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Yang Y, Gong X, Song F, Guo R. Evidence-Do Gap in Quality of Direct-To-Consumer Telemedicine: Cross-Sectional Standardized Patient Study in China. Telemed J E Health 2024; 30:e1126-e1137. [PMID: 38039353 DOI: 10.1089/tmj.2023.0473] [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] [Indexed: 12/03/2023] Open
Abstract
Background: The evidence-do gap between the availability of clinical guidelines and provider practice is well documented, resulting in low health care quality. With the rapid development of telemedicine worldwide, this study aimed to investigate the evidence-do gap and explore the factors for the evidence versus practice deficits as well as low quality in direct-to-consumer telemedicine. Methods: We adopted the standardized patient approach to evaluate the health worker performance and calculate the evidence-do gap in quality of the consultation process, diagnosis, and treatment in telemedicine based on China's national clinical guidelines. Moreover, we further explored the factors associated with the gap through multiple linear regression and logistic regressions. Results: Validated physician-patient interactions (N = 321) were included. On the one hand, the consultation process and treatment quality are less commendable with the huge evidence-do gap. More than three-quarters of the physicians provided low-quality care, as against standard clinical guidelines. On the other hand, the level I, specialized hospitals, doctor, associate chief physicians, and attending physicians, sponsored by Internet enterprises, more times of provider's responses and words were associated with high-quality processes; More total times of provider's responses, urticaria, and nonoffice hours of the visit were associated with high-quality diagnosis; Sponsored by Internet enterprises, more total words of provider's all responses, and urticaria were associated with high-quality treatment. Conclusions: Our findings have important implications in an era in which to better comprehend the evidence-do gap. Efforts to bridge the evidence-do gap should be focused on the important role of institutions and physicians.
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Affiliation(s)
- Yuting Yang
- Department of Health Management and Policy, School of Public Health, Capital Medical University, Beijing, China
| | - Xue Gong
- Department of Quality and Efficiency, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Faying Song
- Department of Health Management and Policy, School of Public Health, Capital Medical University, Beijing, China
| | - Rui Guo
- Department of Health Management and Policy, School of Public Health, Capital Medical University, Beijing, China
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Christensen LD, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB, Huibers L. Point-of-care testing and antibiotics prescribing in out-of-hours general practice: a register-based study in Denmark. BMC PRIMARY CARE 2024; 25:31. [PMID: 38262975 PMCID: PMC10804570 DOI: 10.1186/s12875-024-02264-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND Point-of-care testing may reduce diagnostic uncertainty in case of suspicion of bacterial infection, thereby contributing to prudent antibiotic prescribing. We aimed to study variations in the use of point-of-care tests (C-reactive protein test, rapid streptococcal antigen detection test, and urine dipstick) among general practitioners (GPs) and the potential association between point-of-care testing and antibiotic prescribing in out-of-hours general practice. METHODS We conducted a population-based observational register-based study, based on patient contacts with out-of-hours general practice in the Central Denmark Region in 2014-2017. The tendency of GPs to use point-of-care testing was calculated, and the association between the use of point-of-care testing and antibiotic prescribing was evaluated with the use of binomial regression. RESULTS Out-of-hours general practice conducted 794,220 clinic consultations from 2014 to 2017, of which 16.1% resulted in an antibiotic prescription. The GP variation in the use of point-of-care testing was largest for C-reactive protein tests, with an observed variation (p90/p10 ratio) of 3.0; this means that the GPs in the 90th percentile used C-reactive protein tests three times as often as the GPs in the 10th percentile. The observed variation was 2.1 for rapid streptococcal antigen detection tests and 1.9 for urine dipsticks. The GPs who tended to use more point-of-care tests prescribed significantly more antibiotics than the GPs who tended to use fewer point-of-care tests. The GPs in the upper quintile of the tendency to use C-reactive protein test prescribed 22% more antibiotics than the GPs in the lowest quintile (21% for rapid streptococcal antigen detection tests and 8% for urine dipsticks). Up through the quintiles, this effect exhibited a positive linear dose-response correlation. CONCLUSION The GPs varied in use of point-of-care testing. The GPs who tended to perform more point-of-care testing prescribed more antibiotics compared with the GPs who tended to perform fewer of these tests.
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Affiliation(s)
| | | | - Ellen Keizer
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
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Miller KM, Barnett TC, Cadarette D, Bloom DE, Carapetis JR, Cannon JW. Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study. EBioMedicine 2023; 98:104864. [PMID: 37950997 PMCID: PMC10663680 DOI: 10.1016/j.ebiom.2023.104864] [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: 05/11/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Antibiotic consumption can lead to antimicrobial resistance and microbiome imbalance. We sought to estimate global antibiotic consumption for sore throat, and the potential reduction in consumption due to effective vaccination against group A Streptococcus (Strep A). METHODS We reviewed and analysed articles published between January 2000 and February 2022, identified though Clarivate Analytics' Web of Science search platform, with reference to antibiotic prescribing or consumption, sore throat, pharyngitis, or tonsillitis. We then used those analyses, combined with assumptions for the effectiveness, duration of protection, and coverage of a vaccine, to calculate the estimated reduction in antibiotic prescribing due to the introduction of Strep A vaccines. FINDINGS We identified 101 studies covering 38 countries. The mean prescribing rate for sore throat was approximately 5 courses per 100 population per year, accounting for approximately 5% of all antibiotic consumption. Based on 2020 population estimates for countries with empiric prescribing rates, antibiotic consumption for sore throat was estimated to exceed 37 million courses annually, of which half could be attributable to treatment for Strep A. A vaccine that reduces rates of Strep A infection by 80%, with 80% coverage and 10 year's duration of protection, could avert 2.8 million courses of antibiotics prescribed for sore throat treatment among 5-14 year-olds in countries with observed prescribing rates, increasing to an estimated 7.5 million averted if an effective vaccination program also reduced precautionary prescribing. INTERPRETATION A vaccine that prevents Strep A throat infections in children may reduce antibiotic prescribing for sore throat by 32-87% depending on changes to prescribing and consumption behaviours. FUNDING The Wellcome Trust, grant agreement number 215490/Z/19/Z.
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Affiliation(s)
- Kate M Miller
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Timothy C Barnett
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Marshall Centre for Infectious Diseases Research and Training, School of Biomedical Sciences, University of Western Australia, Nedlands, Western Australia, Australia
| | - Daniel Cadarette
- Harvard Kennedy School, Harvard University, Cambridge, MA, United States
| | - David E Bloom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Jonathan R Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Jeffrey W Cannon
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Centre for Child Health Research, Medical School, University of Western Australia, Nedlands, Western Australia, Australia.
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4
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Sijbom M, Büchner FL, Saadah NH, Numans ME, de Boer MGJ. Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers: a systematic review and construction of a framework. BMJ Open 2023; 13:e065006. [PMID: 37197815 DOI: 10.1136/bmjopen-2022-065006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVES This study aimed to identify determinants of inappropriate antibiotic prescription in primary care in developed countries and to construct a framework with the determinants to help understand which actions can best be targeted to counteract development of antimicrobial resistance (AMR). DESIGN A systematic review of peer-reviewed studies reporting determinants of inappropriate antibiotic prescription published through 9 September 2021 in PubMed, Embase, Web of Science and the Cochrane Library was performed. SETTING All studies focusing on primary care in developed countries where general practitioners (GPs) act as gatekeepers for referral to medical specialists and hospital care were included. RESULTS Seventeen studies fulfilled the inclusion criteria and were used for the analysis which identified 45 determinants of inappropriate antibiotic prescription. Important determinants for inappropriate antibiotic prescription were comorbidity, primary care not considered to be responsible for development of AMR and GP perception of patient desire for antibiotics. A framework was constructed with the determinants and provides a broad overview of several domains. The framework can be used to identify several reasons for inappropriate antibiotic prescription in a specific primary care setting and from there, choose the most suitable intervention(s) and assist in implementing them for combatting AMR. CONCLUSIONS The type of infection, comorbidity and the GPs perception of a patient's desire for antibiotics are consistently identified as factors driving inappropriate antibiotic prescription in primary care. A framework with determinants of inappropriate antibiotic prescription may be useful after validation for effective implementation of interventions for decreasing these inappropriate prescriptions. PROSPERO REGISTRATION NUMBER CRD42023396225.
