Differences in antibiotic use between patients with and without a regular doctor in Hong Kong

Weighing patient attributes in antibiotic prescribing for upper respiratory tract infections: A discrete choice experiment on primary care physicians in Hubei Province, China

Objectives

This study aimed to determine how primary care physicians weigh intervenable patient attributes in their decisions of antibiotic prescribing for upper respiratory tract infections (URTIs).

Methods

A discrete choice experiment (DCE) was conducted on 386 primary care physicians selected through a stratified cluster sampling strategy in Hubei province, China. The patient attributes tested in the DCE were identified through semi-structured interviews with 13 primary care physicians, while the choice scenarios were determined by a D-efficient design with a zero prior parameter value. Conditional logit models (CL) and mixed logit models (MXL) were established to determine the preference of the study participants in antibiotic prescribing for URTI patients with various attributes. Relative importance (RI) was calculated to reflect the influence of each attribute.

Results

In addition to age and duration of symptoms, the interventionable patient attributes were also considered by the primary care physicians in their antibiotic prescribing decisions. They preferred to prescribe antibiotics for URTI patients with difficulties to schedule a follow-up appointment (p < 0.001) and for those without a clear indication of refusal to antibiotics (p < 0.001). Patient request for antibiotics had an RI ranging from 15.2 to 16.3%, compared with 5.1-5.4% for easiness of follow-up appointment. The influence of these two interventionable patient attributes was most profound in the antibiotic prescribing decisions for patients aged between 60 and 75 years as indicated by their interaction effects with age (β = 0.69 for request for antibiotics, p < 0.01; β = -1.2 for easiness of follow-up, p < 0.001).

Conclusion

Reducing patient pressure and improving accessibility and continuity of care may help primary care physicians make rational antibiotic prescribing decisions for URTIs.

Factors influencing inappropriate use of antibiotics in outpatient and community settings in China: a mixed-methods systematic review

BACKGROUND

For decades, antibiotics have been excessively consumed around the world, contributing to increased antimicrobial resistance (AMR) and negatively impacting health outcomes and expenditures. Antibiotic use in China accounts for half of worldwide antibiotic consumption, which mainly takes place in outpatient and community settings, and often unnecessarily for self-limiting community-acquired infections. This study aimed to identify and assess factors of inappropriate use of antibiotics in the Chinese context to inform the development of interventions to mitigate inappropriate consumption in the absence of clinical indications.

METHODS

We conducted a mixed-methods systematic review and included empirical studies with original data conducted in mainland China, Hong Kong and Taiwan that investigated factors of antibiotic use in the community including outpatient care among patients, caregivers and prescribers. We searched MEDLINE, EMBASE, the Cochrane Library, PsycINFO, Google Scholar and one Chinese database CNKI (China Knowledge Resource Integrated Database), using a combination of the key terms 'antibiotic', 'antimicrobial', 'use', 'consumption', 'behaviour', 'prescribe' and related syntax for all peer-reviewed publications published before June 2020. Health Belief Model was employed for data synthesis.

FINDINGS

Fifty-four studies were included in the full-text review: 44 quantitative, 5 qualitative and 5 mixed-methods studies. Despite a high AMR awareness, public perception/misconception of antibiotic efficacy and easy access to antibiotics for self-limiting conditions drive inappropriate demand and use in the community including primary care setting. Providers' prescribing behaviours are influenced by financial incentives, lack of diagnostic capacity and concerns over complications.

CONCLUSIONS

Inappropriate outpatient and community antibiotic use is influenced by non-biomedical factors at the individual, community, health system and societal levels in mainland China, contributing to a high antibiotic use rate. This study calls for context-tailored One Health interventions, restrictive antibiotic drug policy and multifaceted antibiotic stewardship programmes that simultaneously address drivers of inappropriate use from both the supply-side and demand-side within and beyond clinical settings.

PROSPERO REGISTRATION NUMBER

CRD42019139591.

Economic burden of antibiotic resistance in China: a national level estimate for inpatients

BACKGROUND

Antibiotic resistance (AR) threats public health in China. National-level estimation of economic burden of AR is lacking. We aimed to quantify the economic costs of AR in inpatients in China.

METHODS

We performed a multicentre and retrospective cohort study including 15,990 patient episodes at four tertiary hospitals in China from 2013 to 2015 to assess the impact of AR on hospital mortality, length of stay, and costs. We estimated the societal economic burden of AR using findings from the cohort study and secondary data from national surveillance hubs and statistical reports.

RESULTS

Patients with multi-drug resistant (MDR) infection or colonisation caused by Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, Escherichia coli, Klebsiella pneumonia, Pseudomonas aeruginosa, and Acinetobacter baumannii experienced higher individual patient cost ($3391, 95% uncertainty interval (UI) $3188-3594), longer hospital stay (5.48 days, 95% UI 5.10-5.87 days), and higher in-hospital mortality rates (1.50%, 95% UI 1.29-1.70%). In China, 27.45% of bacterial infection or colonisation that occurred in inpatients were resistant, of which 15.77% were MDR. A societal economic burden attributed to AR was estimated to be $77 billion in 2017, which is equivalent to 0.37% of China's yearly gross domestic product, with $57 billion associated with MDR.

CONCLUSIONS

This is the first study to estimate national-level economic burden of AR in China. AR places a significant burden on patient health and healthcare systems. Estimation of economic costs of resistant infection or colonisation is the essential step towards building an economic case for global and national actions to combat AMR.

Do patients with and without a regular primary care physician have their psychological distress looked after differently?

BACKGROUND

While qualitative studies suggested that continuity of care by primary care physicians (PCPs) facilitated consultations for psychological problems, there was limited quantitative evidence. This survey compared management of psychological distress between patients with and without a regular PCP.

METHODS

A questionnaire survey was conducted with 1626 adult primary care attenders from 13 private and 6 public clinics in Hong Kong. Management of psychological distress between respondents with a regular PCP and those without were compared. Effects of demographic factors were adjusted for by multivariable logistic regression.

RESULTS

Among the 1626 respondents, 650 (40.0%) reported that they had ever experienced psychological distress. Of the 650 respondents experienced distress, 307 (47.2%) had a regular PCP. A significantly higher proportion of patients with a regular PCP than those without reported: (i) their PCPs sometimes/often asked about psychological problems [37.7 versus 20.1%, adjusted OR = 2.241]; (ii) they sometimes/often mentioned their psychological problems to PCPs [45.2 versus 24.9%, adjusted OR = 2.503]; and (iii) their distress had been treated by PCPs [22.1 versus 13.4%, adjusted OR = 1.702].

CONCLUSION

Patients with a regular PCP have around double odds of receiving mental health care. Continuity of care by PCPs should be emphasized in mental health care delivery.