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Lescure DLA, Erdem Ö, Nieboer D, Huijser van Reenen N, Tjon-A-Tsien AML, van Oorschot W, Brouwer R, Vos MC, van der Velden AW, Richardus JH, Voeten HACM. Communication training for general practitioners aimed at improving antibiotic prescribing: a controlled before-after study in multicultural Dutch cities. Front Med (Lausanne) 2024; 11:1279704. [PMID: 38323031 PMCID: PMC10844435 DOI: 10.3389/fmed.2024.1279704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/03/2024] [Indexed: 02/08/2024] Open
Abstract
IntroductionSuboptimal doctor-patient communication drives inappropriate prescribing of antibiotics. We evaluated a communication intervention for general practitioners (GPs) in multicultural Dutch cities to improve antibiotic prescribing for respiratory tract infections (RTI).MethodsThis was a non-randomized controlled before-after study. The study period was pre-intervention November 2019 – April 2020 and post-intervention November 2021 – April 2022. The intervention consisted of a live training (organized between September and November 2021), an E-learning, and patient material on antibiotics and antibiotic resistance in multiple languages. The primary outcome was the absolute number of prescribed antibiotic courses indicated for RTIs per GP; the secondary outcome was all prescribed antibiotics per GP. We compared the post-intervention differences in the mean number of prescribed antibiotics between the intervention (N = 25) and the control group (N = 110) by using an analysis of covariance (ANCOVA) test, while adjusting for the pre-intervention number of prescribed antibiotics. Additionally, intervention GPs rated the training and their knowledge and skills before the intervention and 3 months thereafter.ResultsThere was no statistically significant difference in the mean number of prescribed antibiotics for RTI between the intervention and the control group, nor for mean number of overall prescribed antibiotics. The intervention GPs rated the usefulness of the training for daily practice a 7.3 (on a scale from 1–10) and there was a statistically significant difference between pre- and post-intervention on four out of nine items related to knowledge and skills.DiscussionThere was no change in GPs prescription behavior between the intervention and control group. However, GPs found the intervention useful and showed some improvement on self-rated knowledge and communication skills.
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Affiliation(s)
- Dominique L. A. Lescure
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, Netherlands
| | - Özcan Erdem
- Department of Research and Business Intelligence, Municipality of Rotterdam, Rotterdam, Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Aimée M. L. Tjon-A-Tsien
- Department of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, Netherlands
| | | | - Rob Brouwer
- Health Centre Levinas, Pharmacy Ramleh, Rotterdam, Netherlands
| | - Margreet C. Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Alike W. van der Velden
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Hélène A. C. M. Voeten
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, Netherlands
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2
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Do NTT, Vu TVD, Greer RC, Dittrich S, Vandendorpe M, Pham NT, Ta DN, Cao HT, Khuong TV, Le TBT, Duong TH, Nguyen TH, Cai NTH, Nguyen TQT, Trinh ST, van Doorn HR, Lubell Y, Lewycka S. Implementation of point-of-care testing of C-reactive protein concentrations to improve antibiotic targeting in respiratory illness in Vietnamese primary care: a pragmatic cluster-randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2023; 23:1085-1094. [PMID: 37230105 DOI: 10.1016/s1473-3099(23)00125-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND In previous trials, point-of-care testing of C-reactive protein (CRP) concentrations safely reduced antibiotic use in non-severe acute respiratory infections in primary care. However, these trials were done in a research-oriented context with close support from research staff, which could have influenced prescribing practices. To better inform the potential for scaling up point-of-care testing of CRP in respiratory infections, we aimed to do a pragmatic trial of the intervention in a routine care setting. METHODS We did a pragmatic, cluster-randomised controlled trial at 48 commune health centres in Viet Nam between June 1, 2020, and May 12, 2021. Eligible centres served populations of more than 3000 people, handled 10-40 respiratory infections per week, had licensed prescribers on site, and maintained electronic patient databases. Centres were randomly allocated (1:1) to provide point-of-care CRP testing plus routine care or routine care only. Randomisation was stratified by district and by baseline prescription level (ie, the proportion of patients with suspected acute respiratory infections to whom antibiotics were prescribed in 2019). Eligible patients were aged 1-65 years and visiting the commune health centre for a suspected acute respiratory infection with at least one focal sign or symptom and symptoms lasting less than 7 days. The primary endpoint was the proportion of patients prescribed an antibiotic at first attendance in the intention-to-treat population. The per-protocol analysis included only people who underwent CRP testing. Secondary safety outcomes included time to resolution of symptoms and frequency of hospitalisation. This trial is registered with ClinicalTrials.gov, NCT03855215. FINDINGS 48 commune health centres were enrolled and randomly assigned, 24 to the intervention group (n=18 621 patients) and 24 to the control group (n=21 235). 17 345 (93·1%) patients in the intervention group were prescribed antibiotics, compared with 20 860 (98·2%) in the control group (adjusted relative risk 0·83 [95% CI 0·66-0·93]). Only 2606 (14%) of 18 621 patients in the intervention group underwent CRP testing and were included in the per-protocol analysis. When analyses were restricted to this population, larger reductions in prescribing were noted in the intervention group compared with the control group (adjusted relative risk 0·64 [95% CI 0·60-0·70]). Time to resolution of symptoms (hazard ratio 0·70 [95% CI 0·39-1·27]) and frequency of hospitalisation (nine in the intervention group vs 17 in the control group; adjusted relative risk 0·52 [95% CI 0·23-1·17]) did not differ between groups. INTERPRETATION Use of point-of-care CRP testing efficaciously reduced prescription of antibiotics in patients with non-severe acute respiratory infections in primary health care in Viet Nam without compromising patient recovery. The low uptake of CRP testing suggests that barriers to implementation and compliance need to be addressed before scale-up of the intervention. FUNDING Australian Government, UK Government, and the Foundation for Innovative New Diagnostics.
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Affiliation(s)
| | | | - Rachel C Greer
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Sabine Dittrich
- Foundation for Innovative New Diagnostics, Geneva, Switzerland; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | | | - Dieu Ngan Ta
- National Hospital for Tropical Diseases, Hanoi, Viet Nam
| | | | | | | | | | | | | | | | - Son Tung Trinh
- Oxford University Clinical Research Unit, Hanoi, Viet Nam
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Viet Nam; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Sonia Lewycka
- Oxford University Clinical Research Unit, Hanoi, Viet Nam; Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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3
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Sijbom M, Büchner FL, Saadah NH, Numans ME, de Boer MGJ. Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers: a systematic review and construction of a framework. BMJ Open 2023; 13:e065006. [PMID: 37197815 DOI: 10.1136/bmjopen-2022-065006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVES This study aimed to identify determinants of inappropriate antibiotic prescription in primary care in developed countries and to construct a framework with the determinants to help understand which actions can best be targeted to counteract development of antimicrobial resistance (AMR). DESIGN A systematic review of peer-reviewed studies reporting determinants of inappropriate antibiotic prescription published through 9 September 2021 in PubMed, Embase, Web of Science and the Cochrane Library was performed. SETTING All studies focusing on primary care in developed countries where general practitioners (GPs) act as gatekeepers for referral to medical specialists and hospital care were included. RESULTS Seventeen studies fulfilled the inclusion criteria and were used for the analysis which identified 45 determinants of inappropriate antibiotic prescription. Important determinants for inappropriate antibiotic prescription were comorbidity, primary care not considered to be responsible for development of AMR and GP perception of patient desire for antibiotics. A framework was constructed with the determinants and provides a broad overview of several domains. The framework can be used to identify several reasons for inappropriate antibiotic prescription in a specific primary care setting and from there, choose the most suitable intervention(s) and assist in implementing them for combatting AMR. CONCLUSIONS The type of infection, comorbidity and the GPs perception of a patient's desire for antibiotics are consistently identified as factors driving inappropriate antibiotic prescription in primary care. A framework with determinants of inappropriate antibiotic prescription may be useful after validation for effective implementation of interventions for decreasing these inappropriate prescriptions. PROSPERO REGISTRATION NUMBER CRD42023396225.
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Affiliation(s)
- Martijn Sijbom
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Frederike L Büchner
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Nicholas H Saadah
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Mark G J de Boer
- Infectious Diseases, Leidsen University Medical Center, Leiden, Zuid-Holland, The Netherlands
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4
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Chang Y, Cui Z, He X, Zhou X, Zhou H, Fan X, Wang W, Yang G. Effect of unifaceted and multifaceted interventions on antibiotic prescription control for respiratory diseases: A systematic review of randomized controlled trials. Medicine (Baltimore) 2022; 101:e30865. [PMID: 36254082 PMCID: PMC9575778 DOI: 10.1097/md.0000000000030865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The global health system is improperly using antibiotics, particularly in the treatment of respiratory diseases. We aimed to examine the effectiveness of implementing a unifaceted and multifaceted intervention for unreasonable antibiotic prescriptions. METHODS Relevant literature published in the databases of Pubmed, Embase, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure and Wanfang was searched. Data were independently filtered and extracted by 2 reviewers based on a pre-designed inclusion and exclusion criteria. The Cochrane collaborative bias risk tool was used to evaluate the quality of the included randomized controlled trials studies. RESULTS A total of 1390 studies were obtained of which 23 studies the outcome variables were antibiotic prescription rates with the number of prescriptions and intervention details were included in the systematic review. Twenty-two of the studies involved educational interventions for doctors, including: online training using email, web pages and webinar, antibiotic guidelines for information dissemination measures by email, postal or telephone reminder, training doctors in communication skills, short-term interactive educational seminars, and short-term field training sessions. Seventeen studies of interventions for health care workers also included: regular or irregular assessment/audit of antibiotic prescriptions, prescription recommendations from experts and peers delivered at a meeting or online, publicly reporting on doctors' antibiotic usage to patients, hospital administrators, and health authorities, monitoring/feedback prescribing behavior to general practices by email or poster, and studies involving patients and their families (n = 8). Twenty-one randomized controlled trials were rated as having a low risk of bias while 2 randomized controlled trials were rated as having a high risk of bias. Six studies contained negative results. CONCLUSION The combination of education, prescription audit, prescription recommendations from experts, public reporting, prescription feedback and patient or family member multifaceted interventions can effectively reduce antibiotic prescription rates in health care institutions. Moreover, adding multifaceted interventions to educational interventions can control antibiotic prescription rates and may be a more reasonable method. REGISTRATIONS This systematic review was registered in PROSPERO, registration number: CRD42020192560.
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Affiliation(s)
- Yue Chang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, 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, China
| | - Xun He
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, China
| | - Xunrong Zhou
- The Second Affiliated Hospital, Guizhou University of Chinese Medicine, Guiyang, China
| | - Hanni Zhou
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, China
| | - Xingying Fan
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, China
| | - Wenju Wang
- School of Public Health, Guizhou Medical University, Guiyang, China
| | - Guanghong Yang
- School of Public Health, Guizhou Medical University, Guiyang, China
- *Correspondence: Guanghong Yang, School of Public Health, Guizhou Medical University, Guiyang, China (e-mail: )
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5
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Saha SK, Thursky K, Kong DCM, Mazza D. A Novel GPPAS Model: Guiding the Implementation of Antimicrobial Stewardship in Primary Care Utilising Collaboration between General Practitioners and Community Pharmacists. Antibiotics (Basel) 2022; 11:antibiotics11091158. [PMID: 36139938 PMCID: PMC9495087 DOI: 10.3390/antibiotics11091158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022] Open
Abstract
Interprofessional collaboration between general practitioners (GPs) and community pharmacists (CPs) is central to implement antimicrobial stewardship (AMS) programmes in primary care. This study aimed to design a GP/pharmacist antimicrobial stewardship (GPPAS) model for primary care in Australia. An exploratory study design was followed that included seven studies conducted from 2017 to 2021 for the development of the GPPAS model. We generated secondary and primary evidence through a systematic review, a scoping review, a rapid review, nationwide surveys of Australian GPs and CPs including qualitative components, and a pilot study of a GPPAS submodel. All study evidence was synthesised, reviewed, merged, and triangulated to design the prototype GPPAS model using a Systems Engineering Initiative for Patient Safety theoretical framework. The secondary evidence provided effective GPPAS interventions, and the primary evidence identified GP/CP interprofessional issues, challenges, and future needs for implementing GPPAS interventions. The framework of the GPPAS model informed five GPPAS implementation submodels to foster implementation of AMS education program, antimicrobial audits, diagnostic stewardship, delayed prescribing, and routine review of antimicrobial prescriptions, through improved GP–CP collaboration. The GPPAS model could be used globally as a guide for GPs and CPs to collaboratively optimise antimicrobial use in primary care. Implementation studies on the GPPAS model and submodels are required to integrate the GPPAS model into GP/pharmacist interprofessional care models in Australia for improving AMS in routine primary care.
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Affiliation(s)
- Sajal K. Saha
- School of Medicine, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- Department of General Practice, The School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3168, Australia
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, VIC 3000, Australia
- Public Health Unit, Geelong Centre for Emerging Infectious Disease, Barwon Health, Geelong, VIC 3220, Australia
- Correspondence: ; Tel.: +61-0452639559
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, VIC 3000, Australia
| | - David C. M. Kong
- School of Medicine, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, VIC 3000, Australia
- Centre for Medicine Use and Safety, Monash University, 381 Royal Parade Parkville, Melbourne, VIC 3052, Australia
- Pharmacy Department, Ballarat Health Services, Ballarat, VIC 3350, Australia
| | - Danielle Mazza
- Department of General Practice, The School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3168, Australia
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, VIC 3000, Australia
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6
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D’Hulster L, Abrams S, Bruyndonckx R, Anthierens S, Adriaenssens N, Butler CC, Verheij T, Goossens H, Little P, Coenen S. Nationwide implementation of online communication skills training to reduce overprescribing of antibiotics: a stepped-wedge cluster randomized trial in general practice. JAC Antimicrob Resist 2022; 4:dlac070. [PMID: 35774072 PMCID: PMC9240414 DOI: 10.1093/jacamr/dlac070] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Objectives Primary care is responsible for a large proportion of unnecessary antibiotic use, which is one of the main drivers of antibiotic resistance. Randomized trials have found that online communication skills training for GPs reduces antibiotic prescribing for respiratory infections. This study assesses the real-world effect of implementing online communication skills training in general practice. Methods In a closed cohort stepped-wedge cluster randomized trial all Belgian GPs were invited to participate in online communication skills training courses (TRACE and INTRO) and provided with linked patient information booklets. The primary outcome was the antibiotic prescribing rate per 1000 patient contacts. Intention-to-treat and per protocol analyses were performed. Trial registration at ClinicalTrials.gov: NCT03265028. Results In total, 118 487 observations from 10 375 GPs were included in the analysis. Overall, 299 (2.88%) GPs completed TRACE and 93 (0.90%) completed INTRO, 30 of which completed both. There was no effect of the national implementation of TRACE and INTRO on the population-level antibiotic prescribing rate (prescribing rate ratio [PRR] = 0.99 [95% CI: 0.97-1.02]). GPs who actually completed TRACE prescribed fewer antibiotic prescriptions (PRR = 0.93 [95% CI: 0.90-0.95]). Conclusions Inviting GPs to complete an online communication skills training course and providing them with the linked patient information booklets did not reduce antibiotic prescribing. However, GPs who completed TRACE prescribed 7% fewer antibiotics, especially during winter. This suggests a significant decrease in population-wide antibiotic consumption could be achieved by focusing on increasing the uptake of this intervention by identifying and overcoming barriers to participation.
