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Alfayate-Miguélez S, Martín-Ayala G, Jiménez-Guillén C, Alcaraz-Quiñonero M, Delicado RH, Arnau-Sánchez J. Implementation of a Multifaceted Program to Improve the Rational Use of Antibiotics in Children under 3 Years of Age in Primary Care. Antibiotics (Basel) 2024; 13:572. [PMID: 39061254 PMCID: PMC11273502 DOI: 10.3390/antibiotics13070572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024] Open
Abstract
A multifaceted, participatory, open program based on a qualitative and quantitative approach was developed in the Region of Murcia (Spain) aimed to reduce antibiotic use in children under 3 years of age diagnosed with upper respiratory tract infections (acute otitis media, pharyngitis, and common cold). Antibiotic consumption was measured using the defined daily dose per 1000 inhabitants per day (DHD). Pre-intervention data showed a prevalence of antibiotic prescriptions in the primary care setting of 45.7% and a DHD of 19.05. In 2019, after the first year of implementation of the program, antibiotic consumption was 10.25 DHD with an overall decrease of 48% as compared with 2015. Although antibiotic consumption decreased in all health areas, there was a large variability in the magnitude of decreases across health areas (e.g., 12.97 vs. 4.77 DHD). The intervention program was effective in reducing the use of antibiotics in children under 3 years of age with common upper respiratory diseases, but reductions in antibiotic consumption were not consistent among all health areas involved.
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Affiliation(s)
| | - Gema Martín-Ayala
- General Directorate of Health Planning, Research, Pharmacy and Citizen Services, Health Counseling of Murcia Region, E-30001 Murcia, Spain
| | - Casimiro Jiménez-Guillén
- General Directorate of Health Planning, Research, Pharmacy and Citizen Services, Health Counseling of Murcia Region, E-30001 Murcia, Spain
- National Plan for Antibiotic Resistance (PRAN) in Murcia Region, E-30001 Murcia, Spain
| | | | - Rafael Herrero Delicado
- Pharmaceutical Management Service, General Directorate for Health Care, Murciano Health Service, E-30100 Murcia, Spain
| | - José Arnau-Sánchez
- Research Group of Murciano Institute of Biosanitary Research, IMIB, E-30120 Murcia, Spain
- General Directorate of Health Planning, Research, Pharmacy and Citizen Services, Health Counseling of Murcia Region, E-30001 Murcia, Spain
- Nursing Faculty, University of Murcia, E-30120 Murcia, Spain
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Wu S, Magwood O, Dong Q, Wei X. Evaluating population-level interventions to reduce inappropriate antibiotic use in healthcare and community settings: A systematic review protocol. PLoS One 2024; 19:e0300780. [PMID: 38498514 PMCID: PMC10947694 DOI: 10.1371/journal.pone.0300780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/05/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Inappropriate antibiotic use contributes significantly to the global challenge of antimicrobial resistance. While government-initiated population-level interventions are fundamental in addressing this issue, their full potential remains to be explored. This systematic review aims to assess the effectiveness of such interventions in reducing inappropriate antibiotic use among antibiotic providers and users in healthcare and community settings. METHODS We will conduct a systematic literature search across multiple databases and grey literature sources. We will include studies which evaluate the effectiveness of population-level interventions to reduce inappropriate antibiotic use in healthcare and community settings in both high-income and low- and middle-income countries. This includes government-initiated measures targeting antibiotic use through education, restriction, incentivization, coercion, training, persuasion, context modification, behavior modeling, or barrier reduction. Two reviewers will independently perform screening to select eligible studies, followed by data extraction. The outcomes of interest are various measures of antibiotic prescription and consumption, such as Defined Daily Dose (DDD) or number of prescriptions per year. We anticipate including a broad range of study designs and outcome measures. Therefore, we will narratively synthesize results using the categories of the population-level policy interventions of the Behavior Change Wheel Framework. We will organize outcome data by economic contexts, target populations, and implementation settings. DISCUSSION This review will strengthen the evidence base for the use of population-level interventions to address inappropriate antibiotic use. Drawing lessons from global experiences, the findings will provide valuable guidance to health policymakers, public health authorities, and researchers on tailoring interventions to specific economic contexts, populations, and settings, thereby enhancing their capacity to drive substantial improvement in appropriate antibiotic use.
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Affiliation(s)
- Shishi Wu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Olivia Magwood
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Faculty of Health Sciences, Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Quanfang Dong
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Abubakar B, Sárváry A. Knowledge, attitude, and practice on antibiotics use among healthcare workers: A cross-sectional study in Niger state, Nigeria. J Infect Prev 2023; 24:206-215. [PMID: 37736128 PMCID: PMC10510657 DOI: 10.1177/17571774231165407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/01/2023] [Indexed: 09/23/2023] Open
Abstract
Introduction Antibiotic resistance is a public health concern in Nigeria and the world, and healthcare workers contributed to the upsurge of antibiotic resistance in hospital settings. This study focused on the knowledge, attitude, and practice (KAP) of antibiotic use and the frequency of prescriptions of antibiotics from the list of WHO Model Essentials Antibiotics (AWaRe) (in the last 6 months) among healthcare workers and established the determining factors in six hospitals in Niger state, Nigeria. Methodology A KAP survey was conducted in Niger State, Nigeria, from March to June 2022. A structured self-administered, pretested questionnaire was distributed to six hospitals in the state following a stratified random sampling considering the staff capacity, the population of the city, and patients' patronage. Results A total of 350 questionnaires distributed, and 313 (89.4%) completed and returned from the six hospitals. The median scores were knowledge (75%), attitude (69%), practice (62%), and self-reported prescription (70%), and respondents with good scores were knowledge [195 (62.3%)], attitude [185 (59.1%)], practice [201 (64.2%)], and prescription [117 (37.4%)]. In multivariate analysis, older respondents are more likely to have a good prescription (p = 0.006), and prior antimicrobial training improved their knowledge (p < 0.001), attitude (p = 0.007), and prescription pattern (p = 0.009). All the study participants had prescribed one or more of the most prescribed antibiotics; Amoxicillin clavulanate (Access group, 96.5%), Amoxicillin (Access group, 95.9%), and Metronidazole (Access group, 95.7%). Conclusions The study suggests that antibiotic education for healthcare workers and antimicrobial stewardship programs are significant interventions to mitigate antibiotic overuse in the state.
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Affiliation(s)
- Bala Abubakar
- Faculty of Health Sciences, University of Debrecen, Debrecen, Hungary
| | - Attila Sárváry
- Department of Integrative Health Sciences, Faculty of Health Sciences, University of Debrecen, Nyíregyháza, Hungary
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Solomonian L, Blesoff J, Garofalo L, Lucas S, Picardo A, Garber A, Wilson M, Leach M. Naturopathic Management of Acute Pediatric Respiratory Infections: A Modified Delphi Study. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2023; 29:181-195. [PMID: 36827416 DOI: 10.1089/jicm.2022.0669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
Objective: Both the United Nations and the World Health Organization have identified antimicrobial resistance as a significant threat to global health. The Centers for Disease Control and Prevention identified five pediatric respiratory conditions as requiring particular scrutiny in terms of antibiotic stewardship. This study sought to identify strategies used by experienced naturopathic practitioners to treat acute respiratory infections in children. The authors theorize that naturopathic strategies safely fill the gap between watchful waiting and antibiotic prescription, thus reducing the use of antibiotics. Methods: Naturopathic practitioners in Canada, the United States, and Australia with a minimum of 5 years of experience in clinical naturopathic care of children were recruited for a modified Delphi study. A 14-person panel of practitioners was selected to complete a series of four iterative surveys assessing agreement to statements in five domains of knowledge/attitudes, assessment/diagnosis, management, monitoring, and education. Items were deemed to have reached consensus if they reached a predetermined threshold of 70% agreement, or failed to reach a threshold of 40% agreement. Items between these boundaries were modified and retested until either consensus was reached or the four surveys had been completed. Results: Results yielded a large degree of agreement on core naturopathic approaches to the management of acute pediatric respiratory infections, especially lifestyle strategies, including adequate rest and dietary recommendations. The use of vitamins C and D was strongly supported, as were herbs, particularly echinacea and elderberry. Some hydrotherapy and topical applications specific to the individual focus on infection also reached consensus. Results suggested that most respondents, even if they have the authority to prescribe antibiotics, rarely deem it necessary to do so. Conclusion: Findings of this study provide (1) clarity on the role of naturopathic doctors in the management of pediatric health concerns and the stewardship of antibiotics; and (2) initial guidance to less experienced naturopathic practitioners. The findings also identify key priorities for research into the safety and effectiveness of naturopathic interventions to reduce the unnecessary prescribing of antibiotics.
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Affiliation(s)
| | - Jamine Blesoff
- National University of Health Sciences, Lombard, IL, USA
| | | | - Sandra Lucas
- School of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Andrea Picardo
- Canadian College of Naturopathic Medicine, Toronto, ON, Canada
| | - Anna Garber
- Canadian College of Naturopathic Medicine, Toronto, ON, Canada
| | - Mariah Wilson
- Canadian College of Naturopathic Medicine, Toronto, ON, Canada
| | - Matthew Leach
- National Centre for Naturopathic Medicine, Southern Cross University, Lismore, NSW, Australia
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Lu Y, Wang Y, Wang J, Lowe AJ, Grzeskowiak LE, Hu YJ. Early-Life Antibiotic Exposure and Childhood Asthma Trajectories: A National Population-Based Birth Cohort. Antibiotics (Basel) 2023; 12:antibiotics12020314. [PMID: 36830225 PMCID: PMC9952656 DOI: 10.3390/antibiotics12020314] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Early-life antibiotic exposure is common and impacts the development of the child's microbiome and immune system. Information on the impacts of early-life antibiotics exposure on childhood asthma is lacking. METHODS This study examined associations between early-life (0-24 months) antibiotics exposure with childhood (6-15 years) asthma trajectories through the Australian Longitudinal Study of Australian Children (LSAC) and their linked data from the Pharmaceutical Benefits Scheme. Asthma phenotypes were derived by group-based trajectory modeling. RESULTS Of 5107 LSAC participants, 4318 were included in the final analyses (84.6% retention). Four asthma phenotypes were identified: Always-low-risk (79.0%), early-resolving asthma (7.1%), early-persistent asthma (7.9%), and late-onset asthma (6.0%). Any early-life antibiotic exposure increased risk 2.3-fold (95% CI: 1.47-3.67; p < 0.001) for early-persistent asthma among all children. In subgroup analyses, early-persistent asthma risk increased by 2.7-fold with any second-generation cephalosporin exposure, and by 2-fold with any β-lactam other than cephalosporin or macrolide exposure. CONCLUSION We concluded that early-life antibiotic exposure is associated with an increased risk of early-persistent childhood asthma. This reinforces scrutiny of early-life antibiotic use, particularly for common viral infections where no antibiotics are required.
