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Linder JA, Persell SD, Kelley MA, Friedberg M, Goldstein NJ, Knight TK, Kaiser KM, Doctor JN, Mack WJ, Tibbels J, McCabe B, Haenchen S, Meeker D. Antibiotic prescribing for acute respiratory infections during the coronavirus disease 2019 (COVID-19) pandemic: Patterns in a nationwide telehealth service provider. Infect Control Hosp Epidemiol 2024; 45:777-780. [PMID: 38329093 PMCID: PMC11102822 DOI: 10.1017/ice.2023.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 10/17/2023] [Accepted: 12/04/2023] [Indexed: 02/09/2024]
Abstract
We examined 3,046,538 acute respiratory infection (ARI) encounters with 6,103 national telehealth physicians from January 2019 to October 2021. The antibiotic prescribing rates were 44% for all ARIs; 46% were antibiotic appropriate; 65% were potentially appropriate; 19% resulted from inappropriate diagnoses; and 10% were related to coronavirus disease 2019 (COVID-19) diagnosis.
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Affiliation(s)
- Jeffrey A. Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Center for Primary Care Innovation, Institute for Public Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen D. Persell
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Center for Primary Care Innovation, Institute for Public Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Marcella A. Kelley
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
- School of Pharmacy, University of Southern California, Los Angeles, California
| | - Mark Friedberg
- Blue Cross Blue Shield of Massachusetts, Boston, Massachusetts
| | - Noah J. Goldstein
- Anderson School of Management, University of California at Los Angeles, Los Angeles, California
| | - Tara K. Knight
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
| | - Katrina M. Kaiser
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
| | - Jason N. Doctor
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
| | - Wendy J. Mack
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | | | - Daniella Meeker
- Yale School of Medicine, Yale University, New Haven, Connecticut
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2
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Oertli C, Staub M, Zhang M, Katz SE. Impact of mandatory indications for outpatient antibiotic orders on accurate tracking of antibiotic indications. Infect Control Hosp Epidemiol 2024:1-6. [PMID: 38738537 DOI: 10.1017/ice.2024.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
OBJECTIVE We sought to evaluate whether implementing mandatory indications for outpatient electronic antibiotic orders or using encounter International Classification of Diseases, Tenth Revision (ICD10) codes more accurately reflected clinicians' charted diagnosis in encounter notes. Secondarily, we examined the appropriateness of antibiotic prescriptions. DESIGN Cross-sectional study. METHODS Mandatory indications were added to all outpatient electronic antibiotic orders on May 18, 2022. A randomly selected convenience sample of 1300 outpatient encounters with antibiotics from walk-in clinics was reviewed. Adjusted logistic regression was used to compare the congruence between encounter ICD10 code and charted diagnosis for encounters from July 15 to September 15, 2021 (pre-implementation period) to the congruence between encounter ICD10 code, charted diagnosis, and mandatory indication for encounters from July 15 to September 15, 2022 (post-implementation period). Antibiotic appropriateness based on charted diagnosis was also evaluated. RESULTS Among 1300 outpatient encounters, congruence between charted diagnosis and ICD10 code significantly increased in the post-implementation period (87.7% (565/644)) versus pre-implementation (83.3% (540/648), adjusted odds ratio (aOR) 1.52; 95% CI 1.03-2.25). Congruence between charted diagnosis and mandatory indication during post-implementation was 95.2% (613/644) and >5 times more likely to be congruent than charted diagnosis and ICD10 code during pre-implementation (aOR 5.45; 95% CI 3.26-9.11). Antibiotic prescribing based on charted diagnosis was twice as likely to be appropriate in the post-implementation period (aOR1.99; 95% CI 1.32-2.98). CONCLUSIONS Mandatory indications within antibiotic orders show better congruence with charted diagnosis than ICD10 codes and may increase antibiotic appropriateness and congruence between ICD10 code and charted diagnosis.
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Affiliation(s)
- Charles Oertli
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Milner Staub
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Infectious Diseases Section, Medical Service Line, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Minhua Zhang
- Quality, Safety, and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sophie E Katz
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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3
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Stevens RW, Manz J, Mathre M, Bell N, Virk A, Vergidis P, Jensen K. Cracking the code(s): Optimization of encounter-level diagnosis coding to inform outpatient antimicrobial stewardship data modeling. Infect Control Hosp Epidemiol 2024; 45:550-552. [PMID: 38234184 DOI: 10.1017/ice.2023.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Affiliation(s)
- Ryan W Stevens
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - James Manz
- Division of Spine and Neurosurgery, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - Margo Mathre
- Center for Digital Health, Data and Analytics, Healthcare Terminology, Mayo Clinic, Phoenix, Arizona
| | - Natalie Bell
- Center for Digital Health, Data and Analytics, Healthcare Terminology, Mayo Clinic, Rochester, Minnesota
| | - Abinash Virk
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota
| | - Paschalis Vergidis
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kelsey Jensen
- Department of Pharmacy, Mayo Clinic Health System, Austin, Minnesota
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Hart JH, Sakata T, Eve JR, Butler AM, Wallin A, Carman C, Atwood B, Srivastava R, Jones BE, Stenehjem EA, Dean NC. Diagnosis and Treatment of Pneumonia in Urgent Care Clinics: Opportunities for Improving Care. Open Forum Infect Dis 2024; 11:ofae096. [PMID: 38456194 PMCID: PMC10919392 DOI: 10.1093/ofid/ofae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 02/19/2024] [Indexed: 03/09/2024] Open
Abstract
Background Community-acquired pneumonia is a well-studied condition; yet, in the urgent care setting, patient characteristics and adherence to guideline-recommended care are poorly described. Within Intermountain Health, a nonprofit integrated US health care system based in Utah, more patients present to urgent care clinics (UCCs) than emergency departments (EDs) for pneumonia care. Methods We performed a retrospective cohort study 1 January 2019 through 31 December 2020 in 28 UCCs within Utah. We extracted electronic health record data for patients aged ≥12 years with ICD-10 pneumonia diagnoses entered by the bedside clinician, excluding patients with preceding pneumonia within 30 days or missing vital signs. We compared UCC patients with radiographic pneumonia (n = 4689), without radiographic pneumonia (n = 1053), without chest imaging (n = 1472), and matched controls with acute cough/bronchitis (n = 15 972). Additional outcomes were 30-day mortality and the proportion of patients with ED visits or hospital admission within 7 days after the index encounter. Results UCC patients diagnosed with pneumonia and possible/likely radiographic pneumonia by radiologist report had a mean age of 40 years and 52% were female. Almost all patients with pneumonia (93%) were treated with antibiotics, including those without radiographic confirmation. Hospital admissions and ED visits within 7 days were more common in patients with radiographic pneumonia vs patients with "unlikely" radiographs (6% vs 2% and 10% vs 6%, respectively). Observed 30-day all-cause mortality was low (0.26%). Patients diagnosed without chest imaging presented similarly to matched patients with cough/acute bronchitis. Most patients admitted to the hospital the same day after the UCC visit (84%) had an interim ED encounter. Pneumonia severity scores (pneumonia severity index, electronic CURB-65, and shock index) overestimated patient need for hospitalization. Conclusions Most UCC patients with pneumonia were successfully treated as outpatients. Opportunities to improve care include clinical decision support for diagnosing pneumonia with radiographic confirmation and development of pneumonia severity scores tailored to the UCC.