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Affiliation(s)
- Leon D’Hulster
- National Institute for Health and Disability Insurance, Galileelaan 5/01, 1210 Brussels, Belgium
| | - Steven Abrams
- Global Health Institute, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
- Data Science Institute, Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), UHasselt, Diepenbeek, Belgium
| | - Robin Bruyndonckx
- Data Science Institute, Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), UHasselt, Diepenbeek, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Niels Adriaenssens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Chris C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Theo Verheij
- Julius Centre for Health, Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Paul Little
- Primary Care Research Centre, Aldermoor Health Centre, Primary Care Population Sciences and Medical Education Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
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7
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Lambert M, Smit CCH, De Vos S, Benko R, Llor C, Paget WJ, Briant K, Pont L, Van Dijk L, Taxis K. A systematic literature review and meta-analysis of community pharmacist-led interventions to optimise the use of antibiotics. Br J Clin Pharmacol 2022; 88:2617-2641. [PMID: 35112381 PMCID: PMC9313811 DOI: 10.1111/bcp.15254] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 01/11/2022] [Accepted: 01/24/2022] [Indexed: 12/01/2022] Open
Abstract
Aims The aim of this systematic review is to assess the effects of community pharmacist‐led interventions to optimise the use of antibiotics and identify which interventions are most effective. Methods This review was conducted according to the PRISMA guidelines (PROSPERO: CRD42020188552). PubMed, EMBASE and the Cochrane Central Register of Controlled Trials were searched for (randomised) controlled trials. Included interventions were required to target antibiotic use, be set in the community pharmacy context, and be pharmacist‐led. Primary outcomes were quality of antibiotic supply and adverse effects while secondary outcomes included patient‐reported outcomes. Risk of bias was assessed using the ‘Cochrane suggested risk of bias criteria’ and narrative synthesis of primary outcomes conducted. Results Seventeen studies were included covering in total 3822 patients (mean age 45.6 years, 61.9% female). Most studies used educational interventions. Three studies reported on primary outcomes, 12 on secondary outcomes and two on both. Three studies reported improvements in quality of dispensing, interventions led to more intensive symptom assessment (up to 30% more advice given) and a reduction of over‐the‐counter supply up to 53%. Three studies led to higher consumer satisfaction, effects on adherence from nine studies were mixed (risk difference 0.04 [−0.02, 0.10]). All studies had unclear or high risks of bias across at least one domain, with large heterogeneity between studies. Conclusions Our review suggests some positive results from pharmacist‐led interventions, but the interventions do not seem sufficiently effective as currently implemented. This review should be interpreted as exploratory research, as more high‐quality research is needed.
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Affiliation(s)
- Maarten Lambert
- Faculty of Science and Engineering, Department of PharmacoTherapy, - Epidemiology and -Economics, University of Groningen, Groningen, The Netherlands
| | - Chloé C H Smit
- University of Technology Sydney, Graduate School of Health, NSW, Sydney, Australia
| | - Stijn De Vos
- Faculty of Science and Engineering, Department of PharmacoTherapy, - Epidemiology and -Economics, University of Groningen, Groningen, The Netherlands
| | - Ria Benko
- Department of Clinical Pharmacy and Albert Szent-Györgyi Medical Center, Central Pharmacy and Emergency Care Department, University of Szeged, Szeged, Hungary
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Barcelona, Spain.,University of Southern Denmark, Public Health, General Practice, Odense C, Denmark
| | - W John Paget
- Nivel, Netherlands institute for health services research, CR, Utrecht, The Netherlands
| | - Kathryn Briant
- Health Care Consumers' Association, Hackett, ACT, Australia
| | - Lisa Pont
- University of Technology Sydney, Graduate School of Health, NSW, Sydney, Australia
| | - Liset Van Dijk
- Faculty of Science and Engineering, Department of PharmacoTherapy, - Epidemiology and -Economics, University of Groningen, Groningen, The Netherlands.,Nivel, Netherlands institute for health services research, CR, Utrecht, The Netherlands
| | - Katja Taxis
- Faculty of Science and Engineering, Department of PharmacoTherapy, - Epidemiology and -Economics, University of Groningen, Groningen, The Netherlands
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8
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Böhm R, Holtmann-Klenner C, Korn L, Santana AP, Betsch C. Behavioral determinants of antibiotic resistance: The role of social information. Appl Psychol Health Well Being 2022; 14:757-775. [PMID: 35103398 PMCID: PMC9544926 DOI: 10.1111/aphw.12345] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 01/19/2022] [Indexed: 12/01/2022]
Abstract
The increasing development of resistant pathogens is one of the greatest global health challenges. As antibiotic overuse amplifies antibiotic resistance, antibiotic intake poses a social dilemma in which individuals need to decide whether to prosocially reduce their intake in the collective interest versus to (over)use it even in case of mild diseases. We devise a novel behavioral game paradigm to model the social dilemma of antibiotic intake. Using this new method in an incentivized laboratory experiment (N = 272 German participants), we varied whether players had mutual knowledge about their antibiotic intake. The results indicate that there was substantial antibiotic overuse in the absence of social information. Overuse decreased when social information was present. Our postexperimental survey data further suggest that social information impacts people's behavioral motivation, evaluation of the other player, and positive affect. Taken together, providing social information about people's antibiotic intake may help in reducing antibiotic overuse. On a more general level, the novel behavioral game may be adapted to study other aspects of antibiotic intake to promote prudent use of antibiotics.
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Affiliation(s)
- Robert Böhm
- Faculty of Psychology, University of Vienna, Vienna, Austria.,Department of Psychology, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Center for Social Data Science (SODAS), University of Copenhagen, Copenhagen, Denmark
| | - Cindy Holtmann-Klenner
- Center for Empirical Research in Economics and Behavioral Sciences (CEREB), University of Erfurt, Erfurt, Germany
| | - Lars Korn
- Center for Empirical Research in Economics and Behavioral Sciences (CEREB), University of Erfurt, Erfurt, Germany.,Media and Communication Science, University of Erfurt, Erfurt, Germany.,Health Communication, Bernhard Nocht Institute for Tropical Medicine (BNITM), Hamburg, Germany
| | - Ana Paula Santana
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Cornelia Betsch
- Center for Empirical Research in Economics and Behavioral Sciences (CEREB), University of Erfurt, Erfurt, Germany.,Media and Communication Science, University of Erfurt, Erfurt, Germany.,Health Communication, Bernhard Nocht Institute for Tropical Medicine (BNITM), Hamburg, Germany
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9
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Lescure D, van der Velden J, Nieboer D, van Oorschot W, Brouwer R, Huijser van Reenen N, Tjon-A-Tsien A, Erdem Ö, Vos M, van der Velden A, Richardus JH, Voeten H. Reducing antibiotic prescribing by enhancing communication of general practitioners with their immigrant patients: protocol for a randomised controlled trial (PARCA study). BMJ Open 2021; 11:e054674. [PMID: 34635534 PMCID: PMC8506856 DOI: 10.1136/bmjopen-2021-054674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Although antibiotic use and antimicrobial resistance in the Netherlands is comparatively low, inappropriate prescription of antibiotics is substantial, mainly for respiratory tract infections (RTIs). General practitioners (GPs) experience pressure from patients with an immigration background to prescribe antibiotics and have difficulty communicating in a culturally sensitive way. Multifaceted interventions including communication skills training for GPs are shown to be most effective in reducing antibiotic prescription. The PARCA study aims to reduce the number of antibiotic prescriptions for RTIs through implementing a culturally sensitive communication intervention for GPs and evaluate it in a randomised controlled trial (RCT). METHODS AND ANALYSIS A non-blinded RCT including 58 GPs (29 for each arm). The intervention consists of: (1) An E-learning with 4 modules of 10-15 min each; (2) A face-to-face training session in (intercultural) communication skills including role plays with a training actor and (3) Availability of informative patient-facing materials that use simple words (A2/B1 level) in multiple languages. The primary outcome measure is the number of dispensed antibiotic courses qualifying for RTIs in primary care, per 1000 registered patients. The secondary outcome measure is the number of all dispensed antibiotic courses, per 1000 registered patients. The intervention arm will receive the training in Autumn 2021, followed by an observation period of 6 winter months for which numbers of antibiotics will be collected for both trial arms. The GPs/practices in the control arm can attend the training after the observation period. ETHICS AND DISSEMINATION The study protocol was approved by the Medical Ethics Review Committee of Erasmus MC, University Medical Center Rotterdam (MEC-2020-0142). The results of the trial will be published in international peer-reviewed scientific journals and will be disseminated through national and international congresses. The project is funded by The Netherlands Organisation for Health Research and Development (ZonMw). TRIAL REGISTRATION NUMBER NL9450.
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Affiliation(s)
- Dominique Lescure
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
| | | | - Daan Nieboer
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Rob Brouwer
- Health Centre Levinas, Pharmacy Ramleh, Rotterdam, The Netherlands
| | | | - Aimée Tjon-A-Tsien
- Department of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
| | - Özcan Erdem
- Department of Research and Business Intelligence, Municipality of Rotterdam, Rotterdam, The Netherlands
| | - Margreet Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alike van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
| | - Hélène Voeten
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
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10
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Forsetlund L, O'Brien MA, Forsén L, Reinar LM, Okwen MP, Horsley T, Rose CJ. Continuing education meetings and workshops: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2021; 9:CD003030. [PMID: 34523128 PMCID: PMC8441047 DOI: 10.1002/14651858.cd003030.pub3] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review. OBJECTIVES • To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016). SELECTION CRITERIA We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots. MAIN RESULTS We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques. AUTHORS' CONCLUSIONS Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.
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Affiliation(s)
| | - Mary Ann O'Brien
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Lisa Forsén
- Norwegian Institute of Public Health, Oslo, Norway
| | | | - Mbah P Okwen
- Centre for the Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Tanya Horsley
- Research Unit, Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
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11
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Saha SK, Hawes L, Mazza D. Effectiveness of interventions involving pharmacists on antibiotic prescribing by general practitioners: a systematic review and meta-analysis. J Antimicrob Chemother 2021; 74:1173-1181. [PMID: 30698721 DOI: 10.1093/jac/dky572] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The use of community antibiotic stewardship programmes (ASPs) is rising; however, their effectiveness when pharmacists are involved is uncertain. OBJECTIVES To assess the effectiveness of ASPs involving pharmacists at improving antibiotic prescribing by general practitioners (GPs). METHODS Medline, Embase, Emcare, PubMed, PsycINFO, Cochrane CENTRAL, CINAHL Plus and Web of Science databases were searched to February 2018. Randomized and non-randomized studies of ASPs involving pharmacists as interventionists to GPs were included. Primary outcomes were absolute changes in GPs' antibiotic prescribing rate (APR) and antibiotic prescribing adherence rate (APAR) according to recommendations/guidelines. Meta-analysis used random effects models. RESULTS Fifteen studies reporting 18 trials were included in the meta-analysis: 8 assessed the APR and 10 the APAR. APR reductions (OR 0.86, 95% CI 0.78-0.95, moderate-certainty evidence) and APAR improvements (OR 1.96, 95% CI 1.56-2.45, high-certainty evidence) were observed at 6 months median intervention follow-up. High-quality randomized trials reduced the APR (OR 0.92, 95% CI 0.90-0.94) and increased the APAR (OR 2.55, 95% CI 2.16-3.01). Interventions were successful in decreasing the APR (OR 0.93, 95% CI 0.90-0.95) and increasing the APAR (OR 1.72, 95% CI 1.04-2.84) when implemented by a pharmacist-GP team. Interventions involving pharmacist-infectious disease professional teams also decreased the APR (OR 0.81, 95% CI 0.66-1.0) and increased the APAR (OR 2.36, 95% CI 1.87-2.96). GP education plus prescribing feedback, and group meetings were effective in both outcomes, whereas GP education, academic detailing and workshop training were effective in APAR outcome. However, substantial heterogeneity was demonstrated. CONCLUSIONS ASPs involving pharmacists are effective in decreasing antibiotic prescribing and increasing guideline-adherent antibiotic prescribing by GPs.
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Affiliation(s)
- Sajal K Saha
- Department of General Practice, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Victoria, VIC, Australia
- National Centre for Antimicrobial Stewardship (NCAS), The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Lesley Hawes
- Department of General Practice, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Victoria, VIC, Australia
- National Centre for Antimicrobial Stewardship (NCAS), The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Victoria, VIC, Australia
- National Centre for Antimicrobial Stewardship (NCAS), The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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12
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Divergent and Convergent Attitudes and Views of General Practitioners and Community Pharmacists to Collaboratively Implement Antimicrobial Stewardship Programs in Australia: A Nationwide Study. Antibiotics (Basel) 2021; 10:antibiotics10010047. [PMID: 33466476 PMCID: PMC7824809 DOI: 10.3390/antibiotics10010047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 12/29/2020] [Accepted: 01/03/2021] [Indexed: 11/23/2022] Open
Abstract
Setting up an interprofessional team for antimicrobial stewardship (AMS) to improve the quality and safety of antimicrobial use in primary care is essential but challenging. This study aimed to investigate the convergent and divergent attitudes and views of general practitioners (GPs) and community pharmacists (CPs) about AMS implementation and their perceived challenges of collaboration to design a GP–pharmacist collaborative AMS (GPPAS) model. Nationwide surveys of GPs and CPs across Australia were conducted January-October 2019. Chi square statistics and a theoretical framework were used for comparative analyses of quantitative and qualitative data, respectively. In total, 999 participants responded to the surveys with 15.4% (n = 386) response rates for GPs and 30.7% (n = 613) for CPs. GPs and CPs were aware about AMS however their interprofessional perceptions varied to the benefits of AMS programs. CPs indicated that they would need AMS training; significantly higher than GPs (GP vs. CP; 46.4% vs. 76.5%; p < 0.0001). GPs’ use of the Therapeutic Guideline Antibiotic was much higher than CPs (83.2% vs. 45.5%; p < 0.0001). No interprofessional difference was found in the very-limited use of patient information leaflets (p < 0.1162) and point-of-care tests (p < 0.7848). While CPs were more willing (p < 0.0001) to collaborate with GPs, both groups were convergent in views that policies that support GP–CP collaboration are needed to implement GPPAS strategies. GP–pharmacist collaborative group meetings (54.9% vs. 82.5%) and antimicrobial audit (46.1% vs. 86.5%) models were inter-professionally supported to optimise antimicrobial therapy, but an attitudinal divergence was significant (p < 0.001). The challenges towards GP–CP collaboration in AMS were identified by both at personal, logistical and organisational environment level. There are opportunities for GP–CP collaboration to improve AMS in Australian primary care. However, strengthening GP–pharmacy collaborative system structure and practice agreements is a priority to improve interprofessional trust, competencies, and communications for AMS and to establish a GPPAS model in future.