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Affiliation(s)
- Yankun Lu
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC 3053, Australia
| | - Yichao Wang
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Centre for Social and Early Emotional Development, School of Psychology, Deakin University, Geelong, VIC 3220, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Jing Wang
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Adrian J. Lowe
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC 3053, Australia
| | - Luke E. Grzeskowiak
- College of Medicine & Public Health, Flinders University, Adelaide, SA 5042, Australia
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia
| | - Yanhong J. Hu
- Murdoch Children’s Research Institute, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, VIC 3010, Australia
- Correspondence: ; Tel.: +61-467895691
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Goggin K, Hurley EA, Lee BR, Bradley-Ewing A, Bickford C, Pina K, Donis de Miranda E, Yu D, Weltmer K, Linnemayr S, Butler CC, Newland JG, Myers AL. Let's Talk About Antibiotics: a randomised trial of two interventions to reduce antibiotic misuse. BMJ Open 2022; 12:e049258. [PMID: 36410835 PMCID: PMC9680140 DOI: 10.1136/bmjopen-2021-049258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Children with acute respiratory tract infections (ARTIs) receive ≈11.4 million unnecessary antibiotic prescriptions annually. A noted contributor is inadequate parent-clinician communication, however, efforts to reduce overprescribing have only indirectly targeted communication or been impractical. OBJECTIVES Compare two feasible (higher vs lower intensity) interventions for enhancing parent-clinician communication on the rate of inappropriate antibiotic prescribing. DESIGN Multisite, parallel group, cluster randomised comparative effectiveness trial. Data collected between March 2017 and March 2019. SETTING Academic and private practice outpatient clinics. PARTICIPANTS Clinicians (n=41, 85% of eligible approached) and 1599 parent-child dyads (ages 1-5 years with ARTI symptoms, 71% of eligible approached). INTERVENTIONS All clinicians received 20 min ARTI diagnosis and treatment education. Higher intensity clinicians received an additional 50 min communication skills training. All parents viewed a 90 second antibiotic education video. MAIN OUTCOMES AND MEASURES Inappropriate antibiotic treatment was assessed via blinded medical record review by study clinicians and a priori defined as prescriptions for the wrong diagnosis or use of the wrong agent. Secondary outcomes were revisits, adverse drug reactions (both assessed 2 weeks after the visit) and parent ratings of provider communication, shared decision-making and visit satisfaction (assessed at end of the visit on Likert-type scales). RESULTS Most clinicians completed the study (n=38, 93%), were doctors (n=25, 66%), female (n=30, 78%) and averaged 8 years in practice. All parent-child dyad provided data for the main outcome (n=855 (54%) male, n=1043 (53%) <2 years). Inappropriate antibiotic prescribing was similar among patients who consulted with a higher intensity (54/696, 7.8%) versus a lower intensity (85/904, 9.4%) clinician. A generalised linear mixed effect regression model (adjusted for the two-stage nested design, clinician type, clinic setting and clinician experience) revealed that the odds of receiving inappropriate antibiotic treatment did not significantly vary by group (AOR 0.99, 95% CI: 0.52 to 1.89, p=0.98). Secondary outcomes of revisits and adverse reactions did not vary between arms, and parent ratings of satisfaction with quality of parent-provider communication (5/5), shared decision making (9/10) and visit satisfaction (5/5) were similarly high in both arms. CONCLUSIONS AND RELEVANCE Rate of inappropriate prescribing was low in both arms. Clinician education coupled with parent education may be sufficient to yield low inappropriate antibiotic prescribing rates. The absence of a significant difference between groups indicates that communication principles previously thought to drive inappropriate prescribing may need to be re-examined or may not have as much of an impact in practices where prescribing has improved in recent years. TRIAL REGISTRATION NUMBER NCT03037112.
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Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
- School of Pharmacy, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Brian R Lee
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Andrea Bradley-Ewing
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Carey Bickford
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Kimberly Pina
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Evelyn Donis de Miranda
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - David Yu
- Sunflower Medical Group, Kansas City, Kansas, USA
| | - Kirsten Weltmer
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
- General Academic Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | | | - Christopher C Butler
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Angela L Myers
- Pediatric Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
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Sadeq AA, Hasan SS, AbouKhater N, Conway BR, Abdelsalam AE, Shamseddine JM, Babiker ZOE, Nsutebu EF, Bond SE, Aldeyab MA. Exploring Antimicrobial Stewardship Influential Interventions on Improving Antibiotic Utilization in Outpatient and Inpatient Settings: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2022; 11:antibiotics11101306. [PMID: 36289964 PMCID: PMC9598859 DOI: 10.3390/antibiotics11101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022] Open
Abstract
Antimicrobial stewardship interventions are targeted efforts by healthcare organizations to optimize antimicrobial use in clinical practice. The study aimed to explore effective interventions in improving antimicrobial use in hospitals. Literature was systemically searched for interventional studies through PubMed, CINAHL, and Scopus databases that were published in the period between January 2010 to April 2022. A random-effects model was used to pool and evaluate data from eligible studies that reported antimicrobial stewardship (AMS) interventions in outpatient and inpatient settings. Pooled estimates presented as proportions and standardized mean differences. Forty-eight articles were included in this review: 32 in inpatient and 16 in outpatient settings. Seventeen interventions have been identified, and eight outcomes have been targeted. AMS interventions improved clinical, microbiological, and cost outcomes in most studies. When comparing non-intervention with intervention groups using meta-analysis, there was an insignificant reduction in length of stay (MD: -0.99; 95% CI: -2.38, 0.39) and a significant reduction in antibiotics' days of therapy (MD: -2.73; 95% CI: -3.92, -1.54). There were noticeable reductions in readmissions, mortality rates, and antibiotic prescriptions post antimicrobial stewardship multi-disciplinary team (AMS-MDT) interventions. Studies that involved a pharmacist as part of the AMS-MDT showed more significant improvement in measured outcomes than the studies that did not involve a pharmacist.
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Affiliation(s)
- Ahmed A. Sadeq
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Syed Shahzad Hasan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Noha AbouKhater
- Department of Medicine, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Abeer E. Abdelsalam
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Jinan M. Shamseddine
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Zahir Osman Eltahir Babiker
- Division of Infecious Diseases, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Emmanuel Fru Nsutebu
- Division of Infecious Diseases, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Stuart E. Bond
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Pharmacy Department, Mid Yorkshire Hospitals NHS Trust, Wakefield WF1 4DG, UK
| | - Mamoon A. Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Correspondence: ; Tel.: +44-01484-472825
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Zheng K, Xie Y, Dan L, Mao M, Chen J, Li R, Wang X, Hesketh T. Effectiveness of Educational Interventions for Health Workers on Antibiotic Prescribing in Outpatient Settings in China: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2022; 11:antibiotics11060791. [PMID: 35740197 PMCID: PMC9220158 DOI: 10.3390/antibiotics11060791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 02/01/2023] Open
Abstract
Educational interventions are considered an important component of antibiotic stewardship, but their effect has not been systematically evaluated in outpatient settings in China. This research aims to evaluate the effectiveness of educational interventions for health workers on antibiotic prescribing rates in Chinese outpatient settings. Eight databases were searched for relevant randomized clinical trials, non-randomized trials, controlled before–after studies and interrupted time-series studies from January 2001 to July 2021. A total of 16 studies were included in the systematic review and 12 in the meta-analysis. The results showed that educational interventions overall reduced the antibiotic prescription rate significantly (relative risk, RR 0.72, 95% confidence interval, CI 0.61 to 0.84). Subgroup analysis demonstrated that certain features of education interventions had a significant effect on antibiotic prescription rate reduction: (1) combined with compulsory administrative regulations (RR With: 0.65 vs. Without: 0.78); (2) combined with financial incentives (RR With: 0.51 vs. Without: 0.77). Educational interventions can also significantly reduce antibiotic injection rates (RR 0.83, 95% CI 0.74 to 0.94) and the inappropriate use of antibiotics (RR 0.61, 95% CI 0.51 to 0.73). The limited number of high-quality studies limits the validity and reliability of the results. More high-quality educational interventions targeting the reduction of antibiotic prescribing rates are needed.
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Affiliation(s)
- Kunhua Zheng
- People’s Hospital of Kaihua, Quzhou 324300, China; (K.Z.); (M.M.)
| | - Ying Xie
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
| | - Lintao Dan
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
| | - Meixian Mao
- People’s Hospital of Kaihua, Quzhou 324300, China; (K.Z.); (M.M.)
| | - Jie Chen
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
| | - Ran Li
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
- Institute for Global Health, University College London, London WC1E 6BT, UK
| | - Xuanding Wang
- Department of Antimicrobial Stewardship, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310000, China
- Correspondence:
| | - Therese Hesketh
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
- Institute for Global Health, University College London, London WC1E 6BT, UK
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Wu S, Tannous E, Haldane V, Ellen ME, Wei X. Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research. Implement Sci 2022; 17:30. [PMID: 35550169 PMCID: PMC9096759 DOI: 10.1186/s13012-022-01209-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Behavior change interventions that aim to improve rational antibiotic use in prescribers and users have been widely conducted in both high- and LMICs. However, currently, no review has systematically examined challenges unique to LMICs and offered insights into the underlying contextual factors that influence these interventions. We adopted an implementation research perspective to systematically synthesize the implementation barriers and facilitators in LMICs. Methods We conducted literature searches in five electronic databases and identified studies that involved the implementation of behavior change interventions to improve appropriate antibiotic use in prescribers and users in LMICs and reported implementation barriers and facilitators. Behavior change interventions were defined using the behavior change wheel, and the coding and synthesis of barriers and facilitators were guided by the Consolidated Framework for Implementation Research (CFIR). Results We identified 52 eligible studies, with the majority targeting prescribers practicing at tertiary facilities (N=39, 75%). The most commonly reported factors influencing implementation were found in the inner setting domain of the CFIR framework, particularly related to constraints in resources and the infrastructure of the facilities where interventions were implemented. Barriers related to the external policy environment (e.g., lack of national initiatives and policies on antibiotic use), and individual characteristics of target populations (e.g., reluctance to change prescribing behaviors) were also common, as well as facilitators related to intervention characteristics (e.g., embedding interventions in routine practice) and process (e.g., stakeholder engagement). We also provided insights into the interrelationships between these factors and the underlying causes contributing to the implementation challenges in LMICs. Conclusion We presented a comprehensive overview of the barriers and facilitators of implementing behavior change interventions to promote rational antibiotic use in LMICs. Our findings suggest that facilitating the implementation of interventions to improve rational antibiotic use needs comprehensive efforts to address challenges at policy, organizational, and implementation levels. Specific strategies include (1) strengthening political commitment to prompt mobilization of domestic resources and formulation of a sustainable national strategy on AMR, (2) improving the infrastructure of health facilities that allow prescribers to make evidence-based clinical decisions, and (3) engaging local stakeholders to improve their buy-in and facilitate contextualizing interventions. Trial registration PROSPERO: CRD42021252715. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01209-4.
