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Turner A, van Driel ML, Mitchell BL, Davis JS, Fielding A, Davey A, Holliday E, Ball J, Ralston A, Tapley A, Mulquiney K, Baillie EJ, Spike N, Clarke L, Magin P. Temporal patterns of antibiotic prescribing for sore throat, otitis media, and sinusitis: a longitudinal study of general practitioner registrars. Fam Pract 2024; 41:283-291. [PMID: 37226282 PMCID: PMC11167965 DOI: 10.1093/fampra/cmad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Antibiotics provide minimal benefit for sore throat, otitis media, and sinusitis. Antibiotic stewardship, with reduced prescribing, is required to address antibiotic resistance. As most antibiotic prescribing occurs in general practice and prescribing habits develop early, general practitioner (GP) trainees (registrars) are important for effective antibiotic stewardship. OBJECTIVES To establish temporal trends in Australian registrars' antibiotic prescribing for acute sore throat, acute otitis media, and acute sinusitis. DESIGN A longitudinal analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study from 2010 to 2019. PARTICIPANTS ReCEnT is an ongoing cohort study of registrars' in-consultation experiences and clinical behaviours. Pre-2016, 5 of 17 Australian training regions participated. From 2016, 3 of 9 regions (42% of Australian registrars) participate. MAIN MEASURES The outcome was prescription of an antibiotic for a new acute problem/diagnosis of sore throat, otitis media, or sinusitis. The study factor was year (2010-2019). KEY RESULTS Antibiotics were prescribed in 66% of sore throat diagnoses, 81% of otitis media, and in 72% of sinusitis. Prescribing frequencies decreased between 2010 and 2019 by 16% for sore throat (from 76% to 60%) by 11% for otitis media (from 88% to 77%) and by 18% for sinusitis (from 84% to 66%). In multivariable analyses, "Year" was associated with reduced prescribing for sore throat (OR 0.89; 95%CI 0.86-0.92; p < 0.001), otitis media (OR 0.90; 95%CI 0.86-0.94; p < 0.001), and sinusitis (OR 0.90; 95%CI 0.86, 0.94; p < 0.001). CONCLUSIONS Registrars' prescribing rates for sore throat, otitis media, and sinusitis significantly decreased during the period 2010-2019. However, educational (and other) interventions to further reduce prescribing are warranted.
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Affiliation(s)
- Alexandria Turner
- Faculty of Medicine, General Practice Clinical Unit, The University of Queensland, Brisbane, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, Australia
| | - Mieke L van Driel
- Faculty of Medicine, General Practice Clinical Unit, The University of Queensland, Brisbane, Australia
| | - Benjamin L Mitchell
- Faculty of Medicine, General Practice Clinical Unit, The University of Queensland, Brisbane, Australia
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Alison Fielding
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Andrew Davey
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Elizabeth Holliday
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Jean Ball
- Clinical Research Design and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Anna Ralston
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Amanda Tapley
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Katie Mulquiney
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Emma J Baillie
- Faculty of Medicine, General Practice Clinical Unit, The University of Queensland, Brisbane, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training, Regional Training Organisation, Hawthorn, Australia
- Department of General Practice and Primary Health Care, University of Melbourne, Carlton, Australia
- School of Rural Health, Monash University, Clayton, Australia
| | - Lisa Clarke
- General Practice Training Tasmania, Regional Training Organisation, Hobart, Australia
| | - Parker Magin
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
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Magin P, Ralston A, Fielding A, Holliday E, Tran M, Tapley A, van Driel M, Ball J, Moad D, Mitchell B, Fisher K, FitzGerald K, Spike N, Turner R, Davey A. Prediction of general practice licensure/certification examination performance by a measure of 'questionable' activities in clinical practice: a retrospective cohort study. Postgrad Med J 2024; 100:382-390. [PMID: 38298001 DOI: 10.1093/postmj/qgad147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/26/2023] [Accepted: 12/18/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE 'Low-value' clinical care and medical services are 'questionable' activities, being more likely to cause harm than good or with disproportionately low benefit relative to cost. This study examined the predictive ability of the QUestionable In Training Clinical Activities Index (QUIT-CAI) for general practice (GP) registrars' (trainees') performance in Australian GP Fellowship examinations (licensure/certification examinations for independent GP). METHODS The study was nested in ReCEnT, an ongoing cohort study in which Australian GP registrars document their in-consultation clinical practice. Outcome factors in analyses were individual registrars' scores on the three Fellowship examinations ('AKT', 'KFP', and 'OSCE' examinations) and pass/fail rates during 2012-21. Analyses used univariable and multivariable regression (linear or logistic, as appropriate). The study factor in each analysis was 'QUIT-CAI score percentage'-the percentage of times a registrar performed a QUIT-CAI clinical activity when 'at risk' (i.e. when managing a problem where performing a QUIT-CAI activity was a plausible option). RESULTS A total of 1265, 1145, and 553 registrars sat Applied Knowledge Test, Key Features Problem, and Objective Structured Clinical Exam examinations, respectively. On multivariable analysis, higher QUIT-CAI score percentages (more questionable activities) were significantly associated with poorer Applied Knowledge Test scores (P = .001), poorer Key Features Problem scores (P = .003), and poorer Objective Structured Clinical Exam scores (P = .005). QUIT-CAI score percentages predicted Royal Australian College of General Practitioner exam failure [odds ratio 1.06 (95% CI 1.00, 1.12) per 1% increase in QUIT-CAI, P = .043]. CONCLUSION Performing questionable clinical activities predicted poorer performance in the summative Fellowship examinations, thereby validating these examinations as measures of actual clinical performance (by our measure of clinical performance, which is relevant for a licensure/certification examination).
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Affiliation(s)
- Parker Magin
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
- General Practice Training Research Department, Royal Australian College of General Practitioners, Level 1, 20 Mclntosh Drive, Mayfield West, Newcastle, NSW 2304, Australia
| | - Anna Ralston
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
- General Practice Training Research Department, Royal Australian College of General Practitioners, Level 1, 20 Mclntosh Drive, Mayfield West, Newcastle, NSW 2304, Australia
| | - Alison Fielding
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
- General Practice Training Research Department, Royal Australian College of General Practitioners, Level 1, 20 Mclntosh Drive, Mayfield West, Newcastle, NSW 2304, Australia
| | - Elizabeth Holliday
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - Michael Tran
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, High Street and Botany Road, Kensington, Sydney, NSW 2052, Australia
| | - Amanda Tapley
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
- General Practice Training Research Department, Royal Australian College of General Practitioners, Level 1, 20 Mclntosh Drive, Mayfield West, Newcastle, NSW 2304, Australia
| | - Mieke van Driel
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia
| | - Jean Ball
- Clinical Research Design and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute (HMRI), Lot 1, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - Dominica Moad
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
- General Practice Training Research Department, Royal Australian College of General Practitioners, Level 1, 20 Mclntosh Drive, Mayfield West, Newcastle, NSW 2304, Australia
| | - Ben Mitchell
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, 288 Herston Road, Herston, QLD 4006, Australia
| | - Katie Fisher
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
- General Practice Training Research Department, Royal Australian College of General Practitioners, Level 1, 20 Mclntosh Drive, Mayfield West, Newcastle, NSW 2304, Australia
| | - Kristen FitzGerald
- General Practice Training Tasmania (GPTT), Level 3, RACT House, 179 Murray Street, Hobart, TAS 7000, Australia
- School of Medicine, University of Tasmania, Level 1, Medical Science 1, 17 Liverpool Street, Hobart, TAS 7000, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training (EVGPT), 15 Cato Street, Hawthorn, VIC 3122, Australia
- Department of General Practice and Primary Health Care, University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053, Australia
- School of Rural Health, Monash University, Faculty of Medicine, Nursing and Health Sciences. Building 20/26 Mercy Street, Bendigo, VIC 3550, Australia
| | - Rachel Turner
- General Practice Training Research Department, Royal Australian College of General Practitioners, Level 1, 20 McIntosh Drive, Mayfield West, NSW 2304, Australia
| | - Andrew Davey
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
- General Practice Training Research Department, Royal Australian College of General Practitioners, Level 1, 20 Mclntosh Drive, Mayfield West, Newcastle, NSW 2304, Australia
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Baillie EJ, Merlo G, Biezen R, Peprah Boaitey K, Magin PJ, van Driel ML, Hall L. Diagnosis and management of acute infections during telehealth consultations in Australian general practice: a qualitative study. BJGP Open 2024; 8:BJGPO.2023.0142. [PMID: 38092442 PMCID: PMC11169986 DOI: 10.3399/bjgpo.2023.0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/13/2023] [Accepted: 11/24/2023] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND The use of telehealth has increased dramatically since the beginning of the COVID-19 pandemic. Little is known about how GPs manage acute infections during telehealth, and the potential impact on antimicrobial stewardship. AIM To explore the experiences and perceptions of GP trainees' and supervisors' use of telehealth, and how it influences their management of acute infections. DESIGN & SETTING Australian GP registrars (trainees) and supervisors were recruited via email through their training organisations. Semi-structured interviews with 18 participants were conducted between July and August 2022. METHOD Interviews were transcribed verbatim and analysed using a reflexive thematic approach. RESULTS We identified six overall themes. 1. Participants experienced impaired diagnostic capacity during telehealth consultations. 2. Attempts to improve diagnostic acuity included various methods, such as having patients self-examine. 3. The management of clinical uncertainty frequently entailed referring patients for in-person assessment, overinvestigating, or overtreating. 4. Antibiotic prescribing decisions during telehealth were informed by less information than were in-person consults, with varying impact. 5. Participants believed that other GPs improperly prescribed antibiotics during telehealth. 6. Supervisors believed that registrars hadn't developed the knowledge or skills to determine when conditions could be managed appropriately via telehealth. CONCLUSION Telehealth has potential for reducing transmission of acute infections and increasing access to healthcare. However, the implications of GPs, especially less experienced GPs, making diagnoses with less certainty, and consequently compromising antimicrobial stewardship, are a concern. Patient self-assessment tools may improve outcomes of telehealth consultations for acute infections.
