An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial

Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial

OBJECTIVES

To evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also identify effects on antibiotic prescribing from case-mix adjusted feedback reports and messages emphasising antibiotic associated harms.

DESIGN

Pragmatic, factorial randomised controlled trial.

SETTING

Primary care physicians in Ontario, Canada PARTICIPANTS: All primary care physicians were randomly assigned a group if they were eligible and actively prescribing antibiotics to patients 65 years or older. Physicians were excluded if had already volunteered to receive antibiotic prescribing feedback from another agency, or had opted out of the trial.

INTERVENTION

A letter was mailed in January 2022 to physicians with peer comparison antibiotic prescribing feedback compared with the control group who did not receive a letter (4:1 allocation). The intervention group was further randomised in a 2x2 factorial trial to evaluate case-mix adjusted versus unadjusted comparators, and emphasis, or not, on harms of antibiotics.

MAIN OUTCOME MEASURES

Antibiotic prescribing rate per 1000 patient visits for patients 65 years or older six months after intervention. Analysis was in the modified intention-to-treat population using Poisson regression.

RESULTS

5046 physicians were included and analysed: 1005 in control group and 4041 in intervention group (1016 case-mix adjusted data and harms messaging, 1006 with case-mix adjusted data and no harms messaging, 1006 unadjusted data and harms messaging, and 1013 unadjusted data and no harms messaging). At six months, mean antibiotic prescribing rate was 59.4 (standard deviation 42.0) in the control group and 56.0 (39.2) in the intervention group (relative rate 0.95 (95% confidence interval 0.94 to 0.96). Unnecessary antibiotic prescribing (0.89 (0.86 to 0.92)), prolonged duration prescriptions defined as more than seven days (0.85 (0.83 to 0.87)), and broad spectrum prescribing (0.94 (0.92 to 0.95)) were also significantly lower in the intervention group compared with the control group. Results were consistent at 12 months post intervention. No significant effect was seen for including emphasis on harms messaging. A small increase in antibiotic prescribing with case-mix adjusted reports was noted (1.01 (1.00 to 1.03)).

CONCLUSIONS

Peer comparison audit and feedback letters significantly reduced overall antibiotic prescribing with no benefit of case-mix adjustment or harms messaging. Antibiotic prescribing audit and feedback is a scalable and effective intervention and should be a routine quality improvement initiative in primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04594200.

Dental antimicrobial stewardship: a qualitative study of perspectives among Canadian dentistry sector leaders and experts in antimicrobial stewardship

Objectives

Dentistry is a significant contributor to the burden of antimicrobial overprescribing and hence to the global problem of antimicrobial resistance. However, antimicrobial stewardship in Canadian dentistry is nascent, with an acknowledged need for research and coordinated stewardship efforts. This study aimed to gain insights into the perspectives of Canadian dentistry sector leaders and experts on the main drivers of dental antibiotic overprescribing and potential stewardship strategies.

Methods

Exploratory qualitative design. Data collection: four one-time, 1 h focus group discussions with 22 experts and stakeholders in antimicrobial stewardship in Canada, recruited through a mix of purposive and snowball sampling. Data analysis: inductive thematic analysis.

Results

The analysis yielded five themes: outdated patterns; antimicrobials as a Band-Aid; fear and risk aversion; behavioural change; and why reinvent the wheel? Overprescription in dentistry stems primarily from a perpetuation of outdated prescribing patterns, ubiquitous use of antibiotics as a temporary solution, and an overly cautious antibiotic use by risk-averse providers. Stewardship strategies should be grounded on behavioural change (motivation, robust data and enactment of new behaviours) and may be modelled after tested medical interventions.

Conclusions

This study presents a roadmap for behavioural change in dental antibiotic prescribing, and points to the fact that the success of a stewardship actionable plan for Canadian dentistry may depend more on concerted efforts for change than on the creation of novel strategies. Hence, contextualizing and testing medical stewardship programmes in Canadian dentistry may be effective in combatting antibiotic overprescription, thereby contributing to global efforts to reduce antimicrobial resistance.

A Case Study of the Development of a Valid and Pragmatic Implementation Science Measure: The Barriers and Facilitators in Implementation of Task-Sharing Mental Health Interventions (BeFITS-MH) Measure

Background

Few implementation science (IS) measures have been evaluated for validity, reliability and utility - the latter referring to whether a measure captures meaningful aspects of implementation contexts. In this case study, we describe the process of developing an IS measure that aims to assess Barriers and Facilitators in Implementation of Task-Sharing in Mental Health services (BeFITS-MH), and the procedures we implemented to enhance its utility.

Methods

We summarize conceptual and empirical work that informed the development of the BeFITS-MH measure, including a description of the Delphi process, detailed translation and local adaptation procedures, and concurrent pilot testing. As validity and reliability are key aspects of measure development, we also report on our process of assessing the measure's construct validity and utility for the implementation outcomes of acceptability, appropriateness, and feasibility.

Results

Continuous stakeholder involvement and concurrent pilot testing resulted in several adaptations of the BeFITS-MH measure's structure, scaling, and format to enhance contextual relevance and utility. Adaptations of broad terms such as "program," "provider type," and "type of service" were necessary due to the heterogeneous nature of interventions, type of task-sharing providers employed, and clients served across the three global sites. Item selection benefited from the iterative process, enabling identification of relevance of key aspects of identified barriers and facilitators, and what aspects were common across sites. Program implementers' conceptions of utility regarding the measure's acceptability, appropriateness, and feasibility were seen to cluster across several common categories.

Conclusions

This case study provides a rigorous, multi-step process for developing a pragmatic IS measure. The process and lessons learned will aid in the teaching, practice and research of IS measurement development. The importance of including experiences and knowledge from different types of stakeholders in different global settings was reinforced and resulted in a more globally useful measure while allowing for locally-relevant adaptation. To increase the relevance of the measure it is important to target actionable domains that predict markers of utility (e.g., successful uptake) per program implementers' preferences. With this case study, we provide a detailed roadmap for others seeking to develop and validate IS measures that maximize local utility and impact.

Feedback Intervention for the Control of Glucocorticoid Prescription in Primary Care Institutions: A Cluster Randomized Cross-Over Controlled Trial in Southwest China

Purpose

The purpose of this study is to assess the effect of glucocorticoid prescription feedback intervention in complex primary care institutions for regulating its inappropriate use.

Design Setting and Interventions

A six-month cluster randomized cross-over controlled trial was conducted in primary care institutions. A total of 347 physicians from 69 participating institutions were randomly allocated to either group A or group B. Both groups were given feedback interventions or serve as control. The feedback intervention comprised two components: a real-time pop-up warning of inappropriate glucocorticoid prescriptions based on the Hospital Information System and a high-proportion prescription feedback intervention warning system.

Outcome Measures

The primary outcome measure was the 10-day inappropriate glucocorticoid prescription rate, while the 10-day glucocorticoid prescription rate served as secondary outcome measure.

Results

At baseline, the 10-day inappropriate glucocorticoid prescription rates were 66.63% and 66.57% in group A and group B, respectively, showing no significant difference (p = 0.140). Following the intervention, group A exhibited a significant reduction in 10-day inappropriate glucocorticoid prescription rate at the crossing point by 13.69% (p < 0.001). In contrast, group B, which served as the control group, experienced an increase of 5.93% (p = 0.037) at the same crossover point. After the crossover point, there was a decrease in 10-day inappropriate glucocorticoid prescription rate for both groups. Group B as the intervention group demonstrated a reduction of 28.22% compared to the crossing point (p < 0.001), whereas group A showed a decrease of 12.20% (p = 0.339). The characteristics of physicians did not significantly influence the inappropriate glucocorticoid prescription rate.

Conclusion

The real-time pop-up warning of inappropriate glucocorticoid prescriptions based on the Hospital Information System and high-proportion prescription feedback intervention warning system can effectively regulate the inappropriate glucocorticoid prescribing behavior of physicians.

Trial Registration

ISRCTN11747547.

To prescribe or not to prescribe? A review of the Prescribing Competencies Framework for dentistry

OBJECTIVES

Dentists in Australia are the second largest prescriber group, and are generally not formally taught how to prescribe. The objective of this review is to describe the Prescribing Competencies Framework and its relevance to dentistry.

DATA

The four-model stage of prescribing by Coombes and colleagues, and the seven competencies within the Prescribing Competencies Framework devised by the Australian National Prescribing Service MedicineWise, are discussed and applied to dentistry.

SOURCES AND STUDY SELECTION

Each of the seven competencies are analysed and detailed in the context of clinical dental practice. Competencies 1-5 describe the skillset and tasks required by dentists to safely prescribe, whereas Competencies 6 and 7 describe the clinical environment and recommended resources to support dentists to prescribe safely and effectively.