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Affiliation(s)
- Martijn Sijbom
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Frederike L Büchner
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Nicholas H Saadah
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Mark G J de Boer
- Infectious Diseases, Leidsen University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Saust LT, Siersma VD, Bjerrum L, Hansen MP. Development of quality indicators for the diagnosis and treatment of urinary tract infections in general practice: a RAND appropriateness method. BMJ Open Qual 2023; 12:bmjoq-2022-002156. [PMID: 37230738 DOI: 10.1136/bmjoq-2022-002156] [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: 10/14/2022] [Accepted: 05/07/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To develop a set of quality indicators for the diagnosis and antibiotic treatment of adult patients with suspected urinary tract infections in general practice. DESIGN A Research and Development/University of California Los Angeles appropriateness method was used. SETTING Danish general practice. SUBJECTS A panel of nine experts, mainly general practitioners, was asked to rate the relevance of 27 preliminary quality indicators. The set of indicators was based on the most recent Danish guidelines for the management of patients with suspected urinary tract infection. An online meeting was held to resolve misinterpretations and achieve consensus. MAIN OUTCOME MEASURES The experts were asked to rate the indicators on a nine-point Likert scale. Consensus of appropriateness was reached if the overall panel median rating was 7-9 with agreement. Agreement was defined as: no more than one expert rated the indicator outside the three-point region (1-3, 4-6 and 7-9) containing the median. RESULTS A total of 23 of the 27 proposed quality indicators attained consensus. One additional indicator was proposed by the panel of experts, leading to a final set of 24 quality indicators. All indicators focusing on the diagnostic process achieved consensus of appropriateness, while the experts agreed on three quarters of the proposed quality indicators concerning either the treatment decision or the choice of antibiotics. CONCLUSION This set of quality indicators may be used to strengthen general practice's focus on the management of patients with a possible urinary tract infection and to identify potential quality problems.
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Affiliation(s)
- Laura Trolle Saust
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Center for General Practice, Aalborg University, Aalborg, Denmark
| | - Volkert Dirk Siersma
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bjerrum
- Department of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Malene Plejdrup Hansen
- Department of Clinical Medicine, Center for General Practice, Aalborg University, Aalborg, Denmark
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6
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Janssen MWH, de Bont EGPM, Hoebe CJPA, Cals JWL, den Heijer CDJ. Trends in antibiotic prescribing in Dutch general practice and determinants of nonprudent antibiotic prescriptions. Fam Pract 2023; 40:61-67. [PMID: 35723245 DOI: 10.1093/fampra/cmac063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Antibiotic resistance is mainly driven by (incorrect) use of antibiotics. Most antibiotics are prescribed in family medicine. Therefore, regularly monitoring of antibiotic prescriptions and evaluation of their (non-) prudent use in primary care is warranted. OBJECTIVES The aim of this study was to determine time trends in antibiotic prescriptions by Dutch family physicians (FPs) and to identify determinants of nonprudent antibiotic prescriptions by Dutch FPs. METHODS Retrospective study among 27 Dutch general practices from the Research Network Family Medicine Maastricht, from 2015 to 2019. RESULTS In total 801,767 patient years were analysed. Antibiotic prescriptions mainly increased in patients aged 65+ while prescriptions mainly decreased in patients below 65 years. Nonprudent antibiotic prescriptions decreased from 2015 to 2019 with the highest percentage of decline found in skin infections (66.9% [2015] to 53.9% [2019]). Overall, higher likelihood of nonprudent antibiotic prescriptions was found among men (odds ratio [OR] 4.11, 95% confidence interval [CI]: 3.91-4.33), patients aged 80+ (OR 1.44, 95% CI: 1.03-2.01; reference category ≤17 years), patients with comedication (OR 1.24, 95% CI: 1.17-1.31), and patients in urban general practices (OR 1.47, 95% CI: 1.38-1.56). CONCLUSIONS Antibiotic prescriptions increased over time in the elderly aged categories. Although an overall decrease in nonprudent antibiotic prescriptions was established from 2015 to 2019, percentages of nonprudent prescriptions remained high for skin infections and respiratory tract infections. Additionally, men, elderly aged patients (80+), patients with comedication and patients in urban general practices were more likely to receive nonprudent antibiotic prescriptions. Our results will help FPs to prioritize optimalization of antibiotic prescriptions in family medicine.
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Affiliation(s)
- Manon W H Janssen
- Department of Sexual, Health, Infectious Diseases, and Environmental Health, Public Health Service South Limburg, Heerlen, The Netherlands.,Department of Infectious Diseases, St. Jans Gasthuis, Weert, The Netherlands
| | - Eefje G P M de Bont
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Christian J P A Hoebe
- Department of Sexual, Health, Infectious Diseases, and Environmental Health, Public Health Service South Limburg, Heerlen, The Netherlands.,Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.,Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Casper D J den Heijer
- Department of Sexual, Health, Infectious Diseases, and Environmental Health, Public Health Service South Limburg, Heerlen, The Netherlands.,Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.,Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre (MUMC+), PO Box 5800, 6202 AZ Maastricht, The Netherlands
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7
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Verhoeven J, Christensen HC, Blomberg SN, Böbel S, Scholz M, Krafft T. Patient characteristics and dispatch responses of urinary tract infections in a prehospital setting in Copenhagen, Denmark: a retrospective cohort study. BMC PRIMARY CARE 2022; 23:319. [PMID: 36496366 PMCID: PMC9736713 DOI: 10.1186/s12875-022-01915-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 11/16/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Urinary tract infection (UTI) is particularly common in young women and the elderly. The Emergency Medical Services (EMS) in Copenhagen, Denmark can be reached by calling either of two dedicated telephone lines: 1-1-2 in case of an emergency and 1813 during general practitioner's (GP) out-of-office hours (OOH). This study investigated characteristics of patients with symptoms of UTI calling the Copenhagen EMS and the response they received. METHODS A retrospective observational cohort study was conducted in which 7.5 years of telephone data on UTI from the EMS in Copenhagen were analyzed. Descriptive statistics and multinomial logistic regression were used to analyze patient characteristics, the timing of the incident and response. Patients' age and gender were assessed and the use of urinary catheters, the timing of the incident, and the impact on the response were evaluated. RESULTS A total of 278.961 calls were included (78% female, mean age 47), with an average of 120 patients with UTI symptoms calling each day. Most people contacted the 1813-medical helpline (98%) and of those, the majority were referred to the emergency department (ED)(37%). Patients were more likely to be referred to the ED during the weekend compared to a weekday and less likely during OOH compared to in-office hours (IH). Patients with a urinary catheter were more likely to receive specialized care referred to as 'other'. For the smaller proportion of patients calling 1-1-2, most people got a B (urgent) response (1.5%). The most likely response to be given was an A (emergency) or F (non-emergency) response during OOH compared to IH and on weekends compared to weekdays. Patients with a urinary catheter were more likely to receive a D (unmonitored transport) response. CONCLUSIONS Since 2015, there was a decrease in 1813 antibiotic prescription rates and a subsequent increase in referral to the ED of UTI patients. Patients were referred less to the ED during OOH as they were likely to be sent to their GP the next day. During the weekend, patients were referred more to the ED for the likely reason that their GP is closed.
