves, as well as effective communication channels with other primary care professionals, was significant mechanisms. CONCLUSION GPs use a variety of strategies to support patient disclosure and acceptance of their condition. The complexity of GP-patient contexts may influence the clinical thought process. We address some of the gaps in existing literature by exploring postnatal depression diagnosis in primary care and provide tentative explanations to suggest what works, for whom and in what contexts.
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Affiliation(s)
- Ashvanthi Nadira Sriranjan
- Department of Primary Care & Population Health, Institute of Epidemiology & Public Health, UCL Medical School, London, UK
| | - Ruth Abrams
- Department of Primary Care & Population Health, Institute of Epidemiology & Public Health, UCL Medical School, London, UK
| | - Geoff Wong
- Department of Primary Care & Population Health, Institute of Epidemiology & Public Health, UCL Medical School, London, UK
| | - Sophie Park
- Department of Primary Care & Population Health, Institute of Epidemiology & Public Health, UCL Medical School, London, UK
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46
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Beović B, Doušak M, Pulcini C, Béraud G, Paño Pardo JR, Sánchez-Fabra D, Kofteridis D, Cortez J, Pagani L, Klešnik M, Nadrah K, Hafner Fink M, Nathwani D, Uhan S. Young doctors' perspectives on antibiotic use and resistance: a multinational and inter-specialty cross-sectional European Society of Clinical Microbiology and Infectious Diseases (ESCMID) survey. J Antimicrob Chemother 2020; 74:3611-3618. [PMID: 31504568 DOI: 10.1093/jac/dkz375] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/17/2019] [Accepted: 07/31/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Postgraduate training has the potential to shape the prescribing practices of young doctors. OBJECTIVES To investigate the practices, attitudes and beliefs on antibiotic use and resistance in young doctors of different specialties. METHODS We performed an international web-based exploratory survey. Principal component analysis (PCA) and bivariate and multivariate [analysis of variance (ANOVA)] analyses were used to investigate differences between young doctors according to their country of specialization, specialty, year of training and gender. RESULTS Of the 2366 participants from France, Greece, Italy, Portugal, Slovenia and Spain, 54.2% of young doctors prescribed antibiotics predominantly as instructed by a mentor. Associations between the variability of answers and the country of training were observed across most questions, followed by variability according to the specialty. Very few differences were associated with the year of training and gender. PCA revealed five dimensions of antibiotic prescribing culture: self-assessment of knowledge, consideration of side effects, perception of prescription patterns, consideration of patient sickness and perception of antibiotic resistance. Only the country of specialization (partial η2 0.010-0.111) and the type of specialization (0.013-0.032) had a significant effect on all five identified dimensions (P < 0.01). The strongest effects were observed on self-assessed knowledge and in the perception of antibiotic resistance. CONCLUSIONS The country of specialization followed by the type of specialization are the most important determinants of young doctors' perspectives on antibiotic use and resistance. The inclusion of competencies in antibiotic use in all specialty curricula and international harmonization of training should be considered.
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Affiliation(s)
- Bojana Beović
- University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - May Doušak
- Faculty of Social Sciences, University of Ljubljana, Ljubljana, Slovenia
| | - Céline Pulcini
- Université de Lorraine, APEMAC, Nancy, France.,CHRU-Nancy, Infectious Diseases Department, Nancy, France
| | - Guillaume Béraud
- University Hospital of Poitiers, Poitiers, France.,Santé des populations et pratiques optimales en santé University Hospital of Québec-Laval University Research Center, Canada.,EA 2694 Lille University, Lille, France
| | - Jose Ramon Paño Pardo
- Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.,IIS Aragón, Zaragoza, Spain
| | - David Sánchez-Fabra
- Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.,IIS Aragón, Zaragoza, Spain
| | | | | | - Leonardo Pagani
- Integrated Programme for the Reduction of Maternal and Child Mortality, Instituto Marquês de Valle Flôr, Bissau, Guinea-Bissau
| | - Maša Klešnik
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Mitja Hafner Fink
- Faculty of Social Sciences, University of Ljubljana, Ljubljana, Slovenia
| | - Dilip Nathwani
- University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Samo Uhan
- Faculty of Social Sciences, University of Ljubljana, Ljubljana, Slovenia
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Antibiotic use in Kenyan public hospitals: Prevalence, appropriateness and link to guideline availability. Int J Infect Dis 2020; 99:10-18. [PMID: 32781162 PMCID: PMC7562818 DOI: 10.1016/j.ijid.2020.07.084] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/18/2020] [Accepted: 07/26/2020] [Indexed: 11/28/2022] Open
Abstract
We report findings from a point prevalence survey across 14 Kenyan public hospitals. About half of the hospitalised patients received appropriate antibiotic therapy. Laboratory investigations supported less than 1% of the antibiotic prescriptions. Physical availability of treatment guidelines influenced treatment appropriateness. There is need for context-specific, up-to-date, and accessible treatment guidelines.
