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Cardinale F, Barattini DF, Martinucci V, Bordea MM, Barattini L, Rosu S. The Effectiveness of a Dietary Supplement with Honey, Propolis, Pelargonium sidoides Extract, and Zinc in Children Affected by Acute Tonsillopharyngitis: An Open, Randomized, and Controlled Trial. Pharmaceuticals (Basel) 2024; 17:804. [PMID: 38931472 PMCID: PMC11206353 DOI: 10.3390/ph17060804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/13/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Physicians are currently finding products for pediatric respiratory diseases of viral etiology to reduce the inappropriate use of antibiotic therapy. This study evaluated PediaFlù (Pediatrica S.r.l.), a dietary supplement already on the market composed of honey, propolis, Pelargonium sidoides extract, and zinc (DSHPP), in children affected by acute tonsillopharyngitis (ATR). The open-label, randomized, and controlled study compared DSHPP + standard of care (SoC) versus SoC alone for six days. Children between 3 and 10 years with an ATR ≤ 48 h, a negative rapid test for beta-hemolytic Streptococcus, or a culture identification of nasal and/or pharyngeal exudates were included. A tonsillitis severity score (TSS) and the number of treatment failures (using ibuprofen or high-dose paracetamol as rescue medication) were the primary endpoints. DSHPP+ SoC showed better performance than SoC alone for TSS sub-scores: throat pain and erythema on day 6 (p < 0.001 and p < 0.05), swallowing (p < 0.01 on day 4), and TSS total score on days 4 and 6 (p < 0.05 and p < 0.001). Only one patient (SoC group) had treatment failure for ibuprofen administration. No adverse events were reported. DSHPP is an optimal adjuvant in the treatment of URTI and could potentially be useful in the daily clinical practice of paediatricians evaluating the correct antibiotic prescription.
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Affiliation(s)
- Fabio Cardinale
- Complex Operating Unit Paediatrics, Giovanni XXIII Paediatric Hospital, University of Bari, 70124 Bari, Italy
| | | | | | - Maria Morariu Bordea
- Cabinet Medical Medicina de Familie Dr Morariu Bordea, 300425 Timisoara, Romania;
| | | | - Serban Rosu
- Department of Oral and Cranio-Maxillo-Facial Surgery, University of Medicine and Pharmacy Victor Babes, 300041 Timisoara, Romania;
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Ayorinde A, Ghosh I, Shaikh J, Adetunji V, Brown A, Jordan M, Gilham E, Todkill D, Ashiru-Oredope D. Improving healthcare professionals' interactions with patients to tackle antimicrobial resistance: a systematic review of interventions, barriers, and facilitators. Front Public Health 2024; 12:1359790. [PMID: 38841670 PMCID: PMC11150712 DOI: 10.3389/fpubh.2024.1359790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/30/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals' (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions. Methods We searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels. Results Of 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs' interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient's desire for antibiotics and fear of litigation). Conclusion The findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness.
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Affiliation(s)
- Abimbola Ayorinde
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Iman Ghosh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Junaid Shaikh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Victoria Adetunji
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anna Brown
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Mary Jordan
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Ellie Gilham
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Daniel Todkill
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Diane Ashiru-Oredope
- UK Health Security Agency, London, United Kingdom
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
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Llor C, Trapero-Bertran M, Sisó-Almirall A, Monfà R, Abellana R, García-Sangenís A, Moragas A, Morros R. Effects of C-reactive protein rapid testing and communication skills training on antibiotic prescribing for acute cough. A cluster factorial randomised controlled trial. NPJ Prim Care Respir Med 2024; 34:9. [PMID: 38724543 PMCID: PMC11081949 DOI: 10.1038/s41533-024-00368-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
This cluster randomised clinical trial carried out in 20 primary care centres in Barcelona was aimed at assessing the effect of a continuous intervention focused on C-reactive protein (CRP) rapid testing and training in enhanced communication skills (ECS) on antibiotic consumption for adults with acute cough due to lower respiratory tract infection (LRTI). The interventions consisted of general practitioners and nurses' use of CRP point-of-care and training in ECS separately and combined, and usual care. The primary outcomes were antibiotic consumption and variation of the quality-adjusted life years during a 6-week follow-up. The difference in the overall antibiotic prescribing between the winter seasons before and after the intervention was calculated. The sample size calculated could not be reached due to the COVID-19 outbreak. A total of 233 patients were recruited. Compared to the usual care group (56.7%) antibiotic consumption among patients assigned to professionals in the ECS group was significantly lower (33.9%, adjusted odds ratio [aOR] 0.38, 95% CI 0.15-0.94, p = 0.037), whereas patients assigned to CRP consumed 43.8% of antibiotics (aOR 0.70, 95% CI 0.29-1.68, p = 0.429) and 38.4% in the combined intervention group (aOR 0.45, 95% CI, 0.17-1.21; p = 0.112). The overall antibiotic prescribing rates in the centres receiving training were lower after the intervention compared to those assigned to usual care, with significant reductions in β-lactam rates. Patient recovery was similar in all groups. Despite the limited power due to the low number of patients included, we observed that continuous training achieved reductions in antibiotic consumption.
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Affiliation(s)
- Carl Llor
- University Institute in Primary Care Research Jordi Gol (IDIAPJGol), Barcelona, Spain.
- CIBER de Enfermedades Infecciosas. Instituto de Salud Carlos III, Madrid, Spain.
- Research Unit for General Practice. Department of Public Health. University of Southern Denmark, Odense, Denmark.
| | - Marta Trapero-Bertran
- Department of Economics and Business, Faculty of Law, Economics and Tourism, University of Lleida, Lleida, Spain
| | - Antoni Sisó-Almirall
- Catalan Society of Family Medicine (CAMFiC). Fundació d'Atenció Primària, Barcelona, Spain
| | - Ramon Monfà
- University Institute in Primary Care Research Jordi Gol (IDIAPJGol), Barcelona, Spain.
- Plataforma SCReN, UIC IDIAPJGol, Barcelona, Spain.
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain.
| | - Rosa Abellana
- Biostatistics, Department of Basic Clinical Practice, University of Barcelona, Barcelona, Spain
| | - Ana García-Sangenís
- University Institute in Primary Care Research Jordi Gol (IDIAPJGol), Barcelona, Spain
- CIBER de Enfermedades Infecciosas. Instituto de Salud Carlos III, Madrid, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Ana Moragas
- University Institute in Primary Care Research Jordi Gol (IDIAPJGol), Barcelona, Spain
- CIBER de Enfermedades Infecciosas. Instituto de Salud Carlos III, Madrid, Spain
- University Rovira i Virgili, Reus, Spain
- Jaume I Health Centre, Institut Català de la Salut, Tarragona, Spain
| | - Rosa Morros
- University Institute in Primary Care Research Jordi Gol (IDIAPJGol), Barcelona, Spain
- CIBER de Enfermedades Infecciosas. Instituto de Salud Carlos III, Madrid, Spain
- Plataforma SCReN, UIC IDIAPJGol, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
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Ababneh MA, Abujuma H, Altawalbeh S, Al Demour S. Evaluation of Antimicrobial Stewardship Programs and antibiotic prescribing patterns among physicians in ambulatory care settings in Jordan. Expert Rev Pharmacoecon Outcomes Res 2024; 24:405-412. [PMID: 38064312 DOI: 10.1080/14737167.2023.2293197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/28/2023] [Indexed: 02/16/2024]
Abstract
OBJECTIVES Currently, there is an urgent need to implement an Antimicrobial Stewardship Program (ASP) in outpatient settings since nearly half of the antibiotic prescribing is inappropriate or unnecessary. The implementation of ASP should emphasize educational interventions that are more interactive. This study examines the adoption of outpatient ASP by physicians in Jordan. METHODS A cross-sectional study was conducted between 2 March 2022 and 20 May 2022 at major hospitals in Jordan. The survey was distributed randomly among (n = 187) Jordanian physicians. RESULTS It was found that more than half of the physicians were females (51.9%). The participants who reported not including antibiotic stewardship-related duties in position descriptions were (40.1%). While (46.5%) of participants reported writing and displaying public commitments supporting antibiotic stewardship in ambulatory care settings. Physicians' adoption of (action) core elements of ASPs in ambulatory care settings was positive. Almost (24.6%) reported a lack of self-evaluation of their antibiotic-prescribing practices. It was reported that (69.5%) of physicians used effective communication strategies to educate patients about when antibiotics are necessary. CONCLUSION It was fair adoption of the core elements in the ambulatory care settings among Jordanian physicians. Progress necessitates a comprehensive strategy tailored to the needs of the health system.
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Affiliation(s)
- Mera A Ababneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Hana Abujuma
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Shoroq Altawalbeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Saddam Al Demour
- Department of Special Surgery/Division of Urology, The University of Jordan, School of Medicine, Amman, Jordan
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Metusela C, Mullan J, Kobel C, Rhee J, Batterham M, Barnett S, Bonney A. CHIME-GP trial of online education for prescribing, pathology and imaging ordering in general practice - how did it bring about behaviour change? BMC Health Serv Res 2023; 23:1346. [PMID: 38042789 PMCID: PMC10693689 DOI: 10.1186/s12913-023-10374-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND There is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia's online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future. METHODS This mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework. RESULTS Of the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs' perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions. CONCLUSIONS Our education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020).
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Affiliation(s)
- Christine Metusela
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia.
| | - Judy Mullan
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
| | - Conrad Kobel
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Joel Rhee
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Marijka Batterham
- School of Mathematics and Applied Statistics, University of Wollongong, Wollongong, Australia
| | - Stephen Barnett
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
| | - Andrew Bonney
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
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Schuster A, Tigges P, Grune J, Kraft J, Greser A, Gágyor I, Boehme M, Eckmanns T, Klingeberg A, Maun A, Menzel A, Schmiemann G, Heintze C, Bleidorn J. GPs' Perspective on a Multimodal Intervention to Enhance Guideline-Adherence in Uncomplicated Urinary Tract Infections: A Qualitative Process Evaluation of the Multicentric RedAres Cluster-Randomised Controlled Trial. Antibiotics (Basel) 2023; 12:1657. [PMID: 38136690 PMCID: PMC10740691 DOI: 10.3390/antibiotics12121657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Urinary tract infections (UTIs) are among the most common reasons patients seeking health care and antibiotics to be prescribed in primary care. However, general practitioners' (GPs) guideline adherence is low. The RedAres randomised controlled trial aims to increase guideline adherence by implementing a multimodal intervention consisting of four elements: information on current UTI guidelines (1) and regional resistance data (2); feedback regarding prescribing behaviour (3); and benchmarking compared to peers (4). The RedAres process evaluation assesses GPs' perception of the multimodal intervention and the potential for implementation into routine care. We carried out 19 semi-structured interviews with GPs (intervention arm). All interviews were carried out online and audio recorded. For transcription and analysis, Mayring's qualitative content analysis was used. Overall, GPs considered the interventions helpful for knowledge gain and confirmation when prescribing. Information material and resistance were used for patient communication and teaching purposes. Feedback was considered to enhance reflection by breaking routines of clinical workup. Implementation into routine practice could be enhanced by integrating feedback loops into patient management systems and conveying targeted information via trusted channels or institutions. The process evaluation of RedAres intervention was considered beneficial by GPs. It confirms the convenience of multimodal interventions to enhance guideline adherence.
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Affiliation(s)
- Angela Schuster
- Institute of General Practice, Charite University Hospital Berlin, 10117 Berlin, Germany
| | - Paula Tigges
- Institute of General Practice, Charite University Hospital Berlin, 10117 Berlin, Germany
| | - Julianna Grune
- Institute of General Practice, Charite University Hospital Berlin, 10117 Berlin, Germany
| | - Judith Kraft
- Institute of General Practice, Charite University Hospital Berlin, 10117 Berlin, Germany
| | - Alexandra Greser
- Department of General Practice, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Ildikó Gágyor
- Department of General Practice, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Mandy Boehme
- Institute of General Practice, University Hospital Jena, 07743 Jena, Germany (J.B.)
| | | | | | - Andy Maun
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, 79110 Freiburg im Breisgau, Germany
| | - Anja Menzel
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, 79110 Freiburg im Breisgau, Germany
| | - Guido Schmiemann
- Department of Health Service Research, Institute for Public Health and Nursing Research, University of Bremen, 28359 Bremen, Germany
| | - Christoph Heintze
- Institute of General Practice, Charite University Hospital Berlin, 10117 Berlin, Germany
| | - Jutta Bleidorn
- Institute of General Practice, University Hospital Jena, 07743 Jena, Germany (J.B.)