CONCLUSIONS

The Prescribing Competencies Framework provides an overview of safe and effective prescribing. Prescribing is a process, and a separate skillset to clinical dentistry. The process involves information gathering, clinical assessment, effective communication and review of the patient. Access to timely and appropriate resources and relevant electronic sources of health information for clinicians are important to provide the support required for better informed prescribing decisions. The framework describes a patient-centered prescribing process, and ultimately prescribing should be a shared decision between the dentist and the patient.

CLINICAL SIGNIFICANCE

Safe and effective prescribing is an integral part of dentistry and dentists are the second largest prescriber group. However, dentists display high rates of inappropriate and unnecessary prescribing, and to minimise errors, the Prescribing Competencies Framework has been established. This article details how the Framework applies to clinical practice dentistry.

What is the role of randomised trials in implementation science?

BACKGROUND

There is a consistent demand for implementation science to inform global efforts to close the gap between evidence and practice. Key evaluation questions for any given implementation strategy concern the assessment and understanding of effects. Randomised trials are generally accepted as offering the most trustworthy design for establishing effectiveness but may be underused in implementation science.

MAIN BODY

There is a continuing debate about the primacy of the place of randomised trials in evaluating implementation strategies, especially given the evolution of more rigorous quasi-experimental designs. Further critiques of trials for implementation science highlight that they cannot provide 'real world' evidence, address urgent and important questions, explain complex interventions nor understand contextual influences. We respond to these critiques of trials and highlight opportunities to enhance their timeliness and relevance through innovative designs, embedding within large-scale improvement programmes and harnessing routine data. Our suggestions for optimising the conditions for randomised trials of implementation strategies include strengthening partnerships with policy-makers and clinical leaders to realise the long-term value of rigorous evaluation and accelerating ethical approvals and decluttering governance procedures for lower risk studies.

CONCLUSION

Policy-makers and researchers should avoid prematurely discarding trial designs when evaluating implementation strategies and work to enhance the conditions for their conduct.

Best practice guidance for antibiotic audit and feedback interventions in primary care: a modified Delphi study from the Joint Programming Initiative on Antimicrobial resistance: Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN)

BACKGROUND

Primary care is a critical partner for antimicrobial stewardship efforts given its high human antibiotic usage. Peer comparison audit and feedback (A&F) is often used to reduce inappropriate antibiotic prescribing. The design and implementation of A&F may impact its effectiveness. There are no best practice guidelines for peer comparison A&F in antibiotic prescribing in primary care.

OBJECTIVE

To develop best practice guidelines for peer comparison A&F for antibiotic prescribing in primary care in high income countries by leveraging international expertise via the Joint Programming Initiative on Antimicrobial Resistance-Primary Care Antibiotic Audit and Feedback Network.

METHODS

We used a modified Delphi process to achieve convergence of expert opinions on best practice statements for peer comparison A&F based on existing evidence and theory. Three rounds were performed, each with online surveys and virtual meetings to enable discussion and rating of each best practice statement. A five-point Likert scale was used to rate consensus with a median threshold score of 4 to indicate a consensus statement.

RESULTS

The final set of guidelines include 13 best practice statements in four categories: general considerations (n = 3), selecting feedback recipients (n = 1), data and indicator selection (n = 4), and feedback delivery (n = 5).

CONCLUSION

We report an expert-derived best practice recommendations for designing and evaluating peer comparison A&F for antibiotic prescribing in primary care. These 13 statements can be used by A&F designers to optimize the impact of their quality improvement interventions, and improve antibiotic prescribing in primary care.

Designing audit and feedback dashboards for dentists to monitor their opioid prescribing

BACKGROUND AND OBJECTIVE

Prescription drug abuse is a major factor leading to drug overdose deaths in the US and dentists are one of the leading prescribers of opioid pain medication. Knowing that Audit & Feedback (A&F) dashboards are an effective tool and are used as quality improvement interventions, we aimed to develop such dashboards personalized for dental providers which could allow them to monitor their own opioid prescribing performance.

METHODS

In this paper we report on the process for designing the A&F dashboards for dentists which were developed by using an iterative human-centered design process. The results obtained from each iteration were used to enrich the information needs analyses, provide function testing, and guide the design decisions of the next iteration.

RESULTS

Engaging dentists in the development and refinement of the dashboards while using the think-aloud protocol for user-testing, provided rapid feedback and identified areas that were confusing and needed either a redesign or additional explanatory content. The final version of dashboards consisted of displaying necessary information through easy to interpret visualizations and interactive features. These included providing access to current national and organizational prescribing guidelines, displaying changes in individual prescribing behavior over time, comparing individual prescribing rate to peer group rate and target rate, displaying procedure specific prescribing, integrating patient reported post-operative dental pain experience and providing navigation and interpretation tips for users. The dashboards were easy to learn and understand for the dentists and were deemed as worth using often in dental practice.

CONCLUSION

Our research was able to demonstrate the creation of useful and usable A&F dashboards using data from electronic dental records and patient surveys, for dentists to effectively monitor their opioid prescribing behavior. Efficacy of the dashboards will be tested in future work.

Developing a Questionnaire Evaluating Knowledge, Attitudes and Behaviors on Audit & Feedback among General Practitioners: A Mixed Methods Study

BACKGROUND

Audit and Feedback (A&F) is one of the most common strategies used to improve quality in healthcare. However, there is still lack of awareness regarding the enabling factors and barriers that could influence its effectiveness. The aim of this study was to develop a questionnaire to measure the knowledge, attitudes and behaviors of general practitioners (GPs) regarding A&F. The study was performed in the context of the EASY-NET program (project code NET-2016-02364191).

METHODS

The survey was developed according to two steps. Firstly, a scoping review was performed in order to map the literature on the existing similar instruments with the aim of identifying the sub-domains and possible items to include in a preliminary version of the questionnaire. In the second phase, the questionnaire was reviewed by a multidisciplinary group of experts and administrated to a convenience sample in a pilot survey.

RESULTS

Ten papers were included in the scoping review. The survey target and development methodology were heterogenous among the studies. The knowledge, attitudes and behaviors domains were assessed in six, nine and seven studies, respectively. In the first step, 126 pertinent items were extracted and categorized as follows: 8 investigated knowledge, 93 investigated attitudes, and 25 investigated behaviors. Then, 2 sub-domains were identified for knowledge, 14 for attitudes and 7 for behavior. Based on these results, a first version of the survey was developed via consensus among two authors and then revised by the multidisciplinary group of experts in the field of A&F. The final version of the survey included 36 items: 8 in the knowledge domain, 19 in the attitudes domain and 9 in the behaviors domain. The results of the pilot study among 15 GPs suggested a good acceptability and item relevance and accuracy, with positive answers totaling 100% and 93.3% in the proposed questions.

CONCLUSIONS

The methodology used has shown to be a good strategy for the development of the survey. The survey will be administrated before and after the implementation of an A&F intervention to assess both baseline characteristics and changes after the intervention.

International Consensus on a Dental Antibiotic Stewardship Core Outcome Set

INTRODUCTION

Antibiotic resistance is a global health crisis. Ensuring responsible, appropriate use (stewardship) is an important for keeping antibiotics working as long as possible. Around 10% of antibiotics across health care are prescribed by oral health care professionals, with high rates of unnecessary use. To maximise the value from research to optimise antibiotic use in dentistry, this study developed international consensus on a core outcome set for dental antibiotic stewardship.

METHODS

Candidate outcomes were sourced from a literature review. International participants were recruited via professional bodies, patient organisations, and social media, with at least 30 dentists, academics, and patient contributors in total. Outcomes scored "critical for inclusion" by >70% of the participants (dentists, academics, and patients) after 2 Delphi rounds were included in the core outcome set following a final consensus meeting. The study protocol was registered with the COMET Initiative and published in BMC Trials.

RESULTS

A total of 33 participants from 15 countries, including 8 low- and middle-income countries, completed both rounds of the Delphi study. Antibiotic use outcomes (eg, appropriateness of prescribing), adverse or poor outcomes (eg, complications from disease progression), and a patient-reported outcome were included in the final, agreed core set. Outcomes relating to quality, time, and cost were not included.

CONCLUSIONS

This core outcome set for dental antibiotic stewardship represents the minimum which future studies of antibiotic stewardship in dentistry should report. By supporting researchers to design and report their studies in a way meaningful to multiple stakeholders and enabling international comparisons, the oral health profession's contribution to global efforts to tackle antibiotic resistance can be further improved.

