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Aghlmandi S, Halbeisen FS, Saccilotto R, Godet P, Signorell A, Sigrist S, Glinz D, Moffa G, Zeller A, Widmer AF, Kronenberg A, Bielicki J, Bucher HC. Effect of Antibiotic Prescription Audit and Feedback on Antibiotic Prescribing in Primary Care: A Randomized Clinical Trial. JAMA Intern Med 2023; 183:213-220. [PMID: 36745412 PMCID: PMC9989898 DOI: 10.1001/jamainternmed.2022.6529] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/04/2022] [Indexed: 02/07/2023]
Abstract
Importance Antibiotics are commonly prescribed in primary care, increasing the risk of antimicrobial resistance in the population. Objective To investigate the effect of quarterly audit and feedback on antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates. Design, Setting, and Participants This pragmatic randomized clinical trial was conducted from January 1, 2018, to December 31, 2019, among 3426 registered primary care physicians and pediatricians in single or small practices in Switzerland who were among the top 75% prescribers of antibiotics. Intention-to-treat analysis was performed using analysis of covariance models and conducted from September 1, 2021, to January 31, 2022. Interventions Primary care physicians were randomized in a 1:1 fashion to undergo quarterly antibiotic prescribing audit and feedback with peer benchmarking vs no intervention for 2 years, with 2017 used as the baseline year. Anonymized patient-level claims data from 3 health insurers serving roughly 50% of insurees in Switzerland were used for audit and feedback. The intervention group also received evidence-based guidelines for respiratory tract and urinary tract infection management and community antibiotic resistance information. Physicians in the intervention group were blinded regarding the nature of the trial, and physicians in the control group were not informed of the trial. Main Outcomes and Measures The claims data used for audit and feedback were analyzed to assess outcomes. Primary outcome was the antibiotic prescribing rate per 100 consultations during the second year of the intervention. Secondary end points included overall antibiotic use in the first year and over 2 years, use of quinolones and oral cephalosporins, all-cause hospitalizations, and antibiotic use in 3 age groups. Results A total of 3426 physicians were randomized to the intervention (n = 1713) and control groups (n = 1713) serving 629 825 and 622 344 patients, respectively, with a total of 4 790 525 consultations in the baseline year of 2017. In the entire cohort, a 4.2% (95% CI, 3.9%-4.6%) relative increase in the antibiotic prescribing rate was noted during the second year of the intervention compared with 2017. In the intervention group, the median annual antibiotic prescribing rate per 100 consultations was 8.2 (IQR, 6.1-11.4) in the second year of the intervention and was 8.4 (IQR, 6.0-11.8) in the control group. Relative to the overall increase, a -0.1% (95% CI, -1.2% to 1.0%) lower antibiotic prescribing rate per 100 consultations was found in the intervention group compared with the control group. No relevant reductions in specific antibiotic prescribing rates were noted between groups except for quinolones in the second year of the intervention (-0.9% [95% CI, -1.5% to -0.4%]). Conclusions and Relevance This randomized clinical trial found that quarterly personalized antibiotic prescribing audit and feedback with peer benchmarking did not reduce antibiotic prescribing among primary care physicians in Switzerland with medium to high antibiotic prescription rates. Trial Registration ClinicalTrials.gov Identifier: NCT03379194.
