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Impact evaluation of a brief online training module on physician use of the Maryland, USA, Prescription Drug Monitoring Program. PLoS One 2022; 17:e0272217. [PMID: 35944051 PMCID: PMC9362906 DOI: 10.1371/journal.pone.0272217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 07/11/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Prescription Drug Monitoring Programs (PDMPs) are electronic databases that track controlled substance prescriptions in a state. They are underused tools in preventing opioid abuse. Most PDMP education research measures changes in knowledge or confidence rather than behavior.
Objective
To evaluate the impact of online case-based training on healthcare provider use of the Maryland (USA) PDMP.
Methods
We used e-mail distribution lists to recruit providers to complete a brief educational module. Using a pre-training and post-training survey in the module, we measured self-reported PDMP use patterns and perceived PDMP value in specific clinical situations and compared pre- and post-training responses. Within the module, we presented three fictional pain cases and asked participants how they would manage each, both before, and then after presenting prescription drug history simulating a PDMP report. We measured changes in the fictional case treatment plans before and after seeing prescription history. Finally, we measured and compared how often each participant accessed the Maryland PDMP database before and after completing the educational module. We used multivariate logistic regression to measure the effect of the intervention on actual PDMP use frequency.
Results
One hundred and fifty participants enrolled and completed the training module, and we successfully retrieved real-world PDMP use data of 137 of them. Participants’ decisions to prescribe opioids changed significantly after reviewing PDMP data in each of the fictional cases provided in the module. In the months following the training, the rate of PDMP use increased by a median of four use-cases per month among providers in practice for less than 20 years (p = 0.039) and two use-cases per month among infrequent opioid prescribers (p = 0.014).
Conclusion
A brief online case-based educational intervention was associated with a significant increase in the rate of PDMP use among infrequent opioid prescribers and those in practice less than 20 years.
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Rodrigues AT, Nunes JCF, Estrela M, Figueiras A, Roque F, Herdeiro MT. Comparing Hospital and Primary Care Physicians' Attitudes and Knowledge Regarding Antibiotic Prescribing: A Survey within the Centre Region of Portugal. Antibiotics (Basel) 2021; 10:antibiotics10060629. [PMID: 34070337 PMCID: PMC8229910 DOI: 10.3390/antibiotics10060629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/14/2021] [Accepted: 05/23/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Antibiotic resistance is a worldwide public health problem, leading to longer hospital stays, raising medical costs and mortality levels. As physicians' attitudes are key factors to antibiotic prescribing, this study sought to explore their differences between primary care and hospital settings. METHODS A survey was conducted between September 2011 and February 2012 in the center region of Portugal in the form of a questionnaire to compare hospital (n = 154) and primary care (n = 421) physicians' attitudes and knowledge regarding antibiotic prescribing. RESULTS More than 70% of the attitudes were statistically different (p < 0.05) between hospital physicians (HPs) and primary care physicians (PCPs). When compared to PCPs, HPs showed higher agreement with antibiotic resistances being a public health problem and ascribed more importance to microbiological tests and to the influence of prescription on the development of resistances. On the other hand, PCPs tended to agree more regarding the negative impact of self-medication with antibiotics dispensed without medical prescription and the need for rapid diagnostic tests. Seven out of nine sources of knowledge's usefulness were statistically different between both settings, with HPs considering most of the knowledge sources to be more useful than PCPs. CONCLUSIONS Besides the efforts made to improve both antibiotic prescribing and use, there are differences in the opinions between physicians working in different settings that might impact the quality of antibiotic prescribing. In the future, these differences must be considered to develop more appropriate interventions.
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Affiliation(s)
- António Teixeira Rodrigues
- Department of Medical Sciences, iBiMED—Institute of Biomedicine, University of Aveiro, 3800 Aveiro, Portugal; (A.T.R.); (M.E.); (M.T.H.)
- Centre for Health Evaluation and Research (CEFAR), National Association of Pharmacies, 1249 Lisbon, Portugal
| | - João C. F. Nunes
- Department of Chemistry, CICECO—Aveiro Institute of Materials, University of Aveiro, 3800 Aveiro, Portugal;
| | - Marta Estrela
- Department of Medical Sciences, iBiMED—Institute of Biomedicine, University of Aveiro, 3800 Aveiro, Portugal; (A.T.R.); (M.E.); (M.T.H.)
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain;
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health—CIBERESP), 28001 Madrid, Spain
- Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Fátima Roque
- Research Unit for Inland Development, Polytechnic of Guarda (IPG-UDI), 6300 Guarda, Portugal
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200 Covilhã, Portugal
- Correspondence:
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, iBiMED—Institute of Biomedicine, University of Aveiro, 3800 Aveiro, Portugal; (A.T.R.); (M.E.); (M.T.H.)