Dissemination and implementation research for oral and craniofacial health: Background, a review of literature and future directions

Oral conditions are highly prevalent globally and have profound consequence on individuals and communities. Clinical (e.g. dental treatments, behavioural counselling) and non-clinical (e.g. community-based programming, water fluoridation, oral health policy) evidence-based interventions have been identified, recommended and applied at the clinic, community and policy levels. Still, the burden of oral conditions persists, with inequitable distribution across populations. A major driver of this lack of progress is poor translation of research findings, which results in an evidence-to-practice gap. Dissemination and implementation science (DIS) has emerged to address this gap. A relatively new field, application of DIS represents an important avenue for achieving good dental, oral and craniofacial health for all. The goal of this introductory article is to provide a brief background on DIS relevant to researchers in dentistry and oral health. The problem of knowledge translation, basic concepts and terminology in DIS, and approaches to doing dissemination and implementation research-including implementation strategies, key outcomes, and implementation theories, models and frameworks-are discussed. Additionally, the article reviews literature applying DIS to dentistry and oral health. Results of published studies and their implications for the field are presented. Drawing on the literature review and contemporary thinking in DIS, current gaps, opportunities and future directions are discussed. Resources for understanding and applying DIS are provided throughout. This article serves as a primer on DIS for dental and oral health researchers of all types working across a range of contexts; it also serves as a call to action for increased application of DIS to address the burden of oral conditions globally.

The Effectiveness of Interactive Dashboards to Optimise Antibiotic Prescribing in Primary Care: A Systematic Review

Governments and healthcare organisations collect data on antibiotic prescribing (AP) for surveillance. This data can support tools for visualisations and feedback to GPs using dashboards that may prompt a change in prescribing behaviour. The objective of this systematic review was to assess the effectiveness of interactive dashboards to optimise AP in primary care. Six electronic databases were searched for relevant studies up to August 2022. A narrative synthesis of findings was conducted to evaluate the intervention processes and results. Two independent reviewers assessed the relevance, risk of bias and quality of the evidence. A total of ten studies were included (eight RCTs and two non-RCTs). Overall, seven studies showed a slight reduction in AP. However, this reduction in AP when offering a dashboard may not in itself result in reductions but only when combined with educational components, public commitment or behavioural strategies. Only one study recorded dashboard engagement and showed a difference of 10% (95% CI 5% to 15%) between intervention and control. None of the studies reported on the development, pilot or implementation of dashboards or the involvement of stakeholders in design and testing. Interactive dashboards may reduce AP in primary care but most likely only when combined with other educational or behavioural intervention strategies.

Effects of social norm feedback on antibiotic prescribing and its characteristics in behaviour change techniques: a mixed-methods systematic review

Low-cost and low-barrier antibiotic stewardship strategies are urgently needed to deal with the widespread problem of antibiotic resistance. Social norm feedback could be a promising strategy. In this mixed-methods systematic review (PROSPERO: CRD42022361039), we aimed to identify the key behaviour change techniques used in social norm feedback for antibiotic stewardship and assess their effectiveness in reducing antibiotic prescribing. We searched PubMed, Embase, Web of Science, and Scopus for peer-reviewed studies published between Jan 1, 2000, and Jan 20, 2022. 3547 studies were screened, of which 23 studies reporting the effects of social norm feedback interventions on antibiotic prescribing met the inclusion criteria. 19 behaviour change techniques were tested in the included studies. The meta-analyses showed that social norm feedback is an effective strategy for reducing antibiotic prescribing, with an overall rate difference of 4% (p<0·0001). The behaviour change technique with the highest effective ratio (ER=13) was information about health consequences, followed by instruction on how to perform the behaviour (ER=9) and adding objects to the environment (ER=9). Social norm feedback is a promising strategy to reduce antibiotic prescribing, and can be incorporated into the clinical decision-making support system.

Moving the needle on dental antibiotic overuse in Canada post COVID-19

Antimicrobial resistance due to over-prescribing in health care, including in dentistry, has been acknowledged as one of the top ten threats to global health by the World Health Organization. Dentistry is responsible for approximately 10% of antibiotics prescribed worldwide and research has shown up to 80% of antibiotics prescribed by dentists may be unnecessary. During the early months of the coronavirus disease 2019 pandemic, when dental offices handled only dental emergencies, it is probable that antibiotics were prescribed more readily and for longer duration to defer treatment for non-urgent cases. These unprecedented times strengthened the realization that strong dental antimicrobial stewardship practises are required in Canada to keep antimicrobial overuse under control. In countries, such as the United Kingdom and Australia, significant work is ongoing in this regard. Canada has made progress in developing tools for antimicrobial stewardship specifically for physicians in community settings, where the vast majority of antibiotics are prescribed, and it is now time to pay attention to antimicrobial stewardship in the field of dental care. Investments in developing a national level dental prescription database, along with monitoring, education and feedback mechanisms, can strongly support moving the needle on dentist-driven antibiotic overuse in Canada.

Feedback of Antibiotic Prescribing in Primary Care (FAPPC) trial: results of a real-world cluster randomized controlled trial in Scotland, UK

OBJECTIVES

To evaluate the effect of general practice-level prescribing feedback on antibiotic prescribing in a real-world pragmatic cluster randomized controlled trial.

METHODS

Three hundred and forty general practices in four territorial Health Boards in NHS Scotland were randomized in Quarter 1, 2016 to receive four quarterly antibiotic-prescribing feedback reports or not, from Quarter 2, 2016 to Quarter 1, 2017. Reports included different clinical topics, benchmarking against national and health board rates, and behavioural messaging with improvement actions. The primary outcome was total antibiotic prescribing rate. There were 16 secondary prescribing outcomes and 5 hospital admission outcomes (potential adverse effects of reduced prescribing). The main evaluation timepoint was 1 year after the final report (Quarter 1, 2018), with an additional evaluation in the quarter after the final report (Quarter 2, 2017). Routine administrative NHS data were used to generate the feedback reports and analyse the effects.

RESULTS

Total antibiotic prescribing rates were lower at the main evaluation timepoint in both intervention (1.83 versus baseline 1.93 prescriptions/1000 patients/day) and control (1.90 versus baseline 1.98) practices, with no evidence of intervention effect [adjusted rate ratio (ARR) 0.98 (95% CI 0.94-1.02; P = 0.35)]. At the additional timepoint, adjusted total antibiotic prescribing rates were 1.67 and 1.73 prescriptions/1000 patients/day, with evidence of a small intervention effect, ARR 0.99 (0.98-1.00; P = 0.03).

CONCLUSIONS

This well-designed, practice-level antibiotic-prescribing feedback had limited evidence of additional effects in the context of decreasing antibiotic prescribing and an established national stewardship programme.

'Well, in dentistry the dentist is always the boss': a multi-method exploration of which organisational characteristics of dental practices most influence the implementation of evidence-based guidance

OBJECTIVE

To investigate which organisational characteristics of primary care dental practices influence the implementation of evidence-based guidance.

DESIGN

A multimethod study set within primary care dentistry in Scotland comprising: (1) Semistructured interviews with dental teams to inform development of a self-report questionnaire exploring the translation of guidance in primary care dentistry and (2) A questionnaire-based survey and case studies exploring which organisational characteristics influence knowledge translation.

RESULTS

Interview data identified three themes: leadership, communication and context. Survey data revealed compliance with recommendations from three topics of dental guidance to be variable, with only 41% (emergency dental care), 19% (oral health assessment and review) and 4% (drug prescribing) of respondents reporting full compliance. Analysis revealed no significant relationship between practice characteristics and compliance with emergency dental care or drug prescribing recommendations. Positive associations were observed between compliance with oral health assessment and review recommendations and having a practice manager, as well as with the type of treatment offered, with fully private practices more likely, and fully National Health Service practices less likely to comply, when compared with those offering a mixture of treatment. Synthesis of the data identified leadership and context as key drivers of guidance uptake.

CONCLUSIONS

Evidence-based dental recommendations are not routinely translated into practice, with variable leadership and differing practice contexts being central to poor uptake. Guidelines should aim to tailor recommendations and implementation strategies to reflect the complexities and varying contexts that exist in primary care dentistry, thus facilitating the implementation of evidence-based guidance.

Electronic Health Records and Antimicrobial Stewardship Research: a Narrative Review

Purpose of Review

This review summarises epidemiological research using electronic health records (EHR) for antimicrobial stewardship.

Recent Findings

EHRs enable surveillance of antibiotic utilisation and infection consultations. Prescribing for respiratory tract infections has declined in the UK following reduced consultation rates. Reductions in prescribing for skin and urinary tract infections have been less marked. Drug selection has improved and use of broad-spectrum antimicrobics reduced. Diagnoses of pneumonia, sepsis and bacterial endocarditis have increased in primary care. Analytical studies have quantified risks of serious bacterial infections following reduced antibiotic prescribing. EHRs are increasingly used in interventional studies including point-of-care trials and cluster randomised trials of quality improvement. Analytical and interventional studies indicate patient groups for whom antibiotic utilisation may be more safely reduced.