Objective To examine prescription patterns and explore to what extent guidelines are available and how they might influence treatment appropriateness among hospitalised patients in Kenyan hospitals. Methods Data on antimicrobial usage were collected from hospitalised patients across 14 Kenyan public hospitals. For each prescription, appropriateness of treatment was defined using available local and international treatment guidelines and through consensus with local medical specialists. Association between appropriate treatment, guideline availability and other possible explanatory factors was explored using univariate and multiple regression analysis. Results There were 1675 (46.7%) of the 3590 hospitalised patients on antimicrobials with 3145(94%) of the 3363 antimicrobial prescriptions being antibiotics. Two patients (0.1%), had treatment based on available antibiotic susceptibility tests. Appropriate treatment was assessed in 1502 patients who had a single diagnosis. Of these, 805 (53.6%) received appropriate treatment. Physical availability of treatment guidelines increased the odds of receiving appropriate treatment Odds Ratio 6.44[95% CI 4.81–8.64]. Conclusion Appropriate antibiotic prescription remains a challenge in Kenyan public hospitals. This may be improved by the availability of context-specific, up-to-date, and readily accessible treatment guidelines across all the departments, and by providing better diagnostic support.
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48
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McKenzie GAG, Bullock AF, Greenley SL, Lind MJ, Johnson MJ, Pearson M. Implementation of geriatric assessment in oncology settings: A systematic realist review. J Geriatr Oncol 2020; 12:22-33. [PMID: 32680826 DOI: 10.1016/j.jgo.2020.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/04/2020] [Accepted: 07/06/2020] [Indexed: 12/20/2022]
Abstract
Older adults with cancer are more likely to have worse clinical outcomes than their younger counterparts, and shared decision-making can be difficult, due to both complexity from adverse ageing and under-representation in clinical trials. Geriatric assessment (GA) has been increasingly recognised as a predictive and prehabilitative tool for older adults with cancer. However, GA has been notoriously difficult to implement in oncological settings due to workforce, economic, logistical, and practical barriers. We aimed to review the heterogenous literature on implementation of GA in oncology settings to understand the different implementation context configurations of GA and the mechanisms they trigger to enable successful implementation. A systematic realist review was undertaken in two stages: i) systematic searches with structured data extraction combined with iterative key stakeholder consultations to develop programme theories for implementing GA in oncology settings; ii) synthesis to refine programme theories. Medline, Embase, PsycInfo, Cochrane Library, CINAHL, Web of Science, Scopus, ASSIA, Epistemonikos, JBI Database of Systematic Reviews and Implementation Reports, DARE and Health Technology Assessment were searched. Four programme theories were developed from 53 included articles and 20 key stakeholder consultations addressing the major barriers of GA implementation in oncology practice: time (leveraging non-specialists), funding (creating favourable health economics), practicalities (establishing the use of GA in cancer care), and managing limited resources. We demonstrate that a whole system approach is required to improve the implementation of GA in cancer settings. This review will help inform policy decisions regarding implementation of GA and provide a basis for further implementation research.
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Affiliation(s)
- Gordon A G McKenzie
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom.
| | - Alex F Bullock
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom
| | - Sarah L Greenley
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom
| | - Michael J Lind
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom
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Redding LE, Lavigne S, Aceto HW, Nolen-Walston RD. Antimicrobial prescribing patterns of clinicians and clinical services at a large animal veterinary teaching hospital. Am J Vet Res 2020; 81:103-115. [PMID: 31985290 DOI: 10.2460/ajvr.81.2.103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To characterize antimicrobial prescribing patterns of clinicians and clinical services at a large animal veterinary teaching hospital and identify factors associated with antimicrobial prescribing. ANIMALS All large animals (ie, equids, bovids, sheep, goats, camelids, swine, and cervids) evaluated at the New Bolton Center hospital at the University of Pennsylvania from 2013 through 2018. PROCEDURES In a cross-sectional study design, data on antimicrobial use by clinicians and clinical services were collected from administrative and billing records. Multivariable regression modeling was performed to identify factors associated with antimicrobial prescribing patterns. RESULTS Antimicrobials and critically important antimicrobials of the highest priority were dispensed in 42.1% (9,853/23,428) and 24.0% (2,360/9,853) of visits, respectively, and these proportions differed significantly among clinicians. Per visit, the median (interquartile [25th to 75th percentile] range) number of animal-defined daily doses dispensed was 3.6 (0.8 to 11.1) and the mean (SD) number of antimicrobial classes dispensed was 2.0 (1.3). Patient species, age, affected body system, and duration of hospitalization as well as submission of specimens for bacterial culture were significantly associated with prescribing patterns. CONCLUSIONS AND CLINICAL RELEVANCE The frequency and quantity of antimicrobials prescribed differed significantly among clinicians within and across services, even for animals with clinical signs affecting the same body system. Patient- and visit-level factors explained some but not all of the heterogeneity in prescribing patterns, suggesting that other clinician-specific factors drove such practices. More research is needed to better understand antimicrobial prescribing patterns of clinicians, particularly in situations for which no antimicrobial use guidelines have been established.
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50
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Johnston J, Barrett A, Stenfors T. How to … synthesise qualitative data. CLINICAL TEACHER 2020; 17:378-381. [DOI: 10.1111/tct.13169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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