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Affiliation(s)
- Jeske Verhoeven
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Universiteitssingel 60, 6229, ER, Maastricht, the Netherlands.
| | - Helle Collatz Christensen
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2750, Ballerup, Denmark
| | - Stig Nikolaj Blomberg
- Emergency Medical Services Copenhagen, University of Copenhagen, Telegrafvej 5, 2750, Ballerup, Denmark
| | - Simone Böbel
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Universiteitssingel 60, 6229, ER, Maastricht, the Netherlands
| | - Mirjam Scholz
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Universiteitssingel 60, 6229, ER, Maastricht, the Netherlands
| | - Thomas Krafft
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Universiteitssingel 60, 6229, ER, Maastricht, the Netherlands
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Dixon S, Fanshawe TR, Mwandigha L, Edwards G, Turner PJ, Glogowska M, Gillespie MM, Blair D, Hayward GN. The Impact of Point-of-Care Blood C-Reactive Protein Testing on Prescribing Antibiotics in Out-of-Hours Primary Care: A Mixed Methods Evaluation. Antibiotics (Basel) 2022; 11:antibiotics11081008. [PMID: 35892398 PMCID: PMC9332095 DOI: 10.3390/antibiotics11081008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 02/05/2023] Open
Abstract
Improving prescribing antibiotics appropriately for respiratory infections in primary care is an antimicrobial stewardship priority. There is limited evidence to support interventions to reduce prescribing antibiotics in out-of-hours (OOH) primary care. Herein, we report a service innovation where point-of-care C-Reactive Protein (CRP) machines were introduced to three out-of-hours primary care clinical bases in England from August 2018-December 2019, which were compared with four control bases that did not have point-of-care CRP testing. We undertook a mixed-method evaluation, including a comparative interrupted time series analysis to compare monthly antibiotic prescription rates between bases with CRP machines and those without, an analysis of the number of and reasons for the tests performed, and qualitative interviews with clinicians. Antibiotic prescription rates declined during follow-up, but with no clear difference between the two groups of out-of-hours practices. A single base contributed 217 of the 248 CRP tests performed. Clinicians reported that the tests supported decision making and communication about not prescribing antibiotics, where having 'objective' numbers were helpful in navigating non-prescribing decisions and highlighted the challenges of training a fluctuant staff group and practical concerns about using the CRP machine. Service improvements to reduce prescribing antibiotics in out-of-hours primary care need to be developed with an understanding of the needs and context of this service.
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Affiliation(s)
- Sharon Dixon
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
- Correspondence:
| | - Thomas R. Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
| | - Lazaro Mwandigha
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
| | - George Edwards
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
| | - Philip J. Turner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
| | - Marjorie M. Gillespie
- Practice Plus Group, Hawker House, 5–6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW, UK;
| | - Duncan Blair
- Queen Elizabeth Memorial Health Centre, St Michaels Avenue, Tidworth Garrison SP9 7EA, UK;
| | - Gail N. Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
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9
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Huibers L, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB. Variation of GP antibiotic prescribing tendency for contacts with out-of-hours primary care in Denmark - a cross-sectional register-based study. Scand J Prim Health Care 2022; 40:227-236. [PMID: 35703579 PMCID: PMC9397449 DOI: 10.1080/02813432.2022.2073981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To study variation in antibiotic prescribing rates among general practitioners (GP) in out-of-hours (OOH) primary care and to explore GP characteristics associated with these rates. DESIGN Population-based observational registry study using routine data from the OOH primary care registration system on patient contacts and antibiotic prescriptions combined with national register data. SETTING OOH primary care of the Central Denmark Region. SUBJECTS All patient contacts in 2014-2017. MAIN OUTCOME MEASURES GPs' tendency to prescribe antibiotics. Excess variation (not attributable to chance). RESULTS We included 794,220 clinic consultations (16.1% with antibiotics prescription), 281,141 home visits (11.6% antibiotics), and 1,583,919 telephone consultations (5.8% antibiotics). The excess variation in the tendency to prescribe antibiotics was 1.56 for clinic consultations, 1.64 for telephone consultations, and 1.58 for home visits. Some GP characteristics were significantly correlated with a higher tendency to prescribe antibiotics, including 'activity level' (i.e. number of patients seen in the past hour) for clinic and telephone consultations, 'familiarity with OOH care' (i.e. number of OOH shifts in the past 180 days), male sex, and younger age for home visits. Overall, GP characteristics explained little of the antibiotic prescribing variation seen among GPs (Pseudo r2: 0.008-0.025). CONCLUSION Some variation in the GPs' tendency to prescribe antibiotics was found for OOH primary care contacts. Available GP characteristics, such as GPs' activity level and familiarity with OOH care, explained only small parts of this variation. Future research should focus on identifying factors that can explain this variation, as this knowledge could be used for designing interventions.KEY POINTSCurrent awareness:Antibiotic prescribing rates seem to be higher in out-of-hours than in daytime primary care.Most important results:Antibiotic prescribing rates varied significantly among general practitioners after adjustment for contact- and patient-characteristics.This variation remained even after accounting for variation attributable to chance.General practitioners' activity level and familiarity with out-of-hours care were positively associated with their tendency to prescribe antibiotics.
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Affiliation(s)
- Linda Huibers
- Research Unit for General Practice, Aarhus, Denmark
- CONTACT Linda Huibers Research Unit for General Practice, Bartholins Alle 2, Aarhus8000, Denmark
| | | | - Ellen Keizer
- Research Unit for General Practice, Aarhus, Denmark
| | - Bodil Hammer Bech
- Research Unit for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Aarhus, Denmark
- Department of General Practice, Institute for Public Health, Aarhus University, Aarhus, Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice, Aarhus, Denmark
- Department of General Practice, Institute for Public Health, Aarhus University, Aarhus, Denmark
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10
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Guo R, Hou M, Han Y, Feng XL. Access, charge and quality of tele-dermatology e-consults in China: A standardized patients study. Digit Health 2022; 8:20552076221140763. [PMID: 36465986 PMCID: PMC9716584 DOI: 10.1177/20552076221140763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/02/2022] [Indexed: 12/03/2023] Open
Abstract
OBJECTIVE Direct-to-consumer telemedicine is rapidly changing the way that patients seek medical care. This study provided the first report on access, cost and quality of text- and image-based tele-dermatology e-consults, in China. METHODS We adopted the Standardized Patients approach to evaluate the services of tele-dermatology e-consults in two metropolitan cities, that is, Beijing and Hangzhou, in China. We measured quality from four dimensions: service process, diagnosis accuracy, prescription and treatment comprehensiveness, based on China's national clinical guidelines. We performed logistic regressions to investigate factors that were associated with high-quality care. RESULTS For 114 physicians eligible for inclusion, we succeeded in 87 (76%) validated visits. The median waiting time was 100 minutes (IQR 19-243 minutes) and the median length of consultation was 636 minutes (about 10 hours, IQR 188-1528 minutes). Per visit costs varied from $0 to $38, with a median of $8 (IQR 4-9). Among all, 15% of visits showed high quality in service process, 84% arrived in the correct diagnosis, 24% provided high-quality prescriptions and 71% provided comprehensive treatment. Providing images was associated with high quality in service process (OR 7.22, 95% CI 1.49-34.88). Visits in metropolitan Beijing and on non-work days had better prescription quality than that in metropolitan Hangzhou (OR 6.05, 95% CI 1.75-20.95) and that on workdays (OR 3.75, 95%CI 1.27-11.04), respectively. CONCLUSIONS Tele-dermatology e-consults seem to be easy to access and less expensive in China. However, great efforts are warranted to ensure that service processes and prescriptions adhere to clinical guidelines.
