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Hartman EAR, van de Pol AC, Heltveit-Olsen SR, Lindbæk M, Høye S, Lithén SS, Sundvall PD, Sundvall S, Arnljots ES, Gunnarsson R, Kowalczyk A, Godycki-Cwirko M, Platteel TN, Groen WG, Monnier AA, Zuithoff NP, Verheij TJM, Hertogh CMPM. Effect of a multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for suspected urinary tract infections in frail older adults (ImpresU): pragmatic cluster randomised controlled trial in four European countries. BMJ 2023; 380:e072319. [PMID: 36813284 PMCID: PMC9943914 DOI: 10.1136/bmj-2022-072319] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To evaluate whether antibiotic prescribing for suspected urinary tract infections in frail older adults can be reduced through a multifaceted antibiotic stewardship intervention. DESIGN Pragmatic, parallel, cluster randomised controlled trial, with a five month baseline period and a seven month follow-up period. SETTING 38 clusters consisting of one or more general practices (n=43) and older adult care organisations (n=43) in Poland, the Netherlands, Norway, and Sweden, from September 2019 to June 2021. PARTICIPANTS 1041 frail older adults aged 70 or older (Poland 325, the Netherlands 233, Norway 276, Sweden 207), contributing 411 person years to the follow-up period. INTERVENTION Healthcare professionals received a multifaceted antibiotic stewardship intervention consisting of a decision tool for appropriate antibiotic use, supported by a toolbox with educational materials. A participatory-action-research approach was used for implementation, with sessions for education, evaluation, and local tailoring of the intervention. The control group provided care as usual. MAIN OUTCOME MEASURES The primary outcome was the number of antibiotic prescriptions for suspected urinary tract infections per person year. Secondary outcomes included the incidence of complications, all cause hospital referrals, all cause hospital admissions, all cause mortality within 21 days after suspected urinary tract infections, and all cause mortality. RESULTS The numbers of antibiotic prescriptions for suspected urinary tract infections in the follow-up period were 54 prescriptions in 202 person years (0.27 per person year) in the intervention group and 121 prescriptions in 209 person years (0.58 per person year) in the usual care group. Participants in the intervention group had a lower rate of receiving an antibiotic prescription for a suspected urinary tract infection compared with participants in the usual care group, with a rate ratio of 0.42 (95% confidence interval 0.26 to 0.68). No differences between intervention and control group were observed in the incidence of complications (<0.01 v 0.05 per person year), hospital referrals (<0.01 v 0.05), admissions to hospital (0.01 v 0.05), and mortality (0 v 0.01) within 21 days after suspected urinary tract infections, nor in all cause mortality (0.26 v 0.26). CONCLUSIONS Implementation of a multifaceted antibiotic stewardship intervention safely reduced antibiotic prescribing for suspected urinary tract infections in frail older adults. TRIAL REGISTRATION ClinicalTrials.gov NCT03970356.
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Affiliation(s)
- Esther A R Hartman
- Department of Medicine for Older People, Amsterdam UMC, Vrije University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Silje Rebekka Heltveit-Olsen
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbæk
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sigurd Høye
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sara Sofia Lithén
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
| | - Sofia Sundvall
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
| | - Egill Snaebjörnsson Arnljots
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
| | - Ronny Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Borås, Sweden
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, the Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, the Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Tamara N Platteel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Wim G Groen
- Department of Medicine for Older People, Amsterdam UMC, Vrije University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, Netherlands
| | - Annelie A Monnier
- Department of Medicine for Older People, Amsterdam UMC, Vrije University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, Netherlands
| | - Nicolaas P Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam UMC, Vrije University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, Netherlands
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Colliers A, Philips H, Bombeke K, Remmen R, Coenen S, Anthierens S. Safety netting advice for respiratory tract infections in out-of-hours primary care: A qualitative analysis of consultation videos. Eur J Gen Pract 2022; 28:87-94. [PMID: 35535690 PMCID: PMC9103350 DOI: 10.1080/13814788.2022.2064448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND General practitioners (GPs) use safety netting advice to communicate with patients when and how to seek further help when their condition fails to improve or deteriorate. Although many respiratory tract infections (RTI) during out-of-hours (OOH) care are self-limiting, often antibiotics are prescribed. Providing safety netting advice could enable GPs to safely withhold an antibiotic prescription by dealing both with their uncertainty and the patients' concerns. OBJECTIVES To explore how GPs use safety netting advice during consultations on RTIs in OOH primary care and how this advice is documented in the electronic health record. METHODS We analysed video observations of 77 consultations on RTIs from 19 GPs during OOH care using qualitative framework analysis and reviewed the medical records. Videos were collected from August until November 2018 at the Antwerp city GP cooperative, Belgium. RESULTS Safety netting advice on alarm symptoms, expected duration of illness and/or how and when to seek help is often lacking or vague. Communication of safety netting elements is scattered throughout the end phase of the consultation. The advice is seldom recorded in the medical health record. GPs give more safety netting advice when prescribing an antibiotic than when they do not prescribe an antibiotic. CONCLUSION We provided a better understanding of how safety netting is currently carried out in OOH primary care for RTIs. Safety netting advice during OOH primary care is limited, unspecific and not documented in the medical record.