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Affiliation(s)
- Emma J Baillie
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, QL, Australia
| | - Gregory Merlo
- Healthcare Improvement Unit, Queensland Health, Bowen Hills, Brisbane, QL, Australia
| | - Ruby Biezen
- Department of General Practice, The University of Melbourne, Melbourne, VI, Australia
| | - Kwame Peprah Boaitey
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QL, Australia
| | - Parker J Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- GP Training Research Department, Royal Australian College of General Practitioners, Callaghan, NSW, Australia
| | - Mieke L van Driel
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, QL, Australia
| | - Lisa Hall
- School of Public Health, The University of Queensland, Brisbane, QL, Australia
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Baillie EJ, Merlo G, Van Driel ML, Magin PJ, Hall L. Early-career general practitioners' antibiotic prescribing for acute infections: a systematic review. J Antimicrob Chemother 2024; 79:512-525. [PMID: 38252922 PMCID: PMC10904722 DOI: 10.1093/jac/dkae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Antimicrobial resistance is a worldwide threat, exacerbated by inappropriate prescribing. Most antibiotic prescribing occurs in primary care. Early-career GPs are important for the future of antibiotic prescribing and curbing antimicrobial resistance. OBJECTIVES To determine antibiotic prescribing patterns by early-career GPs for common acute infections. METHODS A systematic literature search was conducted using PubMed, Embase and Scopus. Two authors independently screened abstracts and full texts for inclusion. Primary outcomes were antibiotic prescribing rates for common acute infections by GPs with experience of 10 years or less. Secondary outcomes were any associations between working experience and antibiotic prescribing. RESULTS Of 1483 records retrieved, we identified 41 relevant studies. Early-career GPs were less likely to prescribe antibiotics compared with their more experienced colleagues (OR range 0.23-0.67). Their antibiotic prescribing rates for 'any respiratory condition' ranged from 14.6% to 52%, and for upper respiratory tract infections from 13.5% to 33%. Prescribing for acute bronchitis varied by country, from 15.9% in Sweden to 26% in the USA and 63%-73% in Australia. Condition-specific data for all other included acute infections, such as sinusitis and acute otitis media, were limited to the Australian context. CONCLUSIONS Early-career GPs prescribe fewer antibiotics than later-career GPs. However, there are still significant improvements to be made for common acute conditions, as their prescribing is higher than recommended benchmarks. Addressing antimicrobial resistance requires an ongoing worldwide effort and early-career GPs should be the target for long-term change.
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Affiliation(s)
- Emma J Baillie
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Greg Merlo
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Mieke L Van Driel
- General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Parker J Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- GP Training Research Department, Royal Australian College of General Practitioners, Callaghan, NSW, Australia
| | - Lisa Hall
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
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Acampora M, Paleologo M, Graffigna G, Barello S. Uncovering influential factors in human antibiotic prescribing: a meta-synthesis study informed by the Theoretical Domains Framework. J Hosp Infect 2024; 144:28-55. [PMID: 38092303 DOI: 10.1016/j.jhin.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/28/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024]
Abstract
This study aimed to identify modifiable determinants (facilitators and barriers) related to the choice of prescribing antibiotics in human medicine across clinical settings. Enhanced management of antibiotics can help slow the spread of resistant bacteria. A qualitative meta-synthesis approach was used, according to Sandelowski and Barroso's method. Included studies were evaluated using the Critical Appraisal Skills Programme. Findings were extracted and organized to form a qualitative meta-summary. The Theoretical Domains Framework, the Capabilities-Opportunities-Motivation (COM-B) model and the Behaviour Change Wheel were used as a coding matrix for data interpretation. The analysis of 63 included studies revealed barriers and facilitators in 12 of 14 domains specified by the Theoretical Domains Framework. Prescribers' capabilities, motivation and opportunities were found to be the main drivers of antibiotic prescribing behaviour. Knowledge, skills, beliefs, expectations, the influence of patients and colleagues, organizational culture and infrastructure characteristics have a significant impact on prescribing behaviours. A comprehensive inventory of factors related to antibiotic prescribing has been compiled. Interventions to promote appropriate antibiotic prescribing should take a systemic approach rather than focusing solely on individual-level variables. Furthermore, the adoption of co-design approaches for such interventions is desirable to ensure greater applicability and sustainability in the real-world context of organizations.
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Affiliation(s)
- M Acampora
- EngageMinds HUB - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore di Milano e Cremona, Milan and Cremona, Italy; Department of Psychology, Università Cattolica del Sacro Cuore di Milano, Milan, Italy
| | - M Paleologo
- EngageMinds HUB - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore di Milano e Cremona, Milan and Cremona, Italy; Department of Psychology, Università Cattolica del Sacro Cuore di Milano, Milan, Italy
| | - G Graffigna
- EngageMinds HUB - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore di Milano e Cremona, Milan and Cremona, Italy; Department of Psychology, Università Cattolica del Sacro Cuore di Milano, Milan, Italy; Faculty of Agricultural, Food and Environmental Sciences, Università Cattolica del Sacro Cuore di Cremona, Cremona, Italy
| | - S Barello
- Department of Brain and Behavioural Sciences, Università di Pavia, Pavia, Italy.
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He K, Dawson M, Stroh C, Taylor KM, Quigley S, Jones S, Cramm SL, Rangel SJ. A Process Improvement Project to Increase Compliance With Cephalosporin-based Surgical Antimicrobial Prophylaxis in Children With Non-severe Penicillin Allergies. J Pediatr Surg 2024; 59:61-67. [PMID: 37839950 DOI: 10.1016/j.jpedsurg.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND/PURPOSE Cephalosporins are considered safe and first-line prophylaxis in children with non-severe penicillin allergies. However, use of second-line agents is common and is primarily driven by poor allergic response documentation and misunderstanding of cross-reactivity risk. The goal of this project was to improve compliance with cephalosporin prophylaxis through improved documentation and targeted educational efforts. METHODS A multidisciplinary working group including representatives from allergy, surgery, infectious disease, and pharmacy developed staged interventions to facilitate compliance with cephalosporin prophylaxis. These included: (1) caregiver outreach to clarify incomplete allergy documentation, (2) a decision-support algorithm for prophylaxis use in penicillin-allergic patients, (3) standardized educational resources for surgical faculty and rotating trainees, (4) email reminders with prophylaxis recommendations sent out prior to scheduled cases, and (5) EMR-based decision support during antibiotic ordering. Rates of complete allergy documentation and cephalosporin utilization were compared for general surgery procedures between a 12-month pre-intervention and 14-month post-intervention period. RESULTS 578 patients with penicillin allergies recorded in the EMR were included (301 pre-intervention and 277 post-intervention), 54.0% of which received prophylaxis. Compared to the pre-intervention period, complete documentation of allergic reactions increased from 57.1% to 84.2% (p < 0.001) following implementation of all interventions. Appropriate prophylaxis utilization increased from 34.5% to 88.5% following implementation of all interventions (p < 0.001), and evidence of a stepwise increase in appropriate utilization was evident with each intervention stage. Persistent compliance failures during the post-implementation period were most commonly associated with urgent and emergent add-on cases. No adverse events or allergic responses were reported before or after project implementation. CONCLUSIONS Compliance with cephalosporin prophylaxis significantly improved following a multidisciplinary effort targeting education, allergy documentation, and clinical support at the point of care. Ongoing efforts include postoperative audits within 24 h for noncompliant cases in order to identify barriers and improve compliance for urgent and emergent add-on cases. LEVEL OF EVIDENCE III. TYPE OF STUDY Prospective.
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Affiliation(s)
- Katherine He
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michele Dawson
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Crystal Stroh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristina M Taylor
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Quigley
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Jones
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Ho B, Kukan S, McIsaac W. Do family medicine residents optimally prescribe antibiotics for common infectious conditions seen in a primary care setting? JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2023; 8:192-200. [PMID: 38058504 PMCID: PMC10697098 DOI: 10.3138/jammi-2022-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/24/2023] [Indexed: 12/08/2023]
Abstract
Background Antimicrobial resistance is a worldwide phenomenon that leads to a significant number of unnecessary deaths and costly hospital admissions. More than 90% of antibiotic use happens in the community and of this, family physicians account for two-thirds of these prescriptions. Our study aims to determine whether family medicine residents are optimally trained in antibiotic prescribing for common infectious conditions seen in a primary care setting. Methods This study is a secondary analysis of a prior study of antimicrobial stewardship in two urban primary care clinics in central Toronto, Ontario. A total of 1099 adult patient visits were included that involved family medicine resident trainees, seen between 2015 and 2016. The main outcome measures were resident antibiotic prescription rates for each condition and expert-recommended prescribing practices, the rate prescriptions were issued as delayed prescriptions, and the use of first-line recommended narrow-spectrum antibiotics. Results Compared to expert-recommended prescribing rates, family medicine residents overprescribed for uncomplicated upper respiratory tract infections (URI) (5.0% [95% CI 2.2% to 9.7%] versus 0% expert recommended) and sinusitis (44.2% [95% CI 32.8% to 55.9%] versus 11%-18% expert range), and under prescribed for pneumonia (53.5% [95% CI 37.7% to 68.8%] versus 100% expert range]). Prescribing rates were within expert recommended ranges for pharyngitis (28.6% [95% CI 16.6% to 43.3%]), bronchitis (3.6% [95% CI 0% to 18.4%]), and cystitis (79.4% [95% CI 70.6% to 86.6%]). Conclusions The antibiotic prescribing practices of family medicine residents during their training programs indicated overprescribing of antibiotics for some common infection presentations. Further study of antibiotic prescribing in primary care training programs across Canada is recommended to determine if future family physicians are learning appropriate antibiotic prescribing practices.
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Affiliation(s)
- Bernard Ho
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Ray D. Wolfe Department of Family Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Sahana Kukan
- Ray D. Wolfe Department of Family Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Warren McIsaac
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Ray D. Wolfe Department of Family Medicine, Sinai Health System, Toronto, Ontario, Canada
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Poluektova O, Robertson DA, Rafferty A, Cunney R, Lunn PD. A scoping review and behavioural analysis of factors underlying overuse of antimicrobials. JAC Antimicrob Resist 2023; 5:dlad043. [PMID: 37168837 PMCID: PMC10164659 DOI: 10.1093/jacamr/dlad043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
Background Overuse of antimicrobials is a challenging global issue that contributes to antimicrobial resistance. Despite widespread awareness of the problem among members of the medical community and various attempts to improve prescription practices, existing antimicrobial stewardship programmes are not always effective. In our view, this may reflect limited understanding of factors that influence prescription of antimicrobials as empirical therapy, implying a need to address the psychological mechanisms behind some of the specific behaviours involved. Objectives To identify factors that influence the antimicrobials prescription as empirical therapy, and to relate these factors to findings from behavioural science. Methods We conducted a scoping review of the literature on the factors underlying antimicrobial prescription decisions, following the protocol designed using PRISMA guidelines. Results and conclusions From a final sample of 90 sources, we identified ten factors important in antimicrobial prescription decisions. In the second stage of our analysis, we grouped them into five final categories: (1) nature of the decision, (2) social influences, (3) individual differences, (4) characteristics of the patient, (5) context. We analyse these categories using a behavioural science perspective.
