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Li C, Cui Z, Wei D, Zhang Q, Yang J, Wang W, Luo X, Chang Y. Trends and Patterns of Antibiotic Prescriptions in Primary Care Institutions in Southwest China, 2017-2022. Infect Drug Resist 2023; 16:5833-5854. [PMID: 37692470 PMCID: PMC10492579 DOI: 10.2147/idr.s425787] [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: 06/15/2023] [Accepted: 08/22/2023] [Indexed: 09/12/2023] Open
Abstract
Purpose To explore the prescription patterns and usage trends of antibiotics within primary care institutions located in underdeveloped regions of China from 2017 to 2022. Methods A retrospective analysis of antibiotic prescriptions was conducted from 25 primary care institutions in Guizhou Province during the period of 2017-2022. Antibiotic prescriptions were categorized into appropriate and inappropriate use. Appropriate use is further categorized into preferred medication, and antibiotics can be used or substituted. Inappropriate use is further categorized into unnecessary use, incorrect spectrum of antibiotics and combined use of antibiotics. Factors associated with inappropriate use were investigated using generalized estimation equations. Holt-Winters and SARIMA models were employed to predict the number of inappropriate antibiotic prescriptions as the alternative model. Results A total of 941,924 prescriptions were included, revealing a decreasing trend in both the number and inappropriate rates of antibiotic prescriptions from 2017 to 2022. Diseases of the respiratory system (70.66%) was the most frequent target of antibiotic use, with acute upper respiratory infections of multiple and unspecified sites representing 52.04% of these cases. The most commonly used antibiotics were penicillins (64.44%). Among all prescriptions, inappropriate antibiotic prescriptions reached 66.19%. Physicians aged over 35, holding the title of associate chief physician and possessing more than 11 years of experience were more likely to prescribe antibiotics inappropriately. The phenomenon of inappropriate antibiotic use was commoner among children aged five or younger. By comparing model parameters, it was determined that the SARIMA model outperforms the Holt-Winters model in predicting the number of inappropriate antibiotic prescriptions among primary care institutions. Conclusion The number and inappropriate rates of antibiotic prescriptions in southwest China exhibited a downward trend from 2017 to 2022, but inappropriate prescription remains a serious problem in primary care institutions. Therefore, future efforts should focus on strengthening physician education, training, and clinical practice. Additionally, physicians' awareness of common misconceptions about inappropriate antibiotic use must be improved, and the prescribing behavior of physicians who fulfill patients' expectations by prescribing antibiotics needs to be modified.
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Affiliation(s)
- Changlan Li
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Zhezhe Cui
- Guangxi Key Laboratory of Major Infectious Disease Prevention and Control and Biosafety Emergency Response, Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, Guangxi Province, People’s Republic of China
| | - Du Wei
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
- Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Quan Zhang
- Department of Infectious Diseases, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Junli Yang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Wenju Wang
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Xiaobo Luo
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Yue Chang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
- Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
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Lagarde M, Blaauw D. Levels and determinants of overprescribing of antibiotics in the public and private primary care sectors in South Africa. BMJ Glob Health 2023; 8:e012374. [PMID: 37524502 PMCID: PMC10391785 DOI: 10.1136/bmjgh-2023-012374] [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: 03/22/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023] Open
Abstract
Although overprovision of antibiotics in primary care is a key driver of antibiotic resistance, little is known about its determinants in low-income and middle-income countries. Patient demand and financial incentives for providers are often held responsible for overprovision. Yet, inadequate provision exists in their absence and could be fuelled by quality of care issues and incorrect beliefs of providers regarding patients' expectations. We explored these issues in the private and public sector in South Africa, by conducting a cross-sectional study using standardised patients (SPs)-healthy individuals trained to portray a scripted clinical case to providers-presenting with symptoms of a viral respiratory infection in a sample of public and private sector clinics. We linked data from SP visits to rich survey data to compare the practices and their predictors in the two sectors. Unnecessary rates of antibiotics were similarly high in the public (78%) and private sector (67%), but private providers prescribed more antibiotics at higher risk of resistance development. In the private sector, overprescription of antibiotics diminished when consultations were more thorough, but increased for consultations scheduled later in the day, suggesting contrasting effects for provider effort and decision fatigue. We observed differences in beliefs that could be responsible for overprescription: in the public sector, a majority of providers (nurses) wrongly believed that antibiotics would help the patient recover more quickly. In the private sector, a majority of doctors thought patients would not come back if they did not receive antibiotics. Overall, this evidence suggests that different factors may be responsible for the high overprescribing rates of antibiotics in the public and private sectors. Tailored stewardship interventions are urgently needed that tackle providers' engrained habits and incorrect beliefs.
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Affiliation(s)
- Mylene Lagarde
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Duane Blaauw
- Center for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
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Chen Y, Sylvia S, Dill SE, Rozelle S. Structural Determinants of Child Health in Rural China: The Challenge of Creating Health Equity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13845. [PMID: 36360724 PMCID: PMC9654689 DOI: 10.3390/ijerph192113845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 06/16/2023]
Abstract
Over the past two decades, the literature has shown a clear gradient between child health and wealth. The same health-wealth gradient is also observed among children in China, with a large gap in health between rural and urban children. However, there are still unanswered questions about the main causes of China's rural-urban child health inequality. This paper aims to review the major factors that have led to the relatively poor levels of health among China's rural children. In addition to the direct income effect on children's health, children in rural areas face disadvantages compared with their urban counterparts from the beginning of life: Prenatal care and infant health outcomes are worse in rural areas; rural caregivers have poor health outcomes and lack knowledge and support to provide adequate nurturing care to young children; there are large disparities in access to quality health care between rural and urban areas; and rural families are more likely to lack access to clean water and sanitation. In order to inform policies that improve health outcomes for the poor, there is a critical need for research that identifies the causal drivers of health outcomes among children. Strengthening the pediatric training and workforce in rural areas is essential to delivering quality health care for rural children. Other potential interventions include addressing the health needs of mothers and grandparent caregivers, improving parenting knowledge and nurturing care, improving access to clean water and sanitation for remote families, and most importantly, targeting poverty itself.
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Affiliation(s)
- Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Sarah-Eve Dill
- Stanford Center on China’s Economy and Institutions, Stanford University, Stanford, CA 94305, USA
| | - Scott Rozelle
- Stanford Center on China’s Economy and Institutions, Stanford University, Stanford, CA 94305, USA
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Likopa Z, Kivite-Urtane A, Silina V, Pavare J. Impact of educational training and C-reactive protein point-of-care testing on antibiotic prescribing in rural and urban family physician practices in Latvia: a randomised controlled intervention study. BMC Pediatr 2022; 22:556. [PMID: 36127630 PMCID: PMC9490974 DOI: 10.1186/s12887-022-03608-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although self-limiting viral infections are predominant, children with acute infections are often prescribed antibiotics by family physicians. The aim of the study is to evaluate the impact of two interventions, namely C-reactive protein point-of-care testing and educational training, on antibiotic prescribing by family physicians. METHODS This randomised controlled intervention study included acutely ill children consulted by 80 family physicians from urban and rural practices in Latvia. The family physicians were divided into two groups of 40. The family physicians in the intervention group received both interventions, i.e. C-reactive protein point-of-care testing and educational training, whereas the family physicians in the control group continued to dispense their standard care. The primary outcome measure was the antibiotic prescribing at the index consultation (delayed or immediate prescription) in both study groups. The secondary outcome was CRP testing per study group. Patient- and family physician- related predictors of antibiotic prescribing were analysed as associated independent variables. Practice location effect on the outcomes was specially addressed, similar to other scientific literature. RESULTS In total, 2039 children with acute infections were enrolled in the study. The most common infections observed were upper and lower respiratory tract infections. Overall, 29.8% (n = 607) of the study population received antibiotic prescription. Our binary logistic regression analysis did not find a statistically significant association between antibiotic prescriptions and the implemented interventions. In the control group of family physicians, a rural location was associated with more frequent antibiotic prescribing and minimal use of CRP testing of venous blood samples. However, in the intervention group of family physicians, a rural location was associated with a higher level of C-reactive protein point-of-care testing. Furthermore, in rural areas, a significant reduction in antibiotic prescribing was observed in the intervention group compared with the control group (29.0% (n = 118) and 37.8% (n = 128), respectively, p = 0.01). CONCLUSION Our results show that the availabilty of C-reactive protein point-of-care testing and educational training for family physicians did not reduce antibiotic prescribing. Nevertheless, our data indicate that regional variations in antibiotic-prescribing habits exist and the implemented interventions had an effect on family physicians practices in rural areas.