Summary

EHRs offer opportunities for surveillance and interventions that engage practitioners in the effects of improved prescribing practices, with the potential for better outcomes with targeted study designs.

Effectiveness of clinical dashboards as audit and feedback or clinical decision support tools on medication use and test ordering: a systematic review of randomized controlled trials

BACKGROUND

Clinical dashboards used as audit and feedback (A&F) or clinical decision support systems (CDSS) are increasingly adopted in healthcare. However, their effectiveness in changing the behavior of clinicians or patients is still unclear. This systematic review aims to investigate the effectiveness of clinical dashboards used as CDSS or A&F tools (as a standalone intervention or part of a multifaceted intervention) in primary care or hospital settings on medication prescription/adherence and test ordering.

METHODS

Seven major databases were searched for relevant studies, from inception to August 2021. Two authors independently extracted data, assessed the risk of bias using the Cochrane RoB II scale, and evaluated the certainty of evidence using GRADE. Data on trial characteristics and intervention effect sizes were extracted. A narrative synthesis was performed to summarize the findings of the included trials.

RESULTS

Eleven randomized trials were included. Eight trials evaluated clinical dashboards as standalone interventions and provided conflicting evidence on changes in antibiotic prescribing and no effects on statin prescribing compared to usual care. Dashboards increased medication adherence in patients with inflammatory arthritis but not in kidney transplant recipients. Three trials investigated dashboards as part of multicomponent interventions revealing decreased use of opioids for low back pain, increased proportion of patients receiving cardiovascular risk screening, and reduced antibiotic prescribing for upper respiratory tract infections.

CONCLUSION

There is limited evidence that dashboards integrated into electronic medical record systems and used as feedback or decision support tools may be associated with improvements in medication use and test ordering.

Dissemination and implementation strategies for physical activity guidelines among adults with disability, chronic conditions, and pregnancy: a systematic scoping review

BACKGROUND

Physical activity guidelines for adults with disability, chronic conditions, and pregnancy (i.e., specific populations) have been developed to provide guidance for engaging in physical activity. However, specific populations remain considerably less physically active compared to the general population, presenting a knowledge-practice gap.

PURPOSE

The purpose of this systematic scoping review was to identify and evaluate strategies for disseminating and implementing physical activity guidelines among specific populations and/or stakeholders (e.g., healthcare professionals) in Canada.

METHODS

Five search approaches (peer-reviewed literature databases, grey literature database, custom Google search engines, targeted web-based searches, and content expert consultation) identified records documenting and/or evaluating strategies that had been used to disseminate or implement guidelines from a predetermined list. Systematic and scoping review protocols were followed. Risk of bias assessments were conducted for all studies that evaluated strategies.

RESULTS

Eighty-one records reported dissemination strategies (n = 42), implementation strategies (n = 28), or both (n = 11). Twenty-two studies reporting on 29 evaluated strategies were deemed "serious" or "high" risk of bias. Common guideline dissemination and implementation strategies are deliberated and recommendations for future practice are made.

CONCLUSIONS

Findings may inform future dissemination and implementation efforts for physical activity guidelines in Canada or similar countries.

Unlocking the potential of NHS primary care dental datasets

Introduction Maximising the use of routinely collected health data for research is a key part of the UK Government's Industrial Strategy. Rich data are generated by NHS primary care dental services, but the extent of their use in research is unknown.Aims To profile the utility of the post-2006 NHS dental datasets for research, map how they have been used to date and develop recommendations to maximise their utility.Methods The content of and access to the four UK NHS dental datasets was collated using publicly available information and a free-text questionnaire, completed by the relevant data controllers. A scoping review was carried out to identify and map literature that has utilised NHS dental activity data.Results The contents of the UK NHS dental activity datasets are described, alongside how they may be accessed for research. Strengths and weaknesses of these datasets for research are highlighted. The scoping review identified 33 studies which had utilised NHS dental activity data since 2006. We classified 15 as public health practice, 11 as service evaluation and 7 as research.Conclusion In comparision to other NHS activity datasets, it appears that the UK dental datasets have been underutilised for research. We make 11 recommendations on how their utility for research may be increased.

Optimizing responsiveness to feedback about antibiotic prescribing in primary care: protocol for two interrelated randomized implementation trials with embedded process evaluations

Background

Audit and feedback (A&F) that shows how health professionals compare to those of their peers, can be an effective intervention to reduce unnecessary antibiotic prescribing among family physicians. However, the most impactful design approach to A&F to achieve this aim is uncertain. We will test three design modifications of antibiotic A&F that could be readily scaled and sustained if shown to be effective: (1) inclusion of case-mix-adjusted peer comparator versus a crude comparator, (2) emphasizing harms, rather than lack of benefits, and (3) providing a viral prescription pad.

Methods

We will conduct two interrelated pragmatic randomized trials in January 2021. One trial will include family physicians in Ontario who have signed up to receive their MyPractice: Primary Care report from Ontario Health (“OH Trial”). These physicians will be cluster-randomized by practice, 1:1 to intervention or control. The intervention group will also receive a Viral Prescription Pad mailed to their office as well as added emphasis in their report on use of the pad. Ontario family physicians who have not signed up to receive their MyPractice: Primary Care report will be included in the other trial administered by Public Health Ontario (“PHO Trial”). These physicians will be allocated 4:1 to intervention or control. The intervention group will be further randomized by two factors: case-mix adjusted versus unadjusted comparator and emphasis or not on harms of antibiotics. Physicians in the intervention arm of this trial will receive one of four versions of a personalized antibiotic A&F letter from PHO. For both trials, the primary outcome is the antibiotic prescribing rate per 1000 patient visits, measured at 6 months post-randomization, the primary analysis will use Poisson regression and we will follow the intention to treat principle. A mixed-methods process evaluation will use surveys and interviews with family physicians to explore potential mechanisms underlying the observed effects, exploring targeted constructs including intention, self-efficacy, outcome expectancies, descriptive norms, and goal prioritization.

Discussion

This protocol describes the rationale and methodology of two interrelated pragmatic trials testing variations of theory-informed components of an audit and feedback intervention to determine how to optimize A&F interventions for antibiotic prescribing in primary care.

Trial registration

NCT04594200, NCT05044052. CIHR Grant ID: 398514

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01194-8.

BigMouth: development and maintenance of a successful dental data repository

Few clinical datasets exist in dentistry to conduct secondary research. Hence, a novel dental data repository called BigMouth was developed, which has grown to include 11 academic institutions contributing Electronic Health Record data on over 4.5 million patients. The primary purpose for BigMouth is to serve as a high-quality resource for rapidly conducting oral health-related research. BigMouth allows for assessing the oral health status of a diverse US patient population; provides rationale and evidence for new oral health care delivery modes; and embraces the specific oral health research education mission. A data governance framework that encouraged data sharing while controlling contributed data was initially developed. This transformed over time into a mature framework, including a fee schedule for data requests and allowing access to researchers from noncontributing institutions. Adoption of BigMouth helps to foster new collaborations between clinical, epidemiological, statistical, and informatics experts and provides an additional venue for professional development.

Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review

BACKGROUND

There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care.

METHODS

We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review.

RESULTS

Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently.

CONCLUSIONS

This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.

Changing antibiotic prescribing practices in outpatient primary care settings in China: Study protocol for a health information system-based cluster-randomised crossover controlled trial

Background

The overuse and abuse of antibiotics is a major risk factor for antibiotic resistance in primary care settings of China. In this study, the effectiveness of an automatically-presented, privacy-protecting, computer information technology (IT)-based antibiotic feedback intervention will be evaluated to determine whether it can reduce antibiotic prescribing rates and unreasonable prescribing behaviours.

Methods

We will pilot and develop a cluster-randomised, open controlled, crossover, superiority trial. A total of 320 outpatient physicians in 6 counties of Guizhou province who met the standard will be randomly divided into intervention group and control group with a primary care hospital being the unit of cluster allocation. In the intervention group, the three components of the feedback intervention included: 1. Artificial intelligence (AI)-based real-time warnings of improper antibiotic use; 2. Pop-up windows of antibiotic prescription rate ranking; 3. Distribution of educational manuals. In the control group, no form of intervention will be provided. The trial will last for 6 months and will be divided into two phases of three months each. The two groups will crossover after 3 months. The primary outcome is the 10-day antibiotic prescription rate of physicians. The secondary outcome is the rational use of antibiotic prescriptions. The acceptability and feasibility of this feedback intervention study will be evaluated using both qualitative and quantitative assessment methods.