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Affiliation(s)
- Shishi Wu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Elias Tannous
- Faculty of Health Sciences, Department of Clinical Biochemistry and Pharmacology, Ben Gurion University of the Negev, Beer-Sheva, Israel.,Pharmacy services, Hillel Yaffe Medical Center, Hadera, Israel
| | - Victoria Haldane
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Moriah E Ellen
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. .,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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10
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Araújo BCD, Melo RCD, Bortoli MCD, Bonfim JRDA, Toma TS. Prevenção e controle de resistência aos antimicrobianos na Atenção Primária à Saúde: evidências para políticas. CIENCIA & SAUDE COLETIVA 2022; 27:299-314. [DOI: 10.1590/1413-81232022271.22202020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 11/18/2020] [Indexed: 11/21/2022] Open
Abstract
Resumo A resistência aos antimicrobianos é um problema mundial que põe em risco a segurança da saúde da população. O objetivo deste artigo é identificar e avaliar estratégias para prevenção e controle de resistência microbiana, bem como barreiras para sua implementação em serviços de Atenção Primária à Saúde (APS). Realizou-se uma síntese de evidências para políticas. As buscas de evidências foram realizadas entre novembro/dezembro de 2018, em 13 bases de dados. Um diálogo deliberativo foi realizado para validação dos resultados e levantamento de barreiras e facilitadores para implementação das estratégias. As 13 revisões sistemáticas incluídas mostraram que intervenções com foco em educação, uso de sistemas eletrônicos e biomarcadores reduziram o consumo e prescrição de antimicrobianos. É um obstáculo à implementação a expectativa de usuários/cuidadores em receber prescrição de antibióticos, e são facilitadores as ações educativas que envolvem profissionais de saúde. O uso racional de medicamentos se impõe na APS com vistas à prevenção da resistência dos microrganismos aos antibióticos. As intervenções identificadas neste estudo podem ser implementadas isoladamente ou em conjunto, conforme o contexto local.
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11
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Vatovec C, Kolodinsky J, Callas P, Hart C, Gallagher K. Pharmaceutical pollution sources and solutions: Survey of human and veterinary medication purchasing, use, and disposal. JOURNAL OF ENVIRONMENTAL MANAGEMENT 2021; 285:112106. [PMID: 33588165 DOI: 10.1016/j.jenvman.2021.112106] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/13/2021] [Accepted: 01/31/2021] [Indexed: 05/26/2023]
Abstract
Human and veterinary pharmaceuticals offer many benefits, but they also pose risks to both the environment and public health. Life-cycle stewardship of medications offers multiple strategies for minimizing the risks posed by pharmaceuticals, and further insight is required for developing best practices for pharmaceutical management. The goal of this study was to clarify points of intervention for minimizing environmental and public health risks associated with pharmaceuticals. Specifically, our objectives were to provide insight on purchasing, use, and disposal behaviors associated with human and veterinary medications. This study used a state-wide representative sample of Vermont adults (n = 421) to survey both human and veterinary pharmaceuticals as potential sources of the unintended consequences of prescribed and over-the-counter (OTC) medications. The majority (93%) of respondents had purchased some form of medication within the past twelve months, including OTC (85%), prescription (74%), and veterinary (41%) drugs. Leftover drugs of any kind were reported by 59% of respondents. While 56% of people were aware of drug take-back programs, the majority reported never being told what to do with leftover medications by their physician (78%), pharmacist (76%), or veterinarian (53%). Among all respondents, take-back programs were the most common disposal method (22%), followed by trash (19%), and flushing (9%), while 26% of respondents reported keeping unused drugs. Awareness of pharmaceutical pollution in the environment and having received information about proper disposal were both significantly associated with participation in take-back programs. These findings indicate that a large volume of drugs are going unused annually, and that only a portion of leftover medications are returned to take-back programs where they can be appropriately disposed. Our results warrant further investigation of clinical interventions that support lower dose prescribing and dispensing practices in order to reduce the unintended environmental and public health consequences of pharmaceuticals within the consumer sphere. In addition, our findings suggest that directed efforts to raise awareness of proper disposal may be more effective than broad awareness campaigns, and we recommend research on the efficacy of providing disposal instructions on drug packaging.
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Affiliation(s)
- Christine Vatovec
- Gund Institute for Environment & Larner College of Medicine, University of Vermont, Burlington, VT, USA.
| | - Jane Kolodinsky
- Community Development and Applied Economics, University of Vermont, Burlington, VT, USA
| | - Peter Callas
- Department of Mathematics & Statistics, University of Vermont, Burlington, VT, USA
| | - Christine Hart
- Rubenstein School of Environment & Natural Resources, University of Vermont, Burlington, VT, USA
| | - Kati Gallagher
- Community Development and Applied Economics, University of Vermont, Burlington, VT, USA
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12
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Goggin K, Hurley EA, Bradley-Ewing A, Bickford C, Lee BR, Pina K, De Miranda ED, Mackenzie A, Yu D, Weltmer K, Linnemayr S, Butler CC, Miller M, Newland JG, Myers AL. Reductions in Parent Interest in Receiving Antibiotics following a 90-Second Video Intervention in Outpatient Pediatric Clinics. J Pediatr 2020; 225:138-145.e1. [PMID: 32553835 PMCID: PMC7529942 DOI: 10.1016/j.jpeds.2020.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/05/2020] [Accepted: 06/09/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To assess the impact of a 90-second animated video on parents' interest in receiving an antibiotic for their child. STUDY DESIGN This pre-post test study enrolled English and Spanish speaking parents (n = 1051) of children ages 1-5 years presenting with acute respiratory tract infection symptoms. Before meeting with their provider, parents rated their interest in receiving an antibiotic for their child, answered 6 true/false antibiotic knowledge questions, viewed the video, and then rated their antibiotic interest again. Parents rated their interest in receiving an antibiotic using a visual analogue scale ranging from 0 to 100, with 0 being "I definitely do not want an antibiotic," 50 "Neutral," and 100 "I absolutely want an antibiotic." RESULTS Parents were 84% female, with a mean age of 32 ± 6.0, 26.0% had a high school education or less, 15% were black, and 19% were Hispanic. After watching the video, parents' average antibiotic interest ratings decreased by 10 points (mean, 57.0 ± 20 to M ± 21; P < .0001). Among parents with the highest initial antibiotic interest ratings (≥60), even greater decreases were observed (83.0 ± 12.0 to 63.4 ± 22; P < .0001) with more than one-half (52%) rating their interest in the low or neutral ranges after watching the video. CONCLUSIONS A 90-second video can decrease parents' interest in receiving antibiotics, especially among those with higher baseline interest. This scalable intervention could be used in a variety of settings to reduce parents' interest in receiving antibiotics. TRIAL REGISTRATION ClinicalTrials.gov: NCT03037112.
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Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, MO; University of Missouri - Kansas City School of Medicine, Kansas City, MO; University of Missouri - Kansas City School of Pharmacy, Kansas City, MO.
| | - Emily A. Hurley
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City
| | - Andrea Bradley-Ewing
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City
| | - Carey Bickford
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City
| | - Brian R. Lee
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City,University of Missouri – Kansas City School of Medicine, Kansas City
| | - Kimberly Pina
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City
| | | | - Alexander Mackenzie
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City
| | - David Yu
- Sunflower Medical Group, Kansas City
| | - Kirsten Weltmer
- University of Missouri – Kansas City School of Medicine, Kansas City
| | | | | | - Melissa Miller
- University of Missouri – Kansas City School of Medicine, Kansas City,Emergency Department, Children’s Mercy, Kansas City
| | - Jason G. Newland
- Pediatric Infectious Disease, St. Louis Children’s Hospital, St. Louis
| | - Angela L. Myers
- University of Missouri – Kansas City School of Medicine, Kansas City,Pediatric Infectious Diseases, Children’s Mercy, Kansas City
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13
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Measuring Antibiotic Stewardship Programmes and Initiatives: An Umbrella Review in Primary Care Medicine and a Systematic Review of Dentistry. Antibiotics (Basel) 2020; 9:antibiotics9090607. [PMID: 32947838 PMCID: PMC7558917 DOI: 10.3390/antibiotics9090607] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/01/2020] [Accepted: 09/13/2020] [Indexed: 12/15/2022] Open
Abstract
Antibiotic stewardship aims to tackle the global problem of drug-resistant infections by promoting the responsible use of antibiotics. Most antibiotics are prescribed in primary care and widespread overprescribing has been reported, including 80% in dentistry. This review aimed to identify outcomes measured in studies evaluating antibiotic stewardship across primary healthcare. An umbrella review was undertaken across medicine and a systematic review in dentistry. Systematic searches of Ovid Medline, Ovid Embase and Web of Science were undertaken. Two authors independently selected and quality assessed the included studies (using Critical Appraisal Skills Programme for the umbrella review and Quality Assessment Tool for Studies with Diverse Designs for the systematic review). Metrics used to evaluate antibiotic stewardship programmes and interventions were extracted and categorized. Comparisons between medical and dental settings were made. Searches identified 2355 medical and 2704 dental studies. After screening and quality assessment, ten and five studies, respectively, were included. Three outcomes were identified across both medical and dental studies: All focused on antibiotic usage. Four more outcomes were found only in medical studies: these measured patient outcomes, such as adverse effects. To evaluate antibiotic stewardship programmes and interventions across primary healthcare settings, measures of antibiotic use and patient outcomes are recommended.