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Affiliation(s)
- James H Hart
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Theadora Sakata
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
- Healthcare Delivery Institute, Intermountain Health, Murray, Utah, USA
| | - Jacqueline R Eve
- Enterprise Analytics, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Allison M Butler
- Office of Research, Intermountain Medical Center, Murray, Utah, USA
| | - Anthony Wallin
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Chad Carman
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Brenda Atwood
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Health, Murray, Utah, USA
- Division of Pediatric Hospital Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Barbara E Jones
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
- Veterans Administration Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Edward A Stenehjem
- Division of Infectious Disease, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Nathan C Dean
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
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Krueger C, Alqurashi W, Barrowman N, Litwinska M, Le Saux N. The long and the short of pediatric emergency department antibiotic prescribing: A retrospective observational study. Am J Emerg Med 2024; 75:131-136. [PMID: 37950980 DOI: 10.1016/j.ajem.2023.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Most antibiotics prescribed to children are provided in the outpatient and emergency department (ED) settings, yet these prescribers are seldom engaged by antibiotic stewardship programs. We reviewed ED antibiotic prescriptions for three common infections to describe current prescribing practices. METHODS Prescription data between 2018 and 2021 were extracted from the electronic records of children discharged from the Children's Hospital of Eastern Ontario ED with urinary tract infection (UTI), community acquired pneumonia (CAP), and acute otitis media ≥2 years of age (AOM). Antibiotic choice, duration, as well as the provider's time in practice and training background were collected. Antibiotic durations were compared with Canadian guideline recommendations to assess concordance. Provider-level prescribing practices were analyzed using k-means cluster analysis. RESULTS 10,609 prescriptions were included: 2868 for UTI, 2958 for CAP, and 4783 for AOM. Guideline-concordant durations prescribed was generally high (UTI 84.9%, CAP 94.0%, AOM 52.8%), a large proportion of antibiotic-days prescribed were in excess of the minimally recommended duration for each infection (UTI 16.8%, 19.3%, AOM 25.5%). Cluster analysis yielded two clusters of prescribers, with those in one cluster more commonly prescribing durations at the lower end of recommended interval, and the others more commonly prescribing longer durations for all three infections reviewed. No statistically significant differences were found between clusters by career stage or training background. CONCLUSIONS While guideline-concordant antibiotic prescribing was generally high, auditing antibiotic prescriptions identified shifting prescribing towards the minimally recommended duration as a potential opportunity to reduce antibiotic use among children for these infections.
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Affiliation(s)
- Carsten Krueger
- Division of Infectious Diseases, Immunology & Allergy, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
| | - Waleed Alqurashi
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nicholas Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Maria Litwinska
- Business Intelligence Team, Information Services, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nicole Le Saux
- Division of Infectious Diseases, Immunology & Allergy, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Frost HM, Hersh AL, Hyun DY. Next Steps in Ambulatory Stewardship. Infect Dis Clin North Am 2023; 37:749-767. [PMID: 37640612 PMCID: PMC10592236 DOI: 10.1016/j.idc.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Most antibiotics are prescribed in ambulatory setting and at least 30% to 50% of these prescriptions are unnecessary. The use of antibiotics when not needed promotes the development of antibiotic resistant organisms and harms patients by placing them at risk for adverse drug events and Clostridioides difficile infections. National guidelines recommend that health systems implement antibiotic stewardship programs in ambulatory settings. However, uptake of stewardship in ambulatory setting has remained low. This review discusses the current state of ambulatory stewardship in the United States, best practices for the successful implementation of effective ambulatory stewardship programs, and future directions to improve antibiotic use in ambulatory settings.
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Affiliation(s)
- Holly M Frost
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Adam L Hersh
- Division of Infectious Disease, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT 8413, USA
| | - David Y Hyun
- Antimicrobial Resistance Project, The Pew Charitable Trusts, 901 East Street NW, Washington, DC 20004-2008, USA
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Ong’uti SK, Artandi M, Betts B, Weng Y, Desai M, Lentz C, Nelligan I, Ha DR, Holubar MK. A quality-improvement approach to urgent-care antibiotic stewardship for respiratory tract infections during the COVID-19 pandemic: Lessons learned. Infect Control Hosp Epidemiol 2023; 44:2022-2027. [PMID: 36815249 PMCID: PMC10445104 DOI: 10.1017/ice.2023.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 02/24/2023]
Abstract
OBJECTIVE We investigated a decrease in antibiotic prescribing for respiratory illnesses in 2 academic urgent-care clinics during the coronavirus disease 2019 (COVID-19) pandemic using semistructured clinician interviews. METHODS We conducted a quality-improvement project from November 2020 to May 2021. We investigated provider antibiotic decision making using a mixed-methods explanatory design including interviews. We analyzed transcripts using a thematic framework approach to identify emergent themes. Our performance measure was antibiotic prescribing rate (APR) for encounters with respiratory diagnosis billing codes. We extracted billing and prescribing data from the electronic medical record and assessed differences using run charts, p charts and generalized linear regression. RESULTS We observed significant reductions in the APR early during the COVID-19 pandemic (relative risk [RR], 0.20; 95% confidence interval [CI], 0.17-0.25), which was maintained over the study period (P < .001). The average APRs were 14% before the COVID-19 pandemic, 4% during the QI project, and 7% after the project. All providers prescribed less antibiotics for respiratory encounters during COVID-19, but only 25% felt their practice had changed. Themes from provider interviews included changing patient expectations and provider approach to respiratory encounters during COVID-19, the impact of increased telemedicine encounters, and the changing epidemiology of non-COVID-19 respiratory infections. CONCLUSIONS Our findings suggest that the decrease in APR was likely multifactorial. The average APR decreased significantly during the pandemic. Although the APR was slightly higher after the QI project, it did not reach prepandemic levels. Future studies should explore how these factors, including changing patient expectations, can be leveraged to improve urgent-care antibiotic stewardship.