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Affiliation(s)
- Soheila Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Florian S. Halbeisen
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ramon Saccilotto
- Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | | | | | - Dominik Glinz
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Giusi Moffa
- Department of Mathematics and Computer Science, University of Basel, Basel, Switzerland
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Andreas F. Widmer
- Division of Infectious Diseases and Hospital Hygiene, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Julia Bielicki
- Infectious Diseases and Paediatric Pharmacology, University Children’s Hospital Basel and University of Basel, Basel, Switzerland
- Centre for Neonatal and Paediatric Infection, St George’s University London, London, UK
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
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Yang J, Cui Z, Liao X, He X, Wang L, Wei D, Wu S, Chang Y. Effects of a feedback intervention on antibiotic prescription control in primary care institutions based on a Health Information System: a cluster randomized cross-over controlled trial. J Glob Antimicrob Resist 2023; 33:51-60. [PMID: 36828121 DOI: 10.1016/j.jgar.2023.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/16/2022] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVES Overuse and misuse of antibiotics are major factors in the development of antibiotic resistance in primary care institutions of rural China. In this study, the effectiveness of a Health Information System-based, automatic, and confidential antibiotic feedback intervention was evaluated. METHODS A randomized, cross-over, cluster-controlled trial was conducted in primary care institutions. All institutions were randomly divided into two groups and given either a three-month intervention followed by a three-month period without any intervention or vice versa. The intervention consisted of three feedback measures: a real-time pop-up warning message of inappropriate antibiotic prescriptions on the prescribing physician's computer screen, a 10-day antibiotic prescription summary, and distribution of educational manuals. The primary outcome was the 10-day inappropriate antibiotic prescription rate. RESULTS There were no significant differences in inappropriate antibiotic prescription rates (69.1% vs. 72.0%) between two groups at baseline (P = 0.072). After three months (cross-over point), inappropriate antibiotic prescription rates decreased significantly faster in group A (12.3%, P < 0.001) compared to group B (4.4%, P < 0.001). At the end point, the inappropriate antibiotic prescription rates decreased in group B (15.1%, P < 0.001) while the rates increased in group A (7.2%, P < 0.001). The characteristics of physicians did not significantly affect the rate of antibiotic or inappropriate antibiotic prescription rates. CONCLUSION A Health Information System-based, real-time pop-up warnings, a 10-day prescription summary, and the distribution of educational manuals, can effectively reduce the rates of antibiotic and inappropriate antibiotic prescriptions.
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Affiliation(s)
- Junli Yang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Zhezhe Cui
- Guangxi Key Laboratory of Major Infectious Disease Prevention and Control and Biosafety Emergency Response, Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Xingjiang Liao
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China; Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Xun He
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China; Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, China.
| | - Lei Wang
- Primary Health Department of Guizhou Provincial Health Commission, Guiyang, China
| | - Du Wei
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China; Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Shengyan Wu
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China; Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Yue Chang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China; Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, China.
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Garzón-Orjuela N, Parveen S, Amin D, Vornhagen H, Blake C, Vellinga A. The Effectiveness of Interactive Dashboards to Optimise Antibiotic Prescribing in Primary Care: A Systematic Review. Antibiotics (Basel) 2023; 12:antibiotics12010136. [PMID: 36671337 PMCID: PMC9854857 DOI: 10.3390/antibiotics12010136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/02/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
Governments and healthcare organisations collect data on antibiotic prescribing (AP) for surveillance. This data can support tools for visualisations and feedback to GPs using dashboards that may prompt a change in prescribing behaviour. The objective of this systematic review was to assess the effectiveness of interactive dashboards to optimise AP in primary care. Six electronic databases were searched for relevant studies up to August 2022. A narrative synthesis of findings was conducted to evaluate the intervention processes and results. Two independent reviewers assessed the relevance, risk of bias and quality of the evidence. A total of ten studies were included (eight RCTs and two non-RCTs). Overall, seven studies showed a slight reduction in AP. However, this reduction in AP when offering a dashboard may not in itself result in reductions but only when combined with educational components, public commitment or behavioural strategies. Only one study recorded dashboard engagement and showed a difference of 10% (95% CI 5% to 15%) between intervention and control. None of the studies reported on the development, pilot or implementation of dashboards or the involvement of stakeholders in design and testing. Interactive dashboards may reduce AP in primary care but most likely only when combined with other educational or behavioural intervention strategies.
