Potentially Inappropriate Prescribing to Older Patients: Criteria, Prevalence and an Intervention to Reduce It: The Prescription Peer Academic Detailing (Rx-PAD) Study - A Cluster-Randomized, Educational Intervention in Norwegian General Practice

Implementation and outcomes of a clinician-directed intervention to improve antibiotic prescribing for acute respiratory tract infections within the Veterans' Affairs Healthcare System

OBJECTIVE

To determine whether a clinician-directed acute respiratory tract infection (ARI) intervention was associated with improved antibiotic prescribing and patient outcomes across a large US healthcare system.

DESIGN

Multicenter retrospective quasi-experimental analysis of outpatient visits with a diagnosis of uncomplicated ARI over a 7-year period.

PARTICIPANTS

Outpatients with ARI diagnoses: sinusitis, pharyngitis, bronchitis, and unspecified upper respiratory tract infection (URI-NOS). Outpatients with concurrent infection or select comorbid conditions were excluded.

INTERVENTION(S)

Audit and feedback with peer comparison of antibiotic prescribing rates and academic detailing of clinicians with frequent ARI visits. Antimicrobial stewards and academic detailing personnel delivered the intervention; facility and clinician participation were voluntary.

MEASURE(S)

We calculated the probability to receive antibiotics for an ARI before and after implementation. Secondary outcomes included probability for a return clinic visits or infection-related hospitalization, before and after implementation. Intervention effects were assessed with logistic generalized estimating equation models. Facility participation was tracked, and results were stratified by quartile of facility intervention intensity.

RESULTS

We reviewed 1,003,509 and 323,023 uncomplicated ARI visits before and after the implementation of the intervention, respectively. The probability to receive antibiotics for ARI decreased after implementation (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.78-0.86). Facilities with the highest quartile of intervention intensity demonstrated larger reductions in antibiotic prescribing (OR, 0.69; 95% CI, 0.59-0.80) compared to nonparticipating facilities (OR, 0.89; 95% CI, 0.73-1.09). Return visits (OR, 1.00; 95% CI, 0.94-1.07) and infection-related hospitalizations (OR, 1.21; 95% CI, 0.92-1.59) were not different before and after implementation within facilities that performed intensive implementation.

CONCLUSIONS

Implementation of a nationwide ARI management intervention (ie, audit and feedback with academic detailing) was associated with improved ARI management in an intervention intensity-dependent manner. No impact on ARI-related clinical outcomes was observed.

Promoters and inhibitors for quality improvement work in general practice: a qualitative analysis of 2715 free-text replies

BACKGROUND

Continuous quality improvement (QI) is necessary to develop and maintain high quality general practice services. General Practitioners (GPs') motivation is an important factor in the success of QI initiatives. We aimed to identify factors that impair or promote GPs' motivation for and participation in QI projects.

MATERIAL AND METHODS

We analysed 2715 free-text survey replies from 2208 GPs participating in the QI intervention 'Correct Antibiotic Use in the Municipalities'. GPs received reports detailing their individual antibiotic prescriptions for a defined period, including a comparison with a corresponding previous period. The content was discussed in peer group meetings. Each GP individually answered work-sheets on three separate time-points, including free-text questions regarding their experiences with the intervention. Data were analysed using inductive thematic analysis.

RESULTS

We identified three overarching themes in the GPs' thoughts on inhibitors and promoters of QI work: (1) the desire to be a better doctor, (2) structural and organisational factors as both promoters and inhibitors and (3) properties related to different QI measures. The provision of individual prescription data was generally very well received. The participants stressed the importance of a safe peer group, like the Continuous Medical Education group, for discussions, and also underlined the motivating effect of working together with their practice as a whole. Lack of time was essential in GPs' motivation for QI work. QI tools should be easily available and directly relevant in clinical work.

CONCLUSION

The desire to be good doctor is a strong motivator for improvement, but the framework for general practice must allow for QI initiatives. QI tools must be easily obtainable and relevant for practice. Better tools for obtaining clinical data for individual GPs are needed.

Intervention elements to reduce inappropriate prescribing for older adults with multimorbidity receiving outpatient care: a scoping review

OBJECTIVE

Polypharmacy occurs in approximately 30% of older adults aged 65 years or more, particularly among those with multimorbidity. With polypharmacy, there is an associated risk of potentially inappropriate prescribing (PIP). The aims of this scoping review were to (1) identify the intervention elements that have been adopted to reduce PIP in the outpatient setting and (2) determine the behaviour change wheel (BCW) intervention functions performed by each of the identified intervention elements.

DESIGN

Scoping review DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Web of Science and Cochrane Library databases, grey literature sources, six key geriatrics journals and the reference lists of review papers.

STUDY SELECTION

All studies reporting an intervention or strategy that addressed PIP in the older adult population (age ≥65) with multimorbidity in the outpatient setting and in which the primary prescriber is the physician.

DATA EXTRACTION

Data extracted from the included studies can be broadly categorised into (1) publication details, (2) intervention details and (3) results. This was followed by data synthesis and analysis based on the BCW framework.

RESULTS

Of 8195 studies yielded, 80 studies were included in the final analysis and 14 intervention elements were identified. An average of two to three elements were adopted in each intervention. The three most frequently adopted intervention elements were medication review (70%), training (26.3%) and tool/instrument(s) (22.5%). Among medication reviews, 70% involved pharmacists. The 14 intervention elements were mapped onto five intervention functions: 'education', 'persuasion', 'training', 'environmental restructuring' and 'enablement'.

CONCLUSION

PIP is a multifaceted problem that involves multiple stakeholders. As such, interventions that address PIP require multiple elements to target the behaviour of the various stakeholders. The intervention elements and their corresponding functions identified in this scoping review will serve to inform the design of complex interventions that aim to reduce PIP.