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14
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Hawes L, Buising K, Mazza D. Antimicrobial Stewardship in General Practice: A Scoping Review of the Component Parts. Antibiotics (Basel) 2020; 9:E498. [PMID: 32784918 PMCID: PMC7459857 DOI: 10.3390/antibiotics9080498] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/02/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023] Open
Abstract
There is no published health-system-wide framework to guide antimicrobial stewardship (AMS) in general practice. The aim of this scoping review was to identify the component parts necessary to inform a framework to guide AMS in general practice. Six databases and nine websites were searched. The sixteen papers included were those that reported on AMS in general practice in a country where antibiotics were available by prescription from a registered provider. Six multidimensional components were identified: 1. Governance, including a national action plan with accountability, prescriber accreditation, and practice level policies. 2. Education of general practitioners (GPs) and the public about AMS and antimicrobial resistance (AMR). 3. Consultation support, including decision support with patient information resources and prescribing guidelines. 4. Pharmacist and nurse involvement. 5. Monitoring of antibiotic prescribing and AMR with feedback to GPs. 6. Research into gaps in AMS and AMR evidence with translation into practice. This framework for AMS in general practice identifies health-system-wide components to support GPs to improve the quality of antibiotic prescribing. It may assist in the development and evaluation of AMS interventions in general practice. It also provides a guide to components for inclusion in reports on AMS interventions.
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Affiliation(s)
- Lesley Hawes
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Level 1, 270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia;
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Level 5, 792 Elizabeth Street Melbourne, Victoria 3000, Australia;
| | - Kirsty Buising
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Level 5, 792 Elizabeth Street Melbourne, Victoria 3000, Australia;
- Acting Director, Victorian Infectious Diseases Service, Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria 3050, Australia
| | - Danielle Mazza
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Level 1, 270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia;
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Level 5, 792 Elizabeth Street Melbourne, Victoria 3000, Australia;
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15
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Zhuo C, Wei X, Zhang Z, Hicks JP, Zheng J, Chen Z, Haldane V, Walley J, Guan Y, Xu H, Zhong N. An antibiotic stewardship programme to reduce inappropriate antibiotic prescribing for acute respiratory infections in rural Chinese primary care facilities: study protocol for a clustered randomised controlled trial. Trials 2020; 21:394. [PMID: 32398065 PMCID: PMC7216131 DOI: 10.1186/s13063-020-04303-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Inappropriate prescribing of antibiotics for acute respiratory infections at the primary care level represents the major source of antibiotic misuse in healthcare, and is a major driver for antimicrobial resistance worldwide. In this study we will develop, pilot and evaluate the effectiveness of a comprehensive antibiotic stewardship programme in China's primary care hospitals to reduce inappropriate prescribing of antibiotics for acute respiratory infections among all ages. METHODS We will use a parallel-group, cluster-randomised, controlled, superiority trial with blinded outcome evaluation but unblinded treatment (providers and patients). We will randomise 34 primary care hospitals from two counties within Guangdong province into the intervention and control arm (1:1 overall ratio) stratified by county (8:9 within-county ratio). In the control arm, antibiotic prescribing and management will continue through usual care. In the intervention arm, we will implement an antibiotic stewardship programme targeting family physicians and patients/caregivers. The family physician components include: (1) training using new operational guidelines, (2) improved management and peer-review of antibiotic prescribing, (3) improved electronic medical records and smart phone app facilitation. The patient/caregiver component involves patient education via family physicians, leaflets and videos. The primary outcome is the proportion of prescriptions for acute respiratory infections (excluding pneumonia) that contain any antibiotic(s). Secondary outcomes will address how frequently specific classes of antibiotics are prescribed, how frequently key non-antibiotic alternatives are prescribed and the costs of consultations. We will conduct a qualitative process evaluation to explore operational questions regarding acceptability, cultural appropriateness and burden of technology use, as well as a cost-effectiveness analysis and a long-term benefit evaluation. The duration of the intervention will be 12 months, with another 24 months' post-trial long-term follow-up. DISCUSSION Our study is one of the first trials to evaluate the effect of an antibiotic stewardship programme in primary care settings in a low- or middle-income country (LMIC). All interventional activities will be designed to be embedded into routine primary care with strong local ownership. Through the trial we intend to impact on clinical practice and national policy in antibiotic prescription for primary care facilities in rural China and other LMICs. TRIAL REGISTRATION ISRCTN, ID: ISRCTN96892547. Registered on 18 August 2019.
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Affiliation(s)
- Chao Zhuo
- National Center for Respiratory Diseases, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, Laboratory of Guangdong-Hong Kong -Macao Great Bay, Guangzhou Medical University, 151 Yanjiang Xi Rd, Guangzhou City, 510120 Guangdong China
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - Zhitong Zhang
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - Joseph Paul Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Jinkun Zheng
- Yuebei People’s Hospital, Shaoguan, Guangdong China
| | - Zhixu Chen
- National Center for Respiratory Diseases, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, Laboratory of Guangdong-Hong Kong -Macao Great Bay, Guangzhou Medical University, 151 Yanjiang Xi Rd, Guangzhou City, 510120 Guangdong China
| | - Victoria Haldane
- National Center for Respiratory Diseases, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, Laboratory of Guangdong-Hong Kong -Macao Great Bay, Guangzhou Medical University, 151 Yanjiang Xi Rd, Guangzhou City, 510120 Guangdong China
| | - John Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Yubao Guan
- National Center for Respiratory Diseases, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, Laboratory of Guangdong-Hong Kong -Macao Great Bay, Guangzhou Medical University, 151 Yanjiang Xi Rd, Guangzhou City, 510120 Guangdong China
| | - Hongyan Xu
- Yuebei People’s Hospital, Shaoguan, Guangdong China
| | - Nanshan Zhong
- National Center for Respiratory Diseases, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, Laboratory of Guangdong-Hong Kong -Macao Great Bay, Guangzhou Medical University, 151 Yanjiang Xi Rd, Guangzhou City, 510120 Guangdong China
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16
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Hallit S, Zahreddine L, Saleh N, Shakaroun S, Lahoud N. Practice of parents and pharmacists regarding antibiotics use in pediatrics: A 2017 cross-sectional study in Lebanese community pharmacies. J Eval Clin Pract 2020; 26:181-189. [PMID: 31111612 DOI: 10.1111/jep.13165] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess practices of community pharmacists towards prescribing or dispensing antibiotics without prescription to children, determine obstacles that stand in the way of best practices, and determine whether parents misuse antibiotics when administering them to their children. METHODS A cross-sectional study, conducted between June 2017 and August 2017 on a random sample of community pharmacies, enrolled 202 community pharmacists and 204 parents. RESULTS A total of 84.6% of pharmacists prescribed antibiotics for children in community pharmacies, particularly for the treatment of pharyngitis (67.5%), otitis media (56%), or diarrhea/vomiting (40.4%); 54.2% of these pharmacists reported prescribing antibiotics to children under 2 years of age, while 14.4% reported only prescribing antibiotics for children aged six and above. Most pharmacists cited pressure from the child's parents as a reason for prescribing antibiotics, while parents not being able to afford the doctor's visit was cited by 24.7%. When dispensing antibiotics for use by children, 23.5% of the pharmacists reported recommending a small or large spoon two to three times daily, regardless of the standard dose or the child's weight. In addition, 21.7% of the pharmacists reported always dispensing the entire bottle of antibiotics, while 5.4% do not specify the treatment's duration. From the parents' side, 38% reported that the most recent purchase of an antibiotic for their child was made without a medical prescription, while 20.6% reported that they did not follow medical instructions regarding treatment's dosage and duration; 64.3% reported ending the antibiotic treatment early if their child felt better. Most of the parents reported diluting the antibiotic incorrectly, with half of them not shaking the bottle well enough before adding in water. CONCLUSION These study results demonstrated poor practices of community pharmacists towards dispensing antibiotics without a prescription, and in parents when administering them to their children. Educational campaigns to increase awareness on antibiotics misuse in pediatrics are warranted.
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Affiliation(s)
- Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon.,INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Beirut, Lebanon
| | | | - Nadine Saleh
- INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Beirut, Lebanon.,Faculty of Pharmacy, Lebanese University, Hadat, Lebanon.,CERIPH, Center for Research in Public Health, Pharmacoepidemiology Surveillance Unit, Faculty of Public Health, Lebanese University, Fanar, Lebanon.,Faculty of Public Health, Lebanese University, Fanar, Lebanon
| | | | - Nathalie Lahoud
- INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Beirut, Lebanon.,Faculty of Pharmacy, Lebanese University, Hadat, Lebanon.,CERIPH, Center for Research in Public Health, Pharmacoepidemiology Surveillance Unit, Faculty of Public Health, Lebanese University, Fanar, Lebanon.,Faculty of Public Health, Lebanese University, Fanar, Lebanon.,School of Pharmacy, Lebanese International University, Beirut, Lebanon
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17
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Wei X, Deng S, Haldane V, Blacklock C, Zhang W, Zhang Z, Walley JD, King R, Hicks JP, Yin J, Zou G, Huang Y, Vergis M, Jun Z, Sun Q, Lin M. Understanding factors influencing antibiotic prescribing behaviour in rural China: a qualitative process evaluation of a cluster randomized controlled trial. J Health Serv Res Policy 2020; 25:94-103. [PMID: 31986910 DOI: 10.1177/1355819619896588] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives We conducted a qualitative process evaluation embedded in a cluster randomized controlled trial in rural Guangxi China, which successfully reduced antibiotic use for children upper respiratory tract infections. This study aims to report on the factors that influenced behaviour change among providers and caregivers in the intervention arm, and to explore contextual considerations which may have influenced trial outcomes. Methods A total of 35 in-depth interviews were carried out with hospital directors, doctors, and caregivers of children. Participants were recruited from six purposively selected facilities, including two higher performing and two lower performing facilities per trial results. Interviews were conducted in Chinese and translated to English. We also observed guideline training sessions and prescription peer review meetings. Data were analysed using framework analysis. Results Intervention-arm doctors described that training sessions improved their knowledge, skills and confidence in appropriate prescribing. This was contrasted by control arm participants who did not receive training and reported less agency in reducing prescribing rates. Prescription peer review meetings were seen as an opportunity for further education, action planning and goal setting, particularly in high performing hospitals, where these meetings were led by senior doctors who were perceived to have relevant clinical experience. Caregiver participants reported that intervention educational materials were helpful but they identified information from doctors was more useful. Providers and caregivers also described contextual health system factors, including hospital competition, short consultation times, and antibiotic availability without prescription, which shaped care preferences. Conclusions This qualitative process evaluation identified a range of factors that may have influenced behaviour among providers and caregivers leading to observed changes in reducing inappropriate antibiotic prescribing in China. Future interventions to reduce antibiotic prescribing should consider system level and wider contextual factors to better understand behaviours and patient care preferences.