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Affiliation(s)
- Zane Likopa
- Children's Clinical University Hospital, Vienibas Gatve 45, Riga, LV-1004, Latvia. .,Riga Stradins University, Dzirciema 16, Riga, LV-1007, Latvia.
| | - Anda Kivite-Urtane
- Department of Public Health and Epidemiology, Institute of Public Health, Riga Stradins University, Kronvalda boulevard 9, Riga, LV-1010, Latvia
| | - Vija Silina
- Department of Family Medicine, Riga Stradins University, Anninmuizas boulevard 26a, Riga, LV-1067, Latvia
| | - Jana Pavare
- Children's Clinical University Hospital, Vienibas Gatve 45, Riga, LV-1004, Latvia.,Riga Stradins University, Dzirciema 16, Riga, LV-1007, Latvia
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Fang Y, Jiang S, Jiang P, Zhou H, Yang M. Are Rural Primary Care Providers Able to Competently Manage Common Illnesses? A Cross-Sectional Study in Rural Sichuan, Western China. Healthcare (Basel) 2022; 10:healthcare10091750. [PMID: 36141362 PMCID: PMC9498850 DOI: 10.3390/healthcare10091750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/25/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Strengthening primary care is a key focus of the latest healthcare reforms in China. However, many challenges, including the workforce competence, still exist. This study aimed to evaluate the common disease management competency of rural primary care providers in Sichuan Province, western China. Methods: A cross-sectional study was conducted in 9 township health centers and 86 village clinics in 3 counties. Diarrhea and respiratory infection were selected as the evaluation cases. General partitioners were assessed through their abilities to (1) take history; (2) make diagnoses; (3) propose treatment; and (4) deal with clinical cases. Results: In total, 362 healthcare workers were surveyed, and 130 general practitioners were enrolled into our study. On average, rural primary care providers could only answer 46.4% of questions absolutely correctly, with 29.7% partly correctly and 23.8% incorrectly. Conclusion: We suggest strengthening training to improve rural primary care providers’ competencies, especially their capacities of history taking. Policy action is also needed to address regional disparities.
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Affiliation(s)
- Yian Fang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
- School of Public Health, Peking University, Beijing 100191, China
| | - Shaohua Jiang
- The First Affiliated Hospital, Xinjiang Medical University, Urumqi 833054, China
| | - Pei Jiang
- School of Public Health, North Sichuan Medical College, Nanchong 637100, China
| | - Huan Zhou
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
| | - Min Yang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, China
- Faculty of Health, Design and Art, Swinburne University of Technology, Melbourne 3122, Australia
- Correspondence:
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Meng S, Wang Q, Wu Y, Xue H, Li L, Ye R, Chen Y, Pappas L, Akhtar M, Dill SE, Sylvia S, Zhou H, Rozelle S. The know-do gap in quality of health for chronic non-communicable diseases in rural China. Front Public Health 2022; 10:953881. [PMID: 36062129 PMCID: PMC9435052 DOI: 10.3389/fpubh.2022.953881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/25/2022] [Indexed: 01/24/2023] Open
Abstract
Proper management of non-communicable diseases (NCDs) is a severe challenge to China's rural health system. This study investigates what influences the poor medical treatment of NCDs (diabetes and angina) by evaluating the "know-do gap" between provider knowledge and practice. To determine whether low levels of provider knowledge low quality of patient care is the primary constraint on the quality of NCDs diagnosis and treatment in rural China. Providers from Village Clinics (VC) and Township Health Centers (THC), and Standardized Patients (SP) were selected by a multi-stage random sampling method. Clinical vignettes were administered to 306 providers from 103 VCs and 50 THCs in rural Sichuan Province. SPs presented diabetes symptoms completed 97 interactions with providers in 46 VCs and 51 THCs; SPs presented angina symptoms completed 100 interactions with providers in 50 VCs and 50 THCs. Process quality, diagnosis quality, and treatment quality were assessed against national standards for diabetes and angina. Two-tailed T-tests and tests of proportions for continuous outcomes and tests of proportions for binary dependent variables were used to compare vignette and SP results. Differences between vignette and SP data calculated the know-do gap. Regression analyses were used to examine the providers/facility characteristics and knowledge/practice associations. THC providers demonstrated significantly more knowledge in vignettes and better practices in SP visits than VC providers. However, levels of knowledge were low overall: 48.2% of THC providers and 28.2% of VC providers properly diagnosed type 2 diabetes, while 23.8% of THC providers and 14.7% of VC providers properly diagnosed angina. With SPs, 2.1% of THC providers and 6.8% of VC providers correctly diagnosed type 2 diabetes; 25.5% of THC providers and 12.8% of VC providers correctly diagnosed angina. There were significant know-do gaps in diagnosis process quality, diagnosis quality, and treatment quality for diabetes (p < 0.01), and in diagnosis process quality (p < 0.05) and treatment quality for angina (p < 0.01). Providers in rural China display low levels of knowledge when treating diabetes and angina. Despite low knowledge, evidence of the know-do gap indicates that low-quality healthcare is the primary constraint on the quality of NCD diagnosis and treatment in rural China. Our research findings provide a new perspective for the evaluation of the medical quality and a technical basis for the development of new standardized cases in the future.
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Affiliation(s)
- Sha Meng
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China,Department of Operation Management, West China Hospital, Sichuan University, Chengdu, China
| | - Qingzhi Wang
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Yuju Wu
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Xue
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Linhua Li
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Ruixue Ye
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Yunwei Chen
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lucy Pappas
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Muizz Akhtar
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Sarah-Eve Dill
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Huan Zhou
- Department of Health Behavior and Social Medicine, West China School of Public Health, West China Fourth Hospital, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Huan Zhou
| | - Scott Rozelle
- Stanford Center on China's Economy and Institutions, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, United States
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Patient satisfaction and its health provider-related determinants in primary health facilities in rural China. BMC Health Serv Res 2022; 22:946. [PMID: 35883080 PMCID: PMC9316702 DOI: 10.1186/s12913-022-08349-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 07/18/2022] [Indexed: 12/17/2022] Open
Abstract
Background Patient satisfaction is an important outcome measure of health service and is one of the main reasons for the gradual deterioration of doctor–patient relationships in China. This study used the standardized patient (SP) method to explore patient satisfaction and its health provider-related determinants among primary health facilities in rural China. Methods The dataset comprised 1138 clinic cases in 728 rural primary health facilities in 31 counties, spread across four provinces. Information regarding the consultation interaction between the unannounced SPs and primary physicians was recorded. Patient satisfaction was gathered from the feedback of SPs after the visit. Results The overall average score of SP satisfaction with rural primary health facilities was only 13.65 (SD = 3.22) out of 20. The SP scores were found to be consistent with those of real patients. After controlling variances in patient population via the SP method, the regression analysis demonstrated that health provider-related factors, such as physician-level characteristics, consultation process, affordability, and convenience, have a significant correlation with patient satisfaction among primary physicians. Among factors relating to physician-level characteristics, affordability, convenience and the consultation process of the visit, the quality of the consultation process (e.g., consultation time, proactively providing necessary instructions and other crucial information) were found to be the prominent determinants. Conclusions This study revealed the need to improve patient satisfaction in primary health facilities in rural China. To solve this issue, we recommend that policies to increase medical service quality be implemented in rural primary healthcare systems. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08349-9.