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Schmiemann G, Greser A, Maun A, Bleidorn J, Schuster A, Miljukov O, Rücker V, Klingeberg A, Mentzel A, Minin V, Eckmanns T, Heintze C, Heuschmann P, Gágyor I. Effects of a multimodal intervention in primary care to reduce second line antibiotic prescriptions for urinary tract infections in women: parallel, cluster randomised, controlled trial. BMJ 2023; 383:e076305. [PMID: 37918836 PMCID: PMC10620739 DOI: 10.1136/bmj-2023-076305] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVES To evaluate whether a multimodal intervention in general practice reduces the proportion of second line antibiotic prescriptions and the overall proportion of antibiotic prescriptions for uncomplicated urinary tract infections in women. DESIGN Parallel, cluster randomised, controlled trial. SETTING General practices in five regions in Germany. Data were collected between 1 April 2021 and 31 March 2022. PARTICIPANTS General practitioners from 128 randomly assigned practices. INTERVENTIONS Multimodal intervention consisting of guideline recommendations for general practitioners and patients, provision of regional data for antibiotic resistance, and quarterly feedback, which included individual first line and second line proportions of antibiotic prescribing, benchmarking with regional or supra-regional practices, and telephone counselling. Participants in the control group received no information on the intervention. MAIN OUTCOME MEASURES Primary outcome was the proportion of second line antibiotics prescribed by general practices, in relation to all antibiotics prescribed, for uncomplicated urinary tract infections after one year between the intervention and control group. General practices were randomly assigned in blocks (1:1), with a block size of four, into the intervention or control group using SAS version 9.4; randomisation was stratified by region. The secondary outcome was the prescription proportion of all antibiotics, relative within all cases (instances of UTI diagnosis), for the treatment of urinary tract infections after one year between the groups. Adverse events were assessed as exploratory outcomes. RESULTS 110 practices with full datasets identified 10 323 cases during five quarters (ie, 15 months). The mean proportion of second line antibiotics prescribed was 0.19 (standard deviation 0.20) in the intervention group and 0.35 (0.25) in the control group after 12 months. After adjustment for preintervention proportions, the mean difference was -0.13 (95% confidence interval -0.21 to -0.06, P<0.001). The overall proportion of all antibiotic prescriptions for urinary tract infections over 12 months was 0.74 (standard deviation 0.22) in the intervention and 0.80 (0.15) in the control group with a mean difference of -0.08 (95% confidence interval -0.15 to -0.02, P<0.029). No differences were noted in the number of complications (ie, pyelonephritis, admission to hospital, or fever) between the groups. CONCLUSIONS The multimodal intervention in general practice significantly reduced the proportion of second line antibiotics and all antibiotic prescriptions for uncomplicated urinary tract infections in women. TRIAL REGISTRATION German Clinical Trials Register (DRKS), DRKS00020389.
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Affiliation(s)
- Guido Schmiemann
- University of Bremen, Department of Health Services Research, Institute for Public Health and Nursing Research, Bremen, Germany
| | - Alexandra Greser
- University Hospital Wurzburg, Department of General Practice, Wurzburg, Germany
| | - Andy Maun
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jutta Bleidorn
- University Hospital Jena, Institute of General Practice, Jena, Thuringia, Germany
| | - Angela Schuster
- Charité-Universitätsmedizin Berlin, Institute of General Practice and Family Medicine, Berlin, Germany
| | - Olga Miljukov
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | - Viktoria Rücker
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | | | - Anja Mentzel
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Vitalii Minin
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Christoph Heintze
- Charité-Universitätsmedizin Berlin, Institute of General Practice and Family Medicine, Berlin, Germany
| | - Peter Heuschmann
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | - Ildikó Gágyor
- University Hospital Wurzburg, Department of General Practice, Wurzburg, Germany
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Mbatia FN, Orwa J, Adam MB, Mahomoud G, Adam RD. Outpatient management of urinary tract infections by medical officers in Nairobi, Kenya: lack of benefit from audit and feedback on adherence to treatment guidelines. BMC Infect Dis 2023; 23:608. [PMID: 37723454 PMCID: PMC10506338 DOI: 10.1186/s12879-023-08567-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 08/25/2023] [Indexed: 09/20/2023] Open
Abstract
INTRODUCTION Acute uncomplicated urinary tract infections are common in outpatient settings but are not treated optimally. Few studies of the outpatient use of antibiotics for specific diagnoses have been done in sub-Saharan Africa, so little is known about the prescribing patterns of medical officers in the region. METHODS Aga Khan University has 16 outpatient clinics throughout the Nairobi metro area with a medical officer specifically assigned to that clinic. A baseline assessment of evaluation and treatment of suspected UTI was performed from medical records in these clinics. Then the medical officer from each of the 16 clinics was recruited from each clinic was recruited with eight each randomized to control vs. feedback groups. Both groups were given a multimodal educational session including locally adapted UTI guidelines and emphasis on problems identified in the baseline assessment Each record was scored using a scoring system that was developed for the study according to adequacy of history, physical examination, clinical diagnosis matching recorded data, diagnostic workup and treatment. Three audits were done for both groups; baseline (audit 1), post-CME (audit 2), and a final audit, which was after feedback for the feedback group (audit 3). The primary analysis assessed overall guideline adherence in the feedback group versus the CME only group. RESULTS The overall scores in both groups showed significant improvement after the CME in comparison to baseline and for each group, the scores in most domains also improved. However, audit 3 showed persistence of the gains attained after the CME but no additional benefit from the feedback. Some deficiencies that persisted throughout the study included lack of workup of possible STI and excess use of non-UTI laboratory tests such as CBC, stool culture and H. pylori Ag. After the CME, the use of nitrofurantoin rose from only 4% to 8% and cephalosporin use increased from 49 to 67%, accompanied by a drop in quinolone use. CONCLUSION The CME led to modest improvements in patient care in the categories of history taking, treatment and investigations, but feedback had no additional effect. Future studies should consider an enforcement element or a more intensive feedback approach.
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Affiliation(s)
| | - James Orwa
- Department of Population Health, Aga Khan University Nairobi, Nairobi, Kenya
| | | | - Gulnaz Mahomoud
- Department of Family Medicine, Aga Khan University Nairobi, Nairobi, Kenya
| | - Rodney D Adam
- Department of Pathology, Aga Khan University Nairobi, Nairobi, Kenya.
- Department of Medicine, Aga Khan University Nairobi, Nairobi, Kenya.
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Falkenbach P, Raudasoja AJ, Vernooij RWM, Mustonen JMJ, Agarwal A, Aoki Y, Blanker MH, Cartwright R, Garcia-Perdomo HA, Kilpeläinen TP, Lainiala O, Lamberg T, Nevalainen OPO, Raittio E, Richard PO, Violette PD, Tikkinen KAO, Sipilä R, Turpeinen M, Komulainen J. Reporting of costs and economic impacts in randomized trials of de-implementation interventions for low-value care: a systematic scoping review. Implement Sci 2023; 18:36. [PMID: 37605243 PMCID: PMC10440866 DOI: 10.1186/s13012-023-01290-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND De-implementation of low-value care can increase health care sustainability. We evaluated the reporting of direct costs of de-implementation and subsequent change (increase or decrease) in health care costs in randomized trials of de-implementation research. METHODS We searched MEDLINE and Scopus databases without any language restrictions up to May 2021. We conducted study screening and data extraction independently and in duplicate. We extracted information related to study characteristics, types and characteristics of interventions, de-implementation costs, and impacts on health care costs. We assessed risk of bias using a modified Cochrane risk-of-bias tool. RESULTS We screened 10,733 articles, with 227 studies meeting the inclusion criteria, of which 50 included information on direct cost of de-implementation or impact of de-implementation on health care costs. Studies were mostly conducted in North America (36%) or Europe (32%) and in the primary care context (70%). The most common practice of interest was reduction in the use of antibiotics or other medications (74%). Most studies used education strategies (meetings, materials) (64%). Studies used either a single strategy (52%) or were multifaceted (48%). Of the 227 eligible studies, 18 (8%) reported on direct costs of the used de-implementation strategy; of which, 13 reported total costs, and 12 reported per unit costs (7 reported both). The costs of de-implementation strategies varied considerably. Of the 227 eligible studies, 43 (19%) reported on impact of de-implementation on health care costs. Health care costs decreased in 27 studies (63%), increased in 2 (5%), and were unchanged in 14 (33%). CONCLUSION De-implementation randomized controlled trials typically did not report direct costs of the de-implementation strategies (92%) or the impacts of de-implementation on health care costs (81%). Lack of cost information may limit the value of de-implementation trials to decision-makers. TRIAL REGISTRATION OSF (Open Science Framework): https://osf.io/ueq32 .
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Affiliation(s)
- Petra Falkenbach
- Finnish Coordinating Center for Health Technology Assessment, Oulu University Hospital, University of Oulu, Oulu, Finland.
| | - Aleksi J Raudasoja
- Finnish Medical Society Duodecim, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Arnav Agarwal
- Department of Medicine, Division of General Internal Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rufus Cartwright
- Department of Gynaecology, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Herney A Garcia-Perdomo
- Department of Surgery, Division of Urology/Uro-Oncology, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Lainiala
- Department of Radiology, Faculty of Medicine and Health Technologies, Imaging Centre, Tampere University Hospital, Tampere University, Tampere, Finland
| | | | - Olli P O Nevalainen
- Wellbeing Services County of Pirkanmaa, Unit of Health Sciences, Faculty of Social Sciences, Hatanpää Health Center, Tampere University, Tampere, Finland
| | - Eero Raittio
- Department of Dentistry and Oral Health, Oral Health Care, Institute of Dentistry, Aarhus University, University of Eastern, Kuopio, Finland
| | - Patrick O Richard
- Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Philippe D Violette
- Departments of Surgery and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
| | - Miia Turpeinen
- Oulu University Hospital, University of Oulu, Oulu, Finland
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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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11
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Aghlmandi S, Halbeisen FS, Saccilotto R, Godet P, Signorell A, Sigrist S, Glinz D, Moffa G, Zeller A, Widmer AF, Kronenberg A, Bielicki J, Bucher HC. Effect of Antibiotic Prescription Audit and Feedback on Antibiotic Prescribing in Primary Care: A Randomized Clinical Trial. JAMA Intern Med 2023; 183:213-220. [PMID: 36745412 PMCID: PMC9989898 DOI: 10.1001/jamainternmed.2022.6529] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/04/2022] [Indexed: 02/07/2023]
Abstract
Importance Antibiotics are commonly prescribed in primary care, increasing the risk of antimicrobial resistance in the population. Objective To investigate the effect of quarterly audit and feedback on antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates. Design, Setting, and Participants This pragmatic randomized clinical trial was conducted from January 1, 2018, to December 31, 2019, among 3426 registered primary care physicians and pediatricians in single or small practices in Switzerland who were among the top 75% prescribers of antibiotics. Intention-to-treat analysis was performed using analysis of covariance models and conducted from September 1, 2021, to January 31, 2022. Interventions Primary care physicians were randomized in a 1:1 fashion to undergo quarterly antibiotic prescribing audit and feedback with peer benchmarking vs no intervention for 2 years, with 2017 used as the baseline year. Anonymized patient-level claims data from 3 health insurers serving roughly 50% of insurees in Switzerland were used for audit and feedback. The intervention group also received evidence-based guidelines for respiratory tract and urinary tract infection management and community antibiotic resistance information. Physicians in the intervention group were blinded regarding the nature of the trial, and physicians in the control group were not informed of the trial. Main Outcomes and Measures The claims data used for audit and feedback were analyzed to assess outcomes. Primary outcome was the antibiotic prescribing rate per 100 consultations during the second year of the intervention. Secondary end points included overall antibiotic use in the first year and over 2 years, use of quinolones and oral cephalosporins, all-cause hospitalizations, and antibiotic use in 3 age groups. Results A total of 3426 physicians were randomized to the intervention (n = 1713) and control groups (n = 1713) serving 629 825 and 622 344 patients, respectively, with a total of 4 790 525 consultations in the baseline year of 2017. In the entire cohort, a 4.2% (95% CI, 3.9%-4.6%) relative increase in the antibiotic prescribing rate was noted during the second year of the intervention compared with 2017. In the intervention group, the median annual antibiotic prescribing rate per 100 consultations was 8.2 (IQR, 6.1-11.4) in the second year of the intervention and was 8.4 (IQR, 6.0-11.8) in the control group. Relative to the overall increase, a -0.1% (95% CI, -1.2% to 1.0%) lower antibiotic prescribing rate per 100 consultations was found in the intervention group compared with the control group. No relevant reductions in specific antibiotic prescribing rates were noted between groups except for quinolones in the second year of the intervention (-0.9% [95% CI, -1.5% to -0.4%]). Conclusions and Relevance This randomized clinical trial found that quarterly personalized antibiotic prescribing audit and feedback with peer benchmarking did not reduce antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates. Trial Registration ClinicalTrials.gov Identifier: NCT03379194.
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Affiliation(s)
- Soheila Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Florian S. Halbeisen
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ramon Saccilotto
- Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | | | | | - Dominik Glinz
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Giusi Moffa
- Department of Mathematics and Computer Science, University of Basel, Basel, Switzerland
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Andreas F. Widmer
- Division of Infectious Diseases and Hospital Hygiene, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Julia Bielicki
- Infectious Diseases and Paediatric Pharmacology, University Children’s Hospital Basel and University of Basel, Basel, Switzerland
- Centre for Neonatal and Paediatric Infection, St George’s University London, London, UK
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
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Implementing antibiotic stewardship in high-prescribing English general practices: a mixed-methods study. Br J Gen Pract 2023; 73:e164-e175. [PMID: 36823061 PMCID: PMC9975978 DOI: 10.3399/bjgp.2022.0298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Trials have identified antimicrobial stewardship (AMS) strategies that effectively reduce antibiotic use in primary care. However, many are not commonly used in England. The authors co-developed an implementation intervention to improve use of three AMS strategies: enhanced communication strategies, delayed prescriptions, and point-of-care C-reactive protein tests (POC-CRPTs). AIM To investigate the use of the intervention in high-prescribing practices and its effect on antibiotic prescribing. DESIGN AND SETTING Nine high-prescribing practices had access to the intervention for 12 months from November 2019. This was primarily delivered remotely via a website with practices required to identify an 'antibiotic champion'. METHOD Routinely collected prescribing data were compared between the intervention and the control practices. Intervention use was assessed through monitoring. Surveys and interviews were conducted with professionals to capture experiences of using the intervention. RESULTS There was no evidence that the intervention affected prescribing. Engagement with intervention materials differed substantially between practices and depended on individual champions' preconceptions of strategies and the opportunity to conduct implementation tasks. Champions in five practices initiated changes to encourage use of at least one AMS strategy, mostly POC-CRPTs; one practice chose all three. POC-CRPTs was used more when allocated to one person. CONCLUSION Clinicians need detailed information on exactly how to adopt AMS strategies. Remote, one-sided provision of AMS strategies is unlikely to change prescribing; initial clinician engagement and understanding needs to be monitored to avoid misunderstanding and suboptimal use.