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Affiliation(s)
- Rui Guo
- School of Public Health, Capital Medical University, Beijing, China
| | - Mengchi Hou
- China Aerospace Science & Industry Corporation 731 Hospital, Beijing, China
| | - Yangyang Han
- Beijing Chinese Medical Hospital Affiliated to Capital Medical University, Beijing, China
| | - Xing Lin Feng
- Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China
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11
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Colliers A, Bombeke K, Philips H, Remmen R, Coenen S, Anthierens S. Antibiotic Prescribing and Doctor-Patient Communication During Consultations for Respiratory Tract Infections: A Video Observation Study in Out-of-Hours Primary Care. Front Med (Lausanne) 2021; 8:735276. [PMID: 34926492 PMCID: PMC8671733 DOI: 10.3389/fmed.2021.735276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: Communication skills can reduce inappropriate antibiotic prescribing, which could help to tackle antibiotic resistance. General practitioners often overestimate patient expectations for an antibiotic. In this study, we describe how general practitioners and patients with respiratory tract infections (RTI) communicate about their problem, including the reason for encounter and ideas, concerns, and expectations (ICE), and how this relates to (non-)antibiotic prescribing in out-of-hours (OOH) primary care. Methods: A qualitative descriptive framework analysis of video-recorded consultations during OOH primary care focusing on doctor-patient communication. Results: We analyzed 77 videos from 19 general practitioners. General practitioners using patient-centered communication skills received more information on the perspective of the patients on the illness period. For some patients, the reason for the encounter was motivated by their belief that a general practitioner (GP) visit will alter the course of their illness. The ideas, concerns, and expectations often remained implicit, but the concerns were expressed by the choice of words, tone of voice, repetition of words, etc. Delayed prescribing was sometimes used to respond to implicit patient expectations for an antibiotic. Patients accepted a non-antibiotic management plan well. Conclusion: Not addressing the ICE of patients, or their reason to consult the GP OOH, could drive assumptions about patient expectations for antibiotics early on and antibiotic prescribing later in the consultation.
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Affiliation(s)
- Annelies Colliers
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | | | - Hilde Philips
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Roy Remmen
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium.,Vaccine and Infectious Disease Institute (VAXINFECTIO)-Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
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12
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Hendriks-Spoor KD, Wille FL, Doesschate TT, Dorigo-Zetsma JW, Verheij TJM, van Werkhoven CH. Five versus seven days of nitrofurantoin for urinary tract infections in women with diabetes: a retrospective cohort study. Clin Microbiol Infect 2021; 28:377-382. [PMID: 34245906 DOI: 10.1016/j.cmi.2021.06.034] [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: 03/19/2021] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the effectiveness of 5 versus 7 days of nitrofurantoin treatment for urinary tract infection (UTI) in women with diabetes. METHODS Data were collected retrospectively from Dutch general practitioners between 2013 and 2020. Nitrofurantoin prescriptions with a duration of 5 days (5DN) or 7 days (7DN) in women with diabetes were included. Inverse propensity weighting was performed to calculate adjusted risk differences (RD) for treatment failure within 28 days. Secondary outcomes were 14-day treatment failure, severe treatment failure and 28-day treatment failure in defined risk groups. RESULTS Nitrofurantoin was prescribed in 6866 episodes, 3247 (47.3%) episodes with 5DN and 3619 (52.7%) episodes with 7DN. Patients in the 7DN group had more co-morbidities, more diabetes-related complications and were more insulin-dependent. There were 517/3247 (15.9%) failures in the 5DN group versus 520/3619 (14.4%) in the 7DN group. The adjusted RD for failure within 28 days was 1.4% (95% CI -0.6 to 3.4). CONCLUSION We found no clinically significant difference in treatment failure in women with diabetes with UTI treated with either 5DN or 7DN within 28 days. A 5-day treatment should be considered to reduce cumulative nitrofurantoin exposure in DM patients.
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Affiliation(s)
- Kelly D Hendriks-Spoor
- Department of Medical Microbiology, Tergooi Hospital, Hilversum, the Netherlands; Julius Centre for Health Sciences and Primary Care, University Medical Utrecht, University of Utrecht, Utrecht, the Netherlands.
| | - Floor L Wille
- Julius Centre for Health Sciences and Primary Care, University Medical Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Thijs Ten Doesschate
- Julius Centre for Health Sciences and Primary Care, University Medical Utrecht, University of Utrecht, Utrecht, the Netherlands
| | | | - Theo J M Verheij
- Julius Centre for Health Sciences and Primary Care, University Medical Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Cornelis H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Utrecht, University of Utrecht, Utrecht, the Netherlands
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13
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Ten Doesschate T, Hendriks K, van Werkhoven CH, van der Hout EC, Platteel TN, Groenewegen IAM, Muller AE, Hoepelman AIM, Bonten MJM, Geerlings SE. Nitrofurantoin 100 mg versus 50 mg prophylaxis for urinary tract infections, a cohort study. Clin Microbiol Infect 2021; 28:248-254. [PMID: 34111584 DOI: 10.1016/j.cmi.2021.05.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Guidelines do not distinguish between 50 mg or 100 mg nitrofurantoin as daily prophylaxis for recurrent urinary tract infection (UTI), although 50 mg might have a better safety profile. Our objective was to compare the effectiveness and safety of both regimens. METHODS Data were retrospectively collected from 84 Dutch GP practices between 2013 and 2020. Nitrofurantoin prescriptions of 100 mg and 50 mg every 24 hours in women were included. Cox proportional hazard regression analysis was used to calculate hazard ratios on first episode of UTI, pyelonephritis and (adverse) events. Patients were followed for the duration of consecutive repeated prescriptions, assuming non-informative right censoring, up to 1 year. RESULTS Nitrofurantoin prophylaxis was prescribed in 1893 patients. Median lengths of follow up were 90 days (interquartile range (IQR) 37-179 days) for 100 mg (n = 551) and 90 days (IQR 30-146 days) for 50 mg (n = 1342) with few differences in baseline characteristics between populations. Under 100 mg and 50 mg, 82/551 (14.9%) and 199/1342 (14.8%) developed UTI and 46/551 (8.3%) and 81/1342 (6.0%) developed pyelonephritis, respectively. Adjusted HRs of 100 mg versus 50 mg were 1.01 (95% CI 0.78-1.30) on first UTI, 1.37 (95% CI 0.95-1.98) on first pyelonephritis episode, 1.82 (95% CI 1.20-2.74) on first consultation for cough, 2.68 for dyspnoea (95% CI 1.11-6.45) and 2.43 for nausea (95% CI 1.03-5.74). CONCLUSION Daily prophylaxis for recurrent UTI with 100 mg instead of 50 mg nitrofurantoin was associated with an equivalent hazard on UTI or pyelonephritis, and a higher hazard on cough, dyspnoea and nausea. We recommend 50 mg nitrofurantoin as daily prophylaxis.
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Affiliation(s)
- Thijs Ten Doesschate
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, University of Utrecht, Utrecht, the Netherlands.
| | - Kelly Hendriks
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, University of Utrecht, Utrecht, the Netherlands; Department of Medical Microbiology, Tergooi Hospital, Hilversum, the Netherlands
| | - Cornelis Henri van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Evelien C van der Hout
- Department of Pulmonology, University Medical Centre Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Tamara N Platteel
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, University of Utrecht, Utrecht, the Netherlands; van Dijken (GP-practice), NG Veenendaal, the Netherlands
| | | | - Anouk E Muller
- Department of Medical Microbiology, Haaglanden Medical Centre, The Hague, the Netherlands; Department of Medical Microbiology & Infectious Diseases, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Andy I M Hoepelman
- Department of Internal Medicine, University Medical Centre Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Marc J M Bonten
- Department of Medical Microbiology, University Medical Centre Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Amsterdam University Medical Centre, Amsterdam-Zuidoost, the Netherlands
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14
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Trends in Antibiotic Prescribing in Out-of-Hours Primary Care in England from January 2016 to June 2020 to Understand Behaviours during the First Wave of COVID-19. Antibiotics (Basel) 2021; 10:antibiotics10010032. [PMID: 33401408 PMCID: PMC7824631 DOI: 10.3390/antibiotics10010032] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/24/2020] [Accepted: 12/25/2020] [Indexed: 12/18/2022] Open
Abstract
We describe the trend of antibiotic prescribing in out-of-hours (OOH) general practices (GP) before and during England’s first wave of the COVID-19 pandemic. We analysed practice-level prescribing records between January 2016 to June 2020 to report the trends for the total prescribing volume, prescribing of broad-spectrum antibiotics and key agents included in the national Quality Premium. We performed a time-series analysis to detect measurable changes in the prescribing volume associated with COVID-19. Before COVID-19, the total prescribing volume and the percentage of broad-spectrum antibiotics continued to decrease in-hours (IH). The prescribing of broad-spectrum antibiotics was higher in OOH (OOH: 10.1%, IH: 8.7%), but a consistent decrease in the trimethoprim-to-nitrofurantoin ratio was observed OOH. The OOH antibiotic prescribing volume diverged from the historical trend in March 2020 and started to decrease by 5088 items per month. Broad-spectrum antibiotic prescribing started to increase in OOH and IH. In OOH, co-amoxiclav and doxycycline peaked in March to May in 2020, which was out of sync with seasonality peaks (Winter) in previous years. While this increase might be explained by the implementation of the national guideline to use co-amoxiclav and doxycycline to manage pneumonia in the community during COVID-19, further investigation is required to see whether the observed reduction in OOH antibiotic prescribing persists and how this reduction might influence antimicrobial resistance and patient outcomes.