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Affiliation(s)
- Nathaly Garzón-Orjuela
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
- Correspondence:
| | - Sana Parveen
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Doaa Amin
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Heike Vornhagen
- Insight Centre for Data Analytics, University of Galway, H91 AEX4 Galway, Ireland
| | - Catherine Blake
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
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Schwartz KL, Ivers N, Langford BJ, Taljaard M, Neish D, Brown KA, Leung V, Daneman N, Alloo J, Silverman M, Shing E, Grimshaw JM, Leis JA, Wu JHC, Garber G. Effect of Antibiotic-Prescribing Feedback to High-Volume Primary Care Physicians on Number of Antibiotic Prescriptions: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:1165-1173. [PMID: 34228086 PMCID: PMC8261687 DOI: 10.1001/jamainternmed.2021.2790] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Antibiotic overuse contributes to adverse drug effects, increased costs, and antimicrobial resistance. OBJECTIVE To evaluate peer-comparison audit and feedback to high-prescribing primary care physicians (PCPs) and assess the effect of targeted messaging on avoiding unnecessary antibiotic prescriptions and avoiding long-duration prescribing. DESIGN, SETTING, AND PARTICIPANTS In this 3-arm randomized clinical trial, administrative data collected from IQVIA's Xponent database were used to recruit the highest quartile of antibiotic-prescribing PCPs (n = 3500) in Ontario, Canada. INTERVENTIONS Physicians were randomized 3:3:1 to receive a mailed letter sent in December 2018 addressing antibiotic treatment initiation (n = 1500), a letter addressing prescribing duration (n = 1500), or no letter (control; n = 500). Outliers at the 99th percentile at baseline for each arm were excluded from analysis. MAIN OUTCOMES AND MEASURES The primary outcome was total number of antibiotic prescriptions over 12 months postintervention. Secondary outcomes were number of prolonged-duration prescriptions (>7 days) and antibiotic drug costs (in Canadian dollars). Robust Poisson regression controlling for baseline prescriptions was used for analysis. RESULTS Of the 3465 PCPs included in analysis, 2405 (69.4%) were male, and 2116 (61.1%) were 25 or more years from their medical graduation. At baseline, PCPs receiving the antibiotic initiation letter and duration letter prescribed an average of 988 and 1000 antibiotic prescriptions, respectively; at 12 months postintervention, these PCPs prescribed an average of 849 and 851 antibiotic prescriptions, respectively. For the primary outcome of total antibiotic prescriptions 12 months postintervention, there was no statistically significant difference in total antibiotic use between PCPs who received the initiation letter compared with controls (relative risk [RR], 0.96; 97.5% CI, 0.92-1.01; P = .06) and a small statistically significant difference for the duration letter compared with controls (RR, 0.95; 97.5% CI, 0.91-1.00; P = .01). For PCPs receiving the duration letter, this corresponds to an average of 42 fewer antibiotic prescriptions over 12 months. There was no statistically significant difference between the letter arms. For the initiation letter, compared with controls there was an RR of 0.98 (97.5% CI, 0.93-1.03; P = .42) and 0.97 (97.5% CI, 0.92-1.02; P = .19) for the outcomes of prolonged-duration prescriptions and antibiotic drug costs, respectively. At baseline, PCPs who received the duration letter prescribed an average of 332 prolonged-duration prescriptions with $14 470 in drug costs. There was an 8.1% relative reduction (RR, 0.92; 97.5% CI, 0.87-0.97; P < .001) in prolonged-duration prescriptions, and a 6.1% relative reduction in antibiotic drug costs (RR, 0.94; 97.5% CI, 0.89-0.99; P = .01). This corresponds to an average of 24 fewer prolonged-duration prescriptions and $771 in drug cost savings per PCP over 12 months. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, a single mailed letter to the highest-prescribing PCPs in Ontario, Canada providing peer-comparison feedback, including messaging on limiting antibiotic-prescribing durations, led to statistically significant reductions in total and prolonged-duration antibiotic prescriptions, as well as drug costs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03776383.