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Affiliation(s)
- Xiaolin Wei
- Dalla Lana Chair in Global Health Policy, Dalla Lana School of Public Health, University of Toronto, Canada
| | - Simin Deng
- Research Associate, China Global Health Research and Development, China
| | - Victoria Haldane
- Doctoral student, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Canada
| | - Claire Blacklock
- Research Fellow, Nuffield Centre for International Health and Development, University of Leeds, UK
| | - Wei Zhang
- Research Associate, China Global Health Research and Development, China
| | - Zhitong Zhang
- Research Fellow, Dalla Lana School of Public Health, University of Toronto, Canada
| | - John D Walley
- Professor of International Public Health, Nuffield Centre for International Health and Development, University of Leeds, UK
| | - Rebecca King
- Lecturer in International Health, Nuffield Centre for International Health and Development, University of Leeds, UK
| | - Joseph P Hicks
- Lecturer in Medical Statistics, Nuffield Centre for International Health and Development, University of Leeds, UK
| | - Jia Yin
- Associate Professor, School of Health Care Management, Shandong University, China
| | - Guanyang Zou
- Associate Professor, School of Economics and Management, Guangzhou University of Chinese Medicine, China
| | - Yunayuan Huang
- Research Associate, China Global Health Research and Development, China
| | - Mercy Vergis
- Research Fellow, Nuffield Centre for International Health and Development, University of Leeds, UK
| | - Zeng Jun
- Division Director, Guangxi Autonomous Region Centre for Disease Control and Prevention, China
| | - Qiang Sun
- Professor and Dean, School of Health Care Management, Shandong University, China
| | - Mei Lin
- Director in General, Guangxi Autonomous Region Centre for Disease Control and Prevention, China
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18
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Barnett ER, Trepman AZ, Fuson HA, Acquilano SC, McLaren JL, Woloshin S, Leyenaar JK. Deprescribing psychotropic medications in children: results of a national qualitative study. BMJ Qual Saf 2019; 29:655-663. [PMID: 31836627 DOI: 10.1136/bmjqs-2019-010033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Prescriptions for psychotropic medications to children have risen dramatically in recent years despite few regulatory approvals and growing concerns about side effects. Government policy and numerous programmes are attempting to curb this problem. However, the perspectives of practising clinicians have not been explored. To characterise the perspectives and experiences of paediatric primary care clinicians and mental health specialists regarding overprescribing and deprescribing psychotropic medications in children. METHODS We conducted 24 semistructured interviews with clinicians representing diverse geographic regions and practice settings in the USA. Interview questions focused on clinician perspectives surrounding overprescribing and experiences with deprescribing. We transcribed audio files verbatim and verified them for accuracy. We analysed transcripts using a grounded theory approach, identifying emergent themes and developing a conceptual model using axial coding. RESULTS Analysis yielded themes within four domains: social and clinical contextual factors contributing to overprescribing, opportunities for deprescribing, and facilitators and barriers to deprescribing in paediatric outpatient settings. Most participants recognised the problem of overprescribing, and they described complex clinical and social contextual factors, as well as internal and external pressures, that contribute to overprescribing. Opportunities for deprescribing included identification of high-risk medications, routine reassessment of medication needs and recognition of the broader social needs of vulnerable children. Facilitators and barriers to deprescribing were both internal (eg, providing psychoeducation to families) and external (eg, parent and child preferences) to clinicians. CONCLUSION Our findings highlight a discrepancy between clinicians' concerns about overprescribing and a lack of resources to support deprescribing in outpatient paediatric settings. To successfully initiate deprescribing, clinicians will need practical tools and organisational supports, as well as social resources for vulnerable families.
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Affiliation(s)
- Erin R Barnett
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA .,Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Vulnerable Children Research Group, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.,Dartmouth Trauma Interventions Research Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Alissa Z Trepman
- Vulnerable Children Research Group, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Hannah A Fuson
- Vulnerable Children Research Group, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Stephanie C Acquilano
- Vulnerable Children Research Group, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Jennifer L McLaren
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.,Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Vulnerable Children Research Group, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Steven Woloshin
- Vulnerable Children Research Group, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.,Center for Medicine and Media at The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Joanna K Leyenaar
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Vulnerable Children Research Group, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.,Department of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, US
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19
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Richmond J, Mangrum R, Wang G, Maurer M, Sofaer S, Yang M, Carman KL. An informed public's views on reducing antibiotic overuse. Health Serv Res 2019; 54:1283-1294. [PMID: 31172520 PMCID: PMC6863223 DOI: 10.1111/1475-6773.13175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To understand public attitudes about and recommendations to address antibiotic overuse by employing public deliberation (a method for eliciting informed input on value-laden issues). DATA SOURCES/STUDY SETTING Participants in 24 Community Deliberation groups (CD; n = 263), four Citizens' Panel groups (CP; n = 96), and a control group (n = 348). Data were collected in 2012 in four U.S. LOCATIONS STUDY DESIGN Using mixed methods, we analyzed quantitative and qualitative data from a randomized control trial. DATA COLLECTION/EXTRACTION METHODS Using pre/postdeliberation surveys, we compared CD and CP participant attitude changes regarding antibiotic use to the control group. We analyzed deliberation transcripts using qualitative techniques to provide context for survey results. PRINCIPAL FINDINGS Compared to control group participants, CD and CP participants had a larger postdeliberation shift in attitudes toward support of government limits on when doctors can prescribe antibiotics. Participants described unawareness about antibiotic overuse and called for education. When discussing prescription limits, participants debated tensions between preserving patient/doctor autonomy and protecting society from antibiotic-related harms. Participants saw patient, physician, and government roles in antibiotic stewardship policies/programs. CONCLUSION When informed about individual and social consequences of antibiotic overuse, patients may be more receptive to antibiotic prescription limits. Community-physician-government partnerships are needed to create solutions.
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Affiliation(s)
- Jennifer Richmond
- Research and EvaluationAmerican Institutes for ResearchChapel HillNorth Carolina
- Department of Health BehaviorUniversity of North Carolina at Chapel Hill Gillings School of Global Public HealthChapel HillNorth Carolina
| | - Rikki Mangrum
- Research and EvaluationAmerican Institutes for ResearchChapel HillNorth Carolina
| | - Grace Wang
- IMPAQ International, LLCSeattleWashington
| | - Maureen Maurer
- Research and EvaluationAmerican Institutes for ResearchChapel HillNorth Carolina
| | - Shoshanna Sofaer
- Research and EvaluationAmerican Institutes for ResearchNew YorkNew York
| | - Manshu Yang
- Research and EvaluationAmerican Institutes for ResearchChapel HillNorth Carolina
| | - Kristin L. Carman
- Patient‐Centered Outcomes Research InstituteWashingtonDistrict of Columbia
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Dekker ARJ, Verheij TJM, Broekhuizen BDL, Butler CC, Cals JWL, Francis NA, Little P, Sanders EAM, Yardley L, Zuithoff NPA, van der Velden AW. Effectiveness of general practitioner online training and an information booklet for parents on antibiotic prescribing for children with respiratory tract infection in primary care: a cluster randomized controlled trial. J Antimicrob Chemother 2019; 73:1416-1422. [PMID: 29438547 DOI: 10.1093/jac/dkx542] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/25/2017] [Indexed: 11/13/2022] Open
Abstract
Objectives Antibiotics are too often prescribed in childhood respiratory tract infection (RTI), despite limited effectiveness, potential side effects and bacterial resistance. We aimed to reduce antibiotic prescribing for children with RTI by online training for general practitioners (GPs) and information for parents. Methods A pragmatic cluster randomized controlled trial in primary care. The intervention consisted of online training for GPs and an information booklet for parents. The primary outcome was the antibiotic prescription rate for children presenting with RTI symptoms, as registered by GPs. Secondary outcomes were number of reconsultations within the same disease episode, consultations for new episodes, hospital referrals and pharmacy-dispensed antibiotic courses for children. This trial was registered at the Dutch Trial Register (NTR), registration number: NTR4240. Results After randomization, GPs from a total of 32 general practices registered 1009 consultations. An antibiotic was prescribed in 21% of consultations in the intervention group, compared with 33% in the usual care group, controlled for baseline prescribing (rate ratio 0.65, 95% CI 0.46-0.91). The probability of reconsulting during the same RTI episode did not differ significantly between the intervention and control groups, and nor did the numbers of consultations for new episodes and hospital referrals. In the intervention group antibiotic dispensing was 32 courses per 1000 children/year lower than the control group, adjusted for baseline prescribing (rate ratio 0.78, 95% CI 0.66-0.92). The numbers and proportion of second-choice antibiotics did not differ significantly. Conclusions Concise, feasible, online GP training, with an information booklet for parents, showed a relevant reduction in antibiotic prescribing for children with RTI.
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Affiliation(s)
- Anne R J Dekker
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Berna D L Broekhuizen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jochen W L Cals
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Nick A Francis
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Little
- Primary Care Medical Group, University of Southampton Medical School, Southampton, UK
| | - Elisabeth A M Sanders
- Department of Paediatric Immunology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Lucy Yardley
- Academic Unit of Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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21
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Dekker ARJ, van der Velden AW, Luijken J, Verheij TJM, van Giessen A. Cost-effectiveness analysis of a GP- and parent-directed intervention to reduce antibiotic prescribing for children with respiratory tract infections in primary care. J Antimicrob Chemother 2019; 74:1137-1142. [PMID: 30608531 DOI: 10.1093/jac/dky552] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 11/20/2018] [Accepted: 12/03/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We evaluated costs and effects of the RAAK (RAtional Antibiotic use Kids) intervention (GP online training and information booklets for parents), aiming to reduce antibiotic prescribing for children with respiratory tract infection (RTI). METHODS We conducted a trial-based cost-effectiveness analysis from a societal perspective. We included children consulting the GP with RTI for whom parents kept a 2 week (cost) diary. The antibiotic prescribing rate was the percentage of children receiving an antibiotic prescription at the index consultation and during the 2 weeks of follow-up. The cost difference between the intervention and usual care groups per percentage decrease in antibiotic prescribing was calculated. Bootstrapping was used to assess uncertainty surrounding the outcomes. RESULTS Costs and effects of 153 children in the intervention group and 107 children in the usual care group were available for analysis. Antibiotic prescribing was 12% lower in the intervention group and costs were €10.27 higher in the intervention group compared with the usual care group. This resulted in an incremental cost-effectiveness ratio of €0.85 per percentage decrease in antibiotic prescribing. The probability that the intervention was more effective, but more expensive, was 53%, whereas the probability that the intervention was more effective and less expensive compared with usual care was 41%. CONCLUSIONS The online training for GPs and the information booklet for parents resulted in a decrease in antibiotic prescribing in children with RTI, at very low cost, and should therefore be considered for implementation in primary care.