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15
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ten Doesschate T, van Haren E, Wijma R, Koch B, Bonten M, van Werkhoven C. The effectiveness of nitrofurantoin, fosfomycin and trimethoprim for the treatment of cystitis in relation to renal function. Clin Microbiol Infect 2020; 26:1355-1360. [DOI: 10.1016/j.cmi.2020.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/24/2020] [Accepted: 03/01/2020] [Indexed: 12/13/2022]
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16
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Palsdottir HA, Jonsson JS, Sigurdsson EL. Prescriptions of antibiotics in out-of-hours primary care setting in Reykjavik capital area. Scand J Prim Health Care 2020; 38:265-271. [PMID: 32672085 PMCID: PMC7470112 DOI: 10.1080/02813432.2020.1794159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To describe antibiotic prescriptions in out-of-hour (OOH) service in primary care setting in Iceland and to study the indications for prescriptions. DESIGN A population based retrospective study, using electronic data from the OOH registration system. SETTING OOH primary care setting in Reykjavik capital area in Iceland. SUBJECTS All patients that received a prescription for oral antibiotic drug at an OOH service in Reykjavik capital area over a one-year period. MAIN OUTCOME MEASURES Number of oral antibiotic prescriptions and diagnosis connected to the prescriptions according to age and sex. RESULTS There were 75,582 contacts with the OOH primary care of which 25,059 contacts resulted in prescription of an oral antibiotic (33%). The most common antibiotic prescribed in total, and for the diagnosis studied, was amoxicillin with clavulanic acid. It was most often prescribed for acute otitis media. Of those diagnosed with otitis media 50% were treated with amoxicillin with clavulanic acid and 40% of those diagnosed with pneumonia received that treatment. The second most prescribed antibiotic was amoxicillin. Most often it was prescribed for sinusitis, in 47% of cases with that diagnosis. CONCLUSION Antibiotics are often prescribed in OOH primary care in Iceland and a substantial number of the patients diagnosed in OOH primary care with acute otitis media or pneumonia are prescribed broad-spectrum antibiotics. Key points Antibiotic prescription rate is high and broad-spectrum drugs often prescribed in OOH primary care service in Iceland. The results should encourage general practitioners in Iceland to review antibiotic prescriptions in OOH service.
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Affiliation(s)
| | - Jon Steinar Jonsson
- Department of Family Medicine, University of Iceland, Reykjavik, Iceland
- Development Centre for the Primary Care, Reykjavik, Iceland
| | - Emil L. Sigurdsson
- Department of Family Medicine, University of Iceland, Reykjavik, Iceland
- Development Centre for the Primary Care, Reykjavik, Iceland
- CONTACT Emil L. Sigurdsson Department of Family Medicine, University of Iceland, Reykjavik, Iceland
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17
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Cronberg O, Tyrstrup M, Ekblom K, Hedin K. Diagnosis-linked antibiotic prescribing in Swedish primary care - a comparison between in-hours and out-of-hours. BMC Infect Dis 2020; 20:616. [PMID: 32819280 PMCID: PMC7441551 DOI: 10.1186/s12879-020-05334-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/10/2020] [Indexed: 12/28/2022] Open
Abstract
Background The rise in antibiotic resistance is a global public health concern, and antibiotic overuse needs to be reduced. Earlier studies of out-of-hours care have indicated that antibiotic prescribing is less appropriate than that of in-hours care. However, no study has compared the out-of-hours treatment of infections to in-hours treatment within the same population. Methods This retrospective, descriptive study was based on data retrieved from the Kronoberg Infection Database in Primary Care (KIDPC), which consists of all visits to primary care with an infection diagnosis or prescription of antibiotics during 2006–2014. The purpose was to study the trends in antibiotic prescribing and to compare consultations and prescriptions between in-hours and out-of-hours. Results The visit rate for all infections was 434 visits per 1000 inhabitants per year. The visit rate was stable during the study period, but the antibiotic prescribing rate decreased from 266 prescriptions per 1000 inhabitants in 2006 to 194 prescriptions in 2014 (mean annual change − 8.5 [95% CI − 11.9 to − 5.2]). For the out-of-hours visits (12% of the total visits), a similar reduction in antibiotic prescribing was seen. The decrease was most apparent among children and in respiratory tract infections. When antibiotic prescribing during out-of-hours was compared to in-hours, the unadjusted relative risk of antibiotic prescribing was 1.37 (95% CI 1.36 to 1.38), but when adjusted for age, sex, and diagnosis, the relative risk of antibiotic prescribing was 1.09 (95% CI 1.08 to 1.10). The reduction after adjustment was largely explained by a higher visit rate during out-of-hours for infections requiring antibiotics (acute otitis media, pharyngotonsillitis, and lower urinary tract infection). The choices of antibiotics used for common diagnoses were similar. Conclusions Although the infection visit rate was unchanged over the study period, there was a significant reduction in antibiotic prescribing, especially to children and for respiratory tract infections. The higher antibiotic prescribing rate during out-of-hours was small when adjusted for age, sex, and diagnosis. No excess prescription of broad-spectrum antibiotics was seen. Therefore, interventions selectively aiming at out-of-hours centres seem to be unmotivated in a low-prescribing context.
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Affiliation(s)
- Olof Cronberg
- Växjöhälsan Primary Healthcare Center, VC Växjöhälsan, Hjortvägen 1, 352 45, Växjö, Sweden. .,Department of Research and Development, Region Kronoberg, Växjö, Sweden. .,Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.
| | - Mia Tyrstrup
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.,Lundbergsgatan Primary Health Care Centre, Malmö, Sweden
| | - Kim Ekblom
- Department of Research and Development, Region Kronoberg, Växjö, Sweden.,Department of Medical Biosciences, Clinical Chemistry, Umeå University, Umeå, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, Malmö, Sweden.,Futurum, Region Jönköping County and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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18
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D'Atri F, Arthur J, Blix HS, Hicks LA, Plachouras D, Monnet DL. Targets for the reduction of antibiotic use in humans in the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) partner countries. ACTA ACUST UNITED AC 2020; 24. [PMID: 31311620 PMCID: PMC6636213 DOI: 10.2807/1560-7917.es.2019.24.28.1800339] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Unnecessary and inappropriate use of antibiotics in human healthcare is a major driver for the development and spread of antimicrobial resistance; many countries are implementing measures to limit the overuse and misuse of antibiotics e.g. through the establishment of antimicrobial use reduction targets. We performed a review of antimicrobial use reduction goals in human medicine in Transatlantic Taskforce on Antimicrobial Resistance partner countries. On 31 March 2017, the European Centre for Disease Prevention and Control sent a questionnaire to National Focal Points for Antimicrobial Consumption and the National Focal Points for Antimicrobial Resistance in 28 European Union countries, Iceland and Norway. The same questionnaire was sent to the TATFAR implementers in Canada and the United States. Thirty of 32 countries replied. Only nine countries indicated that they have established targets to reduce antimicrobial use in humans. Twenty-one countries replied that no target had been established. However, 17 of these 21 countries indicated that work to establish such targets is currently underway, often in the context of developing a national action plan against antimicrobial resistance. The reported targets varied greatly between countries and can be a useful resource for countries willing to engage in the reduction of antibiotic use in humans.
