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Christensen LD, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB, Huibers L. Point-of-care testing and antibiotics prescribing in out-of-hours general practice: a register-based study in Denmark. BMC PRIMARY CARE 2024; 25:31. [PMID: 38262975 PMCID: PMC10804570 DOI: 10.1186/s12875-024-02264-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND Point-of-care testing may reduce diagnostic uncertainty in case of suspicion of bacterial infection, thereby contributing to prudent antibiotic prescribing. We aimed to study variations in the use of point-of-care tests (C-reactive protein test, rapid streptococcal antigen detection test, and urine dipstick) among general practitioners (GPs) and the potential association between point-of-care testing and antibiotic prescribing in out-of-hours general practice. METHODS We conducted a population-based observational register-based study, based on patient contacts with out-of-hours general practice in the Central Denmark Region in 2014-2017. The tendency of GPs to use point-of-care testing was calculated, and the association between the use of point-of-care testing and antibiotic prescribing was evaluated with the use of binomial regression. RESULTS Out-of-hours general practice conducted 794,220 clinic consultations from 2014 to 2017, of which 16.1% resulted in an antibiotic prescription. The GP variation in the use of point-of-care testing was largest for C-reactive protein tests, with an observed variation (p90/p10 ratio) of 3.0; this means that the GPs in the 90th percentile used C-reactive protein tests three times as often as the GPs in the 10th percentile. The observed variation was 2.1 for rapid streptococcal antigen detection tests and 1.9 for urine dipsticks. The GPs who tended to use more point-of-care tests prescribed significantly more antibiotics than the GPs who tended to use fewer point-of-care tests. The GPs in the upper quintile of the tendency to use C-reactive protein test prescribed 22% more antibiotics than the GPs in the lowest quintile (21% for rapid streptococcal antigen detection tests and 8% for urine dipsticks). Up through the quintiles, this effect exhibited a positive linear dose-response correlation. CONCLUSION The GPs varied in use of point-of-care testing. The GPs who tended to perform more point-of-care testing prescribed more antibiotics compared with the GPs who tended to perform fewer of these tests.
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Affiliation(s)
| | | | - Ellen Keizer
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
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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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3
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After-hours consultations and antibiotic prescribing for self-limiting upper respiratory tract infections in primary-care practices. Infect Control Hosp Epidemiol 2022; 44:755-761. [DOI: 10.1017/ice.2022.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Objectives:
To determine the association between after-hours consultations and the likelihood of antibiotic prescribing for self-limiting upper respiratory tract infections (URTIs) in primary care practices.
Design:
A cross-sectional analysis using Australian national primary-care practice data (MedicineInsight) between February 1, 2016 and January 31, 2019.
Setting:
Nationwide primary-care practices across Australia.
Participants:
Adult and pediatric patients who visited primary care practices for first-time URTIs.
Methods:
We estimated the proportion of first-time URTI episodes for which antibiotic prescribing occurred on the same day (immediate prescribing) using diagnoses and prescription records in the electronic primary-care database. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the likelihood of antibiotic prescribing by the time of primary care visits were calculated using generalized estimating equations.
Results:
Among 357,287 URTI episodes, antibiotics were prescribed in 172,605 episodes (48.3%). After adjusting for patients’ demographics, practice characteristics, and seasons, we detected a higher likelihood of antibiotic prescribing on weekends compared to weekdays (OR, 1.42; 95% CI, 1.39–1.45) and on national public holidays compared to nonholidays (OR, 1.23; 95% CI, 1.17–1.29). When we controlled for patient presentation and diagnosis, the association between antibiotic prescribing and after-hours consultations remained significant: weekend versus weekdays (OR, 1.37; 95% CI, 1.33–1.41) and holidays versus nonholidays (OR, 1.10; 95% CI, 1.03–1.18).
Conclusions:
Primary-care consultations on weekends and public holidays were associated with a higher likelihood of immediate antibiotic prescribing for self-limiting URTIs in primary care. This finding might be attributed to lower resourcing in after-hours health care.