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Affiliation(s)
- Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Unity Health Toronto, Toronto, Ontario, Canada
| | - Noah Ivers
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bradley J Langford
- Public Health Ontario, Toronto, Ontario, Canada.,Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Kevin A Brown
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada.,Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Javed Alloo
- Section on General and Family Practice, Ontario Medical Association, Toronto, Ontario, Canada.,Ontario College of Family Physicians, Toronto, Ontario
| | - Michael Silverman
- Division of Infectious Diseases, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Emily Shing
- Public Health Ontario, Toronto, Ontario, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jerome A Leis
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Gary Garber
- Public Health Ontario, Toronto, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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5
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Imran M, Kwakkenbos L, McCall SJ, McCord KA, Fröbert O, Hemkens LG, Zwarenstein M, Relton C, Rice DB, Langan SM, Benchimol EI, Thabane L, Campbell MK, Sampson M, Erlinge D, Verkooijen HM, Moher D, Boutron I, Ravaud P, Nicholl J, Uher R, Sauvé M, Fletcher J, Torgerson D, Gale C, Juszczak E, Thombs BD. Methods and results used in the development of a consensus-driven extension to the Consolidated Standards of Reporting Trials (CONSORT) statement for trials conducted using cohorts and routinely collected data (CONSORT-ROUTINE). BMJ Open 2021; 11:e049093. [PMID: 33926985 PMCID: PMC8094349 DOI: 10.1136/bmjopen-2021-049093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Randomised controlled trials conducted using cohorts and routinely collected data, including registries, electronic health records and administrative databases, are increasingly used in healthcare intervention research. A Consolidated Standards of Reporting Trials (CONSORT) statement extension for trials conducted using cohorts and routinely collected data (CONSORT-ROUTINE) has been developed with the goal of improving reporting quality. This article describes the processes and methods used to develop the extension and decisions made to arrive at the final checklist. METHODS The development process involved five stages: (1) identification of the need for a reporting guideline and project launch; (2) conduct of a scoping review to identify possible modifications to CONSORT 2010 checklist items and possible new extension items; (3) a three-round modified Delphi study involving key stakeholders to gather feedback on the checklist; (4) a consensus meeting to finalise items to be included in the extension, followed by stakeholder piloting of the checklist; and (5) publication, dissemination and implementation of the final checklist. RESULTS 27 items were initially developed and rated in Delphi round 1, 13 items were rated in round 2 and 11 items were rated in round 3. Response rates for the Delphi study were 92 of 125 (74%) invited participants in round 1, 77 of 92 (84%) round 1 completers in round 2 and 62 of 77 (81%) round 2 completers in round 3. Twenty-seven members of the project team representing a variety of stakeholder groups attended the in-person consensus meeting. The final checklist includes five new items and eight modified items. The extension Explanation & Elaboration document further clarifies aspects that are important to report. CONCLUSION Uptake of CONSORT-ROUTINE and accompanying Explanation & Elaboration document will improve conduct of trials, as well as the transparency and completeness of reporting of trials conducted using cohorts and routinely collected data.