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Affiliation(s)
- Fabio D'Atri
- European Commission, Directorate General for Health and Food Safety, Brussels, Belgium.,European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Jacqueline Arthur
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Canada
| | | | - Lauri A Hicks
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, United States
| | | | - Dominique L Monnet
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
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19
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Edwards G, Brettell R, Bird C, Hunt H, Lasserson D, Hayward G. Paediatric contacts with the UK out-of-hours primary care service and contact outcomes: a regional service evaluation. BMC FAMILY PRACTICE 2020; 21:144. [PMID: 32664869 PMCID: PMC7362454 DOI: 10.1186/s12875-020-01205-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 06/22/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Demand on hospital emergency departments for paediatric problems is increasing. However, the volume and nature of paediatric health demands placed on other parts of the urgent care system have not been explored. This understanding is an important first step in developing and improving out-of-hospital care. We aimed to describe the volume, nature, and outcomes of paediatric contacts with out-of-hours general practice (OOH GP). We performed a retrospective service evaluation using data from 12 months of paediatric patient contacts with the Oxfordshire OOH GP service. METHODS A database of contacts with the Oxfordshire OOH GP service was created for a 12 month period from December 2014 to November 2015. Descriptive statistics were calculated using SPSS Version 25. RESULTS 27,455 contacts were made by 18,987 individuals during a 12 month period. The majority of these were for children aged under 5. Over 70% of contacts were at the weekend. The peak contact period was between 18:30 and 21:30. Over 40% of contacts resulted in advice only (no onward referral, requirement for GP follow up, or prescription). 19.7% of contacts resulted in an antibiotic prescription, most commonly those linked with ear, chest, and throat infections. DISCUSSION Paediatric contacts with the Oxfordshire OOH GP service were predominantly in younger age groups and in the evening, with 19.7% resulting in an antibiotic prescription. Almost half of the contacts had no follow up or prescription, suggesting non-prescribing health care professionals could be involved in providing care in OOH GP. Further research should consider how children and their parents can be best supported to optimise OOH consulting.
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Affiliation(s)
- George Edwards
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, England.
| | - Rachel Brettell
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, England
| | - Chris Bird
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, England
| | - Helen Hunt
- Oxford Health NHS Foundation Trust, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, England
| | - Dan Lasserson
- Institute of Applied Health Research, College of Medical and Dental Sciences, Murray Learning Centre, University of Birmingham, Edgbaston, Birmingham, B15 2TT, England
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, England
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20
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Understanding General Practitioners' Antibiotic Prescribing Decisions in Out-of-Hours Primary Care: A Video-Elicitation Interview Study. Antibiotics (Basel) 2020; 9:antibiotics9030115. [PMID: 32156082 PMCID: PMC7148451 DOI: 10.3390/antibiotics9030115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 11/16/2022] Open
Abstract
Infections are the most common reason why patients consult out-of-hours (OOH) primary care. Too often there is an overprescribing of antibiotics for self-limiting infections and general practitioners (GPs) do not always choose the guideline recommended antibiotics. To improve antibiotic prescribing quality, a better understanding is needed of the (non) antibiotic prescribing decisions of GPs. This study sets out to unravel GPs’ (non) antibiotic prescribing decisions in OOH primary care. We video-recorded 160 consultations on infections during OOH primary care by 21 GPs and performed video-elicitation interviews with each GP. GPs reflected on their decision-making process and communication while watching their consultation. A qualitative thematic analysis was used. GPs found that their (non) antibiotic prescribing decision-making was not only based on objective arguments, but also subconsciously influenced by their own interpretation of information. Often GPs made assumptions (about for example the patients’ reason for encounter or expectations for antibiotics) without objectifying or verifying this with the patient. From the beginning of the consultation GPs follow a dichotomous thinking process: urgent versus not urgent, viral versus bacterial, antibiotics versus no antibiotics. Safety-netting is an important but difficult tool in the OOH care context, with no long-term follow-up or relationship with the patient. GPs talk about strategies they use to talk about diagnostic uncertainty, what patients can expect or should do when things do not improve and the difficulties they encounter while doing this. This video- elicitation interview study provides actionable insights in GPs’ (non) antibiotic prescribing decisions during OOH consultations on infections.
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21
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Hart J, Phillips P. What out-of-hours antibiotic prescribing practices are contributing to antibiotic resistance: a literature review. Br Paramed J 2020; 4:25-33. [PMID: 33456376 PMCID: PMC7783906 DOI: 10.29045/14784726.2020.12.4.4.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Overuse of antibiotics and inappropriate prescribing has resulted in a rapid increase in the rate of antibiotic resistance, with poorer patient outcomes and increased health costs. In the out-of-hours setting, a high proportion of antibiotics are prescribed and practices need to improve to reduce antibiotic resistance. Purpose: To identify antibiotic prescribing practices in European out-of-hours primary care services that are contributing to antibiotic resistance. Design: The review was conducted in alignment with the PRISMA statement (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2009). Methods: A literature search was performed using MySearch to identify European literature. The search was focused on antibiotic/antimicrobial prescribing in an out-of-hours environment, and any reports that described factors correlating with the nature of prescribing practices were examined. Results: The literature search located 91 articles, out of which seven met the inclusion criteria. Two articles described clinicians’ experiences in antibiotic prescribing in out-of-hours, two compared in-office and after-hours prescribing, two described prescribing patterns in out-of-hours and one examined prescribing in children. Four main themes were identified: antibiotics prescribed and conditions associated with prescribing; consultation time; the day of consultation; and parental opinion. Conclusion: Overprescribing to self-limiting conditions, prescribing of broad-spectrum antibiotics, time constraints, safeguarding issues and poor communication are all contributing to inappropriate antibiotic prescribing. Further research is needed relating to whether clinicians are adhering to antibiotic guidelines and to explore patients’ experiences and expectations from the out-of-hours practitioners with respect to antibiotic prescribing.
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Affiliation(s)
- Jasmine Hart
- South Western Ambulance Service NHS Foundation Trust
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22
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Ten Doesschate T, Groenwold RHH, Bonten MJM, van Werkhoven CH. Effectiveness of extended- versus normal-release nitrofurantoin for cystitis: an instrumental variable analysis. J Antimicrob Chemother 2019; 74:3337-3343. [PMID: 31504584 PMCID: PMC6798831 DOI: 10.1093/jac/dkz350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND It is unknown whether nitrofurantoin 50 mg normal-release every 6 h (NF50) and nitrofurantoin 100 mg extended-release every 12 h (NF100) are equally effective for treating cystitis in primary care. In the Netherlands, GP prescription of either option largely depends on pharmacy procurement, rather than on patient-related factors. METHODS GP data between January 2013 and July 2018 were retrospectively collected. Inclusion criteria were the use of nitrofurantoin for uncomplicated cystitis, complicated cystitis or cystitis in pregnancy. Criteria for early and late failure were a second antibiotic prescription for cystitis or pyelonephritis within 14 and 28 days post-prescription, respectively. Crude and confounder-adjusted (CA) risk differences (RDs) were estimated using linear regression. Instrumental variable analysis and CA instrumental variable analysis used GP practice proportion of NF50 versus NF100 use as the instrumental variable. RESULTS For uncomplicated cystitis (n=46855), treatment with NF50 and NF100 resulted in late failure in 9.7% and 9.6%, respectively. The CA RD, instrumental variable RD and CA instrumental variable RD were 0.2% (95% CI=-0.5 to 0.8), -0.7% (95% CI=-1.7 to 0.3) and 0.0% (95% CI=-0.9 to 1.0), respectively. In complicated cystitis (n=10767), late failure occurred in 10.9% and 11.1% after using NF50 and NF100, respectively [CA RD=0.5% (95% CI=-1.2 to 1.8), instrumental variable RD=-0.8% (95% CI=-3.4 to 1.8) and CA instrumental variable RD=-0.3% (95% CI=-3.0 to 2.4)]. For cystitis in pregnancy (n=1087), NF50 and NF100 resulted in late failure in 13.4% and 7.8%, respectively [CA RD=-5.4% (95% CI=-10.0 to -1.4), instrumental variable RD=-8.9% (95% CI=-16.0 to -1.8) and CA instrumental variable RD=-8.9% (95% CI=-16.0 to -1.7)]. No differences were observed in early failure. CONCLUSIONS In patients with cystitis in pregnancy, NF100 was associated with a lower incidence of late clinical failure compared with NF50. We found no differences in clinical failure between NF50 and NF100 for uncomplicated and complicated cystitis.