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Zhao H, Wang S, Meng R, Liu G, Hu J, Zhang H, Yan S, Zhan S. Appropriateness of Antibiotic Prescriptions in Chinese Primary Health Care and the Impact of the COVID-19 Pandemic: A Typically Descriptive and Longitudinal Database Study in Yinchuan City. Front Pharmacol 2022; 13:861782. [PMID: 35496308 PMCID: PMC9049214 DOI: 10.3389/fphar.2022.861782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/11/2022] [Indexed: 12/24/2022] Open
Abstract
Background: The appropriateness of antibiotic prescriptions in primary care has not been well evaluated in China in recent years. Furthermore, the impact of coronavirus disease 2019 (COVID-19) on antibiotic prescriptions has not yet been investigated in China. We aimed to assess the appropriateness of antibiotic prescriptions and to evaluate the potential association between the COVID-19 pandemic and antibiotic prescriptions in primary care settings of Yinchuan, a city in China. Methods: This study included 155 primary care institutions and 10,192,713 outpatient visits. Outpatient prescriptions were classified as appropriate, potentially appropriate, inappropriate, or not linked to any diagnosis for antibiotic use following a validated evaluation scheme. Interrupted time-series analyses were performed to assess the effects of the COVID-19 pandemic on antibiotic prescriptions in Chinese primary care facilities. Results: During the study period, 1,287,678 (12.6%, 95% confidence interval [12.6–12.7]) of 10,192,713 outpatient visits in primary care resulted in antibiotic prescriptions. Among 1,287,678 antibiotic prescriptions, 653,335 (50.7% [50.6–50.9]) were inappropriate, 463,081 (36.0% [35.8–36.1]) were potentially appropriate, 171,056 (13.3% [13.1–13.5]) were appropriate, and 206 could not be linked to any diagnosis. Furthermore, patient, physician, and institutional factors were associated with inappropriate antibiotic prescriptions; there was an overall decreasing trend in the proportions of inappropriate antibiotic prescriptions, with the highest level in 2017 (67.1% [66.8–67.5]) and the lowest in 2021 (40.8% [40.3–41.3]). A total of 1,416,120 individual antibiotics were prescribed, of which 1,087,630 (76.8%) were broad-spectrum and 777,672 (54.9%) were classified in the World Health Organization’s “Watch” category. In addition, the COVID-19 pandemic was associated with changes of −2.8% (−4.4 to −1.3) in the level and 0.3% (0.2–0.3) in the monthly trend of antibiotic prescription rates, as well as changes of −5.9% (−10.2 to −1.5) in the level and 1.3% (1.0–1.6) in the monthly trend of the proportions of inappropriate antibiotic prescriptions. Conclusion: More than half of the antibiotic prescriptions were inappropriate during the study period in primary care in Yinchuan. The COVID-19 pandemic may be associated with a decrease in the overall and inappropriate use of antibiotics in primary care settings in China.
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Affiliation(s)
- Houyu Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Shengfeng Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- *Correspondence: Siyan Zhan, ; Shengfeng Wang, ; Ruogu Meng,
| | - Ruogu Meng
- National Institute of Health Data Science, Peking University, Beijing, China
- *Correspondence: Siyan Zhan, ; Shengfeng Wang, ; Ruogu Meng,
| | - Guozhen Liu
- Peking University Health Information Technology, Beijing, China
| | - Jing Hu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Huina Zhang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Shaohua Yan
- Department of Oncology, Dongfang Hospital Beijing University of Chinese Medicine, Beijing, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
- Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing, China
- *Correspondence: Siyan Zhan, ; Shengfeng Wang, ; Ruogu Meng,
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Kim YC, Park JY, Kim B, Kim ES, Ga H, Myung R, Park SY, Lee MJ, Moon SM, Park SH, Song KH, Kim HB. Prescriptions patterns and appropriateness of usage of antibiotics in non-teaching community hospitals in South Korea: a multicentre retrospective study. Antimicrob Resist Infect Control 2022; 11:40. [PMID: 35193679 PMCID: PMC8861602 DOI: 10.1186/s13756-022-01082-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Although non-teaching community hospitals form the majority of healthcare providers in South Korea, there is limited data on antibiotic usage in them. To evaluate the pattern of antibiotic usage and its appropriateness in hospitals with < 400 beds in South Korea. Methods A multicentre retrospective study was conducted in 10 hospitals (six long-term care hospitals, three acute care hospitals, and one orthopaedic hospital), with < 400 beds in South Korea. We analysed patterns of antibiotic prescription in 2019, and their appropriateness in the participating hospitals. For the evaluation of the appropriateness of the prescription, 25 patients under antibiotic therapy were randomly selected at each hospital, over two separate periods. Due to the heterogeneity of their characteristics, the orthopaedics hospital was excluded from the analysis. Results The most commonly prescribed antibiotics in long-term care hospitals was fluoroquinolone, followed by beta-lactam/beta-lactamase inhibitor (anti-pseudomonal). In acute care hospitals, these were third generation cephalosporin, followed by first generation cephalosporin, and second generation cephalosporin. The major antibiotics that were prescribed in the orthopedics hospital was first generation cephalosporin Only 2.3% of the antibiotics were administered inappropriately. In comparison, 15.3% of patients were prescribed an inappropriate dose. The proportion of inappropriate antibiotic prescriptions was 30.6% of the total antibiotic prescriptions. Conclusions The antibiotic usage patterns vary between non-teaching community hospitals in South Korea. The proportion of inappropriate prescriptions exceeded 30% of the total antibiotic prescriptions. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-022-01082-2.
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Affiliation(s)
- Yong Chan Kim
- Department of Internal Medicine, Division of Infectious Diseases, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Ji Young Park
- Department of Pediatrics, Chung-Ang University Hospital, Seoul, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Korea.
| | - Eu Suk Kim
- Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam, 13620, Gyeonggi-do, Korea.
| | - Hyuk Ga
- Incheon Eun-Hye Hospital, Incheon, Korea
| | - Rangmi Myung
- Department of Economics, College of Political Science and Economics, Korea University, Seoul, Korea
| | - Se Yoon Park
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Myung Jin Lee
- Department of Internal Medicine, Inje University Sanggye-Paik Hospital, Seoul, Korea
| | - Song Mi Moon
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sun Hee Park
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyoung-Ho Song
- Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam, 13620, Gyeonggi-do, Korea
| | - Hong Bin Kim
- Division of Infectious Diseases, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam, 13620, Gyeonggi-do, Korea
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Xingrong S, Rui F, Jing C, Jing C, Oliver I, Lambert H, Wang D. Relationships Between Diagnosis, Bacterial Isolation, and Antibiotic Prescription in Out Patients With Respiratory Tract Infection Symptoms in Rural Anhui, China. Front Public Health 2022; 10:810348. [PMID: 35223737 PMCID: PMC8864097 DOI: 10.3389/fpubh.2022.810348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesThis paper aims to explore the direct associations of antibiotics prescription with clinical diagnosis and bacterial detection. It also analyses the relations of clinical diagnosis with symptoms and bacterial detection, with a hope of revealing indirect links to antibiotic prescription.MethodsThe study was implemented in one village clinic and one township health center in each of four rural residential areas in Anhui Province, China. Observations were conducted to record clinical diagnosis and antibiotic prescription. A semi-structured questionnaire survey was used to collected patients' sociodemographic information and reported symptoms. Sputum and throat swabs were collected for bacterial culture.ResultsAmong 1,068 patients presenting in the study settings who received a diagnosis of respiratory tract infection (RTI), 87.8% of prescriptions included an antibiotic and 35.8% included two or more antibiotics. Symptomatic RTI patients to the site clinics were diagnosed mainly as having upper respiratory tract infection (32.0%), bronchitis/tracheitis (23.4%), others (16.6%), pharyngitis (11.1%), common cold (8.0%), pneumonia/bronchopneumonia (4.6%) and tonsillitis (4.3%). These clinical diagnosis were associated with symptoms to a varied degree especially for upper respiratory tract infection and bronchitis/tracheitis. Prescription of any antibiotics was positively associated with diagnosis of bronchitis/tracheitis (OR: 5.00, 95% CI: 2.63–9.51), tonsillitis (OR: 4.63, 95% CI: 1.48–14.46), pneumonia/bronchopneumonia (OR: 4.28, 95% CI: 1.40–13.04), pharyngitis (OR: 3.22, 95% CI: 1.57–6.59) and upper respiratory tract infection (OR: 3.04, 95% CI: 1.75–5.27). Prescription of two or more antibiotics was statistically significant related to diagnosis of bronchitis/ tracheitis (OR: 2.20, 95% CI: 1.44–3.35) or tonsillitis (OR: 2.97, 95% CI: 1.47–6.00). About 30% of the patients were identified with some type of bacteria. Bacteria detection was linked with pharyngitis (OR: 0.50, 95% CI: 0.28–0.88) but not prescription of antibiotics.ConclusionsAntibiotics prescription were found with a strong relation to diagnosis of RTIs given by the clinician but was not associated with the presence of bacteria in patient samples. Part of the diagnosis may have been given by the clinician to justify their antibiotics prescription. There is clear need to use additional measures (e.g., symptoms) in conjunction with diagnosis to supervise or audit excessive antibiotics use.