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Affiliation(s)
| | - Maja Artandi
- Express Care, Stanford Health Care, Stanford, California
| | - Brooke Betts
- Department of Pharmacy, Stanford Health Care, Stanford, California
| | - Yingjie Weng
- Quantitative Sciences Unit, Stanford University School of Medicine
| | - Manisha Desai
- Quantitative Sciences Unit, Stanford University School of Medicine
- Division of Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, California
| | | | - Ian Nelligan
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - David R. Ha
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California
| | - Marisa K. Holubar
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California
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Ilges D, Jensen K, Draper E, Dierkhising R, Prigge KA, Vergidis P, Virk A, Stevens RW. Evaluation of Multisite Programmatic Bundle to Reduce Unnecessary Antibiotic Prescribing for Respiratory Infections: A Retrospective Cohort Study. Open Forum Infect Dis 2023; 10:ofad585. [PMID: 38111752 PMCID: PMC10727194 DOI: 10.1093/ofid/ofad585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/16/2023] [Indexed: 12/20/2023] Open
Abstract
Background The aim of this study was to evaluate the frequency of unnecessary antibiotic prescribing for Tier 3 upper respiratory infection (URI) syndromes across the Mayo Clinic Enterprise before and after a multifaceted antimicrobial stewardship intervention, and to determine ongoing factors associated with antibiotic prescribing and repeat respiratory healthcare contact in the postintervention period. Methods This was a quasi-experimental, pre/post, retrospective cohort study from 1 January 2019 through 31 December 2022, with 12-month washout during implementation from 1 July 2020 through 30 June 2021. All outpatient encounters, adult and pediatric, from primary care, urgent care, and emergency medicine specialties with a Tier 3 URI diagnosis were included. The intervention was a multifaceted outpatient antibiotic stewardship bundle. The primary outcome was the rate of antibiotic prescribing in Tier 3 encounters. Secondary outcomes included 14-day repeat healthcare contact for respiratory indications and factors associated with persistent unnecessary prescribing. Results A total of 165 658 Tier 3 encounters, 96 125 in the preintervention and 69 533 in the postintervention period, were included. Following intervention, the prescribing rate for Tier 3 encounters decreased from 21.7% to 11.2% (P < .001). Repeat 14-day respiratory healthcare contact in the no antibiotic group was lower postintervention (9.9.% vs 9.4%; P = .004). Multivariable models indicated that increasing patient age, Charlson comorbidity index, and primary diagnosis selected were the most important factors associated with persistent unnecessary antibiotic prescribing. Conclusions Outpatient antibiotic stewardship initiatives can reduce unnecessary antibiotic prescribing for Tier 3 URIs without increasing repeat respiratory healthcare contact. Advancing age and number of comorbidities remain risk factors for persistent unnecessary antibiotic prescribing.
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Affiliation(s)
- Dan Ilges
- Department of Pharmacy Services, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Kelsey Jensen
- Department of Pharmacy Services, Mayo Clinic Health System–Southeast Minnesota, Austin, Minnesota, USA
| | - Evan Draper
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota, USA
| | - Ross Dierkhising
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Paschalis Vergidis
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abinash Virk
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan W Stevens
- Department of Pharmacy Services, Mayo Clinic Health System–Southeast Minnesota, Austin, Minnesota, USA
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Seibert AM, Schenk C, Buckel WR, Patel PK, Fino N, Stanfield V, Hersh AL, Stenehjem E. Beyond antibiotic prescribing rates: first-line antibiotic selection, prescription duration, and associated factors for respiratory encounters in urgent care. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e146. [PMID: 37771738 PMCID: PMC10523551 DOI: 10.1017/ash.2023.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/03/2023] [Accepted: 07/09/2023] [Indexed: 09/30/2023]
Abstract
Objective Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis. Design Retrospective cohort study. Participants All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019-June 30th, 2020. Methods Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5-10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration. Results Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non-first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]). Conclusions First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts.
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Affiliation(s)
- Allan M. Seibert
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
| | | | | | - Payal K. Patel
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Valoree Stanfield
- Office of Patient Experience, Intermountain Health, Salt Lake City, UT, USA
| | - Adam L. Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Eddie Stenehjem
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
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McIntyre MT, Saha S, Morris AM, Lapointe-Shaw L, Tang T, Weinerman A, Fralick M, Agarwal A, Verma A, Razak F. Physician antimicrobial prescribing and patient outcomes on general medical wards: a multicentre retrospective cohort study. CMAJ 2023; 195:E1065-E1074. [PMID: 37604522 PMCID: PMC10442238 DOI: 10.1503/cmaj.221732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Variability in antimicrobial prescribing may indicate an opportunity for improvement in antimicrobial use. We sought to measure physician-level antimicrobial prescribing in adult general medical wards, assess the contribution of patient-level factors to antimicrobial prescribing and evaluate the association between antimicrobial prescribing and clinical outcomes. METHODS Using the General Medicine Inpatient Initiative (GEMINI) database, we conducted a retrospective cohort study of physician-level volume and spectrum of antimicrobial prescribing in adult general medical wards in 4 academic teaching hospitals in Toronto, Ontario, between April 2010 and December 2019. We stratified physicians into quartiles by hospital site based on volume of antimicrobial prescribing (days of therapy per 100 patient-days and antimicrobial-free days) and antibacterial spectrum (modified spectrum score). The modified spectrum score assigns a value to each antibacterial agent based on the breadth of coverage. We assessed patient-level differences among physician quartiles using age, sex, Laboratory-based Acute Physiology Score, discharge diagnosis and Charlson Comorbidity Index. We evaluated the association of clinical outcomes (in-hospital 30-day mortality, length of stay, intensive care unit [ICU] transfer and hospital readmission) with antimicrobial volume and spectrum using multilevel modelling. RESULTS The cohort consisted of 124 physicians responsible for 124 158 hospital admissions. The median physician-level volume of antimicrobial prescribing was 56.1 (interquartile range 51.7-67.5) days of therapy per 100 patient-days. We did not find any differences in baseline patient characteristics by physician prescribing quartile. The difference in mean prescribing between quartile 4 and quartile 1 was 15.8 days of therapy per 100 patient-days (95% confidence interval [CI] 9.6-22.0), representing 30% higher antimicrobial prescribing in the fourth quartile than the first quartile. Patient in-hospital deaths, length of stay, ICU transfer and hospital readmission did not differ by physician quartile. In-hospital mortality was higher among patients cared for by prescribers with higher modified spectrum scores (odds ratio 1.13, 95% CI 1.04-1.24). INTERPRETATION We found that physician-level variability in antimicrobial prescribing was not associated with differences in patient characteristics or outcomes in academic general medicine wards. These findings provide support for considering the lowest quartile of physician antimicrobial prescribing within each hospital as a target for antimicrobial stewardship.
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Affiliation(s)
- Mark T McIntyre
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont.
| | - Sudipta Saha
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Andrew M Morris
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Lauren Lapointe-Shaw
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Terence Tang
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Adina Weinerman
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Michael Fralick
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Arnav Agarwal
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Amol Verma
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Fahad Razak
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
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11
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Hassan SK, Dahmash EZ, Madi T, Tarawneh O, Jomhawi T, Alkhob W, Ghanem R, Halasa Z. Four years after the implementation of antimicrobial stewardship program in Jordan: evaluation of program's core elements. Front Public Health 2023; 11:1078596. [PMID: 37325334 PMCID: PMC10262748 DOI: 10.3389/fpubh.2023.1078596] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
Objectives To combat antimicrobial resistance, the World Health Organization (WHO) urged healthcare organizations in Low- and Middle-Income Countries (LMICs) to implement the core elements of the antimicrobial stewardship (AMS) programs. In response, Jordan took action and developed a national antimicrobial resistance action plan (NAP) in 2017 and commenced the AMS program in all healthcare facilities. It is paramount to evaluate the efforts to implement the AMS programs and understand the challenges of implementing a sustainable and effective program, in Low-Middle Income Country (LMIC) contexts. Therefore, the aim of this study was to appraise the compliance of public hospitals in Jordan to the WHO core elements of effective AMS programs after 4 years of commencement. Methods A cross-sectional study in public hospitals in Jordan, using the WHO AMS program core elements for LMICs was carried out. The questionnaire comprised 30 questions that covered the program's six core elements: leadership commitment, accountability and responsibility, AMS actions, education and training, monitoring, and evaluation, and reporting and feedback. A five-point Likert scale was employed for each question. Results A total of 27 public hospitals participated, with a response rate of 84.4%. Adherence to core elements ranged from (53%) in the leadership commitment domain to (72%) for AMS procedure application (actions). Based on the mean score, there was no significant difference between hospitals according to location, size, and specialty. The most neglected core elements that emerged as top priority areas were the provision of financial support, collaboration, access, as well as monitoring and evaluation. Conclusion The current results revealed significant shortcomings in the AMS program in public hospitals despite 4 years of implementation and policy support. Most of the core elements of the AMS program were below average, which requires hospital leadership commitment, and multifaceted collaborative actions from the concerned stakeholders in Jordan.