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Smedemark SA, Aabenhus R, Llor C, Fournaise A, Olsen O, Jørgensen KJ. Biomarkers as point-of-care tests to guide prescription of antibiotics in people with acute respiratory infections in primary care. Cochrane Database Syst Rev 2022; 10:CD010130. [PMID: 36250577 PMCID: PMC9575154 DOI: 10.1002/14651858.cd010130.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute respiratory infections (ARIs) are by far the most common reason for prescribing an antibiotic in primary care, even though the majority of ARIs are of viral or non-severe bacterial aetiology. It follows that in many cases antibiotic use will not be beneficial to a patient's recovery but may expose them to potential side effects. Furthermore, limiting unnecessary antibiotic use is a key factor in controlling antibiotic resistance. One strategy to reduce antibiotic use in primary care is point-of-care biomarkers. A point-of-care biomarker (test) of inflammation identifies part of the acute phase response to tissue injury regardless of the aetiology (infection, trauma, or inflammation) and may be used as a surrogate marker of infection, potentially assisting the physician in the clinical decision whether to use an antibiotic to treat ARIs. Biomarkers may guide antibiotic prescription by ruling out a serious bacterial infection and help identify patients in whom no benefit from antibiotic treatment can be anticipated. This is an update of a Cochrane Review first published in 2014. OBJECTIVES To assess the benefits and harms of point-of-care biomarker tests of inflammation to guide antibiotic treatment in people presenting with symptoms of acute respiratory infections in primary care settings regardless of patient age. SEARCH METHODS We searched CENTRAL (2022, Issue 6), MEDLINE (1946 to 14 June 2022), Embase (1974 to 14 June 2022), CINAHL (1981 to 14 June 2022), Web of Science (1955 to 14 June 2022), and LILACS (1982 to 14 June 2022). We also searched three trial registries (10 December 2021) for completed and ongoing trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) in primary care patients with ARIs that compared the use of point-of-care biomarkers with standard care. We included trials that randomised individual participants, as well as trials that randomised clusters of patients (cluster-RCTs). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on the following primary outcomes: number of participants given an antibiotic prescription at index consultation and within 28 days follow-up; participant recovery within seven days follow-up; and total mortality within 28 days follow-up. We assessed risk of bias using the Cochrane risk of bias tool and the certainty of the evidence using GRADE. We used random-effects meta-analyses when feasible. We further analysed results with considerable heterogeneity in prespecified subgroups of individual and cluster-RCTs. MAIN RESULTS We included seven new trials in this update, for a total of 13 included trials. Twelve trials (10,218 participants in total, 2335 of which were children) evaluated a C-reactive protein point-of-care test, and one trial (317 adult participants) evaluated a procalcitonin point-of-care test. The studies were conducted in Europe, Russia, and Asia. Overall, the included trials had a low or unclear risk of bias. However all studies were open-labelled, thereby introducing high risk of bias due to lack of blinding. The use of C-reactive protein point-of-care tests to guide antibiotic prescription likely reduces the number of participants given an antibiotic prescription, from 516 prescriptions of antibiotics per 1000 participants in the control group to 397 prescriptions of antibiotics per 1000 participants in the intervention group (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.69 to 0.86; 12 trials, 10,218 participants; I² = 79%; moderate-certainty evidence). Overall, use of C-reactive protein tests also reduce the number of participants given an antibiotic prescription within 28 days follow-up (664 prescriptions of antibiotics per 1000 participants in the control group versus 538 prescriptions of antibiotics per 1000 participants in the intervention group) (RR 0.81, 95% CI 0.76 to 0.86; 7 trials, 5091 participants; I² = 29; high-certainty evidence). The prescription of antibiotics as guided by C-reactive protein tests likely does not reduce the number of participants recovered, within seven or 28 days follow-up (567 participants recovered within seven days follow-up per 1000 participants in the control group versus 584 participants recovered within seven days follow-up per 1000 participants in the intervention group) (recovery within seven days follow-up: RR 1.03, 95% CI 0.96 to 1.12; I² = 0%; moderate-certainty evidence) (recovery within 28 days follow-up: RR 1.02, 95% CI 0.79 to 1.32; I² = 0%; moderate-certainty evidence). The use of C-reactive protein tests may not increase total mortality within 28 days follow-up, from 1 death per 1000 participants in the control group to 0 deaths per 1000 participants in the intervention group (RR 0.53, 95% CI 0.10 to 2.92; I² = 0%; low-certainty evidence). We are uncertain as to whether procalcitonin affects any of the primary or secondary outcomes because there were few participants, thereby limiting the certainty of evidence. We assessed the certainty of the evidence as moderate to high according to GRADE for the primary outcomes for C-reactive protein test, except for mortality, as there were very few deaths, thereby limiting the certainty of the evidence. AUTHORS' CONCLUSIONS The use of C-reactive protein point-of-care tests as an adjunct to standard care likely reduces the number of participants given an antibiotic prescription in primary care patients who present with symptoms of acute respiratory infection. The use of C-reactive protein point-of-care tests likely does not affect recovery rates. It is unlikely that further research will substantially change our conclusion regarding the reduction in number of participants given an antibiotic prescription, although the size of the estimated effect may change. The use of C-reactive protein point-of-care tests may not increase mortality within 28 days follow-up, but there were very few events. Studies that recorded deaths and hospital admissions were performed in children from low- and middle-income countries and older adults with comorbidities. Future studies should focus on children, immunocompromised individuals, and people aged 80 years and above with comorbidities. More studies evaluating procalcitonin and potential new biomarkers as point-of-care tests used in primary care to guide antibiotic prescription are needed. Furthermore, studies are needed to validate C-reactive protein decision algorithms, with a specific focus on potential age group differences.
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Affiliation(s)
- Siri Aas Smedemark
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rune Aabenhus
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- Research Unit of General Practice, Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
| | - Anders Fournaise
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cross-sectoral Collaboration, Region of Southern Denmark, Vejle, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ole Olsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Wen CN, Huang CG, Chang PY, Yang TH, You HL, Ning HC, Tsao KC. Application of the electronic book to promote self-directed learning in medical technologist continuing education: a cross-sectional study. BMC MEDICAL EDUCATION 2022; 22:713. [PMID: 36217143 PMCID: PMC9549609 DOI: 10.1186/s12909-022-03724-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/01/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Continuing education (CE) is essential for health professionals to improve competence in clinical practice, yet many medical technologists still experience barriers to learning in complex clinical settings. To better manage CE and address medical technologists' learning needs, we developed a learner-centred electronic book (e-book) to promote self-directed learning for medical technologists. METHODS A cross-sectional study was conducted to explore the acceptability and learning impacts of the e-book as CE material for medical technologists in two medical centres in Taiwan. We designed the learner-centred context in the e-book based on medical technologists' practice requirements and learning needs. Moreover, we adopted The New World Kirkpatrick Model with four levels (reactions, learning, behaviours and results) to evaluate the e-book's learning impacts on medical technologists. A total of 280 medical technologists were invited to complete a questionnaire and a post-test, providing learning patterns as well as their satisfaction with the e-book and their learning outcomes after using it. RESULTS Most readers had positive learning experiences and better learning outcomes, including knowledge acquisition and behavioural change, after reading the e-book. The e-book became a new CE activity and reached medical technologists in various types of laboratories. CONCLUSIONS The low-cost and learner-centred e-book effectively overcame CE learning barriers for medical technologists. The interactivity and flexibility of e-learning particularly helped learners to engage in clinical scenarios in laboratory medicine. This study could pave the way for medical educators to build a high-quality e-learning model in CE.
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Affiliation(s)
- Chiao-Ni Wen
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Guei Huang
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
| | - Pi-Yueh Chang
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
| | - Tsung-Han Yang
- Department of Medical Laboratories Administrative Center, Chang Gung Medical Foundation, Taoyuan, Taiwan
| | - Huey-Ling You
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hsiao-Chen Ning
- Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan.
- Department of Medical Research and Development Linko Branch, Chang Gung Medical Foundation, Taoyuan City, 333, Taiwan, R.O.C..
| | - Kuo-Chien Tsao
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
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15
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Cook DA, Wilkinson JM, Foo J. Costs of Physician Continuous Professional Development: A Systematic Review. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1554-1563. [PMID: 35830262 DOI: 10.1097/acm.0000000000004805] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE An essential yet oft-neglected step in cost evaluations is the selection of resources (ingredients) to include in cost estimates. The ingredients that most influence the cost of physician continuous professional development (CPD) are unknown, as are the relative costs of instructional modalities. This study's purpose was to estimate the costs of cost ingredients and instructional modalities in physician CPD. METHOD The authors conducted a systematic review in April 2020, searching MEDLINE, Embase, PsycInfo, and the Cochrane Library for comparative cost evaluations of CPD for practicing physicians. Two reviewers, working independently, screened articles for inclusion and extracted information on costs (converted to 2021 U.S. dollars) for each intervention overall, each ingredient, and each modality. RESULTS Of 3,338 eligible studies, 62 were included, enumerating costs for 86 discrete training interventions or instructional modalities. The most frequently reported ingredients were faculty time (25 of 86 interventions), materials (24), administrator/staff time (23), and travel (20). Ingredient costs varied widely, ranging from a per-physician median of $4 for postage (10 interventions) to $525 for learner time (13); equipment (9) and faculty time were also relatively expensive (median > $170). Among instructional modalities (≤ 11 interventions per modality), audit and feedback performed by physician learners, computer-based modules, computer-based virtual patients, in-person lectures, and experiences with real patients were relatively expensive (median > $1,000 per physician). Mailed paper materials, video clips, and audit and feedback performed by others were relatively inexpensive (median ≤ $62 per physician). Details regarding ingredient selection (10 of 62 studies), quantitation (10), and pricing (26) were reported infrequently. CONCLUSIONS Some ingredients, including time, are more important (i.e., contribute more to total costs) than others and should be prioritized in cost evaluations. Data on the relative costs of instructional modalities are insightful but limited. The methods and reporting of cost valuations merit improvement.
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Affiliation(s)
- David A Cook
- D.A. Cook is professor of medicine and medical education, director, Section of Research and Data Analytics, School of Continuous Professional Development, director of education science, Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, and consultant, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-2383-4633
| | - John M Wilkinson
- J.M. Wilkinson is professor of family medicine, Mayo Clinic College of Medicine and Science, and consultant, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-1156-8577
| | - Jonathan Foo
- J. Foo is a lecturer, Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia; ORCID: https://orcid.org/0000-0003-4533-8307
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Educational Interventions to Reduce Prescription and Dispensing of Antibiotics in Primary Care: A Systematic Review of Economic Impact. Antibiotics (Basel) 2022; 11:antibiotics11091186. [PMID: 36139965 PMCID: PMC9495011 DOI: 10.3390/antibiotics11091186] [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: 07/08/2022] [Revised: 08/19/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Antibiotic resistance remains a crucial global public health problem with excessive and inappropriate antibiotic use representing an important driver of this issue. Strategies to improve antibiotic prescription and dispensing are required in primary health care settings. The main purpose of this review is to identify and synthesize available evidence on the economic impact of educational interventions to reduce prescription and dispensing of antibiotics among primary health care professionals. Information about the clinical impact resulting from the implementation of interventions was also gathered. PubMed, Scopus, Web of Science and EMBASE were the scientific databases used to search and identify relevant studies. Of the thirty-three selected articles, most consisted of a simple intervention, such as a guideline implementation, while the others involved multifaceted interventions, and differed regarding study populations, designs and settings. Main findings were grouped either into clinical or cost outcomes. Twenty of the thirty-three articles included studies reporting a reduction in outcome costs, namely in antibiotic cost and associated prescription costs, in part due to an overall improvement in the appropriateness of antibiotic use. The findings of this study show that the implementation of educational interventions is a cost-effective strategy to reduce antibiotic prescription and dispensing among primary healthcare providers.
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Nedved A, Lee BR, Hamner M, Wirtz A, Burns A, El Feghaly RE. Impact of an Antibiotic Stewardship Program on Antibiotic Choice, Dosing, and Duration in Pediatric Urgent Cares. Am J Infect Control 2022; 51:520-526. [PMID: 35940256 DOI: 10.1016/j.ajic.2022.07.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Many antimicrobial stewardship programs (ASPs) focus on decreasing unnecessary antibiotics. We describe the impact of an outpatient ASP on choice, dose, and duration of antibiotics when used for common infections in pediatric urgent care (PUC) centers. METHODS We reviewed encounters at 4 PUC centers within our organization for patients 6 months to 18 years old with acute otitis media, group A streptococcal pharyngitis, community-acquired pneumonia, urinary tract infection, and skin and soft tissue infections who received systemic antibiotics. We determined appropriate antibiotic choice, dose, and duration for each diagnosis. Pearson's χ² test compared appropriate prescribing before ASP implementation (July 2017-July 2018) and postimplementation (August 2018-December 2020). Control charts trended improvement over time. RESULTS Our study included 35,917 encounters. The percentage of prescriptions with the recommend agent at the appropriate dose and duration increased from a mean of 32.7% to 52.4%. The center lines for appropriate agent, dose, and duration all underwent upward shifts. The most substantial changes were seen in antibiotic duration (63.2%-80.5%), and appropriate dose (64.6%-77%). CONCLUSIONS Implementation of an outpatient ASP improved prescribing patterns for choosing the appropriate agent, duration, and dose for many common infections in our PUCs.