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Nabovati E, Jeddi FR, Farrahi R, Anvari S. Information technology interventions to improve antibiotic prescribing for patients with acute respiratory infection: a systematic review. Clin Microbiol Infect 2021; 27:838-845. [PMID: 33813115 DOI: 10.1016/j.cmi.2021.03.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 01/19/2021] [Accepted: 03/14/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Information technology (IT) interventions provide physicians with easy and quick access to information at the point of care and can play a major role in clinical decision-making for antibiotic prescribing. This study aimed to examine the effects and characteristics of IT interventions on improving antibiotic prescribing for patients with acute respiratory infection (ARI). METHODS A comprehensive search was performed in Medline (through PubMed), ISI web of science, Embase, and Cochrane databases from inception to 31 August 2020. Randomized controlled trial (RCT) and cluster RCT (CRCT) studies examining the effectiveness of IT interventions in improving antibiotic prescribing for patients with ARI were included. Participants were patients with ARI. IT interventions were used for improving antibiotic prescribing. Two researchers independently extracted data from studies on methods, characteristics of interventions, and results. The characteristics of interventions were extracted based on three dimensions of IT design, data entry source, and implementation characteristics. RESULTS Eighteen studies (15 CRCTs and three RCTs) were included. Most of included studies (n = 11) were conducted in the United States. In 12 studies (66.7%), IT interventions improved the level of antibiotic prescribing, and in eight of the 12 studies the effect was statistically significant. In two studies the intervention had a statistically significant negative effect, and in two studies the level of antibiotic prescribing was not changed. Seventeen studies (94.4%) used clinical decision support systems (CDSSs) for the intervention. In 12 studies (66.7%) CDSSs were integrated with electronic health records (EHRs). CONCLUSIONS Information technology interventions have the potential to improve prescription of antibiotics for patients with acute respiratory infection and to change physicians' behaviours in this regard. Factors affecting the acceptance of IT-based interventions to improve prescription of antibiotics should be investigated in future studies.
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Affiliation(s)
- Ehsan Nabovati
- Health Information Management Research Centre, Department of Health Information Management & Technology, Kashan University of Medical Sciences, Kashan, Iran.
| | - Fatemeh Rangraz Jeddi
- Health Information Management Research Centre, Department of Health Information Management & Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Razieh Farrahi
- Student Research Committee, Department of Health Information Management & Technology, Kashan University of Medical Sciences, Kashan, Iran.
| | - Shima Anvari
- Student Research Committee, Department of Health Information Management & Technology, Kashan University of Medical Sciences, Kashan, Iran
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Abdoler EA, O'Brien BC, Schwartz BS. Following the Script: An Exploratory Study of the Therapeutic Reasoning Underlying Physicians' Choice of Antimicrobial Therapy. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1238-1247. [PMID: 32379146 DOI: 10.1097/acm.0000000000003498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
PURPOSE Physicians frequently prescribe antimicrobials inappropriately, leading to an increase in the rate of resistance, which in turn, harms patients. To better understand why physicians prescribe specific antimicrobials in particular cases, the authors investigated the decision-making processes underlying physicians' antimicrobial choice (i.e., their antimicrobial reasoning). METHOD Applying a clinical reasoning framework, the authors conducted semi-structured, qualitative interviews with a purposive sample of attending physicians in infectious diseases and hospital medicine at 2 hospitals in fall 2018. An interviewer asked participants to describe how they would choose which antimicrobial to prescribe in 3 clinical vignettes, to recall how they chose an antimicrobial in an example from their own practice, and to indicate their steps in antimicrobial selection generally. The authors identified steps and factors in antimicrobial reasoning through thematic analysis of interviews and the note cards that participants used to delineate their general antimicrobial reasoning processes. RESULTS Sixteen participants described 3 steps in the antimicrobial reasoning process: naming the syndrome, delineating pathogens, and selecting the antimicrobial (therapy script). They mentioned 25 different factors in their reasoning processes, which the authors grouped into 4 areas: preexisting patient characteristics, current case features, provider and health care system factors, and treatment principles. Participants used antimicrobial (therapy) scripts that included 14 different drug characteristics. The authors present the steps and factors in a framework for antimicrobial reasoning. CONCLUSIONS Through this exploratory study, the authors identified steps and factors involved in physicians' antimicrobial reasoning process, as well as the content of their antimicrobial (therapy) scripts. They organized all these findings into a framework for antimicrobial decision making. This information may ultimately be adapted into educational tools to improve antimicrobial prescribing across the spectrum of learners and practicing physicians.