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Affiliation(s)
- Anne R J Dekker
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Janneke Luijken
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anoukh van Giessen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,National Institute of Public Health and the Environment, Bilthoven, The Netherlands
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22
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Wei X, Zhang Z, Hicks JP, Walley JD, King R, Newell JN, Yin J, Zeng J, Guo Y, Lin M, Upshur REG, Sun Q. Long-term outcomes of an educational intervention to reduce antibiotic prescribing for childhood upper respiratory tract infections in rural China: Follow-up of a cluster-randomised controlled trial. PLoS Med 2019; 16:e1002733. [PMID: 30721234 PMCID: PMC6363140 DOI: 10.1371/journal.pmed.1002733] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/19/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescribing causes widespread serious health problems. To reduce prescribing of antibiotics in Chinese primary care to children with upper respiratory tract infections (URTIs), we developed an intervention comprising clinical guidelines, monthly prescribing review meetings, doctor-patient communication skills training, and education materials for caregivers. We previously evaluated our intervention using an unblinded cluster-randomised controlled trial (cRCT) in 25 primary care facilities across two rural counties. When our trial ended at the 6-month follow-up period, we found that the intervention had reduced antibiotic prescribing for childhood URTIs by 29 percentage points (pp) (95% CI -42 to -16). METHODS AND FINDINGS In this long-term follow-up study, we collected our trial outcomes from the one county (14 facilities and 1:1 cluster randomisation ratio) that had electronic records available 12 months after the trial ended, at the 18-month follow-up period. Our primary outcome was the antibiotic prescription rate (APR)-the percentage of outpatient prescriptions containing any antibiotic(s) for children aged 2 to 14 years who had a primary diagnosis of a URTI and had no other illness requiring antibiotics. We also conducted 15 in-depth interviews to understand how interventions were sustained. In intervention facilities, the APR was 84% (1,171 out of 1,400) at baseline, 37% (515 out of 1,380) at 6 months, and 54% (2,748 out of 5,084) at 18 months, and in control facilities, it was 76% (1,063 out of 1,400), 77% (1,084 out of 1,400), and 75% (2,772 out of 3,685), respectively. After adjusting for patient and prescribing doctor covariates, compared to the baseline intervention-control difference, the difference at 6 months represented a 6-month intervention-arm reduction in the APR of -49 pp (95% CI -63 to -35; P < 0.0001), and compared to the baseline difference, the difference at 18 months represented an 18-month intervention-arm reduction in the APR of -36 pp (95% CI -55 to -17; P < 0.0001). Compared to the 6-month intervention-control difference, the difference at 18 months represented no change in the APR: 13 pp (95% CI -7 to 33; P = 0.21). Factors reported to sustain reductions in antibiotic prescribing included doctors' improved knowledge and communication skills and focused prescription review meetings, whereas lack of supervision and monitoring may be associated with relapse. Key limitations were not including all clusters from the trial and not collecting returned visits or sepsis cases. CONCLUSIONS Our intervention was associated with sustained and substantial reductions in antibiotic prescribing at the end of the intervention period and 12 months later. Our intervention may be adapted to similar resource-poor settings. TRIAL REGISTRATION ISRCTN registry ISRCTN14340536.
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Affiliation(s)
- Xiaolin Wei
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - Joseph P. Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - John D. Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Rebecca King
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - James N. Newell
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Jia Yin
- School of Health Care Management, Shandong University, Jinan, China
- Key Laboratory of Health Economics and Policy Research, National Health Commission, Jinan, China
| | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Yan Guo
- School of Public Health, Peking University, Beijing, China
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Ross E. G. Upshur
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Qiang Sun
- School of Health Care Management, Shandong University, Jinan, China
- Key Laboratory of Health Economics and Policy Research, National Health Commission, Jinan, China
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Characterising patient complaints in out-of-hours general practice: a retrospective cohort study in Ireland. Br J Gen Pract 2018; 68:e860-e868. [PMID: 30455221 DOI: 10.3399/bjgp18x699965] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 06/14/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Patient complaints can provide valuable insights into the quality and safety of clinical care. Studies examining the epidemiology of complaints in out-of-hours general practice internationally are limited. AIM To characterise patient complaints in an out-of-hours general practice setting. DESIGN AND SETTING Retrospective cohort study of patient complaints to an out-of-hours service provider in Dublin, Ireland, over a 5-year period (2011-2016). This comprises nurse-led telephone triage and GP consultations for patients with urgent problems. METHOD A modified version of the UK Healthcare Complaints Analysis Tool (HCAT) was utilised to code complaints, which were reviewed independently in duplicate by two academic GPs. RESULTS Of 445 598 telephone contacts, 303 085 resulted in face-to-face GP consultations. Of 234 patients who made 298 complaints, 185 (79%) related to GP care. The remainder related to nurse triage, other staff, and management issues. A total of 109 (46%) related to children aged ≤18 years, and 134 (58%) of complainants were female. There were 0.61 complaints per 1000 GP consultations. Most complaints (n = 126, 42%) were in relation to clinical care problems, largely diagnosis and prescribing. Common themes included unmet management expectations and clinical examination dissatisfaction. Inter-rater reliability was 90% (κ statistic 0.84, 95% confidence interval = 0.80 to 0.88). Following internal investigation, 158 (85%) of GP-related complaints were managed effectively by the out-of-hours service. CONCLUSION The majority of complaints related to clinical care problems and were successfully managed locally. Expectation management may be an important way to mitigate the risk of complaints.
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O'Connor R, O'Doherty J, O'Regan A, Dunne C. Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review. Ir J Med Sci 2018; 187:969-986. [PMID: 29532292 PMCID: PMC6209023 DOI: 10.1007/s11845-018-1774-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 02/23/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Antimicrobial resistance is an emerging global threat to health and is associated with increased consumption of antibiotics. Seventy-four per cent of antibiotic prescribing takes place in primary care. Much of this is for inappropriate treatment of acute respiratory tract infections. AIMS To review the published literature pertaining to antibiotic prescribing in order to identify and understand the factors that affect primary care providers' prescribing decisions. METHODS Six online databases were searched for relevant paper using agreed criteria. One hundred ninety-five papers were retrieved, and 139 were included in this review. RESULTS Primary care providers are highly influenced to prescribe by patient expectation for antibiotics, clinical uncertainty and workload induced time pressures. Strategies proven to reduce such inappropriate prescribing include appropriately aimed multifaceted educational interventions for primary care providers, mass media educational campaigns aimed at healthcare professionals and the public, use of good communication skills in the consultation, use of delayed prescriptions especially when accompanied by written information, point of care testing and, probably, longer less pressurised consultations. Delayed prescriptions also facilitate focused personalised patient education. CONCLUSION There is an emerging consensus in the literature regarding strategies proven to reduce antibiotic consumption for acute respiratory tract infections. The widespread adoption of these strategies in primary care is imperative.
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Affiliation(s)
- Ray O'Connor
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland.
| | - Jane O'Doherty
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
| | - Andrew O'Regan
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
| | - Colum Dunne
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
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25
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Zhang Z, Dawkins B, Hicks JP, Walley JD, Hulme C, Elsey H, Deng S, Lin M, Zeng J, Wei X. Cost-effectiveness analysis of a multi-dimensional intervention to reduce inappropriate antibiotic prescribing for children with upper respiratory tract infections in China. Trop Med Int Health 2018; 23:1092-1100. [PMID: 30058210 DOI: 10.1111/tmi.13132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND We developed a multifaceted intervention to reduce antibiotic prescription rate for children with upper respiratory tract infections (URTIs) among primary care doctors in township hospitals in China. The intervention achieved a 29% (95% CI 16-42) absolute risk reduction in antibiotic prescribing. This study was to assess the cost-effectiveness of our intervention at reducing antibiotic prescribing in rural primary care facilities as measured by the intervention's effect on the antibiotic prescription rates for childhood URTIs. METHODS We took a healthcare provider perspective, measuring costs of consultation (time cost of doctor), prescription monitoring process and peer-review meetings (time cost of participants) and medication costs. Costs on provider side were collected through a bespoke questionnaire from all 25 township hospitals in December 2016, while medication costs were collected prospectively in the trial. Incremental cost-effectiveness ratios were calculated by dividing the mean difference in cost of the two trial arms by the mean difference in antibiotic prescribing rate. RESULTS This showed an incremental cost of $0.03 per percentage point reduction in antibiotic prescribing. In addition to this incremental cost, the cost of implementing the intervention, including training and materials delivered by township hospitals, was $390.65 (SD $145.68) per healthcare facility. CONCLUSIONS This study shows that a multifaceted intervention programme, when embedded into routine practice, is very cost-effective at reducing antibiotic prescribing in primary care facilities and has the potential of scale up in similar resource limited settings.
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Affiliation(s)
- Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - Bryony Dawkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Joseph P Hicks
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - John D Walley
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Helen Elsey
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Simin Deng
- China Global Health Research and Development, Shenzhen, China
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Xiaolin Wei
- Division of Clinical Public Health and Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Walley J, Khan MA, Witter S, Haque R, Newell J, Wei X. Embedded health service development and research: why and how to do it (a ten-stage guide). Health Res Policy Syst 2018; 16:67. [PMID: 30045731 PMCID: PMC6060510 DOI: 10.1186/s12961-018-0344-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/22/2018] [Indexed: 11/10/2022] Open
Abstract
In a world of changing disease burdens, poor quality care and constrained health budgets, finding effective approaches to developing and implementing evidence-based health services is crucial. Much has been published on developing service tools and protocols, operational research and getting policy into practice but these are often undertaken in isolation from one another. This paper, based on 25 years of experience in a range of low and middle income contexts as well as wider literature, presents a systematic approach to connecting these activities in an embedded development and research approach. This approach can circumvent common problems such as lack of local ownership of new programmes, unrealistic resource requirements and poor implementation.We lay out a ten-step process, which is based on long-term partnerships and working within local systems and constraints and may be tailored to the context and needs. Service development and operational research is best prioritised, designed, conducted and replicated when it is embedded within ministry of health and national programmes. Care packages should from the outset be designed for scale-up, which is why the piloting stage is so crucial. In this way, the resulting package of care will be feasible within the context and will address local priorities. Researchers must be entrepreneurial and responsive to windows of funding for scale-up, working in real-world contexts where funding and decisions do not wait for evidence, so evidence generation has to be pragmatic to meet and ensure best use of the policy and financing cycles. The research should generate tested and easily usable tools, training materials and processes for use in scale-up. Development of the package should work within and strengthen the health system and other service delivery strategies to ensure that unintended negative consequences are minimised and that the strengthened systems support quality care and effective scale up of the package.While embedded development and research is promoted in theory, it is not yet practiced at scale by many initiatives, leading to wasted resources and un-sustained programmes. This guide presents a systematic and practical guide to support more effective engagements in future, both in developing interventions and supporting evidence-based scale-up.