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Affiliation(s)
- Annelies Colliers
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Hilde Philips
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | | | - Roy Remmen
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO) – Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
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Colliers A, Bombeke K, Philips H, Remmen R, Coenen S, Anthierens S. Antibiotic Prescribing and Doctor-Patient Communication During Consultations for Respiratory Tract Infections: A Video Observation Study in Out-of-Hours Primary Care. Front Med (Lausanne) 2021; 8:735276. [PMID: 34926492 PMCID: PMC8671733 DOI: 10.3389/fmed.2021.735276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: Communication skills can reduce inappropriate antibiotic prescribing, which could help to tackle antibiotic resistance. General practitioners often overestimate patient expectations for an antibiotic. In this study, we describe how general practitioners and patients with respiratory tract infections (RTI) communicate about their problem, including the reason for encounter and ideas, concerns, and expectations (ICE), and how this relates to (non-)antibiotic prescribing in out-of-hours (OOH) primary care. Methods: A qualitative descriptive framework analysis of video-recorded consultations during OOH primary care focusing on doctor-patient communication. Results: We analyzed 77 videos from 19 general practitioners. General practitioners using patient-centered communication skills received more information on the perspective of the patients on the illness period. For some patients, the reason for the encounter was motivated by their belief that a general practitioner (GP) visit will alter the course of their illness. The ideas, concerns, and expectations often remained implicit, but the concerns were expressed by the choice of words, tone of voice, repetition of words, etc. Delayed prescribing was sometimes used to respond to implicit patient expectations for an antibiotic. Patients accepted a non-antibiotic management plan well. Conclusion: Not addressing the ICE of patients, or their reason to consult the GP OOH, could drive assumptions about patient expectations for antibiotics early on and antibiotic prescribing later in the consultation.
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Affiliation(s)
- Annelies Colliers
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | | | - Hilde Philips
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Roy Remmen
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium.,Vaccine and Infectious Disease Institute (VAXINFECTIO)-Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
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Russell G, Advocat J, Lane R, Neil J, Staunton-Smith T, Alexander KE, Hattle S, Crabtree BF, Miller WL, Setunge SN, Sturgiss EA. How do general practices respond to a pandemic? Protocol for a prospective qualitative study of six Australian practices. BMJ Open 2021; 11:e046086. [PMID: 34521660 PMCID: PMC8441220 DOI: 10.1136/bmjopen-2020-046086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic has transformed healthcare systems worldwide. Primary care providers have been at the forefront of the pandemic response and have needed to rapidly adjust processes and routines around service delivery. The pandemic provides a unique opportunity to understand how general practices prepare for and respond to public health emergencies. We will follow a range of general practices to characterise the changes to, and factors influencing, modifications to clinical and organisational routines within Australian general practices amidst the COVID-19 pandemic. METHODS AND ANALYSIS This is a prospective case study of multiple general practices using a participatory approach for design, data collection and analysis. The study is informed by the sociological concept of routines and will be set in six general practices in Melbourne, Australia during the 2020-2021 COVID-19 pandemic. General practitioners associated with the Monash University Department of General Practice will act as investigators who will shape the project and contribute to the data collection and analysis. The data will include investigator diaries, an observation template and interviews with practice staff and investigators. Data will first be analysed by two external researchers using a constant comparative approach and then later refined at regular investigator meetings. Cross-case analysis will explain the implementation, uptake and sustainability of routine changes that followed the commencement of the pandemic. ETHICS AND DISSEMINATION Ethics approval was granted by Monash University (23950) Human Research Ethics Committees. Practice reports will be made available to all participating practices both during the data analysis process and at the end of the study. Further dissemination will occur via publications and presentations to practice staff and medical practitioners.