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Affiliation(s)
- Emily A Abdoler
- E.A. Abdoler is assistant professor, Department of Medicine, University of Michigan, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0002-0938-0527
| | - Bridget C O'Brien
- B.C. O'Brien is associate professor, Department of Medicine, University of California, San Francisco, San Francisco, California; ORCID: https://orcid.org/0000-0001-9591-5243
| | - Brian S Schwartz
- B.S. Schwartz is professor, Department of Medicine, University of California, San Francisco, San Francisco, California; ORCID: https://orcid.org/0000-0003-2852-6808
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Practice variation and practice guidelines: Attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants. PLoS One 2018; 13:e0191943. [PMID: 29385203 PMCID: PMC5792011 DOI: 10.1371/journal.pone.0191943] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 01/13/2018] [Indexed: 11/21/2022] Open
Abstract
Objective To understand clinicians' beliefs about practice variation and how variation might be reduced. Methods We surveyed board-certified physicians (N = 178), nurse practitioners (N = 60), and physician assistants (N = 12) at an academic medical center and two community clinics, representing family medicine, general internal medicine, and cardiology, from February—April 2016. The Internet-based questionnaire ascertained clinicians' beliefs regarding practice variation, clinical practice guidelines, and costs. Results Respondents agreed that practice variation should be reduced (mean [SD] 4.5 [1.1]; 1 = strongly disagree, 6 = strongly agree), but agreed less strongly (4.1 [1.0]) that it can realistically be reduced. They moderately agreed that variation is justified by situational differences (3.9 [1.2]). They strongly agreed (5.2 [0.8]) that clinicians should help reduce healthcare costs, but agreed less strongly (4.4 [1.1]) that reducing practice variation would reduce costs. Nearly all respondents (234/249 [94%]) currently depend on practice guidelines. Clinicians rated differences in clinician style and experience as most influencing practice variation, and inaccessibility of guidelines as least influential. Time to apply standards, and patient decision aids, were rated most likely to help standardize practice. Nurse practitioners and physicians assistants (vs physicians) and less experienced (vs senior) clinicians rated more favorably several factors that might help to standardize practice. Differences by specialty and academic vs community practice were small. Conclusions Clinicians believe that practice variation should be reduced, but are less certain that this can be achieved. Accessibility of guidelines is not a significant barrier to practice standardization, whereas more time to apply standards is viewed as potentially helpful.
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Klein EY, Martinez EM, May L, Saheed M, Reyna V, Broniatowski DA. Categorical Risk Perception Drives Variability in Antibiotic Prescribing in the Emergency Department: A Mixed Methods Observational Study. J Gen Intern Med 2017; 32. [PMID: 28634909 PMCID: PMC5602760 DOI: 10.1007/s11606-017-4099-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Adherence to evidence-based antibiotic therapy guidelines for treatment of upper respiratory tract infections (URIs) varies widely among clinicians. Understanding this variability is key for reducing inappropriate prescribing. OBJECTIVE To measure how emergency department (ED) clinicians' perceptions of antibiotic prescribing risks affect their decision-making. DESIGN Clinician survey based on fuzzy-trace theory, a theory of medical decision-making, combined with retrospective data on prescribing outcomes for URI/pneumonia visits in two EDs. The survey predicts the categorical meanings, or gists, that individuals derive from given information. PARTICIPANTS ED physicians, residents, and physician assistants (PAs) who completed surveys and treated patients with URI/pneumonia diagnoses between August 2014 and December 2015. MAIN MEASURES Gists derived from survey responses and their association with rates of antibiotic prescribing per visit. KEY RESULTS Of 4474 URI/pneumonia visits, 2874 (64.2%) had an antibiotic prescription. However, prescribing rates varied from 7% to 91% for the 69 clinicians surveyed (65.2% response rate). Clinicians who framed therapy-prescribing decisions as a categorical choice between continued illness and possibly beneficial treatment ("why not take a risk?" gist, which assumes antibiotic therapy is essentially harmless) had higher rates of prescribing (OR 1.28 [95% CI, 1.06-1.54]). Greater agreement with the "antibiotics may be harmful" gist was associated with lower prescribing rates (OR 0.81 [95% CI, 0.67-0.98]). CONCLUSIONS Our results indicate that clinicians who perceive prescribing as a categorical choice between patients remaining ill or possibly improving from therapy are more likely to prescribe antibiotics. However, this strategy assumes that antibiotics are essentially harmless. Clinicians who framed decision-making as a choice between potential harms from therapy and continued patient illness (e.g., increased appreciation of potential harms) had lower prescribing rates. These results suggest that interventions to reduce inappropriate prescribing should emphasize the non-negligible possibility of serious side effects.