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Affiliation(s)
- Amanda Nedved
- Department of Pediatrics, Division of Urgent Care, Children's Mercy Kansas City, Kansas City, MO; University of Missouri-Kansas City, Kansas City, MO
| | - Brian R Lee
- University of Missouri-Kansas City, Kansas City, MO; Department of Pediatrics, Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO
| | - Megan Hamner
- Department of Pediatrics, Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO
| | - Ann Wirtz
- University of Missouri-Kansas City, Kansas City, MO; Department of Pediatrics, Division of Pharmacy, Children's Mercy Kansas City, Kansas City, MO
| | - Alaina Burns
- University of Missouri-Kansas City, Kansas City, MO; Department of Pediatrics, Division of Pharmacy, Children's Mercy Kansas City, Kansas City, MO
| | - Rana E El Feghaly
- University of Missouri-Kansas City, Kansas City, MO; Department of Pediatrics, Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO.
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Liu E, Linder KE, Kuti JL. Antimicrobial Stewardship at Transitions of Care to Outpatient Settings: Synopsis and Strategies. Antibiotics (Basel) 2022; 11:antibiotics11081027. [PMID: 36009896 PMCID: PMC9405265 DOI: 10.3390/antibiotics11081027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 02/01/2023] Open
Abstract
Inappropriate antibiotic use and associated consequences, including pathogen resistance and Clostridioides difficile infection, continue to serve as significant threats in the United States, with increasing incidence in the community setting. While much attention has been granted towards antimicrobial stewardship in acute care settings, the transition to the outpatient setting represents a significant yet overlooked area to target optimized antimicrobial utilization. In this article, we highlight notable areas for improved practices and present an interventional approach to stewardship tactics with a framework of disease, drug, dose, and duration. In doing so, we review current evidence regarding stewardship strategies at transitional settings, including diagnostic guidance, technological clinical support, and behavioral and educational approaches for both providers and patients.
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Affiliation(s)
- Elaine Liu
- Department of Pharmacy Services, Hartford Healthcare, Hartford, CT 06106, USA; (E.L.); (K.E.L.)
| | - Kristin E. Linder
- Department of Pharmacy Services, Hartford Healthcare, Hartford, CT 06106, USA; (E.L.); (K.E.L.)
| | - Joseph L. Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT 06106, USA
- Correspondence:
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Yamaguchi R, Okamoto K, Yamamoto T, Harada S, Tanaka T, Suzuki H, Moriya K. Impact of targeted intervention using a collaborative approach for oral third-generation cephalosporins: An interrupted time-series analysis. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e115. [PMID: 36483396 PMCID: PMC9726576 DOI: 10.1017/ash.2022.251] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVES To assess the effectiveness of a targeted intervention using a collaborative approach, added to a comprehensive educational intervention, to facilitate the appropriate use of oral third-generation cephalosporins (3GCs). DESIGN Quasi-experimental study. SETTING The University of Tokyo Hospital, a tertiary-care teaching hospital. PARTICIPANTS Approximately 2,000,000 outpatients and 80,000 inpatients at the hospital between April 2017 and March 2020. INTERVENTION The targeted intervention using the collaborative approach was implemented in the departments with the highest use of oral 3GCs (ophthalmology and dermatology departments). Interrupted time-series analysis was applied to assess the change in days of therapy (DOT) of oral 3GCs between the preintervention period (April 2017-April 2019) and the postintervention period (May 2019-March 2020) for both inpatients and outpatients. RESULTS After the introduction of the targeted intervention with oral 3GCs, a significant immediate reduction of 13.48 DOT per 1,000 patient days was detected in inpatients (P < .001). However, no significant change in slope was observed before and after the intervention (-0.02 DOT per 1,000 patient days per month; P = .94). Although a temporary increase was observed after the targeted intervention in outpatients, the slope significantly decreased (-0.69 DOT per 1,000 outpatient visits per month; P = .044). No differences were observed in the use of other oral antibiotics after the intervention. CONCLUSIONS The targeted intervention contributed to a reduction in DOT of oral 3GCs in both inpatients and outpatients. Targeted interventions using a collaborative approach might be helpful in further decreasing the inappropriate use of antibiotics.
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Affiliation(s)
- Ryo Yamaguchi
- Department of Pharmacy, the University of Tokyo Hospital, Tokyo, Japan
| | - Koh Okamoto
- Department of Infectious Diseases, the University of Tokyo Hospital, Tokyo, Japan
| | - Takehito Yamamoto
- Department of Pharmacy, the University of Tokyo Hospital, Tokyo, Japan
- The Education Center for Clinical Pharmacy, Graduate School of Pharmaceutical Sciences, the University of Tokyo, Tokyo, Japan
| | - Sohei Harada
- Department of Infection Control and Prevention, Faculty of Medicine, the University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Tanaka
- Department of Pharmacy, the University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Suzuki
- Department of Pharmacy, the University of Tokyo Hospital, Tokyo, Japan
| | - Kyoji Moriya
- Department of Infectious Diseases, the University of Tokyo Hospital, Tokyo, Japan
- Department of Infection Control and Prevention, Faculty of Medicine, the University of Tokyo Hospital, Tokyo, Japan
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Mangione-Smith R, Robinson JD, Zhou C, Stout JW, Fiks AG, Shalowitz M, Gerber JS, Burges D, Hedrick B, Warren L, Grundmeier RW, Kronman MP, Shone LP, Steffes J, Wright M, Heritage J. Fidelity evaluation of the dialogue around respiratory illness treatment (DART) program communication training. PATIENT EDUCATION AND COUNSELING 2022; 105:2611-2616. [PMID: 35341612 PMCID: PMC9203931 DOI: 10.1016/j.pec.2022.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/04/2022] [Accepted: 03/10/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate receipt fidelity of communication training content included in a multifaceted intervention known to reduce antibiotic over-prescribing for pediatric acute respiratory tract infections (ARTIs), by examining the degree to which clinicians implemented the intended communication behavior changes. METHODS Parents were surveyed regarding clinician communication behaviors immediately after attending 1026 visits by children 6 months to < 11 years old diagnosed with ARTIs by 53 clinicians in 18 pediatric practices. Communication outcomes analyzed were whether clinicians: (A) provided both a combined (negative + positive) treatment recommendation and a contingency plan (full implementation); (B) provided either a combined treatment recommendation or a contingency plan (partial implementation); or (C) provided neither (no implementation). We used mixed effects multinomial logistic regression to determine whether these 3 communication outcomes changed between baseline and the time periods following each of 3 training modules. RESULTS After completing the communication training, the adjusted probability of clinicians fully implementing the intended communication behavior changes increased by an absolute 8.1% compared to baseline (95% Confidence Interval [CI]: 2.4%, 13.8%, p = .005). CONCLUSIONS Our findings support the receipt fidelity of the intervention's communication training content. PRACTICAL IMPLICATIONS Clinicians can be trained to implement communication behaviors that may aid in reducing antibiotic over-prescribing for ARTIs.
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Affiliation(s)
| | - Jeffrey D Robinson
- Department of Communication, Portland State University, Portland, OR, USA.
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA.
| | - James W Stout
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Alexander G Fiks
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Primary Care Research, American Academy of Pediatrics, IL, USA.
| | - Madeleine Shalowitz
- Department of Psychiatry and Behavioral Medicine, Rush University School of Medicine, Chicago, IL, USA.
| | - Jeffrey S Gerber
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Dennis Burges
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Benjamin Hedrick
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Louise Warren
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Robert W Grundmeier
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Matthew P Kronman
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA.
| | - Laura P Shone
- Primary Care Research, American Academy of Pediatrics, IL, USA.
| | | | - Margaret Wright
- Primary Care Research, American Academy of Pediatrics, IL, USA.
| | - John Heritage
- Department of Sociology, University of California Los Angeles, Los Angeles, CA, USA.
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Petruschke I, Stichling K, Greser A, Gagyor I, Bleidorn J. [The general practitioner perspective of a multimodal intervention for the adequate use of antibiotics in urinary tract infection - a qualitative interview study]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2022; 170:1-6. [PMID: 35283054 DOI: 10.1016/j.zefq.2021.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 11/13/2021] [Accepted: 12/19/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Contrary to current guideline recommendations, second-line antibiotics are still frequently used in the ambulatory treatment of uncomplicated urinary tract infections (UTI), which are associated with a high risk of antibiotic resistance development. The REDARES project (REDuction of Antibiotic RESistance in uncomplicated urinary tract infections by treatment according to national guidelines in ambulatory care), funded by the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA)/Innovation Fund is developing a multimodal intervention for primary care physicians to support them in a guideline-based approach. The intervention consists of the following components: (1) provision of local resistance data of pathogens of uncomplicated UTI (Robert Koch Institute), (2) concise guideline content on the therapy of uncomplicated UTI for patients (paper and online), and (3) prescription feedback on practice level and benchmarking among the study participants (anonymized). In a participatory approach and as part of the process evaluation, representatives of the intended target group were interviewed in advance about the acceptance and feasibility of the intervention. METHODS Using guided individual interviews, Thuringian GPs were interviewed before the start of the intervention phase. Following a description of the study concept and the planned components of the intervention, the interviewees were asked about their assessment regarding acceptance and feasibility. The individual interviews were recorded, transcribed verbatim and qualitatively analyzed according to Mayring. RESULTS A total of ten interviews with an average duration of 29minutes were conducted and evaluated. 40 per cent of the interviewed GPs were female and, on average, 45 years old. The interviewees described the uncomplicated UTI as an easily manageable condition. The practical nature of the research question was described as a reason to potentially participate in the intervention phase; lack of time or human resources were cited as potential barriers. Regarding the intervention elements, the provision of local resistance data of UTI pathogens was considered beneficial to their own work. The extraction of their own antibiotic prescription data from the practice software was basically assessed as feasible. The interviewees differed in their assessment of whether they would take account of the feedback on their prescribing behavior in their daily work. DISCUSSION The interviews generated a detailed picture of the different diagnostic and therapeutic pathways used by respondents for uncomplicated UTI. Overall, they predominantly regarded both the study concept and the intervention components as feasible. Although the study population is small and not representative, some of the results seem to be transferable to other regions in Germany. CONCLUSION A research question relating to their daily routine can increase participation of primary care physicians in (intervention) studies. Starting the process evaluation before the intervention seems to be reasonable since the results will be integrated into the design of the intervention. The method of data extraction from practice software by practice teams seems to be promising.
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Affiliation(s)
- Inga Petruschke
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | - Kathleen Stichling
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Jena, Deutschland
| | - Alexandra Greser
- Institut für Allgemeinmedizin, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Ildiko Gagyor
- Institut für Allgemeinmedizin, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Jutta Bleidorn
- Institut für Allgemeinmedizin, Universitätsklinikum Jena, Jena, Deutschland.
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Martínez-González NA, Plate A, Jäger L, Senn O, Neuner-Jehle S. The Role of Point-of-Care C-Reactive Protein Testing in Antibiotic Prescribing for Respiratory Tract Infections: A Survey among Swiss General Practitioners. Antibiotics (Basel) 2022; 11:antibiotics11050543. [PMID: 35625187 PMCID: PMC9137646 DOI: 10.3390/antibiotics11050543] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 02/05/2023] Open
Abstract
Understanding the decision-making strategies of general practitioners (GPs) could help reduce suboptimal antibiotic prescribing. Respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing in primary care, a key driver of antibiotic resistance (ABR). We conducted a nationwide prospective web-based survey to explore: (1) The role of C-reactive protein (CRP) point-of-care testing (POCT) on antibiotic prescribing decision-making for RTIs using case vignettes; and (2) the knowledge, attitudes and barriers/facilitators of antibiotic prescribing using deductive analysis. Most GPs (92–98%) selected CRP-POCT alone or combined with other diagnostics. GPs would use lower CRP cut-offs to guide prescribing for (more) severe RTIs than for uncomplicated RTIs. Intermediate CRP ranges were significantly wider for uncomplicated than for (more) severe RTIs (p = 0.001). Amoxicillin/clavulanic acid was the most frequently recommended antibiotic across all RTI case scenarios (65–87%). Faced with intermediate CRP results, GPs preferred 3–5-day follow-up to delayed prescribing or other clinical approaches. Patient pressure, diagnostic uncertainty, fear of complications and lack of ABR understanding were the most GP-reported barriers to appropriate antibiotic prescribing. Stewardship interventions considering CRP-POCT and the barriers and facilitators to appropriate prescribing could guide antibiotic prescribing decisions at the point of care.
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Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, CH-6002 Lucerne, Switzerland
- Correspondence: or
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Levy Jäger
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
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Beilfuss S, Linde S, Norton B. Accountable care organizations and physician antibiotic prescribing behavior. Soc Sci Med 2022; 294:114707. [PMID: 35030393 DOI: 10.1016/j.socscimed.2022.114707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 12/30/2021] [Accepted: 01/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Physician accountable care organization (ACO) affiliation has been found to reduce cost and improve quality across metrics that are directly measured by the Medicare ACO programs. However, little is known about potential spillover effects from this program onto non-measured physician behavior such as antibiotic prescribing. METHODS Using a two-part structural selection model that accounts for selection into treatment (ACO group), and non-treatment (control group), we compare physician antibiotic prescribing across these groups with adjustment for volume, patient, physician and institutional characteristics. We also estimate heterogeneous treatment responses across specialties, focusing on physicians with a primary specialty of internal medicine, family or general practice, nurse practitioners, as well as general and orthopedic surgeons. RESULTS We find that ACO affiliation helps reduce antibiotic prescribing by 20.4 (95%CI = -26.65 to -14.16, p-value<0.001) prescriptions (about 19.5%) per year. We show that each additional hospital and practice affiliation increases prescriptions by 1.6 (95%CI = 1.27 to 1.95, p-value<0.001) and 1.7 (95%CI = 1.00 to 2.47, p-value<0.001), respectively. However, the use of electronic health records and high-quality medical training is associated with a decrease in antibiotic use of 7.9 (95%CI = -8.79 to -7.07, p-value<0.001) and 3.6 (95%CI = -4.47 to -2.73, p-value<0.001) claims, respectively. The treatment effects are found to vary with specialty, where internal medicine physicians experience an average decrease of 23.6 (95%CI = -29.98 to -17.20, p-value<0.001), family and general practice physicians a decrease of 22.1 (95%CI = -28.37 to -15.77, p-value<0.001), nurse practitioners a decrease of 7.1 (95%CI = -13.99 to -0.77, p-value = 0.028), general surgeons a decrease of 9.6 (95%CI = -16.02 to -3.25, p-value = 0.003), and orthopedic surgeons a reduction of 8.1 (95%CI = -14.84 to -1.42, p-value = 0.018) in their antibiotic prescribing per year. CONCLUSIONS In assessing the impact of Medicare ACO programs it is important to account for spillover effects. Our study finds that ACO affiliation has had a measurable impact on physician antibiotic prescribing.