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13
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Figueiras A, López-Vázquez P, Gonzalez-Gonzalez C, Vázquez-Lago JM, Piñeiro-Lamas M, López-Durán A, Sánchez C, Herdeiro MT, Zapata-Cachafeiro M. Impact of a multifaceted intervention to improve antibiotic prescribing: a pragmatic cluster-randomised controlled trial. Antimicrob Resist Infect Control 2020; 9:195. [PMID: 33287881 PMCID: PMC7722452 DOI: 10.1186/s13756-020-00857-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 11/18/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study sought to assess the effectiveness and return on investment (ROI) of a multifaceted intervention aimed at improving antibiotic prescribing for acute respiratory infections in primary care. DESIGN Large-sized, two-arm, open-label, pragmatic, cluster-randomised controlled trial. SETTING All primary care physicians working for the Spanish National Health Service (NHS) in Galicia (region in north-west Spain). PARTICIPANTS The seven spatial clusters were distributed by unequal randomisation (3:4) of the intervention and control groups. A total of 1217 physicians (1.30 million patients) were recruited from intervention clusters and 1393 physicians (1.46 million patients) from control clusters. INTERVENTIONS One-hour educational outreach visits tailored to training needs identified in a previous study; an online course integrated in practice accreditation; and a clinical decision support system. MAIN OUTCOME MEASURES Changes in the ESAC (European Surveillance of Antimicrobial Consumption) quality indicators for outpatient antibiotic use. We used generalised linear mixed and conducted a ROI analysis to ascertain the overall cost savings. RESULTS Median follow-up was 19 months. The adjusted effect on overall antibiotic prescribing attributable to the intervention was - 4.2% (95% CI: - 5.3% to - 3.2%), with this being more pronounced for penicillins - 6.5 (95% CI: - 7.9% to - 5.2%) and for the ratio of consumption of broad- to narrow-spectrum penicillins, cephalosporins, and macrolides - 9.0% (95% CI: - 14.0 to - 4.1%). The cost of the intervention was €87 per physician. Direct savings per physician attributable to the reduction in antibiotic prescriptions was €311 for the NHS and €573 for patient contributions, with an ROI of €2.57 and €5.59 respectively. CONCLUSIONS Interventions designed on the basis of gaps in physicians' knowledge of and attitudes to misprescription can improve antibiotic prescribing and yield important direct cost savings. TRIAL REGISTRATION Current Controlled Trials ISRCTN24158380 . Registered 5 February 2009.
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Affiliation(s)
- Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15786, Santiago de Compostela, Spain.
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública- CIBERESP), Santiago de Compostela, Spain.
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.
| | - Paula López-Vázquez
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15786, Santiago de Compostela, Spain
| | - Cristian Gonzalez-Gonzalez
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15786, Santiago de Compostela, Spain
| | - Juan Manuel Vázquez-Lago
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15786, Santiago de Compostela, Spain
| | - María Piñeiro-Lamas
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública- CIBERESP), Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Ana López-Durán
- Department of Clinical Psychology and Psychobiology, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Coro Sánchez
- Pontevedra Primary Care Service, SERGAS Eoxi Pontevedra-Salnés, Pontevedra, Spain
| | - María Teresa Herdeiro
- Department of Medical Sciences & Institute for Biomedicine - iBiMED, University of Aveiro, Aveiro, Portugal
| | - Maruxa Zapata-Cachafeiro
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15786, Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública- CIBERESP), Santiago de Compostela, Spain
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14
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Yao L, Yin J, Huo R, Yang D, Shen L, Wen S, Sun Q. The effects of the primary health care providers' prescription behavior interventions to improve the rational use of antibiotics: a systematic review. Glob Health Res Policy 2020; 5:45. [PMID: 33088917 PMCID: PMC7568391 DOI: 10.1186/s41256-020-00171-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/08/2020] [Indexed: 01/21/2023] Open
Abstract
Background Irrational antibiotics use in clinical prescription, especially in primary health care (PHC) is accelerating the spread of antibiotics resistance (ABR) around the world. It may be greatly useful to improve the rational use of antibiotics by effectively intervening providers' prescription behaviors in PHC. This study aimed to systematically review the interventions targeted to providers' prescription behaviors in PHC and its' effects on improving the rational use of antibiotics. Methods The literatures were searched in Ovid Medline, Web of Science, PubMed, Cochrane Library, and two Chinese databases with a time limit from January 1st, 1998 to December 1st, 2018. The articles included in our review were randomized control trial, controlled before-and-after studies and interrupted time series, and the main outcomes measured in these articles were providers' prescription behaviors. The Cochrane Collaboration criteria were used to assess the risk of bias of the studies by two reviewers. Narrative analysis was performed to analyze the effect size of interventions. Results A total of 4422 studies were identified in this study and 17 of them were included in the review. Among 17 included studies, 13 studies were conducted in the Europe or in the United States, and the rest were conducted in low-income and-middle-income countries (LMICs). According to the Cochrane Collaboration criteria, 12 studies had high risk of bias and 5 studies had medium risk of bias. There was moderate-strength evidence that interventions targeted to improve the providers' prescription behaviors in PHC decreased the antibiotics prescribing and improved the rational use of antibiotics. Conclusions Interventions targeted PHC providers' prescription behaviours could be an effective way to decrease the use of antibiotics in PHC and to promote the rational use of antibiotics. However, we cannot compare the effects between different interventions because of heterogeneity of interventions and outcome measures.
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Affiliation(s)
- Lu Yao
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China.,NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012 China.,Cangzhou Central Hospital, Cangzhou, 061001 Hebei China
| | - Jia Yin
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China.,NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012 China
| | - Ruiting Huo
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China.,NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012 China
| | - Ding Yang
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China.,NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012 China
| | - Liyan Shen
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China.,NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012 China
| | - Shuqin Wen
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China.,NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012 China
| | - Qiang Sun
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012 China.,NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan, 250012 China
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15
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Neo JRJ, Niederdeppe J, Vielemeyer O, Lau B, Demetres M, Sadatsafavi H. Evidence-Based Strategies in Using Persuasive Interventions to Optimize Antimicrobial Use in Healthcare: a Narrative Review. J Med Syst 2020; 44:64. [PMID: 32040649 DOI: 10.1007/s10916-020-1531-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 01/24/2020] [Indexed: 01/22/2023]
Abstract
A rise in antimicrobial resistance, seen especially since 2000, is in part caused by indiscriminate antimicrobial use. Varied types of persuasive interventions aimed to optimize antimicrobial use have been tried with varying success. Our review seeks to identify and assess factors associated with the successful implementation of persuasive interventions. We searched five databases (MEDLINE, EMBASE, The Cochrane Library, PsycINFO, and ERIC) to identify critical studies published between 2000 and December 2018 of interventions employing audit and feedback, education through meetings, academic detailing, reminders, and patient, family, or public education. Outcome measures of interest were any means to measure antimicrobial use. We included 26 articles in our analysis. Seventeen examined multimodal interventions and the most common was audit and feedback and meeting (four studies). Nine examined single interventions and the most common was audit and feedback (five studies). Our findings inform four evidence-based strategies to enable healthcare administrators, clinicians, and researchers to make informed choices when planning and designing an antimicrobial stewardship program: (1) implement a combination of persuasive interventions from both groups: audit and feedback, academic detailing, or patient, family, or provider education; and meeting or reminders, (2) design interventions that last one year or longer; post-intervention, assess the intervention's long-term effects for at least another one year, (3) conduct quality improvement projects examining persuasive interventions if the prescribing database provides adequate diagnosis information, and most importantly, (4) make patient, family, or provider education an integral component of multimodal intervention.
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Affiliation(s)
- Jun Rong Jeffrey Neo
- Department of Design and Environmental Analysis, Cornell University, Martha Van Rensselaer Hall, Ithaca, NY, 14853, USA.
| | - Jeff Niederdeppe
- Department of Communication, Cornell University, 476 Mann Library Building, Ithaca, NY, 14853, USA
| | - Ole Vielemeyer
- Weill Cornell Medicine, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
| | - Brandyn Lau
- Johns Hopkins Medicine, Department of Radiology and Radiological Science, 600 North Wolfe Street - Radiology 127, Baltimore, MD, 21205, USA
| | | | - Hessam Sadatsafavi
- Department of Emergency Medicine, University of Virginia School of Medicine, University of Virginia Health Sciences Center, P.O. Box 800699, Charlottesville, VA, 22908, USA
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16
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Clay-Williams R, Stephens JH, Williams H, Hallahan A, Dalton C, Hibbert P, Ting HP, Arnolda G, Wiles L, Braithwaite J. Assessing the appropriateness of the management of otitis media in Australia: A population-based sample survey. J Paediatr Child Health 2020; 56:215-223. [PMID: 31317635 DOI: 10.1111/jpc.14560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 06/20/2019] [Accepted: 06/21/2019] [Indexed: 02/05/2023]
Abstract
AIM Acute otitis media (AOM) is the most common infectious disease for which antibiotics are prescribed; its management is costly and has the potential to increase the antimicrobial resistance of this infection. This study measured the levels of adherence to the clinical practice guidelines (CPGs) of AOM and otitis media with effusion (OME) management in Australian children. METHODS We searched for national and international CPGs relating to AOM and OME in children and created 37 indicators for assessment. We reviewed medical records for adherence to these indicators in 120 locations, across one inpatient and three ambulatory health-care settings. Our review sample was obtained from three Australian states that contain 60% of the nation's children. RESULTS We reviewed the records of 1063 children with one or more assessments of CPG adherence for otitis media. Of 22 indicators with sufficient data, estimated adherence ranged from 7.4 to 99.1%. Overuse of treatment, particularly overprescribing of antibiotics, was more common than underuse. A frequent lack of adherence with recommended care was observed for children aged between 1 and 2 years with AOM. Adherence varied by health-care setting, with emergency departments and inpatient settings more adherent to CPGs than general practices. CONCLUSIONS Our assessment of a number of indicators in the common settings in which otitis media is treated found that guideline adherence varied widely between individual indicators. Internationally agreed standards for diagnosis and treatment, coupled with clinician education on the existence and content of CPGs and clinical decision support, are needed to improve the management of children presenting with AOM and OME.
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Affiliation(s)
- Robyn Clay-Williams
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jacqueline H Stephens
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Helena Williams
- Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Andrew Hallahan
- Children's Health Queensland, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | | | - Peter Hibbert
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.,School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Hsuen P Ting
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Gaston Arnolda
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Louise Wiles
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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17
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Stallwood J, Shirlow A, Hibbert A. A UK-based survey of cat owners' perceptions and experiences of antibiotic usage. J Feline Med Surg 2020; 22:69-76. [PMID: 30720397 PMCID: PMC10814557 DOI: 10.1177/1098612x19826353] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
OBJECTIVES The aim of this study was to explore owners' knowledge of antibiotics, experience of antibiotic use in their cats and involvement in decision-making regarding antibiotic prescriptions. METHODS Cat owners were recruited via social media and veterinary practices to complete a survey designed to evaluate general knowledge of antibiotics, attitudes to antibiotic stewardship and experiences of antibiotic use in their own cat between November 2017 and March 2018. Data were analysed descriptively. RESULTS A total of 1436 surveys were completed; 247 respondents (17.2%) had a veterinary background. The majority of the remaining respondents correctly identified that antibiotics treat bacterial infections (84.0%; n = 999) but do not treat viral infections (72.8%; n = 865). A minority (n = 338; 28.4%) agreed that antibiotic resistance was a problem in cats in the UK; 92.3% (n = 1097) identified that resistance was a problem in human medicine. Seventy percent (n = 832) of the respondents' cats had received antibiotics; 29.6% (n = 246) received a long-acting injectable antibiotic (14 days' duration). Diagnostic tests were performed before antibiotic prescription in 38.7% (n = 322) of cats; 1.4% (n = 7) of respondents reported declining suggested tests and 65.8% (n = 778) indicated that they would be happy to pay for diagnostic tests to allow selection of the most appropriate antibiotic. Most respondents (95.8%; n = 792) indicated that they were happy to follow their veterinarian's advice and recommendations; however, 49.2% (n = 405) had expected antibiotics to be prescribed. CONCLUSIONS AND RELEVANCE Cat owners demonstrated good knowledge of antibiotic action; however, greater owner education regarding the potential for veterinary antibiotic resistance, requirement for diagnostic testing and training in the administration of oral medication with first-line antibiotics, as well as the use of veterinary antibiotic guidelines, will improve antibiotic stewardship. Good communication between veterinarians and owners is necessary for rational antibiotic use.
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Affiliation(s)
| | - Alex Shirlow
- 4 Clockhouse Mews, School Road, Wrington, Bristol, UK
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18
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Aoybamroong N, Kantamalee W, Thadanipon K, Techasaensiri C, Malathum K, Apiwattanakul N. Impact of an Antibiotic Stewardship Program on Antibiotic Prescription for Acute Respiratory Tract Infections in Children: A Prospective Before-After Study. Clin Pediatr (Phila) 2019; 58:1166-1174. [PMID: 31431068 DOI: 10.1177/0009922819870248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We assessed the effectiveness of an antibiotic stewardship program (ASP) on antibiotic prescriptions for acute respiratory tract infection (ARTI) in a medical school. Our ASP included delivering an antibiotic use guideline via e-mail and LINE (an instant messaging app) to faculty staff, fellows, and residents, and posting of the guideline in examination rooms. Medical records of pediatric patients diagnosed with ARTI were reviewed to assess the appropriateness of antibiotic prescription. ASP could increase the rate of appropriateness from 78% (1979 out of 2553 visits) to 83.4% (2449 out of 2935 visits; P < .001). The baseline of appropriateness was higher in residents (95%) compared with fellows (82%) and faculty staff (75%). The ASP significantly increased the appropriateness only in faculty staff, especially in semiprivate clinics (75% to 83%, P < .001). In conclusion, our ASP increased appropriateness of antibiotic prescriptions for ARTI, with the greatest impact among faculty staff in semiprivate clinics.
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19
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Rohde AM, Wiese-Posselt M, Zweigner J, Schwab F, Mischnik A, Seifert H, Gastmeier P, Kern WV. High admission prevalence of fluoroquinolone resistance in third-generation cephalosporin-resistant Enterobacteriaceae in German university hospitals. J Antimicrob Chemother 2019; 73:1688-1691. [PMID: 29490046 DOI: 10.1093/jac/dky040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/19/2018] [Indexed: 11/14/2022] Open
Abstract
Objectives Fluoroquinolone resistance (FQR) in third-generation cephalosporin-resistant Enterobacteriaceae (3GCRE) presents serious limitations to antibiotic therapy. The aim of this study was to investigate whether the FQR proportion among 3GCRE differs between community-acquired (CA) and hospital-acquired (HA) isolates. Methods In a prospective observational study covering 2014 and 2015, we monitored the occurrence of 3GCRE in adult hospitalized patients in six German university hospitals. 3GCRE clinical isolates were subdivided into CA and HA. Multivariable analysis identified factors associated with in vitro non-susceptibility to ciprofloxacin. Results The dataset included 5721 3GCRE isolates of which 52.9% were HA and 52.7% exhibited FQR. Interestingly, the FQR proportion was higher in CA 3GCRE than in HA 3GCRE (overall, 60.1% versus 46.2%, respectively, P < 0.001). Multivariable analysis adjusting for age confirmed community acquisition as a risk factor for FQR [adjusted rate ratio (aRR) 1.33, 95% CI 1.17-1.53]. Escherichia coli and Klebsiella spp. were associated with a much higher FQR proportion than other Enterobacteriaceae species (aRR 8.14, 95% CI 6.86-9.65 and aRR 7.62 with 95% CI 6.74-8.61, respectively). Conclusions The high FQR proportion observed among CA 3GCRE, particularly in E. coli and Klebsiella spp., indicates that selection pressure in the outpatient setting needs to be addressed with antibiotic stewardship and other interventions in order to limit further spread of MDR.