Discussion

This study will overcome limitations of our previous study, which only focused on reducing antibiotic prescription rates. AI techniques and an educational intervention will be used in this study to effectively reduce antibiotic prescription rates and antibiotic irregularities. This study will also provide new ideas and approaches for further research in this area.

Trial registration

ISRCTN, ID: ISRCTN13817256. Registered on 11 January 2020.

From intention to action: A systematic literature review of provider behaviour change-focused interventions in physical health and behavioural health settings

RATIONALE, AIMS AND OBJECTIVES

It is clear there are significant delays in the uptake of best practices as part of routine care in the healthcare system, yet there is conflicting evidence on how to specifically align provider behaviour with best practices.

METHOD

We conducted a review of interventions utilized to change any aspect of provider behaviour. To extend prior research, studies were included in the present review if they had an active intervention targeting behaviour change of providers in health or behavioural-health settings and were published between 2001 and 2020.

RESULTS

Of 1547 studies, 44 met inclusion criteria. Of 44 studies identified, 28 studies utilized contextually relevant interventions (eg, tailored to a specific provider population). Twenty six interventions with a contextually relevant approach resulted in provider behaviour change.

CONCLUSIONS

Findings are promising for encouraging provider behaviour change when interventions are tailored to be contextually relevant, as both single-component and multifaceted interventions were successful when they were contextually relevant. It is critical to conduct additional research to ensure that providers sustain behaviour changes over a long-term beyond an intervention's implementation and evaluation period.

'You had to do something': prescribing antibiotics in Scotland during the COVID-19 pandemic restrictions and remobilisation

Introduction The COVID-19 pandemic brought about seismic change for dentistry including the direction to provide remote advice and prescribe analgesia and antimicrobials. The possibilities for care have widened, but the impact of both restrictions and remobilisation on antibiotic prescribing is not known.Aims To report the impact of COVID-19 restrictions and remobilisation on dental antibiotic prescriptions and explore dentists' intentions and attitudes towards antibiotic prescribing.Design and setting Public Health Scotland national prescribing and claims data are reported alongside an online survey of Scottish general and public health service dentists including closed and open-ended questions.Results Antibiotic prescribing rose by 49% following the suspension of routine dental care, to a peak of 34,993 antibiotics (July 2020). The data also show that since the remobilisation of NHS dental care, antibiotic prescribing remains raised at levels around 28% higher than pre-pandemic. The survey highlights dentists' frustrations and concerns about this increased use of antibiotics. Most dentists intend to reduce their prescribing; however, significant challenges to this being realised were raised.Conclusions The previous success within dentistry to protect against the development of antimicrobial resistance has suffered a knock-back during the pandemic. A renewed focus on reducing unnecessary antibiotics within dentistry is required but, crucially, needs to be approached sensitively alongside the current backdrop of challenges within the service.

General practice responses to opioid prescribing feedback: a qualitative process evaluation

BACKGROUND

The rise in opioid prescribing in primary care represents a significant public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. An evidence-based bimonthly feedback intervention to reduce opioid prescribing was developed and implemented, targeting 316 general practices in West Yorkshire over 1 year.

AIM

To understand how general practice staff received and responded to the feedback intervention.

DESIGN AND SETTING

Qualitative process evaluation involving semi-structured interviews, guided by Normalisation Process Theory (NPT), of primary care healthcare professionals targeted by feedback.

METHOD

Participants were purposively recruited according to baseline opioid prescribing levels and degree of change following feedback. Interview data were coded to NPT constructs, and thematically analysed.

RESULTS

Interviews were conducted with 21 staff from 20 practices. Reducing opioid prescribing was recognised as a priority. While high achievers had clear structures for quality improvement, feedback encouraged some less structured practices to embed changes. The non-prescriptive nature of the feedback reports allowed practices to develop strategies consistent with their own ways of working and existing resources. Practice concerns were allayed by the credibility of the reports and positive experiences of reducing opioid prescribing. The scale, frequency, and duration of feedback may have ensured a good overall level of practice population reach.

CONCLUSION

The intervention engaged general practice staff in change by targeting an issue of emerging concern, and allowing adaption to different ways of working. Practice efforts to reduce opioid prescribing were reinforced by regular feedback, credible comparative data showing progress, and shared experiences of patient benefit.

Development and Evaluation of an Audit and Feedback Process for Prevention of Acute Kidney Injury During Coronary Angiography and Intervention

Background

Contrast-associated acute kidney injury (CA-AKI) is a potentially preventable complication of coronary angiography and intervention. Relatively little research has been done to determine how knowledge on CA-AKI prevention can be translated into clinical practice.

Methods

We developed, implemented, and surveyed end-users about the usability, acceptability, and utility of an audit and feedback process for CA-AKI prevention in Alberta, Canada. The audit and feedback reported on amount of radiocontrast dye used, hemodynamic optimization of intravenous fluids, and CA-AKI incidence for each cardiologist practicing coronary angiography or percutaneous coronary intervention, compared with peers at their site and across the province. Reports were developed through an iterative process involving interventional cardiologists throughout the design process and usability testing.

Results

Cardiologists participating in usability testing indicated a preference for the visual displays of data and summarizing indicators on the front page, and endorsed the value of peer-to-peer comparisons of performance measures. Of 31 eligible cardiologists from across Alberta, 17 responded to a survey evaluating the audit and feedback process. Fifteen respondents (88.2%) agreed that the data presented in the audit and feedback report were understandable; 17 respondents (100%) agreed or strongly agreed that the presentation of the report helped them better understand their performance compared with that of their peers; and 14 (82.4%) agreed that the audit and feedback process helped them identify ways to reduce the risk of AKI for their patients.

Conclusions

Conducting an audit and providing feedback was an understandable and acceptable intervention to help cardiologists identify ways to improve prevention of CA-AKI during coronary angiography or intervention.

Factors, Perceptions and Beliefs Associated with Inappropriate Antibiotic Prescribing in German Primary Dental Care: A Qualitative Study

Dentists account for up to 10% of all prescribed antibiotics in primary care, with up to 80% being inappropriate. Targeted approaches to change prescription behavior are scarce. This study aimed at identifying specific barriers and facilitators for prudent antibiotic use in German dentistry by using qualitative methods. Nine in-depth interviews and two focus group discussions with another nine dentists were conducted and analyzed thematically. Dentists described being conflicted by the discordance of available treatment time and the necessity of thorough therapy. Lacking the opportunity of follow-up led to uncertainty. Dentists felt a lack of medical competency concerning prophylaxis for infectious endocarditis. A lack of empowerment to make therapeutic decisions interfered with guideline-conformity. The communication with fellow physicians is conflictual and improvement was wished for. In consequence, dentists felt pressure by potential medico-legal liability. Patients demanding quick and easy pain relief put extra strain on the interviewed dentists. Our hypotheses concord with preliminary data, mainly from the UK, but highlighted specifically medico-legal concerns and interprofessional communication as even greater barriers as described before. Tailored interventional concepts based on our findings may have the potential to lower antibiotic prescriptions in German primary dental care.

The effect of electronic audits and feedback in primary care and factors that contribute to their effectiveness: a systematic review

PURPOSE

The aim of this systematic review was (i) to assess whether electronic audit and feedback (A&F) is effective in primary care and (ii) to evaluate important features concerning content and delivery of the feedback in primary care, including the use of benchmarks, the frequency of feedback, the cognitive load of feedback and the evidence-based aspects of the feedback.

DATA SOURCES

The MEDLINE, Embase, CINAHL and CENTRAL databases were searched for articles published since 2010 by replicating the search strategy used in the last Cochrane review on A&F.

STUDY SELECTION

Two independent reviewers assessed the records for their eligibility, performed the data extraction and evaluated the risk of bias. Our search resulted in 8744 records, including the 140 randomized controlled trials (RCTs) from the last Cochrane Review. The full texts of 431 articles were assessed to determine their eligibility. Finally, 29 articles were included.

DATA EXTRACTION

Two independent reviewers extracted standard data, data on the effectiveness and outcomes of the interventions, data on the kind of electronic feedback (static versus interactive) and data on the aforementioned feedback features.

RESULTS OF DATA SYNTHESIS

Twenty-two studies (76%) showed that electronic A&F was effective. All interventions targeting medication safety, preventive medicine, cholesterol management and depression showed an effect. Approximately 70% of the included studies used benchmarks and high-quality evidence in the content of the feedback. In almost half of the studies, the cognitive load of feedback was not reported. Due to high heterogeneity in the results, no meta-analysis was performed.