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Affiliation(s)
- Svetlana Beilfuss
- Eastern Michigan University, Department of Economics, Address: 703 Pray, Harrold, Ypsilanti, MI, 48197, USA.
| | - Sebastian Linde
- Medical College of Wisconsin, Department of Medicine, Division of General Internal Medicine, Address: 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, United States; Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Brandon Norton
- Purdue University, Department of Economics, Krannert School of Management, Address: 403 West State Street, West Lafayette, IN, 47907-2056, United States.
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Chang Y, Yao Y, Cui Z, Yang G, Li D, Wang L, Tang L. Changing antibiotic prescribing practices in outpatient primary care settings in China: Study protocol for a health information system-based cluster-randomised crossover controlled trial. PLoS One 2022; 17:e0259065. [PMID: 34995279 PMCID: PMC8741015 DOI: 10.1371/journal.pone.0259065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/01/2021] [Indexed: 11/18/2022] Open
Abstract
Background
The overuse and abuse of antibiotics is a major risk factor for antibiotic resistance in primary care settings of China. In this study, the effectiveness of an automatically-presented, privacy-protecting, computer information technology (IT)-based antibiotic feedback intervention will be evaluated to determine whether it can reduce antibiotic prescribing rates and unreasonable prescribing behaviours.
Methods
We will pilot and develop a cluster-randomised, open controlled, crossover, superiority trial. A total of 320 outpatient physicians in 6 counties of Guizhou province who met the standard will be randomly divided into intervention group and control group with a primary care hospital being the unit of cluster allocation. In the intervention group, the three components of the feedback intervention included: 1. Artificial intelligence (AI)-based real-time warnings of improper antibiotic use; 2. Pop-up windows of antibiotic prescription rate ranking; 3. Distribution of educational manuals. In the control group, no form of intervention will be provided. The trial will last for 6 months and will be divided into two phases of three months each. The two groups will crossover after 3 months. The primary outcome is the 10-day antibiotic prescription rate of physicians. The secondary outcome is the rational use of antibiotic prescriptions. The acceptability and feasibility of this feedback intervention study will be evaluated using both qualitative and quantitative assessment methods.
Discussion
This study will overcome limitations of our previous study, which only focused on reducing antibiotic prescription rates. AI techniques and an educational intervention will be used in this study to effectively reduce antibiotic prescription rates and antibiotic irregularities. This study will also provide new ideas and approaches for further research in this area.
Trial registration
ISRCTN, ID: ISRCTN13817256. Registered on 11 January 2020.
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Affiliation(s)
- Yue Chang
- School of Public Health, Guizhou Medical University, Guiyang, Guizhou Province, China
- * E-mail: (YC); (GY); (DL)
| | - Yuanfan Yao
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Zhezhe Cui
- Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nan’ning, Guangxi Province, China
| | - Guanghong Yang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China
- * E-mail: (YC); (GY); (DL)
| | - Duan Li
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China
- * E-mail: (YC); (GY); (DL)
| | - Lei Wang
- Primary Health Department of Guizhou Provincial Health Commission, Guiyang, Guizhou Province, China
| | - Lei Tang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China
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Cook DA, Stephenson CR, Wilkinson JM, Maloney S, Foo J. Cost-effectiveness and Economic Benefit of Continuous Professional Development for Drug Prescribing: A Systematic Review. JAMA Netw Open 2022; 5:e2144973. [PMID: 35080604 PMCID: PMC8792887 DOI: 10.1001/jamanetworkopen.2021.44973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/01/2021] [Indexed: 11/19/2022] Open
Abstract
Importance The economic impact of continuous professional development (CPD) education is incompletely understood. Objective To systematically identify and synthesize published research examining the costs associated with physician CPD for drug prescribing. Evidence Review MEDLINE, Embase, PsycInfo, and the Cochrane Database were searched from inception to April 23, 2020, for comparative studies that evaluated the cost of CPD focused on drug prescribing. Two reviewers independently screened all articles for inclusion and reviewed all included articles to extract data on participants, educational interventions, study designs, and outcomes (costs and effectiveness). Results were synthesized for educational costs, health care costs, and cost-effectiveness. Findings Of 3338 articles screened, 38 were included in this analysis. These studies included at least 15 659 health care professionals and 1 963 197 patients. Twelve studies reported on educational costs, ranging from $281 to $183 554 (median, $15 664). When economic outcomes were evaluated, 31 of 33 studies (94%) comparing CPD with no intervention found that CPD was associated with reduced health care costs (drug costs), ranging from $4731 to $6 912 000 (median, $79 373). Four studies found reduced drug costs for 1-on-1 outreach compared with other CPD approaches. Regarding cost-effectiveness, among 5 studies that compared CPD with no intervention, the incremental cost-effectiveness ratio for a 10% improvement in prescribing ranged from $15 390 to $437 027 to train all program participants. Four comparisons of alternative CPD approaches found that 1-on-1 educational outreach was more effective but more expensive than group education or mailed materials (incremental cost-effectiveness ratio, $18-$4105 per physician trained). Conclusions and Relevance In this systematic review, CPD for drug prescribing was associated with reduced health care (drug) costs. The educational costs and cost-effectiveness of CPD varied widely. Several CPD instructional approaches (including educational outreach) were more effective but more costly than comparators.
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Affiliation(s)
- David A. Cook
- School of Continuous Professional Development, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Stephen Maloney
- School of Primary and Allied Health Care, Monash University, Victoria, Australia
| | - Jonathan Foo
- School of Primary and Allied Health Care, Monash University, Victoria, Australia
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Abstract
Antibiotic use (and misuse) accelerates antimicrobial resistance (AMR), and addressing this complex problem necessitates behaviour change related to infection prevention and management and to antibiotic prescribing and use. As most antibiotic courses are prescribed in primary care, a key focus of antimicrobial stewardship (AMS) is on changing behaviours outside of hospital. Behavioural science draws on behaviour change theories, techniques and methods developed in health psychology, and can be used to help understand and change behaviours related to AMR/AMS. Qualitative methodologies can be used together with a behavioural science approach to explore influences on behaviour and develop and evaluate behavioural interventions. This paper provides an overview of how the behavioural science approach, together with qualitative methods, can contribute and add value to AMS projects. First, it introduces and explains the relevance of the behavioural science approach to AMR/AMS. Second, it provides an overview of behaviour change ‘tools’: behaviour change theories/models, behavioural determinants and behaviour change techniques. Third, it explains how behavioural methods can be used to: (i) define a clinical problem in behavioural terms and identify behavioural influences; (ii) develop and implement behavioural AMS interventions; and (iii) evaluate them. These are illustrated with examples of using qualitative methods in AMS studies in primary care. Finally, the paper concludes by summarizing the main contributions of taking the behavioural science approach to qualitative AMS research in primary care and discussing the key implications and future directions for research and practice.
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Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Corresponding author. E-mail:
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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Mortrude GC, Rehs MT, Sherman KA, Gundacker ND, Dysart CE. Implementation of Veterans Affairs Primary Care Antimicrobial Stewardship Interventions For Asymptomatic Bacteriuria And Acute Respiratory Infections. Open Forum Infect Dis 2021; 8:ofab449. [PMID: 34909435 PMCID: PMC8665674 DOI: 10.1093/ofid/ofab449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/31/2021] [Indexed: 11/14/2022] Open
Abstract
Background Outpatient antimicrobial prescribing is an important target for antimicrobial stewardship (AMS) interventions to decrease antimicrobial resistance. The objective of this study was to design, implement, and evaluate the impact of AMS interventions focused on asymptomatic bacteriuria (ASB) and acute respiratory infections (ARIs) in the primary care setting. Methods This stepped-wedge trial evaluated the impact of multifaceted educational interventions to providers on adult patients presenting to primary care clinics for ARIs and ASB. The primary outcome was percentage of overall antibiotic prescriptions as a composite of prescriptions for ASB, acute bronchitis, upper respiratory infection not otherwise specified, uncomplicated sinusitis, and uncomplicated pharyngitis. Secondary outcomes were the individual components of the primary outcome; a composite safety endpoint of related hospital, emergency department, or primary care visits within 4 weeks; antibiotic selection appropriateness; and patient satisfaction surveys. Results A total of 887 patients were included (405 preintervention and 482 postintervention). After controlling for type I error using Bonferroni correction, the primary outcome was not significantly different between groups (56% vs 49%). There was a statistically significant decrease in prescriptions for acute bronchitis (20.99% vs 12.66%; P = .0003). Appropriateness of antibiotic prescriptions for uncomplicated sinusitis (odds ratio [OR], 4.96 [95% confidence interval {CI}, 1.79–13.75]; P = .0021) and pharyngitis (OR, 5.36 [95% CI, 1.93–14.90]; P = .0013) was improved in the postintervention vs the preintervention group. The composite safety outcome and patient satisfaction surveys did not differ between groups. Conclusions Multifaceted educational interventions targeting providers can improve antibiotic prescribing for indications rarely requiring antimicrobials without increasing re-visits or patient satisfaction surveys.
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Affiliation(s)
- Grace C Mortrude
- Infectious Diseases Service Pharmacy, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Mary T Rehs
- Primary Care, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Katherine A Sherman
- Research Division, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Nathan D Gundacker
- Infectious Diseases, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA.,Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Claire E Dysart
- Infectious Diseases Service Pharmacy, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
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Gágyor I, Greser A, Heuschmann P, Rücker V, Maun A, Bleidorn J, Heintze C, Jede F, Eckmanns T, Klingeberg A, Mentzel A, Schmiemann G. REDuction of Antibiotic RESistance (REDARES) in urinary tract infections using treatments according to national clinical guidelines: study protocol for a pragmatic randomized controlled trial with a multimodal intervention in primary care. BMC Infect Dis 2021; 21:990. [PMID: 34556027 PMCID: PMC8461906 DOI: 10.1186/s12879-021-06660-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/06/2021] [Indexed: 11/14/2022] Open
Abstract
Background Urinary tract infections (UTIs) are a common cause of prescribing antibiotics in family medicine. In Germany, about 40% of UTI-related prescriptions are second-line antibiotics, which contributes to emerging resistance rates. To achieve a change in the prescribing behaviour among family physicians (FPs), this trial aims to implement the guideline recommendations in German family medicine. Methods/design In a randomized controlled trial, a multimodal intervention will be developed and tested in family practices in four regions across Germany. The intervention will consist of three elements: information on guideline recommendations, information on regional resistance and feedback of prescribing behaviour for FPs on a quarterly basis. The effect of the intervention will be compared to usual practice. The primary endpoint is the absolute difference in the mean of prescribing rates of second-line antibiotics among the intervention and the control group after 12 months. To detect a 10% absolute difference in the prescribing rate after one year, with a significance level of 5% and a power of 86%, a sample size of 57 practices per group will be needed. Assuming a dropout rate of 10%, an overall number of 128 practices will be required. The accompanying process evaluation will provide information on feasibility and acceptance of the intervention. Discussion If proven effective and feasible, the components of the intervention can improve adherence to antibiotic prescribing guidelines and contribute to antimicrobial stewardship in ambulatory care. Trial registration DRKS, DRKS00020389, Registered 30 January 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020389.