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Affiliation(s)
- Shen Xingrong
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Feng Rui
- Department of Literature Review and Analysis, Library of Anhui Medical University, Hefei, China
| | - Chai Jing
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Cheng Jing
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Isabel Oliver
- National Infection Service, Public Health England, Bristol, United Kingdom
| | - Helen Lambert
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Debin Wang
- School of Health Service Management, Anhui Medical University, Hefei, China
- *Correspondence: Debin Wang
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11
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Liu C, Wang D, Duan L, Zhang X, Liu C. Coping With Diagnostic Uncertainty in Antibiotic Prescribing: A Latent Class Study of Primary Care Physicians in Hubei China. Front Public Health 2021; 9:741345. [PMID: 34957007 PMCID: PMC8695689 DOI: 10.3389/fpubh.2021.741345] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Misuse of antibiotics is prevalent worldwide and primary care is a major contributor. Although a clear diagnosis is fundamental for rational antibiotic use, primary care physicians often struggle with diagnostic uncertainty. However, we know little about how physicians cope with this situation and its association with antibiotic prescribing. Methods: A total of 583 primary care physicians were surveyed using the Dealing with Uncertainty Questionnaire. Their prescriptions (n = 949,181) over the year 2018 were retrieved retrospectively. Two categories of behavioral patterns of participants were identified based on latent class analyses (high vs. low openness and collaborativeness) in responding to diagnostic uncertainty. Multi-level logistic regression models were established to determine the associations between these behavioral patterns and antibiotic prescribing (overall and broad-spectrum antibiotics) for illness without an indication for antibiotics and those with a conditional indication for antibiotics, respectively, after adjustment for variations of patient (level one) and physician (level two) characteristics. Results: Most physicians reported open communications with their patients (80.96%), collected further information (85.08%), and referred patients to specialists (68.95%) in dealing with diagnostic uncertainly. More than half (56.95%) sought help from colleagues. Less than 20% acted on intuition or adopted a “wait and see” strategy. About 40% participants (n = 238) were classified into the group of low openness and collaborativeness in coping with diagnostic uncertainty. They were more likely to prescribe antibiotics for the recorded illness without an indication for antibiotics (AOR = 1.013 for all antibiotics, p = 0.024; AOR = 1.047 for broad-spectrum antibiotics, p < 0.001), as well as for the recorded illness with a conditional indication for antibiotics (AOR = 1.226 for all antibiotic, p < 0.001; AOR = 1.257 for broad-spectrum antibiotics, p < 0.001). Conclusion: Low tolerance with diagnostic uncertainty is evident in primary care. Inappropriate and over antibiotic prescribing is shaped by physicians' coping methods of diagnostic uncertainty. Physicians' openness and collaborativeness in responding to diagnostic uncertainty is associated with lower antibiotic prescribing in primary care. Interventions targeting on better management of diagnostic uncertainty may offer a promising approach in reducing antibiotic use in primary care.
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Affiliation(s)
- Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Dan Wang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Lixia Duan
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Chenxi Liu
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
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12
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Rao S, Xue H, Teuwen DE, Shi H, Yi H. Measurements of quality of village-level care and patients' healthcare-seeking behaviors in rural China. BMC Public Health 2021; 21:1873. [PMID: 34657604 PMCID: PMC8520638 DOI: 10.1186/s12889-021-11946-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background Although the progress in global health initiatives has improved the availability of primary health care (PHC), unqualified healthcare remains a serious challenge in low- and middle-income countries, where PHC is often underutilized. This study examines factors associated with patients’ healthcare-seeking behaviors in rural Chin—seeking healthcare at village-level PHC providers, at higher-level health facilities, self-medicating, and refraining from seeking medical help. We focus on provider-side factors, including (1) the unobservable quality indicator, (2) the observable quality indicator, and (3) the observable signal indicator. Methods We analyzed 1578 episodes of healthcare-seeking behaviors of patients with diarrhea or cough/runny nose symptom from surveys conducted in July 2017 and January 2018 in 114 villages of the Yunnan province. We investigated the correlation between quality-related factors with patients’ healthcare-seeking behaviors by multinomial logit regression. Results We found that rural patients were insensitive to the unobservable quality of healthcare providers, as measured by standardized clinical vignettes, which might be attributable to the credence nature of PHC. The observable quality indicator, whether the clinician has received full-time junior college formal medical education, was associated with patients’ healthcare choices. Patients, however, were more likely to select healthcare based on the observable signal indicator, which was measured by the availability of medicines. Additionally, the observable signal indicator had no significant association with two quality indicators. Notably, socioeconomically-disadvantaged patients relied more on the village-level PHC, which emphasized the role of PHC in promoting the welfare of rural populations. Conclusions Our study found an inconsistency between objective quality of healthcare provided by providers and subjective quality perceived by patients. Patients could not identify the actual quality of PHC precisely, while they were more likely to make decisions based on the observable signal indicator. Therefore, the quality of PHC should be more observable to patients. This study not only supplements the literature on healthcare-seeking choices by examining four types of behaviors simultaneously but also clarifies rural patients’ perceptions of the quality of PHC for policy decision-making on increasing the utilization of PHC and improving the medical welfare of the vulnerable. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11946-8.
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Affiliation(s)
- Sihang Rao
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Room 408B, Wangkezhen Building, No. 5, Yiheyuan Road, Haidian, Beijing, 100871, China
| | - Hao Xue
- Stanford Center on China's Economy and Institutions, Stanford University, California, USA
| | - Dirk E Teuwen
- Medical Sustainability, UCB, Brussels, Belgium.,Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Haonan Shi
- Business Development Center, Red Cross Society of China, Beijing, China
| | - Hongmei Yi
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Room 408B, Wangkezhen Building, No. 5, Yiheyuan Road, Haidian, Beijing, 100871, China.
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13
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Yau JW, Thor SM, Tsai D, Speare T, Rissel C. Antimicrobial stewardship in rural and remote primary health care: a narrative review. Antimicrob Resist Infect Control 2021; 10:105. [PMID: 34256853 PMCID: PMC8278763 DOI: 10.1186/s13756-021-00964-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies. METHODS The international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools. RESULTS Fifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing. CONCLUSIONS Inappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.
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Affiliation(s)
- Jun Wern Yau
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500, Bandar Sunway, Malaysia
| | - Sze Mun Thor
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500, Bandar Sunway, Malaysia
| | - Danny Tsai
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia.,Alice Springs Hospital, Central Australian Health Service, Alice Springs, NT, 0870, Australia.,University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Tobias Speare
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia.,Alice Springs Hospital, Central Australian Health Service, Alice Springs, NT, 0870, Australia
| | - Chris Rissel
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia.