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Huibers L, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB. Variation of GP antibiotic prescribing tendency for contacts with out-of-hours primary care in Denmark - a cross-sectional register-based study. Scand J Prim Health Care 2022; 40:227-236. [PMID: 35703579 PMCID: PMC9397449 DOI: 10.1080/02813432.2022.2073981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To study variation in antibiotic prescribing rates among general practitioners (GP) in out-of-hours (OOH) primary care and to explore GP characteristics associated with these rates. DESIGN Population-based observational registry study using routine data from the OOH primary care registration system on patient contacts and antibiotic prescriptions combined with national register data. SETTING OOH primary care of the Central Denmark Region. SUBJECTS All patient contacts in 2014-2017. MAIN OUTCOME MEASURES GPs' tendency to prescribe antibiotics. Excess variation (not attributable to chance). RESULTS We included 794,220 clinic consultations (16.1% with antibiotics prescription), 281,141 home visits (11.6% antibiotics), and 1,583,919 telephone consultations (5.8% antibiotics). The excess variation in the tendency to prescribe antibiotics was 1.56 for clinic consultations, 1.64 for telephone consultations, and 1.58 for home visits. Some GP characteristics were significantly correlated with a higher tendency to prescribe antibiotics, including 'activity level' (i.e. number of patients seen in the past hour) for clinic and telephone consultations, 'familiarity with OOH care' (i.e. number of OOH shifts in the past 180 days), male sex, and younger age for home visits. Overall, GP characteristics explained little of the antibiotic prescribing variation seen among GPs (Pseudo r2: 0.008-0.025). CONCLUSION Some variation in the GPs' tendency to prescribe antibiotics was found for OOH primary care contacts. Available GP characteristics, such as GPs' activity level and familiarity with OOH care, explained only small parts of this variation. Future research should focus on identifying factors that can explain this variation, as this knowledge could be used for designing interventions.KEY POINTSCurrent awareness:Antibiotic prescribing rates seem to be higher in out-of-hours than in daytime primary care.Most important results:Antibiotic prescribing rates varied significantly among general practitioners after adjustment for contact- and patient-characteristics.This variation remained even after accounting for variation attributable to chance.General practitioners' activity level and familiarity with out-of-hours care were positively associated with their tendency to prescribe antibiotics.
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Affiliation(s)
- Linda Huibers
- Research Unit for General Practice, Aarhus, Denmark
- CONTACT Linda Huibers Research Unit for General Practice, Bartholins Alle 2, Aarhus8000, Denmark
| | | | - Ellen Keizer
- Research Unit for General Practice, Aarhus, Denmark
| | - Bodil Hammer Bech
- Research Unit for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Aarhus, Denmark
- Department of General Practice, Institute for Public Health, Aarhus University, Aarhus, Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice, Aarhus, Denmark
- Department of General Practice, Institute for Public Health, Aarhus University, Aarhus, Denmark
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Hartman EAR, Groen WG, Heltveit-Olsen SR, Lindbæk M, Høye S, Sundvall PD, Skoglund I, Snaebjörnsson Arnljots E, Gunnarsson R, Kowalczyk A, Godycki-Cwirko M, Kosiek K, Platteel TN, van de Pol AC, Verheij TJM, Monnier AA, Hertogh CMPM. Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study in four European countries. Age Ageing 2022; 51:afac134. [PMID: 35697352 PMCID: PMC9191618 DOI: 10.1093/ageing/afac134] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND a suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Frequently, antibiotics are prescribed unnecessarily. To increase appropriate antibiotic use for UTIs through antibiotic stewardship interventions, we need to thoroughly understand the factors that contribute to these prescribing decisions. OBJECTIVES (1) to obtain insight into factors contributing to antibiotic prescribing for suspected UTIs in frail older adults. (2) To develop an overarching model integrating these factors to guide the development of antibiotic stewardship interventions for UTIs in frail older adults. METHODS we conducted an exploratory qualitative study with 61 semi-structured interviews in older adult care settings in Poland, the Netherlands, Norway and Sweden. We interviewed physicians, nursing staff, patients and informal caregivers. RESULTS participants described a chain of decisions by patients, caregivers and/or nursing staff preceding the ultimate decision to prescribe antibiotics by the physician. We identified five themes of influence: (1) the clinical situation and its complexity within the frail older patient, (2) diagnostic factors, such as asymptomatic bacteriuria, (3) knowledge (gaps) and attitude, (4) communication: interprofessional, and with patients and relatives and (5) context and organisation of care, including factors such as availability of antibiotics (over the counter), antibiotic stewardship efforts and factors concerning out-of-hours care. CONCLUSIONS decision-making on suspected UTIs in frail older adults is a complex, multifactorial process. Due to the diverse international setting and stakeholder variety, we were able to provide a comprehensive overview of factors to guide the development of antibiotic stewardship interventions.