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Affiliation(s)
- Anna M Rohde
- German Center for Infection Research (DZIF), Braunschweig, Germany.,Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Miriam Wiese-Posselt
- German Center for Infection Research (DZIF), Braunschweig, Germany.,Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Janine Zweigner
- German Center for Infection Research (DZIF), Braunschweig, Germany.,Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,Institute of Medical Microbiology, Immunology and Hygiene, University Hospital Cologne, Cologne, Germany
| | - Frank Schwab
- German Center for Infection Research (DZIF), Braunschweig, Germany.,Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Alexander Mischnik
- German Center for Infection Research (DZIF), Braunschweig, Germany.,Division of Infectious Diseases, Department of Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harald Seifert
- German Center for Infection Research (DZIF), Braunschweig, Germany.,Institute of Medical Microbiology, Immunology and Hygiene, University Hospital Cologne, Cologne, Germany
| | - Petra Gastmeier
- German Center for Infection Research (DZIF), Braunschweig, Germany.,Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - Winfried V Kern
- German Center for Infection Research (DZIF), Braunschweig, Germany.,Division of Infectious Diseases, Department of Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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20
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Eilermann K, Halstenberg K, Kuntz L, Martakis K, Roth B, Wiesen D. The Effect of Expert Feedback on Antibiotic Prescribing in Pediatrics: Experimental Evidence. Med Decis Making 2019; 39:781-795. [PMID: 31423892 PMCID: PMC6843625 DOI: 10.1177/0272989x19866699] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background. Inappropriate prescribing of antibiotics, which is common in pediatric care, is a key driver of antimicrobial resistance. To mitigate the development of resistance, antibiotic stewardship programs often suggest the inclusion of feedback targeted at individual providers. Empirically, however, it is not well understood how feedback affects individual physicians’ antibiotic prescribing decisions. Also, the question of how physicians’ characteristics, such as clinical experience, relate to antibiotic prescribing decisions and to responses to feedback is largely unexplored. Objective. To analyze the causal effect of descriptive expert feedback (and individual characteristics) on physicians’ antibiotic prescribing decisions in pediatrics. Design. We employed a randomized, controlled framed field experiment, in which German pediatricians (n=73) decided on the length of first-line antibiotic treatment for routine pediatric cases. In the intervention group (n=39), pediatricians received descriptive feedback in form of an expert benchmark, which allowed them to compare their own prescribing decisions with expert recommendations. The recommendations were elicited in a survey of pediatric department directors (n=20), who stated the length of antibiotic therapies they would choose for the routine cases. Pediatricians’ characteristics were elicited in a comprehensive questionnaire. Results. Providing pediatricians with expert feedback significantly reduced the length of antibiotic therapies by 10% on average. Also, the deviation of pediatricians’ decisions from experts’ recommendations significantly decreased. Antibiotic therapy decisions were significantly related to pediatricians’ clinical experience, risk attitudes, and personality traits. The effect of feedback was significantly associated with physicians’ experience. Conclusion. Our results indicate that descriptive expert feedback can be an effective means to guide pediatricians, especially those who are inexperienced, toward more appropriate antibiotic prescribing. Therefore, it seems to be suitable for inclusion in antibiotic stewardship programs.
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Affiliation(s)
- Kerstin Eilermann
- Cologne Graduate School in Management, Economics, and Social Sciences (CGS), Department of Business Administration and Health Care Management, University of Cologne, Cologne, Germany
| | - Katrin Halstenberg
- Medical Faculty and University Hospital, Department of Pediatrics, University of Cologne, Cologne, Germany
| | - Ludwig Kuntz
- />Department of Business Administration and Health Care Management, University of Cologne, Cologne, Germany
- />Operations Management Group, Judge Business School, University of Cambridge, Cambridge, UK
| | - Kyriakos Martakis
- />Medical Faculty and University Hospital, Department of Pediatrics, University of Cologne, Cologne, Germany
- />Department of International Health, Care and Public Health Research Institute, School CAPHRI, Maastricht University, Maastricht, the Netherlands
- />Department of Pediatric Neurology, University Children’s Hospital (UKGM) and Medical Faculty, Justus Liebig University of Giessen, Giessen, Germany
| | - Bernhard Roth
- Medical Faculty and University Hospital, Department of Pediatrics, University of Cologne, Cologne, Germany
| | - Daniel Wiesen
- Daniel Wiesen, Department of Business Administration and Health Care Management, University of Cologne, Albertus-Magnus-Platz, Cologne, 50923, Germany ()
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21
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Najmi A, Karimi F, Kunhikatta V, Varma M, Nair S. Resistance Trend, Antibiotic Utilization and Mortality in Patients with E. coli Bacteraemia. Open Access Maced J Med Sci 2019; 7:1119-1123. [PMID: 31049092 PMCID: PMC6490482 DOI: 10.3889/oamjms.2019.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND: Incidence of bacteraemia and driving concerns about antibiotic resistance is increasing globally. Risk factors for developing antimicrobial resistance are antibiotic overuse, incorrect dosing and extended duration of administration. AIM: This study was conducted to examine the prescription and susceptibility pattern of antibiotics in bacteraemia patients with ESBL producing and Non-ESBL-producing E. coli and their correlation with mortality. METHODS: Data were collected from medical records of the patients aged 18 years and above, diagnosed with E. coli bacteremia from January 2013 through July 2017. Institutional ethics committee approval was obtained before the study (IEC 483/2017). Cumulative sensitivity/resistance pattern of isolated microorganisms and DDD/100 bed days of prescribed antibiotics were obtained. RESULTS: 182 cases of E. coli bacteraemia were reviewed. 59.9% (n = 109) were male with an age range of 20-90 years. The mortality rate was 24.9% (n = 44). 55.5% (n = 101) of the isolated organisms were ESBL-producing. A high percentage of resistance to cephalosporins and fluoroquinolones were observed among the patients, and most of the identified isolates were sensitive to the aminoglycosides, carbapenems and β-lactam and β-lactamase inhibitor combinations (BLBLIs). CONCLUSIONS: Frequent utilisation of the high-end antibiotics and increase in microorganism’s resistance to different antibiotics can lead to a worrisome level. Local antibiotic resistance data and consumption policy are essential to prevent and slow down this process. We observed a descending resistance trend for amoxicillin-clavulanic acid combination in our setting to both the ESBL producing and non-producing.
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Affiliation(s)
- Amirreza Najmi
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Fateme Karimi
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vijayanarayan Kunhikatta
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Muralidhar Varma
- Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sreedharan Nair
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
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22
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Little P, Stuart B, Francis N, Douglas E, Tonkin-Crine S, Anthierens S, Cals JWL, Melbye H, Santer M, Moore M, Coenen S, Butler CC, Hood K, Kelson M, Godycki-Cwirko M, Mierzecki A, Torres A, Llor C, Davies M, Mullee M, O'Reilly G, van der Velden A, Geraghty AWA, Goossens H, Verheij T, Yardley L. Antibiotic Prescribing for Acute Respiratory Tract Infections 12 Months After Communication and CRP Training: A Randomized Trial. Ann Fam Med 2019; 17:125-132. [PMID: 30858255 PMCID: PMC6411389 DOI: 10.1370/afm.2356] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/10/2018] [Accepted: 12/31/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE C-reactive-protein (CRP) is useful for diagnosis of lower respiratory tract infections (RTIs). A large international trial documented that Internet-based training in CRP point-of-care testing, in enhanced communication skills, or both reduced antibiotic prescribing at 3 months, with risk ratios (RRs) of 0.68, 0.53, 0.38, respectively. We report the longer-term impact in this trial. METHODS A total of 246 general practices in 6 countries were cluster-randomized to usual care, Internet-based training on CRP point-of-care testing, Internet-based training on enhanced communication skills and interactive booklet, or both interventions combined. The main outcome was antibiotic prescribing for RTIs after 12 months. RESULTS Of 228 practices providing 3-month data, 74% provided 12-month data, with no demonstrable attrition bias. Between 3 months and 12 months, prescribing for RTIs decreased with usual care (from 58% to 51%), but increased with CRP training (from 35% to 43%) and with both interventions combined (from 32% to 45%); at 12 months, the adjusted RRs compared with usual care were 0.75 (95% CI, 0.51-1.00) and 0.70 (95% CI, 0.49-0.93), respectively. Between 3 months and 12 months, the reduction in prescribing with communication training was maintained (41% and 40%, with an RR at 12 months of 0.70 [95% CI, 0.49-0.94]). Although materials were provided for free, clinicians seldom used booklets and rarely used CRP point-of-care testing. Communication training, but not CRP training, remained efficacious for reducing prescribing for lower RTIs (RR = 0.7195% CI, 0.45-0.99, and RR = 0.76; 95% CI, 0.47-1.06, respectively), whereas both remained efficacious for reducing prescribing for upper RTIs (RR = 0.60; 95% CI, 0.37-0.94, and RR = 0.58; 95% CI, 0.36-0.92, respectively). CONCLUSIONS Internet-based training in enhanced communication skills remains effective in the longer term for reducing antibiotic prescribing. The early improvement seen with CRP training wanes, and this training becomes ineffective for lower RTIs, the only current indication for using CRP testing.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye).
| | - Beth Stuart
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Nick Francis
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Elaine Douglas
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Sarah Tonkin-Crine
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Sibyl Anthierens
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Jochen W L Cals
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Hasse Melbye
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Miriam Santer
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Michael Moore
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Samuel Coenen
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Chris C Butler
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Kerenza Hood
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Mark Kelson
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Maciek Godycki-Cwirko
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Artur Mierzecki
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Antoni Torres
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Carl Llor
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Melanie Davies
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Mark Mullee
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Gilly O'Reilly
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Alike van der Velden
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Adam W A Geraghty
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Herman Goossens
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Theo Verheij
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
| | - Lucy Yardley
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, United Kingdom (Little, Mullee, Stuart, O'Reilly, Moore, Geraghty, Santer); School of Psychological Science, University of Bristol, Bristol, United Kingdom (Yardley); Economics Division, Stirling Management School, University of Stirling, Stirling, UK (Douglas); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands (Verheij, van der Velden); Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom (Butler, Tonkin-Crine); Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom (Francis); South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, United Kingdom (Hood); Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK (Kelson); Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Łódź , Łódź , Poland (Godycki-Cwirko); Laboratory of Family Physician Education, Pomeranian Medical University, Szczecin, Poland (Mierzecki); Ely Bridge Surgery, Ely, Cardiff, United Kingdom (Davies); Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-University of Barcelona (UB)-Ciber de Enfermedades Respiratorias (Ciberes) Villarroel, Barcelona, Spain (Torres); Department of Primary and Interdisciplinary Care (ELIZA), Department of Epidemiology and Social Medicine and Vaccine & Infectious Disease Institute (VAXIN-FECTIO), University of Antwerp, Antwerp, Belgium (Coenen); Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium (Goossens); Department of Primary and Interdisciplinary Care (ELIZA), Universityof Antwerp, Antwerp, Belgium (Anthierens); University Rovira i Virgili, Tarragona, Spain, Spanish Society of Family Medicine (semFYC) (Llor); Maastricht University/CAPHRI, Maastricht, The Netherlands (Cals); and General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway (Melbye)
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Rohrbasser A, Harris J, Mickan S, Tal K, Wong G. Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae- A scoping review. PLoS One 2018; 13:e0202616. [PMID: 30557329 PMCID: PMC6296539 DOI: 10.1371/journal.pone.0202616] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/04/2018] [Indexed: 01/02/2023] Open
Abstract
Quality circles or peer review groups, and similar structured small groups of 6–12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners’ behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.
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Affiliation(s)
- Adrian Rohrbasser
- Department of Continuing Education University of Oxford, Oxford, United Kingdom
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- * E-mail:
| | - Janet Harris
- University of Sheffield School of Health & Related Research, Sheffield, United Kingdom
| | - Sharon Mickan
- The Gold Coast Health, Griffith University, Southport, Australia
| | - Kali Tal
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Shaikhan F, Rawaf S, Majeed A, Hassounah S. Knowledge, attitude, perception and practice regarding antimicrobial use in upper respiratory tract infections in Qatar: a systematic review. JRSM Open 2018; 9:2054270418774971. [PMID: 30202533 PMCID: PMC6122249 DOI: 10.1177/2054270418774971] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To explore the knowledge, attitude, perception and practice towards antimicrobial use in upper respiratory tract infections in patients visiting healthcare settings in Qatar. DESIGN Systematic review was performed using a predetermined protocol and in accordance with standardized reporting guidelines. MEDLINE, PubMed, EMBASE, Global Health and PsycINFO were searched for relevant published studies using relevant MESH terms and keywords. SETTING All healthcare settings in Qatar including both inpatient and ambulatory care. PARTICIPANTS All published articles exploring the antimicrobial use in upper respiratory tract infections at any health setting in Qatar were considered for inclusion in the study. No age, gender or population were excluded. MAIN OUTCOME MEASURES The outcome of interest was antimicrobial use in upper respiratory tract infections in Qatar. We included all related studies to explore the knowledge, attitude, perception and practice for patients visiting all health care settings. RESULTS Three articles were included, one in a primary care setting, one in a secondary care setting and one in the private sector. Overprescribing was noted in all settings. Our findings demonstrate low expectations to receive antibiotics, among the Qatari population, in primary care (28.1%). In fact, the majority of patients would be satisfied with reassurance rather than receiving antimicrobials. Many patients were satisfied with explanation from physicians and counselling. Private sector registered high prevalence of antimicrobial misuse for respiratory tract infections in which 85% deemed inappropriate. This finding was also noted at a medical intensive care unit which showed high antimicrobial use (76%) and respiratory tract infections accounted for 57% of prescriptions. CONCLUSION Studies are needed to determine factors and population-based rates of antimicrobial use in all healthcare settings. There is also a need for interventional programs for both physicians and public on appropriate use of antimicrobials to combat global antimicrobial resistance.
