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McCleary N, Francis JJ, Campbell MK, Ramsay CR, Burton CD, Allan JL. Antibiotic prescribing for respiratory tract infection: exploring drivers of cognitive effort and factors associated with inappropriate prescribing. Fam Pract 2021; 38:740-750. [PMID: 33972999 DOI: 10.1093/fampra/cmab030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Antibiotics are over-prescribed for upper respiratory tract infection (URTI). It is unclear how factors known to influence prescribing decisions operate 'in the moment': dual process theories, which propose two systems of thought ('automatic' and 'analytical'), may inform this. OBJECTIVE(S) Investigate cognitive processes underlying antibiotic prescribing for URTI and the factors associated with inappropriate prescribing. METHODS We conducted a mixed methods study. Primary care physicians in Scotland (n = 158) made prescribing decisions for patient scenarios describing sore throat or otitis media delivered online. Decision difficulty and decision time were recorded. Decisions were categorized as appropriate or inappropriate based on clinical guidelines. Regression analyses explored relationships between scenario and physician characteristics and decision difficulty, time and appropriateness. A subgroup (n = 5) verbalized their thoughts (think aloud) whilst making decisions for a subset of scenarios. Interviews were analysed inductively. RESULTS Illness duration of 4+ days was associated with greater difficulty. Inappropriate prescribing was associated with clinical factors suggesting viral cause and with patient preference against antibiotics. In interviews, physicians made appropriate decisions quickly for easier cases, with little deliberation, reflecting automatic-type processes. For more difficult cases, physicians deliberated over information in some instances, but not in others, with inappropriate prescribing occurring in both instances. Some interpretations of illness duration and unilateral ear examination findings (for otitis media) were associated with inappropriate prescribing. CONCLUSION Both automatic and analytical processes may lead to inappropriate prescribing. Interventions to support appropriate prescribing may benefit from targeting interpretation of illness duration and otitis media ear exam findings and facilitating appropriate use of both modes of thinking.
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Affiliation(s)
- Nicola McCleary
- Aberdeen Health Psychology Group, University of Aberdeen, Aberdeen, UK.,Health Services Research Unit, University of Aberdeen, Aberdeen, UK.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa,Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Jill J Francis
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa,Canada.,School of Health Sciences, City University of London, London, UK.,School of Health Sciences, University of Melbourne, Melbourne, Australia
| | | | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Julia L Allan
- Aberdeen Health Psychology Group, University of Aberdeen, Aberdeen, UK.,Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Olsen JK, Lykkegaard J, Hansen MP, Waldorff FB, Lous J, Andersen MK. Prescription of antibiotics to children with acute otitis media in Danish general practice. BMC FAMILY PRACTICE 2020; 21:177. [PMID: 32854621 PMCID: PMC7457240 DOI: 10.1186/s12875-020-01248-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/17/2020] [Indexed: 11/10/2022]
Abstract
Background Acute otitis media (AOM) is a common and most often self-limiting infection in childhood, usually managed in general practice. Even though antibiotics are only recommended when certain diagnostic and clinical criteria are met a high antibiotic prescription rate is observed. The study’s objective was to analyse associations between patient- and general practitioner (GP) characteristics and antibiotic prescribing for children with AOM in an effort to explain the high antibiotic prescribing rates. Methods All general practices in the Northern, Southern and Central regions of Denmark were invited to record symptoms, examinations, findings and antibiotic treatment for all children ≤7 years of age diagnosed with AOM during a four-week winter period in 2017/2018. Associations were analysed by means of multivariate logistic regressions. The study design was cross-sectional. Results GPs from 60 general practices diagnosed 278 children with AOM of whom 207 (74%) were prescribed antibiotics, most often penicillin V (60%). About half of the children had tympanometry performed. Antibiotic prescribing rates varied considerably between practices (0–100%). Antibiotic prescribing was associated with fever (odds ratio (OR) 3.69 95% confidence interval (CI) 1.93–7.05), purulent ear secretion (OR 2.35 95% CI 1.01–5.50) and poor general condition (OR 3.12 95% CI 1.31–7.46), and the practice’s antibiotic prescribing rate to other patients with symptoms of an acute respiratory tract infection (OR 2.85 CI 95% 1.07–7.60) and specifically to other children with AOM (OR 4.15 CI 95% 1.82–9.47). Conclusion GPs’ antibiotic prescribing rates for children with AOM vary considerably even considering the of signs, symptoms, request for antibiotics, and use of tympanometry. Interventions to reduce overprescribing should be targeted high-prescribing practices.
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Affiliation(s)
- Jonas K Olsen
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, DK-5000, Odense C, Denmark.