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Affiliation(s)
- Esther A R Hartman
- Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wim G Groen
- Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands
| | - Silje Rebekka Heltveit-Olsen
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbæk
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sigurd Høye
- The 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 & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ingmarie Skoglund
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, 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 & Innovation, Primary Health Care, Region Västra Götaland, 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 & Innovation, Primary Health Care, Region Västra Götaland, Sweden
- Primary Health Care Clinic for Homeless People, Närhälsan, Region Västra Götaland, Sweden
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, the Faculty of Health Sciences, The Medical University of Lodz, Lodz, Poland
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, the Faculty of Health Sciences, The Medical University of Lodz, Lodz, Poland
| | | | - Tamara N Platteel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Annelie A Monnier
- Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands
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6
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Harbin NJ, Lindbæk M, Romøren M. Barriers and facilitators of appropriate antibiotic use in primary care institutions after an antibiotic quality improvement program - a nested qualitative study. BMC Geriatr 2022; 22:458. [PMID: 35624423 PMCID: PMC9137170 DOI: 10.1186/s12877-022-03161-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs. METHODS After implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke. RESULTS We identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents' next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound. CONCLUSIONS Our qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians.
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Affiliation(s)
- Nicolay Jonassen Harbin
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0317, Oslo, Norway.
| | - Morten Lindbæk
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0317, Oslo, Norway
| | - Maria Romøren
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Wanat M, Santillo M, Borek AJ, Butler CC, Anthierens S, Tonkin-Crine S. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac026. [PMID: 35321397 PMCID: PMC8935206 DOI: 10.1093/jacamr/dlac026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In order to design appropriate antimicrobial stewardship (AMS) programmes, it is crucial to understand challenges to tackling antibiotic resistance (AMR) specific to each healthcare setting. Antibiotic prescribing in primary care accounts for most prescriptions with a significant proportion considered clinically inappropriate. Qualitative research has a long history in social sciences, but its value and contribution are still contested in medical journals including in the AMR/AMS field. However, through its focus on understanding, meaning making and explaining, qualitative research can offer insights in how to improve AMS efforts in primary care. This paper provides an overview of unique considerations, contributions and challenges related to using qualitative research in AMS to help the AMS community new to qualitative research to utilize its potential most fully. First, we discuss specific considerations for AMS in relation to the stages of conducting a qualitative study, including identifying a research question and choosing a suitable methodology; sampling appropriate participants; planning a recruitment strategy; choosing a method of data collection; and conducting data analysis. These are illustrated with examples of qualitative AMS studies in primary care. Second, we highlight the importance of patient and public involvement throughout all stages of the project and ensuring quality in qualitative AMS research. Finally, drawing on these considerations, we make a further case for the value and contribution of qualitative methodologies in AMS/AMR research while outlining future directions for both AMS and qualitative research, including the need for studies with diverse actors; interdisciplinary collaborations; and complex decisions on methodologies and timelines.