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14
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Lin L, Sun R, Yao T, Zhou X, Harbarth S. Factors influencing inappropriate use of antibiotics in outpatient and community settings in China: a mixed-methods systematic review. BMJ Glob Health 2021; 5:bmjgh-2020-003599. [PMID: 33184066 PMCID: PMC7662435 DOI: 10.1136/bmjgh-2020-003599] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND For decades, antibiotics have been excessively consumed around the world, contributing to increased antimicrobial resistance (AMR) and negatively impacting health outcomes and expenditures. Antibiotic use in China accounts for half of worldwide antibiotic consumption, which mainly takes place in outpatient and community settings, and often unnecessarily for self-limiting community-acquired infections. This study aimed to identify and assess factors of inappropriate use of antibiotics in the Chinese context to inform the development of interventions to mitigate inappropriate consumption in the absence of clinical indications. METHODS We conducted a mixed-methods systematic review and included empirical studies with original data conducted in mainland China, Hong Kong and Taiwan that investigated factors of antibiotic use in the community including outpatient care among patients, caregivers and prescribers. We searched MEDLINE, EMBASE, the Cochrane Library, PsycINFO, Google Scholar and one Chinese database CNKI (China Knowledge Resource Integrated Database), using a combination of the key terms 'antibiotic', 'antimicrobial', 'use', 'consumption', 'behaviour', 'prescribe' and related syntax for all peer-reviewed publications published before June 2020. Health Belief Model was employed for data synthesis. FINDINGS Fifty-four studies were included in the full-text review: 44 quantitative, 5 qualitative and 5 mixed-methods studies. Despite a high AMR awareness, public perception/misconception of antibiotic efficacy and easy access to antibiotics for self-limiting conditions drive inappropriate demand and use in the community including primary care setting. Providers' prescribing behaviours are influenced by financial incentives, lack of diagnostic capacity and concerns over complications. CONCLUSIONS Inappropriate outpatient and community antibiotic use is influenced by non-biomedical factors at the individual, community, health system and societal levels in mainland China, contributing to a high antibiotic use rate. This study calls for context-tailored One Health interventions, restrictive antibiotic drug policy and multifaceted antibiotic stewardship programmes that simultaneously address drivers of inappropriate use from both the supply-side and demand-side within and beyond clinical settings. PROSPERO REGISTRATION NUMBER CRD42019139591.
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Affiliation(s)
- Leesa Lin
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ruyu Sun
- Institute of Social Medicine, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tingting Yao
- Institute of Social Medicine, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xudong Zhou
- Institute of Social Medicine, School of Medicine, Zhejiang University, Hangzhou, China
| | - Stephan Harbarth
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland.,Infectious Diseases Division, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
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15
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Sulis G, Daniels B, Kwan A, Gandra S, Daftary A, Das J, Pai M. Antibiotic overuse in the primary health care setting: a secondary data analysis of standardised patient studies from India, China and Kenya. BMJ Glob Health 2021; 5:bmjgh-2020-003393. [PMID: 32938614 PMCID: PMC7493125 DOI: 10.1136/bmjgh-2020-003393] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Determining whether antibiotic prescriptions are inappropriate requires knowledge of patients’ underlying conditions. In low-income and middle-income countries (LMICs), where misdiagnoses are frequent, this is challenging. Additionally, such details are often unavailable for prescription audits. Recent studies using standardised patients (SPs) offer a unique opportunity to generate unbiased prevalence estimates of antibiotic overuse, as the research design involves patients with predefined conditions. Methods Secondary analyses of data from nine SP studies were performed to estimate the proportion of SP–provider interactions resulting in inappropriate antibiotic prescribing across primary care settings in three LMICs (China, India and Kenya). In all studies, SPs portrayed conditions for which antibiotics are unnecessary (watery diarrhoea, presumptive tuberculosis (TB), angina and asthma). We conducted descriptive analyses reporting overall prevalence of antibiotic overprescribing by healthcare sector, location, provider qualification and case. The WHO Access–Watch–Reserve framework was used to categorise antibiotics based on their potential for selecting resistance. As richer data were available from India, we examined factors associated with antibiotic overuse in that country through hierarchical Poisson models. Results Across health facilities, antibiotics were given inappropriately in 2392/4798 (49.9%, 95% CI 40.8% to 54.5%) interactions in India, 83/166 (50.0%, 95% CI 42.2% to 57.8%) in Kenya and 259/899 (28.8%, 95% CI 17.8% to 50.8%) in China. Prevalence ratios of antibiotic overuse in India were significantly lower in urban versus rural areas (adjusted prevalence ratio (aPR) 0.70, 95% CI 0.52 to 0.96) and higher for qualified versus non-qualified providers (aPR 1.55, 95% CI 1.42 to 1.70), and for presumptive TB cases versus other conditions (aPR 1.19, 95% CI 1.07 to 1.33). Access antibiotics were predominantly used in Kenya (85%), but Watch antibiotics (mainly quinolones and cephalosporins) were highly prescribed in India (47.6%) and China (32.9%). Conclusion Good-quality SP data indicate alarmingly high levels of antibiotic overprescription for key conditions across primary care settings in India, China and Kenya, with broad-spectrum agents being excessively used in India and China.
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Affiliation(s)
- Giorgia Sulis
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada.,McGill International TB Centre, McGill University, Montreal, Québec, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
| | - Ada Kwan
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Medicine, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, York University, Toronto, Ontario, Canada.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA.,Centre for Policy Research, New Delhi, Delhi, India
| | - Madhukar Pai
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada .,McGill International TB Centre, McGill University, Montreal, Québec, Canada.,Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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16
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Green C, Hollingsworth B, Yang M. The impact of social health insurance on rural populations. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:473-483. [PMID: 33638010 PMCID: PMC7954739 DOI: 10.1007/s10198-021-01268-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 01/16/2021] [Indexed: 06/12/2023]
Abstract
Improving health outcomes of rural populations in low- and middle-income countries represents a significant challenge. A key part of this is ensuring access to health services and protecting households from financial risk caused by unaffordable medical care. In 2003, China introduced a heavily subsidised voluntary social health insurance programme that aimed to provide 800 million rural residents with access to health services and curb medical impoverishment. This paper provides new evidence on the impact of the scheme on health care utilisation and medical expenditure. Given the voluntary nature of the insurance enrolment, we exploit the uneven roll-out of the programme across rural counties as a natural experiment to explore causal inference. We find little effect of the insurance on the use of formal medical care and out-of-pocket health payments. However, there is evidence that it directed people away from informal health care towards village clinics, especially among patients with lower income. The insurance has also led to a reduction in the use of city hospitals among the rich. The shift to village clinics from informal care and higher-level hospitals suggests that the NRCMS has the potential to improve efficiency within the health care system and help patients to obtain less costly primary care. However, the poor quality of primary care and insufficient insurance coverage for outpatient services remains a concern.