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Affiliation(s)
- F Shaikhan
- WHO Collaborating Centre for Public
Health Education and Training, Department of Primary Care and Public Health,
Imperial College London, London, UK
| | - S Rawaf
- Department of Primary Care and Public
Health, Imperial College London, London, UK
| | - A Majeed
- Department of Primary Care and Public
Health, Imperial College London, London, UK
| | - S Hassounah
- WHO Collaborating Centre for Public
Health Education and Training, Department of Primary Care and Public Health,
Imperial College London, London, UK
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Saha SK, Hawes L, Mazza D. Improving antibiotic prescribing by general practitioners: a protocol for a systematic review of interventions involving pharmacists. BMJ Open 2018; 8:e020583. [PMID: 29654036 PMCID: PMC5898351 DOI: 10.1136/bmjopen-2017-020583] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Effective antibiotic options in general practice for patients with infections are declining significantly due to antibiotic over-prescribing and emerging antibiotic resistance. To better improve antibiotic prescribing by general practitioner (GP), pharmacist-GP collaborations have been promoted under antibiotic stewardship programmes. However, there is insufficient information about whether and how pharmacists help GPs to more appropriately prescribe antibiotics. This systematic review aims to determine whether pharmacist-led or pharmacist-involved interventions are effective at improving antibiotic prescribing by GPs. METHODS AND ANALYSIS A systematic review of English language randomised controlled trials (RCTs), cluster RCTs, controlled before-and-after studies and interrupted time series studies cited in MEDLINE, EMBASE, EMCARE, CINAHL Plus, PubMed, PsycINFO, Cochrane Central Register of Controlled Trials and Web of Science databases will be conducted. Studies will be included if a pharmacist is involved as the intervention provider and GPs are the intervention recipients in general practice setting. Data extraction and management will be conducted using Effective Practice and Organisation of Care data abstraction tools and a template for intervention description and replication. The Cochrane and ROBINS-I risk of bias assessment tools will be used to assess the methodological quality of studies. Primary outcome measures include changes (overall, broad spectrum and guidelines concordance) of GP-prescribed antibiotics. Secondary outcomes include quality of antibiotic prescribing, delayed antibiotic use, acceptability and feasibility of interventions. Meta-analysis for combined effect and forest plots, χ2 test and I2 statistics for detailed heterogeneity and sensitivity analysis will be performed if data permit. Grading of Recommendations Assessment, Development and Evaluation and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidance will be used to report findings. ETHICS AND DISSEMINATION No ethics approval is required as no primary, personal or confidential data are being collected in this study. The findings will be disseminated to national and international scientific sessions and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42017078478.
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Affiliation(s)
- Sajal K Saha
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
| | - Lesley Hawes
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
| | - Danielle Mazza
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
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Kim H, Oh JK, Kim MK, Bae K, Choi H. Reduced antibiotic prescription rates following physician-targeted interventions in a dental practice. Acta Odontol Scand 2018; 76:204-211. [PMID: 29161952 DOI: 10.1080/00016357.2017.1402209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The prescription rate for antibiotics in dental clinics is not declining despite the increase in the antibiotic resistance problem. In this study, we observed the change in antibiotic prescription rates by dentists in a Korean dental hospital for various treatments after conducting interventions targeting dentists. METHODS The first intervention was to distribute guidelines. The second intervention was to remove the bundled prescription button containing antibiotics from the Electronic Medical Record system. A total of 22,098 treatment records were divided into 12 main treatment categories, and Chi-square tests and logistic regression analyses were performed. RESULTS After the interventions were applied, the overall prescription rate for antibiotics dropped. The antibiotic prescription rate decreased by an odds ratio of 0.774 (95% CI: 0.686-0.873) after intervention 1 and by an odds ratio of 0.574 (95% CI: 0.501-0.658) after intervention 2. The treatments with significantly reduced antibiotic prescription rates were extraction for orthodontic treatment, dental implant surgery, extraction of an impacted tooth and general extraction. These treatments are typically performed in patients without an active infection. The prescription rate did not change for periodontal treatments or endodontic treatments, which are usually performed in patients with an infection. The prescription rate also remained constant for minor operations and other basic treatments. CONCLUSION The interventions induced behavioural changes in the dentists and were effective in lowering the antibiotic prescription rates in a dental hospital. In particular, there was a significant reduction in the prescription rates for implant surgery and tooth extraction in the absence of infection.
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Affiliation(s)
- Hyesung Kim
- Research Institute, Apple Tree Dental Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Jeong Kyu Oh
- Research Institute, Apple Tree Dental Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Myeng Ki Kim
- Dental Research Institute, Graduate School of Dentistry, Seoul National University, Seoul, South Korea
| | - Kwanghak Bae
- Research Institute, Apple Tree Dental Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Hyungkil Choi
- Research Institute, Apple Tree Dental Hospital, Goyang-si, Gyeonggi-do, South Korea
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Köchling A, Löffler C, Reinsch S, Hornung A, Böhmer F, Altiner A, Chenot JF. Reduction of antibiotic prescriptions for acute respiratory tract infections in primary care: a systematic review. Implement Sci 2018; 13:47. [PMID: 29554972 PMCID: PMC5859410 DOI: 10.1186/s13012-018-0732-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 02/27/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although most respiratory tract infections (RTIs) are due to viral infections, they cause the majority of antibiotic (Abx) prescriptions in primary care. This systematic review summarises the evidence on the effectiveness of interventions in primary care aiming to reduce Abx prescriptions in patients ≥ 13 years for acute RTI. METHODS We searched the databases "MEDLINE/PubMed" and "Cochrane Library" for the period from January 1, 2005, to August 31, 2016, for randomised controlled trials (RCTs) in primary care aiming at the reduction of Abx prescriptions for patients suffering from RTI. Out of 690 search results, 67 publications were retrieved and 17 RCTs were included. We assumed an absolute change of 10% as minimal important change. RESULTS Twelve out of 17 included RCTs showed statistically significant lower Abx prescription rates in the intervention groups, but only six of them reported a clinically relevant reduction according to our definition. Communication skills training (CST) and point-of-care testing (POCT) were the most effective interventions. Pre-intervention Abx prescription rates varied between 13.5% and 80% and observed reductions ranged from 1.5 to 23.3%. Studies with post-intervention rates lower than 20% had no significant effects. Post-intervention observation periods ranged from 2 weeks up to 3.5 years. The design of the trials was heterogeneous precluding calculation of pooled effect size. The reporting of many RCTs was poor. CONCLUSIONS CST and POCT alone or as adjunct can reduce antibiotic prescriptions for RTI. Eleven out of 17 trials were not successfully reducing Abx prescription rates according to our definition of minimal important change. However, five of them reported a statistically significant reduction. Trials with initially lower prescription rates were less likely to be successful. Future trials should investigate sustainability of intervention effects for a longer time period. The generalisability of findings was limited due to heterogeneous designs and outcome measures. Therefore, a consensus of designing and reporting of studies aiming at reducing antibiotic prescriptions is urgently needed to generate meaningful evidence.
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Affiliation(s)
- Anna Köchling
- Clinic for Psychosomatic Medicine and Psychotherapy, University Medical Center, Rostock, Germany
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Christin Löffler
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Stefan Reinsch
- Department of Pediatric Pneumology, Immunology & Intensive Care Medicine Charité, University Medical Center Berlin, Berlin, Germany
| | - Anne Hornung
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, University Medical Center Rostock, Rostock, Germany
| | - Femke Böhmer
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Attila Altiner
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Jean-François Chenot
- Institute for Community Medicine—Department of Family Medicine, University Greifswald, Greifswald, Germany
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Caverly T, Matlock D, Thompson J, Combs B. Qualitative evaluation of a narrative reflection program to help medical trainees recognize and avoid overuse: "Am I doing what's right for the patient?". PATIENT EDUCATION AND COUNSELING 2018; 101:475-480. [PMID: 28899714 DOI: 10.1016/j.pec.2017.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 08/30/2017] [Accepted: 09/01/2017] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The Do No Harm Project is a novel reflective writing program that encourages medical trainees to reflect on and write up clinical narratives about instances of avoidable medical overuse. Our goal is to describe this program and to explore the effect of the program on those participating. METHODS Semi-structured interviews were conducted to explore how participating in the project influenced the thinking, attitudes, and behaviors of participating internal medicine residents. Interviews were conducted with 20 out of the 24 participants from the first 15 months of the program. RESULTS The following themes emerged from our analysis: 1) learning through reflection (with three sub-themes: empathy for the patient perspective, a critical approach to one's own clinical practice, and awareness of the problem of overuse); 2) empowerment to discuss instances of overuse and act before it occurs; and 3) perceptions of enhanced evidence-based practice and shared decision-making. CONCLUSION Trainees volunteering to complete a reflective writing exercise perceived improved ability to avoid overuse and improved self-efficacy to change clinical behaviors that do not align with optimal patient care. PRACTICE IMPLICATIONS Reflective writing may help trainees recognize and avoid medical overuse.
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Affiliation(s)
- Tanner Caverly
- Ann Arbor Veterans Affairs Center for Clinical Management Research, USA; University of Michigan Medical School, Department of Medicine & Learning Health Sciences, Ann Arbor, USA
| | - Daniel Matlock
- University of Colorado School of Medicine, Department of Medicine, Aurora, USA
| | - Jocelyn Thompson
- University of Colorado School of Medicine, Department of Medicine, Aurora, USA
| | - Brandon Combs
- University of Colorado School of Medicine, Department of Medicine, Aurora, USA; The Lown Institute, Brookline, MA, USA.
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Magin P, Tapley A, Morgan S, Davis JS, McElduff P, Yardley L, Henderson K, Dallas A, McArthur L, Mulquiney K, Davey A, Little P, Spike N, van Driel ML. Reducing early career general practitioners' antibiotic prescribing for respiratory tract infections: a pragmatic prospective non-randomised controlled trial. Fam Pract 2018; 35:53-60. [PMID: 28985369 DOI: 10.1093/fampra/cmx070] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescription and consequent antibacterial resistance is a major threat to healthcare. OBJECTIVES To evaluate the efficacy of a multifaceted intervention in reducing early career general practitioners' (GPs') antibiotic prescribing for upper respiratory tract infections (URTIs) and acute bronchitis/bronchiolitis. METHODS A pragmatic non-randomized trial employing a non-equivalent control group design nested within an existing cohort study of GP registrars' (trainees') clinical practice. The intervention included access to online modules (covering the rationale of current clinical guidelines recommending non-prescription of antibiotics for URTI and bronchitis/bronchiolitis, and communication skills in management of acute bronchitis) followed by a face-to-face educational session. The intervention was delivered to registrars (and their supervisors) in two of Australia's seventeen regional GP training providers (RTPs). Three other RTPs were the control group. Outcomes were proportion of registrars' URTI consultations and bronchitis/bronchiolitis consultations prescribed antibiotics. Intention-to-treat analyses employed logistic regression within a Generalised Estimating Equation framework, adjusted for relevant independent variables. The predictors of interest were time; treatment group; and an interaction term for time-by-treatment group. The P value associated with an interaction term determined statistically significant differences in antibiotic prescribing. RESULTS Analyses include data of 217 intervention RTPs' and 311 control RTPs' registrars. There was no significant reduction in antibiotic prescribing for URTIs. For bronchitis/bronchiolitis, a significant reduction (interaction P value = 0.024) remained true for analysis adjusted for independent variables (P value = 0.040). The adjusted absolute reduction in prescribing was 15.8% (95% CI: 4.2%-27.5%). CONCLUSIONS A multifaceted intervention reduced antibiotic prescribing for bronchitis/bronchiolitis but not URTIs.
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Affiliation(s)
- Parker Magin
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | - Amanda Tapley
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | - Simon Morgan
- Elermore Vale General Practice, Elermore Vale, Australia
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,Menzies School of Health Research, Royal Darwin Hospital Campus, Casuarina, Australia.,John Hunter Hospital, New Lambton Heights, Australia
| | - Patrick McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Lucy Yardley
- Centre for Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Kim Henderson
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | | | - Lawrie McArthur
- Department of General Practice, University of Adelaide, Adelaide, Australia
| | - Katie Mulquiney
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | - Andrew Davey
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Paul Little
- Primary Care & Population Sciences Academic Units, University of Southampton, Southampton, UK
| | - Neil Spike
- Department of General Practice, University of Melbourne, Melbourne, Australia.,Eastern Victoria General Practice Training, Melbourne, Australia
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia
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Ivanovska V, Angelovska B, van Dijk L, Zdravkovska M, Leufkens HG, Mantel-Teeuwisse AK. Change in parental knowledge, attitudes and practice of antibiotic use after a national intervention programme. Eur J Public Health 2018; 28:724-729. [DOI: 10.1093/eurpub/ckx240] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Verica Ivanovska
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Faculty of Medical Sciences, University “Goce Delcev”, Stip, Macedonia
| | - Bistra Angelovska
- Faculty of Medical Sciences, University “Goce Delcev”, Stip, Macedonia
| | - Liset van Dijk
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Milka Zdravkovska
- Faculty of Medical Sciences, University “Goce Delcev”, Stip, Macedonia
| | - Hubert G Leufkens
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Medicines Evaluation Board, Utrecht, The Netherlands
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Tonkin‐Crine SKG, Tan PS, van Hecke O, Wang K, Roberts NW, McCullough A, Hansen MP, Butler CC, Del Mar CB. Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD012252. [PMID: 28881002 PMCID: PMC6483738 DOI: 10.1002/14651858.cd012252.pub2] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Antibiotic resistance is a worldwide health threat. Interventions that reduce antibiotic prescribing by clinicians are expected to reduce antibiotic resistance. Disparate interventions to change antibiotic prescribing behaviour for acute respiratory infections (ARIs) have been trialled and meta-analysed, but not yet synthesised in an overview. This overview synthesises evidence from systematic reviews, rather than individual trials. OBJECTIVES To systematically review the existing evidence from systematic reviews on the effects of interventions aimed at influencing clinician antibiotic prescribing behaviour for ARIs in primary care. METHODS We searched the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, CINAHL, PsycINFO, and Science Citation Index to June 2016. We also searched the reference lists of all included reviews. We ran a pre-publication search in May 2017 and placed additional studies in 'awaiting classification'.We included both Cochrane and non-Cochrane reviews of randomised controlled trials evaluating the effect of any clinician-focussed intervention on antibiotic prescribing behaviour in primary care. Two overview authors independently extracted data and assessed the methodological quality of included reviews using the ROBIS tool, with disagreements reached by consensus or by discussion with a third overview author. We used the GRADE system to assess the quality of evidence in included reviews. The results are presented as a narrative overview. MAIN RESULTS We included eight reviews in this overview: five Cochrane Reviews (33 included trials) and three non-Cochrane reviews (11 included trials). Three reviews (all Cochrane Reviews) scored low risk across all the ROBIS domains in Phase 2 and low risk of bias overall. The remaining five reviews scored high risk on Domain 4 of Phase 2 because the 'Risk of bias' assessment had not been specifically considered and discussed in the review Results and Conclusions. The trials included in the reviews varied in both size and risk of bias. Interventions were compared to usual care.Moderate-quality evidence indicated that C-reactive protein (CRP) point-of-care testing (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92, 3284 participants, 6 trials), shared decision making (odds ratio (OR) 0.44, 95% CI 0.26 to 0.75, 3274 participants, 3 trials; RR 0.64, 95% CI 0.49 to 0.84, 4623 participants, 2 trials; risk difference -18.44, 95% CI -27.24 to -9.65, 481,807 participants, 4 trials), and procalcitonin-guided management (adjusted OR 0.10, 95% CI 0.07 to 0.14, 1008 participants, 2 trials) probably reduce antibiotic prescribing in general practice. We found moderate-quality evidence that procalcitonin-guided management probably reduces antibiotic prescribing in emergency departments (adjusted OR 0.34, 95% CI 0.28 to 0.43, 2605 participants, 7 trials). The overall effect of these interventions was small (few achieving greater than 50% reduction in antibiotic prescribing, most about a quarter or less), but likely to be clinically important.Compared to usual care, shared decision making probably makes little or no difference to reconsultation for the same illness (RR 0.87, 95% CI 0.74 to 1.03, 1860 participants, 4 trials, moderate-quality evidence), and may make little or no difference to patient satisfaction (RR 0.86, 95% CI 0.57 to 1.30, 1110 participants, 2 trials, low-quality evidence). Similarly, CRP testing probably has little or no effect on patient satisfaction (RR 0.79, 95% CI 0.57 to 1.08, 689 participants, 2 trials, moderate-quality evidence) or reconsultation (RR 1.08, 95% CI 0.93 to 1.27, 5132 participants, 4 trials, moderate-quality evidence). Procalcitonin-guided management probably results in little or no difference in treatment failure in general practice compared to normal care (adjusted OR 0.95, 95% CI 0.73 to 1.24, 1008 participants, 2 trials, moderate-quality evidence), however it probably reduces treatment failure in the emergency department compared to usual care (adjusted OR 0.76, 95% CI 0.61 to 0.95, 2605 participants, 7 trials, moderate-quality evidence).The quality of evidence for interventions focused on clinician educational materials and decision support in reducing antibiotic prescribing in general practice was either low or very low (no pooled result reported) and trial results were highly heterogeneous, therefore we were unable draw conclusions about the effects of these interventions. The use of rapid viral diagnostics in emergency departments may have little or no effect on antibiotic prescribing (RR 0.86, 95% CI 0.61 to 1.22, 891 participants, 3 trials, low-quality evidence) and may result in little to no difference in reconsultation (RR 0.86, 95% CI 0.59 to 1.25, 200 participants, 1 trial, low-quality evidence).None of the trials in the included reviews reported on management costs for the treatment of an ARI or any associated complications. AUTHORS' CONCLUSIONS We found evidence that CRP testing, shared decision making, and procalcitonin-guided management reduce antibiotic prescribing for patients with ARIs in primary care. These interventions may therefore reduce overall antibiotic consumption and consequently antibiotic resistance. There do not appear to be negative effects of these interventions on the outcomes of patient satisfaction and reconsultation, although there was limited measurement of these outcomes in the trials. This should be rectified in future trials.We could gather no information about the costs of management, and this along with the paucity of measurements meant that it was difficult to weigh the benefits and costs of implementing these interventions in practice.Most of this research was undertaken in high-income countries, and it may not generalise to other settings. The quality of evidence for the interventions of educational materials and tools for patients and clinicians was either low or very low, which prevented us from drawing any conclusions. High-quality trials are needed to further investigate these interventions.