CONCLUSION

This systematic review included 29 articles examining electronic A&F interventions in primary care, and 76% of the interventions were effective. Our findings suggest electronic A&F is effective in primary care for different conditions such as medication safety and preventive medicine. Some of the benefits of electronic A&F include its scalability and the potential to be cost effective. The use of benchmarks as comparators and feedback based on high-quality evidence are widely used and important features of electronic feedback in primary care. However, other important features such as the cognitive load of feedback and the frequency of feedback provision are poorly described in the design of many electronic A&F intervention, indicating that a better description or implementation of these features is needed. Developing a framework or methodology for automated A&F interventions in primary care could be useful for future research.

"What We Have Here, Is a Failure to [Replicate]": Ways to Solve a Replication Crisis in Implementation Science

Adapting the classic line from the 1967 film Cool Hand Luke, the title is meant to convey that implementation science (IS), like other fields, has not been embracing replication studies, which is a key component to the open science movement. The purpose of this article is to review what is known about replication of implementation trials and identify the gaps and next steps to continue increasing the transparency, openness, and replicability of implementation research. After presenting an overview of study replication and how it is a key component of open science, the article will examine how replication of implementation studies has (or more accurately has not) been approached in IS. As will be discussed, replication in IS shares some challenges with studies that attempt to replicate interventions, but also presents unique challenges. This article discusses different types of replications (e.g., direct vs. conceptual) and how they can benefit the field of IS. The article then presents a specific example of an implementation strategy called Getting To Outcomes© to describe how to design a replication study and interpret the results. The article ends with multiple options implementation scientists could consider to improve the likelihood and quality of replication studies. The discussion also envisions how implementation science can enable researchers and practitioners to work together in real-world contexts to encourage wide replication of implementation studies and advance the goal of improving public health.

Nudging Emergency Care Providers to Reduce Opioid Prescribing Using Peer Norm Comparison Feedback: A Pilot Randomized Trial

OBJECTIVE

To determine the feasibility, acceptability, and potential impact of using audit and feedback (A&F) with or without peer norm comparison on opioid prescribing by emergency medicine providers.

METHODS

A convenience sample of 37 emergency medicine providers were recruited from 16 emergency departments in Western Pennsylvania for a pilot randomized controlled trial. Participants completed a baseline survey, were randomly allocated to A&F (N = 17) or A&F with peer norm comparison (N = 20), and were asked to complete a postintervention survey. We matched each participant 1:1 to a control who was not exposed to either intervention.

RESULTS

At baseline, 57% of participants perceived that they prescribed opioids at the same frequency as their peers, whereas 32% perceived prescribing less than and 11% perceived prescribing more than their peers. Most participants rated the interventions as helpful, with no differences between conditions. For the A&F with peer norm comparison condition, from pre- to postintervention, there was a relative increase of 20% in the percentage of participants who perceived that they prescribed more opioids than their peers but no change in the A&F condition (P = 0.02). 56.8% of controls, 52.9% of A&F participants, and 75.5% of A&F with peer norm comparison participants reduced their opioid prescribing (P = 0.33). The mean reduction in opioid prescriptions (SD) was 3.3. (9.6) for controls, 3.9 (10.5) for A&F, and 7.3 (7.8) for A&F with peer norm comparison (P = 0.31).

CONCLUSIONS

Audit and feedback interventions with peer norm comparisons are helpful to providers, can alter perceptions about prescribing norms, and are a potentially effective way to alter ED providers' opioid prescribing behavior.

Trends in Australian dental prescribing of antibiotics: 2005-2016

BACKGROUND

Prescribing of antibiotics by dentists for surgical prophylaxis or as an adjunct to managing dental infections is a substantial part of the overall landscape for prescribed antibiotics in health care settings.

METHODS

We explored trends in the antibiotic prescribing patterns of Australian dentists over the 12-year period, 2005-2016. We obtained data on dispensed prescriptions of antibiotics from registered dentists subsidized on the Pharmaceutical Benefits Scheme.

RESULTS

Australian dentists were responsible for almost 7 million dispensed prescriptions of antibiotics over 12 years; an average of 24 prescriptions per year per dentist. The most commonly prescribed antibiotic was amoxicillin, followed by amoxicillin + clavulanic acid and metronidazole. These top three antibiotics constituted more than 80% of all antibiotics prescribed and their use increased dramatically over time. There was a large increase in the prescribing of broad-spectrum antibiotics over time, most of which occurred from 2011 to 2016.

CONCLUSIONS

Excessive prescribing of broad-spectrum antibiotics runs contrary to national antimicrobial stewardship (AMS) initiatives and guidelines. Multifaceted educational strategies are essential to align prescribing with current best practice. High-level evidence to inform clear guidelines on antibiotic prescribing in dental infections, with audit and feedback, should reduce the inappropriate use of antibiotics in dentistry.

Audit and feedback with or without training in-practice targeting antibiotic prescribing (TiPTAP): a study protocol of a cluster randomised trial in dental primary care

BACKGROUND

Antimicrobial resistance is an increasingly serious threat to global public health and patient safety. Overuse of antibiotics has aggravated this issue. Around 7% of all antibiotics in Scotland are prescribed by dentists. Audit and feedback has been shown to decrease these prescriptions, but there is evidence that dentists still prescribe unnecessarily. Our aim is to compare the effectiveness of a theory-informed in-practice training session (TiPTAP) in addition to individualised audit and feedback, with audit and feedback alone for reducing antibiotic prescribing by NHS dentists working in NHS primary care dental practices.

METHODS

We will conduct a 2-arm parallel cluster randomised trial: out of 228 practices, 114 will be randomised to the theory-informed in-practice training session targeting antibiotic prescribing and individualised audit and feedback; 114 practices will be randomised to audit and feedback alone. The theory-informed session will include (a) an introductory session including several behaviour change techniques; (b) problem solving discussion, setting and recording action plans; (c) practice-level prescribing feedback discussion. The primary outcome is the number of antibiotic items per 100 NHS treatment claims over a 1-year period post-randomisation for each dentist. Secondary outcomes are the number of amoxicillin 3 g and broad spectrum antibiotics prescribed per 100 NHS treatment claims over a 1-year period; amoxicillin 3 g and broad spectrum antibiotics defined daily doses of antibiotics per 100 claims. Process measures include fidelity, knowledge, and confidence. Primary and secondary outcomes will be obtained using routine data.

DISCUSSION

This study provides the opportunity to robustly assess the effect of adding an in-practice training co-intervention to audit and feedback. Its behaviour change theory-informed content will allow replication of the different components and can inform future training interventions.

TRIAL REGISTRATION

ISRCTN, ISRCTN12345678 . Registered 18 June 2020.

What influences adherence to guidance for postoperative instillation of intravesical chemotherapy to patients with bladder cancer?

OBJECTIVE

To understand the barriers and facilitators to single instillation of intravesical chemotherapy (SI-IVC) use after resection of non-muscle-invasive bladder cancer (NMIBC) in Scotland and England using a behavioural theory-informed approach.

SUBJECTS AND METHODS

In a cross-sectional descriptive study of practices at seven hospitals, we investigated care pathways, policies, and interviewed 30 urology staff responsible for SI-IVC. We used the Theoretical Domains Framework (TDF) to organise our investigation and conducted deductive thematic analyses, while inductively coding emergent beliefs.

RESULTS

Barriers to SI-IVC were present at different organisational levels and professional roles. In four hospitals, there was a policy to not instil SI-IVC in theatre. Six hospitals' staff reported delays in mitomycin C (MMC) ordering and/or local storage. Lack of training, skills and perceived workload affected motivation. Facilitators included access to modern instilling devices (four hospitals) and incorporating reminders in operation proforma (four hospitals). Performance targets (with audit and feedback) within a national governance framework were present in Scotland but not England. Differences in coordinated leadership, sharing best practices, and disliking being perceived as underperforming, were evident in Scotland.

CONCLUSIONS

High-certainty evidence shows that SI-IVC, such as MMC, after NMIBC resection reduces recurrences. This evidence underpins international guidance. The number of eligible patients receiving SI-IVC is variable indicating suboptimal practice. Improving SI-IVC adherence requires modifications to theatre instilling policies, delivery and storage of MMC, staff training, and documentation. Centralising care, with bladder cancer expert leadership and best practices sharing with performance targets, likely led to improvements in Scotland. National quality improvement, incorporating audit and feedback, with additional implementation strategies targeted to professional role could improve adherence and patient outcomes elsewhere. This process should be controlled to clarify implementation intervention effectiveness.