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Affiliation(s)
- Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 5801 Smith Avenue, Suite 3220, Office 265, Davis Building, Baltimore, MD, 21209, USA. .,Center for Disease Dynamics, Economics & Policy, Washington, DC, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Elena M Martinez
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 5801 Smith Avenue, Suite 3220, Office 265, Davis Building, Baltimore, MD, 21209, USA
| | - Valerie Reyna
- Human Neuroscience Institute, Center for Behavioral Economics and Decision Research and Human Neuroscience Institute, Cornell University, Ithaca, NY, USA
| | - David A Broniatowski
- Department of Engineering Management and Systems Engineering, The George Washington University, Washington, DC, USA
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Gifford J, Vaeth E, Richards K, Siddiqui T, Gill C, Wilson L, DeLisle S. Decision support during electronic prescription to stem antibiotic overuse for acute respiratory infections: a long-term, quasi-experimental study. BMC Infect Dis 2017; 17:528. [PMID: 28760143 PMCID: PMC5537944 DOI: 10.1186/s12879-017-2602-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 07/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interventions to support decision-making can reduce inappropriate antibiotic use for acute respiratory infections (ARI), but they may not be sustainable. The objective of the study is to evaluate the long-term effectiveness of a clinical decision-support system (CDSS) interposed at the time of electronic (e-) prescriptions for selected antibiotics. METHODS This is a retrospective, observational intervention study, conducted within a large, statewide Veterans Affairs health system. Participants are outpatients with an initial visit for ARI. A CDSS was deployed upon e-prescription of selected antibiotics during the study period. From 01/2004 to 05/2006 (pre-withdrawal period), the CDSS targeted azithromycin and the fluoroquinolone gatifloxacin. From 05/2006 to 12/2011 (post-withdrawal period), the CDSS was retained for azithromycin but withdrawn for the fluoroquinolone. A manual record review was conducted to determine concordance of antibiotic prescription with ARI treatment guidelines. RESULTS Of 1131 included ARI visits, 380 (33.6%) were guideline-concordant. For azithromycin, concordance did not change between the pre- and post-withdrawal periods, and adjusted odds of concordance was 8.8 for the full study period, compared to unrestricted antibiotics. For fluoroquinolones, guideline concordance decreased from 88.6% (39 of 44 visits) to 51.3% (59 of 115 visits), pre- vs. post-withdrawal periods (p < 0.005). The adjusted odds of concordance compared to "All Other Antibiotics" visits decreased from 24.4 (95% CI 9.0-66.3) pre-withdrawal to 5.5 (95% CI 3.5-8.8) post-withdrawal (p = .008). Concordance did not change between those same time periods for antibiotics that were never subjected to the intervention ("All Other Antibiotics"). CONCLUSIONS A CDSS interposed at the time of e-prescription of selected antibiotics can shift their use toward ARI treatment guidelines, and this effect can be maintained over the long term as long as the CDSS remains in place. Removal of the CDSS after 3.5 years of implementation resulted in a rise in guideline-discordant antibiotic use.
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Affiliation(s)
- Jeneen Gifford
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA.,School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Elisabeth Vaeth
- Maryland Department of Health and Mental Hygiene, Baltimore, MD, USA
| | | | - Tariq Siddiqui
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA.,School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Christine Gill
- School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Lucy Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, MD, USA
| | - Sylvain DeLisle
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA. .,School of Medicine, University of Maryland, Baltimore, MD, USA. .,Professor of Medicine and Clinical Sciences, University of Texas Southwestern, 8B, Building 2, Dallas VA Medical Center, 4500 S Lancaster Rd, Dallas, TX, 75216, USA.
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What Drives Variation in Antibiotic Prescribing for Acute Respiratory Infections? J Gen Intern Med 2016; 31:918-24. [PMID: 27067351 PMCID: PMC4945551 DOI: 10.1007/s11606-016-3643-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 12/30/2015] [Accepted: 02/12/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Acute respiratory infections are the most common symptomatic reason for seeking care among patients in the US, and account for the majority of all antibiotic prescribing, yet a large fraction of antibiotic prescriptions are inappropriate. OBJECTIVE We sought to identify the underlying factors driving variation in antibiotic prescribing across clinicians and settings. DESIGN, PARTICIPANTS Using electronic health data for adult ambulatory visits for acute respiratory infections to a retail clinic chain and primary care practices from an integrated healthcare system, we identified a random sample of clinicians for survey. MAIN MEASURES We evaluated independent predictors of overall prescribing and imperfect antibiotic prescribing, controlling for clinician and site of care. We defined imperfect antibiotic prescribing as prescribing for non-antibiotic-appropriate diagnoses, failure to prescribe for an antibiotic-appropriate diagnosis, or prescribing a non-guideline-concordant antibiotic. KEY RESULTS Response rates were 34 % for retail clinics and 24 % for physicians' offices (N = 187). Clinicians in physicians' offices prescribed antibiotics less often than those in retail clinics (53 % versus 67 %; p < 0.01), but had a higher imperfect antibiotic prescribing rate (65 % versus 31 %; p < 0.01). Feeling rushed was associated with higher antibiotic prescribing (OR 1.34; 95 % CI 1.03, 1.75). Antibiotic prescribing was also associated with clinician disagreement that antibiotics are overused (OR 1.60, 95 % CI, 1.16, 2.20). Imperfect antibiotic prescribing was associated with receiving antibiotic prescribing feedback (OR 1.35, 95 % CI 1.04, 1.75) and disagreement that patient demand was a problem (OR 1.66, 95 % CI 1.00, 2.73). Imperfect antibiotic prescribing was less common with clinicians who perceived that they prescribed antibiotics less often than their peers (OR 0.63, 95 % CI 0.46, 0.87). CONCLUSIONS Poor-quality antibiotic prescribing was associated with feeling rushed, believing less strongly that antibiotics were overused, and believing that patient demand was not an issue, factors that can be assessed and addressed in future interventions.