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Affiliation(s)
- Thijs Ten Doesschate
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, ZA Leiden, The Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, CX Utrecht, The Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, CX Utrecht, The Netherlands
| | - Cornelis H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, CX Utrecht, The Netherlands
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Colliers A, Adriaenssens N, Anthierens S, Bartholomeeusen S, Philips H, Remmen R, Coenen S. Antibiotic Prescribing Quality in Out-of-Hours Primary Care and Critical Appraisal of Disease-Specific Quality Indicators. Antibiotics (Basel) 2019; 8:antibiotics8020079. [PMID: 31212871 PMCID: PMC6628021 DOI: 10.3390/antibiotics8020079] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/05/2019] [Accepted: 06/07/2019] [Indexed: 12/25/2022] Open
Abstract
Outpatient antibiotic use in Belgium is among the highest in Europe. The most common reason for an encounter in out-of-hours (OOH) primary care is an infection. In this study, we assessed all consultations from July 2016 to June 2018 at five OOH services. We described antibiotic prescribing by diagnosis, calculated disease-specific antibiotic prescribing quality indicators’ (APQI) values and critically appraised these APQI. We determined that 111,600 encounters resulted in 26,436 (23.7%) antibiotic prescriptions. The APQI diagnoses (i.e., bronchitis, upper respiratory infection, cystitis, tonsillitis, sinusitis, otitis media, and pneumonia) covered 14,927 (56.7%) antibiotic prescriptions. Erysipelas (1344 (5.1%)) and teeth/gum disease (982 (3.7%)) covered more prescriptions than sinusitis or pneumonia. Over 75% of patients with tonsillitis and over 50% with bronchitis, sinusitis, and otitis media were prescribed an antibiotic. Only for otitis media the choice of antibiotic was near the acceptable range. Over 10% of patients with bronchitis or pneumonia and over 25% of female patients with an acute cystitis received quinolones. The APQI cover the diagnoses for only 57% of all antibiotic prescriptions. As 5.1% and 3.7% of antibiotic prescriptions are made for erysipelas and teeth/gum disease, respectively, we propose to add these indications when assessing antibiotic prescribing quality in OOH primary care.
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Affiliation(s)
- Annelies Colliers
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Niels Adriaenssens
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Sibyl Anthierens
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Stephaan Bartholomeeusen
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Hilde Philips
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Roy Remmen
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
| | - Samuel Coenen
- Department of Primary and Interdisciplinary Care (ELIZA)-Centre for General Practice, University of Antwerp, Faculty of Medicine and Health Sciences, Doornstraat 331, B-2610 Antwerp, Belgium.
- Department of Epidemiology and Social Medicine (ESOC), University of Antwerp, Faculty of Medicine and Health Sciences, Universiteitsplein 1, B-2610 Antwerp, Belgium.
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Faculty of Medicine and Health Sciences, Universiteitsplein 1, B-2610 Antwerp, Belgium.
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24
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O’Connor R, O’Doherty J, O’Regan A, O’Neill A, McMahon C, Dunne CP. Medical management of acute upper respiratory infections in an urban primary care out-of-hours facility: cross-sectional study of patient presentations and expectations. BMJ Open 2019; 9:e025396. [PMID: 30772860 PMCID: PMC6398638 DOI: 10.1136/bmjopen-2018-025396] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES The purpose of this study was to examine the expectations of patients attending an urban primary care out-of-hours (OOH) facility with acute upper respiratory tract infection (acute URTI) regarding clinical examination, symptom management, information on their condition, reassurance, antibiotic treatment and other possible options including referral. DESIGN Cross-sectional design. SETTING One urban primary care OOH facility located in the midwest of Ireland. PARTICIPANTS 457 patients filled out a questionnaire while waiting in the OOH facility; 22 surveys were excluded as the patients did not present with symptoms of acute URTI resulting in 435 patients' data being included in this study. There were 59.5% female participants and 40.5% male participants. RESULTS 435 patients with acute URTI symptoms participated in the survey, representing 25.4% of those attending the single branch where the survey was conducted (n=1715). Of the study participants, 43% were aged under 6 years and 60% were women. The most common presenting symptoms were cough (72%), throat ache (46%) and common cold (26%). The most common expectations were for further examination (53%), reassurance (51%), information (49%) and medication for cough (47%), with 34% expecting an antibiotic. CONCLUSIONS Only one in three patients attending this primary care OOH facility with acute URTI symptoms had an expectation of antibiotics, with most seeking further assessment, information and reassurance. Recognition of such expectations may be important considerations for clinicians when deciding on management options for patients with acute URTI.
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Affiliation(s)
- Raymond O’Connor
- Graduate Entry Medical School, University of Limerick Faculty of Education and Health Sciences, Limerick, Ireland
| | - Jane O’Doherty
- Graduate Entry Medical School, University of Limerick Faculty of Education and Health Sciences, Limerick, Ireland
| | - Andrew O’Regan
- Graduate Entry Medical School, University of Limerick Faculty of Education and Health Sciences, Limerick, Ireland
| | - Aoife O’Neill
- Department of Mathematics and Statistics, University of Limerick, Limerick, Ireland
| | - Claire McMahon
- Clinical Quality and Administration Department, Shannondoc Out of Hours General Practitioner Service, Limerick, Ireland
| | - Colum P Dunne
- Graduate Entry Medical School, University of Limerick Faculty of Education and Health Sciences, Limerick, Ireland
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25
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O'Doherty J, Leader LFW, O'Regan A, Dunne C, Puthoopparambil SJ, O'Connor R. Over prescribing of antibiotics for acute respiratory tract infections; a qualitative study to explore Irish general practitioners' perspectives. BMC FAMILY PRACTICE 2019; 20:27. [PMID: 30764777 PMCID: PMC6374900 DOI: 10.1186/s12875-019-0917-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 02/04/2019] [Indexed: 11/10/2022]
Abstract
Background Anti-microbial resistance (AMR) is a global threat to public health and antibiotics are often unnecessarily prescribed for acute respiratory tract infections (ARTIs) in general practice. We aimed to investigate why general practitioners (GPs) continue to prescribe antibiotics for ARTIs despite increasing knowledge of their poor efficacy and worsening antimicrobial resistance. Methods We used an explorative qualitative study design. Thirteen GPs were recruited through purposive sampling to represent urban and rural settings and years of experience. They were based in general practices within the Mid-West of Ireland. GPs took part in semi-structured interviews that were digitally audio recorded and transcribed. Results Three main themes and three subthemes were identified. Themes include (1) non-comprehensive guidelines; how guideline adherence can be difficult, (2) GPs under pressure; pressures to prescribe from patients and perceived patient expectations and (3) Unnecessary prescribing; how to address it and the potential of public interventions to reduce it. Conclusions GPs acknowledge their failure to implement guidelines because they feel they are less usable in clinical situations. GPs felt pressurised to prescribe, especially for fee-paying patients and in out of hours settings (OOH), suggesting the need for interventions that target the public’s perceptions of antibiotics. GPs behaviours surrounding prescribing antibiotics need to change in order to reduce AMR and change patients’ expectations. Electronic supplementary material The online version of this article (10.1186/s12875-019-0917-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jane O'Doherty
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
| | - Leonard F W Leader
- Royal College of Surgeons in Ireland - Medical University of Bahrain, Busaiteen, Muharraq Governorate, Kingdom of Bahrain
| | - Andrew O'Regan
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Colum Dunne
- Centre for Infections in Infection, Inflammation & Immunity (41), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Soorej Jose Puthoopparambil
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.,International Maternal and Child Health (IMCH), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Raymond O'Connor
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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O'Connor R, O'Doherty J, O'Regan A, Dunne C. Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review. Ir J Med Sci 2018; 187:969-986. [PMID: 29532292 PMCID: PMC6209023 DOI: 10.1007/s11845-018-1774-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 02/23/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Antimicrobial resistance is an emerging global threat to health and is associated with increased consumption of antibiotics. Seventy-four per cent of antibiotic prescribing takes place in primary care. Much of this is for inappropriate treatment of acute respiratory tract infections. AIMS To review the published literature pertaining to antibiotic prescribing in order to identify and understand the factors that affect primary care providers' prescribing decisions. METHODS Six online databases were searched for relevant paper using agreed criteria. One hundred ninety-five papers were retrieved, and 139 were included in this review. RESULTS Primary care providers are highly influenced to prescribe by patient expectation for antibiotics, clinical uncertainty and workload induced time pressures. Strategies proven to reduce such inappropriate prescribing include appropriately aimed multifaceted educational interventions for primary care providers, mass media educational campaigns aimed at healthcare professionals and the public, use of good communication skills in the consultation, use of delayed prescriptions especially when accompanied by written information, point of care testing and, probably, longer less pressurised consultations. Delayed prescriptions also facilitate focused personalised patient education. CONCLUSION There is an emerging consensus in the literature regarding strategies proven to reduce antibiotic consumption for acute respiratory tract infections. The widespread adoption of these strategies in primary care is imperative.