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Affiliation(s)
- Samar Khaled Hassan
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Eman Zmaily Dahmash
- Department of Chemical and Pharmaceutical Sciences, School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Kingston upon Thames, United Kingdom
| | - Thaira Madi
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Omar Tarawneh
- Department of Consultation, Healthcare Accreditation Council, Amman, Jordan
| | - Tuqa Jomhawi
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Worood Alkhob
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Rola Ghanem
- Laboratory Directorate, Ministry of Health, Amman, Jordan
| | - Zina Halasa
- Clinical Pharmacy Directorate, Ministry of Health, Amman, Jordan
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12
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Stenehjem E, Wallin A, Willis P, Kumar N, Seibert AM, Buckel WR, Stanfield V, Brunisholz KD, Fino N, Samore MH, Srivastava R, Hicks LA, Hersh AL. Implementation of an Antibiotic Stewardship Initiative in a Large Urgent Care Network. JAMA Netw Open 2023; 6:e2313011. [PMID: 37166794 PMCID: PMC10176123 DOI: 10.1001/jamanetworkopen.2023.13011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/19/2023] [Indexed: 05/12/2023] Open
Abstract
Importance Urgent Care (UC) encounters result in more inappropriate antibiotic prescriptions than other outpatient setting. Few stewardship interventions have focused on UC. Objective To evaluate the effectiveness of an antibiotic stewardship initiative to reduce antibiotic prescribing for respiratory conditions in a UC network. Design, Setting, and Participants This quality improvement study conducted in a UC network with 38 UC clinics and 1 telemedicine clinic included 493 724 total UC encounters. The study compared the antibiotic prescribing rates of all UC clinicians who encountered respiratory conditions for a 12-month baseline period (July 1, 2018, through June 30, 2019) with an intervention period (July 1, 2019, through June 30, 2020). A sustainability period (July 1, 2020, through June 30, 2021) was added post hoc. Interventions Stewardship interventions included (1) education for clinicians and patients, (2) electronic health record (EHR) tools, (3) a transparent clinician benchmarking dashboard, and (4) media. Occurring independently but concurrent with the interventions, a stewardship measure was introduced by UC leadership into the quality measures, including a financial incentive. Main Outcomes and Measures The primary outcome was the percentage of UC encounters with an antibiotic prescription for a respiratory condition. Secondary outcomes included antibiotic prescribing when antibiotics were not indicated (tier 3 encounters) and first-line antibiotics for acute otitis media, sinusitis, and pharyngitis. Interrupted time series with binomial generalized estimating equations were used to compare periods. Results The baseline period included 207 047 UC encounters for respiratory conditions (56.8% female; mean [SD] age, 30.0 [21.4] years; 92.0% White race); the intervention period included 183 893 UC encounters (56.4% female; mean [SD] age, 30.7 [20.8] years; 91.2% White race). Antibiotic prescribing for respiratory conditions decreased from 47.8% (baseline) to 33.3% (intervention). During the initial intervention month, a 22% reduction in antibiotic prescribing occurred (odds ratio [OR], 0.78; 95% CI, 0.71-0.86). Antibiotic prescriptions decreased by 5% monthly during the intervention (OR, 0.95; 95% CI, 0.94-0.96). Antibiotic prescribing for tier 3 encounters decreased by 47% (OR, 0.53; 95% CI, 0.44-63), and first-line antibiotic prescriptions increased by 18% (OR, 1.18; 95% CI, 1.09-1.29) during the initial intervention month. Antibiotic prescriptions for tier 3 encounters decreased by an additional 4% each month (OR, 0.96; 95% CI, 0.94-0.98), whereas first-line antibiotic prescriptions did not change (OR, 1.00; 95% CI, 0.99-1.01). Antibiotic prescribing for respiratory conditions remained stable in the sustainability period. Conclusions and relevance The findings of this quality improvement study indicated that a UC antibiotic stewardship initiative was associated with decreased antibiotic prescribing for respiratory conditions. This study provides a model for UC antibiotic stewardship.
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Affiliation(s)
- Edward Stenehjem
- Division of Infectious Diseases and Epidemiology, Intermountain Health, Salt Lake City, Utah
| | - Anthony Wallin
- Intermountain Urgent Care, Intermountain Health, Salt Lake City, Utah
| | - Park Willis
- Intermountain Urgent Care, Intermountain Health, Salt Lake City, Utah
| | - Naresh Kumar
- Office of Research, Intermountain Health, Salt Lake City, Utah
| | - Allan M. Seibert
- Division of Infectious Diseases and Epidemiology, Intermountain Health, Salt Lake City, Utah
| | - Whitney R. Buckel
- System Pharmacy Services, Intermountain Health, Salt Lake City, Utah
| | - Valoree Stanfield
- Division of Infectious Diseases and Epidemiology, Intermountain Health, Salt Lake City, Utah
| | | | - Nora Fino
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City
| | - Matthew H. Samore
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City
| | - Rajendu Srivastava
- Intermountain Health Delivery Institute, Intermountain Health, Salt Lake City, Utah
- Department of Pediatrics, Division of Pediatric Inpatient Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lauri A. Hicks
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adam L. Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City
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13
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Butler AM, Brown DS, Newland JG, Nickel KB, Sahrmann JM, O’Neil CA, Olsen MA, Zetts RM, Hyun DY, Durkin MJ. Comparative Safety and Attributable Healthcare Expenditures Following Inappropriate Versus Appropriate Outpatient Antibiotic Prescriptions Among Adults With Upper Respiratory Infections. Clin Infect Dis 2023; 76:986-995. [PMID: 36350187 PMCID: PMC10226742 DOI: 10.1093/cid/ciac879] [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: 09/02/2022] [Revised: 10/28/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections. METHODS We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type. RESULTS Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections. CONCLUSIONS Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.