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Affiliation(s)
- Mahrukh Imran
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Linda Kwakkenbos
- Behavioural Science Institute, Clinical Psychology, Radboud University, Nijmegen, Netherlands
| | - Stephen J McCall
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Ras Beirut, Lebanon
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Kimberly A McCord
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ole Fröbert
- Faculty of Health, Department of Cardiology, Örebro University, Örebro, Sweden
| | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Merrick Zwarenstein
- Department of Family Medicine, Western University, London, Ontario, Canada
- IC/ES Western, London, Ontario, Canada
| | - Clare Relton
- Centre for Clinical Trials and Methodology, Barts Institute of Population Health Science, Queen Mary University, London, UK
| | - Danielle B Rice
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
- Department of Psychology, McGill University, Montreal, Quebec, Canada
| | - Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Eric I Benchimol
- Department of Pediatrics and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Margaret Sampson
- Library Services, Children's Hospital of Eastern Ontario, Ontario, Ottawa, Canada
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Helena M Verkooijen
- University Medical Center Utrecht, Utrecht, Netherlands
- University of Utrecht, Utrecht, Netherlands
| | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Isabelle Boutron
- INSERM, Paris, France
- Centre d'Épidémiologie Clinique, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Philippe Ravaud
- INSERM, Paris, France
- Centre d'Épidémiologie Clinique, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rudolf Uher
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Maureen Sauvé
- Scleroderma Society of Ontario, Hamilton, Ontario, Canada
- Scleroderma Canada, Hamilton, Ontario, Canada
| | | | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Brett D Thombs
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
- Departments of Psychiatry; Epidemiology, Biostatistics and Occupational Health; Medicine; and Educational and Counselling Psychology; and Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
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Glinz D, Mc Cord KA, Moffa G, Aghlmandi S, Saccilotto R, Zeller A, Widmer AF, Bielicki J, Kronenberg A, Bucher HC. Antibiotic prescription monitoring and feedback in primary care in Switzerland: Design and rationale of a nationwide pragmatic randomized controlled trial. Contemp Clin Trials Commun 2021; 21:100712. [PMID: 33665467 PMCID: PMC7897989 DOI: 10.1016/j.conctc.2021.100712] [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: 08/05/2020] [Revised: 11/26/2020] [Accepted: 01/12/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Antibiotic consumption is highest in primary care, and antibiotic overuse furthers antimicrobial resistance. In our recently published pilot-RCT, we used monthly aggregated claims data to provide personalized antibiotic prescription feedback to general practitioners (GPs). The pilot-RCT has shown that personalized prescription feedback is a feasible and promising low-cost intervention to reduce antibiotic prescribing. Here, we describe the rationale and design of the follow-up RCT with 3426 GPs in Switzerland. We now have access to pseudonymized patient-level data from routinely collected health insurance data of the three largest health insurers in Switzerland. METHODS AND ANALYSIS 1713 GPs randomized to the intervention group received once evidence-based treatment guidelines at the beginning, including region-specific antibiotic resistance information from the community and personalized feedback of their antibiotic prescribing, followed by quarterly personalized prescription feedback for two years. The first and the last mailings were sent out in December 2017 and September 2019, respectively. The 1713 GPs randomized to the control group were not notified about the study and they received no guidelines and no prescription feedback. The personalized prescription feedbacks and the analyses of the primary and secondary outcomes are entirely based on pseudonymized patient-level data from routinely collected health insurance data. The primary outcome is prescribed antibiotics per 100 patient consultations during the second year of intervention. The secondary outcomes include antibiotic use during the entire two-year trial period, use of broad-spectrum antibiotics, hospitalization rates (all-cause and infection-related), and antibiotic use in different age groups. If the feedback intervention proves to be efficacious, the intervention could be continued systemwide. ETHICS AND DISSEMINATION The trial is publicly funded by the Swiss National Science Foundation (SNSF, grant number 407240_167066). The trial was approved by the ethics committee "Ethikkommission Nordwest-und Zentralschweiz" (EKNZ Project-ID 2017-00888). Results will be disseminated in peer-reviewed journals and international conferences.