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Affiliation(s)
- Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Corresponding author. E-mail: ; @SKGTonkinCrine, @BorekAleksandra, @MartaSantillo, @marta_wanat, @sibylanthierens, @ChrisColButler
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Aleksandra J. Borek
- 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
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
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8
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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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Colliers A, De Man J, Adriaenssens N, Verhoeven V, Anthierens S, De Loof H, Philips H, Coenen S, Morreel S. Antibiotic Prescribing Trends in Belgian Out-of-Hours Primary Care during the COVID-19 Pandemic: Observational Study Using Routinely Collected Health Data. Antibiotics (Basel) 2021; 10:antibiotics10121488. [PMID: 34943701 PMCID: PMC8698421 DOI: 10.3390/antibiotics10121488] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/20/2021] [Accepted: 12/01/2021] [Indexed: 12/27/2022] Open
Abstract
Antibiotic overprescribing is one of the main drivers of the global and growing problem of antibiotic resistance, especially in primary care and for respiratory tract infections (RTIs). RTIs are the most common reason for patients to consult out-of-hours (OOH) primary care. The COVID-19 pandemic has changed the way general practitioners (GPs) work, both during office hours and OOH. In Belgian OOH primary care, remote consultations with the possibility of issuing prescriptions and telephone triage were implemented. We aimed to describe the impact of COVID-19 on GPs’ antibiotic prescribing during OOH primary care. In an observational study, using routinely collected health data from GP cooperatives (GPCs) in Flanders, we analyzed GPs’ antibiotic prescriptions in 2019 (10 GPCs) and 2020 (20 GPCs) during OOH consultations (telephone and face-to-face). We used autoregressive integrated moving average (ARIMA) modeling to identify any changes after lockdowns were implemented. In total, 388,293 contacts and 268,430 prescriptions were analyzed in detail. The number of antibiotic prescriptions per weekend, per 100,000 population was 11.47 (95% CI: 9.08–13.87) or 42.9% lower after compared to before the implementation of lockdown among all contacts. For antibiotic prescribing per contact, we found a decrease of 12.2 percentage points (95% CI: 10.6–13.7) or 56.5% among all contacts and of 5.3 percentage points (95% CI: 3.7–6.9) or 23.2% for face-to-face contacts only. The decrease in the number of prescriptions was more pronounced for cases with respiratory symptoms that corresponded with symptoms of COVID-19 and for antibiotics that are frequently prescribed for RTIs, such as amoxicillin (a decrease of 64.9%) and amoxicillin/clavulanate (a decrease of 38.1%) but did not appear for others such as nitrofurantoin. The implementation of COVID-19 lockdown measures coincided with an unprecedented drop in the number of antibiotic prescriptions, which can be explained by a decrease in face-to-face patient contacts, as well as a lower number of antibiotics prescriptions per face-to-face patient contact. The decrease was seen for antibiotics used for RTIs but not for nitrofurantoin, the first-choice antibiotic for urinary tract infections.
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Affiliation(s)
- Annelies Colliers
- Department of Family Medicine & Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (J.D.M.); (N.A.); (V.V.); (S.A.); (H.P.); (S.C.); (S.M.)
- Correspondence: ; Tel.: +32-(0)3-265-18-32
| | - Jeroen De Man
- Department of Family Medicine & Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (J.D.M.); (N.A.); (V.V.); (S.A.); (H.P.); (S.C.); (S.M.)
| | - Niels Adriaenssens
- Department of Family Medicine & Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (J.D.M.); (N.A.); (V.V.); (S.A.); (H.P.); (S.C.); (S.M.)
| | - Veronique Verhoeven
- Department of Family Medicine & Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (J.D.M.); (N.A.); (V.V.); (S.A.); (H.P.); (S.C.); (S.M.)
| | - Sibyl Anthierens
- Department of Family Medicine & Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (J.D.M.); (N.A.); (V.V.); (S.A.); (H.P.); (S.C.); (S.M.)
| | - Hans De Loof
- Laboratory of Physiopharmacology, Department of Pharmaceutical Sciences, Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, 2610 Antwerp, Belgium;
| | - Hilde Philips
- Department of Family Medicine & Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (J.D.M.); (N.A.); (V.V.); (S.A.); (H.P.); (S.C.); (S.M.)
| | - Samuel Coenen
- Department of Family Medicine & Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (J.D.M.); (N.A.); (V.V.); (S.A.); (H.P.); (S.C.); (S.M.)