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Affiliation(s)
- Anne M Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Derek S Brown
- Brown School, Washington University, St. Louis, Missouri, USA
| | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, St. Louis, Missouri, USA
| | - Katelin B Nickel
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John M Sahrmann
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Caroline A O’Neil
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Margaret A Olsen
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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14
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Medvedeva N, Ong’uti S, Hersh AL, Chang A, Mui E, Stenehjem E, Ha D, Holubar M. Validity of Coronavirus Disease 2019 International Classification of Diseases, Tenth Revision in the Urgent Care Setting and Impact on Antibiotic Prescribing Rates. Open Forum Infect Dis 2023; 10:ofad010. [PMID: 36751646 PMCID: PMC9897297 DOI: 10.1093/ofid/ofad010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/07/2023] [Indexed: 01/11/2023] Open
Abstract
We validated different coronavirus disease 2019 (COVID-19) International Classification of Diseases, Tenth Edition (ICD-10) encounter definitions across 2 urgent care clinics. Sensitivity of definitions varied throughout the pandemic. Inclusion of COVID-19 and COVID-19-like illness (CLI) ICD-10s rendered highest sensitivity but lowest specificity. Antibiotic prescribing rates were low for COVID-19 ICD-10 encounters, increasing with CLI ICD-10 encounters.
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Affiliation(s)
- Natalia Medvedeva
- Correspondence: Natalia Medvedeva, MD, 300 Pasteur Drive Lane Bldg., Room L123 MC5107, Stanford, CA, USA 94304 (). Sharon Ong’uti, MD, MPH, 1161 21st Avenue South, A2200 MCN, Nashville, TN, USA 37232 ()
| | - Sharon Ong’uti
- Correspondence: Natalia Medvedeva, MD, 300 Pasteur Drive Lane Bldg., Room L123 MC5107, Stanford, CA, USA 94304 (). Sharon Ong’uti, MD, MPH, 1161 21st Avenue South, A2200 MCN, Nashville, TN, USA 37232 ()
| | - Adam L Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Amy Chang
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Emily Mui
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California, USA,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Edward Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - David Ha
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California, USA,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Marisa Holubar
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA,Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, Stanford, California, USA
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15
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Mannix MK, Vandehei T, Ulrich E, Black TA, Wrotniak B, Islam S. Pediatric Antibiotic Prescribing and Utilization Practices for RTIs at Private Urgent Care Centers. Clin Pediatr (Phila) 2022; 61:830-839. [PMID: 35762069 DOI: 10.1177/00099228221106554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Data on pediatric antibiotic prescribing and utilization practices at urgent care centers (UCC) remain limited. In this study, an electronic medical record-based review of UCC encounters for respiratory tract infections (RTI) of patients belonging to one mid-sized pediatric practice was performed. Antibiotic prescribing and guideline adherence were compared between UCCs that were staffed exclusively by pediatric-trained providers to those staffed otherwise. Of a total of 457 RTI visits, 330 (72%) occurred at the pediatric UCC. Across all bacterial RTIs, 82% of encounters at the pediatric UCC were guideline-adherent versus 59% at nonpediatric UCCs (P < .001). At nonpediatric UCCs, pharyngitis was the most common RTI encounter diagnosis (40%), and full streptococcal management guideline adherence was 41%. While 93% of RTI-UCC encounters for <2 years were at pediatric UCCs, the majority of children >10 presented to nonpediatric UCCs. RTI guideline education to UCCs should be a focus of ambulatory stewardship efforts.
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Affiliation(s)
| | - Thor Vandehei
- Division of Pediatric Medical Education, Department of Pediatrics, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Emily Ulrich
- Department of Pediatrics, Prisma Health Children's Hospital - Midlands, University of South Carolina School of Medicine, Columbia, SC, USA
| | - Thomas A Black
- Department of Pediatrics, Prisma Health Children's Hospital - Midlands, University of South Carolina School of Medicine, Columbia, SC, USA
| | - Brian Wrotniak
- Department of Pediatrics, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Shamim Islam
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University at Buffalo, State University of New York, Buffalo, NY, USA
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16
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Seibert AM, Hersh AL, Patel PK, Matheu M, Stanfield V, Fino N, Hicks LA, Tsay SV, Kabbani S, Stenehjem E. Urgent-care antibiotic prescribing: An exploratory analysis to evaluate health inequities. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e184. [PMID: 36406162 PMCID: PMC9672912 DOI: 10.1017/ash.2022.329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 06/16/2023]
Abstract
Healthcare disparities and inequities exist in a variety of environments and manifest in diagnostic and therapeutic measures. In this commentary, we highlight our experience examining our organization's urgent care respiratory encounter antibiotic prescribing practices. We identified differences in prescribing based on several individual characteristics including patient age, race, ethnicity, preferred language, and patient and/or clinician gender. Our approach can serve as an electronic health record (EHR)-based methodology for disparity and inequity audits in other systems and for other conditions.
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Affiliation(s)
- Allan M. Seibert
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
| | - Adam L. Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Payal K. Patel
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
| | - Michelle Matheu
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
| | | | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Lauri A. Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sharon V. Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Edward Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
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17
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Arensman Hannan KN, Draper EW, Uecker-Bezdicek KA, Gomez-Urena EO, Jensen KL. Identification of priority targets for intervention in outpatient antimicrobial stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e133. [PMID: 36483403 PMCID: PMC9726512 DOI: 10.1017/ash.2022.277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 06/17/2023]
Abstract
A multimodal antimicrobial stewardship intervention was associated with a decrease in antibiotic prescribing for targeted non-coronavirus disease 2019 (COVID-19) upper respiratory infections from 27.6% in 2019 to 7.6% in 2021. We describe our approach to prioritizing departments for 3 levels of interventions in the setting of limited stewardship personnel.
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Affiliation(s)
| | - Evan W. Draper
- Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | | | - Eric O. Gomez-Urena
- Division of Infectious Diseases, Mayo Clinic Health System, Mankato, Minnesota
| | - Kelsey L. Jensen
- Department of Pharmacy Services, Mayo Clinic Health System, Austin, Minnesota
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18
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Danino D, Ben-Shimol S, Sharf A, Greenberg D, Givon-Lavi N. Remote Versus In-person Outpatient Clinic Visits and Antibiotic Use Among Children During the COVID-19 Pandemic. Pediatr Infect Dis J 2022; 41:636-641. [PMID: 35544725 PMCID: PMC9281428 DOI: 10.1097/inf.0000000000003570] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The proportion of remote clinic visits was expected to increase among children during the COVID-19 pandemic which might result in antibiotic overuse. METHODS In southern Israel, 2 ethnic groups, Jewish and Bedouin, live side-by-side. Computerized data on visits for children <18 years were examined from clinics with ≥50 insured children, active both pre-COVID-19 and during the COVID-19 pandemic. Visits were divided into in-person and remote. Monthly infectious diagnoses and dispensed antibiotic prescription rates were calculated by age (<5, 5-17 years) and ethnic groups. Mean monthly rates of 2 parallel seasons (pre-COVID-19 and COVID-19 periods) were compared. RESULTS Overall 2,120,253 outpatient clinic visits were recorded. Remote clinic visit rates (per 1000 children) increased from 97.04 and 33.86 in the pre-COVID-19 to 179.75 and 50.05 in the COVID-19 period in Jewish and Bedouin children, respectively ( P < 0.01) along with a reduction of in-person visit rates in both populations. Comparing pre-COVID-19 and COVID-19 periods, the rates of overall infectious diagnoses in remote visits increased. Nevertheless, dispensed antibiotic prescription rates in remote visits (per 1000 visits) remained unchanged (9.84 vs. 8.67, P = 0.70, in the Jewish population and 14.32 vs. 14.17, P = 1.00, in the Bedouin population in the pre-COVID-19 and COVID-19 periods, respectively) with a similar distribution of antibiotic categories. CONCLUSIONS COVID-19 pandemic resulted in an expansion of remote visits of children <18 years with an increase in infectious diagnoses. However, remote dispensed antibiotic prescription rates remained unchanged. These dynamics were more accentuated in Jewish children, characterized by higher socio-economic conditions, compared to Bedouin children.