Multicentre stepped-wedge cluster randomised controlled trial of an antimicrobial stewardship programme in residential aged care: protocol for the START trial

INTRODUCTION

Antimicrobial resistance is a growing global health threat, driven by increasing inappropriate use of antimicrobials. High prevalence of unnecessary use of antimicrobials in residential aged care facilities (RACFs) has driven demand for the development and implementation of antimicrobial stewardship (AMS) programmes. The Stepped-wedge Trial to increase antibiotic Appropriateness in Residential aged care facilities and model Transmission of antimicrobial resistance (START) will implement and evaluate the impact of a nurse-led AMS programme on antimicrobial use in 12 RACFs.

METHODS AND ANALYSIS

The START trial will implement and evaluate a nurse-led AMS programme via a stepped-wedge cluster randomised controlled trial design in 12 RACFs over 16 months. The AMS programme will incorporate education, aged care-specific treatment guidelines, documentation forms, and audit and feedback strategies that will target aged care staff, general practitioners, pharmacists, and residents and their families. The intervention will primarily focus on urinary tract infections, lower respiratory tract infections, and skin and soft tissue infections. RACFs will transition from control to intervention phases in random order, two at a time, every 2 months, with a 2-month transition, wash-in period. The primary outcome is the cumulative proportion of residents within each facility prescribed an antibiotic during each month and total days of antibiotic use per 1000 occupied bed days. Secondary outcomes include the number of courses of systemic antimicrobial therapy, antimicrobial appropriateness, antimicrobial resistant organisms, Clostridioides difficile infection, change in antimicrobial susceptibility profiles, hospitalisations and all-cause mortality. Analyses will be conducted according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/591). Research findings will be disseminated through peer-reviewed publications, conferences and summarised reports provided to participating RACFs.

TRIAL REGISTRATION NUMBER

NCT03941509.

Social norms interventions to change clinical behaviour in health workers: a systematic review and meta-analysis

Background

A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. These low-cost interventions can be used to encourage health workers to follow recommended professional practice.

Objective

To summarise evidence on whether or not social norms interventions are effective in encouraging health worker behaviour change, and to identify the most effective social norms interventions.

Design

A systematic review and meta-analysis of randomised controlled trials.

Data sources

The following databases were searched on 24 July 2018: Ovid MEDLINE (1946 to week 2 July 2018), EMBASE (1974 to 3 July 2018), Cumulative Index to Nursing and Allied Health Literature (1937 to July 2018), British Nursing Index (2008 to July 2018), ISI Web of Science (1900 to present), PsycINFO (1806 to week 3 July 2018) and Cochrane trials (up to July 2018).

Participants

Health workers took part in the study.

Interventions

Behaviour change interventions based on social norms.

Outcome measures

Health worker clinical behaviour, for example prescribing (primary outcome), and patient health outcomes, for example blood test results (secondary), converted into a standardised mean difference.

Methods

Titles and abstracts were reviewed against the inclusion criteria to exclude any that were clearly ineligible. Two reviewers independently screened the remaining full texts to identify relevant papers. Two reviewers extracted data independently, coded for behaviour change techniques and assessed quality using the Cochrane risk-of-bias tool. We performed a meta-analysis and presented forest plots, stratified by behaviour change technique. Sources of variation were explored using metaregression and network meta-analysis.

Results

A total of 4428 abstracts were screened, 477 full texts were screened and findings were based on 106 studies. Most studies were in primary care or hospitals, targeting prescribing, ordering of tests and communication with patients. The interventions included social comparison (in which information is given on how peers behave) and credible source (which refers to communication from a well-respected person in support of the behaviour). Combined data suggested that interventions that included social norms components were associated with an improvement in health worker behaviour of 0.08 standardised mean differences (95% confidence interval 0.07 to 0.10 standardised mean differences) (n = 100 comparisons), and an improvement in patient outcomes of 0.17 standardised mean differences (95% confidence interval 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I 2 of 85.4% (primary) and 91.5% (secondary). Network meta-analysis suggested that three types of social norms intervention were most effective, on average, compared with control: credible source (0.30 standardised mean differences, 95% confidence interval 0.13 to 0.47); social comparison combined with social reward (0.39 standardised mean differences, 95% confidence interval 0.15 to 0.64); and social comparison combined with prompts and cues (0.33 standardised mean differences, 95% confidence interval 0.22 to 0.44).

Limitations

The large number of studies prevented us from requesting additional information from authors. The trials varied in design, context and setting, and we combined different types of outcome to provide an overall summary of evidence, resulting in a very heterogeneous review.

Conclusions

Social norms interventions are an effective method of changing clinical behaviour in a variety of health service contexts. Although the overall result was modest and very variable, there is the potential for social norms interventions to be scaled up to target the behaviour of a large population of health workers and resulting patient outcomes.

Future work

Development of optimised credible source and social comparison behaviour change interventions, including qualitative research on acceptability and feasibility.

Study registration

This study is registered as PROSPERO CRD42016045718.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 41. See the NIHR Journals Library website for further project information.

Measuring Antibiotic Stewardship Programmes and Initiatives: An Umbrella Review in Primary Care Medicine and a Systematic Review of Dentistry

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.

Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study

BACKGROUND

Unnecessary prescribing of antibiotics in primary care is contributing to the emergence of antimicrobial drug resistance.

OBJECTIVES

To develop and evaluate a multicomponent intervention for antimicrobial stewardship in primary care, and to evaluate the safety of reducing antibiotic prescribing for self-limiting respiratory infections (RTIs).

INTERVENTIONS

A multicomponent intervention, developed as part of this study, including a webinar, monthly reports of general practice-specific data for antibiotic prescribing and decision support tools to inform appropriate antibiotic prescribing.

DESIGN

A parallel-group, cluster randomised controlled trial.

SETTING

The trial was conducted in 79 general practices in the UK Clinical Practice Research Datalink (CPRD).

PARTICIPANTS

All registered patients were included.

MAIN OUTCOME MEASURES

The primary outcome was the rate of antibiotic prescriptions for self-limiting RTIs over the 12-month intervention period.

COHORT STUDY

A separate population-based cohort study was conducted in 610 CPRD general practices that were not exposed to the trial interventions. Data were analysed to evaluate safety outcomes for registered patients with 45.5 million person-years of follow-up from 2005 to 2014.

RESULTS

There were 41 intervention trial arm practices (323,155 patient-years) and 38 control trial arm practices (259,520 patient-years). There were 98.7 antibiotic prescriptions for RTIs per 1000 patient-years in the intervention trial arm (31,907 antibiotic prescriptions) and 107.6 per 1000 patient-years in the control arm (27,923 antibiotic prescriptions) [adjusted antibiotic-prescribing rate ratio (RR) 0.88, 95% confidence interval (CI) 0.78 to 0.99; p = 0.040]. There was no evidence of effect in children aged < 15 years (RR 0.96, 95% CI 0.82 to 1.12) or adults aged ≥ 85 years (RR 0.97, 95% CI 0.79 to 1.18). Antibiotic prescribing was reduced in adults aged between 15 and 84 years (RR 0.84, 95% CI 0.75 to 0.95), that is, one antibiotic prescription was avoided for every 62 patients (95% CI 40 to 200 patients) aged 15-84 years per year. Analysis of trial data for 12 safety outcomes, including pneumonia and peritonsillar abscess, showed no evidence that these outcomes might be increased as a result of the intervention. The analysis of data from non-trial practices showed that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then 1.1 (95% CI 0.6 to 1.5) more cases of pneumonia per year and 0.9 (95% CI 0.5 to 1.3) more cases of peritonsillar abscesses per decade may be observed. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess or Lemierre syndrome were more frequent at low-prescribing practices.

LIMITATIONS

The research was based on electronic health records that may not always provide complete data. The number of practices included in the trial was smaller than initially intended.

CONCLUSIONS

This study found evidence that, overall, general practice antibiotic prescribing for RTIs was reduced by this electronically delivered intervention. Antibiotic prescribing rates were reduced for adults aged 15-84 years, but not for children or the senior elderly.

FUTURE WORK

Strategies for antimicrobial stewardship should employ stratified interventions that are tailored to specific age groups. Further research into the safety of reduced antibiotic prescribing is also needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN95232781.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 11. See the NIHR Journals Library website for further project information.

Antimicrobial stewardship in dental practice

BACKGROUND

Antibiotic resistance is a global public health problem that is responsible for increased patient morbidity and mortality and financial burden. Dental antibiotic prescribing contributes to approximately 10% of all antibiotic prescriptions, and an estimated 80% of that prescribing is deemed inappropriate. Dental antimicrobial stewardship (AMS) has an important role to play in international efforts to tackle antibiotic resistance. The aim of the authors was to comment on the implementation of AMS strategies in outpatient dental practices.