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Affiliation(s)
- Ildikó Gágyor
- Department of General Practice, University Hospital Wuerzburg, Josef-Schneider-Str. 2, D7, 97080, Wuerzburg, Germany
| | - Alexandra Greser
- Department of General Practice, University Hospital Wuerzburg, Josef-Schneider-Str. 2, D7, 97080, Wuerzburg, Germany.
| | - Peter Heuschmann
- Institute for Clinical Epidemiology and Biometry (IKE-B), University of Wuerzburg, Wuerzburg, Germany.,Clinical Trial Centre Wuerzburg, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Viktoria Rücker
- Institute for Clinical Epidemiology and Biometry (IKE-B), University of Wuerzburg, Wuerzburg, Germany
| | - Andy Maun
- Division of General Practice, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jutta Bleidorn
- Department of General Practice, University Hospital Jena, Jena, Thuringia, Germany
| | - Christoph Heintze
- Department of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Jede
- Department of General Practice, University Hospital Wuerzburg, Josef-Schneider-Str. 2, D7, 97080, Wuerzburg, Germany
| | | | | | - Anja Mentzel
- Division of General Practice, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Guido Schmiemann
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany
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Borek AJ, Campbell A, Dent E, Moore M, Butler CC, Holmes A, Walker AS, McLeod M, Tonkin-Crine S. Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice. Implement Sci Commun 2021; 2:104. [PMID: 34526140 PMCID: PMC8441243 DOI: 10.1186/s43058-021-00209-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/30/2021] [Indexed: 11/21/2022] Open
Abstract
Background Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care. Methods We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified ‘guiding principles’ with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals. Results Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an ‘implementation support’ website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts). Conclusions We used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00209-7.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Anne Campbell
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Elle Dent
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Alison Holmes
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - A Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Monsey McLeod
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK.,NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Gunnlaugsdottir MR, Linnet K, Jonsson JS, Blondal AB. Encouraging rational antibiotic prescribing behaviour in primary care - prescribing practice among children aged 0-4 years 2016-2018: an observational study. Scand J Prim Health Care 2021; 39:373-381. [PMID: 34348560 PMCID: PMC8475099 DOI: 10.1080/02813432.2021.1958506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To study antibiotic prescriptions among 0- to 4-year-old children before and after implementing a quality project on prudent prescribing of antibiotics in primary healthcare in the capital region of Iceland. DESIGN An observational, descriptive, retrospective study using quantitative methodology. SETTING Primary healthcare in the Reykjavik area with a total population of approximately 220,000. SUBJECTS A total of 6420 children 0-4 years of age presenting at the primary healthcare centres in the metropolitan area over three years from 2016 to 2018. MAIN OUTCOME MEASURES Reduction of antibiotic prescriptions and change in antibiotic profile. Data on antibiotic prescriptions for children 0-4 years of age was obtained from the medical records. Out-of-hours prescriptions were not included in the database. RESULTS The number of prescriptions during the study period ranged from 263.6 to 289.6 prescriptions/1000 inhabitants/year. A reduction of 9% in the total number of prescriptions between 2017-2018 was observed. More than half of all prescriptions were for otitis media, followed by pneumonia and skin infections. Amoxicillin accounted for over half of all prescriptions, increasing between 2016 and 2018 by 51.3%. During this period, the prescribing of co-amoxiclav and macrolides decreased by 52.3% and 40.7%, respectively. These changes were significant in all cases, p < 0.0001. CONCLUSION The results show an overall decrease in antibiotic prescribing concurrent with a change in the choice of antibiotics prescribed and in line with the recommendations presented in the prescribing guidelines implemented by the Primary Healthcare of the Capital Area, and consistent with the project's goals.Key pointsA substantial proportion of antibiotic prescribing can be considered inappropriate and the antibiotic prescription rate is highest in Iceland of the Nordic countries.After implementing guidance on the treatment of common infections together with feedback on antibiotic prescribing, a decrease in the total number of prescriptions accompanied by a shift in the antibiotic profile was observed.
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Affiliation(s)
| | | | - Jon Steinar Jonsson
- Development Centre for Primary Healthcare, Iceland
- Department of Family Medicine, University of Iceland, Reykjavík, Iceland
| | - Anna Bryndis Blondal
- Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavík, Iceland
- Development Centre for Primary Healthcare, Iceland
- CONTACT Anna Bryndis Blondal , Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavík, Iceland
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Leung V, Langford BJ, Ha R, Schwartz KL. Metrics for evaluating antibiotic use and prescribing in outpatient settings. JAC Antimicrob Resist 2021; 3:dlab098. [PMID: 34286273 PMCID: PMC8287042 DOI: 10.1093/jacamr/dlab098] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Antimicrobial stewardship interventions in outpatient settings are diverse and a variety of outcomes have been used to evaluate these efforts. This narrative review describes, compares and provides specific examples of antibiotic use and other prescribing measures to help antimicrobial stewards better understand, interpret and implement metrics for this setting. A variety of data have been used including those generated from drug sales, prescribing and dispensing activities, however data generated closest to when an individual patient consumes an antibiotic is usually more accurate for estimating antibiotic use. Availability of data is often dependent on context such as information technology infrastructure and the healthcare system under consideration. While there is no ideal antibiotic use or prescribing metric for evaluating antimicrobial stewardship activities in the outpatient setting, the intervention of interest and available data sources are important factors. Common metrics for estimating antimicrobial use include DDD per 1000 inhabitants per day (DID) and days of therapy per 1000 inhabitants/day (DOTID). Other prescribing metrics such as antibiotic prescribing rate (APR), proportion of prescriptions containing an antibiotic, proportion of prolonged antibiotic courses prescribed, estimated appropriate APR and quality indicators are used to assess specific aspects of antimicrobial prescribing behaviour such as initiation, selection, duration and appropriateness. Understanding the context of prescribing practices helps to ensure feasibility and relevance when implementing metrics and targets for improvement in the outpatient setting.
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Affiliation(s)
- Valerie Leung
- Public Health Ontario, ON, Canada
- Toronto East Health Network, Michael Garron Hospital, ON, Canada
| | - Bradley J Langford
- Public Health Ontario, ON, Canada
- Hotel Dieu Shaver Health and Rehabilitation Centre, ON, Canada
| | - Rita Ha
- North York Family Health Team, ON, Canada
| | - Kevin L Schwartz
- Public Health Ontario, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, ON, Canada
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Dutcher L, Degnan K, Adu-Gyamfi AB, Lautenbach E, Cressman L, David MZ, Cluzet V, Szymczak JE, Pegues DA, Bilker W, Tolomeo P, Hamilton KW. Improving Outpatient Antibiotic Prescribing for Respiratory Tract Infections in Primary Care; a Stepped-Wedge Cluster Randomized Trial. Clin Infect Dis 2021; 74:947-956. [PMID: 34212177 DOI: 10.1093/cid/ciab602] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescribing is common in primary care (PC), particularly for respiratory tract diagnoses (RTDs). However, the optimal approach for improving prescribing remains unknown. METHODS We conducted a stepped-wedge study in PC practices within a health system to assess the impact of a provider-targeted intervention on antibiotic prescribing for RTDs. RTDs were grouped into tiers based on appropriateness of antibiotic prescribing: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). Providers received education on appropriate RTD prescribing followed by monthly peer comparison feedback on antibiotic prescribing for (1) all tiers and (2) tier 3 RTDs. Chi-squared testing was used to compare the proportion of visits with antibiotic prescriptions before and during the intervention. Mixed-effects multivariable logistic regression analysis was performed to assess the association between the intervention and antibiotic prescribing. RESULTS Across 30 PC practices and 185,755 total visits, overall antibiotic prescribing was reduced with the intervention, from 35.2% to 23.0% of visits (p<0.001). In multivariable analysis, the intervention was associated with a reduced odds of antibiotic prescription for tiers 2 (OR 0.57; 95% CI 0.52 - 0.62) and 3 (OR 0.57; 95% CI 0.53 - 0.61), but not for tier 1 (OR 0.98; 95% CI 0.83 - 1.16). CONCLUSION A provider-focused intervention reduced overall antibiotic prescribing for RTDs without affecting prescribing for infections that likely require antibiotics. Future research should examine the sustainability of such interventions, potential unintended adverse effects on patient health or satisfaction, and provider perceptions and acceptability.
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Affiliation(s)
- Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kathleen Degnan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael Z David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Valerie Cluzet
- Division of Infectious Diseases, Health Quest, Poughkeepsie, NY, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Warren Bilker
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Pam Tolomeo
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Keith W Hamilton
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Aksoy M, Isli F, Kadi E, Varimli D, Gursoz H, Tolunay T, Kara A, Unal S, Alp Mese E. Evaluation of more than one billion outpatient prescriptions and eight-year trend showing a remarkable reduction in antibiotic prescription in Turkey: A success model of governmental interventions at national level. Pharmacoepidemiol Drug Saf 2021; 30:1242-1249. [PMID: 34155708 DOI: 10.1002/pds.5311] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 11/06/2022]
Abstract
PURPOSE To present the antibiotic prescription trend between 2011-2018 at primary healthcare in Turkey in order to evaluate the effects of interventions at national level for providing rational prescription of antibiotics. METHODS Electronic prescription data of the family physicians collected from January 1, 2011 to December 31, 2018 in 81 provinces of Turkey were recorded through the Prescription Information System and screened for the antimicrobial drugs. The interventions to promote rational antibiotic use during 2011-2018 in Turkey includes reminding the legislation to stop access of antibiotics without prescription, monitoring of antibiotic prescription behaviors of primary healthcare physicians, and education of healthcare workers and the public on the appropriate use of antibiotics. RESULTS A total of 1 054 261 396 prescriptions for outpatients of all age groups were recorded during this period. Of the prescriptions written by family physcians, 34.94% were containing at least one antibiotic in 2011, which declined to 24.55% in 2018. Antibiotics constituted 13.99% of all the items in prescriptions in 2011 and 10.47% in 2018. Percentage of total antibiotic expenditure to the total drug expanditure decreased from 14.14% to 4.12% during 2011-2018. The most commonly prescribed antibiotics were amoxicillin and enzyme inhibitor combination, cefdinir, and cefuroxime during 2011-2018, with an increasing trend for prescription of first-line antibiotic, amoxicillin, in recent years. CONCLUSIONS Governmental interventions at national level have contributed to reducing antibiotic prescription and increasing preference of first-line antibiotics at primary healthcare level in Turkey over a course of 8 years. Turkey's model of governmental interventions may set an example for other countries with high consumption of antibiotics, and contribute to the actions against antimicrobial resistance worldwide.
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Affiliation(s)
- Mesil Aksoy
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Fatma Isli
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Esma Kadi
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Didem Varimli
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Hakki Gursoz
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Tolga Tolunay
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Ates Kara
- Hacettepe University, Ankara, Turkey
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Borek AJ, Anthierens S, Allison R, McNulty CAM, Lecky DM, Costelloe C, Holmes A, Butler CC, Walker AS, Tonkin-Crine S. How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals. J Antimicrob Chemother 2021; 75:2681-2688. [PMID: 32573692 DOI: 10.1093/jac/dkaa224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented. OBJECTIVES To understand responses to the QP and how it was perceived to influence antibiotic prescribing. METHODS Semi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically. RESULTS The findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off. CONCLUSIONS CCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Rosalie Allison
- Primary Care and Interventions Unit, Public Health England, Gloucester, UK
| | | | - Donna M Lecky
- Primary Care and Interventions Unit, Public Health England, Gloucester, UK
| | - Ceire Costelloe
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Alison Holmes
- Department of Infectious Diseases, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - A Sarah Walker
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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Talkhan H, Stewart D, Mcintosh T, Ziglam H, Abdulrouf PV, Al-Hail M, Diab M, Cunningham S. The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. J Antimicrob Chemother 2021; 75:2394-2410. [PMID: 32356877 DOI: 10.1093/jac/dkaa154] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/06/2020] [Accepted: 03/27/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES This systematic review (SR) reviews the evidence on use of theory in developing and evaluating behaviour change interventions (BCIs) to improve clinicians' antimicrobial prescribing (AP). METHODS The SR protocol was registered with PROSPERO. Eleven databases were searched from inception to October 2018 for peer-reviewed, English-language, primary literature in any healthcare setting and for any medical condition. This included research on changing behavioural intentions (e.g. in simulated scenarios) and research measuring actual AP. All study designs/methodologies were included. Excluded were: grey literature and/or those which did not state a theory. Two reviewers independently extracted and quality assessed the data. The Theory Coding Scheme (TCS) evaluated the extent of the use of theory. RESULTS Searches found 4227 potentially relevant papers after removal of duplicates. Screening of titles/abstracts led to dual assessment of 38 full-text papers. Ten (five quantitative, three qualitative and two mixed-methods) met the inclusion criteria. Studies were conducted in the UK (n = 8), Canada (n = 1) and Sweden (n = 1), most in primary care settings (n = 9), targeting respiratory tract infections (n = 8), and medical doctors (n = 10). The most common theories used were Theory of Planned Behaviour (n = 7), Social Cognitive Theory (n = 5) and Operant Learning Theory (n = 5). The use of theory to inform the design and choice of intervention varied, with no optimal use as recommended in the TCS. CONCLUSIONS This SR is the first to investigate theoretically based BCIs around AP. Few studies were identified; most were suboptimal in theory use. There is a need to consider how theory is used and reported and the systematic use of the TCS could help.
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Affiliation(s)
- Hend Talkhan
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Trudi Mcintosh
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Hisham Ziglam
- Infectious Diseases Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Moza Al-Hail
- Pharmacy Department, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Mohammad Diab
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Scott Cunningham
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
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Changes in antibiotic prescription following an education strategy for acute respiratory infections. NPJ Prim Care Respir Med 2021; 31:34. [PMID: 34083534 PMCID: PMC8175562 DOI: 10.1038/s41533-021-00247-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/26/2021] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to assess the impact of an education intervention for primary health care physicians, based on the knowledge of clinical practice guidelines and availability of rapid antigen detection test for group A streptococci (GAS), on the improvement of antibiotic prescription for patients with acute respiratory tract infections. Before and after the intervention, physicians collected data from ten consecutive patients who attended during a 3-week period. This process was performed twice a year for 6 consecutive years (2012–2017). A total of 18,001 patients were visited by 391 primary care physicians during the study period, 55.6% before intervention and 44.4% after intervention. After intervention, the antibiotic prescription decreased significantly, from 33.0 to 23.4% (p < 0.01). However, there was a statistically significant increase (p < 0.01) in the use of penicillins. This study, carried out in daily practice conditions, confirms that the educational strategy was associated with an overall reduction in the use of antibiotics and an improvement in the antibiotic prescription profile in acute respiratory tract infections.
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Moe S, Kan T, Soobiah C, Golian A, Li T, Raybardhan S. Using a behavioural framework to optimize antibiotic prescribing by family medicine residents. MEDEDPUBLISH 2021; 10:113. [PMID: 38486590 PMCID: PMC10939518 DOI: 10.15694/mep.2021.000113.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
This article was migrated. The article was marked as recommended. Background and objectives:Overprescribing of antibiotics in primary care is a prominent concern in the context of increasing antimicrobial resistance worldwide. Medical trainees are a key group to deliver thoughtful antimicrobial stewardship training. This study examined the factors influencing antibiotic prescribing for upper respiratory tract infections (URTI) by family medicine residents in order to identify educational interventions. Methods: Using purposive sampling of family medicine residents, semi-structured interviews were conducted until thematic saturation was reached. Interviews were coded into the domains of the Theoretical Domains Framework (TDF). Belief statements were created to characterize each domain and categorized as enablers or barriers to appropriate prescribing. Domains were plotted on the Behaviour Change Wheel (BCW) and intervention functions identified. Results:Twelve participants were interviewed. Nine domains of the TDF were relevant to antibiotic prescribing. Social influence was a prominent theme with the preceptor and patient being key influences on resident prescribing. Learning goals were also a key theme including the desire to strengthen independent clinical decision-making skills and improve antibiotic knowledge. Residents' beliefs about capabilities were challenged when faced with diagnostic uncertainty. Additional domains included: professional role; environmental context and resources; intentions; beliefs about consequences and capabilities, and knowledge. Using the BCW, nine intervention functions were identified to change antibiotic prescribing behaviour. Conclusion: This study found nine domains of the TDF were relevant to family medicine resident antibiotic prescribing for URTI. Nine intervention functions could be used to guide intervention design.