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Affiliation(s)
| | - Deirdre A Robertson
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, School of Psychology, Dublin, Ireland
| | - Aisling Rafferty
- Children’s Health Ireland, Department of Pharmacy, Dublin, Ireland
- University of Birmingham, School of Pharmacy, Institute of Clinical Sciences,Birmingham, UK
| | - Robert Cunney
- Children’s Health Ireland, Irish Meningitis and Sepsis Reference Laboratory, Dublin, Ireland
- Royal College of Surgeons in Ireland, Department of Microbiology, Dublin, Ireland
- Children’s Health Ireland, Department of Microbiology, Dublin, Ireland
| | - Peter D Lunn
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, Department of Economics, Dublin, Ireland
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Baillie EJ, Merlo G, Magin P, Tapley A, Mulquiney KJ, Davis JS, Fielding A, Davey A, Holliday E, Ball J, Spike N, FitzGerald K, van Driel ML. Antibiotic prescribing for upper respiratory tract infections and acute bronchitis: a longitudinal analysis of general practitioner trainees. Fam Pract 2022; 39:1063-1069. [PMID: 35640041 PMCID: PMC9680663 DOI: 10.1093/fampra/cmac052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Most antibiotic prescribing for upper respiratory tract infections (URTIs) and acute bronchitis is inappropriate. Substantive and sustained reductions in prescribing are needed to reduce antibiotic resistance. Prescribing habits develop early in clinicians' careers. Hence, general practice (GP) trainees are an important group to target. OBJECTIVES We aimed to establish temporal trends in antibiotic prescribing for URTIs and acute bronchitis/bronchiolitis by Australian GP trainees (registrars). METHODS A longitudinal analysis, 2010-2019, of the Registrars Clinical Encounters in Training (ReCEnT) dataset. In ReCEnT, registrars record clinical and educational content of 60 consecutive consultations, on 3 occasions, 6 monthly. Analyses were of new diagnoses of URTI and acute bronchitis/bronchiolitis, with the outcome variable a systemic antibiotic being prescribed. The independent variable of interest was year of prescribing (modelled as a continuous variable). RESULTS 28,372 diagnoses of URTI and 5,289 diagnoses of acute bronchitis/bronchiolitis were recorded by 2,839 registrars. Antibiotic prescribing for URTI decreased from 24% in 2010 to 12% in 2019. Prescribing for acute bronchitis/bronchiolitis decreased from 84% to 72%. "Year" was significantly, negatively associated with antibiotic prescribing for both URTI (odds ratio [OR] 0.90; 95% confidence interval [CI]: 0.88-0.93) and acute bronchitis/bronchiolitis (OR 0.92; 95% CI: 0.88-0.96) on multivariable analysis, with estimates representing the mean annual change. CONCLUSIONS GP registrars' prescribing for URTI and acute bronchitis/bronchiolitis declined over the 10-year period. Prescribing for acute bronchitis/bronchiolitis, however, remains higher than recommended benchmarks. Continued education and programme-level antibiotic stewardship interventions are required to further reduce registrars' antibiotic prescribing for acute bronchitis/bronchiolitis to appropriate levels.
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Affiliation(s)
- Emma J Baillie
- General Practice Clinical Unit, The University of Queensland, Brisbane, QLD 4006, Australia
| | - Gregory Merlo
- General Practice Clinical Unit, The University of Queensland, Brisbane, QLD 4006, Australia
| | - Parker Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,GP Synergy NSW & ACT Research and Evaluation Unit, Newcastle, NSW, Australia
| | - Amanda Tapley
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,GP Synergy NSW & ACT Research and Evaluation Unit, Newcastle, NSW, Australia
| | - Katie J Mulquiney
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,GP Synergy NSW & ACT Research and Evaluation Unit, Newcastle, NSW, Australia
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Alison Fielding
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,GP Synergy NSW & ACT Research and Evaluation Unit, Newcastle, NSW, Australia
| | - Andrew Davey
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.,GP Synergy NSW & ACT Research and Evaluation Unit, Newcastle, NSW, Australia
| | - Elizabeth Holliday
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Jean Ball
- Hunter Medical Research Institute, Clinical Research Design and Statistical Support Unit (CReDITSS), New Lambton Heights, NSW 2305, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training, Regional Training Organisation, Hawthorn, VIC 3122, Australia.,University of Melbourne, Department of General Practice and Primary Health Care, Berkeley Street, Carlton, VIC 3053, Australia.,Monash University, School of Rural Health, Wellington Road, Clayton, VIC 3800, Australia
| | - Kristen FitzGerald
- University of Tasmania, Tasmanian School of Medicine, Hobart, TAS 7000, Australia.,General Practice Training Tasmania, Regional Training Organisation, Hobart, TAS 7000, Australia
| | - Mieke L van Driel
- General Practice Clinical Unit, The University of Queensland, Brisbane, QLD 4006, Australia
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Lamb E, Burford B, Alberti H. The impact of role modelling on the future general practitioner workforce: a systematic review. EDUCATION FOR PRIMARY CARE 2022; 33:265-279. [PMID: 35904161 PMCID: PMC9519122 DOI: 10.1080/14739879.2022.2079097] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Role modelling has been identified as an important phenomenon in medical education. Key reports have highlighted the ability of role modelling to support medical students towards careers in family medicine although the literature of specific relevance to role modelling in speciality has not been systematically explored. This systematic review aimed to fill this evidence gap by assimilating the worldwide literature on the impact of role modelling on the future general practitioner (GP) workforce. A systematic search was conducted in Medline, Embase, Scopus, Web of Science, Cochrane, ERIC and CINAHL, and all authors were involved in the article screening process. A review protocol determined those articles selected for inclusion, which were then quality assessed, coded and thematically analysed. Forty-six articles were included which generated four broad themes: the identity of role models in general practice, role modelling and becoming a doctor, the impact of role modelling on attitudes towards the speciality, and the subsequent influence on behaviours/career choice. Our systematic review confirmed that role modelling in both primary and secondary care has a crucial impact on the future GP workforce, with the potential to shape perceptions, to attract and deter individuals from the career, and to support their development as professionals. Role modelling must be consciously employed and supported as an educational strategy to facilitate the training of future GPs.
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Affiliation(s)
- Elizabeth Lamb
- School of Medical Education, The Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Bryan Burford
- School of Medical Education, The Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Hugh Alberti
- School of Medical Education, The Medical School, Newcastle University, Newcastle upon Tyne, UK
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11
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Improving Pharmacists’ Awareness of Inadequate Antibiotic Use for URTIs through an Educational Intervention: A Pilot Study. Healthcare (Basel) 2022; 10:healthcare10081385. [PMID: 35893207 PMCID: PMC9394361 DOI: 10.3390/healthcare10081385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022] Open
Abstract
The inadequate use of antibiotics led to the development of multi-resistant bacteria that are now causing millions of deaths worldwide. Since most antibiotics are prescribed/dispensed to treat respiratory tract infections, it is important to raise awareness among health professionals to optimize antibiotic use, especially within the primary care context. Thus, this pilot study aimed to evaluate pharmacists’ feedback about the eHealthResp platform, composed by an online course and a mobile application (app) to help in the management of upper respiratory tract infections (URTIs). Ten community pharmacists were invited to participate in this study, exploring the contents of the eHealthResp platforms and answering a content validation questionnaire composed by eight qualitative and thirty-five quantitative questions about the online course and mobile app. The eHealthResp platform is a comprehensive, consistent, and high-quality e-learning tool. Median scores of 5.00 were attributed to the course contents’ and clinical cases’ adequacy and correction. Most qualitative feedback was about completeness and objectivity of the course, and its usefulness for clinical practice. This study showed that eHealthResp has great potential as an e-health tool for the management of URTIs’ symptoms, which may ultimately aid in reducing inappropriate antibiotic use.
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12
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Rahimi-Ardabili H, Spooner C, Harris MF, Magin P, Tam CWM, Liaw ST, Zwar N. Online training in evidence-based medicine and research methods for GP registrars: a mixed-methods evaluation of engagement and impact. BMC MEDICAL EDUCATION 2021; 21:492. [PMID: 34521409 PMCID: PMC8439372 DOI: 10.1186/s12909-021-02916-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 08/28/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Evidence-based medicine (EBM) is a core skillset for enhancing the quality and safety of patients' care. Online EBM education could improve clinicians' skills in EBM, particularly when it is conducted during vocational training. There are limited studies on the impact of online EBM training on clinical practice among general practitioner (GP) registrars (trainees in specialist general practice). We aimed to describe and evaluate the acceptability, utility, satisfaction and applicability of the GP registrars experience with the online course. The course was developed by content-matter experts with educational designers to encompass effective teaching methods (e.g. it was interactive and used multiple teaching methods). METHODS Mixed-method data collection was conducted after individual registrars' completion of the course. The course comprised six modules that aimed to increase knowledge of research methods and application of EBM skills to everyday practice. GP registrars who completed the online course during 2016-2020 were invited to complete an online survey about their experience and satisfaction with the course. Those who completed the course within the six months prior to data collection were invited to participate in semi-structured phone interviews about their experience with the course and the impact of the course on clinical practice. A thematic analysis approach was used to analyse the data from qualitative interviews. RESULTS The data showed the registrars were generally positive towards the course and the concept of EBM. They stated that the course improved their confidence, knowledge, and skills and consequently impacted their practice. The students perceived the course increased their understanding of EBM with a Cohen's d of 1.6. Registrars identified factors that influenced the impact of the course. Of those, some were GP-related including their perception of EBM, and being comfortable with what they already learnt; some were work-place related such as time, the influence of supervisors, access to resources; and one was related to patient preferences. CONCLUSIONS This study showed that GP registrars who attended the online course reported that it improved their knowledge, confidence, skill and practice of EBM over the period of three months. The study highlights the supervisor's role on GP registrars' ability in translating the EBM skills learnt in to practice and suggests exploring the effect of EBM training for supervisors.
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Affiliation(s)
| | - Catherine Spooner
- Centre for Primary Health Care and Equity, UNSW Sydney, Sydney, NSW 2052 Australia
| | - Mark F. Harris
- Centre for Primary Health Care and Equity, UNSW Sydney, Sydney, NSW 2052 Australia
| | - Parker Magin
- Research and Evaluation Unit, GP Synergy, Sydney, NSW 2304 Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2304 Australia
| | - Chun Wah Michael Tam
- Primary and Integrated Care Unit, South Western Sydney Local Health District, Liverpool, NSW 2170 Australia
| | - Siaw-Teng Liaw
- WHO Collaborating Centre (eHealth), School of Population Health, UNSW Sydney, Sydney, NSW 2052 Australia
| | - Nicholas Zwar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, 4229 Australia
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Yau JW, Thor SM, Tsai D, Speare T, Rissel C. Antimicrobial stewardship in rural and remote primary health care: a narrative review. Antimicrob Resist Infect Control 2021; 10:105. [PMID: 34256853 PMCID: PMC8278763 DOI: 10.1186/s13756-021-00964-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies. METHODS The international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools. RESULTS Fifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing. CONCLUSIONS Inappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.
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Affiliation(s)
- Jun Wern Yau
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500, Bandar Sunway, Malaysia
| | - Sze Mun Thor
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500, Bandar Sunway, Malaysia
| | - Danny Tsai
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia
- Alice Springs Hospital, Central Australian Health Service, Alice Springs, NT, 0870, Australia
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Tobias Speare
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia
- Alice Springs Hospital, Central Australian Health Service, Alice Springs, NT, 0870, Australia
| | - Chris Rissel
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia.