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Key Words
- Antibiotics
- Antimicrobial resistance
- CI, confidence interval
- CONSORT, consolidated standards of reporting trials
- Claims
- DRG, Diagnosis Related Groups
- EKNZ, Ethikkommission Nordwest-und Zentralschweiz
- FMH, Foederatio Medicorum Helveticorum
- GP, general practitioners
- HRA, Human Research Act
- HRO, Human Research Ordinance
- Health-system level
- Hospitalization
- Low-cost intervention
- Prescription feedback
- Primary care
- RCT, randomized controlled trials
- Routinely collected patient data
- ZSR, Zentralregisternummer
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Affiliation(s)
- Dominik Glinz
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Kimberly A. Mc Cord
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Giusi Moffa
- Department of Mathematics and Computer Science, University of Basel, Basel, Switzerland
| | - Soheila Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ramon Saccilotto
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Andreas F. Widmer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Julia Bielicki
- Infectious Diseases and Vaccinology, University of Basel Children's Hospital, Switzerland
- St. George's University London, London, UK
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
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Patel A, Pfoh ER, Misra Hebert AD, Chaitoff A, Shapiro A, Gupta N, Rothberg MB. Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study. J Gen Intern Med 2020; 35:1182-1188. [PMID: 31630364 PMCID: PMC7174444 DOI: 10.1007/s11606-019-05433-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/23/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022]
Abstract
IMPORTANCE Inappropriate antibiotic use for upper respiratory tract infections (URTIs) is an ongoing problem in primary care. There is extreme variation in the prescribing practices of individual physicians, which cannot be explained by clinical factors. OBJECTIVE To identify factors associated with high and low prescriber status for management of URTIs in primary care practice. DESIGN AND PARTICIPANTS Exploratory sequential mixed-methods design including interviews with primary care physicians in a large health system followed by a survey. Twenty-nine physicians participated in the qualitative interviews. Interviews were followed by a survey in which 109 physicians participated. MAIN MEASURES Qualitative interviews were used to obtain perspectives of high and low prescribers on factors that influenced their decision making in the management of URTIs. A quantitative survey was created based on qualitative interviews and responses compared to actual prescribing rates. An assessment of self-prescribing pattern relative to their peers was also conducted. RESULTS Qualitative interviews identified themes such as clinical factors (patient characteristics, symptom duration, and severity), nonclinical factors (physician-patient relationship, concern for patient satisfaction, preference and expectation, time pressure), desire to follow evidence-based medicine, and concern for adverse effects to influence prescribing. In the survey, reported concern regarding antibiotic side effects and the desire to practice evidence-based medicine were associated with lower prescribing rates whereas reported concern for patient satisfaction and patient demand were associated with high prescribing rates. High prescribers were generally unaware of their high prescribing status. CONCLUSIONS AND RELEVANCE Physicians report that nonclinical factors frequently influence their decision to prescribe antibiotics for URTI. Physician concerns regarding antibiotic side effects and patient satisfaction are important factors in the decision-making process. Changes in the health system addressing both physicians and patients may be necessary to attain desired prescribing levels.
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Affiliation(s)
- Aditi Patel
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth R Pfoh
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.,Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Anita D Misra Hebert
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.,Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.,Quantitative Health Services, Cleveland, OH, USA
| | - Alexander Chaitoff
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Aryeh Shapiro
- University Hospitals Portage Medical Center, Ravenna, OH, USA
| | - Niyati Gupta
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Michael B Rothberg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA. .,Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA.
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Evaluation of clinicians' knowledge, attitudes, and planned behaviors related to an intervention to improve acute respiratory infection management. Infect Control Hosp Epidemiol 2020; 41:672-679. [PMID: 32178749 DOI: 10.1017/ice.2020.42] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acute respiratory tract infections (ARIs) are commonly diagnosed and major drivers of antibiotic prescribing. Clinician-focused interventions can reduce unnecessary antibiotic prescribing for ARIs. We elicited clinician feedback to design sustainable interventions to improve ARI management by understanding the mental framework of clinicians surrounding antibiotic prescribing within Veterans' Health Administration clinics. METHODS We conducted one-on-one interviews with clinicians (n = 20) from clinics targeted for intervention at 5 facilities. The theory of planned behavior guided interview questions. Interviews were audio recorded and transcribed for qualitative analysis. An iterative coding approach identified 6 themes. RESULTS Emergent themes: (1) barriers to appropriate prescribing are multifactorial and include challenges of behavior change; (2) antibiotic prescribing decisions are perceived as autonomous yet, diagnostic uncertainty and perceptions of patient demand can make prescribing decisions difficult; (3) clinicians perceive variation in peer prescribing practices and influences; (4) clinician-focused interventions are valuable if delivered with sensitivity; (5) communication strategies for educating patients are preferred to a shared decisions process; and (6) team standardization of practice and communication are key to facilitate appropriate prescribing. Clinicians perceived audit-and-feedback with peer comparison, academic detailing, and enhanced patient communication strategies as viable approaches to improving appropriate prescribing. CONCLUSION Implementation strategies that enable clinicians to overcome diagnostic uncertainty, perceived patient demand, and improve patient education are desired. Implementation strategies were welcomed, and some were more readily accepted (eg, audit feedback) than others (eg, shared decision making). Implementation strategies should address clinicians' perceptions of antibiotic prescribing practices and should enhance their patient communication skills.