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Hermsen ED, Jenkins R, Vlaev I, Iley S, Rajgopal T, Sackier JM, Loubser P, Pronk N, Wilkinson E, Chow Y, Gunther C. The Role of the Private Sector in Advancing Antimicrobial Stewardship: Recommendations from the Global Chief Medical Officers' Network. Popul Health Manag 2021; 24:231-240. [PMID: 32667844 PMCID: PMC8060714 DOI: 10.1089/pop.2020.0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Antimicrobial resistance (AMR) occurs when microorganisms develop the ability to defeat the drugs designed to kill them. If allowed to increase at the current rate, AMR could kill an estimated 10 million people per year and cost society approximately 100-200 trillion USD globally by 2050. The slow development of novel antimicrobials further exacerbates the problem. Most human antibiotic use occurs in homes and workplaces, where antibiotic-resistant infections may contribute to diminished performance and loss of work productivity. Employers in the private sector have the ability to reach large populations of employees and their families, raise awareness about AMR, and promote antimicrobial stewardship (AMS) among their workforce. The authors describe 4 steps a company can take to help advance AMS: (1) sign the AMR Pledge, (2) perform a gap analysis, (3) implement and/or modify standard practices, and (4) measure and report outcomes. Real-world examples are provided, including barriers faced, in order to successfully implement initiatives to promote better AMS. Behavioral methods to influence change in the workplace are also presented. Both large and small companies can make a difference to support responsible use of antibiotics and improve the health and well-being of their employees.
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Affiliation(s)
| | | | - Ivo Vlaev
- Warwick Business School, Coventry, United Kingdom
| | - Steve Iley
- Jaguar Land Rover, Warwick, United Kingdom
| | | | | | | | - Nico Pronk
- HealthPartners, Minneapolis, Minnesota, USA
| | | | - Yat Chow
- Quality HealthCare Medical Services, Hong Kong, China
| | - Cathryn Gunther
- Global Population Health, Merck & Co., Inc., Kenilworth, New Jersey, USA
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Glinz D, Mc Cord KA, Moffa G, Aghlmandi S, Saccilotto R, Zeller A, Widmer AF, Bielicki J, Kronenberg A, Bucher HC. Antibiotic prescription monitoring and feedback in primary care in Switzerland: Design and rationale of a nationwide pragmatic randomized controlled trial. Contemp Clin Trials Commun 2021; 21:100712. [PMID: 33665467 PMCID: PMC7897989 DOI: 10.1016/j.conctc.2021.100712] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/26/2020] [Accepted: 01/12/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Antibiotic consumption is highest in primary care, and antibiotic overuse furthers antimicrobial resistance. In our recently published pilot-RCT, we used monthly aggregated claims data to provide personalized antibiotic prescription feedback to general practitioners (GPs). The pilot-RCT has shown that personalized prescription feedback is a feasible and promising low-cost intervention to reduce antibiotic prescribing. Here, we describe the rationale and design of the follow-up RCT with 3426 GPs in Switzerland. We now have access to pseudonymized patient-level data from routinely collected health insurance data of the three largest health insurers in Switzerland. METHODS AND ANALYSIS 1713 GPs randomized to the intervention group received once evidence-based treatment guidelines at the beginning, including region-specific antibiotic resistance information from the community and personalized feedback of their antibiotic prescribing, followed by quarterly personalized prescription feedback for two years. The first and the last mailings were sent out in December 2017 and September 2019, respectively. The 1713 GPs randomized to the control group were not notified about the study and they received no guidelines and no prescription feedback. The personalized prescription feedbacks and the analyses of the primary and secondary outcomes are entirely based on pseudonymized patient-level data from routinely collected health insurance data. The primary outcome is prescribed antibiotics per 100 patient consultations during the second year of intervention. The secondary outcomes include antibiotic use during the entire two-year trial period, use of broad-spectrum antibiotics, hospitalization rates (all-cause and infection-related), and antibiotic use in different age groups. If the feedback intervention proves to be efficacious, the intervention could be continued systemwide. ETHICS AND DISSEMINATION The trial is publicly funded by the Swiss National Science Foundation (SNSF, grant number 407240_167066). The trial was approved by the ethics committee "Ethikkommission Nordwest-und Zentralschweiz" (EKNZ Project-ID 2017-00888). Results will be disseminated in peer-reviewed journals and international conferences.
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Key Words
- Antibiotics
- Antimicrobial resistance
- CI, confidence interval
- CONSORT, consolidated standards of reporting trials
- Claims
- DRG, Diagnosis Related Groups
- EKNZ, Ethikkommission Nordwest-und Zentralschweiz
- FMH, Foederatio Medicorum Helveticorum
- GP, general practitioners
- HRA, Human Research Act
- HRO, Human Research Ordinance
- Health-system level
- Hospitalization
- Low-cost intervention
- Prescription feedback
- Primary care
- RCT, randomized controlled trials
- Routinely collected patient data
- ZSR, Zentralregisternummer
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Affiliation(s)
- Dominik Glinz
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Kimberly A. Mc Cord
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Giusi Moffa
- Department of Mathematics and Computer Science, University of Basel, Basel, Switzerland
| | - Soheila Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ramon Saccilotto
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Andreas F. Widmer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Julia Bielicki
- Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Switzerland
- St. George's University London, London, UK
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
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Borek AJ, Campbell A, Dent E, Butler CC, Holmes A, Moore M, Walker AS, McLeod M, Tonkin-Crine S. Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices. BMC FAMILY PRACTICE 2021; 22:25. [PMID: 33485324 PMCID: PMC7825381 DOI: 10.1186/s12875-021-01371-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/09/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Trials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use. METHODS This was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically. RESULTS Nine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience - participants viewed the strategies as having limited value as 'clinical tools', perceiving them as useful only in 'rare' instances of clinical uncertainty and/or for those less experienced. Strategies as 'social tools' - participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities - participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context - various other situational and practical issues were raised with implementing the strategies. CONCLUSIONS High-prescribing practices do not view DPs and POC-CRPT as sufficiently useful 'clinical tools' in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as 'social tools' to reduce unnecessary antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Anne Campbell
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Elle Dent
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Alison Holmes
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - A Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Monsey McLeod
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK.,NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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van Bodegraven B, Palin V, Mistry C, Sperrin M, White A, Welfare W, Ashcroft DM, van Staa TP. Infection-related complications after common infection in association with new antibiotic prescribing in primary care: retrospective cohort study using linked electronic health records. BMJ Open 2021; 11:e041218. [PMID: 33452190 PMCID: PMC7813359 DOI: 10.1136/bmjopen-2020-041218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Determine the association of incident antibiotic prescribing levels for common infections with infection-related complications and hospitalisations by comparing high with low prescribing general practitioner practices. DESIGN RETROSPECTIVE COHORT STUDY Retrospective cohort study. DATA SOURCE UK primary care records from the Clinical Practice Research Datalink (CPRD GOLD) and SAIL Databank (SAIL) linked with Hospital Episode Statistics (HES) data, including 546 CPRD, 346 CPRD-HES and 338 SAIL-HES practices. EXPOSURES Initial general practice visit for one of six common infections and the proportion of antibiotic prescribing in each practice. MAIN OUTCOME MEASURES Incidence of infection-related complications (as recorded in general practice) or infection-related hospital admission within 30 days after consultation for a common infection. RESULTS A practice with 10.4% higher antibiotic prescribing (the IQR) was associated with a 5.7% lower rate of infection-related hospital admissions (adjusted analysis, 95% CI 3.3% to 8.0%). The association varied by infection with larger associations in hospital admissions with lower respiratory tract infection (16.1%; 95% CI 12.4% to 19.7%) and urinary tract infection (14.7%; 95% CI 7.6% to 21.1%) and smaller association in hospital admissions for upper respiratory tract infection (6.5%; 95% CI 3.5% to 9.5%) The association of antibiotic prescribing levels and hospital admission was largest in patients aged 18-39 years (8.6%; 95% CI 4.0% to 13.0%) and smallest in the elderly aged 75+ years (0.3%; 95% CI -3.4% to 3.9%). CONCLUSIONS There is an association between lower levels of practice level antibiotic prescribing and higher infection-related hospital admissions. Indiscriminately reducing antibiotic prescribing may lead to harm. Greater focus is needed to optimise antibiotic use by reducing inappropriate antibiotic prescribing and better targeting antibiotics to patients at high risk of infection-related complications.
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Affiliation(s)
- Birgitta van Bodegraven
- Health e-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Victoria Palin
- Health e-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Chirag Mistry
- Health e-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Matthew Sperrin
- Health e-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Andrew White
- NHS Greater Manchester Shared Service, Oldham, UK
| | | | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
| | - Tjeerd Pieter van Staa
- Health e-Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
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Khoshgoftar M, Zamani-Alavijeh F, Kasaian N, Shahzamani K, Rostami S, Nakhodian Z, Pirzadeh A. The effect of public health educational campaign regarding antibiotic use and microbial resistance on knowledge, attitude, and practice in the Iran. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2021; 10:3. [PMID: 33688512 PMCID: PMC7933621 DOI: 10.4103/jehp.jehp_629_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 06/27/2020] [Indexed: 05/03/2023]
Abstract
INTRODUCTION The aim of the present study was to show the effect of public health educational campaign regarding antibiotic use and microbial resistance on knowledge, attitude, and practice of people in Isfahan. MATERIALS AND METHODS This quasi-experimental study was conducted in October 2019 on the public population in Isfahan (a city in the center of Iran). Simple random sampling was done in ten urban areas.). A total of 708 people participated in the study. For assessing the knowledge, attitude, and practice a related researchers-made questionnaire was used in the present study. Finally, data were entered into SPSS (20) and analytical statistics including paired t-test were used. The statistical significance level was considered <0.05. RESULTS The majority of participants in this study were female 434 (61.9%) and the rest of them were male. The mean ± standard deviation of age was 31.68 (11.11), range of 11-67. More than 50 present of participants had a Bachelor's degree (37.7%) and diploma (27.7%). Most individuals were self-employed 277 (43.1%). About the type of marriage, 54.89% were single and others were married. Results showed that the mean of knowledge and attitude was increased after the intervention (P < 0.05). CONCLUSION Increase knowledge between people, adherence to treatment and minimizes healthcare costs, however, "antibiotics are misused so often because of the belief that these are benign drugs. In the absence of urgent corrective and protective actions, the world is heading towards a postantibiotic era, in which many common infections will no longer have a cure and once again, kill unabated.
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Affiliation(s)
- Mohadeseh Khoshgoftar
- Department of Health Education and Health Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fereshteh Zamani-Alavijeh
- Department of Health Education and Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nazila Kasaian
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Kiana Shahzamani
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Soodabeh Rostami
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zari Nakhodian
- Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Asiyeh Pirzadeh
- Department of Health Education and Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
- Address for correspondence: Dr. Asiyeh Pirzadeh, Department of Health Education and Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail:
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Poß-Doering R, Kuehn L, Kamradt M, Glassen K, Fleischhauer T, Kaufmann-Kolle P, Koeppen M, Wollny A, Altiner A, Wensing M. Converting habits of antibiotic use for respiratory tract infections in German primary care (CHANGE-3) - process evaluation of a complex intervention. BMC FAMILY PRACTICE 2020; 21:274. [PMID: 33341114 PMCID: PMC7749701 DOI: 10.1186/s12875-020-01351-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 12/08/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study "Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)" aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components. METHODS A mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data. RESULTS Uptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use. CONCLUSIONS The process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population. TRIAL REGISTRATION ISRCTN, ISRCTN15061174 . Registered 13 July 2018 - Retrospectively registered.