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Sanchez GV, Roberts RM, Albert AP, Johnson DD, Hicks LA. Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States. Emerg Infect Dis 2016; 20:2041-7. [PMID: 25418868 PMCID: PMC4257826 DOI: 10.3201/eid2012.140331] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Primary care providers were familiar with recommendations for antibiotic drug selection for common infections, but do not always comply with them. Appropriate selection of antibiotic drugs is critical to optimize treatment of infections and limit the spread of antibiotic resistance. To better inform public health efforts to improve prescribing of antibiotic drugs, we conducted in-depth interviews with 36 primary care providers in the United States (physicians, nurse practitioners, and physician assistants) to explore knowledge, attitudes, and self-reported practices regarding antibiotic drug resistance and antibiotic drug selection for common infections. Participants were generally familiar with guideline recommendations for antibiotic drug selection for common infections, but did not always comply with them. Reasons for nonadherence included the belief that nonrecommended agents are more likely to cure an infection, concern for patient or parent satisfaction, and fear of infectious complications. Providers inconsistently defined broad- and narrow-spectrum antibiotic agents. There was widespread concern for antibiotic resistance; however, it was not commonly considered when selecting therapy. Strategies to encourage use of first-line agents are needed in addition to limiting unnecessary prescribing of antibiotic drugs.
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Wright H, Skinner AC, Jhaveri R. Evaluating Guideline-Recommended Antibiotic Practices for Childhood Respiratory Infections: Is It Time to Consider Case-Based Formats? Clin Pediatr (Phila) 2016; 55:118-21. [PMID: 25986442 DOI: 10.1177/0009922815587091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We sought to better understand barriers to adherence to published guidelines for respiratory infections among community providers. METHODS A case-based survey was developed and emailed to all members of the state pediatric society. Providers chose their preferred management for acute otitis media, acute bacterial sinusitis, and community-acquired pneumonia. An "answer key" and a follow-up questionnaire were distributed to assess reevaluation of current practices. RESULTS We received 173 completed surveys (15% response rate). While most responders followed guideline recommendations (6 of the 10 questions with ≥ 65% choosing recommended antibiotic), discrepancies existed in several cases. After receiving the answer key, respondents said they reviewed the guidelines (69%), adjusted their practice (26%), used cases for teaching (9%), and discussed guidelines with colleagues (21%). CONCLUSIONS The majority of respondents followed published guidelines, but there was a tendency to overuse azithromycin in certain cases. Future guidelines including case-based discussions may enhance adherence.
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Affiliation(s)
- Heather Wright
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | | | - Ravi Jhaveri
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Dantes R, Mu Y, Hicks LA, Cohen J, Bamberg W, Beldavs ZG, Dumyati G, Farley MM, Holzbauer S, Meek J, Phipps E, Wilson L, Winston LG, McDonald LC, Lessa FC. Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection. Open Forum Infect Dis 2015; 2:ofv113. [PMID: 26509182 PMCID: PMC4551478 DOI: 10.1093/ofid/ofv113] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/03/2015] [Indexed: 01/21/2023] Open
Abstract
A modest, 10% reduction in outpatient antibiotic prescribing among U.S. adults
could result in a substantial 17% reduction in Clostridium
difficile infections that originate in the community. Background. Antibiotic use predisposes patients to
Clostridium difficile infections (CDI), and approximately
32% of these infections are community-associated (CA) CDI. The
population-level impact of antibiotic use on adult CA-CDI rates is not well
described. Methods. We used 2011 active population- and
laboratory-based surveillance data from 9 US geographic locations to identify adult
CA-CDI cases, defined as C difficile-positive stool specimens (by
toxin or molecular assay) collected from outpatients or from patients ≤3 days
after hospital admission. All patients were surveillance area residents and aged
≥20 years with no positive test ≤8 weeks prior and no overnight stay in a
healthcare facility ≤12 weeks prior. Outpatient oral antibiotic prescriptions
dispensed in 2010 were obtained from the IMS Health Xponent database. Regression
models examined the association between outpatient antibiotic prescribing and adult
CA-CDI rates. Methods. Healthcare providers prescribed 5.2
million courses of antibiotics among adults in the surveillance population in 2010,
for an average of 0.73 per person. Across surveillance sites, antibiotic prescription
rates (0.50–0.88 prescriptions per capita) and unadjusted CA-CDI rates
(40.7–139.3 cases per 100 000 persons) varied. In regression modeling, reducing
antibiotic prescribing rates by 10% among persons ≥20 years old was
associated with a 17% (95% confidence interval,
6.0%–26.3%; P = .032) decrease in CA-CDI
rates after adjusting for age, gender, race, and type of diagnostic assay. Reductions
in prescribing penicillins and amoxicillin/clavulanic acid were associated with the
greatest decreases in CA-CDI rates. Conclusions and Relevance. Community-associated
CDI prevention should include reducing unnecessary outpatient antibiotic use. A
modest reduction of 10% in outpatient antibiotic prescribing can have a
disproportionate impact on reducing CA-CDI rates.