METHODS

The authors included previous studies regarding outpatient antibiotic stewardship, longitudinal studies quantifying dispensed dental antibiotic prescription use, and interventional studies aimed at implementing AMS interventions in dentistry.

RESULTS

Researchers in several studies conducted trials regarding the use of various interventions, mostly comprising a combination of audit, feedback, dissemination of guidelines, and educational components to improve dental prescribing.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

In regard to the establishment of an AMS strategy, aspects to be considered should include raising awareness about the risks of unnecessary use of antibiotics. Engaging and educating the entire dental team and patients, as well as collaborating with other specialized professionals, are important elements. Context-specific interventions with a methodical and measured approach are ideal.

Antimicrobial Stewardship Audit and Feedback rounds: moving beyond the restricted antibiotic list and the impact of electronic systems

BACKGROUND

Current methods of antimicrobial usage surveillance have limited efficacy in changing practice due to delayed reporting to clinicians and the inability to stratify by medical specialty. This study was undertaken in a tertiary teaching hospital with a well-established Antimicrobial Stewardship (AMS) programme and electronic medicines management (eMM) system in Sydney, Australia.

AIMS

The aim was to describe and analyse the implementation of a novel AMS audit and feedback method, in the context of an eMM system.

METHODS

The AMS team conducted the audit weekly, and the study design was a prospective, observational study. All acute, adult inpatients were included in this intervention. All active systemic antimicrobial prescriptions on the day of the rounds were included.

RESULTS

The prevalence of patients on antimicrobial therapy was 37%. The median time taken per round was 44 min for eMM compared to 58 min for paper. All key performance indicators improved over the study period. Appropriateness compared to guidelines increased from 55% to 71%, and documentation of an indication increased from 75% to 98%. 1413 recommendations were made with the most common being to cease an antimicrobial agent. The recommendation uptake rate was 47% at 24 h post-round.

CONCLUSIONS

AMS rounds are an effective tool for auditing and providing feedback on antimicrobial use and should include all antimicrobials rather than solely 'restricted' agents. These rounds had a high uptake rate, improvements in the appropriateness of antimicrobial use, and a planned duration or review date. A benefit of eMM was improvement in the documentation of indication for antimicrobial agents, and reduced time taken to audit. This article is protected by copyright. All rights reserved.

Improvement of dental prescribing practices using education and a prescribing tool: A pilot intervention study

AIMS

Antibiotic resistance is a global public health problem. Around 55% of dental antibiotic prescribing is deemed inappropriate. The aim of this multimodal interventional pilot study was to assess the effect on prescribing of education and a dentally designed prescribing website.

METHODS

Twenty-six dentists were recruited for the 12-week study using a pre-post design. Dentists self-recorded their prescribing of antibiotics, analgesics and anxiolytics for 6 weeks. After dentists were provided education and website access, they recorded their prescribing for a further 6 weeks. Four outcomes were measured comparing the prescribing before and after the intervention: (i) the number of inappropriate indications for which antibiotics were prescribed; (ii) the number of prescriptions; (iii) accuracy of the prescriptions according to the Australian therapeutic guidelines; and (iv) the confidence of practitioners towards the prescribing website. Participants were interviewed for feedback.

RESULTS

There was a substantial reduction of 44.6% in the number of inappropriate indications for which antibiotics were prescribed after the intervention and a decrease of 40.5% in the total number of antibiotics. Paracetamol with codeine substantially reduced by 56.8%. For the 3 most commonly prescribed antibiotics (amoxicillin, phenoxymethylpenicillin and metronidazole), there was the improvement in the accuracy of the prescriptions ranging from 0-64.7 to 74.2-100%.

CONCLUSION

This pilot study showed the intervention of targeted education and the prescribing tool was effective in improving dental prescribing, knowledge and confidence of practitioners, as well as providing an effective antibiotic stewardship tool. This context-specific intervention shows substantial promise for implementation into dental practice.

Effect of a computer network-based feedback program on antibiotic prescription rates of primary care physicians: A cluster randomized crossover-controlled trial

OBJECTIVE

Antibiotic overuse is one of the major prescription problems in rural China and a major risk factor for antibiotic resistance. Low antibiotic prescription rates can effectively reduce the risk of antibiotic resistance. We hypothesized that under a paperless, computer-based feedback system the rates of antibiotic prescriptions among primary care physicians can be reduced.

METHODS

A cluster randomized crossover open controlled trial was conducted in 31 hospitals. These hospitals were randomly allocated to two groups to receive the intervention for three months followed by no intervention for three months in a random sequence. The feedback intervention information, which displayed the physicians' antibiotic prescription rates and ranking, was updated every 10 days. The primary outcome was the 10-day antibiotic prescription rate of the physicians.

RESULTS

There were 82 physicians in group 1 (intervention first followed by control) and 81 in group 2 (control first followed by intervention). Baseline comparison showed no significant difference in antibiotic prescription rate between the two groups (30.8% vs 35.2%, P-value=0.07). At the crossover point, the relative reduction in antibiotic prescription rate was significantly higher among physicians in the intervention group than in the control group (33.1% vs 20.3%, P-value<0.001). After a further 3 months, the rate of decline in antibiotic prescriptions was also significantly greater in the intervention group compared to the control group (14.2% vs 4.6%, P-value<0.001). The characteristics of physicians did not significantly determine the change in rate of antibiotic prescriptions.

CONCLUSION

A computer network-based feedback intervention can significantly reduce the antibiotic prescription rates of primary care outpatient physicians and continuously affected their prescription behavior for up to six months.

TRIAL REGISTRATION

ChiCTR1900021823.

Barriers to and Enablers of Implementation of High-Value Interventions by Renal Pharmacists: A Qualitative Study Informed by the Theoretical Domains Framework

BACKGROUND

Previous studies have shown that patients with chronic kidney disease who are followed by a renal clinical pharmacist have improved clinical outcomes. In 2016, a consensus list of quality indicator drug therapy problems (QI-DTPs) was developed by renal clinical pharmacists to help prioritize which renal patients should receive interventions. Before QI-DTP interventions can be implemented in clinical practice, barriers to and enablers of their use need to be identified, to allow development of strategies to overcome the barriers and apply the enablers.

OBJECTIVE

To identify modifiable barriers to and enablers of implementation of renal QI-DTP interventions by renal clinical pharmacists.

METHODS

In this exploratory qualitative descriptive study, one-on-one, semistructured, audio-recorded telephone interviews were conducted with renal clinical pharmacists to identify the barriers to and enablers of implementation of renal QI-DTP interventions. The interviews consisted of questions developed according to the Theoretical Domains Framework.

RESULTS

Interviews were conducted with 13 renal pharmacists from across Canada. The main barriers to implementation of renal QI-DTP interventions that participants identified were knowledge gaps, prioritization, and nephrologist acceptance. The main enablers identified were training, colleague support, and better patient care.

CONCLUSION

Three barriers to and three enablers of implementation of renal QI-DTP interventions were identified. These barriers and enablers can be used to help with pharmacist education and to optimize the care that pharmacists provide to renal patients.

Revitalising audit and feedback to improve patient care

Audit and feedback are widely used in quality improvement. Robbie Foy and colleagues argue that their full potential to improve patient care could be realised through a more evidence based and imaginative approach

The effectiveness of guideline implementation strategies in the dental setting: a systematic review

BACKGROUND

Guideline implementation has been an ongoing challenge in the dental practice setting. Despite this, there are no reviews summarising the existing evidence regarding effective guideline implementation strategies in this setting. In order to address this, this systematic review examines the effectiveness of guideline implementation strategies in the dental practice setting.

METHODS

A systematic search was undertaken according to the PRISMA statement across nine electronic databases, targeting randomised controlled trials and quasi-experimental studies which evaluated the effectiveness of guideline implementation strategies in improving guideline adherence in the dental setting. All records were independently examined for relevance and appraised for study quality by two authors, with consensus achieved by a third author. Data were extracted from included studies using a standardised data extraction pro forma.

RESULTS

A total of 15 records were eligible for inclusion in this review, which focused on the effects of audit and feedback, reminders, education, patient-mediated interventions, pay for performance and multifaceted interventions. Although there were some conflicting evidence, studies within each category of implementation strategy indicated a positive effect on guideline adherence.

CONCLUSIONS

This study has identified education, reminders and multifaceted interventions as effective implementation strategies for the dental practice setting. Although this is similar to research findings from other health sectors, there is some evidence to suggest patient-mediated interventions may be less effective and pay for performance may be more effective in the dental setting. These findings can inform policy makers, professional associations, colleges and organisations in the future adoption of clinical guidelines in the dental practice setting.

TRIAL REGISTRATION

This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration ID CRD42018093023.