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Affiliation(s)
- Sarah KG Tonkin‐Crine
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Pui San Tan
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Oliver van Hecke
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Kay Wang
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Amanda McCullough
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia
| | | | - Christopher C Butler
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia
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Al-Tawfiq JA, Alawami AH. A multifaceted approach to decrease inappropriate antibiotic use in a pediatric outpatient clinic. Ann Thorac Med 2017; 12:51-54. [PMID: 28197223 PMCID: PMC5264174 DOI: 10.4103/1817-1737.197779] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND: Inappropriate use of antimicrobial agents is the major cause for the development of resistance. Thus, it is important to include outpatient clinics in the development of antibiotic stewardship program. METHODS: We report a multifaceted approach to decrease inappropriate antibiotic use in upper respiratory tract infections (URTIs) in an outpatient pediatric clinic. The interventions included educational grand round, academic detailing, and prospective audit and feedback and peer comparison. RESULTS: During the study period, a total of 3677 outpatient clinic visits for URTIs were evaluated. Of all the included patients, 12% were <1 year of age, 42% were 1–5 years, and 46% were >5 years of age. Of the total patients, 684 (17.6%) received appropriate antibiotics, 2812 (76.4%) appropriately did not receive antibiotics, and 217 (6%) inappropriately received antibiotics. The monthly rate of prescription of inappropriate antibiotics significantly decreased from 12.3% at the beginning of the study to 3.8% at the end of the study (P < 0.0001). Antibiotic prescription among those who had rapid streptococcal antigen test (RSAT) was 40% compared with 78% among those who did not have RSAT (P < 0.0001). CONCLUSIONS: The combination of education and academic detailing is important to improve antibiotic use.
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Affiliation(s)
- Jaffar A Al-Tawfiq
- Department of Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Amel H Alawami
- Department of Pediatric, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
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O'Sullivan JW, Harvey RT, Glasziou PP, McCullough A. Written information for patients (or parents of child patients) to reduce the use of antibiotics for acute upper respiratory tract infections in primary care. Cochrane Database Syst Rev 2016; 11:CD011360. [PMID: 27886368 PMCID: PMC6464519 DOI: 10.1002/14651858.cd011360.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute upper respiratory tract infections (URTIs) are frequently managed in primary care settings. Although many are viral, and there is an increasing problem with antibiotic resistance, antibiotics continue to be prescribed for URTIs. Written patient information may be a simple way to reduce antibiotic use for acute URTIs. OBJECTIVES To assess if written information for patients (or parents of child patients) reduces the use of antibiotics for acute URTIs in primary care. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Web of Science, clinical trials.gov, and the World Health Organization (WHO) trials registry up to July 2016 without language or publication restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) involving patients (or parents of child patients) with acute URTIs, that compared written patient information delivered immediately before or during prescribing, with no information. RCTs needed to have measured our primary outcome (antibiotic use) to be included. DATA COLLECTION AND ANALYSIS Two review authors screened studies, extracted data, and assessed study quality. We could not meta-analyse included studies due to significant methodological and statistical heterogeneity; we summarised the data narratively. MAIN RESULTS Two RCTs met our inclusion criteria, involving a total of 827 participants. Both studies only recruited children with acute URTIs (adults were not involved in either study): 558 children from 61 general practices in England and Wales; and 269 primary care doctors who provided data on 33,792 patient-doctor consultations in Kentucky, USA. The UK study had a high risk of bias due to lack of blinding and the US cluster-randomised study had a high risk of bias because the methods to allocate participants to treatment groups was not clear, and there was evidence of baseline imbalance.In both studies, clinicians provided written information to parents of child patients during primary care consultations: one trained general practitioners (GPs) to discuss an eight-page booklet with parents; the other conducted a factorial trial with two comparison groups (written information compared to usual care and written information plus prescribing feedback to clinicians compared to prescribing feedback alone). Doctors in the written information arms received 25 copies of two-page government-sponsored pamphlets to distribute to parents.Compared to usual care, we found moderate quality evidence (one study) that written information significantly reduced the number of antibiotics used by patients (RR 0.53, 95% CI 0.35 to 0.80; absolute risk reduction (ARR) 20% (22% versus 42%)) and had no significant effect on reconsultation rates (RR 0.79, 95% CI 0.47 to 1.32), or parent satisfaction with consultation (RR 0.95, 95% CI 0.87 to 1.03). Low quality evidence (two studies) demonstrated that written information also reduced antibiotics prescribed by clinicians (RR 0.47, 95% CI 0.28 to 0.78; ARR 21% (20% versus 41%); and RR 0.84, 95% CI 0.81 to 0.86; 9% ARR (45% versus 54%)). Neither study measured resolution of symptoms, patient knowledge about antibiotics for acute URTIs, or complications for this comparison.Compared to prescribing feedback, we found low quality evidence that written information plus prescribing feedback significantly increased the number of antibiotics prescribed by clinicians (RR 1.13, 95% CI 1.09 to 1.17; absolute risk increase 6% (50% versus 44%)). Neither study measured reconsultation rate, resolution of symptoms, patient knowledge about antibiotics for acute URTIs, patient satisfaction with consultation or complications for this comparison. AUTHORS' CONCLUSIONS Compared to usual care, moderate quality evidence from one study showed that trained GPs providing written information to parents of children with acute URTIs in primary care can reduce the number of antibiotics used by patients without any negative impact on reconsultation rates or parental satisfaction with consultation. Low quality evidence from two studies shows that, compared to usual care, GPs prescribe fewer antibiotics for acute URTIs but prescribe more antibiotics when written information is provided alongside prescribing feedback (compared to prescribing feedback alone). There was no evidence addressing resolution of patients' symptoms, patient knowledge about antibiotics for acute URTIs, or frequency of complications.To fill evidence gaps, future studies should consider testing written information on antibiotic use for adults with acute URTIs in high- and low-income settings provided without clinician training and presented in different formats (such as electronic). Future study designs should endeavour to ensure blinded outcome assessors. Study aims should include measurement of the effect of written information on the number of antibiotics used by patients and prescribed by clinicians, patient satisfaction, reconsultation, patients' knowledge about antibiotics, resolution of symptoms, and complications.
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Affiliation(s)
- Jack W O'Sullivan
- University of OxfordNuffield Department of Primary Care Health SciencesNew Radcliffe House, Radcliffe Observatory QuarterOxfordUK
| | - Robert T Harvey
- Queensland HealthPrincess Alexandra Hospital199 Ipswich road WollongabbaBrisbaneQueenslandAustralia4102
| | - Paul P Glasziou
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)University DriveGold CoastQueenslandAustralia4229
| | - Amanda McCullough
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)University DriveGold CoastQueenslandAustralia4229
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Elouafkaoui P, Young L, Newlands R, Duncan EM, Elders A, Clarkson JE, Ramsay CR. An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial. PLoS Med 2016; 13:e1002115. [PMID: 27575599 PMCID: PMC5004857 DOI: 10.1371/journal.pmed.1002115] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 07/22/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Dentists prescribe approximately 10% of antibiotics dispensed in UK community pharmacies. Despite clear clinical guidance, dentists often prescribe antibiotics inappropriately. This cluster-randomised controlled trial used routinely collected National Health Service (NHS) dental prescribing and treatment claim data to compare the impact of individualised audit and feedback (A&F) interventions on dentists' antibiotic prescribing rates. METHODS AND FINDINGS All 795 antibiotic prescribing NHS general dental practices in Scotland were included. Practices were randomised to the control (practices = 163; dentists = 567) or A&F intervention group (practices = 632; dentists = 1,999). A&F intervention practices were allocated to one of two A&F groups: (1) individualised graphical A&F comprising a line graph plotting an individual dentist's monthly antibiotic prescribing rate (practices = 316; dentists = 1,001); or (2) individualised graphical A&F plus a written behaviour change message synthesising and reiterating national guidance recommendations for dental antibiotic prescribing (practices = 316; dentists = 998). Intervention practices were also simultaneously randomised to receive A&F: (i) with or without a health board comparator comprising the addition of a line to the graphical A&F plotting the monthly antibiotic prescribing rate of all dentists in the health board; and (ii) delivered at 0 and 6 mo or at 0, 6, and 9 mo, giving a total of eight intervention groups. The primary outcome, measured by the trial statistician who was blinded to allocation, was the total number of antibiotic items dispensed per 100 NHS treatment claims over the 12 mo post-delivery of the baseline A&F. Primary outcome data was available for 152 control practices (dentists = 438) and 609 intervention practices (dentists = 1,550). At baseline, the number of antibiotic items prescribed per 100 NHS treatment claims was 8.3 in the control group and 8.5 in the intervention group. At follow-up, antibiotic prescribing had decreased by 0.4 antibiotic items per 100 NHS treatment claims in control practices and by 1.0 in intervention practices. This represents a significant reduction (-5.7%; 95% CI -10.2% to -1.1%; p = 0.01) in dentists' prescribing rate in the intervention group relative to the control group. Intervention subgroup analyses found a 6.1% reduction in the antibiotic prescribing rate of dentists who had received the written behaviour change message relative to dentists who had not (95% CI -10.4% to -1.9%; p = 0.01). There was no significant between-group difference in the prescribing rate of dentists who received a health board comparator relative to those who did not (-4.3%; 95% CI -8.6% to 0.1%; p = 0.06), nor between dentists who received A&F at 0 and 6 mo relative to those who received A&F at 0, 6, and 9 mo (0.02%; 95% CI -4.2% to 4.2%; p = 0.99). The key limitations relate to the use of routinely collected datasets which did not allow evaluation of any effects on inappropriate prescribing. CONCLUSIONS A&F derived from routinely collected datasets led to a significant reduction in the antibiotic prescribing rate of dentists. TRIAL REGISTRATION Current Controlled Trials ISRCTN49204710.
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Affiliation(s)
- Paula Elouafkaoui
- NHS Education for Scotland (NES), Dundee Dental Education Centre, Frankland Building, Dundee, United Kingdom
- Dental Health Services Research Unit (DHSRU), University of Dundee, Park Place, Dundee, United Kingdom
| | - Linda Young
- NHS Education for Scotland (NES), Dundee Dental Education Centre, Frankland Building, Dundee, United Kingdom
- * E-mail:
| | - Rumana Newlands
- Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, United Kingdom
| | - Eilidh M. Duncan
- Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, United Kingdom
| | - Andrew Elders
- NMAHP Research Unit, Glasgow Caledonian University, Cowcaddens Road, Glasgow, United Kingdom
| | - Jan E. Clarkson
- NHS Education for Scotland (NES), Dundee Dental Education Centre, Frankland Building, Dundee, United Kingdom
- Dental Health Services Research Unit (DHSRU), University of Dundee, Park Place, Dundee, United Kingdom
| | - Craig R. Ramsay
- Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, United Kingdom
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Alothman A, Algwizani A, Alsulaiman M, Alalwan A, Binsalih S, Bosaeed M. Knowledge and Attitude of Physicians Toward Prescribing Antibiotics and the Risk of Resistance in Two Reference Hospitals. Infect Dis (Lond) 2016; 9:33-8. [PMID: 27429557 PMCID: PMC4941866 DOI: 10.4137/idrt.s40047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/15/2016] [Accepted: 06/19/2016] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Antibiotics are essential and abundantly prescribed in hospitals because of their effectiveness and lifesaving benefits. However, the unnecessary use of antibiotics has been observed in earlier studies, and it has persisted through recent years as a major issue since it is one of the leading causes of antibiotic resistance. The increase in antibiotic resistance nowadays is one of the most critical concerns in global public health around the world. The objective of this study was to evaluate the knowledge and perceptions related to antibiotic prescription among physicians at our medical centers. METHOD A cross-sectional survey of non-infectious diseases specialized physicians. The study was conducted during 2015 at two tertiary care centers in Riyadh, Saudi Arabia. RESULT Of the 107 returned questionnaires, 93 were complete and valuable. Most respondents (82%) perceived antibiotic resistance to be a critical problem globally, and 78% also think that it is a very important national problem. These attitudes did not differ across specialty or level of training. Widespread antibiotic use and inappropriate empirical choices were believed by 81% of the participants to be important general causes of resistance. Only half of respondents thought that antibiotic restriction is a useful intervention to decrease the antibiotic resistance. The physicians believed educational interventions are the most useful and effective way to improve prescription patterns and decrease antibiotic resistance. Complications due to infection with resistant organisms were acknowledged by almost all of the participants, with some differences in their estimations of how often it will occur. CONCLUSION Antimicrobial resistance, globally and nationally, is considered as a serious threat, and physicians in this survey acknowledged that. Among the most significant factors is antimicrobial misuse, either by overprescribing or providing inappropriate drugs with some ambivalence, as well as the importance of hand hygiene and antibiotic restrictions. By adhering to local guidelines, continuous education, and other practical interventions, the burden of resistance can be alleviated, as highlighted in this survey.