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Immediate and delayed antibiotic prescribing strategies used by Australian early-career general practitioners. Br J Gen Pract 2021; 71:e895-e903. [PMID: 34097641 PMCID: PMC8574222 DOI: 10.3399/bjgp.2021.0026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/21/2021] [Indexed: 11/29/2022] Open
Abstract
Background Antibiotics are overused for non-pneumonia acute respiratory tract infections (ARTIs). Aim To establish prevalence and explore associations of delayed and immediate antibiotic prescribing strategies of Australian early-career GPs (specialist GP vocational trainees, also known as GP registrars) for non-pneumonia ARTIs. Design and setting Cross-sectional analysis of data collected between September 2016 and December 2017 from the Registrar Clinical Encounters in Training cohort (ReCEnT) study, an ongoing cohort study of GP registrars’ in-practice clinical experiences in four Australian states and territories. Method Multinomial logistic regression with outcome antibiotic prescribing (no prescribing, immediate prescribing, and delayed prescribing). Results Of 7156 new ARTI diagnoses, no antibiotics were prescribed for 4892 (68%); antibiotics were prescribed for immediate use for 1614 diagnoses (23%) and delayed antibiotics were used for 650 diagnoses (9%). Delayed prescribing was used in 22% of otitis media, 16% of sinusitis, 13% of sore throat, 11% of acute bronchitis/bronchiolitis, and 5% of upper respiratory tract infection (URTI) diagnoses. Delayed prescribing was used for 29% of all prescriptions written. Delayed prescribing and immediate prescribing were associated with markers of clinical concern. Delayed prescribing was associated with longer duration of consultation and with fewer diagnoses/problems dealt with in the consultation. Conclusion Australian early-career GPs use no prescribing for ARTIs substantially more than established GPs; however, except where URTIs are concerned, they still prescribe antibiotics in excess of validated benchmarks. Australian early-career GPs may use delayed prescribing more often than European established GPs, and may use it to manage diagnostic uncertainty and, possibly, conflicting influences on prescribing behaviour. The use of delayed prescribing may enable a transition to an environment of more-rational antibiotic prescribing for ARTIs.
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15
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Rodrigues AT, Nunes JCF, Estrela M, Figueiras A, Roque F, Herdeiro MT. Comparing Hospital and Primary Care Physicians' Attitudes and Knowledge Regarding Antibiotic Prescribing: A Survey within the Centre Region of Portugal. Antibiotics (Basel) 2021; 10:antibiotics10060629. [PMID: 34070337 PMCID: PMC8229910 DOI: 10.3390/antibiotics10060629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/14/2021] [Accepted: 05/23/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Antibiotic resistance is a worldwide public health problem, leading to longer hospital stays, raising medical costs and mortality levels. As physicians' attitudes are key factors to antibiotic prescribing, this study sought to explore their differences between primary care and hospital settings. METHODS A survey was conducted between September 2011 and February 2012 in the center region of Portugal in the form of a questionnaire to compare hospital (n = 154) and primary care (n = 421) physicians' attitudes and knowledge regarding antibiotic prescribing. RESULTS More than 70% of the attitudes were statistically different (p < 0.05) between hospital physicians (HPs) and primary care physicians (PCPs). When compared to PCPs, HPs showed higher agreement with antibiotic resistances being a public health problem and ascribed more importance to microbiological tests and to the influence of prescription on the development of resistances. On the other hand, PCPs tended to agree more regarding the negative impact of self-medication with antibiotics dispensed without medical prescription and the need for rapid diagnostic tests. Seven out of nine sources of knowledge's usefulness were statistically different between both settings, with HPs considering most of the knowledge sources to be more useful than PCPs. CONCLUSIONS Besides the efforts made to improve both antibiotic prescribing and use, there are differences in the opinions between physicians working in different settings that might impact the quality of antibiotic prescribing. In the future, these differences must be considered to develop more appropriate interventions.
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Affiliation(s)
- António Teixeira Rodrigues
- Department of Medical Sciences, iBiMED—Institute of Biomedicine, University of Aveiro, 3800 Aveiro, Portugal; (A.T.R.); (M.E.); (M.T.H.)
- Centre for Health Evaluation and Research (CEFAR), National Association of Pharmacies, 1249 Lisbon, Portugal
| | - João C. F. Nunes
- Department of Chemistry, CICECO—Aveiro Institute of Materials, University of Aveiro, 3800 Aveiro, Portugal;
| | - Marta Estrela
- Department of Medical Sciences, iBiMED—Institute of Biomedicine, University of Aveiro, 3800 Aveiro, Portugal; (A.T.R.); (M.E.); (M.T.H.)
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain;
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health—CIBERESP), 28001 Madrid, Spain
- Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Fátima Roque
- Research Unit for Inland Development, Polytechnic of Guarda (IPG-UDI), 6300 Guarda, Portugal
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200 Covilhã, Portugal
- Correspondence:
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, iBiMED—Institute of Biomedicine, University of Aveiro, 3800 Aveiro, Portugal; (A.T.R.); (M.E.); (M.T.H.)
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Moe S, Kan T, Soobiah C, Golian A, Li T, Raybardhan S. Using a behavioural framework to optimize antibiotic prescribing by family medicine residents. MEDEDPUBLISH 2021; 10:113. [PMID: 38486590 PMCID: PMC10939518 DOI: 10.15694/mep.2021.000113.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
This article was migrated. The article was marked as recommended. Background and objectives:Overprescribing of antibiotics in primary care is a prominent concern in the context of increasing antimicrobial resistance worldwide. Medical trainees are a key group to deliver thoughtful antimicrobial stewardship training. This study examined the factors influencing antibiotic prescribing for upper respiratory tract infections (URTI) by family medicine residents in order to identify educational interventions. Methods: Using purposive sampling of family medicine residents, semi-structured interviews were conducted until thematic saturation was reached. Interviews were coded into the domains of the Theoretical Domains Framework (TDF). Belief statements were created to characterize each domain and categorized as enablers or barriers to appropriate prescribing. Domains were plotted on the Behaviour Change Wheel (BCW) and intervention functions identified. Results:Twelve participants were interviewed. Nine domains of the TDF were relevant to antibiotic prescribing. Social influence was a prominent theme with the preceptor and patient being key influences on resident prescribing. Learning goals were also a key theme including the desire to strengthen independent clinical decision-making skills and improve antibiotic knowledge. Residents' beliefs about capabilities were challenged when faced with diagnostic uncertainty. Additional domains included: professional role; environmental context and resources; intentions; beliefs about consequences and capabilities, and knowledge. Using the BCW, nine intervention functions were identified to change antibiotic prescribing behaviour. Conclusion: This study found nine domains of the TDF were relevant to family medicine resident antibiotic prescribing for URTI. Nine intervention functions could be used to guide intervention design.
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Impact of cascade reporting of antimicrobial susceptibility on fluoroquinolone and meropenem consumption at a Veterans' Affairs medical center. Infect Control Hosp Epidemiol 2021; 43:199-204. [PMID: 33820578 DOI: 10.1017/ice.2021.83] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine whether cascade reporting is associated with a change in meropenem and fluoroquinolone consumption. DESIGN A quasi-experimental study was conducted using an interrupted time series to compare antimicrobial consumption before and after the implementation of cascade reporting. SETTING A 399-bed, tertiary-care, Veterans' Affairs medical center. PARTICIPANTS Antimicrobial consumption data across 8 inpatient units were extracted from the Center for Disease Control and Prevention (CDC) National Health Safety Network (NHSN) antimicrobial use (AU) module from April 2017 through March 2019, reported as antimicrobial days of therapy (DOT) per 1,000 days present (DP). INTERVENTION Cascade reporting is a strategy of reporting antimicrobial susceptibility test results in which secondary agents are only reported if an organism is resistant to primary, narrow-spectrum agents. A multidisciplinary team developed cascade reporting algorithms for gram-negative bacteria based on local antibiogram and infectious diseases practice guidelines, aimed at restricting the use of fluoroquinolones and carbapenems. The algorithms were implemented in March 2018. RESULTS Following the implementation of cascade reporting, mean monthly meropenem (P =.005) and piperacillin/tazobactam (P = .002) consumption decreased and cefepime consumption increased (P < .001). Ciprofloxacin consumption decreased by 2.16 DOT per 1,000 DP per month (SE, 0.25; P < .001). Clostridioides difficile rates did not significantly change. CONCLUSION Ciprofloxacin consumption significantly decreased after the implementation of cascade reporting. Mean meropenem consumption decreased after cascade reporting was implemented, but we observed no significant change in the slope of consumption. cascade reporting may be a useful strategy to optimize antimicrobial prescribing.
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Cherry MD, Tapley A, Quain D, Holliday EG, Ball J, Davey A, van Driel ML, Fielding A, Spike N, FitzGerald K, Magin P. Antibiotic prescribing patterns of general practice registrars for infective conjunctivitis: a cross-sectional analysis. J Prim Health Care 2021; 13:5-14. [PMID: 33785106 DOI: 10.1071/hc20040] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 01/14/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Over-prescription of antibiotics for common infective conditions is an important health issue. Infective conjunctivitis represents one of the most common eye-related complaints in general practice. Despite its self-limiting nature, there is evidence of frequent general practitioner (GP) antibiotic prescribing for this condition, which is inconsistent with evidence-based guidelines. AIM To investigate the prevalence and associations of GP registrars' (trainees') prescription of antibiotics for infective conjunctivitis. METHODS We performed a cross-sectional analysis of the Registrar Encounters in Clinical Training (ReCEnT) ongoing prospective cohort study, which documents GP registrars' clinical consultations (involving collection of information from 60 consecutive consultations, at three points during registrar training). The outcome of the analyses was antibiotic prescription for a new diagnosis of conjunctivitis. Patient, registrar, practice and consultation variables were included in uni- and multivariable logistic regression analyses to test associations of these prescriptions. RESULTS In total, 2333 registrars participated in 18 data collection rounds from 2010 to 2018. There were 1580 new cases of infective conjunctivitis (0.31% of all problems). Antibiotics (mainly topical) were prescribed in 1170 (74%) of these cases. Variables associated with antibiotic prescription included patients' Aboriginal or Torres Strait Islander status, registrar organisation of a follow up (both registrar and other GP follow up), and earlier registrar training term (more junior status). DISCUSSION GP registrars, like established GPs, prescribe antibiotics for conjunctivitis in excess of guideline recommendations, but prescribing rates are lower in later training. These prescribing patterns have educational, social and economic consequences. Further educational strategies may enhance attenuation of registrars' prescribing during training.