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Affiliation(s)
- Ray O'Connor
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland.
| | - Jane O'Doherty
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
| | - Andrew O'Regan
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
| | - Colum Dunne
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
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27
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Shen X, Lu M, Feng R, Cheng J, Chai J, Xie M, Dong X, Jiang T, Wang D. Web-Based Just-in-Time Information and Feedback on Antibiotic Use for Village Doctors in Rural Anhui, China: Randomized Controlled Trial. J Med Internet Res 2018; 20:e53. [PMID: 29444768 PMCID: PMC5830611 DOI: 10.2196/jmir.8922] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/01/2017] [Accepted: 12/18/2017] [Indexed: 02/02/2023] Open
Abstract
Background Excessive use of antibiotics is very common worldwide, especially in rural China; various measures that have been used in curbing the problem have shown only marginal effects. Objective The objective of this study was to test an innovative intervention that provided just-in-time information and feedback (JITIF) to village doctors on care of common infectious diseases. Methods The information component of JITIF consisted of a set of theory or evidence-based ingredients, including operation guideline, public commitment, and takeaway information, whereas the feedback component tells each participating doctor about his or her performance scores and percentages of antibiotic prescriptions. These ingredients were incorporated together in a synergetic way via a Web-based aid. Evaluation of JITIF adopted a randomized controlled trial design involving 24 village clinics randomized into equal control and intervention arms. Measures used included changes between baseline and endpoint (1 year after baseline) in terms of: percentages of patients with symptomatic respiratory or gastrointestinal tract infections (RTIs or GTIs) being prescribed antibiotics, delivery of essential service procedures, and patients’ beliefs and knowledge about antibiotics and infection prevention. Two researchers worked as a group in collecting the data at each site clinic. One performed nonparticipative observation of the service process, while the other performed structured exit interviews about patients’ beliefs and knowledge. Data analysis comprised mainly of: (1) descriptive estimations of beliefs or knowledge, practice of indicative procedures, and use of antibiotics at baseline and endpoint for intervention and control groups and (2) chi-square tests for the differences between these groups. Results A total of 1048 patients completed the evaluation, including 532 at baseline (intervention=269, control=263) and 516 at endpoint (intervention=262, control=254). Patients diagnosed with RTIs and GTIs accounted for 76.5% (407/532) and 23.5% (125/352), respectively, at baseline and 80.8% (417/532) and 19.2% (99/532) at endpoint. JITIF resulted in substantial improvement in delivery of essential service procedures (2.6%-24.8% at baseline on both arms and at endpoint on the control arm vs 88.5%-95.0% at endpoint on the intervention arm, P<.001), beliefs favoring rational antibiotics use (11.5%-39.8% at baseline on both arms and at endpoint on the control arm vs 19.8%-62.6% at endpoint on the intervention arm, P<.001) and knowledge about side effects of antibiotics (35.7% on the control arm vs 73.7% on the intervention arm, P<.001), measures for managing or preventing RTIs (39.1% vs 66.7%, P=.02), and measures for managing or preventing GTIs (46.8% vs 69.2%, P<.001). It also reduced antibiotics prescription (from 88.8%-62.3%, P<.001), and this decrease was consistent for RTIs (87.1% vs 64.3%, P<.001) and GTIs (94.7% vs 52.4%, P<.001). Conclusions JITIF is effective in controlling antibiotics prescription at least in the short term and may provide a low-cost and sustainable solution to the widespread excessive use of antibiotics in rural China.
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Affiliation(s)
- XingRong Shen
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Manman Lu
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Rui Feng
- Department of Literature Review and Analysis, Library of Anhui Medical University, Hefei, China
| | - Jing Cheng
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Jing Chai
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Maomao Xie
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Xuemeng Dong
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Tao Jiang
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Debin Wang
- School of Health Service Management, Anhui Medical University, Hefei, China
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28
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Colliers A, Coenen S, Philips H, Remmen R, Anthierens S. Optimising the quality of antibiotic prescribing in out-of-hours primary care in Belgium: a study protocol for an action research project. BMJ Open 2017; 7:e017522. [PMID: 29038184 PMCID: PMC5652575 DOI: 10.1136/bmjopen-2017-017522] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Antimicrobial resistance is a major public health threat driven by inappropriate antibiotic use, mainly in general practice and for respiratory tract infections. In Belgium, the quality of general practitioners' (GPs) antibiotic prescribing is low. To improve antibiotic use, we need a better understanding of this quality problem and corresponding interventions. A general practitioners cooperative (GPC) for out-of-hours (OOH) care presents a unique opportunity to reach a large group of GPs and work on quality improvement. Participatory action research (PAR) is a bottom-up approach that focuses on implementing change into daily practice and has the potential to empower practitioners to produce their own solutions to optimise their antibiotic prescribing. METHODS This PAR study to improve antibiotic prescribing quality in OOH care uses a mixed methods approach. In a first exploratory phase, we will develop a partnership with a GPC and map the existing barriers and opportunities. In a second phase, we will focus on facilitating change and implementing interventions through PDSA (Plan-Do-Study-Act) cycles. In a third phase, antibiotic prescribing quality outside and antibiotic use during office hours will be evaluated. Equally important are the process evaluation and theory building on improving antibiotic prescribing. ETHICS The study protocol was approved by the Ethics Committee of the Antwerp University Hospital/University of Antwerp. PAR unfolds in response to the needs and issues of the stakeholders, therefore new ethics approval will be obtained at each new stage of the research. DISSEMINATION Interventions to improve antibiotic prescribing are needed now more than ever and outcomes will be highly relevant for GPCs, GPs in daily practice, national policymakers and the international scientific community. TRIAL REGISTRATION NUMBER NCT03082521; Pre-results.
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Affiliation(s)
- Annelies Colliers
- Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
| | - Samuel Coenen
- Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
- Department of Epidemiology and Social Medicine (ESOC), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
| | - Hilde Philips
- Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
| | - Roy Remmen
- Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Primary and Interdisciplinary Care (ELIZA) – Centre for General Practice, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Antwerp, Belgium
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