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Affiliation(s)
- Dana Danino
- From the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- The Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
| | - Shalom Ben-Shimol
- From the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- The Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
| | - Amir Sharf
- Economics and Data Analysis, Clalit HMO South district, Israel
| | - David Greenberg
- From the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- The Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
| | - Noga Givon-Lavi
- From the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- The Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
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19
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Weichman BM, Bushman AM, Rogers KL, Rosa R. Impact of fluoroquinolone cascade reporting of urine samples on antibiotic prescribing rates in a network of urgent care clinics. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e97. [PMID: 36483384 PMCID: PMC9726480 DOI: 10.1017/ash.2022.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 06/17/2023]
Abstract
Cascade reporting is an antimicrobial stewardship strategy that has been successfully implemented in inpatient settings, but evidence of its impact on outpatient settings is scarce. We report on the impact on fluroquinolone prescribing at a network of urgent care clinics following the implementation of cascade reporting of Enterobacterales in urine cultures.
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Affiliation(s)
| | | | | | - Rossana Rosa
- Department of Medicine, University of Iowa-Des Moines, Des Moines, Iowa
- Infectious Diseases Service, UnityPoint Health, Des Moines, Iowa (Present affiliations: Microbiology Laboratory, Nebraska Medicine, Omaha, Nebraska [K.L.R.] and Department of Quality and Patient Safety, Jackson Health System, Miami, Florida [R.R.])
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20
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Seibert AM, Stenehjem E, Wallin A, Willis P, Brunisholz K, Kumar N, Stanfield V, Fino N, Shapiro DJ, Hersh A. Rapid streptococcal pharyngitis testing and antibiotic prescribing before and during the coronavirus disease 2019 (COVID-19) pandemic. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e80. [PMID: 36483435 PMCID: PMC9726542 DOI: 10.1017/ash.2022.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 06/17/2023]
Affiliation(s)
- Allan M. Seibert
- Office of Research, Intermountain Healthcare, Salt Lake City, Utah
| | - Edward Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Anthony Wallin
- Intermountain Urgent Care, Intermountain Healthcare, Salt Lake City, Utah
| | - Park Willis
- Intermountain Urgent Care, Intermountain Healthcare, Salt Lake City, Utah
| | - Kim Brunisholz
- Healthcare Delivery Institute Intermountain Healthcare, Salt Lake City, Utah
| | - Naresh Kumar
- Office of Research, Intermountain Healthcare, Salt Lake City, Utah
| | | | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Daniel J. Shapiro
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Adam Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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21
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Ha D, Ong’uti S, Chang A, Mui E, Nelligan I, Betts B, Lentz C, Alegria W, Fox E, Meng L, Stenehjem E, Hersh AL, Deresinski S, Artandi M, Holubar M. Sustained Reduction in Urgent Care Antibiotic Prescribing During the COVID-19 pandemic: An Academic Medical Center’s Experience. Open Forum Infect Dis 2022; 9:ofab662. [PMID: 35111874 PMCID: PMC8802794 DOI: 10.1093/ofid/ofab662] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022] Open
Abstract
We compared antibiotic prescribing before and during the coronavirus disease 2019 (COVID-19) pandemic at 2 academic urgent care clinics and found a sustained decrease in prescribing driven by respiratory encounters and despite transitioning to telemedicine. Antibiotics were rarely prescribed during encounters for COVID-19 or COVID-19 symptoms. COVID-19 revealed opportunities for outpatient stewardship programs.
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Affiliation(s)
- David Ha
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, California, USA
| | - Sharon Ong’uti
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, California, USA
| | - Amy Chang
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, California, USA
| | - Emily Mui
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, California, USA
| | - Ian Nelligan
- Primary Care and Population Health, Stanford, California, USA
| | - Brooke Betts
- Department of Pharmacy, Stanford Health Care, Stanford, California, USA
| | | | - William Alegria
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, California, USA
| | - Emily Fox
- Department of Pharmacy, Stanford Health Care, Stanford, California, USA
| | - Lina Meng
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, California, USA
| | - Edward Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Adam L Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Stanley Deresinski
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, California, USA
| | - Maja Artandi
- Express Care, Stanford Health Care, Stanford, California, USA
| | - Marisa Holubar
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, California, USA
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22
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Antibiotic prescribing for acute infections in synchronous telehealth consultations: a systematic review and meta-analysis. BJGP Open 2021; 5:BJGPO.2021.0106. [PMID: 34497096 PMCID: PMC9447298 DOI: 10.3399/bjgpo.2021.0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/24/2021] [Indexed: 11/15/2022] Open
Abstract
Background Antibiotic overprescribing is a major concern that contributes to the problem of antibiotic resistance. Aim To assess the effect on antibiotic prescribing in primary care of telehealth (TH) consultations compared with face-to-face (F2F). Design & setting Systematic review and meta-analysis of adult or paediatric patients with a history of a community-acquired acute infection (respiratory, urinary, or skin and soft tissue). Studies were included that compared synchronous TH consultations (phone or video-based) to F2F consultations in primary care. Method PubMed, Embase, Cochrane CENTRAL (inception–2021), clinical trial registries and citing–cited references of included studies were searched. Two review authors independently screened the studies and extracted the data. Results Thirteen studies were identified. The one small randomised controlled trial (RCT) found a non-significant 25% relative increase in antibiotic prescribing in the TH group. The remaining 10 were observational studies but did not control well for confounding and, therefore, were at high risk of bias. When pooled by specific infections, there was no consistent pattern. The six studies of sinusitis — including one before–after study — showed significantly less prescribing for acute rhinosinusitis in TH consultations, whereas the two studies of acute otitis media showed a significant increase. Pharyngitis, conjunctivitis, and urinary tract infections showed non-significant higher prescribing in the TH group. Bronchitis showed no change in prescribing. Conclusion The impact of TH on prescribing appears to vary between conditions, with more increases than reductions. There is insufficient evidence to draw strong conclusions, however, and higher quality research is urgently needed.