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Affiliation(s)
- Adel Alothman
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.; College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdullah Algwizani
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mohammed Alsulaiman
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdullah Alalwan
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Salih Binsalih
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.; College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohammad Bosaeed
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Dyrkorn R, Gjelstad S, Espnes KA, Lindbæk M. Peer academic detailing on use of antibiotics in acute respiratory tract infections. A controlled study in an urban Norwegian out-of-hours service. Scand J Prim Health Care 2016; 34:180-5. [PMID: 27054812 PMCID: PMC4977941 DOI: 10.3109/02813432.2016.1163035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To analyse if peer academic detailing by experienced general practitioners (GPs) could be a useful way to change Medical Doctors, (MDs) prescription of antibiotics for acute respiratory tract infections (ARTIs) in out-of-hours service. METHOD An educational Intervention study based on prescription data among MDs working in an out-of-hours service from June 2006 through October 2008. Specially trained GPs lectured a peer educational program (3 × 45 minutes) about use of antibiotics for ARTIs according to national recommendations. OUTCOME MEASURES The type and frequency of antibiotics prescribed for different ARTIs before and after intervention comparing the intervention group with the control group. SUBJECTS 22 MDs in the intervention group and 31 MDs in the control group. RESULTS The intervention group showed an overall statistically significantly absolute increase in the use of penicillin V (Penicillin V) of 9.8% (95% CI: 2.3%-17.4% p < 0.05), and similarly an statistically significantly absolute decrease in the use of macrolides and lincosamides of 8.8% (95% CI: 2.6%-14.9.2% p < 0.05) for all diagnoses. For subgroups of ARTIs we found a significant increase in the use of Penicillin V for acute otitis media, sinusitis, pneumonia and upper ARTIs. There was no significant changes in total prescription rates in the two groups. 41% of all consultations with respiratory tract infections resulted in antibiotic prescription. CONCLUSIONS Using trained GPs to give peer academic detailing to colleagues in combination with open discussion on prescription, showed a significant change in prescription of antibiotics towards national guidelines. Key points Phenoxymethylpenicillin is the first choice for the most of respiratory tract infections when indicated. Despite the guidelines for the choice of antibiotics in Norway, general practitioners' choice often differs from these. We showed that a session of three times 45 min of peer academic detailing changed significantly the choice of antibiotics towards the National Guidelines in an urban Norwegian out-of-hours service.
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Affiliation(s)
- Roar Dyrkorn
- Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim, Norway;
- CONTACT Roar Dyrkorn Clinical Pharmacologist and GP, Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim, Norway
| | - Svein Gjelstad
- Department of General Practice, Antibiotic centre for primary care, Institute for health and society, University of Oslo, Oslo, Norway
| | - Ketil Arne Espnes
- Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim, Norway;
| | - Morten Lindbæk
- Department of General Practice, Antibiotic centre for primary care, Institute for health and society, University of Oslo, Oslo, Norway
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Hammersen F, Goetz K, Soennichsen A, Emcke T, Steinhaeuser J. Effects of communication training with the MAAS-Global-D instrument on the antibiotic prescribing for respiratory infections in primary care: study protocol of a randomised controlled trial. Trials 2016; 17:180. [PMID: 27038798 PMCID: PMC4818904 DOI: 10.1186/s13063-016-1293-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 03/16/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary care physicians account for the majority of antibiotic prescribing in ambulatory care in Germany. Respiratory diseases are, regardless of effectiveness, often treated with antibiotics. Research has found this use without indication to be caused largely by communication problems (e.g. expectations on the patient's part or false assumptions about them by the physician). The present randomised controlled trial (RCT) study evaluates whether communication training for primary care physicians can reduce the antibiotic prescribing rate for respiratory tract infections. METHODS/DESIGN The study consists of three groups: group A will receive communication training; group B will be given the same, plus additional, access to an evidence-based point-of-care tool; and group C will function as the control group. The primary endpoint is the difference between intervention and control groups regarding the antibiotic prescribing rate before and after the intervention assessed through routine data. The communication skills are captured with the help of the communication instrument MAAS-Global-D, as well as individual videos of physician-patient consultations recorded by the primary care physicians. These skills will also be regarded with respect to the antibiotic prescribing rate. A process evaluation using qualitative as well as quantitative methods should provide information about barriers and enablers to implementing the communication training. DISCUSSION The trial contributes to an insight into the effectiveness of the different components to reduce antibiotic prescribing, which will also be supported by an extensive evaluation. Communication training could be an effective method of reducing antibiotic prescribing in primary care. TRIAL REGISTRATION DRKS00009566 DATE REGISTRATION: 5 November 2015.
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Affiliation(s)
- Friederike Hammersen
- Institute of Family Medicine, University Hospital of Luebeck (UKSH), Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany.
| | - Katja Goetz
- Institute of Family Medicine, University Hospital of Luebeck (UKSH), Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Andreas Soennichsen
- Institute of General Practice and Family Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58448, Witten, Germany
| | - Timo Emcke
- Association of Statutory Health Insurance Physicians Schleswig-Holstein, Bismarckallee 1-6, 23795, Bad Segeberg, Germany
| | - Jost Steinhaeuser
- Institute of Family Medicine, University Hospital of Luebeck (UKSH), Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
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Dyar OJ, Beović B, Vlahović-Palčevski V, Verheij T, Pulcini C. How can we improve antibiotic prescribing in primary care? Expert Rev Anti Infect Ther 2016; 14:403-13. [PMID: 26853235 DOI: 10.1586/14787210.2016.1151353] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antibiotic stewardship is a necessity given the worldwide antimicrobial resistance crisis. Outpatient antibiotic use represents around 90% of total antibiotic use, with more than half of these prescriptions being either unnecessary or inappropriate. Efforts to improve antibiotic prescribing need to incorporate two complementary strategies: changing healthcare professionals' behaviour, and modifying the healthcare system. In this review, we present a broad perspective on antibiotic stewardship in primary care in high and high-middle income country settings, focussing on studies published in the last five years. We present the limitations of available literature, discuss perspectives, and provide suggestions for where future work should be concentrated.
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Affiliation(s)
- Oliver J Dyar
- a Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
| | - Bojana Beović
- b Department of Infectious Diseases, University Medical Centre Ljubljana and Faculty of Medicine , University of Ljubljana , Ljubljana , Slovenia
| | - Vera Vlahović-Palčevski
- c Department of Clinical Pharmacology, University Hospital Rijeka and Medical Faculty , University of Rijeka , Rijeka , Croatia
| | - Theo Verheij
- d Julius Center for Health Sciences and Primary Care , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Céline Pulcini
- e EA 4360 APEMAC , Université de Lorraine and Service de maladies infectieuses et tropicales, CHU de Nancy , Nancy , France
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Reducing antibiotic prescriptions for respiratory tract infections in family practice: results of a cluster randomized controlled trial evaluating a multifaceted peer-group-based intervention. NPJ Prim Care Respir Med 2016; 26:15083. [PMID: 26845640 PMCID: PMC4741286 DOI: 10.1038/npjpcrm.2015.83] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 11/10/2015] [Accepted: 12/07/2015] [Indexed: 12/26/2022] Open
Abstract
Irrational antibiotic use for respiratory tract infections (RTI) is a major driver of bacterial resistance. The aim of this study was to evaluate the effect of a multifaceted peer-group based intervention aiming to reduce RTI-related antibiotic prescriptions in family practice. This was a cluster randomized controlled trial with pre- and follow-up measurement. The intervention was implemented through PharmacoTherapy Audit Meetings (PTAM) in which family physicians (FPs) and pharmacists collaborate. Four PTAM groups received the intervention consisting of: (1) FP communication skills training, including communication about delayed prescribing; (2) implementation of antibiotic prescribing agreements in FPs’ Electronic Prescribing Systems; (3) quarterly feedback figures for FPs. Four other PTAM groups were matched controls. Primary outcome measure was the number of RTI-related antibiotic prescriptions after the intervention, assessed with multilevel linear regression analyses. Total number and number of prescriptions stratified by age (under/over 12 years) were analysed. At baseline, the average total number of RTI-related antibiotic prescriptions per 1,000 patients was 207.9 and 176.7 in the intervention and control PTAM groups, respectively. At follow-up, FPs in both the intervention and control groups prescribed significantly less antibiotics. For adolescents and adults, the drop in number of antibiotic prescription was significantly larger in the intervention groups (−27.8 per 1,000 patients) than the control groups (−7.2 per 1,000 patients; P<0.05). This multifaceted peer-group-based intervention was effective in reducing the number of RTI-related antibiotic prescriptions for adolescents and adults. To affect antibiotic prescribing in children other methods are needed.
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Mendelson M, Røttingen JA, Gopinathan U, Hamer DH, Wertheim H, Basnyat B, Butler C, Tomson G, Balasegaram M. Maximising access to achieve appropriate human antimicrobial use in low-income and middle-income countries. Lancet 2016; 387:188-98. [PMID: 26603919 DOI: 10.1016/s0140-6736(15)00547-4] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Access to quality-assured antimicrobials is regarded as part of the human right to health, yet universal access is often undermined in low-income and middle-income countries. Lack of access to the instruments necessary to make the correct diagnosis and prescribe antimicrobials appropriately, in addition to weak health systems, heightens the challenge faced by prescribers. Evidence-based interventions in community and health-care settings can increase access to appropriately prescribed antimicrobials. The key global enablers of sustainable financing, governance, and leadership will be necessary to achieve access while preventing excess antimicrobial use.
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Affiliation(s)
- Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - John-Arne Røttingen
- Norwegian Institute of Public Health, Oslo, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Unni Gopinathan
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Davidson H Hamer
- Zambia Center for Applied Health Research and Development, Lusaka, Zambia; Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Heiman Wertheim
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, National Hospital for Tropical Diseases, Hanoi, Vietnam; Nuffield Department of Clinical Medicine, Centre for Tropical Diseases, Oxford, UK
| | - Buddha Basnyat
- Oxford University Clinical Research Unit-Nepal, Kathmandu, Nepal
| | - Christopher Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Göran Tomson
- Departments of Learning, Informatics, Management, Ethics and Public Health Sciences, Karolinska Institute, Stockholm, Sweden
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Ashworth M, White P, Jongsma H, Schofield P, Armstrong D. Antibiotic prescribing and patient satisfaction in primary care in England: cross-sectional analysis of national patient survey data and prescribing data. Br J Gen Pract 2016; 66:e40-6. [PMID: 26639947 PMCID: PMC4684034 DOI: 10.3399/bjgp15x688105] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 06/05/2015] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Concerns about adverse effects on patient satisfaction may be an important obstacle to attempts to curtail antibiotic prescribing. AIM To determine the relationship between antibiotic prescribing in general practice and reported patient satisfaction. DESIGN AND SETTING Retrospective cross-sectional study of general practices in England. METHOD Data were obtained from the General Practice Patient Survey (GPPS) in 2012 (2.7 million questionnaires in England; 982 999 responses; response rate 36%); the national Quality and Outcomes Framework dataset for England, 2011-2012 (8164 general practices); and general practice and demographic characteristics. Standardised measures of antibiotic prescribing volumes were obtained for each practice in England during 2012-2013, together with 12 other nationally available prescribing variables. The role of antibiotic prescribing volume was identified as a determinant of GPPS scores and adjusted for demographic and practice factors using multiple linear regression. RESULTS The final dataset consisted of 7800 (95.5%) practices. A total of 33.7 million antibiotic prescriptions were issued to a registered population of 53.8 million patients. Antibiotic prescribing volume was a significant positive predictor of all 'doctor satisfaction' and 'practice satisfaction' scores in the GPPS, and was the strongest predictor of overall satisfaction out of 13 prescribing variables. A theoretical 25% reduction in antibiotic prescribing volume would be associated with 0.5-1.0% lower patient satisfaction scores, a drop of 3-6 centile points in national satisfaction ranking. CONCLUSION Patients were less satisfied in practices with frugal antibiotic prescribing. A cautious approach to antibiotic prescribing may require a trade-off in terms of patient satisfaction.
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Affiliation(s)
- Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College London, UK
| | - Patrick White
- Department of Primary Care and Public Health Sciences, King's College London, UK
| | - Hannah Jongsma
- Department of Primary Care and Public Health Sciences, King's College London, UK
| | - Peter Schofield
- Department of Primary Care and Public Health Sciences, King's College London, UK
| | - David Armstrong
- Department of Primary Care and Public Health Sciences, King's College London, UK
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Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev 2015; 2015:CD010907. [PMID: 26560888 PMCID: PMC6464273 DOI: 10.1002/14651858.cd010907.pub2] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Shared decision making is an important component of patient-centred care. It is a set of communication and evidence-based practice skills that elicits patients' expectations, clarifies any misperceptions and discusses the best available evidence for benefits and harms of treatment. Acute respiratory infections (ARIs) are one of the most common reasons for consulting in primary care and obtaining prescriptions for antibiotics. However, antibiotics offer few benefits for ARIs, and their excessive use contributes to antibiotic resistance - an evolving public health crisis. Greater explicit consideration of the benefit-harm trade-off within shared decision making may reduce antibiotic prescribing for ARIs in primary care. OBJECTIVES To assess whether interventions that aim to facilitate shared decision making increase or reduce antibiotic prescribing for ARIs in primary care. SEARCH METHODS We searched CENTRAL (2014, Issue 11), MEDLINE (1946 to November week 3, 2014), EMBASE (2010 to December 2014) and Web of Science (1985 to December 2014). We searched for other published, unpublished or ongoing trials by searching bibliographies of published articles, personal communication with key trial authors and content experts, and by searching trial registries at the National Institutes of Health and the World Health Organization. SELECTION CRITERIA Randomised controlled trials (RCTs) (individual level or cluster-randomised), which evaluated the effectiveness of interventions that promote shared decision making (as the focus or a component of the intervention) about antibiotic prescribing for ARIs in primary care. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and collected data. Antibiotic prescribing was the primary outcome, and secondary outcomes included clinically important adverse endpoints (e.g. re-consultations, hospital admissions, mortality) and process measures (e.g. patient satisfaction). We assessed the risk of bias of all included trials and the quality of evidence. We contacted trial authors to obtain missing information where available. MAIN RESULTS We identified 10 published reports of nine original RCTs (one report was a long-term follow-up of the original trial) in over 1100 primary care doctors and around 492,000 patients.The main risk of bias came from participants in most studies knowing whether they had received the intervention or not, and we downgraded the rating of the quality of evidence because of this.We meta-analysed data using a random-effects model on the primary and key secondary outcomes and formally assessed heterogeneity. Remaining outcomes are presented narratively.There is moderate quality evidence that interventions that aim to facilitate shared decision making reduce antibiotic use for ARIs in primary care (immediately after or within six weeks of the consultation), compared with usual care, from 47% to 29%: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55 to 0.68. Reduction in antibiotic prescribing occurred without an increase in patient-initiated re-consultations (RR 0.87, 95% CI 0.74 to 1.03, moderate quality evidence) or a decrease in patient satisfaction with the consultation (OR 0.86, 95% CI 0.57 to 1.30, low quality evidence). There were insufficient data to assess the effects of the intervention on sustained reduction in antibiotic prescribing, adverse clinical outcomes (such as hospital admission, incidence of pneumonia and mortality), or measures of patient and caregiver involvement in shared decision making (such as satisfaction with the consultation; regret or conflict with the decision made; or treatment compliance following the decision). No studies assessed antibiotic resistance in colonising or infective organisms. AUTHORS' CONCLUSIONS Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term. Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death.