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Affiliation(s)
- Colin Green
- Present Address: Department of Economics, Norweigian University of Science and Technology, Trondheim, Norway
| | | | - Miaoqing Yang
- Department of Economics, Lancaster University Management School, Lancaster University, Lancaster, LA2 0PF UK
- Present Address: National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF UK
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17
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Gautham M, Spicer N, Chatterjee S, Goodman C. What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India. Soc Sci Med 2021; 275:113813. [PMID: 33721743 PMCID: PMC8164106 DOI: 10.1016/j.socscimed.2021.113813] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/08/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022]
Abstract
In many low- and middle-income countries, providers without formal training are an important source of antibiotics, but may provide these inappropriately, contributing to the rising burden of drug resistant infections. Informal providers (IPs) who practise allopathic medicine are part of India's pluralistic health system legacy. They outnumber formal providers but operate in a policy environment of unclear legitimacy, creating unique challenges for antibiotic stewardship. Using a systems approach we analysed the multiple intrinsic (provider specific) and extrinsic (community, health and regulatory system and pharmaceutical industry) drivers of antibiotic provision by IPs in rural West Bengal, to inform the design of community stewardship interventions. We surveyed 291 IPs in randomly selected village clusters in two contrasting districts and conducted in-depth interviews with 30 IPs and 17 key informants including pharmaceutical sales representatives, managers and wholesalers/retailers; medically qualified private and public doctors and health and regulatory officials. Eight focus group discussions were conducted with community members. We found a mosaic or bricolage of informal practices conducted by IPs, qualified doctors and industry stakeholders that sustained private enterprise and supplemented the weak public health sector. IPs' intrinsic drivers included misconceptions about the therapeutic necessity of antibiotics, and direct and indirect economic benefits, though antibiotics were not the most profitable category of drug sales. Private doctors were a key source of IPs' learning, often in exchange for referrals. IPs constituted a substantial market for local and global pharmaceutical companies that adopted aggressive business strategies to exploit less-saturated rural markets. Paradoxically, the top-down nature of regulations produced a regulatory impasse wherein regulators were reluctant to enforce heavy sanctions for illegal sales, fearing an adverse impact on rural healthcare, but could not implement enabling strategies to improve antibiotic provision due to legal barriers. We discuss the implications for a multi-stakeholder antibiotic stewardship strategy in this setting.
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Affiliation(s)
- Meenakshi Gautham
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17, Tavistock Place, London, WC1H 9SH, UK.
| | - Neil Spicer
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17, Tavistock Place, London, WC1H 9SH, UK.
| | | | - Catherine Goodman
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17, Tavistock Place, London, WC1H 9SH, UK.
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18
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Wang D, Liu C, Zhang X, Liu C. Does diagnostic uncertainty increase antibiotic prescribing in primary care? NPJ Prim Care Respir Med 2021; 31:17. [PMID: 33767206 PMCID: PMC7994848 DOI: 10.1038/s41533-021-00229-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 02/17/2021] [Indexed: 01/05/2023] Open
Abstract
This study aimed to determine the association between factors relevant to diagnostic uncertainty and physicians' antibiotic-prescribing behaviour in primary care. A questionnaire survey was conducted on 327 physicians that measured their diagnostic ability, perceived frequency of diagnostic uncertainty, tolerance, and perceived patient tolerance of uncertainty. Physician antibiotic-prescribing behaviours were assessed based on their prescriptions (n = 207,804) of three conditions: upper respiratory tract infections (URTIs, antibiotics not recommended), acute tonsillitis (cautious use of antibiotics), and pneumonia (antibiotics recommended). A two-level logistic regression model determined the association between diagnostic uncertainty factors and physician antibiotic prescribing. Physicians perceived a higher frequency of diagnostic uncertainty resulting in higher antibiotic use for URTIs and less antibiotic use for pneumonia. Higher antibiotic use for acute tonsillitis was related to a low tolerance of uncertainty of physicians and patients. This study suggests that reducing diagnostic uncertainty and improving physician and patient uncertainty management could reduce antibiotic use.
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Affiliation(s)
- Dan Wang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chenxi Liu
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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19
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Shen L, James Dyar O, Sun Q, Wei X, Yang D, Sun C, Wang Y, Li H, Liu Y, Luo Y, Yin J, Stålsby Lundborg C. The Effectiveness of an Educational Intervention on Knowledge, Attitudes and Reported Practices on Antibiotic Use in Humans and Pigs: A Quasi-Experimental Study in Twelve Villages in Shandong Province, China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041940. [PMID: 33671284 PMCID: PMC7922583 DOI: 10.3390/ijerph18041940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/07/2021] [Accepted: 02/12/2021] [Indexed: 11/16/2022]
Abstract
Our aim was to evaluate the effectiveness of an intervention for residents in rural China on knowledge, attitudes and reported practices (KAP) on antibiotic use in humans and pigs. A quasi-experimental study was conducted in 12 villages in rural Shandong province, divided into intervention and control groups, covering a two-year period from July 2015 to June 2017. A package of health education-based interventions including training sessions, speakerphone messages, posters and handbooks for residents was developed and implemented over a one-year period to improve the use of antibiotics in humans and pigs. The intervention net effects were evaluated by Difference-in-Difference (DID) analysis based on responses to a questionnaire concerning KAP towards antibiotic use in humans and pigs. A total of 629 participants completed both baseline and post-trial questionnaires, including 127 participants with backyard pig farms. Significant improvements were found in KAP towards antibiotic use in humans, but changes related to antibiotic use for pigs were not significant. Participants who were in the intervention group (p < 0.001) were more likely to have improved their knowledge on antibiotic use in humans. Participants who had higher attitude scores were less likely to report self-medicating with stored antibiotics in the previous year (p < 0.001). Our results suggest that our health education-based intervention was effective in improving KAP on human antibiotic use, but it had little effect regarding antibiotic use for pigs.
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Affiliation(s)
- Liyan Shen
- NHC Key Lab of Health Economics and Policy Research, Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China; (L.S.); (Q.S.); (D.Y.); (H.L.)
| | - Oliver James Dyar
- Department of Global Public Health, Karolinska Institutet, 17177 Stockholm, Sweden; (O.J.D.); (C.S.L.)
| | - Qiang Sun
- NHC Key Lab of Health Economics and Policy Research, Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China; (L.S.); (Q.S.); (D.Y.); (H.L.)
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 2E8, Canada;
| | - Ding Yang
- NHC Key Lab of Health Economics and Policy Research, Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China; (L.S.); (Q.S.); (D.Y.); (H.L.)
| | - Chengtao Sun
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Veterinary Medicine, China Agricultural University, Beijing 100083, China; (C.S.); (Y.W.)
| | - Yang Wang
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Veterinary Medicine, China Agricultural University, Beijing 100083, China; (C.S.); (Y.W.)
| | - Hongyu Li
- NHC Key Lab of Health Economics and Policy Research, Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China; (L.S.); (Q.S.); (D.Y.); (H.L.)
| | - Yuqing Liu
- Institute of Animal Science and Veterinary Medicine, Shandong Academy of Agricultural Science, Jinan 250100, China; (Y.L.); (Y.L.)
| | - Yanbo Luo
- Institute of Animal Science and Veterinary Medicine, Shandong Academy of Agricultural Science, Jinan 250100, China; (Y.L.); (Y.L.)
| | - Jia Yin
- NHC Key Lab of Health Economics and Policy Research, Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China; (L.S.); (Q.S.); (D.Y.); (H.L.)
- Correspondence:
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Karolinska Institutet, 17177 Stockholm, Sweden; (O.J.D.); (C.S.L.)
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Wang D, Liu C, Wang X, Zhang X. Association between Physicians' Perception of Shared Decision Making with Antibiotic Prescribing Behavior in Primary Care in Hubei, China: A Cross-Sectional Study. Antibiotics (Basel) 2020; 9:antibiotics9120876. [PMID: 33302365 PMCID: PMC7762535 DOI: 10.3390/antibiotics9120876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/04/2020] [Accepted: 12/05/2020] [Indexed: 01/21/2023] Open
Abstract
Shared decision-making (SDM) has been advocated as one effective strategy for improving physician–patient relationships and optimizing clinical outcomes. Our study aimed to measure physicians’ perception of SDM and establish the relationship between physicians’ perception of SDM and prescribing behavior in patients with upper respiratory tract infections. One cross-sectional study was conducted in Hubei Province from December 2019 to January 2020. The SDM questionnaire and prescription data of 2018 from electronic health records data were matched for each physician in this study. Multilevel modeling was applied to explore the relationship between physicians’ perception of SDM and antibiotic prescribing in primary care. Analyses were statistically controlled for demographic characteristics of the physicians and patients. Physicians’ positive perception of SDM had small but statistically significant effects on lower prescribing of antibiotics in the patient group aged over 40 years (odds ratio (OR) < 1; p < 0.05). Moreover, female physicians (OR = 0.71; p = 0.007) with higher educational levels (bachelor’s degree and above; OR = 0.71; p = 0.024) were significantly associated with the prescribing of less antibiotics (p < 0.05). A more positive perception of SDM was demonstrated as one significant predictor of less prescribing of antibiotics in the patient group over 40 years. There may be a promising focus of implementing SDM strategies targeting physician–patient communication in primary care.