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9
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Bowen A, Agboatwalla M, Pitz A, Salahuddin S, Brum J, Plikaytis B. Effect of Bismuth Subsalicylate vs Placebo on Use of Antibiotics Among Adult Outpatients With Diarrhea in Pakistan: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e199441. [PMID: 31418805 PMCID: PMC6705140 DOI: 10.1001/jamanetworkopen.2019.9441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Many of the 4.5 billion annual episodes of diarrhea are treated unnecessarily with antibiotics; prevalence of antibiotic resistance among diarrheal pathogens is increasing. Knowledge-based antibiotic stewardship interventions typically yield little change in antibiotic use. OBJECTIVE To compare antibiotic use among adult outpatients with diarrhea given bismuth subsalicylate (BSS) or placebo. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial took place from April to October 2014. Participants were patients aged 15 to 65 years with acute, nonbloody diarrhea from 22 outpatient clinics in Karachi, Pakistan. Participants were interviewed about symptoms and health care utilization during the 5 days after enrollment. Group assignment was concealed from participants, field staff, and the statistician. Primary analysis occurred from August to September 2015. INTERVENTIONS Participants were randomly assigned (1:1) to receive BSS or placebo for 48 hours or less. MAIN OUTCOMES AND MEASURES Use of systemic antibiotics within 5 days of enrollment. Secondary outcomes included measures of duration and severity of illness. RESULTS Among eligible patients, 39 declined to participate, 440 enrolled, and 1 enrolled participant was lost to follow-up, for a total of 439 patients included in the analysis. Median (interquartile range) participant age was 32 (23-45) years and 187 (43%) were male. Two hundred twenty patients were randomized to BSS and 220 were randomized to placebo. Overall, 54 participants (12%) used systemic antibiotics (16% in the placebo group and 9% in the BSS group); all antibiotic use followed consultation with a physician. Use of any antibiotic was significantly lower in the BSS group (20 of 220 vs 34 of 219 patients; odds ratio [OR], 0.54; 95% CI, 0.30-0.98), as was use of fluoroquinolones (8 of 220 vs 20 of 219 patients; OR, 0.38; 95% CI, 0.16-0.88). Rates of care seeking and hospitalization were similar between groups and no difference was detected in timing of diarrhea resolution. However, those in the BSS group less commonly received intravenous rehydration (14 of 220 vs 27 of 219 patients; OR, 0.48; 95% CI, 0.25-0.95) and missed less work (median [interquartile range], 0 [0-1] vs 1 [0-1] day; P = .04) during follow-up. CONCLUSIONS AND RELEVANCE This study found less antibiotic use among participants given BSS for acute diarrhea in a setting where antibiotics are commonly used to treat diarrhea. Encouraging health care professionals in such settings to recommend BSS as frontline treatment for adults with diarrhea, and promoting BSS for diarrhea self-management, may reduce antibiotic use and rates of antibiotic resistance globally. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02047162.