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Affiliation(s)
| | - Yi Mu
- Centers for Disease Control and Prevention , Atlanta
| | - Lauri A Hicks
- Centers for Disease Control and Prevention , Atlanta
| | - Jessica Cohen
- Centers for Disease Control and Prevention , Atlanta ; Atlanta Research and Education Foundation, Georgia
| | - Wendy Bamberg
- Colorado Department of Public Health and Environment, Denver
| | | | | | - Monica M Farley
- Emory University , Atlanta ; Atlanta Veterans Affairs Medical Center , Georgia
| | | | - James Meek
- Connecticut Emerging Infections Program , New Haven
| | | | - Lucy Wilson
- Maryland Emerging Infections Program Baltimore ; Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Lisa G Winston
- University of California , San Francisco ; San Francisco General Hospital , California
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Almatar MA, Peterson GM, Thompson A, McKenzie DS, Anderson TL. Community-acquired pneumonia: why aren't national antibiotic guidelines followed? Int J Clin Pract 2015; 69:259-66. [PMID: 25439025 DOI: 10.1111/ijcp.12538] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 08/07/2014] [Indexed: 12/14/2022] Open
Abstract
AIMS Adherence to guidelines for the management of community-acquired pneumonia (CAP) has been shown to improve patients' clinical outcomes. This study aimed to assess adherence to the Australian Therapeutic Guidelines (TG14) for the empirical management of CAP, and explore the potential barriers affecting adherence to these guidelines. METHODS Medical records were reviewed for all patients who were diagnosed with CAP within 24 h of presentation at the Royal Hobart Hospital, the main teaching hospital in Tasmania, Australia, between July 2010 and March 2011. A survey of emergency department and medical team prescribers was also undertaken to identify potential barriers to adhere with the guidelines. χ(2) and Fisher's exact tests were used to test the significance between categorical data. To compare categorical and scale data, the Mann-Whitney U-test was used. RESULTS A total of 193 patient records were assessed. The overall adherence to TG14 for the empirical antibiotic management of CAP was 16.1% (3.1%, 20.7% and 25.4% for patients with mild, moderate and severe CAP, respectively). Ceftriaxone was prescribed to 34.4%, 26.8% and 57.4% of patients with mild, moderate and severe CAP, respectively. The response rate to the barrier survey was 43.1%; of those who responded, 46.4% thought the influence of senior doctors on junior doctors could be a factor affecting adherence to the guidelines. Other barriers noted were a lack of guideline awareness (39.3%), the requirement to calculate the severity of CAP (35.7%), and the existence of other guidelines that conflict with TG14 (28.6%). CONCLUSIONS Adherence to CAP treatment guidelines was poor, especially in patients with mild disease. Prescribing was mainly influenced by senior doctors. Efforts to improve compliance with CAP treatment guidelines should consider the potential barriers that hinder adherence.