| | - Jesper Lykkegaard
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, DK-5000, Odense C, Denmark.,Audit Project Odense, Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Malene Plejdrup Hansen
- Audit Project Odense, Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark.,Center for General Practice at Aalborg University, Aalborg, Denmark
| | - Frans B Waldorff
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, DK-5000, Odense C, Denmark
| | - Jørgen Lous
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, DK-5000, Odense C, Denmark
| | - Merethe K Andersen
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, DK-5000, Odense C, Denmark.,Audit Project Odense, Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
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Schilder AGM, Marom T, Bhutta MF, Casselbrant ML, Coates H, Gisselsson-Solén M, Hall AJ, Marchisio P, Ruohola A, Venekamp RP, Mandel EM. Panel 7: Otitis Media: Treatment and Complications. Otolaryngol Head Neck Surg 2017; 156:S88-S105. [PMID: 28372534 DOI: 10.1177/0194599816633697] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective We aimed to summarize key articles published between 2011 and 2015 on the treatment of (recurrent) acute otitis media, otitis media with effusion, tympanostomy tube otorrhea, chronic suppurative otitis media and complications of otitis media, and their implications for clinical practice. Data Sources PubMed, Ovid Medline, the Cochrane Library, and Clinical Evidence (BMJ Publishing). Review Methods All types of articles related to otitis media treatment and complications between June 2011 and March 2015 were identified. A total of 1122 potential related articles were reviewed by the panel members; 118 relevant articles were ultimately included in this summary. Conclusions Recent literature and guidelines emphasize accurate diagnosis of acute otitis media and optimal management of ear pain. Watchful waiting is optional in mild to moderate acute otitis media; antibiotics do shorten symptoms and duration of middle ear effusion. The additive benefit of adenoidectomy to tympanostomy tubes in recurrent acute otitis media and otitis media with effusion is controversial and age dependent. Topical antibiotic is the treatment of choice in acute tube otorrhea. Symptomatic hearing loss due to persistent otitis media with effusion is best treated with tympanostomy tubes. Novel molecular and biomaterial treatments as adjuvants to surgical closure of eardrum perforations seem promising. There is insufficient evidence to support the use of complementary and alternative treatments. Implications for Practice Emphasis on accurate diagnosis of otitis media, in its various forms, is important to reduce overdiagnosis, overtreatment, and antibiotic resistance. Children at risk for otitis media and its complications deserve special attention.
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Affiliation(s)
- Anne G M Schilder
- 1 evidENT, Ear Institute, University College London, London, United Kingdom.,2 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Tal Marom
- 3 Department of Otolaryngology-Head and Neck Surgery, Assaf Harofeh Medical Center, Faculty of Medicine, Tel Aviv University, Zerifin, Israel
| | - Mahmood F Bhutta
- 4 Royal National Throat Nose and Ear Hospital, London, United Kingdom
| | - Margaretha L Casselbrant
- 5 Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Harvey Coates
- 6 Department of Otolaryngology, School of Paediatrics and Child Health, The University of Western Australia, Nedlands, WA, Australia
| | - Marie Gisselsson-Solén
- 7 Department of Clinical Sciences, Division of Otorhinolaryngology, Head and Neck Surgery, Lund University Hospital, Lund, Sweden
| | - Amanda J Hall
- 8 University Hospitals Bristol NHS Foundation Trust and School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Paola Marchisio
- 9 Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Aino Ruohola
- 10 Department of Pediatrics, University of Turku, Turku, Finland
| | - Roderick P Venekamp
- 2 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ellen M Mandel
- 5 Division of Pediatric Otolaryngology, Children's Hospital of Pittsburgh of UPMC, Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Thromboembolic complications following a first isolated episode of superficial vein thrombosis: a cross-sectional retrospective study. J Thromb Thrombolysis 2016; 43:31-37. [DOI: 10.1007/s11239-016-1414-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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O'Brien K, Bellis TW, Kelson M, Hood K, Butler CC, Edwards A. Clinical predictors of antibiotic prescribing for acutely ill children in primary care: an observational study. Br J Gen Pract 2015; 65:e585-92. [PMID: 26324495 PMCID: PMC4540398 DOI: 10.3399/bjgp15x686497] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 05/12/2015] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Antibiotic overuse and inappropriate prescribing drive antibiotic resistance. Children account for a high proportion of antibiotics prescribed in primary care. AIM To determine the predictors of antibiotic prescription in young children presenting to UK general practices with acute illness. DESIGN AND SETTING Prospective observational study in general practices in Wales. METHOD A total of 999 children were recruited from 13 practices between March 2008 and July 2010. Multilevel, multivariable logistic regression analysis was performed to determine predictors of antibiotic prescribing. RESULTS Oral antibiotics were prescribed to 261 children (26.1%). Respiratory infections were responsible for 77.4% of antibiotic prescriptions. The multivariable model included 719 children. Children were more likely to be prescribed antibiotics if they were older (odds ratio [OR] 1.3; 95% confidence intervals [CI] = 1.1 to 1.7); presented with poor sleep (OR 2.7; 95% CI = 1.5 to 5.0); had abnormal ear (OR 6.5; 95% CI = 2.5 to 17.2), throat (OR 2.2; 95% CI = 1.1 to 4.5) or chest examination (OR 13.6; 95% CI = 5.8 to 32.2); were diagnosed with lower respiratory tract infection (OR 9.5; 95% CI = 3.7 to 25.5), tonsillitis/sore throat (OR 119.3; 95% CI = 28.2 to 504.6), ear infection (OR 26.5; 95% CI = 7.4 to 95.7) or urinary tract infection (OR 12.7; 95% CI = 4.4 to 36.5); or if the responsible clinician perceived the child to be moderately to severely unwell (OR 4.0; 95% CI = 1.4 to 11.4). The area under the receiver operating characteristic curve was 0.9371. CONCLUSION Respiratory infections were responsible for 74.4% of antibiotic prescriptions. Diagnoses of tonsillitis, sore throat, or ear infection were associated most with antibiotic prescribing. Diagnosis seemed to be more important than abnormal examination findings in predicting antibiotic prescribing, although these were correlated.
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Affiliation(s)
| | | | - Mark Kelson
- South East Wales Trials Unit, Cardiff University, Cardiff
| | - Kerenza Hood
- South East Wales Trials Unit, Cardiff University, Cardiff
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences Oxford University, Oxford and Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Division of Population Medicine and professor of primary care, School of Medicine
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