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Affiliation(s)
- Grant Russell
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jenny Advocat
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Riki Lane
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Jennifer Neil
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Timothy Staunton-Smith
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Karyn E Alexander
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Altona North Medical Group, Altona North, Victoria, Australia
| | - Simon Hattle
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - William L Miller
- Department of Family Medicine, Leigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Sumudu Neilya Setunge
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Elizabeth Ann Sturgiss
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
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Arieti F, Göpel S, Sibani M, Carrara E, Pezzani MD, Murri R, Mutters NT, Lòpez-Cerero L, Voss A, Cauda R, Tacconelli E. White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in the outpatient sector-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks. J Antimicrob Chemother 2021; 75:ii42-ii51. [PMID: 33280045 PMCID: PMC7719405 DOI: 10.1093/jac/dkaa428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background The outpatient setting is a key scenario for the implementation of antimicrobial stewardship (AMS) activities, considering that overconsumption of antibiotics occurs mainly outside hospitals. This publication is the result of a joint initiative by the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks, which is aimed at formulating a set of target actions for linking surveillance data with AMS activities in the outpatient setting. Methods A scoping review of the literature was carried out in three research areas: AMS leadership and accountability; antimicrobial usage and AMS; antimicrobial resistance and AMS. Consensus on the actions was reached through a RAND-modified Delphi process involving over 40 experts in infectious diseases, clinical microbiology, AMS, veterinary medicine or public health, from 18 low-, middle- and high-income countries. Results Evidence was retrieved from 38 documents, and an initial 25 target actions were proposed, differentiating between essential or desirable targets according to clinical relevance, feasibility and applicability to settings and resources. In the first consultation round, preliminary agreement was reached for all targets. Further to a second review, 6 statements were re-considered and 3 were deleted, leading to a final list of 22 target actions in the form of a practical checklist. Conclusions This White Paper is a pragmatic and flexible tool to guide the development of calibrated surveillance-based AMS interventions specific to the outpatient setting, which is characterized by substantial inter- and intra-country variability in the organization of healthcare structures, maintaining a global perspective and taking into account the feasibility of the target actions in low-resource settings.
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Affiliation(s)
- Fabiana Arieti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Siri Göpel
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany.,German Centre for Infection Research (DZIF), Clinical Research Unit for healthcare associated infections, Tübingen, Germany
| | - Marcella Sibani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Rita Murri
- Institute of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Universitá Cattolica del Sacro Cuore, Rome, Italy
| | - Nico T Mutters
- Institute of Hygiene and Public Health, Bonn University Hospital, Bonn, Germany
| | - Lorena Lòpez-Cerero
- Microbiology and Infectious Diseases Unit, University Hospital Virgen Macarena, Sevilla, Spain
| | - Andreas Voss
- Department of Clinical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Roberto Cauda
- Institute of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Universitá Cattolica del Sacro Cuore, Rome, Italy
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.,Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany.,German Centre for Infection Research (DZIF), Clinical Research Unit for healthcare associated infections, Tübingen, Germany
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Kurotschka PK, Serafini A, Massari M, Da Cas R, Figueiras A, Forte V, Moro MF, Massidda M, Contu F, Minerba L, Marcias M, Nardelli M, Perra A, Carta MG, Spila Alegiani S. Broad Spectrum project: factors determining the quality of antibiotic use in primary care: an observational study protocol from Italy. BMJ Open 2020; 10:e038843. [PMID: 32636291 PMCID: PMC7342852 DOI: 10.1136/bmjopen-2020-038843] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The overuse of antibiotics is causing worldwide spread of antimicrobial resistance (AMR). Compared with other countries, Italy has both high antibiotic consumption rates and high rates of AMR. Due to the fact that around 90% of antibiotics are prescribed by general practitioners (GPs), this study aims to measure the impact of knowledge, attitudes and sociodemographic and workplace-related factors on the quality of antibiotic prescriptions filled by GPs in the Italian Region of Sardinia. METHODS AND ANALYSIS Knowledge, attitude, sociodemographic and workplace-related factors deemed to influence physicians prescribing behaviour will be evaluated in a cross-sectional study conducted among all GPs of the Italian Region of Sardinia (n=1200). A knowledge and attitudes questionnaire (Knowledge and Attitudes on Antibiotics and Resistance - Italian version: ITA-KAAR) accompanied by a sociodemographic form will be linked to drug prescription data reimbursed by the National Health System. European Surveillance of Antibiotic Consumption quality indicators for outpatient antibiotic use will be calculated from drug prescription records. Every GP will be deemed to have demonstrated an adequate quality of prescriptions of antibiotics if half of the indicator score plus one is better than the median of the region. A multivariate Poisson regression model with robust variance estimation will be used to evaluate the impact of the determinants of antibiotic prescriptions on the actual prescribing quality of each physician. ETHICS AND DISSEMINATION The project has been approved by the ethics committee of the Regional Health Trust of Sardinia (176/2019/CE, 24 September 2019). The results will be useful to inform evidence-based interventions to tackle irrational antibiotic use in the community.