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Wang D, Liu C, Zhang X, Liu C. Identifying Antibiotic Prescribing Patterns Through Multi-Level Latent Profile Analyses: A Cross-Sectional Survey of Primary Care Physicians. Front Pharmacol 2020; 11:591709. [PMID: 33343361 PMCID: PMC7748108 DOI: 10.3389/fphar.2020.591709] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Overuse of antibiotics significantly fuels the development of Antimicrobial resistance, which threating the global population health. Great variations existed in antibiotic prescribing practices among physicians, indicating improvement potential for rational use of antibiotics. This study aims to identify antibiotic prescribing patterns of primary care physicians and potential determinants. Methods: A cross-sectional survey was conducted on 551 physicians from 67 primary care facilities in Hubei selected through random cluster sampling, tapping into their knowledge, attitudes and prescribing practices toward antibiotics. Prescriptions (n = 501,072) made by the participants from 1 January to March 31, 2018 were extracted from the medical records system. Seven indicators were calculated for each prescriber: average number of medicines per prescription, average number of antibiotics per prescription, percentage of prescriptions containing antibiotics, percentage of antibiotic prescriptions containing broad-spectrum antibiotics, percentage of antibiotic prescriptions containing parenteral administered antibiotics, percentage of antibiotic prescriptions containing restricted antibiotics, and percentage of antibiotic prescriptions containing antibiotics included in the WHO “Watch and Reserve” list. Two-level latent profile analyses were performed to identify the antibiotic prescribing patterns of physicians based on those indicators. Multi-nominal logistic regression models were established to identify determinants with the antibiotic prescribing patterns. Results: On average, each primary care physician issued 909 (ranging from 100 to 11,941 with a median of 474) prescriptions over the study period. The mean percentage of prescriptions containing antibiotics issued by the physicians reached 52.19% (SD = 17.20%). Of those antibiotic prescriptions, an average of 82.29% (SD = 15.83%) contained broad-spectrum antibiotics; 71.92% (SD = 21.42%) contained parenteral administered antibiotics; 23.52% (SD = 19.12%) contained antibiotics restricted by the regional government; and 67.74% (SD = 20.98%) contained antibiotics listed in the WHO “Watch and Reserve” list. About 28.49% of the prescribers were identified as low antibiotic users, compared with 51.18% medium users and 20.33% high users. Higher use of antibiotics was associated with insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location of the prescribers. Conclusion: Great variation in antibiotic prescribing patterns exists among primary care physicians in Hubei of China. High use of antibiotics is not only associated with knowledge shortfalls but also low socioeconomic status of prescribers.
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Affiliation(s)
- Dan Wang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Chenxi Liu
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
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22
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Guo W, Sylvia S, Umble K, Chen Y, Zhang X, Yi H. The competence of village clinicians in the diagnosis and treatment of heart disease in rural China: A nationally representative assessment. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2020; 2:100026. [PMID: 34327377 PMCID: PMC8315592 DOI: 10.1016/j.lanwpc.2020.100026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/27/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023]
Abstract
Background While strengthening primary care quality is key to China's health system reforms, evidence to guide this work has been limited, particularly for rural areas. This study provides the first nationally-representative assessment of village doctors’ competence in diagnosing and managing presumptive heart disease. Methods A cross-sectional study of village clinics was conducted across five provinces. We presented standardized clinical vignettes to evaluate clinicians’ competence in diagnosing and managing unstable angina. Enumerators accompanying mock patients documented the interaction, including questions, physical examinations, diagnoses, and management options provided by the doctor. We measured diagnostic process competence as adherence to “recommended” questions and examinations based on national clinical practice guidelines, diagnostic competence according to whether clinicians provided a correct diagnosis, and management as correct medication and/or referral. Management was assessed twice: following clinicians’ own diagnoses determined through questioning and examinations, and after enumerators provided doctors with the correct diagnosis. Findings Clinicians completed 26% (95% CI 24% to 28%) of recommended diagnostic questions and examinations; 20% (14% to 27%) arrived at a correct diagnosis. Rates of correct management were 43% (35% to 51%) following clinicians’ own diagnosis and 51% (43% to 59%) after being given the correct diagnosis. When given the correct diagnosis and only asked to provide treatment, clinicians prescribed 82% fewer potentially harmful medications than in treatments based on their own (potentially incorrect) diagnosis. Interpretation The ability of village doctors to diagnose a textbook case of unstable angina is limited. Deficits in diagnostic competence led to low rates of correct management.
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Affiliation(s)
- Wilson Guo
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, United States
| | - Sean Sylvia
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, United States
| | - Karl Umble
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, United States
| | - Yunwei Chen
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, United States
| | - Xiaoyuan Zhang
- Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, NY, United States
| | - Hongmei Yi
- School of Advanced Agricultural Sciences, Peking University, Room 408B, Wangkezhen Building, No. 5, Yiheyuan Road, Haidian, Beijing 100871, China
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23
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Yi H, Wu P, Zhang X, Teuwen DE, Sylvia S. Market competition and demand for skills in a credence goods market: Evidence from face-to-face and web-based non-physician clinician training in rural China. PLoS One 2020; 15:e0233955. [PMID: 32555610 PMCID: PMC7302647 DOI: 10.1371/journal.pone.0233955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/13/2020] [Indexed: 11/19/2022] Open
Abstract
Background Non-physician clinicians (NPCs) providing services in functionally private markets account for a large share of the workforce in the primary care system in many low-income and middle-income countries. Although regular in-service training is believed to be crucial to updating NPCs’ professional knowledge, skills, and practices, participation rates are often low. Low participation may result from the “credence good” nature of the market for primary care: if patients are unable to observe quality improvements from training, NPCs have weaker incentives to participate. Empirical evidence is limited on the relationship between market competition and NPC participation in-service training as well as how participation varies with the type of training available. Methods The study uses a dataset of 301 NPCs from three prefectures in Yunnan, a province in southwest China, collected in July 2017. Logistic regression is used to estimate the relationship between competition and NPC’s participation in in-service training. We assess the relationship between participation and both the quantity of competition (number of competitors in the same village and surrounding villages) and the quality of competition (proxied using characteristics of competing clinicians). Results In 2016, nearly two thirds of NPCs participated in face-to-face or web-based in-service trainings at least once. Specifically, 58 percent of NPCs participated in face-to-face in-service trainings, and 24 percent of NPCs participated in web-based in-service trainings. The quantity of competitors is unrelated to participation in in-service training. The quality of competition is not related to face-to-face training but has a significant positive relationship with participation in web-based training. Conclusions Web-based trainings may be a better approach to increase NPC skills in developing country primary care markets.
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Affiliation(s)
- Hongmei Yi
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
- * E-mail:
| | - Paiou Wu
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Xiaoyuan Zhang
- Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, New York, United States of America
| | - Dirk E. Teuwen
- Corporate Societal Responsibility, UCB, Brussels, Belgium
| | - Sean Sylvia
- Department of Health Policy and Management and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Sulis G, Adam P, Nafade V, Gore G, Daniels B, Daftary A, Das J, Gandra S, Pai M. Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis. PLoS Med 2020; 17:e1003139. [PMID: 32544153 PMCID: PMC7297306 DOI: 10.1371/journal.pmed.1003139] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/08/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate. METHODS AND FINDINGS We searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%-53%), with a prediction interval of 44%-60%. Individual studies' estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription. CONCLUSIONS Antibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines. TRIAL REGISTRATION PROSPERO registration number: CRD42019123269.