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
| | - Stefan Morreel
- Department of Family Medicine & Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (J.D.M.); (N.A.); (V.V.); (S.A.); (H.P.); (S.C.); (S.M.)
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Hartman EAR, Groen WG, Heltveit-Olsen SR, Lindbaek M, Hoye S, Sundvall PD, Gunnarsson R, Skoglund I, Snaebjörnsson Arnljots E, Godycki-Cwirko M, Kowalczyk A, Platteel TN, Zuithoff NPA, Monnier AA, Verheij TJM, Hertogh CMPM, van de Pol AC. Multifaceted antibiotic stewardship intervention using a participatory-action-research approach to improve antibiotic prescribing for urinary tract infections in frail elderly (ImpresU): study protocol for a European qualitative study followed by a pragmatic cluster randomised controlled trial. BMJ Open 2021; 11:e052552. [PMID: 34620666 PMCID: PMC8499316 DOI: 10.1136/bmjopen-2021-052552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Almost 60% of antibiotics in frail elderly are prescribed for alleged urinary tract infections (UTIs). A substantial part of this comprises prescriptions in case of non-specific symptoms or asymptomatic bacteriuria, for which the latest guidelines promote restrictiveness with antibiotics. We aim to reduce inappropriate antibiotic use for UTIs through an antibiotic stewardship intervention (ASI) that encourages to prescribe according to these guidelines. To develop an effective ASI, we first need a better understanding of the complex decision-making process concerning suspected UTIs in frail elderly. Moreover, the implementation approach requires tailoring to the heterogeneous elderly care setting. METHODS AND ANALYSIS First, we conduct a qualitative study to explore factors contributing to antibiotic prescribing for UTIs in frail elderly, using semi-structured interviews with general practitioners, nursing staff, patients and informal caregivers. Next, we perform a pragmatic cluster randomised controlled trial in elderly care organisations. A multifaceted ASI is implemented in the intervention group; the control group receives care as usual. The ASI is centred around a decision tool that promotes restrictive antibiotic use, supported by a toolbox with educational materials. For the implementation, we use a modified participatory-action-research approach, guided by the results of the qualitative study. The primary outcome is the number of antibiotic prescriptions for suspected UTIs. We aim to recruit 34 clusters with in total 680 frail elderly residents ≥70 years. Data collection takes place during a 5-month baseline period and a 7-month follow-up period. Finally, we perform a process evaluation. The study has been delayed for 6 months due to COVID-19 and is expected to end in July 2021. ETHICS AND DISSEMINATION Ethical approvals and/or waivers were obtained from the ethical committees in Poland, the Netherlands, Norway and Sweden. The results will be disseminated through publication in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT03970356.
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Affiliation(s)
- Esther A R Hartman
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wim G Groen
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Silje Rebekka Heltveit-Olsen
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbaek
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sigurd Hoye
- The 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 & Innovation, Primary Health Care, Region Västra Götaland, 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 & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Ingmarie Skoglund
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, 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 & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - Maciej Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, 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, The Netherlands
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Annelie A Monnier
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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11
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Antibiotic prescribing in UK out-of-hours primary care services: a realist-informed scoping review of training and guidelines for healthcare professionals. BJGP Open 2021; 5:BJGPO.2020.0167. [PMID: 33757961 PMCID: PMC8278500 DOI: 10.3399/bjgpo.2020.0167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022] Open
Abstract
Background Antibiotic overuse has contributed to antimicrobial resistance, which is a global public health problem. In the UK, despite the fall in rates of antibiotic prescription since 2013, prescribing levels remain high in comparison with other European countries. Prescribing in out-of-hours (OOH) care provides unique challenges for prudent prescribing, for which professionals may not be prepared. Aim To explore the guidance available to professionals on prescribing antibiotics for common infections in OOH primary care within the UK, with a focus on training resources, guidelines, and clinical recommendations. Design & setting A realist-informed scoping review of peer-reviewed articles and grey literature. Method The review focused on antibiotic prescribing OOH (for example, clinical guidelines and training videos). General prescribing guidance was searched whenever OOH-focused resources were unavailable. Electronic databases and websites of national agencies and professional societies were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Findings were organised according to realist review components, that is, mechanisms, contexts, and outcomes. Results In total, 46 clinical guidelines and eight training resources were identified. Clinical guidelines targeted adults and children, and included recommendations on prescription strategy, spectrum of the antibiotic prescribed, communication with patients, treatment duration, and decision-making processes. No clinical guidelines or training resources focusing specifically on OOH were found. Conclusion The results highlight a lack of knowledge about whether existing resources address the challenges faced by OOH antibiotic prescribers. Further research is needed to explore the training needs of OOH health professionals, and whether further OOH-focused resources need to be developed given the rates of antibiotic prescribing in this setting.