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Affiliation(s)
- Marcus D Cherry
- University of Newcastle, School of Medicine and Public Health, Faculty of Health and Medicine, Callaghan, New South Wales, Australia
| | - Amanda Tapley
- University of Newcastle, School of Medicine and Public Health, Faculty of Health and Medicine, Callaghan, New South Wales, Australia; and GP Synergy, General Practice Regional Training Organisation, NSW and ACT Research and Evaluation Unit, Newcastle, New South Wales, Australia
| | - Debbie Quain
- University of Newcastle, School of Medicine and Public Health, Faculty of Health and Medicine, Callaghan, New South Wales, Australia; and GP Synergy, General Practice Regional Training Organisation, NSW and ACT Research and Evaluation Unit, Newcastle, New South Wales, Australia
| | - Elizabeth G Holliday
- University of Newcastle, School of Medicine and Public Health, Faculty of Health and Medicine, Callaghan, New South Wales, Australia
| | - Jean Ball
- Hunter Medical Research Institute, Clinical Research Design IT and Statistical Support Unit, New Castle, NSW, Australia
| | - Andrew Davey
- University of Newcastle, School of Medicine and Public Health, Faculty of Health and Medicine, Callaghan, New South Wales, Australia; and GP Synergy, General Practice Regional Training Organisation, NSW and ACT Research and Evaluation Unit, Newcastle, New South Wales, Australia
| | - Mieke L van Driel
- The University of Queensland, Primary Care Clinical Unit, Faculty of Medicine, Brisbane, Queensland, Australia
| | - Alison Fielding
- University of Newcastle, School of Medicine and Public Health, Faculty of Health and Medicine, Callaghan, New South Wales, Australia; and GP Synergy, General Practice Regional Training Organisation, NSW and ACT Research and Evaluation Unit, Newcastle, New South Wales, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training, Melbourne, Victoria, Australia; and Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Parker Magin
- University of Newcastle, School of Medicine and Public Health, Faculty of Health and Medicine, Callaghan, New South Wales, Australia; and GP Synergy, General Practice Regional Training Organisation, NSW and ACT Research and Evaluation Unit, Newcastle, New South Wales, Australia; and Corresponding author.
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Dallas A, Davey A, Mulquiney K, Davis J, Glasziou P, Van Driel M, Magin P. Delayed prescribing of antibiotics for acute respiratory infections by GP registrars: a qualitative study. Fam Pract 2020; 37:406-411. [PMID: 31784735 DOI: 10.1093/fampra/cmz079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Antibiotic prescribing for acute self-limiting respiratory tract infections (ARTIs) in Australia is higher than international benchmarks. Antibiotics have little or no efficacy in these conditions, and unnecessary use contributes to antibiotic resistance. Delayed prescribing has been shown to reduce antibiotic use. GP registrars are at a career-stage when long-term prescribing patterns are being established. AIM To explore experiences, perceptions and attitudes of GP registrars and supervisors to delayed antibiotic prescribing for ARTIs. DESIGN AND SETTING A qualitative study of Australian GP registrars and supervisors using a thematic analysis approach. METHOD GP registrars and supervisors were recruited across three Australian states/territories, using maximum variation sampling. Telephone interviews explored participants' experience and perceptions of delayed prescribing of antibiotics in ARTIs. Data collection and analysis were concurrent and iterative. RESULTS A total of 12 registrars and 10 supervisors were interviewed. Key themes included the use of delayed prescribing as a safety-net in cases of diagnostic uncertainty or when clinical review was logistically difficult. Delayed prescribing was viewed as a method of educating and empowering patients, and building trust and the doctor-patient relationship. Conversely, it was also seen as a loss of control over management decisions. Supervisors, more so than registrars, appreciated the psychosocial complexity of ARTI consultations and the importance of delayed antibiotic prescribing in this context. CONCLUSION Better awareness and understanding by GP registrars of the evidence for delayed antibiotic prescription may be a means of reducing antibiotic prescribing. Understanding both registrar and supervisor usage, uncertainties and attitudes should inform educational approaches on this topic.
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Affiliation(s)
| | - Andrew Davey
- NSW & ACT Research and Evaluation Unit, GP Synergy, Newcastle
- Discipline of General Practice, University of Newcastle, Newcastle
| | - Katie Mulquiney
- NSW & ACT Research and Evaluation Unit, GP Synergy, Newcastle
- Discipline of General Practice, University of Newcastle, Newcastle
| | | | | | - Mieke Van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Parker Magin
- NSW & ACT Research and Evaluation Unit, GP Synergy, Newcastle
- Discipline of General Practice, University of Newcastle, Newcastle
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Liao S, Rhodes J, Jandarov R, DeVore Z, Sopirala MM. Out of Sight-Out of Mind: Impact of Cascade Reporting on Antimicrobial Usage. Open Forum Infect Dis 2020; 7:ofaa002. [PMID: 32055636 PMCID: PMC7008474 DOI: 10.1093/ofid/ofaa002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/03/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There is a paucity of data evaluating the strategy of suppressing broader-spectrum antibiotic susceptibilities on utilization. Cascade reporting (CR) is a strategy of reporting antimicrobial susceptibility test results in which secondary (eg, broader-spectrum, costlier) agents may only be reported if an organism is resistant to primary agents within a particular drug class. Our objective was to evaluate the impact of ceftriaxone-based cascade reporting on utilization of cefepime and clinical outcomes in patients with ceftriaxone-susceptible Escherichia and Klebsiella clinical cultures. METHODS We compared post-CR (July 2014-June 2015) with baseline (July 2013-June 2014), evaluating utilization of cefepime, cefazolin, ceftriaxone, ampicillin derivatives, fluoroquinolones, piperacillin/tazobactam, ertapenem, and meropenem; new Clostridium difficile infection; and length of stay (LOS) after the positive culture, 30-day readmission, and in-hospital all-cause mortality. RESULTS Mean days of therapy (DOT) among patients who received any antibiotic for cefepime decreased from 1.229 days during the baseline period to 0.813 days post-CR (adjusted relative risk, 0.668; P < .0001). Mean DOT of ceftriaxone increased from 0.864 days to 0.962 days, with an adjusted relative risk of 1.113 (P = .004). No significant differences were detected in other antibiotics including ertapenem and meropenem, demonstrating the direct association of the decrease in cefepime utilization with CR based on ceftriaxone susceptibility. Average LOS in the study population decreased from 14.139 days to 10.882 days from baseline to post-CR and was found to be statistically significant (P < .0001). CONCLUSIONS In conclusion, we demonstrated significant association of decreased cefepime utilization with the implementation of a CR based on ceftriaxone susceptibility. We demonstrated the safety of deescalation, with LOS being significantly lower during the post-CR period than in the baseline period, with no change in in-hospital mortality.
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Affiliation(s)
- Siyun Liao
- Department of Pharmacy, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Judith Rhodes
- Department of Pathology, University of College of Medicine, Cincinnati, Ohio, USA
| | - Roman Jandarov
- Division of Biostatistics and Bioinformatics, Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Zachary DeVore
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Madhuri M Sopirala
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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21
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Heal C, Gorges H, van Driel ML, Tapley A, Davis J, Davey A, Holliday L, Ball J, Najib N, Spike N, FitzGerald K, Magin P. Antibiotic stewardship in skin infections: a cross-sectional analysis of early-career GP's management of impetigo. BMJ Open 2019; 9:e031527. [PMID: 31662391 PMCID: PMC6830714 DOI: 10.1136/bmjopen-2019-031527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/12/2019] [Accepted: 08/23/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To establish the prevalence and associations of systemic antibiotic prescription for impetigo by early-career general practitioners (GPs) (GP registrars in their first 18 months in general practice). DESIGN A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. SETTING ReCEnT is an ongoing multisite cohort study of Australian registrars' in-consultation clinical practice across five Australian states. PARTICIPANTS Registrars participating in ReCEnT from 2010 to 2017. OUTCOME MEASURES Management of impetigo with systemic antibiotics. RESULTS 1741 registrars (response rate 96%) provided data from 384 731 problems identified in 246 434 consultations. Impetigo, on first presentation or follow-up, was managed in 930 (0.38%, 95% CI 0.35 to 0.40) consultations and comprised 0.24% (95% CI 0.23 to 0.26) of problems. 683 patients presented with a new diagnosis of impetigo of which 38/683 (5.6%) were not prescribed antibiotics; 239/683 (35.0%) were prescribed solely topical antibiotics; 306/683 (44.8%) solely systemic antibiotics and 100/683 (14.6%) both systemic and topical antibiotics. The most common systemic antibiotic prescribed was cephalexin (53.5%). Variables independently associated with prescription of systemic antibiotics were an inner regional (compared with major city) location (OR 1.82, 95% CI 1.06 to 3.13; p=0.028), seeking in-consultation information or advice (OR 2.17, 95% CI 1.47 to 3.23; p<0.001) and ordering pathology (OR 2.13, 95% CI 1.37 to 3.33; p=0.01). CONCLUSIONS Australian early-career GPs prescribe systemic antibiotics (the majority broad-spectrum) for a high proportion of initial impetigo presentations. Impetigo guidelines should clearly specify criteria for systemic antibiotic prescription and individual antibiotic choice. The role of non-antibiotic management and topical antiseptics needs to be explored further.
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Affiliation(s)
- Clare Heal
- School of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
| | - Hilary Gorges
- Department of General Practice and Rural Medicine, James Cook University, Mackay, Queensland, Australia
| | - Mieke L van Driel
- Academic Discipline of General Practice, University of Queensland, Brisbane, Queensland, Australia
| | - Amanda Tapley
- NSW & ACT Research and Evaluation Unit, GP Synergy Ltd - Newcastle, Newcastle, New South Wales, Australia
- Discipline of General Practice, School of Medicine & Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Josh Davis
- Global and Tropical Health Division, Menzies School of Health Research, Casuarina, New South Wales, Australia
| | - Andrew Davey
- GP Synergy Ltd, Liverpool Westfield, New South Wales, Australia
| | - L Holliday
- The University of Newcastle, Newcastle, New South Wales, Australia
| | - Jean Ball
- Clinical Research Design and Statistics, The University of Newcastle Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Nashwa Najib
- GP Synergy Ltd, Liverpool Westfield, New South Wales, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | | | - Parker Magin
- Discipline of General Practice, University of Newcastle, Callaghan, New South Wales, Australia
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22
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Magin P, Tapley A, Dunlop AJ, Davey A, van Driel M, Holliday E, Morgan S, Henderson K, Ball J, Catzikiris N, Mulquiney K, Spike N, Kerr R, Holliday S. Changes in Australian Early-Career General Practitioners' Benzodiazepine Prescribing: a Longitudinal Analysis. J Gen Intern Med 2018; 33:1676-1684. [PMID: 30039495 PMCID: PMC6153232 DOI: 10.1007/s11606-018-4577-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 05/18/2018] [Accepted: 07/02/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Australian and international guidelines recommend benzodiazepines and related drugs (hereafter "benzodiazepines") as second-line, short-term medications only. Most benzodiazepines are prescribed by general practitioners (GPs; family physicians). Australian GP registrars ("trainees" or "residents" participating in a post-hospital training, apprenticeship-like, practice-based vocational training program), like senior GPs, prescribe benzodiazepines at high rates. Education within a training program, and experience in general practice, would be expected to reduce benzodiazepine prescribing. OBJECTIVE To establish if registrars' prescribing of benzodiazepines decreases with time within a GP training program DESIGN: Longitudinal analysis from the Registrar Clinical Encounters in Training multi-site cohort study PARTICIPANTS: Registrars of five of Australia's 17 Regional Training Providers. Analyses were restricted to patients ≥ 16 years. MAIN MEASURES The main outcome factor was prescription of a benzodiazepine. Conditional logistic regression was used, with registrar included as a fixed effect, to assess within-registrar changes in benzodiazepine-prescribing rates. The "time" predictor variable was "training term" (6-month duration Terms 1-4). To contextualize these "within-registrar" changes, a mixed effects logistic regression model was used, including a random effect for registrar, to assess within-program changes in benzodiazepine-prescribing rates over time. The "time" predictor variable was "year" (2010-2015). KEY RESULTS Over 12 terms of data collection, 2010-2015, 1161 registrars (response rate 96%) provided data on 136,809 face-to-face office-based consultations. Two thousand six hundred thirty-two benzodiazepines were prescribed (for 1.2% of all problems managed). In the multivariable model, there was a significant reduction in within-program benzodiazepine prescribing over time (year) (p = < 0.001, OR = 0.94, CI = 0.90, 0.97). However, there was no significant change in 'within-registrar' prescribing over time (registrar Term) (p = 0.92, OR = 1.00 [95% CI = 0.94-1.06]). CONCLUSIONS Despite a welcome temporal trend for reductions in overall benzodiazepine prescribing from 2010 to 2015, there is still room for improvement and our findings suggest a lack of effect of specific GP vocational training program education and, thus, an opportunity for targeted education.