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Affiliation(s)
- Giorgia Sulis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Pierrick Adam
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Vaidehi Nafade
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Genevieve Gore
- Schulich Library of Physical Sciences, Life Sciences and Engineering, McGill University, Montreal, Quebec, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, United States of America
| | - Amrita Daftary
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- School of Health Policy and Management, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, United States of America
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Dyar OJ, Yang D, Yin J, Sun Q, Stålsby Lundborg C. Variations in antibiotic prescribing among village doctors in a rural region of Shandong province, China: a cross-sectional analysis of prescriptions. BMJ Open 2020; 10:e036703. [PMID: 32487580 PMCID: PMC7265041 DOI: 10.1136/bmjopen-2019-036703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To assess variation in antibiotic prescribing practices among village doctors in a rural region of Shandong province, China. DESIGN, SETTING AND PARTICIPANTS Almost all outpatient encounters at village clinics result in a prescription being issued. Prescriptions were collected over a 2.5-year period from 8 primary care village clinics staffed by 24 doctors located around a town in rural Shandong province. A target of 60 prescriptions per clinic per month was sampled from an average total of around 300. Prescriptions were analysed at both aggregate and individual-prescriber levels, with a focus on diagnoses of likely viral acute upper respiratory tract infections (AURIs), defined as International Classification of Diseases, 10th Revision codes J00 and J06.9. MAIN OUTCOME MEASURES Proportions of prescriptions for AURIs containing (1) at least one antibiotic, (2) multiple antibiotics, (3) at least one parenteral antibiotic; classes and agents of antibiotics prescribed. RESULTS In total, 14 471 prescriptions from 23 prescribers were ultimately included, of which 5833 (40.3%) contained at least 1 antibiotic. Nearly two-thirds 62.5% (3237/5177) of likely viral AURI prescriptions contained an antibiotic, accounting for 55.5% (3237/5833) of all antibiotic-containing prescriptions. For AURIs, there was wide variation at the individual level in antibiotic prescribing rates (33.1%-88.0%), as well multiple antibiotic prescribing rates (1.3%-60.2%) and parenteral antibiotic prescribing rates (3.2%-62.1%). Each village doctor prescribed between 11 and 21 unique agents for AURIs, including many broad-spectrum antibiotics. Doctors in the highest quartile for antibiotic prescribing rates for AURI also had higher antibiotic prescribing rates than doctors in the lowest quartile for potentially bacterial upper respiratory tract infections (pharyngitis, tonsillitis, laryngopharyngitis; 89.1% vs 72.4%, p=0.002). CONCLUSIONS All village doctors overused antibiotics for respiratory tract infections. Variations in individual prescriber practices are significant even in a small homogenous setting and should be accounted for when developing targets and interventions to improve antibiotic use.
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Affiliation(s)
- Oliver James Dyar
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Ding Yang
- School of Health Care Management, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Jia Yin
- School of Health Care Management, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Qiang Sun
- School of Health Care Management, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
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Wu Y, Zhou H, Ma X, Shi Y, Xue H, Zhou C, Yi H, Medina A, Li J, Sylvia S. Using standardised patients to assess the quality of medical records: an application and evidence from rural China. BMJ Qual Saf 2019; 29:491-498. [PMID: 31776199 PMCID: PMC7244376 DOI: 10.1136/bmjqs-2019-009890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/25/2019] [Accepted: 11/10/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Medical records play a fundamental role in healthcare delivery, quality assessment and improvement. However, there is little objective evidence on the quality of medical records in low and middle-income countries. OBJECTIVE To provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China. METHODS A sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardised patients (SPs) presented to providers following standardised scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records. RESULTS Medical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incompletely recorded category of information was patient symptoms (74.3% unrecorded), followed by non-drug treatments (65.2% unrecorded). Most of the recorded information was accurate, but accuracy fell below 80% for some items. The keeping of any medical records was positively correlated with the provider's income (β 0.05, 95% CI 0.01 to 0.09). Providers at hospitals with prescription review were less likely to record completely (β -0.87, 95% CI -1.68 to 0.06). Significant variation by disease type was also found in keeping of any medical record and completeness. CONCLUSION Despite the importance of medical records for health system functioning, many rural facilities have yet to implement systems for maintaining patient records, and records are often incomplete when they exist. Prescription review tied to performance evaluation should be implemented with caution as it may create disincentives for record keeping. Interventions to improve record keeping and management are needed.
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Affiliation(s)
- Yuju Wu
- Department of Health and Social Behavior, West China School of Public Health and West China Forth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huan Zhou
- Department of Health and Social Behavior, West China School of Public Health and West China Forth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiao Ma
- Department of Health and Social Behavior, West China School of Public Health and West China Forth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yaojiang Shi
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, Shaanxi, China
| | - Hao Xue
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, Shaanxi, China
| | - Chengchao Zhou
- Institute of Social Medicine and Health Administration, Shandong University, Jinan, Shandong, China
| | - Hongmei Yi
- School of Advanced Agricultural Sciences, Peking University, Beijing, Beijing, China
| | - Alexis Medina
- Freeman Spogli Institute for International Studies, Stanford, California, USA
| | - Jason Li
- Freeman Spogli Institute for International Studies, Stanford, California, USA
| | - Sean Sylvia
- Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Abstract
Despite improvements in antibiotic use in tertiary hospitals, problems remain in other parts of the health system, say Ping He and colleagues
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Affiliation(s)
- Ping He
- China Center for Health Development Studies, Peking University, Beijing 100191, China
| | - Qiang Sun
- School of Health Care Management, Shandong University, Shandong Jinan 250012, China
| | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Qingyue Meng
- China Center for Health Development Studies, Peking University, Beijing 100191, China
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Xue H, Hager J, An Q, Liu K, Zhang J, Auden E, Yang B, Yang J, Liu H, Nie J, Wang A, Zhou C, Shi Y, Sylvia S. The Quality of Tuberculosis Care in Urban Migrant Clinics in China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2037. [PMID: 30231511 PMCID: PMC6163912 DOI: 10.3390/ijerph15092037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 02/07/2023]
Abstract
Large and increasing numbers of rural-to-urban migrants provided new challenges for tuberculosis control in large cities in China and increased the need for high quality tuberculosis care delivered by clinics in urban migrant communities. Based on a household survey in migrant communities, we selected and separated clinics into those that mainly serve migrants and those that mainly serve local residents. Using standardized patients, this study provided an objective comparison of the quality of tuberculosis care delivered by both types of clinics and examined factors related to quality care. Only 27% (95% confidence interval (CI) 14⁻46) of cases were correctly managed in migrant clinics, which is significantly worse than it in local clinics (50%, 95% CI 28⁻72). Clinicians with a base salary were 41 percentage points more likely to demonstrate better case management. Furthermore, clinicians with upper secondary or higher education level charged 20 RMB lower out of pocket fees than less-educated clinicians. In conclusion, the quality of tuberculosis care accessed by migrants was very poor and policies to improve the quality should be prioritized in current health reforms. Providing a base salary was a possible way to improve quality of care and increasing the education attainment of urban community clinicians might reduce the heavy barrier of medical expenses for migrants.
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Affiliation(s)
- Hao Xue
- School of Economics and Management, Northwest University, Xi'an 710069, China.
| | - Jennifer Hager
- Department of Health, Sport, and Exercise Sciences, School of Education, University of Kansas, Lawrence, KS 66045, USA.
| | - Qi An
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
| | - Kai Liu
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
| | - Jing Zhang
- Faculty of Liberal Arts, Northwest University, Xi'an 710069, China.
| | - Emma Auden
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
- Rural Education Action Program, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA 94305, USA.
| | - Bingyan Yang
- School of Economics and Management, Wuhan University, Wuhan 430072, China.
| | - Jie Yang
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
| | - Hongyan Liu
- School of Economics, Northwest University of Political Science and Law, Xi'an 710122, China.
| | - Jingchun Nie
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
| | - Aiqin Wang
- School of Economics and Finance, Xi'an Jiaotong University, Xi'an 710061, China.
| | - Chengchao Zhou
- Institute of Social Medicine and Health Administration, School of Public Health, Shandong University, Jinan 250012, China.
| | - Yaojiang Shi
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an 710127, China.
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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