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Affiliation(s)
- R. Poß-Doering
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - L. Kuehn
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - M. Kamradt
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - K. Glassen
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Th. Fleischhauer
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | | | - M. Koeppen
- aQua Institut, Maschmuehlenweg 8-10, 37073 Goettingen, Germany
| | - A. Wollny
- University Medical Center Rostock, Institute of General Practice, Doberaner Str. 142, 18057 Rostock, Germany
| | - A. Altiner
- University Medical Center Rostock, Institute of General Practice, Doberaner Str. 142, 18057 Rostock, Germany
| | - M. Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
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Borek AJ, Wanat M, Atkins L, Sallis A, Ashiru-Oredope D, Beech E, Butler CC, Chadborn T, Hopkins S, Jones L, McNulty CAM, Roberts N, Shaw K, Taborn E, Tonkin-Crine S. Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies. BMJ Open 2020; 10:e039284. [PMID: 33334829 PMCID: PMC7747536 DOI: 10.1136/bmjopen-2020-039284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 10/29/2020] [Accepted: 11/20/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE While various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions. SETTINGS English primary care. INTERVENTIONS AMS interventions targeting healthcare professionals' antibiotic prescribing for respiratory tract infections. METHODS We conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing. RESULTS We identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: 'beliefs about consequences', 'social influences', 'skills', 'environmental context and resources', 'intentions' and 'emotions'. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%-67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none. CONCLUSIONS Further improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, 'forming/reversing habits', 'reducing negative emotions', 'social support'). These could be incorporated into existing, or developed as new, AMS interventions.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Louise Atkins
- Centre for Behaviour Change, University College London, London, UK
| | - Anna Sallis
- Behavioural Insights, Public Health England, London, UK
| | - Diane Ashiru-Oredope
- Antimicrobial Resistance and Stewardship and Healthcare Associated Infections (HCAI), Public Health England, London, UK
| | | | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Tim Chadborn
- Behavioural Insights, Public Health England, London, UK
| | - Susan Hopkins
- Antimicrobial Resistance and Stewardship and Healthcare Associated Infections (HCAI), Public Health England, London, UK
| | - Leah Jones
- Primary Care and Interventions Unit, Public Health England, Gloucester, UK
| | | | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Karen Shaw
- Antimicrobial Resistance and Stewardship and Healthcare Associated Infections (HCAI), Public Health England, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Esther Taborn
- NHS England and NHS Improvement, London, UK
- NHS East Kent Clinical Commissioning Groups, Canterbury, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
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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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Mowbray F, Sivyer K, Santillo M, Jones N, Peto TEA, Walker AS, Llewelyn MJ, Yardley L. Patient engagement with antibiotic messaging in secondary care: a qualitative feasibility study of the ‘review and revise’ experience. Pilot Feasibility Stud 2020; 6:43. [PMID: 32280483 PMCID: PMC7126355 DOI: 10.1186/s40814-020-00590-5] [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: 06/18/2019] [Accepted: 03/24/2020] [Indexed: 01/22/2023] Open
Abstract
Abstract
Background
We aimed to investigate and optimise the acceptability and usefulness of a patient leaflet about antibiotic prescribing decisions made during hospitalisation, and to explore individual patient experiences and preferences regarding the process of antibiotic prescription ‘review and revise’ which is a key strategy to minimise antibiotic overuse in hospitals.
Methods
In this qualitative study, run within the feasibility study of a large, cluster-randomised stepped wedge trial of 36 hospital organisations, a series of semi-structured, think-aloud telephone interviews were conducted and data were analysed using thematic analysis. Fifteen adult patients who had experienced a recent acute medical hospital admission during which they had been prescribed antimicrobials and offered a patient leaflet about antibiotic prescribing were recruited to the study.
Results
Participants reacted positively to the leaflet, reporting that it was both an accessible and important source of information which struck the appropriate balance between informing and reassuring. Participants all valued open communication with clinicians, and were keen to be involved in antibiotic prescribing decisions, with individuals reporting positive experiences regarding antibiotic prescription changes or stopping. Many participants had prior experience or knowledge of antibiotics and resistance, and generally welcomed efforts to reduce antibiotic usage. Overall, there was a feeling that healthcare professionals (HCPs) are trusted experts providing the most appropriate treatment for individual patient conditions.
Conclusions
This study offers novel insights into how patients within secondary care are likely to respond to messages advocating a reduction in the use of antibiotics through the ‘review and revise’ approach. Due to the level of trust that patients place in their care provider, encouraging HCPs within secondary care to engage patients with greater communication and information provision could provide great advantages in the drive to reduce antibiotic use. It may also be beneficial for HCPs to view patient experiences as cumulative events that have the potential to impact future behaviour around antibiotic use. Finally, pre-testing messages about antibiotic prescribing and resistance is vital to dispelling any misconceptions either around effectiveness of treatment for patients, or perceptions of how messages may be received.
Trial registration
Current Controlled Trials ISRCTN12674243 (10 April 2017),
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Poss-Doering R, Kuehn L, Kamradt M, Glassen K, Wensing M. Applying Digital Information Delivery to Convert Habits of Antibiotic Use in Primary Care in Germany: Mixed-Methods Study. J Med Internet Res 2020; 22:e18200. [PMID: 32960773 PMCID: PMC7578814 DOI: 10.2196/18200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/29/2020] [Accepted: 08/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Antimicrobial resistance is an important global health issue. In Germany, the national agenda supports various interventions to convert habits of antibiotic use. In the CHANGE-3 (Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care) study, digital tools were applied for information delivery: tablet computers in primary care practices, e-learning platforms for medical professionals, and a public website to promote awareness and health literacy among primary care physicians, their teams, and their patients. OBJECTIVE This study is embedded in the process evaluation of the CHANGE-3 study. The aim of this study was to evaluate the acceptance and uptake of digital devices for the delivery of health-related information to enhance awareness and change habits of antibiotic use in primary care in Germany. METHODS This study used a convergent-parallel mixed-methods design. Audio-recorded semistructured telephone interviews were conducted with physicians, nonphysician health professionals, and patients in the CHANGE-3 program. Pseudonymized verbatim transcripts were coded using thematic analysis. In-depth analysis was performed based on the inductive category of information provision via digital information tools. Identified themes were related to the main postulates of Diffusion of Innovations theory (DIT) to provide an explanatory frame. In addition, data generated through a structured survey with physicians and nonphysician health professionals in the program were analyzed descriptively and integrated with the qualitative data to explore the complementarity of the findings. RESULTS Findings regarding the acceptance and uptake of digital devices were related to three postulates of DIT: innovation characteristics, communication channels, and unanticipated consequences. Participants considered the provided digital educative solutions to be supportive for promoting health literacy regarding conversion of habits of antibiotic use. However, health care professionals found it challenging to integrate these solutions into existing routines in primary care and to align them with their professional values. Low technology affinity was a major barrier to the use of digital information in primary care. Patients welcomed the general idea of introducing health-related information in digital formats; however, they expressed concerns about device-related hygiene and the appropriateness of the digital tools for older patients. CONCLUSIONS Patients and medical professionals in German primary care are reluctant to use digital devices for information and education. Using a Diffusion of Innovations approach can support assessment of existing barriers and provide information about setting-specific preconditions that are necessary for future tailoring of implementation strategies. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number (ISRCTN) 15061174; http://www.isrctn.com/ISRCTN15061174.
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Affiliation(s)
- Regina Poss-Doering
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Lukas Kuehn
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Martina Kamradt
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Katharina Glassen
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
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Cotterill S, Tang MY, Powell R, Howarth E, McGowan L, Roberts J, Brown B, Rhodes S. Social norms interventions to change clinical behaviour in health workers: a systematic review and meta-analysis. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background
A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. These low-cost interventions can be used to encourage health workers to follow recommended professional practice.
Objective
To summarise evidence on whether or not social norms interventions are effective in encouraging health worker behaviour change, and to identify the most effective social norms interventions.
Design
A systematic review and meta-analysis of randomised controlled trials.
Data sources
The following databases were searched on 24 July 2018: Ovid MEDLINE (1946 to week 2 July 2018), EMBASE (1974 to 3 July 2018), Cumulative Index to Nursing and Allied Health Literature (1937 to July 2018), British Nursing Index (2008 to July 2018), ISI Web of Science (1900 to present), PsycINFO (1806 to week 3 July 2018) and Cochrane trials (up to July 2018).
Participants
Health workers took part in the study.
Interventions
Behaviour change interventions based on social norms.
Outcome measures
Health worker clinical behaviour, for example prescribing (primary outcome), and patient health outcomes, for example blood test results (secondary), converted into a standardised mean difference.
Methods
Titles and abstracts were reviewed against the inclusion criteria to exclude any that were clearly ineligible. Two reviewers independently screened the remaining full texts to identify relevant papers. Two reviewers extracted data independently, coded for behaviour change techniques and assessed quality using the Cochrane risk-of-bias tool. We performed a meta-analysis and presented forest plots, stratified by behaviour change technique. Sources of variation were explored using metaregression and network meta-analysis.
Results
A total of 4428 abstracts were screened, 477 full texts were screened and findings were based on 106 studies. Most studies were in primary care or hospitals, targeting prescribing, ordering of tests and communication with patients. The interventions included social comparison (in which information is given on how peers behave) and credible source (which refers to communication from a well-respected person in support of the behaviour). Combined data suggested that interventions that included social norms components were associated with an improvement in health worker behaviour of 0.08 standardised mean differences (95% confidence interval 0.07 to 0.10 standardised mean differences) (n = 100 comparisons), and an improvement in patient outcomes of 0.17 standardised mean differences (95% confidence interval 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I
2 of 85.4% (primary) and 91.5% (secondary). Network meta-analysis suggested that three types of social norms intervention were most effective, on average, compared with control: credible source (0.30 standardised mean differences, 95% confidence interval 0.13 to 0.47); social comparison combined with social reward (0.39 standardised mean differences, 95% confidence interval 0.15 to 0.64); and social comparison combined with prompts and cues (0.33 standardised mean differences, 95% confidence interval 0.22 to 0.44).
Limitations
The large number of studies prevented us from requesting additional information from authors. The trials varied in design, context and setting, and we combined different types of outcome to provide an overall summary of evidence, resulting in a very heterogeneous review.
Conclusions
Social norms interventions are an effective method of changing clinical behaviour in a variety of health service contexts. Although the overall result was modest and very variable, there is the potential for social norms interventions to be scaled up to target the behaviour of a large population of health workers and resulting patient outcomes.
Future work
Development of optimised credible source and social comparison behaviour change interventions, including qualitative research on acceptability and feasibility.
Study registration
This study is registered as PROSPERO CRD42016045718.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 41. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sarah Cotterill
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Mei Yee Tang
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Rachael Powell
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Elizabeth Howarth
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Laura McGowan
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jane Roberts
- Outreach and Evidence Search Service, Library and E-learning Service, Northern Care Alliance, NHS Group, Royal Oldham Hospital, Oldham, UK
| | - Benjamin Brown
- Health e-Research Centre, Farr Institute for Health Informatics Research, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Centre for Primary Care, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Rhodes
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Improving pain management in childhood acute otitis media in general practice: a cluster randomised controlled trial of a GP-targeted educational intervention. Br J Gen Pract 2020; 70:e684-e695. [PMID: 32839161 PMCID: PMC7449377 DOI: 10.3399/bjgp20x712589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background Pain management in acute otitis media (AOM) is often suboptimal, potentially leading to unnecessary discomfort, GP reconsultation, and antibiotic prescribing. Aim To assess the effectiveness of a GP-targeted educational intervention to improve pain management in children with AOM. Design and setting Pragmatic, cluster randomised controlled trial (RCT). GPs in 37 practices (intervention n = 19; control n = 18) across the Netherlands recruited 224 children with GP-confirmed AOM and ear pain (intervention n = 94; control n = 130) between February 2015 and May 2018. Method GPs in practices allocated to the intervention group were trained (online and face-to-face) to discuss pain management with parents using an information leaflet, and prompted to prescribe weight-appropriate dosed paracetamol. Ibuprofen was additionally prescribed if pain control was still insufficient. GPs in the control group provided usual care. Results Mean ear pain scores over the first 3 days were similar between groups (4.66 versus 4.36; adjusted mean difference = −0.05; 95% confidence intervals [CI] = −0.93 to 0.83), whereas analgesic use, in particular ibuprofen, was higher in the intervention group. The total number of antibiotic prescriptions during the 28-day follow-up was similar (mean rate 0.43 versus 0.47; adjusted rate ratio [aRR] 0.97; 95% CI = 0.68 to 1.38). Parents of children in the intervention group were more likely to reconsult for AOM-related complaints (mean rate 0.70 versus 0.41; aRR 1.73; 95% CI = 1.14 to 2.62). Conclusion An intervention aimed at improving pain management for AOM increases analgesic use, particularly ibuprofen, but does not provide symptomatic benefit. GPs are advised to carefully weigh the potential benefits of ibuprofen against its possible harms.
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Santillo M, Sivyer K, Krusche A, Mowbray F, Jones N, Peto TEA, Walker AS, Llewelyn MJ, Yardley L. Intervention planning for Antibiotic Review Kit (ARK): a digital and behavioural intervention to safely review and reduce antibiotic prescriptions in acute and general medicine. J Antimicrob Chemother 2020; 74:3362-3370. [PMID: 31430366 PMCID: PMC6798845 DOI: 10.1093/jac/dkz333] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/07/2019] [Accepted: 07/07/2019] [Indexed: 12/11/2022] Open
Abstract
Background Hospital antimicrobial stewardship strategies, such as ‘Start Smart, Then Focus’ in the UK, balance the need for prompt, effective antibiotic treatment with the need to limit antibiotic overuse using ‘review and revise’. However, only a minority of review decisions are to stop antibiotics. Research suggests that this is due to both behavioural and organizational factors. Objectives To develop and optimize the Antibiotic Review Kit (ARK) intervention. ARK is a complex digital, organizational and behavioural intervention that supports implementation of ‘review and revise’ to help healthcare professionals safely stop unnecessary antibiotics. Methods A theory-, evidence- and person-based approach was used to develop and optimize ARK and its implementation. This was done through iterative stakeholder consultation and in-depth qualitative research with doctors, nurses and pharmacists in UK hospitals. Barriers to and facilitators of the intervention and its implementation, and ways to address them, were identified and then used to inform the intervention’s development. Results A key barrier to stopping antibiotics was reportedly a lack of information about the original prescriber’s rationale for and their degree of certainty about the need for antibiotics. An integral component of ARK was the development and optimization of a Decision Aid and its implementation to increase transparency around initial prescribing decisions. Conclusions The key output of this research is a digital and behavioural intervention targeting important barriers to stopping antibiotics at review (see http://bsac-vle.com/ark-the-antibiotic-review-kit/ and http://antibioticreviewkit.org.uk/). ARK will be evaluated in a feasibility study and, if successful, a stepped-wedge cluster-randomized controlled trial at acute hospitals across the NHS.
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Affiliation(s)
- M Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - K Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - A Krusche
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - F Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - N Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - T E A Peto
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,NIHR Biomedical Centre, Oxford, UK
| | - A S Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,NIHR Biomedical Centre, Oxford, UK
| | - M J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - L Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Bristol, UK
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