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Affiliation(s)
- Parker Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia. .,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia.
| | - Amanda Tapley
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Adrian J Dunlop
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Drug and Alcohol Clinical Services, Hunter New England Health, Newcastle, Australia
| | - Andrew Davey
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Mieke van Driel
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Elizabeth Holliday
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - Simon Morgan
- GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Kim Henderson
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Jean Ball
- Hunter Medical Research Institute, Newcastle, Australia
| | - Nigel Catzikiris
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Katie Mulquiney
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,GP Synergy General Practice Regional Training Organisation, Newcastle, Australia
| | - Neil Spike
- Eastern Victoria GP Training, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Rohan Kerr
- General Practice Training Tasmania, Hobart, Australia
| | - Simon Holliday
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Drug and Alcohol Clinical Services, Hunter New England Health, Newcastle, Australia
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23
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Antibiotic prescribing for acute respiratory tract infections in primary care: an updated and expanded meta-ethnography. Br J Gen Pract 2018; 68:e633-e645. [PMID: 29914880 DOI: 10.3399/bjgp18x697889] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/15/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Reducing unnecessary prescribing remains a key priority for tackling the global rise of antibiotic-resistant infections. AIM The authors sought to update a 2011 qualitative synthesis of GPs' experiences of antibiotic prescribing for acute respiratory tract infections (ARTIs), including their views of interventions aimed at more prudent prescribing. They expanded the original scope to encompass all primary care professionals (PCPs) who can prescribe or dispense antibiotics for ARTIs (for example, nurses and pharmacists). DESIGN AND SETTING Systematic review and meta-ethnography of qualitative studies. METHOD A systematic search was conducted on MEDLINE, EMBASE, PsycINFO, CINAHL, ASSIA, and Web of Science. No date or language restrictions were used. Identified studies were grouped according to their thematic focus (usual care versus intervention), and two separate syntheses were performed. RESULTS In all, 53 articles reporting the experiences of >1200 PCPs were included. Analysis of usual-care studies showed that PCPs tend to assume multiple roles in the context of ARTI consultations (the expert self, the benevolent self, the practical self), depending on the range of intrapersonal, interpersonal, and contextual situations in which they find themselves. Analysis of intervention studies identified four possible ways in which PCPs may experience quality improvement interventions (compromise, 'supportive aids', source of distress, and unnecessary). CONCLUSION Contrary to the original review, these results suggest that the use of the same intervention is experienced in a totally different way by different PCPs, and that the same elements that are perceived as benefits by some could be viewed as drawbacks by others. Acceptability of interventions is likely to increase if these are context sensitive and take into account PCPs' varying roles and changing priorities.
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24
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Lum EP, Page K, Whitty JA, Doust J, Graves N. Antibiotic prescribing in primary healthcare: Dominant factors and trade-offs in decision-making. Infect Dis Health 2018. [DOI: 10.1016/j.idh.2017.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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25
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06100] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundInterventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.ObjectivesThis study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.DesignThe review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.SettingPrimary and secondary care.ParticipantsNot applicable.InterventionsStudies related to antimicrobial prescribing for doctors in training.Main outcome measuresNot applicable.Data sourcesEMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.Review methodsClearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.ResultsA total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.LimitationsMost articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.ConclusionsThis review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.Future workMore work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.Study registrationThis study is registered as PROSPERO CRD42015017802.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Mark Pearson
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - Simon Briscoe
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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26
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Magin P, Tapley A, Morgan S, Davis JS, McElduff P, Yardley L, Henderson K, Dallas A, McArthur L, Mulquiney K, Davey A, Little P, Spike N, van Driel ML. Reducing early career general practitioners' antibiotic prescribing for respiratory tract infections: a pragmatic prospective non-randomised controlled trial. Fam Pract 2018; 35:53-60. [PMID: 28985369 DOI: 10.1093/fampra/cmx070] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescription and consequent antibacterial resistance is a major threat to healthcare. OBJECTIVES To evaluate the efficacy of a multifaceted intervention in reducing early career general practitioners' (GPs') antibiotic prescribing for upper respiratory tract infections (URTIs) and acute bronchitis/bronchiolitis. METHODS A pragmatic non-randomized trial employing a non-equivalent control group design nested within an existing cohort study of GP registrars' (trainees') clinical practice. The intervention included access to online modules (covering the rationale of current clinical guidelines recommending non-prescription of antibiotics for URTI and bronchitis/bronchiolitis, and communication skills in management of acute bronchitis) followed by a face-to-face educational session. The intervention was delivered to registrars (and their supervisors) in two of Australia's seventeen regional GP training providers (RTPs). Three other RTPs were the control group. Outcomes were proportion of registrars' URTI consultations and bronchitis/bronchiolitis consultations prescribed antibiotics. Intention-to-treat analyses employed logistic regression within a Generalised Estimating Equation framework, adjusted for relevant independent variables. The predictors of interest were time; treatment group; and an interaction term for time-by-treatment group. The P value associated with an interaction term determined statistically significant differences in antibiotic prescribing. RESULTS Analyses include data of 217 intervention RTPs' and 311 control RTPs' registrars. There was no significant reduction in antibiotic prescribing for URTIs. For bronchitis/bronchiolitis, a significant reduction (interaction P value = 0.024) remained true for analysis adjusted for independent variables (P value = 0.040). The adjusted absolute reduction in prescribing was 15.8% (95% CI: 4.2%-27.5%). CONCLUSIONS A multifaceted intervention reduced antibiotic prescribing for bronchitis/bronchiolitis but not URTIs.
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Affiliation(s)
- Parker Magin
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | - Amanda Tapley
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | - Simon Morgan
- Elermore Vale General Practice, Elermore Vale, Australia
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,Menzies School of Health Research, Royal Darwin Hospital Campus, Casuarina, Australia.,John Hunter Hospital, New Lambton Heights, Australia
| | - Patrick McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Lucy Yardley
- Centre for Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Kim Henderson
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | | | - Lawrie McArthur
- Department of General Practice, University of Adelaide, Adelaide, Australia
| | - Katie Mulquiney
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organization, Newcastle, Australia
| | - Andrew Davey
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Paul Little
- Primary Care & Population Sciences Academic Units, University of Southampton, Southampton, UK
| | - Neil Spike
- Department of General Practice, University of Melbourne, Melbourne, Australia.,Eastern Victoria General Practice Training, Melbourne, Australia
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia
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27
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Deckx L, Anthierens S, Magin PJ, Morgan S, McArthur L, Yardley L, Dallas A, Little P, van Driel ML. Focus on early-career GPs: qualitative evaluation of a multi-faceted educational intervention to improve antibiotic prescribing. Fam Pract 2018; 35:99-104. [PMID: 28985300 DOI: 10.1093/fampra/cmx074] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND We conducted an educational intervention emphasizing rational antibiotic prescribing in early-career General Practitioners (GP) in vocational training (trainees). The intervention consisted of an online introduction module, an online communication training module, face-to-face workshops, and cases to be discussed one-on-one by the trainee-supervisor dyad during regular scheduled education sessions. OBJECTIVES To explore the participants' experiences with the intervention. METHODS A qualitative study of 14 GP trainees and supervisors. Interviews followed a semi-structured interview guide, were transcribed and analysed using concurrent thematic analysis. RESULTS Overall, the intervention was well received. Resources were not often used in practice, but GP trainees used the information in communicating with patients. The intervention improved trainees' confidence and provided new communication strategies, e.g. explicitly asking about patients' expectations and talking patients through the examination to form an overall clinical picture. Trainees seemed eager to learn and adapt their practice, whereas GP supervisors rather commented that the intervention was reinforcing. None of the participants reported prescribing conflicts between trainee and supervisor. However, most participants identified conflicts within the GP practice or with specialists: other doctors who prescribe more antibiotics perpetuate patients' ideas that antibiotics will fix everything, which in turn causes conflict with the patient and undermines attempts to improve antibiotic prescribing. CONCLUSION The educational intervention was received positively. Early-career GPs thought it influenced their prescribing behaviour and improved their confidence in non-prescribing. Interventions that target teams (e.g. entire practice) could minimize conflict, ensure consistency of messages and support overall antibiotic stewardship in primary care.