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12
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Smits M, Colliers A, Jansen T, Remmen R, Bartholomeeusen S, Verheij R. Examining differences in out-of-hours primary care use in Belgium and the Netherlands: a cross-sectional study. Eur J Public Health 2020; 29:1018-1024. [PMID: 31086964 PMCID: PMC6896980 DOI: 10.1093/eurpub/ckz083] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background The organizational model of out-of-hours primary care is likely to affect healthcare use. We aimed to examine differences in the use of general practitioner cooperatives for out-of-hours care in the Netherlands and Belgium (Flanders) and explore if these are related to organizational differences. Methods A cross-sectional observational study using routine electronic health record data of the year 2016 from 77 general practitioner cooperatives in the Netherlands and 5 general practitioner cooperatives in Belgium (Flanders). Patient age, gender and health problem were analyzed using descriptive statistics. Results The number of consultations per 1000 residents was 2.3 times higher in the Netherlands than in Belgium. Excluding telephone consultations, which are not possible in Belgium, the number of consultations was 1.4 times higher. In Belgium, the top 10 of health problems was mainly related to infections, while in the Netherlands there were a larger variety of health problems. In addition, the health problem codes in the Dutch top 10 were more often symptoms, while the codes in the Belgian top 10 were more often diagnoses. In both countries, a relatively large percentage of GPC patients were young children and female patients. Conclusion Differences in the use of general practitioner cooperatives seem to be related to the gatekeeping role of general practitioners in the Netherlands and to organizational differences such as telephone triage, medical advice by telephone, financial thresholds and number of years of experience with the system. The information can benefit policy decisions about the organization of out-of-hours primary care.
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Affiliation(s)
- Marleen Smits
- Netherlands Institute for Health Services Research (Nivel), Utrecht, The Netherlands.,Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annelies Colliers
- Department of Primary and Interdisciplinary Care (ELIZA), Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Tessa Jansen
- Netherlands Institute for Health Services Research (Nivel), Utrecht, The Netherlands
| | - Roy Remmen
- Department of Primary and Interdisciplinary Care (ELIZA), Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Stephaan Bartholomeeusen
- Department of Primary and Interdisciplinary Care (ELIZA), Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Robert Verheij
- Netherlands Institute for Health Services Research (Nivel), Utrecht, The Netherlands
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13
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Benkő R, Gajdács M, Matuz M, Bodó G, Lázár A, Hajdú E, Papfalvi E, Hannauer P, Erdélyi P, Pető Z. Prevalence and Antibiotic Resistance of ESKAPE Pathogens Isolated in the Emergency Department of a Tertiary Care Teaching Hospital in Hungary: A 5-Year Retrospective Survey. Antibiotics (Basel) 2020; 9:antibiotics9090624. [PMID: 32961770 PMCID: PMC7560131 DOI: 10.3390/antibiotics9090624] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
Antibiotic treatments initiated on Emergency Departments (ED) are empirical. Therefore, knowledge of local susceptibility patterns is important. Despite this, data on expected pathogens and their resistance profile are scarce from EDs internationally. The study aim was to assess the epidemiology and resistance patterns of bacterial isolates from a tertiary-care ED over 5 years, focusing on ESKAPE bacteria (including the Enterobacterales group). After removal of duplicates, n = 6887 individual bacterial isolates were recovered, out of which n = 4974 (72.22%) were ESKAPE isolates. E. coli was the most frequent isolate (2193, 44.1%), followed by the Klebsiella genus (664; 13.4%). The third most frequent isolate was S. aureus (561, 11.3%). In total, multi-drug resistance (MDR) was present in 23.8% and was most prevalent in A. baumanii (65.5%), P. mirabilis (42.7%), and K. pneumoniae (32.6%). MRSA was isolated in 19.6%, while ESBL-producing Enterobacterales in 17.7%, and these were associated with remarkably higher resistance to other antibacterials as well. Difficult-to-treat resistance (DTR) was detected in 0.5%. The frequent isolation of some ESKAPE bacteria and the detected considerable acquired resistance among ED patients raise concern. The revealed data identified problematic pathogens and will guide us to set up the optimal empiric antibiotic protocol for clinicians.