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Affiliation(s)
- John Walley
- Leeds Institute of Health Sciences, University of Leeds, England, United Kingdom
| | | | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, Edinburgh EH21 6UU United Kingdom
| | | | - James Newell
- Leeds Institute of Health Sciences, University of Leeds, England, United Kingdom
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
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Goggin K, Bradley-Ewing A, Myers AL, Lee BR, Hurley EA, Delay KB, Schlachter S, Ramphal A, Pina K, Yu D, Weltmer K, Linnemayr S, Butler CC, Newland JG. Protocol for a randomised trial of higher versus lower intensity patient-provider communication interventions to reduce antibiotic misuse in two paediatric ambulatory clinics in the USA. BMJ Open 2018; 8:e020981. [PMID: 29743330 PMCID: PMC5942422 DOI: 10.1136/bmjopen-2017-020981] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Children with acute respiratory tract infections (ARTIs) are prescribed up to 11.4 million unnecessary antibiotic prescriptions annually. Inadequate parent-provider communication is a chief contributor, yet efforts to reduce overprescribing have only indirectly targeted communication or been impractical. This paper describes our multisite, parallel group, cluster randomised trial comparing two feasible interventions for enhancing parent-provider communication on the rate of inappropriate antibiotic prescribing (primary outcome) and revisits, adverse drug reactions and parent-rated quality of shared decision-making, parent-provider communication and visit satisfaction (secondary outcomes). METHODS/ANALYSIS We will attempt to recruit all eligible paediatricians and nurse practitioners (currently 47) at an academic children's hospital and a private practice. Using a 1:1 randomisation, providers will be assigned to a higher intensity education and communication skills or lower intensity education-only intervention and trained accordingly. We will recruit 1600 eligible parent-child dyads. Parents of children ages 1-5 years who present with ARTI symptoms will be managed by providers trained in either the higher or lower intensity intervention. Before their consultation, all parents will complete a baseline survey and view a 90 s gain-framed antibiotic educational video. Parent-child dyads consulting with providers trained in the higher intensity intervention will, in addition, receive a gain-framed antibiotic educational brochure promoting cautious use of antibiotics and rate their interest in receiving an antibiotic which will be shared with their provider before the visit. All parents will complete a postconsultation survey and a 2-week follow-up phone survey. Due to the two-stage nested design (parents nested within providers and clinics), we will employ generalised linear mixed-effect regression models. ETHICS/DISSEMINATION Ethical approval was obtained from the Children's Mercy Hospital Pediatric Institutional Review Board (#16060466). Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03037112; Pre-results.
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Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
- School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Andrea Bradley-Ewing
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Angela L Myers
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
- Infectious Diseases, Children's Mercy, Kansas City, Missouri, USA
| | - Brian R Lee
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Kirsten B Delay
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Sarah Schlachter
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Areli Ramphal
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Kimberly Pina
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - David Yu
- Sunflower Medical Group, Kansas City, Kansas, USA
| | - Kirsten Weltmer
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jason G Newland
- Pediatric Infectious Disease, St. Louis Children's Hospital, St. Louis, Missouri, USA
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Wei X, Zhang Z, Walley JD, Hicks JP, Zeng J, Deng S, Zhou Y, Yin J, Newell JN, Sun Q, Zou G, Guo Y, Upshur REG, Lin M. Effect of a training and educational intervention for physicians and caregivers on antibiotic prescribing for upper respiratory tract infections in children at primary care facilities in rural China: a cluster-randomised controlled trial. Lancet Glob Health 2017; 5:e1258-e1267. [PMID: 29102353 DOI: 10.1016/s2214-109x(17)30383-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/11/2017] [Accepted: 09/15/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Inappropriate antibiotic prescribing contributes to the generation of drug resistance worldwide, and is particularly common in China. We assessed the effectiveness of an antimicrobial stewardship programme aiming to reduce inappropriate antibiotic prescribing in paediatric outpatients by targeting providers and caregivers in primary care hospitals in rural China. METHODS We did a pragmatic, cluster-randomised controlled trial with a 6-month intervention period. Clusters were primary care township hospitals in two counties of Guangxi province in China, which were randomly allocated to the intervention group or the control group (in a 1:1 ratio in Rong county and in a 5:6 ratio in Liujiang county). Randomisation was stratified by county. Eligible participants were children aged 2-14 years who attended a township hospital as an outpatient and were given a prescription following a primary diagnosis of an upper respiratory tract infection. The intervention included clinician guidelines and training on appropriate prescribing, monthly prescribing peer-review meetings, and brief caregiver education. In hospitals allocated to the control group, usual care was provided, with antibiotics prescribed at the individual clinician's discretion. Patients were masked to their allocated treatment group but doctors were not. The primary outcome was the antibiotic prescription rate in children attending the hospitals, defined as the cluster-level proportion of prescriptions for upper respiratory tract infections in 2-14-year-old outpatients, issued during the final 3 months of the 6-month intervention period (endline), that included one or more antibiotics. The outcome was based on prescription records and analysed by modified intention-to-treat. This study is registered with the ISRCTN registry, number ISRCTN14340536. FINDINGS We recruited all 25 eligible township hospitals in the two counties (14 hospitals in Rong county and 11 in Liujiang county), and randomly allocated 12 to the intervention group and 13 to the control group. We implemented the intervention in three internal pilot clusters between July 1, 2015, and Dec 31, 2015, and in the remaining nine intervention clusters between Oct 1, 2016 and March 31, 2016. Between baseline (the 3 months before implementation of the intervention) and endline (the final 3 months of the 6-month intervention period) the antibiotic prescription rate at the individual level decreased from 82% (1936/2349) to 40% (943/2351) in the intervention group, and from 75% (1922/2548) to 70% (1782/2552) in the control group. After adjusting for the baseline antibiotic prescription rate, stratum (county), and potentially confounding patient and prescribing doctor covariates, this endline difference between the groups represented an intervention effect (absolute risk reduction in antibiotic prescribing) of -29% (95% CI -42 to -16; p=0·0002). INTERPRETATION In China's primary care setting, pragmatic interventions on antimicrobial stewardship targeting providers and caregivers substantially reduced prescribing of antibiotics for childhood upper respiratory tract infections. FUNDING Department of International Development (UKAID) through Communicable Diseases Health Service Delivery.
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Affiliation(s)
- Xiaolin Wei
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - John D Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Joseph P Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Simin Deng
- China Global Health Research and Development, Shenzhen, China
| | - Yu Zhou
- China Global Health Research and Development, Shenzhen, China
| | - Jia Yin
- School of Health Care Management, Shandong University, Jinan, China
| | - James N Newell
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Qiang Sun
- School of Health Care Management, Shandong University, Jinan, China
| | - Guanyang Zou
- China Global Health Research and Development, Shenzhen, China
| | - Yan Guo
- Centre for Global Health, School of Public Health, Peking University, Beijing, China
| | - Ross E G Upshur
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China.
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Reducing antibiotic prescriptions for childhood upper respiratory tract infections. LANCET GLOBAL HEALTH 2017; 5:e1170-e1171. [DOI: 10.1016/s2214-109x(17)30423-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 11/21/2022]
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Tonkin‐Crine SKG, Tan PS, van Hecke O, Wang K, Roberts NW, McCullough A, Hansen MP, Butler CC, Del Mar CB. Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD012252. [PMID: 28881002 PMCID: PMC6483738 DOI: 10.1002/14651858.cd012252.pub2] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Antibiotic resistance is a worldwide health threat. Interventions that reduce antibiotic prescribing by clinicians are expected to reduce antibiotic resistance. Disparate interventions to change antibiotic prescribing behaviour for acute respiratory infections (ARIs) have been trialled and meta-analysed, but not yet synthesised in an overview. This overview synthesises evidence from systematic reviews, rather than individual trials. OBJECTIVES To systematically review the existing evidence from systematic reviews on the effects of interventions aimed at influencing clinician antibiotic prescribing behaviour for ARIs in primary care. METHODS We searched the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, CINAHL, PsycINFO, and Science Citation Index to June 2016. We also searched the reference lists of all included reviews. We ran a pre-publication search in May 2017 and placed additional studies in 'awaiting classification'.We included both Cochrane and non-Cochrane reviews of randomised controlled trials evaluating the effect of any clinician-focussed intervention on antibiotic prescribing behaviour in primary care. Two overview authors independently extracted data and assessed the methodological quality of included reviews using the ROBIS tool, with disagreements reached by consensus or by discussion with a third overview author. We used the GRADE system to assess the quality of evidence in included reviews. The results are presented as a narrative overview. MAIN RESULTS We included eight reviews in this overview: five Cochrane Reviews (33 included trials) and three non-Cochrane reviews (11 included trials). Three reviews (all Cochrane Reviews) scored low risk across all the ROBIS domains in Phase 2 and low risk of bias overall. The remaining five reviews scored high risk on Domain 4 of Phase 2 because the 'Risk of bias' assessment had not been specifically considered and discussed in the review Results and Conclusions. The trials included in the reviews varied in both size and risk of bias. Interventions were compared to usual care.Moderate-quality evidence indicated that C-reactive protein (CRP) point-of-care testing (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92, 3284 participants, 6 trials), shared decision making (odds ratio (OR) 0.44, 95% CI 0.26 to 0.75, 3274 participants, 3 trials; RR 0.64, 95% CI 0.49 to 0.84, 4623 participants, 2 trials; risk difference -18.44, 95% CI -27.24 to -9.65, 481,807 participants, 4 trials), and procalcitonin-guided management (adjusted OR 0.10, 95% CI 0.07 to 0.14, 1008 participants, 2 trials) probably reduce antibiotic prescribing in general practice. We found moderate-quality evidence that procalcitonin-guided management probably reduces antibiotic prescribing in emergency departments (adjusted OR 0.34, 95% CI 0.28 to 0.43, 2605 participants, 7 trials). The overall effect of these interventions was small (few achieving greater than 50% reduction in antibiotic prescribing, most about a quarter or less), but likely to be clinically important.Compared to usual care, shared decision making probably makes little or no difference to reconsultation for the same illness (RR 0.87, 95% CI 0.74 to 1.03, 1860 participants, 4 trials, moderate-quality evidence), and may make little or no difference to patient satisfaction (RR 0.86, 95% CI 0.57 to 1.30, 1110 participants, 2 trials, low-quality evidence). Similarly, CRP testing probably has little or no effect on patient satisfaction (RR 0.79, 95% CI 0.57 to 1.08, 689 participants, 2 trials, moderate-quality evidence) or reconsultation (RR 1.08, 95% CI 0.93 to 1.27, 5132 participants, 4 trials, moderate-quality evidence). Procalcitonin-guided management probably results in little or no difference in treatment failure in general practice compared to normal care (adjusted OR 0.95, 95% CI 0.73 to 1.24, 1008 participants, 2 trials, moderate-quality evidence), however it probably reduces treatment failure in the emergency department compared to usual care (adjusted OR 0.76, 95% CI 0.61 to 0.95, 2605 participants, 7 trials, moderate-quality evidence).The quality of evidence for interventions focused on clinician educational materials and decision support in reducing antibiotic prescribing in general practice was either low or very low (no pooled result reported) and trial results were highly heterogeneous, therefore we were unable draw conclusions about the effects of these interventions. The use of rapid viral diagnostics in emergency departments may have little or no effect on antibiotic prescribing (RR 0.86, 95% CI 0.61 to 1.22, 891 participants, 3 trials, low-quality evidence) and may result in little to no difference in reconsultation (RR 0.86, 95% CI 0.59 to 1.25, 200 participants, 1 trial, low-quality evidence).None of the trials in the included reviews reported on management costs for the treatment of an ARI or any associated complications. AUTHORS' CONCLUSIONS We found evidence that CRP testing, shared decision making, and procalcitonin-guided management reduce antibiotic prescribing for patients with ARIs in primary care. These interventions may therefore reduce overall antibiotic consumption and consequently antibiotic resistance. There do not appear to be negative effects of these interventions on the outcomes of patient satisfaction and reconsultation, although there was limited measurement of these outcomes in the trials. This should be rectified in future trials.We could gather no information about the costs of management, and this along with the paucity of measurements meant that it was difficult to weigh the benefits and costs of implementing these interventions in practice.Most of this research was undertaken in high-income countries, and it may not generalise to other settings. The quality of evidence for the interventions of educational materials and tools for patients and clinicians was either low or very low, which prevented us from drawing any conclusions. High-quality trials are needed to further investigate these interventions.