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Affiliation(s)
- Laura Deckx
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Sibyl Anthierens
- Department of Primary Care and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Parker J Magin
- GP Synergy NSW and ACT Research and Evaluation Unit, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Mayfield, New South Wales, Australia
| | - Simon Morgan
- Elermore Vale General Practice, Elermore Vale, New South Wales, Australia
| | - Lawrie McArthur
- Rural Clinical School, The University of Adelaide, Adelaide, Australia
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
| | - Anthea Dallas
- School of Medicine, University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
| | - Paul Little
- Primary Care & Population Sciences Academic Units, University of Southampton, Southampton, UK
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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28
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review. J Antimicrob Chemother 2017; 72:2418-2430. [PMID: 28859445 PMCID: PMC5890780 DOI: 10.1093/jac/dkx194] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/20/2017] [Accepted: 05/22/2017] [Indexed: 12/14/2022] Open
Abstract
Background Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Mark Pearson
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Peninsula Schools of Medicine & Dentistry, Plymouth University, Drake Circus Plymouth, Devon PL4 8AA, UK
| | - Simon Briscoe
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
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29
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Alawi MM, Darwesh BM. A stepwise introduction of a successful antimicrobial stewardship program. Experience from a tertiary care university hospital in Western, Saudi Arabia. Saudi Med J 2017; 37:1350-1358. [PMID: 27874151 PMCID: PMC5303774 DOI: 10.15537/smj.2016.12.15739] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objectives To analyze and evaluate the safety and cost-effectiveness of a gradually-implemented antimicrobial stewardship programs (ASP) in a tertiary care center. Methods Prospective data were collected from an ASP that was gradually introduced between April 2012 and December 2013 in 6 hospital departments, over successive periods of 3 months each. A multidisciplinary team supervised antibiotic use and regulated pharmacy dispensations of a list of restricted antimicrobials (RAs). Indicators were prospectively monitored and included hospital mortality as the safety indicator; incidence of multi-drug resistance (MDR) infections as the effectiveness indicator, RA cost savings as the cost-effectiveness indicator and RA consumption indicated the process implementation. Results Between 2012 and 2014, dispensations of RAs decreased by 67% and prescriptions by 75%; no increase in mortality rate was observed. Microbiologically, there was a decreasing trend of incidence across all monitored infections, but this was only significant for Acinetobacter baumannii (p=0.007). Cost analysis showed a decrease in expenditure for RAs, with an average monthly saving of up to 326,020USD. Conclusions Stepwise implementation of ASPs is a safe and cost-effective strategy for improving antibiotic prescribing practice and to reduce multi-drug resistance.
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Affiliation(s)
- Maha M Alawi
- Infection Control & Environmental Health Unit, Department of Medical Microbiology & Parasitology, Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia. E-mail.
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Dallas A, van Driel M, Morgan S, Tapley A, Henderson K, Oldmeadow C, Ball J, Davey A, Mulquiney K, Davis J, Spike N, McArthur L, Stewart R, Magin P. Antibiotic prescribing for acute otitis media and acute sinusitis: a cross-sectional analysis of the ReCEnT study exploring the habits of early career doctors in family practice. Fam Pract 2017; 34:180-187. [PMID: 28158735 DOI: 10.1093/fampra/cmw144] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Antibiotic resistance is a public health concern, and is linked to over-prescribing. In self-limiting infections such as acute otitis media (AOM) and acute sinusitis, prescribing remains high despite strong guideline recommendations against the routine use of antibiotics. Early career General Practitioners may find evidence-based prescribing challenging. AIM To establish the prevalence and associations of antibiotic prescribing for AOM and acute sinusitis by Australian vocational trainees in General Practice. METHOD A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. This ongoing, multicentre prospective cohort study documents trainees' consultation-based clinical experiences. Univariate and logistic regression analyses were conducted on data recorded in consultations for AOM or acute sinusitis in nine collection periods during 2010-2014. RESULTS Data from 856 individual trainees (response rate 95.2%) were analysed. AOM was managed in 0.9% of encounters. Antibiotics were prescribed in 78.8% of cases. Prescribing was significantly associated with longer consultation time and first presentation for this problem. There was no significant association with patient age group. Acute sinusitis was managed in 0.9% of encounters. Antibiotics were prescribed in 71.2% of cases. Later-stage trainees and trainees who did not receive their primary medical qualification in Australia were more likely to prescribe an antibiotic for acute sinusitis. CONCLUSION Early career GPs are not prescribing in an evidence-based manner. The complexity of guidelines for AOM and acute sinusitis may be confusing for prescribers, especially early career doctors struggling with inexperience and diagnostic uncertainty. Educational interventions are necessary to bring prescribing rates closer to quality benchmarks.
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Affiliation(s)
- Anthea Dallas
- Discipline of General Practice, University of Queensland, Brisbane, Australia
| | - Mieke van Driel
- Discipline of General Practice, University of Queensland, Brisbane, Australia
| | - Simon Morgan
- Elermore Vale General Practice, Newcastle, Australia
| | | | | | | | - Jean Ball
- HMRI / CReDITTS, Newcastle, Australia
| | - Andrew Davey
- Discipline of General Practice, University of Newcastle, Newcastle, Australia
| | | | - Joshua Davis
- Department of Infectious Diseases, John Hunter Hospital, Newcastle, Australia.,Global and Tropical Health Division, Menzies School of Health Research, Darwin, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training, Melbourne, Australia.,Department of General Practice, University of Melbourne, Melbourne, Australia
| | | | | | - Parker Magin
- GP Synergy, Newcastle, Australia.,Discipline of General Practice, University of Newcastle, Newcastle, Australia
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Does brief chronic pain management education change opioid prescribing rates? A pragmatic trial in Australian early-career general practitioners. Pain 2016; 158:278-288. [DOI: 10.1097/j.pain.0000000000000755] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Morgan S, Morgan A, Kerr R, Tapley A, Magin P. Test ordering by GP trainees: Effects of an educational intervention on attitudes and intended practice. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:733-741. [PMID: 27629671 PMCID: PMC5023346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the effectiveness of an educational intervention on test-ordering attitudes and intended practice of GP trainees, and any associations between changes in test ordering and trainee characteristics. DESIGN Preworkshop and postworkshop survey of attitudes to test ordering, intended test-ordering practices for 3 clinical scenarios (fatigue, screening, and shoulder pain), and tolerance for uncertainty. SETTING Three Australian regional general practice training providers. PARTICIPANTS General practice trainees (N = 167). INTERVENTION A 2-hour workshop session and an online module. MAIN OUTCOME MEASURES Proportion of trainees who agreed with attitudinal statements before and after the workshop; proportion of trainees who would order tests, mean number of tests ordered, and number of appropriate and inappropriate tests ordered for each scenario before and after the workshop. RESULTS Of 167 trainees, 132 (79.0%) completed both the preworkshop and postworkshop questionnaires. A total of 122 trainees attended the workshop. At baseline, 88.6% thought that tests can harm patients, 84.8% believed overtesting was a problem, 72.0% felt pressured by patients, 52.3% believed that tests would reassure patients, and 50.8% thought that they were less likely to be sued if they ordered tests. There were desirable changes in all attitudes after the workshop. Before the workshop, the mean number of tests that trainees would have ordered was 4.4, 4.8, and 1.5 for the fatigue, screening, and shoulder pain scenarios, respectively. After the workshop there were decreases in the mean number of both appropriate tests (decrease of 0.94) and inappropriate tests (decrease of 0.24) in the fatigue scenario; there was no change in the mean number of appropriate tests and a decrease in inappropriate tests (decrease of 0.76) in the screening scenario; and there was an increase in the proportion of trainees who would appropriately not order tests in the shoulder pain scenario. There were no significant associations between changes in test ordering and trainee demographic characteristics or tolerance for uncertainty subscale scores. CONCLUSION General practice trainees have conflicting attitudes to test ordering and demonstrate nonrational test ordering in 3 common scenarios. A workshop on rational test ordering led to desirable changes in attitudes and more rational intended test ordering. Our findings inform the development of appropriate educational interventions that address nonrational testing in family medicine.
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Affiliation(s)
- Simon Morgan
- GP and Medical Educator with General Practice Training Valley to Coast, practising in Newcastle, NSW, Australia.
| | - Andy Morgan
- Senior Medical Educator at Victorian Metropolitan Alliance and Senior Lecturer in the Department of General Practice at Monash University in Melbourne, Australia
| | - Rohan Kerr
- Senior Medical Educator with General Practice Training Tasmania and a GP at Claremont Village Medical Centre in Hobart, Australia
| | - Amanda Tapley
- Research officer at General Practice Training Valley to Coast
| | - Parker Magin
- GP and Medical Educator at General Practice Training Valley to Coast, and Conjoint Professor in the Discipline of General Practice at the University of Newcastle
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Magin PJ, Morgan S, Tapley A, Henderson KM, Holliday EG, Ball J, Davis JS, Dallas A, Davey AR, Spike NA, McArthur L, Stewart R, Mulquiney KJ, van Driel ML. Changes in early-career family physicians' antibiotic prescribing for upper respiratory tract infection and acute bronchitis: a multicentre longitudinal study. Fam Pract 2016; 33:360-7. [PMID: 27095798 DOI: 10.1093/fampra/cmw025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescription and subsequent antibacterial resistance are major threats to health worldwide. OBJECTIVES We aimed to establish whether early-career 'apprenticeship-model' experience in family practice influences antibiotic prescribing for respiratory tract infections and to also establish other associations of antibiotic prescribing changes during this early-career experience. METHODS A longitudinal analysis (2010-2014) of a cohort study of Australian GP registrars' (vocational trainees') consultations. Registrars from five regional training programs recorded data from 60 consecutive consultations, once each 6-month training Term, including the diagnoses managed and medications prescribed. The outcomes were whether an antibiotic was prescribed for the diagnoses 'upper respiratory tract infection (URTI)' and 'acute bronchitis/bronchiolitis'. Generalized linear mixed modelling was used to account for repeated measures on registrars and to include the time component: 'Term'. RESULTS A total of 856 registrars recorded 108759 consultations, including 8715 'URTI' diagnoses (5.15% of diagnoses) and 2110 'acute bronchitis/bronchiolitis' diagnoses (1.25%). Antibiotics were prescribed in 16.3% [95% confidence interval (CI) 14.9-17.8] of URTI and 72.2% (95% CI 69.6-74.6) of acute bronchitis/bronchiolitis diagnoses. Moving from an earlier to later term did not significantly influence registrars' antibiotic prescribing for URTI [adjusted odds ratio (OR) 0.95; 95% CI 0.87, 1.04, P = 0.27] or acute bronchitis/bronchiolitis [OR 1.01 (95% CI 0.90-1.14), P = 0.86]. Significant associations of antibiotic prescribing for URTIs were the registrar being non-Australian educated, greater patient age, practices not privately billing patients, pathology being ordered, longer consultation duration and the registrar seeking in-consultation information or advice (including from their supervisor). CONCLUSIONS Early-career experience/training failed to produce rational antibiotic prescribing for URTI and acute bronchitis/bronchiolitis. Our findings suggest that prescribing interventions could target the registrar-supervisor dyad.