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Affiliation(s)
- Anna Bowen
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Adam Pitz
- Procter & Gamble Health Care, Cincinnati, Ohio
| | | | - Jose Brum
- Procter & Gamble Health Care, Cincinnati, Ohio
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10
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Glinz D, Leon Reyes S, Saccilotto R, Widmer AF, Zeller A, Bucher HC, Hemkens LG. Quality of antibiotic prescribing of Swiss primary care physicians with high prescription rates: a nationwide survey. J Antimicrob Chemother 2018; 72:3205-3212. [PMID: 28961815 DOI: 10.1093/jac/dkx278] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 07/10/2017] [Indexed: 11/13/2022] Open
Abstract
Objectives To assess the quality of antibiotic prescribing of Swiss primary care physicians with high prescription rates. Methods In January 2015, we mailed a structured questionnaire to 2900 primary care physicians in Switzerland. They were included in a nationwide pragmatic randomized controlled trial on routine antibiotic prescription monitoring and feedback based on health insurance claims data. We asked them to record the diagnosis and antibiotic treatment for 44 consecutive patients with the most common conditions associated with antibiotic prescribing in primary care. We evaluated if the disease-specific antibiotic prescribing and the proportion of non-recommended antibiotics used, in particular quinolones, were within 'acceptable ranges' using adapted European Surveillance of Antimicrobial Consumption (ESAC) quality indicators. Results Two hundred and fifty physicians (8.6%) responded, providing 9961 patient records. Responders were similar to the entire physician population. Overall, antibiotics were prescribed to 32.1% of patients. For tonsillitis/pharyngitis, acute otitis media, acute rhinosinusitis and acute bronchitis the acceptable maximum of antibiotic prescriptions was exceeded by 24.4%, 49.6%, 27.4% and 11.5%, respectively. The proportion of non-recommended antibiotics was for all diagnoses above the recommended maximum of 20% (31.5%-88.7% across all conditions). Quinolones were prescribed to 37.2% of women with urinary tract infections, substantially exceeding the recommended maximum of 5%. Conclusions Antibiotic prescribing quality of Swiss primary care physicians with high prescription rates is low according to the indicators used, with substantial overtreatment of tonsillitis/pharyngitis, acute rhinosinusitis, acute otitis media and acute bronchitis. Routine nationwide and continuous monitoring of antibiotic use and specific interventions are warranted to improve prescribing in primary care.
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Affiliation(s)
- Dominik Glinz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Selene Leon Reyes
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Ramon Saccilotto
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Andreas F Widmer
- Division of Infectious Diseases and Hospital Hygiene, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Andreas Zeller
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, and University of Basel, Basel, Switzerland.,Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, and University of Basel, Basel, Switzerland
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A Timeout on the Antimicrobial Timeout: Where Does It Stand and What Is Its Future? CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0146-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Djalali S, Markun S, Rosemann T. [Routine Data in Health Services Research: an Underused Resource]. PRAXIS 2017; 106:365-372. [PMID: 28357901 DOI: 10.1024/1661-8157/a002630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Zusammenfassung. Routinedaten entstehen als Nebenprodukt des normalen Betriebsalltags. Diese ohne Zusatzaufwand massenhaft generierten Daten lassen sich mit ökonomischen oder im Falle der Medizin auch mit gesundheitlichen Fragestellungen auswerten. Durch die nicht-kontrollierte Art der Sammlung von Routinedaten sowie aufgrund der uneinheitlichen Handhabung von elektronischen Krankengeschichten ergeben sich aber je nach Fragestellung Grenzen der Aussagekraft von Resultaten. Dieser Artikel widmet sich den Fragen rund um Herkunft, Verarbeitung, Interpretation und Nutzen von Routinedaten. Dabei werden auch Machine Learning und Big Data kritisch in den Kontext gebracht, sowie die Aspekte Datenschutz und Ethik. Hinsichtlich des Schweizer Gesundheitssystems zeigt der Artikel die notwendigen Voraussetzungen, damit das Potential von Routinedaten auch hierzulande zugunsten einer besseren medizinischen Versorgung genutzt werden kann.
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Affiliation(s)
- Sima Djalali
- 1 Institut für Hausarztmedizin, Universität Zürich
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