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Affiliation(s)
- M A Almatar
- School of Pharmacy, University of Tasmania, Hobart, Tas., Australia
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Hedin K, Strandberg EL, Gröndal H, Brorsson A, Thulesius H, André M. Management of patients with sore throats in relation to guidelines: an interview study in Sweden. Scand J Prim Health Care 2014; 32:193-9. [PMID: 25363143 PMCID: PMC4278394 DOI: 10.3109/02813432.2014.972046] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To explore how a group of Swedish general practitioners (GPs) manage patients with a sore throat in relation to current guidelines as expressed in interviews. DESIGN Qualitative content analysis was used to analyse semi-structured interviews. SETTING Swedish primary care. SUBJECTS A strategic sample of 25 GPs. MAIN OUTCOME MEASURES Perceived management of sore throat patients. RESULTS It was found that nine of the interviewed GPs were adherent to current guidelines for sore throat and 16 were non-adherent. The two groups differed in terms of guideline knowledge, which was shared within the team for adherent GPs while idiosyncratic knowledge dominated for the non-adherent GPs. Adherent GPs had no or low concerns for bacterial infections and differential diagnosis whilst non-adherent GPs believed that in patients with a sore throat any bacterial infection should be identified and treated with antibiotics. Patient history and examination was mainly targeted by adherent GPs whilst for non-adherent GPs it was often redundant. Non-adherent GPs reported problems getting patients to abstain from antibiotics, whilst no such problems were reported in adherent GPs. CONCLUSION This interview study of sore throat management in a strategically sampled group of Swedish GPs showed that while two-thirds were non-adherent and had a liberal attitude to antibiotics one-third were guideline adherent with a restricted view on antibiotics. Non-adherent GPs revealed significant knowledge gaps. Adherent GPs had discussed guidelines within the primary care team while non-adherent GPs had not. Guideline implementation thus seemed to be promoted by knowledge shared in team discussions.
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Affiliation(s)
- Katarina Hedin
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Sweden
- Unit for Research and Development, Kronoberg County Council, Växjö, Sweden
| | - Eva Lena Strandberg
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Sweden
- Blekinge Centre of Competence, Blekinge County Council, Karlskrona, Sweden
| | - Hedvig Gröndal
- Department of Sociology, Uppsala University, Uppsala, Sweden
| | - Annika Brorsson
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Sweden
- Center for Primary Health Care Research, Skåne Region, Malmö, Sweden
| | - Hans Thulesius
- Department of Clinical Sciences, Malmö, Family Medicine, Lund University, Sweden
- Unit for Research and Development, Kronoberg County Council, Växjö, Sweden
| | - Malin André
- Department of Medicine and Health Sciences, Family Medicine, Linköping University, Linköping, Sweden
- Department of Public Health and Caring Sciences Family Medicine and Preventive Medicine, Uppsala University, Sweden
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Abstract
Abstract
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Kaya Z, Küçükcongar A, Vurallı D, Emeksiz HC, Gürsel T. Leukocyte populations and C-reactive protein as predictors of bacterial infections in febrile outpatient children. Turk J Haematol 2014; 31:49-55. [PMID: 24764729 PMCID: PMC3996630 DOI: 10.4274/tjh.2013.0057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 07/02/2013] [Indexed: 12/03/2022] Open
Abstract
Objective: Infections remain the major cause of unnecessary antibiotic use in pediatric outpatient settings. Complete blood count (CBC) is the essential test in the diagnosis of infections. C-reactive protein (CRP) is also useful for assessment of young children with serious bacterial infections. The purpose of the study was to evaluate leukocyte populations and CRP level to predict bacterial infections in febrile outpatient children. Materials and Methods: The values of CBC by Cell-DYN 4000 autoanalyzer and serum CRP levels were evaluated in 120 febrile patients with documented infections (n:74 bacterial, n:46 viral) and 22 healthy controls. Results: The mean CRP, neutrophil and immature granulocyte (IG) values were significantly higher in bacterial infections than in viral infections and controls (p<0.05). C-reactive protein was significantly correlated with neutrophil level in bacterial infections (r: 0.76, p<0.05). Specificity of IG was greatest at 93%, only a modest 56% for neutrophil and mild 18% for CRP, whereas 100% for combination of IG, neutrophil and CRP. Conclusion: Acute bacterial infection seems to be very unlikely in children with normal leukocyte populations and CRP values, even if clinically signs and symptoms indicate acute bacterial infections.