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Affiliation(s)
- Ria Benkő
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725 Szeged, Hungary;
- Central Pharmacy Department, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary;
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
- Correspondence: ; Tel.: +36-62-342572
| | - Márió Gajdács
- Department of Pharmacodynamics and Biopharmacy, Faculty of Pharmacy, University of Szeged, 6720 Szeged, Hungary;
| | - Mária Matuz
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725 Szeged, Hungary;
- Central Pharmacy Department, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary;
| | - Gabriella Bodó
- Central Pharmacy Department, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary;
| | - Andrea Lázár
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, 6725 Szeged, Hungary;
| | - Edit Hajdú
- Infectious Disease Ward, 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Medical Center, 6725 Szeged, Hungary; (E.H.); (E.P.)
| | - Erika Papfalvi
- Infectious Disease Ward, 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Medical Center, 6725 Szeged, Hungary; (E.H.); (E.P.)
| | - Peter Hannauer
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
| | - Péter Erdélyi
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
| | - Zoltán Pető
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
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14
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Cronberg O, Tyrstrup M, Ekblom K, Hedin K. Diagnosis-linked antibiotic prescribing in Swedish primary care - a comparison between in-hours and out-of-hours. BMC Infect Dis 2020; 20:616. [PMID: 32819280 PMCID: PMC7441551 DOI: 10.1186/s12879-020-05334-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/10/2020] [Indexed: 12/28/2022] Open
Abstract
Background The rise in antibiotic resistance is a global public health concern, and antibiotic overuse needs to be reduced. Earlier studies of out-of-hours care have indicated that antibiotic prescribing is less appropriate than that of in-hours care. However, no study has compared the out-of-hours treatment of infections to in-hours treatment within the same population. Methods This retrospective, descriptive study was based on data retrieved from the Kronoberg Infection Database in Primary Care (KIDPC), which consists of all visits to primary care with an infection diagnosis or prescription of antibiotics during 2006–2014. The purpose was to study the trends in antibiotic prescribing and to compare consultations and prescriptions between in-hours and out-of-hours. Results The visit rate for all infections was 434 visits per 1000 inhabitants per year. The visit rate was stable during the study period, but the antibiotic prescribing rate decreased from 266 prescriptions per 1000 inhabitants in 2006 to 194 prescriptions in 2014 (mean annual change − 8.5 [95% CI − 11.9 to − 5.2]). For the out-of-hours visits (12% of the total visits), a similar reduction in antibiotic prescribing was seen. The decrease was most apparent among children and in respiratory tract infections. When antibiotic prescribing during out-of-hours was compared to in-hours, the unadjusted relative risk of antibiotic prescribing was 1.37 (95% CI 1.36 to 1.38), but when adjusted for age, sex, and diagnosis, the relative risk of antibiotic prescribing was 1.09 (95% CI 1.08 to 1.10). The reduction after adjustment was largely explained by a higher visit rate during out-of-hours for infections requiring antibiotics (acute otitis media, pharyngotonsillitis, and lower urinary tract infection). The choices of antibiotics used for common diagnoses were similar. Conclusions Although the infection visit rate was unchanged over the study period, there was a significant reduction in antibiotic prescribing, especially to children and for respiratory tract infections. The higher antibiotic prescribing rate during out-of-hours was small when adjusted for age, sex, and diagnosis. No excess prescription of broad-spectrum antibiotics was seen. Therefore, interventions selectively aiming at out-of-hours centres seem to be unmotivated in a low-prescribing context.