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Affiliation(s)
- Peter Konstantin Kurotschka
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
- General Practitioner in Training, Primary Care Department, Regional Health Trust of Sardinia, Cagliari, Italy
| | - Alice Serafini
- General Practitioner in Training, Primary Care Department, Local Health Trust Modena, Modena, Italy
| | - Marco Massari
- National Centre for Pre-Clinical and Clinical Drug Research and Surveillance (CNRVF), Istituto Superiore di Sanita, Rome, Italy
| | - Roberto Da Cas
- National Centre for Pre-Clinical and Clinical Drug Research and Surveillance (CNRVF), Istituto Superiore di Sanita, Rome, Italy
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, Universidade de Santiago de Compostela, Santiago de Compostela, Spain
| | - Viviana Forte
- General Practitioner, Primary Care Department, Regional Health Trust, Cagliari, Italy
| | | | - Matteo Massidda
- General Practitioner in Training, Primary Care Department, Regional Health Trust of Sardinia, Cagliari, Italy
| | - Federico Contu
- General Practitioner in Training, Primary Care Department, Regional Health Trust of Sardinia, Cagliari, Italy
| | - Luigi Minerba
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Maurizio Marcias
- Health Technology Assessment Unit, Regional Health Trust of Sardinia, Cagliari, Italy
| | - Marco Nardelli
- Brayford Square Surgery, Tower Hamlets Primary Care Trust, London, UK
| | - Alessandra Perra
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Mauro Giovanni Carta
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Stefania Spila Alegiani
- National Centre for Pre-Clinical and Clinical Drug Research and Surveillance (CNRVF), Istituto Superiore di Sanita, Rome, Italy
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Understanding General Practitioners' Antibiotic Prescribing Decisions in Out-of-Hours Primary Care: A Video-Elicitation Interview Study. Antibiotics (Basel) 2020; 9:antibiotics9030115. [PMID: 32156082 PMCID: PMC7148451 DOI: 10.3390/antibiotics9030115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 11/16/2022] Open
Abstract
Infections are the most common reason why patients consult out-of-hours (OOH) primary care. Too often there is an overprescribing of antibiotics for self-limiting infections and general practitioners (GPs) do not always choose the guideline recommended antibiotics. To improve antibiotic prescribing quality, a better understanding is needed of the (non) antibiotic prescribing decisions of GPs. This study sets out to unravel GPs’ (non) antibiotic prescribing decisions in OOH primary care. We video-recorded 160 consultations on infections during OOH primary care by 21 GPs and performed video-elicitation interviews with each GP. GPs reflected on their decision-making process and communication while watching their consultation. A qualitative thematic analysis was used. GPs found that their (non) antibiotic prescribing decision-making was not only based on objective arguments, but also subconsciously influenced by their own interpretation of information. Often GPs made assumptions (about for example the patients’ reason for encounter or expectations for antibiotics) without objectifying or verifying this with the patient. From the beginning of the consultation GPs follow a dichotomous thinking process: urgent versus not urgent, viral versus bacterial, antibiotics versus no antibiotics. Safety-netting is an important but difficult tool in the OOH care context, with no long-term follow-up or relationship with the patient. GPs talk about strategies they use to talk about diagnostic uncertainty, what patients can expect or should do when things do not improve and the difficulties they encounter while doing this. This video- elicitation interview study provides actionable insights in GPs’ (non) antibiotic prescribing decisions during OOH consultations on infections.