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Affiliation(s)
- Zühre Kaya
- Gazi University Medical School, The Pediatric Hematology Unit, Department of Pediatrics, Ankara, Turkey
| | - Aynur Küçükcongar
- Gazi University Medical School, The Pediatric Hematology Unit, Department of Pediatrics, Ankara, Turkey
| | - Doğuş Vurallı
- Gazi University Medical School, The Pediatric Hematology Unit, Department of Pediatrics, Ankara, Turkey
| | - Hamdi Cihan Emeksiz
- Gazi University Medical School, The Pediatric Hematology Unit, Department of Pediatrics, Ankara, Turkey
| | - Türkiz Gürsel
- Gazi University Medical School, The Pediatric Hematology Unit, Department of Pediatrics, Ankara, Turkey
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Lozman RL, Belcher A, Sloand E. Does a 30-min quality improvement clinical practice meeting reviewing the recommended Papanicolaou test guidelines for adolescents improve provider adherence to guidelines in a pediatric primary care office? J Am Assoc Nurse Pract 2013; 25:584-7. [PMID: 24170532 DOI: 10.1111/1745-7599.12019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this quality improvement project was to evaluate adherence to Papanicolaou (Pap) test guidelines 6 months prior to and 6 months following a 30-min educational clinical practice meeting in a pediatric primary care office. Guidelines for Pap tests have been revised in recent years by the American Academy of Obstetrics and Gynecology, the American Cancer Society, and the U.S. Preventive Task Force, but providers often do not adhere to the guidelines. DATA SOURCES A total of 777 charts from a pediatric primary care office were reviewed. Eighty-four percent (652) met criteria for inclusion. CONCLUSIONS Among sexually active adolescents, there was a statistically significant relationship between rates of Pap tests following the clinical practice meeting (χ(2) (1) = 13.5, p = .001). Prior to the meeting there were 29 Pap tests recorded, whereas after there were two Pap tests done. After the focused clinical practice meeting, providers performed far fewer Pap tests, which is in accordance with the guidelines for this population. IMPLICATIONS FOR PRACTICE Providers may not always practice in accordance with recommended clinical practice guidelines for various reasons. Focused, in-office educational interventions via clinical practice meetings may be an effective way of discussing recommended guidelines to improve provider adherence.
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Affiliation(s)
- Rebecca L Lozman
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
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Use of an electronic health record clinical decision support tool to improve antibiotic prescribing for acute respiratory infections: the ABX-TRIP study. J Gen Intern Med 2013; 28:810-6. [PMID: 23117955 PMCID: PMC3663943 DOI: 10.1007/s11606-012-2267-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 10/11/2012] [Accepted: 10/18/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Antibiotics are often inappropriately prescribed for acute respiratory infections (ARIs). OBJECTIVE To assess the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs. DESIGN A two-phase, 27-month demonstration project. SETTING Nine primary care practices in PPRNet, a practice-based research network whose members use a common electronic health record (EHR). PARTICIPANTS Thirty-nine providers were included in the project. INTERVENTION A CDSS was designed as an EHR progress note template. To facilitate CDSS implementation, each practice participated in two to three site visits, sent representatives to two project meetings, and received quarterly performance reports on antibiotic prescribing for ARIs. MAIN OUTCOME MEASURES 1) Use of antibiotics for inappropriate indications. 2) Use of broad spectrum antibiotics when inappropriate. 3) Use of antibiotics for sinusitis and bronchitis. KEY RESULTS The CDSS was used 38,592 times during the 27-month intervention; its use was sustained for the study duration. Use of antibiotics for encounters at which diagnoses for which antibiotics are rarely appropriate did not significantly change through the course of the study (estimated 27-month change, 1.57% [95% CI, -5.35%, 8.49%] in adults and -1.89% [95% CI, -9.03%, 5.26%] in children). However, use of broad spectrum antibiotics for ARI encounters improved significantly (estimated 27 month change, -16.30%, [95% CI, -24.81%, -7.79%] in adults and -16.30 [95%CI, -23.29%, -9.31%] in children). Prescribing for bronchitis did not change significantly, but use of broad spectrum antibiotics for sinusitis declined. CONCLUSIONS This multi-method intervention appears to have had a sustained impact on reducing the use of broad spectrum antibiotics for ARIs. This intervention shows promise for promoting judicious antibiotic use in primary care.
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Ahn S, Smith ML, Ory MG. Physicians' discussions about body weight, healthy diet, and physical activity with overweight or obese elderly patients. J Aging Health 2012; 24:1179-202. [PMID: 22918131 DOI: 10.1177/0898264312454573] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the correlates of physician-patient discussions about body weight, healthy diet, and physical activity. METHOD Subjects were 635 adults (≥65 years; mean 72.8 years) who had an increased body mass index (BMI≥25 kg/m2) and participated in a self-administered community survey. Logistic regression analyses were performed. RESULTS While approximately half of study participants reported having discussed healthy diets (51%) and physical activity (52%) with their physician, only 42% of those who were overweight or obese reported being recognized as such by their physician. Being moderately or severely obese, more chronic conditions, and more frequent physician visits increased the likelihood of being recognized as overweight or obese and reporting lifestyle discussions. DISCUSSION The health care provider is important in recognizing older patient's weight problems and discussing practical lifestyle changes. Tools for more proactive screening and implementation of follow-up behavioral counseling can help the health care providers better address obesity prevention in clinical practice.
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Affiliation(s)
- SangNam Ahn
- School of Public Health, University of Memphis, Memphis, TN 38152-3530, USA.
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Whipple EC, E. Dixon B, J. McGowan J. Linking health information technology to patient safety and quality outcomes: a bibliometric analysis and review. Inform Health Soc Care 2012; 38:1-14. [DOI: 10.3109/17538157.2012.678451] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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