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Affiliation(s)
- Peter Coxeter
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia4229
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia4229
| | - Leanne McGregor
- Griffith UniversityCentre of National Research on Disability and Rehabilitation (CONROD), Menzies Health Institute Queensland | School of Allied HealthParklands DriveSouthportQLDAustralia4215
| | - Elaine M Beller
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia4229
| | - Tammy C Hoffmann
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia4229
- The University of QueenslandSchool of Health and Rehabilitation SciencesBrisbaneQueenslandAustralia
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Meumann EM, Mitchell BG, McGregor A, McBryde E, Cooley L. Urinary Escherichia coli antimicrobial susceptibility profiles and their relationship with community antibiotic use in Tasmania, Australia. Int J Antimicrob Agents 2015; 46:389-93. [PMID: 26187365 DOI: 10.1016/j.ijantimicag.2015.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/13/2015] [Accepted: 05/13/2015] [Indexed: 11/19/2022]
Abstract
This study assessed urinary Escherichia coli antibiotic susceptibility patterns in Tasmania, Australia, and examined their association with community antibiotic use. The susceptibility profiles of all urinary E. coli isolates collected in Tasmania between January 2010 and December 2012 were included. The amount of Pharmaceutical Benefits Scheme (PBS)-subsidised use of amoxicillin, amoxicillin/clavulanic acid (AMC), cefalexin, norfloxacin, ciprofloxacin and trimethoprim was retrieved (at the Tasmanian population level) and the number of defined daily doses per 1000 population per day in Tasmania for these antibiotics was calculated for each month during the study period. Antimicrobial susceptibility data were assessed for changes over time in the 3-year study period. Antimicrobial use and susceptibility data were assessed for seasonal differences and lag in resistance following antibiotic use. Excluding duplicates, 28145 E. coli isolates were included. Resistance levels were low; 35% of isolates were non-susceptible to amoxicillin, 14% were non-susceptible to trimethoprim and <5% were non-susceptible to AMC, cefalexin, gentamicin and norfloxacin. Amoxicillin use increased by 35% during winter/spring compared with summer/autumn, and AMC use increased by 21%. No seasonal variation in quinolone use or resistance was detected. The low levels of antimicrobial resistance identified may relate to Tasmania's isolated geographical location. Significant seasonal variation in amoxicillin and AMC use is likely to be due to increased use of these antibiotics for treatment of respiratory tract infections in winter. Quinolone use is restricted by the PBS in Australia, which is the likely explanation for the low levels of quinolone use and resistance identified.
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Affiliation(s)
- Ella M Meumann
- Department of Infectious Diseases & Microbiology, Royal Hobart Hospital, GPO Box 1061, Hobart, TAS 7000, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC 3050, Australia.
| | - Brett G Mitchell
- Faculty of Nursing and Health, Avondale College of Higher Education, P.O. Box 19, Cooranbong, NSW 2265, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, P.O. Box 256, Dickson, ACT 2602, Australia
| | - Alistair McGregor
- Department of Infectious Diseases & Microbiology, Royal Hobart Hospital, GPO Box 1061, Hobart, TAS 7000, Australia
| | - Emma McBryde
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
| | - Louise Cooley
- Department of Infectious Diseases & Microbiology, Royal Hobart Hospital, GPO Box 1061, Hobart, TAS 7000, Australia
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Easton G, Saxena S. Antibiotic prescribing for upper respiratory tract infections in children: how can we improve? LONDON JOURNAL OF PRIMARY CARE 2015; 3:37-41. [PMID: 25949616 DOI: 10.1080/17571472.2010.11493294] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 05/07/2010] [Indexed: 10/23/2022]
Abstract
Upper respiratory tract infection (URTI) in children is one of the most common problems that general practitioners (GPs) see. Although complications from URTIs are rare, and antibiotics offer little or no benefit in uncomplicated cases, antibiotic prescribing has increased in recent years following a decline in the late 1990s. This article explores possible reasons for the increase, weighs the evidence on withholding antibiotics and asks how GPs will interpret recent National Institute for Health and Clinical Excellent (NICE) guidelines when dealing with URTI in children. We review some of the latest approaches to help implement antibiotic prescribing guidelines and suggest some practical solutions to help busy GPs.
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Affiliation(s)
- Graham Easton
- General Practitioner, Ealing PCT, London, UK and Senior Clinical Teaching Fellow, Department of Primary Care and Public Health, Imperial College London, UK
| | - Sonia Saxena
- GP and Consultant Senior Lecturer in Primary Care, Department of Primary Care and Public Health, Imperial College London, UK
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Baker R, Camosso‐Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N, Wensing M, Fiander M, Eccles MP, Godycki‐Cwirko M, van Lieshout J, Jäger C. Tailored interventions to address determinants of practice. Cochrane Database Syst Rev 2015; 2015:CD005470. [PMID: 25923419 PMCID: PMC7271646 DOI: 10.1002/14651858.cd005470.pub3] [Citation(s) in RCA: 313] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants. OBJECTIVES To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants. SEARCH METHODS We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals. SELECTION CRITERIA Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified. MAIN RESULTS We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression. AUTHORS' CONCLUSIONS Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.
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Affiliation(s)
- Richard Baker
- University of LeicesterDepartment of Health Sciences22‐28 Princess Rd WestLeicesterLeicestershireUKLE1 6TP
| | | | - Clare Gillies
- University of LeicesterUniversity Division of Medicine for the ElderlyThe Glenfield HospitalGroby RoadLeicesterUKLE5 4PW
| | - Elizabeth J Shaw
- National Institute for Health and Care Excellence (NICE)Level 1A, City PlazaPiccadilly PlazaManchesterUKM1 4BD
| | - Francine Cheater
- School of Health Sciences, University of East AngliaEdith Cavell BuildingNorwichNorfolkUK
| | - Signe Flottorp
- Norwegian Knowledge Centre for the Health ServicesBox 7004, St. Olavs plassOsloNorway0130
| | - Noelle Robertson
- Leicester UniversitySchool of Psychology (Clinical Section)104 Regent RoadLeicesterLeicestershireUKLE1 7LT
| | - Michel Wensing
- Radboud University Medical CenterRadboud Institute for Health SciencesPO Box 9101117 KWAZONijmegenNetherlands6500 HB
| | | | - Martin P Eccles
- Newcastle UniversityInstitute of Health and SocietyBadiley Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Maciek Godycki‐Cwirko
- Medical University of LodzCentre for Family and Community MedicineKopcindkiego 20LodzPoland90‐153
| | - Jan van Lieshout
- Radboud University Medical CenterScientific Institute for Quality of HealthcareP.O.Box 9101NijmegenNetherlands6500 HB
| | - Cornelia Jäger
- University Hospital of HeidelbergDepartment of General Practice and Health Services ResearchVoßstr. 2, Geb. 37HeidelbergGermany69115
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Educational effectiveness, target, and content for prudent antibiotic use. BIOMED RESEARCH INTERNATIONAL 2015; 2015:214021. [PMID: 25945327 PMCID: PMC4402196 DOI: 10.1155/2015/214021] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 03/20/2015] [Indexed: 11/18/2022]
Abstract
Widespread antimicrobial use and concomitant resistance have led to a significant threat to public health. Because inappropriate use and overuse of antibiotics based on insufficient knowledge are one of the major drivers of antibiotic resistance, education about prudent antibiotic use aimed at both the prescribers and the public is important. This review investigates recent studies on the effect of interventions for promoting prudent antibiotics prescribing. Up to now, most educational efforts have been targeted to medical professionals, and many studies showed that these educational efforts are significantly effective in reducing antibiotic prescribing. Recently, the development of educational programs to reduce antibiotic use is expanding into other groups, such as the adult public and children. The investigation of the contents of educational programs for prescribers and the public demonstrates that it is important to develop effective educational programs suitable for each group. In particular, it seems now to be crucial to develop appropriate curricula for teaching medical and nonmedical (pharmacy, dentistry, nursing, veterinary medicine, and midwifery) undergraduate students about general medicine, microbial virulence, mechanism of antibiotic resistance, and judicious antibiotic prescribing.
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Nifakos S, Tomson T, Zary N. Combining physical and virtual contexts through augmented reality: design and evaluation of a prototype using a drug box as a marker for antibiotic training. PeerJ 2014; 2:e697. [PMID: 25548733 PMCID: PMC4273933 DOI: 10.7717/peerj.697] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Accepted: 11/22/2014] [Indexed: 01/21/2023] Open
Abstract
Introduction. Antimicrobial resistance is a global health issue. Studies have shown that improved antibiotic prescription education among healthcare professionals reduces mistakes during the antibiotic prescription process. The aim of this study was to investigate novel educational approaches that through the use of Augmented Reality technology could make use of the real physical context and thereby enrich the educational process of antibiotics prescription. The objective is to investigate which type of information related to antibiotics could be used in an augmented reality application for antibiotics education. Methods. This study followed the Design-Based Research Methodology composed of the following main steps: problem analysis, investigation of information that should be visualized for the training session, and finally the involvement of the end users the development and evaluation processes of the prototype. Results. Two of the most important aspects in the antibiotic prescription process, to represent in an augmented reality application, are the antibiotic guidelines and the side effects. Moreover, this study showed how this information could be visualized from a mobile device using an Augmented Reality scanner and antibiotic drug boxes as markers. Discussion. In this study we investigated the usage of objects from a real physical context such as drug boxes and how they could be used as educational resources. The logical next steps are to examine how this approach of combining physical and virtual contexts through Augmented Reality applications could contribute to the improvement of competencies among healthcare professionals and its impact on the decrease of antibiotics resistance.
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Affiliation(s)
- Sokratis Nifakos
- Department of Learning Informatics Management and Ethics, Karolinska Institutet , Stockholm , Sweden
| | - Tanja Tomson
- Department of Learning Informatics Management and Ethics, Karolinska Institutet , Stockholm , Sweden
| | - Nabil Zary
- Department of Learning Informatics Management and Ethics, Karolinska Institutet , Stockholm , Sweden
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Roque F, Herdeiro MT, Soares S, Teixeira Rodrigues A, Breitenfeld L, Figueiras A. Educational interventions to improve prescription and dispensing of antibiotics: a systematic review. BMC Public Health 2014; 14:1276. [PMID: 25511932 PMCID: PMC4302109 DOI: 10.1186/1471-2458-14-1276] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings. Methods We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011. Results We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively. Conclusion The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Maria Teresa Herdeiro
- Centre for Cell Biology, University of Aveiro (Centro de Biologia Celular - CBC/UA); Campus Universitário de Santiago, 3810-193 Aveiro, Portugal.
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Trietsch J, van Steenkiste B, Hobma S, Frericks A, Grol R, Metsemakers J, van der Weijden T. The challenge of transferring an implementation strategy from academia to the field: a process evaluation of local quality improvement collaboratives in Dutch primary care using the normalization process theory. J Eval Clin Pract 2014; 20:1162-71. [PMID: 25410767 DOI: 10.1111/jep.12287] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2014] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES A quality improvement strategy consisting of comparative feedback and peer review embedded in available local quality improvement collaboratives proved to be effective in changing the test-ordering behaviour of general practitioners. However, implementing this strategy was problematic. We aimed for large-scale implementation of an adapted strategy covering both test ordering and prescribing performance. Because we failed to achieve large-scale implementation, the aim of this study was to describe and analyse the challenges of the transferring process. METHODS In a qualitative study 19 regional health officers, pharmacists, laboratory specialists and general practitioners were interviewed within 6 months after the transfer period. The interviews were audiotaped, transcribed and independently coded by two of the authors. The codes were matched to the dimensions of the normalization process theory. RESULTS The general idea of the strategy was widely supported, but generating the feedback was more complex than expected and the need for external support after transfer of the strategy remained high because participants did not assume responsibility for the work and the distribution of resources that came with it. CONCLUSION Evidence on effectiveness, a national infrastructure for these collaboratives and a general positive attitude were not sufficient for normalization. Thinking about managing large databases, responsibility for tasks and distribution of resources should start as early as possible when planning complex quality improvement strategies. Merely exploring the barriers and facilitators experienced in a preceding trial is not sufficient. Although multifaceted implementation strategies to change professional behaviour are attractive, their inherent complexity is also a pitfall for large-scale implementation.
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Affiliation(s)
- Jasper Trietsch
- School for Public Health and Primary Care (CAPHRI), Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
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Speksnijder DC, Jaarsma ADC, van der Gugten AC, Verheij TJM, Wagenaar JA. Determinants associated with veterinary antimicrobial prescribing in farm animals in the Netherlands: a qualitative study. Zoonoses Public Health 2014; 62 Suppl 1:39-51. [PMID: 25421456 DOI: 10.1111/zph.12168] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Indexed: 11/30/2022]
Abstract
Antimicrobial use in farm animals might contribute to the development of antimicrobial resistance in humans and animals, and there is an urgent need to reduce antimicrobial use in farm animals. Veterinarians are typically responsible for prescribing and overseeing antimicrobial use in animals. A thorough understanding of veterinarians' current prescribing practices and their reasons to prescribe antimicrobials might offer leads for interventions to reduce antimicrobial use in farm animals. This paper presents the results of a qualitative study of factors that influence prescribing behaviour of farm animal veterinarians. Semi-structured interviews with eleven farm animal veterinarians were conducted, which were taped, transcribed and iteratively analysed. This preliminary analysis was further discussed and refined in an expert meeting. A final conceptual model was derived from the analysis and sent to all the respondents for validation. Many conflicting interests are identifiable when it comes to antimicrobial prescribing by farm animal veterinarians. Belief in the professional obligation to alleviate animal suffering, financial dependency on clients, risk avoidance, shortcomings in advisory skills, financial barriers for structural veterinary herd health advisory services, lack of farmers' compliance to veterinary recommendations, public health interests, personal beliefs regarding the veterinary contribution to antimicrobial resistance and major economic powers are all influential determinants in antimicrobial prescribing behaviour of farm animal veterinarians. Interventions to change prescribing behaviour of farm animal veterinarians could address attitudes and advisory skills of veterinarians, as well as provide tools to deal with (perceived) pressure from farmers and advisors to prescribe antimicrobials. Additional (policy) measures could probably support farm animal veterinarians in acting as a more independent animal health consultant.
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Affiliation(s)
- D C Speksnijder
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Utrecht, the Netherlands; Veterinary Clinic Tweestromenland, Wijchen, the Netherlands
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