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Affiliation(s)
- Olof Cronberg
- Växjöhälsan Primary Healthcare Center, VC Växjöhälsan, Hjortvägen 1, 352 45, Växjö, Sweden. .,Department of Research and Development, Region Kronoberg, Växjö, Sweden. .,Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.
| | - Mia Tyrstrup
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.,Lundbergsgatan Primary Health Care Centre, Malmö, Sweden
| | - Kim Ekblom
- Department of Research and Development, Region Kronoberg, Växjö, Sweden.,Department of Medical Biosciences, Clinical Chemistry, Umeå University, Umeå, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.,Futurum, Region Jönköping County and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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15
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Edwards G, Brettell R, Bird C, Hunt H, Lasserson D, Hayward G. Paediatric contacts with the UK out-of-hours primary care service and contact outcomes: a regional service evaluation. BMC FAMILY PRACTICE 2020; 21:144. [PMID: 32664869 PMCID: PMC7362454 DOI: 10.1186/s12875-020-01205-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 06/22/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Demand on hospital emergency departments for paediatric problems is increasing. However, the volume and nature of paediatric health demands placed on other parts of the urgent care system have not been explored. This understanding is an important first step in developing and improving out-of-hospital care. We aimed to describe the volume, nature, and outcomes of paediatric contacts with out-of-hours general practice (OOH GP). We performed a retrospective service evaluation using data from 12 months of paediatric patient contacts with the Oxfordshire OOH GP service. METHODS A database of contacts with the Oxfordshire OOH GP service was created for a 12 month period from December 2014 to November 2015. Descriptive statistics were calculated using SPSS Version 25. RESULTS 27,455 contacts were made by 18,987 individuals during a 12 month period. The majority of these were for children aged under 5. Over 70% of contacts were at the weekend. The peak contact period was between 18:30 and 21:30. Over 40% of contacts resulted in advice only (no onward referral, requirement for GP follow up, or prescription). 19.7% of contacts resulted in an antibiotic prescription, most commonly those linked with ear, chest, and throat infections. DISCUSSION Paediatric contacts with the Oxfordshire OOH GP service were predominantly in younger age groups and in the evening, with 19.7% resulting in an antibiotic prescription. Almost half of the contacts had no follow up or prescription, suggesting non-prescribing health care professionals could be involved in providing care in OOH GP. Further research should consider how children and their parents can be best supported to optimise OOH consulting.
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Affiliation(s)
- George Edwards
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, England.
| | - Rachel Brettell
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, England
| | - Chris Bird
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, England
| | - Helen Hunt
- Oxford Health NHS Foundation Trust, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, England
| | - Dan Lasserson
- Institute of Applied Health Research, College of Medical and Dental Sciences, Murray Learning Centre, University of Birmingham, Edgbaston, Birmingham, B15 2TT, England
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, England
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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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17
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Klimek L, Kardos P. [Cough following airway infections]. MMW Fortschr Med 2020; 162:35-42. [PMID: 32221870 DOI: 10.1007/s15006-020-0007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Ludger Klimek
- Zentrum für Rhinologie und Allergologie, An den Quellen 10, D-65183, Wiesbaden, Deutschland.
| | - Peter Kardos
- Pneumologische Gemeinschaftspraxis Frankfurt, Deutschland
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18
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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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