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Affiliation(s)
- Parker J Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW General Practice Training-Valley to Coast, Mayfield, NSW
| | - Simon Morgan
- General Practice Training-Valley to Coast, Mayfield, NSW
| | - Amanda Tapley
- General Practice Training-Valley to Coast, Mayfield, NSW
| | | | | | - Jean Ball
- Hunter Medical Research Institute, CReDITTS, New Lambton Heights, NSW
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW Menzies School of Health Research, Royal Darwin Hospital Campus, Casuarina, NT John Hunter Hospital, New Lambton Heights, NSW
| | - Anthea Dallas
- Discipline of General Practice, University of Queensland, Brisbane, QLD
| | - Andrew R Davey
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW
| | - Neil A Spike
- Victorian Metropolitan Alliance General Practice Training, Hawthorn, VIC Department of General Practice, University of Melbourne, Carlton, VIC
| | - Lawrie McArthur
- Adelaide to Outback GP Training Program, North Adelaide, SA and
| | | | | | - Mieke L van Driel
- Discipline of General Practice, University of Queensland, Brisbane, QLD
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van Driel ML, Morgan S, Tapley A, McArthur L, McElduff P, Yardley L, Dallas A, Deckx L, Mulquiney K, Davis JS, Davey A, Henderson K, Little P, Magin PJ. Changing the Antibiotic Prescribing of general practice registrars: the ChAP study protocol for a prospective controlled study of a multimodal educational intervention. BMC FAMILY PRACTICE 2016; 17:67. [PMID: 27267983 PMCID: PMC4895975 DOI: 10.1186/s12875-016-0470-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/02/2016] [Indexed: 11/10/2022]
Abstract
Background Australian General Practitioners (GPs) are generous prescribers of antibiotics, prompting concerns including increasing antimicrobial resistance in the community. Recent data show that GPs in vocational training have prescribing patterns comparable with the high prescribing rate of their established GP supervisors. Evidence-based guidelines consistently advise that antibiotics are not indicated for uncomplicated upper respiratory tract infections (URTI) and are rarely indicated for acute bronchitis. A number of interventions have been trialled to promote rational antibiotic prescribing by established GPs (with variable effectiveness), but the impact of such interventions in a training setting is unclear. We hypothesise that intervening while early-career GPs are still developing their practice patterns and prescribing habits will result in better adherence to evidence-based guidelines as manifested by lower antibiotic prescribing rates for URTIs and acute bronchitis. Methods/design The intervention consists of two online modules, a face-to-face workshop for GP trainees, a face-to-face workshop for their supervisors and encouragement for the trainee-supervisor dyad to include a case-based discussion of evidence-based antibiotic prescribing in their weekly one-on-one teaching meetings. We will use a non-randomised, non-equivalent control group design to assess the impact on antibiotic prescribing for acute upper respiratory infections and acute bronchitis by GP trainees in vocational training. Discussion Early-career GPs who are still developing their clinical practice and prescribing habits are an underutilized target-group for interventions to curb the growth of antimicrobial resistance in the community. Interventions that are embedded into existing training programs or are linked to continuing professional development have potential to increase the impact of existing interventions at limited additional cost. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12614001209684 (registered 17/11/2014). Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0470-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mieke L van Driel
- Discipline of General Practice, School of Medicine, the University of Queensland, L8 Health Sciences Building 16/910, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia.
| | - Simon Morgan
- Elermore Vale General Practice, Shop 10-13, Croudace Rd, Elermore Vale, NSW, 2287, Australia
| | - Amanda Tapley
- GP Synergy NSW & ACT Research and Evaluation Unit, 17 Bolton St, Newcastle, NSW, 2300, Australia
| | - Lawrie McArthur
- Rural Clinical School, The University of Adelaide, 122 Frome Street, Adelaide, SA, 5005, Australia
| | - Patrick McElduff
- School of Medicine and Public Health, University of Newcastle, Newbolds Building, Corner Frith andGavey Streets, Mayfield, NSW, 2304, Australia
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Shakleton Building, Highfield, Southampton, SO17 1BJ, UK
| | - Anthea Dallas
- School of Medicine, University of Notre Dame Australia, 160 Oxford St, Darlinghurst, NSW, 2010, Australia
| | - Laura Deckx
- Discipline of General Practice, School of Medicine, the University of Queensland, L8 Health Sciences Building 16/910, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia
| | - Katie Mulquiney
- GP Synergy NSW & ACT Research and Evaluation Unit, 17 Bolton St, Newcastle, NSW, 2300, Australia
| | - Joshua S Davis
- School of Medicine and Public Health, University of Newcastle, Newbolds Building, Corner Frith andGavey Streets, Mayfield, NSW, 2304, Australia.,Department of Infectious Diseases, John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW, 2305, Australia.,Global and Tropical Health Division, Menzies School of Health Research, PO Box 41096, Casuarina, NT, 0811, Australia
| | - Andrew Davey
- Discipline of General Practice, School of Medicine and Public Health, University of Newcastle, Newbolds Building, Corner Frith and Gavey Streets, Mayfield, NSW, 2304, Australia
| | - Kim Henderson
- GP Synergy NSW & ACT Research and Evaluation Unit, 17 Bolton St, Newcastle, NSW, 2300, Australia
| | - Paul Little
- Primary Care and Population Sciences Division, University of Southampton, Aldermoor Health Centre, Aldermoor Close Southampton SO16 5ST, Southampton, UK
| | - Parker J Magin
- GP Synergy NSW & ACT Research and Evaluation Unit, 17 Bolton St, Newcastle, NSW, 2300, Australia.,Discipline of General Practice, School of Medicine and Public Health, University of Newcastle, Newbolds Building, Corner Frith and Gavey Streets, Mayfield, NSW, 2304, Australia
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Dallas A, van Driel M, Morgan S, Tapley A, Henderson K, Ball J, Oldmeadow C, Davey A, Mulquiney K, Davis J, Spike N, McArthur L, Magin P. Antibiotic prescribing for sore throat: a cross-sectional analysis of the ReCEnT study exploring the habits of early-career doctors in family practice. Fam Pract 2016; 33:302-8. [PMID: 26993484 DOI: 10.1093/fampra/cmw014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Acute sore throat is a common condition presenting to family practitioners. It is usually self-limiting, with antibiotic treatment recommended only for high-risk presentations. Overprescribing of antibiotics contributes to individual and community resistance. Learning to prescribe in the context of diagnostic uncertainty and patient pressures is a challenge for early-career doctors. Prescribing habits develop early and tend not to change with time. OBJECTIVE To establish the prevalence and associations of antibiotic prescribing for acute sore throat by Australian vocational trainees in family practice. METHOD A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. This ongoing, multicentre prospective cohort study documents the nature of trainees' consultation-based clinical experiences. Univariate and logistic regression analyses were conducted on data recorded in consultations for sore throat in nine collection periods during 2010-14. RESULTS Data from 856 individual trainees (response rate 95.2%) were analysed. Sore throat was managed in 2.3% encounters. Antibiotics were prescribed for 71.5% of sore throat diagnoses. The variables associated with prescribing were inner-regional location and higher socio-economic area. There was no significant association with younger age of patient or greater trainee experience. If an antibiotic was prescribed, the trainee was more likely to seek information from guidelines or a supervisor. CONCLUSIONS The high frequency of antibiotic prescribing and the lack of attenuation in prescribing with increased experience suggest current educational interventions and the apprenticeship model of training is not fostering appropriate practice in this important clinical area. Targeted educational interventions, for supervisors as well as trainees, are indicated.
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Affiliation(s)
- Anthea Dallas
- Discipline of General Practice, University of Queensland, Brisbane,
| | - Mieke van Driel
- Discipline of General Practice, University of Queensland, Brisbane
| | - Simon Morgan
- General Practice Training-Valley to Coast, Newcastle
| | - Amanda Tapley
- General Practice Training-Valley to Coast, Newcastle
| | - Kim Henderson
- General Practice Training-Valley to Coast, Newcastle
| | | | | | - Andrew Davey
- General Practice Training-Valley to Coast, Newcastle
| | | | - Joshua Davis
- Department of Infectious Diseases, John Hunter Hospital, Newcastle, Global and Tropical Health Division, Menzies School of Health Research, Darwin
| | - Neil Spike
- Victorian Metropolitan Alliance General Practice Training, Melbourne, Department of General Practice, University of Melbourne, Melbourne
| | - Lawrie McArthur
- Adelaide to Outback GP Training Program, Adelaide, Australia and
| | - Parker Magin
- General Practice Training-Valley to Coast, Newcastle, Discipline of General Practice, University of Newcastle, Newcastle, Australia
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Magin PJ, Morgan S, Tapley A, Davis JS, McArthur L, Henderson KM, Mulquiney KJ, Dallas A, Davey AR, Scott J, van Driel ML. Reducing general practice trainees' antibiotic prescribing for respiratory tract infections: an evaluation of a combined face-to-face workshop and online educational intervention. EDUCATION FOR PRIMARY CARE 2015; 27:98-105. [PMID: 27005837 DOI: 10.1080/14739879.2015.1106085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Over-prescription of antibiotics for non-pneumonia respiratory tract infections (RTIs) is a major concern in general practice. Australian general practice registrars (trainees) have inappropriately high rates of prescription of antibiotics for RTIs. The 'apprenticeship' educational model and the trainee-trainer relationship are drivers of this inappropriate prescribing. We aimed to reduce registrars' non-pneumonia RTI antibiotic prescribing via an educational intervention (a 90-min face-to-face workshop supported by online modules), complemented by delivery of the same intervention, separately, to their trainers. We conducted a pre- and post-intervention comparison of the registrars' intention to prescribe antibiotics for common RTIs using McNemar's test. We similarly tested changes in supervisors' intended prescribing. Prescribing intentions were elicited by responses to six written clinical vignettes (upper respiratory tract infection, otitis media, sore throat and three acute bronchitis vignettes). We found that, for registrars, there were statistically significant reductions in antibiotic prescribing for the sore throat (24.0% absolute reduction), otitis media (17.5% absolute reduction) and two of the three acute bronchitis (12.0% and 18.0% absolute reduction) vignettes. There were significant reductions in supervisors' antibiotic prescribing intentions for the same four vignettes. We conclude that our intervention produced a significant change in registrars' intention to prescribe antibiotics for non-pneumonia RTIs.
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Affiliation(s)
- Parker J Magin
- a General Practice Training Valley to Coast , Newcastle , Australia.,b School of Medicine and Public Health , University of Newcastle , Newcastle , Australia
| | - Simon Morgan
- a General Practice Training Valley to Coast , Newcastle , Australia
| | - Amanda Tapley
- a General Practice Training Valley to Coast , Newcastle , Australia
| | - Joshua S Davis
- b School of Medicine and Public Health , University of Newcastle , Newcastle , Australia.,c Menzies School of Health Research , Darwin , Australia.,d Department of Immunology and Infectious Diseases , John Hunter Hospital , Newcastle , Australia
| | - Lawrie McArthur
- e Adelaide to Outback General Practice Training , Adelaide , Australia
| | - Kim M Henderson
- a General Practice Training Valley to Coast , Newcastle , Australia
| | | | - Anthea Dallas
- f Discipline of General Practice , University of Notre Dame , Sydney , Australia
| | - Andrew R Davey
- b School of Medicine and Public Health , University of Newcastle , Newcastle , Australia
| | - John Scott
- a General Practice Training Valley to Coast , Newcastle , Australia
| | - Mieke L van Driel
- g Discipline of General Practice , University of Queensland , Brisbane , Australia
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