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23
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Jensen KL, Rivera CG, Draper EW, Ausman SE, Anderson BJ, Dinnes LM, Christopherson DR, Prigge KA, Rajapakse NS, Vergidis P, Virk A, Stevens RW. From concept to reality: Building an ambulatory antimicrobial stewardship program. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Kelsey L. Jensen
- Department of Pharmacy Services Mayo Clinic Health System Austin Minnesota USA
| | | | - Evan W. Draper
- Department of Pharmacy Services Mayo Clinic Rochester Minnesota USA
| | - Sara E. Ausman
- Department of Pharmacy Services Mayo Clinic Health System Eau Claire Wisconsin USA
| | | | - Laura M. Dinnes
- Department of Pharmacy Services Mayo Clinic Rochester Minnesota USA
| | | | | | | | | | - Abinash Virk
- Division of Infectious Diseases Mayo Clinic Rochester Minnesota USA
| | - Ryan W. Stevens
- Department of Pharmacy Services Mayo Clinic Rochester Minnesota USA
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24
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Damschroder LJ, Knighton AJ, Griese E, Greene SM, Lozano P, Kilbourne AM, Buist DSM, Crotty K, Elwy AR, Fleisher LA, Gonzales R, Huebschmann AG, Limper HM, Ramalingam NS, Wilemon K, Ho PM, Helfrichfcr CD. Recommendations for strengthening the role of embedded researchers to accelerate implementation in health systems: Findings from a state-of-the-art (SOTA) conference workgroup. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 8 Suppl 1:100455. [PMID: 34175093 DOI: 10.1016/j.hjdsi.2020.100455] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 05/15/2020] [Accepted: 07/14/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND Traditional research approaches do not promote timely implementation of evidence-based innovations (EBIs) to benefit patients. Embedding research within health systems can accelerate EBI implementation by blending rigorous methods with practical considerations in real-world settings. A state-of-the-art (SOTA) conference was convened in February 2019 with five workgroups that addressed five facets of embedded research and its potential to impact healthcare. This article reports on results from the workgroup focused on how embedded research programs can be implemented into heath systems for greatest impact. METHODS Based on a pre-conference survey, participants indicating interest in accelerating implementation were invited to participate in the SOTA workgroup. Workgroup participants (N = 26) developed recommendations using consensus-building methods. Ideas were grouped by thematic clusters and voted on to identify top recommendations. A summary was presented to the full SOTA membership. Following the conference, the workgroup facilitators (LJD, CDH, NR) summarized workgroup findings, member-checked with workgroup members, and were used to develop recommendations. RESULTS The workgroup developed 12 recommendations to optimize impact of embedded researchers within health systems. The group highlighted the tension between "ROI vs. R01" goals-where health systems focus on achieving return on their investments (ROI) while embedded researchers focus on obtaining research funding (R01). Recommendations are targeted to three key stakeholder groups: researchers, funders, and health systems. Consensus for an ideal foundation to support optimal embedded research is one that (1) maximizes learning; (2) aligns goals across all 3 stakeholders; and (3) implements EBIs in a consistent and timely fashion. CONCLUSIONS Four cases illustrate a variety of ways that embedded research can be structured and conducted within systems, by demonstrating key embedded research values to enable collaborations with academic affiliates to generate actionable knowledge and meaningfully accelerate implementation of EBIs to benefit patients. IMPLICATIONS Embedded research approaches have potential for transforming health systems and impacting patient health. Accelerating embedded research should be a focused priority for funding agencies to maximize a collective return on investment.
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Affiliation(s)
- Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd. Building 16, Floor 3, (152), Ann Arbor, MI, 48105, USA.
| | - Andrew J Knighton
- Healthcare Delivery Institute, Intermountain Healthcare, 5026 South State Street, 3rd Floor, Murray, UT, 84107, USA.
| | - Emily Griese
- Sanford Research, Sanford Health, 2301 E 60th Street, N Sioux Falls, SD, 57106, USA.
| | - Sarah M Greene
- Health Care Systems Research Network, 1249 NE 89th Street, Seattle, WA, 98115, USA.
| | - Paula Lozano
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.
| | - Amy M Kilbourne
- Quality Enhancement Research Initiative (QUERI), U.S. Dept of Veterans Affairs, 810 N Vermont Avenue (10X2), Washington, DC, 20420, USA; Learning Health Science, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Bldg 16 Ann Arbor, MI, 48198, USA.
| | - Diana S M Buist
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.
| | - Karen Crotty
- RTI International, 3040 E. Cornwallis Road, Hobbs 139 P.O. Box 12194, Durham, NC, 27709, USA.
| | - A Rani Elwy
- VA Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road (152), Bedford, MA, 01730, USA; Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Box G-BH, Providence, RI, 02912, USA.
| | - Lee A Fleisher
- Department of Anesthesiology and Critical Care, Leonard Davis Institute of Health Economics, University of Pennsylvania, 3400 Spruce Street, Dulles 680, Philadelphia, PA, 19104, USA.
| | - Ralph Gonzales
- Division of General Internal Medicine, Department of Medicine, UCSF, 350 Parnassus Avenue, Box 0361, San Francisco, CA, 94117-0361, USA.
| | - Amy G Huebschmann
- University of Colorado (CU) School of Medicine, Department of Medicine, Division of General Internal Medicine, 12631 E. 17th Ave., Mailstop, B180, Aurora, CO, 80045, USA.
| | - Heather M Limper
- Vanderbilt University Medical Center, 2525 West End Ave, Nashville, TN, 37203, USA.
| | - NithyaPriya S Ramalingam
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Park Rd, Portland, 97239, USA.
| | - Katherine Wilemon
- 680 East Colorado Boulevard, Suite #180, Pasadena, CA 91101-6144, USA.
| | - P Michael Ho
- Cardiology Section, Rocky Mountain Regional VA Medical Center, 1700 N. Wheeling St, Aurora, CO 80045, USA.
| | - Christian D Helfrichfcr
- Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, 1660 South Columbian Way, S-152, Seattle, WA, 98108, USA.
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25
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Inappropriate outpatient antibiotic use in children insured by Kentucky Medicaid. Infect Control Hosp Epidemiol 2021; 43:582-588. [PMID: 33975663 DOI: 10.1017/ice.2021.177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe risk factors associated with inappropriate antibiotic prescribing to children. DESIGN Cross-sectional, retrospective analysis of antibiotic prescribing to children, using Kentucky Medicaid medical and pharmacy claims data, 2017. PARTICIPANTS Population-based sample of pediatric Medicaid patients and providers. METHODS Antibiotic prescriptions were identified from pharmacy claims and used to describe patient and provider characteristics. Associated medical claims were identified and linked to assign diagnoses. An existing classification scheme was applied to determine appropriateness of antibiotic prescriptions. RESULTS Overall, 10,787 providers wrote 779,813 antibiotic prescriptions for 328,515 children insured by Kentucky Medicaid in 2017. Moreover, 154,546 (19.8%) of these antibiotic prescriptions were appropriate, 358,026 (45.9%) were potentially appropriate, 163,654 (21.0%) were inappropriate, and 103,587 (13.3%) were not associated with a diagnosis. Half of all providers wrote 12 prescriptions or less to Medicaid children. The following child characteristics were associated with inappropriate antibiotic prescribing: residence in a rural area (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07-1.1), having a visit with an inappropriate prescriber (OR, 4.15; 95% CI, 4.1-4.2), age 0-2 years (OR, 1.39; 95% CI, 1.37-1.41), and presence of a chronic condition (OR, 1.31; 95% CI, 1.28-1.33). CONCLUSIONS Inappropriate antibiotic prescribing to Kentucky Medicaid children is common. Provider and patient characteristics associated with inappropriate prescribing differ from those associated with higher volume. Claims data are useful to describe inappropriate use and could be a valuable metric for provider feedback reports. Policies are needed to support analysis and dissemination of antibiotic prescribing reports and should include all provider types and geographic areas.