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Colliers A, Adriaenssens N, Anthierens S, Bartholomeeusen S, Philips H, Remmen R, Coenen S. Antibiotic Prescribing Quality in Out-of-Hours Primary Care and Critical Appraisal of Disease-Specific Quality Indicators. Antibiotics (Basel) 2019; 8:antibiotics8020079. [PMID: 31212871 PMCID: PMC6628021 DOI: 10.3390/antibiotics8020079] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/05/2019] [Accepted: 06/07/2019] [Indexed: 12/25/2022] Open
Abstract
Outpatient antibiotic use in Belgium is among the highest in Europe. The most common reason for an encounter in out-of-hours (OOH) primary care is an infection. In this study, we assessed all consultations from July 2016 to June 2018 at five OOH services. We described antibiotic prescribing by diagnosis, calculated disease-specific antibiotic prescribing quality indicators’ (APQI) values and critically appraised these APQI. We determined that 111,600 encounters resulted in 26,436 (23.7%) antibiotic prescriptions. The APQI diagnoses (i.e., bronchitis, upper respiratory infection, cystitis, tonsillitis, sinusitis, otitis media, and pneumonia) covered 14,927 (56.7%) antibiotic prescriptions. Erysipelas (1344 (5.1%)) and teeth/gum disease (982 (3.7%)) covered more prescriptions than sinusitis or pneumonia. Over 75% of patients with tonsillitis and over 50% with bronchitis, sinusitis, and otitis media were prescribed an antibiotic. Only for otitis media the choice of antibiotic was near the acceptable range. Over 10% of patients with bronchitis or pneumonia and over 25% of female patients with an acute cystitis received quinolones. The APQI cover the diagnoses for only 57% of all antibiotic prescriptions. As 5.1% and 3.7% of antibiotic prescriptions are made for erysipelas and teeth/gum disease, respectively, we propose to add these indications when assessing antibiotic prescribing quality in OOH primary care.
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Affiliation(s)
- Annelies Colliers
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Niels Adriaenssens
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Sibyl Anthierens
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Stephaan Bartholomeeusen
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Hilde Philips
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Roy Remmen
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Samuel Coenen
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
- Department of Epidemiology and Social Medicine (ESOC), University of Antwerp, Faculty of Medicine and Health Sciences, Universiteitsplein 1, B-2610 Antwerp, Belgium.
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Faculty of Medicine and Health Sciences, Universiteitsplein 1, B-2610 Antwerp, Belgium.
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9
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Colliers A, Coenen S, Remmen R, Philips H, Anthierens S. How do general practitioners and pharmacists experience antibiotic use in out-of-hours primary care? An exploratory qualitative interview study to inform a participatory action research project. BMJ Open 2018; 8:e023154. [PMID: 30269072 PMCID: PMC6169767 DOI: 10.1136/bmjopen-2018-023154] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
RATIONALE Antibiotics (ABs) are one of the most prescribed medications in out-of-hours (OOH) care in Belgium. Developing a better understanding of why ABs are prescribed in this setting is essential to improve prescribing habits. OBJECTIVES To assess AB prescribing and dispensing challenges for general practitioners (GPs) and pharmacists in OOH primary care, and to identify context-specific elements that can help the implementation of behaviour change interventions to improve AB prescribing in this setting. DESIGN This is an exploratory qualitative study using semistructured interviews. This study is part of a participatory action research project. SETTING AND PARTICIPANTS Participants include 17 GPs and 1 manager, who work in a Belgian OOH general practitioners cooperative (GPC), and 5 pharmacists of the area covered by the GPC. The GPC serves a population of more than 187 000 people. RESULTS GPs feel the threshold to prescribe AB in OOH care is lower in comparion to office hours. GPs and pharmacists talk about the difference in their professional identity in OOH (they define their task differently, they feel more isolated, insecure, have the need to please and so on), type of patients (unknown patients, vulnerable patients, other ethnicities, demanding patients and so on), workload (they feel time-pressured) and lack of diagnostic tools or follow-up. They are aware of the problem of AB overprescribing, but they do not feel ownership of the problem. CONCLUSION The implementation of behaviour change interventions to improve AB prescribing in OOH primary care has to take these context specifics into account and could involve interprofessional collaboration between GPs and pharmacists. TRIAL REGISTRATION NUMBER NCT03082521; Pre-results.
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Affiliation(s)
- Annelies Colliers
- Department of General Practice - Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Samuel Coenen
- Department of General Practice - Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Vaccine and Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Department of Epidemiology and Social Medicine (ESOC), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Roy Remmen
- Department of General Practice - Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Hilde Philips
- Department of General Practice - Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Sibyl Anthierens
- Department of General Practice - Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
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