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Affiliation(s)
- Sarah KG Tonkin‐Crine
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Pui San Tan
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Oliver van Hecke
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Kay Wang
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Nia W Roberts
- University of OxfordBodleian Health Care LibrariesKnowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
| | - Amanda McCullough
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia
| | | | - Christopher C Butler
- University of OxfordNuffield Department of Primary Care Health SciencesWoodstock RoadOxfordOxonUKOX2 6GG
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia
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Wei X, Yin J, Walley JD, Zhang Z, Hicks JP, Zhou Y, Sun Q, Zeng J, Lin M. Impact of China's essential medicines scheme and zero-mark-up policy on antibiotic prescriptions in county hospitals: a mixed methods study. Trop Med Int Health 2017; 22:1166-1174. [PMID: 28665490 DOI: 10.1111/tmi.12922] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the impact of the national essential medicines scheme and zero-mark-up policy on antibiotic prescribing behaviour. METHODS In rural Guangxi, a natural experiment compared one county hospital which implemented the policy with a comparison hospital which did not. All outpatient and inpatient records in 2011 and 2014 were extracted from the two hospitals. Primary outcome indicator was antibiotic prescribing rate (APR) among children aged 2-14 presenting in outpatients with a primary diagnosis of upper respiratory tract infection (URTI). We organised independent physician reviews to determine inappropriate prescribing for inpatients. Difference-in-difference analyses based on multivariate regressions were used to compare APR over time after adjusting potential confounders. We conducted 12 in-depth interviews with paediatricians, hospital directors and health officials. RESULTS A total of 8219 and 4142 outpatient prescriptions of childhood URTIs were included in the intervention and comparison hospitals, respectively. In 2011, APR was 30% in the intervention and 88% in the comparison hospital. In 2014, the intervention hospital significantly reduced outpatient APR by 21% (95% CI:-23%, -18%), intravenous infusion by 58% (95% CI: -64%, -52%) and prescription cost by 31 USD (95% CI: -35, -28), compared with the controls. We collected 251 inpatient records, but did not find reductions in inappropriate antibiotic use. Interviews revealed that the intervention hospital implemented a thorough antibiotics stewardship programme containing training, peer review of prescriptions and restrictions for overprescribing. CONCLUSION The national essential medicines scheme and zero-mark-up policy, when implemented with an antimicrobial stewardship programme, may be associated with reductions in outpatient antibiotic prescribing and intravenous infusions.
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Affiliation(s)
- Xiaolin Wei
- Division of Clinical Public Health, and Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jia Yin
- Shandong University, Jinan, China
| | - John D Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - Joseph P Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Yu Zhou
- China Global Health Research and Development, Shenzhen, China
| | | | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
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Zhang Z, Hu Y, Zou G, Lin M, Zeng J, Deng S, Zachariah R, Walley J, Tucker JD, Wei X. Antibiotic prescribing for upper respiratory infections among children in rural China: a cross-sectional study of outpatient prescriptions. Glob Health Action 2017; 10:1287334. [PMID: 28462635 PMCID: PMC5496075 DOI: 10.1080/16549716.2017.1287334] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/19/2017] [Indexed: 10/30/2022] Open
Abstract
BACKGROUND Overuse of antibiotics contributes to the development of antimicrobial resistance. OBJECTIVE This study aims to assess the condition of antibiotic use at health facilities at county, township and village levels in rural Guangxi, China. METHODS We conducted a cross-sectional study of outpatient antibiotic prescriptions in 2014 for children aged 2-14 years with upper respiratory infections (URI). Twenty health facilities were randomly selected, including four county hospitals, eight township hospitals and eight village clinics. Prescriptions were extracted from the electronic records in the county hospitals and paper copies in the township hospitals and village clinics. RESULTS The antibiotic prescription rate was higher in township hospitals (593/877, 68%) compared to county hospitals (2736/8166, 34%) and village clinics (96/297, 32%) (p < 0.001). Among prescriptions containing antibiotics, county hospitals were found to have the highest use rate of broad-spectrum antibiotics (82 vs 57% [township], vs 54% [village], p < 0.001), injectable antibiotics (65 vs 43% [township], vs 33% [village], p < 0.001) and multiple antibiotics (47 vs 15% [township], vs 0% [village], p < 0.001). Logistic regression showed that the likelihood of prescribing an antibiotic was significantly associated with patients being 6-14 years old compared with being 2-5 years old (adjusted odds ratio [aOR] = 1.3, 95% CI 1.2-1.5), and receiving care at township hospitals compared with county hospitals (aOR = 5.0, 95% CI 4.1-6.0). Prescriptions with insurance copayment appeared to lower the risk of prescribing antibiotics compared with those without (aOR = 0.8, 95% CI 0.7-0.9). CONCLUSIONS Inappropriate use of antibiotics was high for outpatient childhood URI in the four counties of Guangxi, China, with the highest rate found in township hospitals. A significant high proportion of prescriptions containing antibiotics were broad-spectrum, by intravenous infusion or with multiple antibiotics, especially at county hospitals. Urgent attention is needed to address this challenge.
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Affiliation(s)
- Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - Yanhong Hu
- School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Guanyang Zou
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Mei Lin
- Guangxi Zhuang Autonomous Region Center for Disease Prevention and Control, Nanning, China
| | - Jun Zeng
- Guangxi Zhuang Autonomous Region Center for Disease Prevention and Control, Nanning, China
| | - Simin Deng
- China Global Health Research and Development, Shenzhen, China
| | - Rony Zachariah
- Medical Department, Operational Research Unit, Médecins sans Frontières, Brussels Operational Center, Luxembourg City, Luxembourg
| | - John Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Joseph D. Tucker
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Zou G, Wei X, Hicks JP, Hu Y, Walley J, Zeng J, Elsey H, King R, Zhang Z, Deng S, Huang Y, Blacklock C, Yin J, Sun Q, Lin M. Protocol for a pragmatic cluster randomised controlled trial for reducing irrational antibiotic prescribing among children with upper respiratory infections in rural China. BMJ Open 2016; 6:e010544. [PMID: 27235297 PMCID: PMC4885273 DOI: 10.1136/bmjopen-2015-010544] [Citation(s) in RCA: 10] [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: 02/07/2023] Open
Abstract
INTRODUCTION Irrational use of antibiotics is a serious issue within China and internationally. In 2012, the Chinese Ministry of Health issued a regulation for antibiotic prescriptions limiting them to <20% of all prescriptions for outpatients, but no operational details have been issued regarding policy implementation. This study aims to test the effectiveness of a multidimensional intervention designed to reduce the use of antibiotics among children (aged 2-14 years old) with acute upper respiratory infections in rural primary care settings in China, through changing doctors' prescribing behaviours and educating parents/caregivers. METHODS AND ANALYSIS This is a pragmatic, parallel-group, controlled, cluster-randomised superiority trial, with blinded evaluation of outcomes and data analysis, and un-blinded treatment. From two counties in Guangxi Province, 12 township hospitals will be randomised to the intervention arm and 13 to the control arm. In the control arm, the management of antibiotics prescriptions will continue through usual care via clinical consultations. In the intervention arm, a provider and patient/caregiver focused intervention will be embedded within routine primary care practice. The provider intervention includes operational guidelines, systematic training, peer review of antibiotic prescribing and provision of health education to patient caregivers. We will also provide printed educational materials and educational videos to patients' caregivers. The primary outcome is the proportion of all prescriptions issued by providers for upper respiratory infections in children aged 2-14 years old, which include at least one antibiotic. ETHICS AND DISSEMINATION The trial has received ethical approval from the Ethics Committee of Guangxi Provincial Centre for Disease Control and Prevention, China. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, local and international conferences. TRIAL REGISTRATION NUMBER ISRCTN14340536; Pre-results.
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Affiliation(s)
- Guanyang Zou
- China Global Health Research and Development, Shenzhen, China
| | - Xiaolin Wei
- China Global Health Research and Development, Shenzhen, China
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Joseph P Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Yanhong Hu
- School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - John Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Helen Elsey
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Rebecca King
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - Simin Deng
- China Global Health Research and Development, Shenzhen, China
| | - Yuanyuan Huang
- China Global Health Research and Development, Shenzhen, China
| | - Claire Blacklock
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Jia Yin
- School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Qiang Sun
- Centre for Health Management and Policy, Shandong University, Jinan, China
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
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