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26
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Evaluation of antibiotic prescribing in emergency departments and urgent care centers across the Veterans' Health Administration. Infect Control Hosp Epidemiol 2020; 42:694-701. [PMID: 33308352 DOI: 10.1017/ice.2020.1289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs). DESIGN This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016-2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis. RESULTS There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0-52.7) and sites (median, 38.2%; IQR, 31.7-49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1-68.6) and sites (median, 40.0%; IQR, 30.4-59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001). CONCLUSIONS Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.
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27
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Implementing Antibiotic Stewardship in a Network of Urgent Care Centers. Jt Comm J Qual Patient Saf 2020; 46:682-690. [DOI: 10.1016/j.jcjq.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
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28
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Gill M, Blacketer C, Chitti F, Telfer K, Papanicolas L, Dann LM, Tucker EC, Bryant RV, Costello SP. Physician and patient perceptions of fecal microbiota transplant for recurrent or refractory Clostridioides difficile in the first 6 years of a central stool bank. JGH OPEN 2020; 4:950-957. [PMID: 33102769 PMCID: PMC7578309 DOI: 10.1002/jgh3.12396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/14/2020] [Indexed: 11/08/2022]
Abstract
Background and Aim Fecal microbiota transplantation (FMT) is a highly effective therapy for recurrent or refractory Clostridioides difficile infection (rCDI). Despite inclusion in society guidelines, the uptake of FMT therapy has been variable. Physician and patient attitudes may be a barrier to evidence‐based uptake of therapies; however, data assessing attitudes regarding FMT for rCDI are limited. Methods The South Australian FMT for CDI database prospectively recorded patient outcomes of FMT for CDI from August 2013 to January 2019. A total of 93 consecutive patients who underwent FMT for rCDI in South Australia were invited to participate in a 20‐question survey regarding the patient experience of FMT. All gastroenterologists and infectious disease physicians practicing in South Australia were invited to participate in an online survey comprised of 22 questions that addressed referral experience, indications for referral, perceived risks, and regulation and funding. Results Fifty‐four patients (54/93, 58%) returned the survey, of whom 52 (96%) would recommend FMT to others, and 51 (94%) were satisfied with treatment outcome. Fifty physicians returned the online survey (50/100, 50%), of whom 23 (46%) were concerned about disease transmission risk, and 15 (30%) believed that the risk of FMT would outweigh the benefit. Infectious diseases physicians and advanced trainees had significantly greater concern regarding the potential alteration of the microbiome than gastroenterology physicians and advanced trainees (8/17 (47%) vs 6/33 (18%); P = 0.047). Conclusion Despite high levels of patient‐reported satisfaction following FMT, physician‐reported reservations exist and may present a barrier to uptake of this therapy.
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Affiliation(s)
- Madeleine Gill
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia
| | - Charlotte Blacketer
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia
| | - Franco Chitti
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia
| | - Karmen Telfer
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia.,School of Medicine University of Adelaide Adelaide South Australia Australia
| | - Lito Papanicolas
- School of Medicine Flinders University Adelaide South Australia Australia.,Department of Infectious Diseases Royal Adelaide Hospital Adelaide South Australia Australia
| | - Lisa M Dann
- BiomeBank Adelaide South Australia Australia
| | - Emily C Tucker
- BiomeBank Adelaide South Australia Australia.,Department of Infectious Diseases Flinders Medical Centre Adelaide South Australia Australia
| | - Robert V Bryant
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia.,School of Medicine University of Adelaide Adelaide South Australia Australia.,BiomeBank Adelaide South Australia Australia
| | - Samuel P Costello
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia.,School of Medicine University of Adelaide Adelaide South Australia Australia.,BiomeBank Adelaide South Australia Australia
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Antimicrobial prescribing practices at a tertiary-care center in patients diagnosed with COVID-19 across the continuum of care. Infect Control Hosp Epidemiol 2020; 42:89-92. [PMID: 32703323 PMCID: PMC7417978 DOI: 10.1017/ice.2020.370] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In a single-center review of antibiotic prescribing in COVID-19 patients, 10% of patients received antimicrobials, and inpatients encounters had the highest rate and spectrum of prescribing. Prescribing rate, spectrum, and duration appeared to increase with disease severity in inpatients. Antimicrobial prescribing in patients managed in ambulatory encounters was less common.
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30
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Dyar OJ, Yang D, Yin J, Sun Q, Stålsby Lundborg C. Variations in antibiotic prescribing among village doctors in a rural region of Shandong province, China: a cross-sectional analysis of prescriptions. BMJ Open 2020; 10:e036703. [PMID: 32487580 PMCID: PMC7265041 DOI: 10.1136/bmjopen-2019-036703] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To assess variation in antibiotic prescribing practices among village doctors in a rural region of Shandong province, China. DESIGN, SETTING AND PARTICIPANTS Almost all outpatient encounters at village clinics result in a prescription being issued. Prescriptions were collected over a 2.5-year period from 8 primary care village clinics staffed by 24 doctors located around a town in rural Shandong province. A target of 60 prescriptions per clinic per month was sampled from an average total of around 300. Prescriptions were analysed at both aggregate and individual-prescriber levels, with a focus on diagnoses of likely viral acute upper respiratory tract infections (AURIs), defined as International Classification of Diseases, 10th Revision codes J00 and J06.9. MAIN OUTCOME MEASURES Proportions of prescriptions for AURIs containing (1) at least one antibiotic, (2) multiple antibiotics, (3) at least one parenteral antibiotic; classes and agents of antibiotics prescribed. RESULTS In total, 14 471 prescriptions from 23 prescribers were ultimately included, of which 5833 (40.3%) contained at least 1 antibiotic. Nearly two-thirds 62.5% (3237/5177) of likely viral AURI prescriptions contained an antibiotic, accounting for 55.5% (3237/5833) of all antibiotic-containing prescriptions. For AURIs, there was wide variation at the individual level in antibiotic prescribing rates (33.1%-88.0%), as well multiple antibiotic prescribing rates (1.3%-60.2%) and parenteral antibiotic prescribing rates (3.2%-62.1%). Each village doctor prescribed between 11 and 21 unique agents for AURIs, including many broad-spectrum antibiotics. Doctors in the highest quartile for antibiotic prescribing rates for AURI also had higher antibiotic prescribing rates than doctors in the lowest quartile for potentially bacterial upper respiratory tract infections (pharyngitis, tonsillitis, laryngopharyngitis; 89.1% vs 72.4%, p=0.002). CONCLUSIONS All village doctors overused antibiotics for respiratory tract infections. Variations in individual prescriber practices are significant even in a small homogenous setting and should be accounted for when developing targets and interventions to improve antibiotic use.
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Affiliation(s)
- Oliver James Dyar
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Ding Yang
- School of Health Care Management, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Jia Yin
- School of Health Care Management, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
| | - Qiang Sun
- School of Health Care Management, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- NHC Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, Shandong, China
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31
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Improving Antimicrobial Use in Adult Outpatient Clinics: the New Frontier for Antimicrobial Stewardship Programs. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00722-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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